Marji Gold

Determinants of intrauterine contraception provision among US family physicians: a national survey of knowledge, attitudes and practice

BACKGROUND Poor contraception adherence contributes to unintended pregnancy. Intrauterine contraception (IUC) is user-independent thus adherence is not an issue, yet few US women use IUC. We compared family physicians (FPs) who do and do not insert IUC in order to ascertain determinants of inserting IUC. STUDY DESIGN We surveyed 3500 US FPs. The primary outcome variable was whether a physician inserts IUC in their current clinical practice. We also sought to describe their clinical practice with IUC insertions. RESULTS FPs who insert IUC had better knowledge about IUC (adjusted OR 1.85, 95% CI 1.32-2.60), more comfort discussing IUC (adjusted OR 2.35, 95% CI 1.30-4.27), and were more likely to believe their patients are receptive to discussing IUC (adjusted OR 2.96, 95% CI 2.03-4.32). The more IUC inserted during residency, the more likely to insert currently (adjusted OR 1.44, 95% CI 1.12-1.84). Only 24% of respondents inserted IUC in the prior 12 months. CONCLUSIONS US FPs have training and knowledge gaps, as well as attitudes, that result in missed opportunities to discuss and provide IUC for all eligible patients.

The Visit Before the Morning After: Barriers to Preprescribing Emergency Contraception

BACKGROUND Research suggests that while advance prescription of emergency contraception (EC) increases women’s access, this prescribing model is rarely used. The present study sought to explore attitudes towards EC among patients and physicians, with the goal of understanding potential barriers to advance prescription. METHODS Qualitative, semistructured interviews were conducted with patients and clinicians in a New York City family practice clinic. RESULTS Using qualitative interviews, we found that attitudes towards EC among patients and clinicians are complex. Both groups of participants reported favorable attitudes towards EC. There was general agreement that physicians should take a proactive role in educating patients about the method. A notable minority in each group described substantial reservations, however, especially regarding the potential for EC abuse. Such attitudes emerged mainly in the context of discussions about advance prescription. Advance prescription was viewed as greatly facilitating access to EC, but some patients and clinicians feared that ready access would encourage irresponsible sex. Some participants condoned the occasional, accidental, or emergency use of EC; however, habitual use, or the plan not to plan for sex, was viewed as morally indefensible. CONCLUSION Findings suggest that even when attitudes towards EC are generally favorable, some physicians and patients have substantial reservations about advance prescription. Education and dialogue are needed to overcome these reservations.

Acceptability of home use of mifepristone for medical abortion

BACKGROUND Most medical abortion protocols require women to take mifepristone in the doctors office. We assessed the acceptability of home use of mifepristone among women and their providers. STUDY DESIGN In this multicenter trial, eligible women requesting termination of early pregnancy (n=301) chose whether to take mifepristone in the office or at home. Data on safety, efficacy, acceptability and disability were collected. RESULTS One hundred thirty-nine women (46%) chose to take mifepristone at home, and 162 (54%) chose office administration. Ninety-five percent of home users said that they would take the mifepristone in the same place in the future. Home users were not more likely to call the doctors office or make an unplanned visit, and providers would recommend home use again for 95% of patients who chose home use. CONCLUSIONS Home administration of mifepristone was safe and acceptable to women and providers in our study. Women should be offered this choice to allow more flexibility, comfort and privacy in their abortion experiences.

Barriers to Adolescents' Getting Emergency Contraception Through Pharmacy Access in California: Differences by Language and Region

CONTEXT In California, emergency contraception is available without a prescription to females younger than 18 through pharmacy access. Timely access to the method is critical to reduce the rate of unintended pregnancy among adolescents, particularly Latinas. METHODS In 2005-2006, researchers posing as English- and Spanish-speaking females-who said they either were 15 and had had unprotected intercourse last night or were 18 and had had unprotected sex four days ago-called 115 pharmacy-access pharmacies in California. Each pharmacy received one call using each scenario; a call was considered successful if the caller was told she could come in to obtain the method. Chi-square tests were used to assess differences between subgroups. In-depth interviews with 22 providers and pharmacists were also conducted, and emergent themes were identified. RESULTS Thirty-six percent of all calls were successful. Spanish speakers were less successful than English speakers (24% vs. 48%), and callers to rural pharmacies were less successful than callers to urban ones (27% vs. 44%). Although rural pharmacies were more likely to offer Spanish-language services, Spanish-speaking callers to these pharmacies were the least successful of all callers (17%). Spanish speakers were also less successful than English speakers when calling urban pharmacies (30% vs. 57%). Interviews suggested that little cooperation existed between pharmacists and clinicians and that dispensing the method at clinics was a favorable option for adolescents. CONCLUSIONS Adolescents face significant barriers to obtaining emergency contraception, but the expansion of Spanish-language services at pharmacies and greater collaboration between providers and pharmacists could improve access.

Knowledge and Likelihood to Recommend Intrauterine Devices for Adolescents Among School-based Health Center Providers

PURPOSE The American College of Obstetricians and Gynecologists and the Centers for Disease Control and Prevention recommend intrauterine devices (IUDs) as safe and highly effective contraceptives for adolescents. Nevertheless, many U.S. providers do not recommend or provide IUDs to adolescents-a population at high risk for unintended pregnancy. The purpose of this study was to identify barriers to IUD provision for adolescents. METHODS A 36-item self-administered survey of knowledge and attitudes regarding IUDs was completed by 162 staff of New York City school-based health centers, including 69 clinicians (e.g., pediatricians and nurse practitioners) and 93 nonclinicians (e.g., social workers and health educators). RESULTS Half (55%) of all respondents would be likely to recommend an IUD to a patient under age 20 years. Respondents were less likely to recommend an IUD for patients with history of recent STD (31%), remote pelvic inflammatory disease (37%), and patients not in a monogamous relationship (38%). Whereas 77% of respondents indicated that IUDs are safe for adolescents, 18% of those respondents would be unlikely to recommend an IUD to a patient under age 20 years. While 86% of respondents knew that IUDs can be used in nulliparous women, 25% of those respondents would be unlikely to recommend an IUD to a patient who has never been pregnant. Additionally, 61% believed that counseling patients about IUDs would take more time than other methods. CONCLUSIONS Misinformation about risks associated with IUDs and beliefs about patient eligibility may present barriers to provision. Apparent contradictions between knowledge and likelihood to recommend IUDs warrant further study.

The accuracy of using last menstrual period to determine gestational age for first trimester medication abortion: a systematic review.

OBJECTIVE We sought to evaluate the accuracy of assessing gestational age (GA) prior to first trimester medication abortion using last menstrual period (LMP) compared to ultrasound (U/S). STUDY DESIGN We searched Medline, Embase and Cochrane databases through October 2013 for peer-reviewed articles comparing LMP to U/S for GA dating in abortion care. Two teams of investigators independently evaluated data using standard abstraction forms. The US Preventive Services Task Force and Quality Assessment of Diagnostic Accuracy Studies guidelines were used to assess quality. RESULTS Of 318 articles identified, 5 met inclusion criteria. Three studies reported that 2.5-11.8% of women were eligible for medication abortion by LMP and ineligible by U/S. The number of women who underestimated GA using LMP compared to U/S ranged from 1.8 to 14.8%, with lower rates found when the sample was limited to a GA <63 days. Most women (90.5-99.1%) knew their LMP, 70.8-90.5% with certainty. CONCLUSION Our results support that LMP can be used to assess GA prior to medication abortion at GA <63 days. Further research looking at patient outcomes and identifying women eligible for medication abortion by LMP but ineligible by U/S is needed to confirm the safety and effectiveness of providing medication abortion using LMP alone to determine GA.

Beliefs about abortion risks in women returning to the clinic after their abortions: a pilot study

BACKGROUND Misinformation regarding the risks of abortion is prevalent and commonly includes medical inaccuracies about health, depression, infertility and breast cancer. This pilot study sought to assess misinformation among abortion clients as well as the origin(s) of their abortion knowledge. STUDY DESIGN Women who presented to the Mount Sinai School of Medicine Family Planning Division for postabortion follow-up were recruited for participation. Participants completed a researcher-administered survey regarding knowledge and beliefs about abortion. RESULTS Sixty-seven women completed the survey between 1/11/10 and 8/6/12. Common sources of abortion information included clinicians (79.1%), Web sites (70.1%), friends (50.7%) and family (40.3%). Over two thirds of women (77.6%) overestimated the health risks, and close to half (43.3%) overestimated the risk of depression after a first trimester abortion. CONCLUSIONS Misperceptions about the health risks of abortion were prevalent among this sample. Education tools should be developed to provide accurate information about the risks of abortion.

Family Formation in the Inner City: Low-income Men's Perception of Their Role in Unplanned Conception and Pregnancy Prevention

Purpose. Research documents the importance of partners in womens contraception use, pregnancy prevention/planning, and decision-making around unintended pregnancy. Little is known of mens perceptions of this crucial role.Methods. Semi-structured, in-depth interviews (n = 20) with low-income, inner-city men, aged 18–45 years, who had brought about a pregnancy.Results. Responsibility framed mens understanding of their reproductive and parenting roles. Uniformly, men equated being responsible with providing financially for their families. Interpretations of being responsible evolved over mens reproductive lifetimes, influencing their perceived role in planning or preventing pregnancy, and consideration of abortion for unplanned pregnancies. The desire to take responsibility for children they fathered was limited by the structural realities of these mens lives, which were often characterized by poverty, unemployment, violence, and crime. Conclusions. Though financial responsibility is highly valued, poverty and related social factors are significant barriers to mens ability to achieve this goal. Discussions with men about family planning should reflect these realities.

If we can do it for misoprostol, why not for mifepristone? The case for taking mifepristone out of the office in medical abortion ☆

Given the highly political nature of abortion in the United States, the provision of medical abortion with mifepristone (Mifeprex®) and misoprostol has always occurred under a unique set of circumstances. The Food and Drug Administration-approved regimen requires clinicians to administer the mifepristone in the office and also requires women to return to the office for the misoprostol. In the US, where off-label drug use is an accepted practice when supportive evidence exists, most clinicians give women the misoprostol at the initial visit for her to take at home, eliminating an unnecessary visit to the office. This commentary suggests that, based on current studies, there is also enough evidence to offer women the option to self-administer mifepristone out of the office and that this is just another feature of off-label use. Six studies, enrolling over 1800 women, found that the option of taking mifepristone out of the office was popular and acceptable among women and providers. Given that it is safe, highly acceptable and not burdensome on providers, outside-office-use of mifepristone should be offered to all women as part of routine medical abortion services.

What Women Want: A Qualitative Study of Contraception in Jail.

OBJECTIVES We undertook this study to understand womens perceptions of receiving contraception at Rikers Island Jail. METHODS We conducted semi-structured in-depth interviews in 2011 to 2012 with 32 women incarcerated at Rikers Island Jail. We analyzed the data using standard qualitative techniques. RESULTS Almost all participants believed that contraception should be provided at the jail. However, many said they would hesitate to use these services themselves. Reservations were caused in part by womens negative views of health care services at the jail. Fears about the safety of birth control, difficulties associated with follow-up in the community, and desire for pregnancy were other factors that influenced interest in accepting contraception. CONCLUSIONS Contraception at the jail must be provided by trusted medical providers delivering high quality care with the goal of allowing women to control their own fertility; this would ensure that women could access birth control and cease using birth control when desired.