Kari White

Unmet demand for highly effective postpartum contraception in Texas

OBJECTIVES We aimed to assess womens contraceptive preferences and use in the first 6 months after delivery. The postpartum period represents a key opportunity for women to learn about and obtain effective contraception, especially since 50% of unintended pregnancies to parous women occur within 2 years of a previous birth. METHODS We conducted a prospective cohort study of 800 postpartum women recruited from three hospitals in Austin and El Paso, TX. Women aged 18-44 who wanted to delay childbearing for at least 24 months were eligible for the study and completed interviews following delivery and at 3 and 6 months postpartum. Participants were asked about the contraceptive method they were currently using and the method they would prefer to use at 6 months after delivery. RESULTS At 6 months postpartum, 13% of women were using an intrauterine device or implant, and 17% were sterilized or had a partner who had had a vasectomy. Twenty-four percent were using hormonal methods, and 45% relied on less effective methods, mainly condoms and withdrawal. Yet 44% reported that they would prefer to be using sterilization, and 34% would prefer to be using long-acting reversible contraception (LARC). CONCLUSIONS This study shows a considerable preference for LARC and permanent methods at 6 months postpartum. However, there is a marked discordance between womens method preference and actual use, indicating substantial unmet demand for highly effective methods of contraception. IMPLICATIONS In two Texas cities, many more women preferred long-acting and permanent contraceptive methods (LAPM) than were able to access these methods at 6 months postpartum. Womens contraceptive needs could be better met by counseling about all methods, by reducing cost barriers and by making LAPM available at more sites.

Change in abortion services after implementation of a restrictive law in Texas

OBJECTIVES In 2013, Texas passed omnibus legislation restricting abortion services. Provisions restricting medical abortion, banning most procedures after 20 weeks and requiring physicians to have hospital-admitting privileges were enforced in November 2013; by September 2014, abortion facilities must meet the requirements of ambulatory surgical centers (ASCs). We aimed to rapidly assess the change in abortion services after the first three provisions went into effect. STUDY DESIGN We requested information from all licensed Texas abortion facilities on abortions performed between November 2012 and April 2014, including the abortion method and gestational age (< 12 weeks vs. ≥ 12 weeks). RESULTS In May 2013, there were 41 facilities providing abortion in Texas; this decreased to 22 in November 2013. Both clinics closed in the Rio Grande Valley, and all but one closed in West Texas. Comparing November 2012-April 2013 to November 2013-April 2014, there was a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 15-44). Medical abortion decreased by 70%, from 28.1% of all abortions in the earlier period to 9.7% after November 2013 (p<0.001). Second-trimester abortion increased from 13.5% to 13.9% of all abortions (p<0.001). Only 22% of abortions were performed in the states six ASCs. CONCLUSIONS The closure of clinics and restrictions on medical abortion in Texas appear to be associated with a decline in the in-state abortion rate and a marked decrease in the number of medical abortions. IMPLICATIONS Supply-side restrictions on abortion - especially restrictions on medical abortion - can have a profound impact on access to services. Access to abortion care will become even further restricted in Texas when the ASC requirement goes into effect in 2014.

Clinic Versus Over-the-Counter Access to Oral Contraception: Choices Women Make Along the US–Mexico Border

OBJECTIVES As part of the Border Contraceptive Access Study, we interviewed oral contraceptive (OC) users living in El Paso, Texas, to assess motivations for patronizing a US clinic or a Mexican pharmacy with over-the-counter (OTC) pills and to determine which women were likely to use the OTC option. METHODS We surveyed 532 clinic users and 514 pharmacy users about background characteristics, motivations for choosing their OC source, and satisfaction with this source. RESULTS Older women and women born and educated in Mexico were more likely to patronize pharmacies. Cost of pills was the main motivation for choosing their source for 40% of pharmacy users and 23% of clinic users. The main advantage cited by 49% of clinic users was availability of other health services. Bypassing the requirement to obtain a doctors prescription was most important for 27% of pharmacy users. Both groups were very satisfied with their pill source. CONCLUSIONS Women of different ages, parities, and educational levels would likely take advantage of an OTC option were OCs available at low cost. Improving clinic provision of OCs should be considered.

Contraception after delivery and short interpregnancy intervals among women in the United States.

OBJECTIVE: To investigate womens patterns of contraceptive use after delivery and the association between method use and risk of pregnancy within 18 months. METHODS: We used the 2006–2010 National Survey of Family Growth to examine womens contraceptive use after delivery and at 3, 6, 12, and 18 months after giving birth. The sample included 3,005 births that occurred within 3 years of the survey date and for which information on contraceptive use was available. We estimated multivariable-adjusted Cox regression models to assess the association between womens method use and risk of pregnancy within 18 months after delivery. We also examined the percentage of pregnancies occurring 18 months or less after the index birth that were unintended. RESULTS: Between delivery and 3 months postpartum, contraceptive use increased from 21% to 72%. At 3 months, 13% of women used permanent contraception, 6% used long-acting reversible contraceptives, 28% used other hormonal methods, and 25% relied on less-effective methods; the distribution of method use was similar in subsequent months. Among women using hormonal methods, 12.6% became pregnant within 18 months of delivery or less compared with 0.5% using permanent and long-acting contraception (adjusted hazard ratio [HR] 21.2, 95% confidence interval [CI] 6.17–72.8). Additionally, 17.8% of women using less-effective methods (HR 34.8, 95% CI 9.26–131) and 23% using no method (HR 43.2, 95% CI 12.3–152) became pregnant 18 months or less. At least 70% of pregnancies within 1 year after delivery were unintended. CONCLUSION: Few women use long-acting reversible contraceptives after delivery, and those using less-effective methods have an increased risk of unintended pregnancy. LEVEL OF EVIDENCE: II

Impact of Clinic Closures on Women Obtaining Abortion Services After Implementation of a Restrictive Law in Texas

OBJECTIVES To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the introduction of House Bill 2 in 2013. METHODS In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood-affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open. RESULTS For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open (P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than

Contraindications to Combined Oral Contraceptives Among Over-the-Counter Compared With Prescription Users

100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P < .05). CONCLUSIONS Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care.

Contraindications to progestin-only oral contraceptive pills among reproductive-aged women

OBJECTIVE: To compare the estimated proportion of contraindications to combined oral contraceptives between women who obtained combined oral contraceptives in U.S. public clinics compared with women who obtained combined oral contraceptives over the counter (OTC) in Mexican pharmacies. METHODS: We recruited a cohort of 501 women who were residents of El Paso, Texas, who obtained OTC combined oral contraceptives in Mexico and 514 women who obtained combined oral contraceptives from family planning clinics in El Paso. Based on self-report of World Health Organization category 3 and 4 contraindications and interviewer-measured blood pressure, we estimated the proportion of contraindications and, using multivariable-adjusted logistic regression, identified possible predictors of contraindications. RESULTS: The estimated proportion of any category 3 or 4 contraindication was 18%. Relative contraindications (category 3) were more common among OTC users (13% compared with 9% among clinic users, P=.006). Absolute contraindications (category 4) were not different between the groups (5% for clinic users compared with 7% for OTC users, P=.162). Hypertension was the most prevalent contraindication (5.6% of clinic users and 9.8% of OTC users). After multivariable adjustment, OTC users had higher odds of having contraindications compared with clinic users (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.11–2.29). Women aged 35 years or older (OR 5.30, 95% CI 3.59–7.81) and those with body mass index 30.0 or more (OR 2.24, 95% CI 1.40–3.56) also had higher odds of having contraindications. CONCLUSION: Relative combined oral contraceptive contraindications are more common among OTC users in this setting. Progestin-only pills might be a better candidate for the first OTC product given their fewer contraindications. LEVEL OF EVIDENCE: II

Impact of Alabama’s Immigration Law on Access to Health Care Among Latina Immigrants and Children: Implications for National Reform

BACKGROUND Progestin-only oral contraceptive pills (POPs) have fewer contraindications to use compared to combined pills. However, the overall prevalence of contraindications to POPs among reproductive-aged women has not been assessed. STUDY DESIGN We collected information on contraindications to POPs in two studies: (1) the Self-Screening Study, a sample of 1267 reproductive-aged women in the general population in El Paso, TX, and (2) the Prospective Study of OC Users, a sample of current oral contraceptive (OC) users who obtained their pills in El Paso clinics (n=532) or over the counter (OTC) in Mexican pharmacies (n=514). In the Self-Screening Study, we also compared womens self-assessment of contraindications using a checklist to a clinicians evaluation. RESULTS Only 1.6% of women in the Self-Screening Study were identified as having at least one contraindication to POPs. The sensitivity of the checklist for identifying women with at least one contraindication was 75.0% [95% confidence interval (CI): 50.6%-90.4%], and the specificity was 99.4% (95% CI: 98.8%-99.7%). In total, 0.6% of women in the Prospective Study of OC Users reported having any contraindication to POPs. There were no significant differences between clinic and OTC users. CONCLUSION The prevalence of contraindications to POPs was very low in these samples. POPs may be the best choice for the first OTC oral contraceptive in the United States.

Frustrated Demand for Sterilization Among Low-Income Latinas in El Paso, Texas

We conducted in-depth interviews in May to July 2012 to evaluate the effect of Alabamas 2011 omnibus immigration law on Latina immigrants and their US- and foreign-born childrens access to and use of health services. The predominant effect of the law on access was a reduction in service availability. Affordability and acceptability of care were adversely affected because of economic insecurity and womens increased sense of discrimination. Nonpregnant women and foreign-born children experienced the greatest barriers, but pregnant women and mothers of US-born children also had concerns about accessing care. The implications of restricting access to health services and the potential impact this has on public health should be considered in local and national immigration reform discussions.

Complications from first-trimester aspiration abortion: a systematic review of the literature

CONTEXT Sterilization is the most commonly used contraceptive in the United States, yet access to this method is limited for some. METHODS A 2006-2008 prospective study of low-income pill users in El Paso, Texas, assessed unmet demand for sterilization among 801 women with at least one child. Multivariable logistic regression analysis identified characteristics associated with wanting sterilization. In 2010, at an 18-month follow-up, women who had wanted sterilization were recontacted; 120 semistructured and seven in-depth interviews were conducted to assess motivations for undergoing the procedure and the barriers faced in trying to obtain it. RESULTS At baseline, 56% of women wanted no more children; at nine months, 65% wanted no more children, and of these, 72% wanted sterilization. Only five of the women interviewed at 18 months had undergone sterilization; two said their partners had obtained a vasectomy. Women who had not undergone sterilization were still strongly motivated to do so, mainly because they wanted no more children and were concerned about long-term pill use. Among womens reasons for not having undergone sterilization after their last pregnancy were not having signed the Medicaid consent form in time and having been told that they were too young or there was no funding for the procedure. CONCLUSIONS Because access to a full range of contraceptive methods is limited for low-income women, researchers and providers should not assume a womans current method is her method of choice.