Perspectives on Sexual and Reproductive Health, May 22, 2023
IntroductionAgency in contraceptive decision‐making is an essential aspect of reproductive autono... more IntroductionAgency in contraceptive decision‐making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct.MethodologyWe held four focus group discussions and seven interviews with sexually‐active individuals assigned female at birth, ages 16–29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision‐making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes.ResultsThe sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision‐making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non‐judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions.DiscussionMost participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.
ABSTRACT The pelvic examination is under scrutiny given revised cervical cancer screening guideli... more ABSTRACT The pelvic examination is under scrutiny given revised cervical cancer screening guidelines. Recent studies have examined physician attitudes and practices, but data are scarce on women's preferences. General mistrust of medical care is higher among Hispanics and blacks, but we know little about attitudes toward the pelvic examination by race and ethnicity. We examined variation in pelvic examination attitudes with baseline data from a cluster randomized trial on contraception. Women ages 18-25 years (n=1,500) were enrolled at 40 Planned Parenthood clinics across the United States. This secondary analysis used multivariable logistic regression with generalized estimating equations for clustering to examine variation in pelvic examination attitudes by race and ethnicity, controlling for individual variables (age, parity, prior contraceptive use, health insurance), site characteristics, and intervention. Hispanic women (67%) were less likely than black (84%) and white (85%) women to have had a pelvic examination (P=.001). However, Hispanic (61%) and black (69%) women were more likely than white women (43%) to report they would want a pelvic examination even if not required for contraception (Hispanic: adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 1.8-2.7; black: adjusted OR 3.2, 95% CI 2.3-4.4). Hispanic (8%) and black (10%) women were less likely than white women (17%) to have delayed going to a clinic for contraception to avoid a pelvic examination (Hispanic: adjusted OR 0.5, 95% CI 0.4-0.7; black: adjusted OR 0.6, 95% CI 0.4-0.9). The majority of young women in this contraceptive study had a pelvic examination, and perspectives on the examination varied by race and ethnicity. Women should be given the opportunity to avoid the examination when not medically necessary, as in provision of contraceptives.
A number of studies identify distinct dimensions of psychological and subjective wellbeing. Howev... more A number of studies identify distinct dimensions of psychological and subjective wellbeing. However, few investigations have examined how these distinctive wellbeing dimensions may be related over time. The present study aimed to contribute to this growing body of research by adopting a measurement burst design to examine the association between psychological functioning with daily and intra-individual variation in affect over a 14-day period, controlling for personality. Participants (N = 45) comprised a sample of Australian adults from Canberra, Australia who were observed on up to 14 days over a 2-week period (Mobs = 10.9 (SD = 3.1)). Maximum Likelihood (ML) estimates from a multi-level structural equation model identified psychological functioning as only weakly associated with daily positive affect, and unrelated to daily levels of negative affect and intra-individual variation in both affect domains when adjusting for demographic, personality and daily stressors. Positive and negative daily events were most strongly associated with positive and negative feelings, respectively. Post-hoc analysis within a Bayesian context confirmed our ML results whilst a Monte Carlo simulation identified sufficient statistical power of significant parameters. Overall, evidence for an association between psychological functioning and daily affect was not identified.
Objective To analyse the current provision of long-acting reversible contraception (LARC) and cli... more Objective To analyse the current provision of long-acting reversible contraception (LARC) and clinician training needs in HIV-prevalent settings. Design Nationally representative survey of clinicians. Setting HIV-prevalent settings in South Africa and Zimbabwe. Population Clinicians in South Africa and Zimbabwe. Methods Nationally representative surveys of clinicians were conducted in South Africa and Zimbabwe (n = 1444) to assess current clinical practice in the provision of LARC in HIVprevalent settings. Multivariable logistic regression was used to analyse contraceptive provision and clinician training needs. Main outcome measure Multivariable logistic regression of contraceptive provision and clinician training needs. Results Provision of the most effective reversible contraceptives is limited: only 14% of clinicians provide copper intrauterine devices (IUDs), 4% levonorgestrel-releasing IUDs and 16% contraceptive implants. Clinicians' perceptions of patient eligibility for IUD use were overly restrictive, especially related to HIV risks. Less than 5% reported that IUDs were appropriate for women at high risk of HIV or for HIV-positive women, contrary to evidence-based guidelines. Only 15% viewed implants as appropriate for women at risk of HIV. Most clinicians (82%), however, felt that IUDs were underused by patients, and over half desired additional training on LARC methods. Logistic regression analysis showed that LARC provision was largely restricted to physicians, hospital settings and urban areas. Results also showed that clinicians in rural areas and clinics, including nurses, were especially interested in training. Conclusions Clinician competency in LARC provision is important in southern Africa, given the low use of methods and high rates of unintended pregnancy among HIV-positive and atrisk women. Despite low provision, clinician interest is high, suggesting the need for increased evidence-based training in LARC to reduce unintended pregnancy and associated morbidities.
Objectives: General concerns about STIs can dissuade providers from offering intrauterine contrac... more Objectives: General concerns about STIs can dissuade providers from offering intrauterine contraception to eligible young women at high risk of unintended pregnancy. This study aimed to educate providers on updated evidence for IUD provision. Methods: We conducted a cluster randomized trial with a provider IUD training intervention in 40 Planned Parenthood clinics and measured patient outcomes among 1500 women aged 18-25. This secondary analysis assessed provider IUD counseling and patient decision to use IUD, by STI history. We also measured whether there was any difference in STI acquisition (chlamydia or gonorrhea) during 1-year follow-up by IUD method. We used generalized estimating equations for clustered data to analyze patient contraceptive outcomes and survival analysis to measure STI incidence. Results: While patients in the intervention arm were more likely to receive IUD counseling, there was no difference in IUD counseling by patient STI history (OR=1.1, 95% CI 0.85-1.40). Patient decision to use IUDs also varied by intervention, but not by STI history (OR=1.3, 95% CI 0.93-1.85). During the study, there were 6.8 chlamydia or gonorrhea cases per 100 person-years, with no differences by study arm (HR=1.3, 95% CI 0.86-1.96) or IUD method choice at baseline (HR=0.90, 95% CI 0.51-1.57). However, there was significantly higher STI incidence among those with multiple partners (HR=1.87, 95% CI 1.22-2.87). Conclusions: Providers included women with STI history in IUD counseling, consistent with evidence-based guidelines. The provider counseling intervention and the decision to use IUDs did not increase chlamydia or gonorrhea infection during the study among patients aged 25 or younger.
Perspectives on Sexual and Reproductive Health, Oct 28, 2013
Low knowledge of long-acting reversible contraceptives (LARC) and restrictive counseling practice... more Low knowledge of long-acting reversible contraceptives (LARC) and restrictive counseling practices have been documented among contraceptive care clinicians. However, little is known about health educators' counseling on LARC, how their practices compare with clinicians' and their specific training needs. A survey conducted in 2011-2012 assessed knowledge and practices related to LARC counseling and provision among 410 staff at 40 Planned Parenthood clinics. Clinicians' and health educators' knowledge and practices were compared via chi-square tests; use of evidence-based criteria was assessed in multivariable logistic regression analyses. At least half of both types of staff routinely discussed LARC with clients, and nearly all considered the methods safe. Health educators considered a smaller proportion of clients candidates for LARC than did clinicians (57% vs. 77%), and they were less likely to consider IUDs for teenagers (79% vs. 96%), nulliparous women (82% vs. 98%) and unmarried clients (90% vs. 99%). In a multivariable model, health educators were less likely than clinicians to counsel clients using the least restrictive evidence-based criteria (odds ratio, 0.1). Sixty-four percent of health educators and 40% of clinicians desired additional LARC training. Even in clinics that specialize in reproductive health care, health educators are less likely than clinicians to apply current evidence-based criteria in counseling about LARC. To provide evidence-based contraceptive counseling, health educators need training on LARC eligibility and indications.
Journal of Pediatric and Adolescent Gynecology, Jun 1, 2021
Study Objective.Provider misconceptions regarding intrauterine device safety for adolescents and ... more Study Objective.Provider misconceptions regarding intrauterine device safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of N gonorrhaeae or C trachomatis diagnoses among young women adopting intrauterine devices.Design.Secondary analysis of a cluster-randomized provider educational trial.Setting.40 U.S.-based reproductive health centers.Participants.1,350 participants aged 18–25 seeking contraceptive care were followed for 12-months.Interventions.The parent study assessed the impact of a provider training on evidence-based contraceptive counseling.Main Outcome Measures.We assessed incidence of N gonorrhaeae or C trachomatis (GC/CT) diagnoses by IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations.Results.204 participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over 12-month follow-up. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs. 8.0 otherwise. In adjusted models, IUD use (aHR 1.31, 95% CI 0.71–2.40), adolescent age (aHR 1.28, 95% CI 0.72–2.27), history of GC/CT (aHR 1.23, 95% CI 0.75–2.00) and intervention status (aHR 1.12, 95% CI 0.74–1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals reporting multiple partners at baseline (aHR 2.0, 95%CI 1.34–2.98).Conclusion.In this young study population with GC/CT history, this use of intrauterine devices was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.
Background: Unprotected intercourse is common, especially among teens and young women. Access to ... more Background: Unprotected intercourse is common, especially among teens and young women. Access to intrauterine device (IUD) as emergency contraception (EC) can help interested patients more effectively prevent unintended pregnancy and can also offer ongoing contraception. This study evaluated young women's awareness of IUD as EC and interest in case of need. Study design: We conducted a secondary analysis of data from young women aged 18-25 years, not desiring pregnancy within 12 months, and receiving contraceptive counseling within a cluster-randomized trial in 40 US Planned Parenthood health centers in 2011-2013 (n=1500). Heath centers were randomized to receive enhanced training on contraceptive counseling and IUD placement, or to provide standard care. The intervention did not focus specifically on IUD as EC. We assessed awareness of IUD as EC, desire to learn more about EC and most trusted source of information of EC among women in both intervention and control groups completing baseline and 3-or 6-month follow-up questionnaires (n=1138). Results: At follow-up, very few young women overall (7.5%) visiting health centers had heard of IUD as EC. However, if they needed EC, most (68%) reported that they would want to learn about IUDs in addition to EC pills, especially those who would be very unhappy to become pregnant (adjusted odds ratio [aOR], 1.3; 95% confidence interval, 1.0-1.6, p<.05). Most (91%) reported a doctor or nurse as their most trusted source of EC information, over Internet (6%) or friends (2%), highlighting providers' essential role. Conclusion: Most young women at risk of unintended pregnancy are not aware of IUD as EC and look to their providers for trusted information. Contraceptive education should explicitly address IUD as EC.
Background Patient agency in contraceptive decision-making is an essential component of reproduct... more Background Patient agency in contraceptive decision-making is an essential component of reproductive autonomy. Objective We aimed to develop a psychometrically robust measure of patient contraceptive agency in the clinic visit, as a measure does not yet exist. Design For scale development, we generated and field tested 54 questionnaire items, grounded in qualitative research. We used item response theory–based methods to select and evaluate scale items for psychometric performance. We iteratively examined model fit, dimensionality, internal consistency, internal structure validity, and differential item functioning to arrive at a final scale. Participants A racially/ethnically diverse sample of 338 individuals, aged 15–34 years, receiving contraceptive care across nine California clinics in 2019–2020. Main Measures Contraceptive Agency Scale (CAS) of patient agency in preventive care. Key Results Participants were 20.5 mean years, with 36% identifying as Latinx, 26% White, 20% Black...
BACKGROUND: Concern regarding pelvic examinations may be more common among women experiencing int... more BACKGROUND: Concern regarding pelvic examinations may be more common among women experiencing intimate partner violence. OBJECTIVE: We examined women's attitudes towards pelvic examination with history of intimate partner violence (pressured to have sex, or verbal, or physical abuse). DESIGN: Secondary analysis of data from a cluster randomized trial on contraceptive access. PARTICIPANTS: Women aged 18-25 were recruited at 40 reproductive health centers across the USA (2011-2013). MAIN MEASURES: Delays in clinic visits for contraception and preference to avoid pelvic examinations, by history of ever experiencing pressured sex, verbal, or physical abuse from a sexual partner, reported by frequency (never, rarely, sometimes, often). We used multivariable logistic regression with generalized estimating equations for clustered data. KEY RESULTS: A total of 1490 women were included. Ever experiencing pressured sex was reported by 32.4% of participants, with 16.5% reporting it rarely, 12.1% reporting it sometimes, and 3.8% reporting it often. Ever experiencing verbal abuse was reported by 19.4% and physical abuse by 10.2% of participants. Overall, 13.2% of participants reported ever having delayed going to the clinic for contraception to avoid having a pelvic examination, and 38.2% reported a preference to avoid pelvic examinations. In multivariable analysis, women reporting that they experienced pressured sex often had significantly higher odds of delaying a clinic visit for birth control (aOR 3.10 95% CI 1.39-6.84) and for reporting a preference to avoid pelvic examinations (aOR 2.91 95% CI 1.57-5.40). We found no associations between delay of clinic visits or preferences to avoid a pelvic examination and verbal or physical abuse. CONCLUSIONS: History of pressured sex from an intimate partner is common. Among women who have experienced pressured sex, concern regarding pelvic examinations i s a potential b arrier to contraception. Communicating that routine pelvic examinations are no longer recommended by professional societies could potentially reduce barriers and increase preventive healthcare visits.
International Journal of Gynecology & Obstetrics, 2018
Objective: To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies... more Objective: To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies is associated with reduced post-abortion contraceptive use in Nepal. Methods: The present prospective observational study compared contraceptive use among women aged 16-45 years and up to 63 days of pregnancy, who presented at one of six privately-owned pharmacies or six public health facilities in the Chitwan and Jhapa districts of Nepal for medical abortion between October 16, 2014, and September 1, 2015. Participants obtained medical abortions per Nepali protocol and completed a follow-up visit and interview at 14-21 days. Effective contraceptive use was compared between abortion care settings using multivariable mixed effects logistic regression.
Objectives: Emergency response skills are essential when complications such as hemorrhage, seizur... more Objectives: Emergency response skills are essential when complications such as hemorrhage, seizure or anaphylaxis occur in the outpatient setting. As services and procedures increasingly move outside the hospital, residents must have optimal training to manage such complications. The objective of this study was to evaluate a simulation-based curriculum with the outcome measures of resident self-efficacy and graded performance in medical emergencies in the outpatient setting. Methods: This prepost test study enrolled ob-gyn and family medicine residents who participated in a simulation-based training on managing emergencies in the outpatient setting, completed self-efficacy questionnaires and were evaluated on a graded rubric of three medical emergency scenariosseizure, oversedation and hemorrhagein the simulation lab. Results: Thirty-six residents completed the training and pre-and postevaluations. Pre-and posttest self-efficacy evaluations demonstrated improvement in two of the three scenarios. Subjects' performance scores improved in all five domains (pb.05) in all scenarios. When stratified by training level, all participants demonstrated improvement in the global scores on all scenarios regardless of level of training. When stratified by prior outpatient simulation experience, subjects with prior experience did not improve their global scores in the management of excess sedation. Self-efficacy assessment showed improvement in comfort managing outpatient emergencies (p=.001) and ability to communicate well in emergency situations (p=.04). Conclusions: Simulation-based training improved both self-efficacy and global performance in management of medical emergencies. Such training should be incorporated into residency programs.
misoprostol-alone (pb.001). Major complications were similar between the mifepristone cohort (5.8... more misoprostol-alone (pb.001). Major complications were similar between the mifepristone cohort (5.8%) and the misoprostol-only cohorts (7.7%) (p=.4). In the mifepristone and misoprostol-alone cohorts, respectively, 9 (4%) and 8 (6%) women received blood transfusions, and 2 (1%) and 3 (2%) had infections requiring IV antibiotics. Ninety percent of women in the mifepristone cohort said that they would recommend the method to a friend, compared to 70% in the misoprostol-alone cohorts (pb.001). Conclusion: Consistent with other clinical trials, mifepristone resulted in a significantly shorter induction interval, shorter hospitalization and improved patient satisfaction in these public hospitals in South Africa. Introduction of the mifepristone regimen has reduced costs and streamlined later abortion care in this setting, leading one hospital to establish a day unit to provide second-trimester abortion services.
Perspectives on Sexual and Reproductive Health, 2012
CONTEXT: Long‐acting reversible contraceptive (LARC) methods (IUDs and implants) are the most eff... more CONTEXT: Long‐acting reversible contraceptive (LARC) methods (IUDs and implants) are the most effective and cost‐effective methods for women. Although they are safe to place immediately following an abortion, most clinics do not offer this service, in part because of the increased cost. METHODS: In 2009, telephone interviews were conducted with 20 clinicians and 24 health educators at 25 abortion care practices across the country. A structured topic guide was used to explore general practice characteristics; training, knowledge and attitudes about LARC; and postabortion LARC counseling and provision. Transcripts of the digitally recorded interviews were coded and analyzed using inductive and deductive processes. RESULTS: Respondents were generally positive about the safety and effectiveness of LARC methods; those working in clinics that offered LARC methods immediately postabortion tended to have greater knowledge about LARC than others, and to perceive fewer risks and employ more e...
ABSTRACT Unintended pregnancy remains persistently high in the United States. Few randomized inte... more ABSTRACT Unintended pregnancy remains persistently high in the United States. Few randomized interventions have effectively reduced pregnancy. We conducted a cluster randomized trial in 40 Planned Parenthood sites, including family planning and abortion, to assess the effect of a clinic-wide training in long-acting reversible contraceptives (LARCs) on patient outcomes. A cohort of 1,500 patients, 18-25 years, who received contraceptive counseling and did not want to become pregnant in the next 12 months, were recruited from intervention and control clinics. Pregnancy was measured over 12 months with questionnaires, pregnancy tests, and medical record review. In blinded intent-to-treat analyses, we used survival analysis with shared frailty for clustered data to measure the intervention effect compared with standard care. The trial was registered with ClinicalTrials.gov and followed CONSORT (Consolidated Standards of Reporting Trials) guidelines. Participants were similar in baseline characteristics by arm. At enrollment, after counseling, participants in arm 1 were twice as likely to choose a LARC method as those in arm 2 using generalized estimating equation models for clustered data and robust standard errors (odds ratio 2.0, 95% confidence interval [CI] 1.3-2.9). In family planning settings, pregnancy during the study was lower in arm 1 (7.5%) than in arm 2 (13.8%). Analyses of the intervention effect in a model with an interaction for setting type showed a highly significant effect on reduced pregnancy in family planning settings (hazard ratio 0.5, 95% CI 0.3-0.8). However, there were no significant differences in pregnancy by arm in the abortion setting. A half-day replicable LARC intervention effectively reduced pregnancy in family planning clinics.
Perspectives on Sexual and Reproductive Health, May 22, 2023
IntroductionAgency in contraceptive decision‐making is an essential aspect of reproductive autono... more IntroductionAgency in contraceptive decision‐making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct.MethodologyWe held four focus group discussions and seven interviews with sexually‐active individuals assigned female at birth, ages 16–29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision‐making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes.ResultsThe sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision‐making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non‐judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions.DiscussionMost participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.
ABSTRACT The pelvic examination is under scrutiny given revised cervical cancer screening guideli... more ABSTRACT The pelvic examination is under scrutiny given revised cervical cancer screening guidelines. Recent studies have examined physician attitudes and practices, but data are scarce on women&#39;s preferences. General mistrust of medical care is higher among Hispanics and blacks, but we know little about attitudes toward the pelvic examination by race and ethnicity. We examined variation in pelvic examination attitudes with baseline data from a cluster randomized trial on contraception. Women ages 18-25 years (n=1,500) were enrolled at 40 Planned Parenthood clinics across the United States. This secondary analysis used multivariable logistic regression with generalized estimating equations for clustering to examine variation in pelvic examination attitudes by race and ethnicity, controlling for individual variables (age, parity, prior contraceptive use, health insurance), site characteristics, and intervention. Hispanic women (67%) were less likely than black (84%) and white (85%) women to have had a pelvic examination (P=.001). However, Hispanic (61%) and black (69%) women were more likely than white women (43%) to report they would want a pelvic examination even if not required for contraception (Hispanic: adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 1.8-2.7; black: adjusted OR 3.2, 95% CI 2.3-4.4). Hispanic (8%) and black (10%) women were less likely than white women (17%) to have delayed going to a clinic for contraception to avoid a pelvic examination (Hispanic: adjusted OR 0.5, 95% CI 0.4-0.7; black: adjusted OR 0.6, 95% CI 0.4-0.9). The majority of young women in this contraceptive study had a pelvic examination, and perspectives on the examination varied by race and ethnicity. Women should be given the opportunity to avoid the examination when not medically necessary, as in provision of contraceptives.
A number of studies identify distinct dimensions of psychological and subjective wellbeing. Howev... more A number of studies identify distinct dimensions of psychological and subjective wellbeing. However, few investigations have examined how these distinctive wellbeing dimensions may be related over time. The present study aimed to contribute to this growing body of research by adopting a measurement burst design to examine the association between psychological functioning with daily and intra-individual variation in affect over a 14-day period, controlling for personality. Participants (N = 45) comprised a sample of Australian adults from Canberra, Australia who were observed on up to 14 days over a 2-week period (Mobs = 10.9 (SD = 3.1)). Maximum Likelihood (ML) estimates from a multi-level structural equation model identified psychological functioning as only weakly associated with daily positive affect, and unrelated to daily levels of negative affect and intra-individual variation in both affect domains when adjusting for demographic, personality and daily stressors. Positive and negative daily events were most strongly associated with positive and negative feelings, respectively. Post-hoc analysis within a Bayesian context confirmed our ML results whilst a Monte Carlo simulation identified sufficient statistical power of significant parameters. Overall, evidence for an association between psychological functioning and daily affect was not identified.
Objective To analyse the current provision of long-acting reversible contraception (LARC) and cli... more Objective To analyse the current provision of long-acting reversible contraception (LARC) and clinician training needs in HIV-prevalent settings. Design Nationally representative survey of clinicians. Setting HIV-prevalent settings in South Africa and Zimbabwe. Population Clinicians in South Africa and Zimbabwe. Methods Nationally representative surveys of clinicians were conducted in South Africa and Zimbabwe (n = 1444) to assess current clinical practice in the provision of LARC in HIVprevalent settings. Multivariable logistic regression was used to analyse contraceptive provision and clinician training needs. Main outcome measure Multivariable logistic regression of contraceptive provision and clinician training needs. Results Provision of the most effective reversible contraceptives is limited: only 14% of clinicians provide copper intrauterine devices (IUDs), 4% levonorgestrel-releasing IUDs and 16% contraceptive implants. Clinicians' perceptions of patient eligibility for IUD use were overly restrictive, especially related to HIV risks. Less than 5% reported that IUDs were appropriate for women at high risk of HIV or for HIV-positive women, contrary to evidence-based guidelines. Only 15% viewed implants as appropriate for women at risk of HIV. Most clinicians (82%), however, felt that IUDs were underused by patients, and over half desired additional training on LARC methods. Logistic regression analysis showed that LARC provision was largely restricted to physicians, hospital settings and urban areas. Results also showed that clinicians in rural areas and clinics, including nurses, were especially interested in training. Conclusions Clinician competency in LARC provision is important in southern Africa, given the low use of methods and high rates of unintended pregnancy among HIV-positive and atrisk women. Despite low provision, clinician interest is high, suggesting the need for increased evidence-based training in LARC to reduce unintended pregnancy and associated morbidities.
Objectives: General concerns about STIs can dissuade providers from offering intrauterine contrac... more Objectives: General concerns about STIs can dissuade providers from offering intrauterine contraception to eligible young women at high risk of unintended pregnancy. This study aimed to educate providers on updated evidence for IUD provision. Methods: We conducted a cluster randomized trial with a provider IUD training intervention in 40 Planned Parenthood clinics and measured patient outcomes among 1500 women aged 18-25. This secondary analysis assessed provider IUD counseling and patient decision to use IUD, by STI history. We also measured whether there was any difference in STI acquisition (chlamydia or gonorrhea) during 1-year follow-up by IUD method. We used generalized estimating equations for clustered data to analyze patient contraceptive outcomes and survival analysis to measure STI incidence. Results: While patients in the intervention arm were more likely to receive IUD counseling, there was no difference in IUD counseling by patient STI history (OR=1.1, 95% CI 0.85-1.40). Patient decision to use IUDs also varied by intervention, but not by STI history (OR=1.3, 95% CI 0.93-1.85). During the study, there were 6.8 chlamydia or gonorrhea cases per 100 person-years, with no differences by study arm (HR=1.3, 95% CI 0.86-1.96) or IUD method choice at baseline (HR=0.90, 95% CI 0.51-1.57). However, there was significantly higher STI incidence among those with multiple partners (HR=1.87, 95% CI 1.22-2.87). Conclusions: Providers included women with STI history in IUD counseling, consistent with evidence-based guidelines. The provider counseling intervention and the decision to use IUDs did not increase chlamydia or gonorrhea infection during the study among patients aged 25 or younger.
Perspectives on Sexual and Reproductive Health, Oct 28, 2013
Low knowledge of long-acting reversible contraceptives (LARC) and restrictive counseling practice... more Low knowledge of long-acting reversible contraceptives (LARC) and restrictive counseling practices have been documented among contraceptive care clinicians. However, little is known about health educators&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; counseling on LARC, how their practices compare with clinicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; and their specific training needs. A survey conducted in 2011-2012 assessed knowledge and practices related to LARC counseling and provision among 410 staff at 40 Planned Parenthood clinics. Clinicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; and health educators&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; knowledge and practices were compared via chi-square tests; use of evidence-based criteria was assessed in multivariable logistic regression analyses. At least half of both types of staff routinely discussed LARC with clients, and nearly all considered the methods safe. Health educators considered a smaller proportion of clients candidates for LARC than did clinicians (57% vs. 77%), and they were less likely to consider IUDs for teenagers (79% vs. 96%), nulliparous women (82% vs. 98%) and unmarried clients (90% vs. 99%). In a multivariable model, health educators were less likely than clinicians to counsel clients using the least restrictive evidence-based criteria (odds ratio, 0.1). Sixty-four percent of health educators and 40% of clinicians desired additional LARC training. Even in clinics that specialize in reproductive health care, health educators are less likely than clinicians to apply current evidence-based criteria in counseling about LARC. To provide evidence-based contraceptive counseling, health educators need training on LARC eligibility and indications.
Journal of Pediatric and Adolescent Gynecology, Jun 1, 2021
Study Objective.Provider misconceptions regarding intrauterine device safety for adolescents and ... more Study Objective.Provider misconceptions regarding intrauterine device safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of N gonorrhaeae or C trachomatis diagnoses among young women adopting intrauterine devices.Design.Secondary analysis of a cluster-randomized provider educational trial.Setting.40 U.S.-based reproductive health centers.Participants.1,350 participants aged 18–25 seeking contraceptive care were followed for 12-months.Interventions.The parent study assessed the impact of a provider training on evidence-based contraceptive counseling.Main Outcome Measures.We assessed incidence of N gonorrhaeae or C trachomatis (GC/CT) diagnoses by IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations.Results.204 participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over 12-month follow-up. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs. 8.0 otherwise. In adjusted models, IUD use (aHR 1.31, 95% CI 0.71–2.40), adolescent age (aHR 1.28, 95% CI 0.72–2.27), history of GC/CT (aHR 1.23, 95% CI 0.75–2.00) and intervention status (aHR 1.12, 95% CI 0.74–1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals reporting multiple partners at baseline (aHR 2.0, 95%CI 1.34–2.98).Conclusion.In this young study population with GC/CT history, this use of intrauterine devices was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.
Background: Unprotected intercourse is common, especially among teens and young women. Access to ... more Background: Unprotected intercourse is common, especially among teens and young women. Access to intrauterine device (IUD) as emergency contraception (EC) can help interested patients more effectively prevent unintended pregnancy and can also offer ongoing contraception. This study evaluated young women's awareness of IUD as EC and interest in case of need. Study design: We conducted a secondary analysis of data from young women aged 18-25 years, not desiring pregnancy within 12 months, and receiving contraceptive counseling within a cluster-randomized trial in 40 US Planned Parenthood health centers in 2011-2013 (n=1500). Heath centers were randomized to receive enhanced training on contraceptive counseling and IUD placement, or to provide standard care. The intervention did not focus specifically on IUD as EC. We assessed awareness of IUD as EC, desire to learn more about EC and most trusted source of information of EC among women in both intervention and control groups completing baseline and 3-or 6-month follow-up questionnaires (n=1138). Results: At follow-up, very few young women overall (7.5%) visiting health centers had heard of IUD as EC. However, if they needed EC, most (68%) reported that they would want to learn about IUDs in addition to EC pills, especially those who would be very unhappy to become pregnant (adjusted odds ratio [aOR], 1.3; 95% confidence interval, 1.0-1.6, p<.05). Most (91%) reported a doctor or nurse as their most trusted source of EC information, over Internet (6%) or friends (2%), highlighting providers' essential role. Conclusion: Most young women at risk of unintended pregnancy are not aware of IUD as EC and look to their providers for trusted information. Contraceptive education should explicitly address IUD as EC.
Background Patient agency in contraceptive decision-making is an essential component of reproduct... more Background Patient agency in contraceptive decision-making is an essential component of reproductive autonomy. Objective We aimed to develop a psychometrically robust measure of patient contraceptive agency in the clinic visit, as a measure does not yet exist. Design For scale development, we generated and field tested 54 questionnaire items, grounded in qualitative research. We used item response theory–based methods to select and evaluate scale items for psychometric performance. We iteratively examined model fit, dimensionality, internal consistency, internal structure validity, and differential item functioning to arrive at a final scale. Participants A racially/ethnically diverse sample of 338 individuals, aged 15–34 years, receiving contraceptive care across nine California clinics in 2019–2020. Main Measures Contraceptive Agency Scale (CAS) of patient agency in preventive care. Key Results Participants were 20.5 mean years, with 36% identifying as Latinx, 26% White, 20% Black...
BACKGROUND: Concern regarding pelvic examinations may be more common among women experiencing int... more BACKGROUND: Concern regarding pelvic examinations may be more common among women experiencing intimate partner violence. OBJECTIVE: We examined women's attitudes towards pelvic examination with history of intimate partner violence (pressured to have sex, or verbal, or physical abuse). DESIGN: Secondary analysis of data from a cluster randomized trial on contraceptive access. PARTICIPANTS: Women aged 18-25 were recruited at 40 reproductive health centers across the USA (2011-2013). MAIN MEASURES: Delays in clinic visits for contraception and preference to avoid pelvic examinations, by history of ever experiencing pressured sex, verbal, or physical abuse from a sexual partner, reported by frequency (never, rarely, sometimes, often). We used multivariable logistic regression with generalized estimating equations for clustered data. KEY RESULTS: A total of 1490 women were included. Ever experiencing pressured sex was reported by 32.4% of participants, with 16.5% reporting it rarely, 12.1% reporting it sometimes, and 3.8% reporting it often. Ever experiencing verbal abuse was reported by 19.4% and physical abuse by 10.2% of participants. Overall, 13.2% of participants reported ever having delayed going to the clinic for contraception to avoid having a pelvic examination, and 38.2% reported a preference to avoid pelvic examinations. In multivariable analysis, women reporting that they experienced pressured sex often had significantly higher odds of delaying a clinic visit for birth control (aOR 3.10 95% CI 1.39-6.84) and for reporting a preference to avoid pelvic examinations (aOR 2.91 95% CI 1.57-5.40). We found no associations between delay of clinic visits or preferences to avoid a pelvic examination and verbal or physical abuse. CONCLUSIONS: History of pressured sex from an intimate partner is common. Among women who have experienced pressured sex, concern regarding pelvic examinations i s a potential b arrier to contraception. Communicating that routine pelvic examinations are no longer recommended by professional societies could potentially reduce barriers and increase preventive healthcare visits.
International Journal of Gynecology & Obstetrics, 2018
Objective: To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies... more Objective: To examine whether auxiliary nurse-midwife provision of medical abortion in pharmacies is associated with reduced post-abortion contraceptive use in Nepal. Methods: The present prospective observational study compared contraceptive use among women aged 16-45 years and up to 63 days of pregnancy, who presented at one of six privately-owned pharmacies or six public health facilities in the Chitwan and Jhapa districts of Nepal for medical abortion between October 16, 2014, and September 1, 2015. Participants obtained medical abortions per Nepali protocol and completed a follow-up visit and interview at 14-21 days. Effective contraceptive use was compared between abortion care settings using multivariable mixed effects logistic regression.
Objectives: Emergency response skills are essential when complications such as hemorrhage, seizur... more Objectives: Emergency response skills are essential when complications such as hemorrhage, seizure or anaphylaxis occur in the outpatient setting. As services and procedures increasingly move outside the hospital, residents must have optimal training to manage such complications. The objective of this study was to evaluate a simulation-based curriculum with the outcome measures of resident self-efficacy and graded performance in medical emergencies in the outpatient setting. Methods: This prepost test study enrolled ob-gyn and family medicine residents who participated in a simulation-based training on managing emergencies in the outpatient setting, completed self-efficacy questionnaires and were evaluated on a graded rubric of three medical emergency scenariosseizure, oversedation and hemorrhagein the simulation lab. Results: Thirty-six residents completed the training and pre-and postevaluations. Pre-and posttest self-efficacy evaluations demonstrated improvement in two of the three scenarios. Subjects' performance scores improved in all five domains (pb.05) in all scenarios. When stratified by training level, all participants demonstrated improvement in the global scores on all scenarios regardless of level of training. When stratified by prior outpatient simulation experience, subjects with prior experience did not improve their global scores in the management of excess sedation. Self-efficacy assessment showed improvement in comfort managing outpatient emergencies (p=.001) and ability to communicate well in emergency situations (p=.04). Conclusions: Simulation-based training improved both self-efficacy and global performance in management of medical emergencies. Such training should be incorporated into residency programs.
misoprostol-alone (pb.001). Major complications were similar between the mifepristone cohort (5.8... more misoprostol-alone (pb.001). Major complications were similar between the mifepristone cohort (5.8%) and the misoprostol-only cohorts (7.7%) (p=.4). In the mifepristone and misoprostol-alone cohorts, respectively, 9 (4%) and 8 (6%) women received blood transfusions, and 2 (1%) and 3 (2%) had infections requiring IV antibiotics. Ninety percent of women in the mifepristone cohort said that they would recommend the method to a friend, compared to 70% in the misoprostol-alone cohorts (pb.001). Conclusion: Consistent with other clinical trials, mifepristone resulted in a significantly shorter induction interval, shorter hospitalization and improved patient satisfaction in these public hospitals in South Africa. Introduction of the mifepristone regimen has reduced costs and streamlined later abortion care in this setting, leading one hospital to establish a day unit to provide second-trimester abortion services.
Perspectives on Sexual and Reproductive Health, 2012
CONTEXT: Long‐acting reversible contraceptive (LARC) methods (IUDs and implants) are the most eff... more CONTEXT: Long‐acting reversible contraceptive (LARC) methods (IUDs and implants) are the most effective and cost‐effective methods for women. Although they are safe to place immediately following an abortion, most clinics do not offer this service, in part because of the increased cost. METHODS: In 2009, telephone interviews were conducted with 20 clinicians and 24 health educators at 25 abortion care practices across the country. A structured topic guide was used to explore general practice characteristics; training, knowledge and attitudes about LARC; and postabortion LARC counseling and provision. Transcripts of the digitally recorded interviews were coded and analyzed using inductive and deductive processes. RESULTS: Respondents were generally positive about the safety and effectiveness of LARC methods; those working in clinics that offered LARC methods immediately postabortion tended to have greater knowledge about LARC than others, and to perceive fewer risks and employ more e...
ABSTRACT Unintended pregnancy remains persistently high in the United States. Few randomized inte... more ABSTRACT Unintended pregnancy remains persistently high in the United States. Few randomized interventions have effectively reduced pregnancy. We conducted a cluster randomized trial in 40 Planned Parenthood sites, including family planning and abortion, to assess the effect of a clinic-wide training in long-acting reversible contraceptives (LARCs) on patient outcomes. A cohort of 1,500 patients, 18-25 years, who received contraceptive counseling and did not want to become pregnant in the next 12 months, were recruited from intervention and control clinics. Pregnancy was measured over 12 months with questionnaires, pregnancy tests, and medical record review. In blinded intent-to-treat analyses, we used survival analysis with shared frailty for clustered data to measure the intervention effect compared with standard care. The trial was registered with ClinicalTrials.gov and followed CONSORT (Consolidated Standards of Reporting Trials) guidelines. Participants were similar in baseline characteristics by arm. At enrollment, after counseling, participants in arm 1 were twice as likely to choose a LARC method as those in arm 2 using generalized estimating equation models for clustered data and robust standard errors (odds ratio 2.0, 95% confidence interval [CI] 1.3-2.9). In family planning settings, pregnancy during the study was lower in arm 1 (7.5%) than in arm 2 (13.8%). Analyses of the intervention effect in a model with an interaction for setting type showed a highly significant effect on reduced pregnancy in family planning settings (hazard ratio 0.5, 95% CI 0.3-0.8). However, there were no significant differences in pregnancy by arm in the abortion setting. A half-day replicable LARC intervention effectively reduced pregnancy in family planning clinics.
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Papers by Cynthia Harper