Objectives: The Ryan LARC program supplies free LARC devices (IUDs and implants) to 57 ob-gyn dep... more Objectives: The Ryan LARC program supplies free LARC devices (IUDs and implants) to 57 ob-gyn departments across the United States to expand training for nursing, medical students, residents and family planning fellows in evidence-based utilization of LARC; and increase patient access to LARC 323 Abstracts / Contraception 90 (2014) 298-351
More than tears: associations between exposure to chemical agents used by law enforcement and adverse reproductive health outcomes
Frontiers in Epidemiology
Despite routine law enforcement use of chemical agents for crowd control, the reproductive health... more Despite routine law enforcement use of chemical agents for crowd control, the reproductive health safety profiles of these products are unknown. Moreover, limited evidence has documented a link between such exposures and adverse reproductive health outcomes including abnormal uterine bleeding and potential pregnancy disruption. This cross-sectional study examined reproductive outcomes in adults with uteri exposed to chemical agents used by law enforcement, more commonly known as “tear gas”. Participants were recruited through social media in the wake of police violence protests. Of the 1,276 participants included in analysis, 83% reported experiencing at least one of the outcomes of interest, included uterine cramping (69%), early menstrual bleeding (55%), breast tenderness (30%), and delayed menstrual bleeding (19%). Chemical agent exposure was significantly associated with higher odds of an adverse reproductive health outcome, those with 5 days or more of exposure have 2.6 times t...
Background There is high global demand for new methods of male birth control (MBC). However, cont... more Background There is high global demand for new methods of male birth control (MBC). However, contemporary evidence regarding men’s method-specific attitudes and their determinants is sparse. Methods Non-sterilized cisgender men ages 18–45 with recent history of female sex partners were surveyed at a large community event in the Midwestern US. We examined variation in participants’ willingness to use MBC by method (gel, pill, injection, implant, and vas occlusion), potential side effects, and potential barriers. We estimated crude and adjusted prevalence ratios (aPRs) for associations between participant characteristics and willingness to use ≥ 1 MBC method. Results Overall, 72% of participants (n = 187; mean age, 29) were very willing to use ≥ 1 MBC method although support for individual methods ranged widely from 62% (pill) to 24% (vas occlusion). In bivariate analysis of sociodemographic and health characteristics, few demonstrated associations with MBC willingness. In a multivari...
Background. Despite the established effectiveness of expedited partner therapy (EPT) in partner t... more Background. Despite the established effectiveness of expedited partner therapy (EPT) in partner treatment of bacterial sexually transmitted infections (STI), the practice is underutilized. Objective. To estimate the relative effectiveness of strategies to increase EPT uptake (numbers of partners treated for chlamydia). Methods. We developed a care cascade model of cumulative probabilities to estimate the number of partners treated under strategies to increase EPT uptake in Minnesota. The care cascade model used data from clinical trials, population-based studies, and Minnesota chlamydia surveillance as well as in-depth interviews of health providers who regularly treat STI patients and a statewide survey of health providers across Minnesota. Results. Several strategies could improve EPT uptake among providers, including facilitating treatment payment (additional 1,932 partners treated) and implementing electronic health record reminders (additional 1,755 partners treated). Addressin...
Current implementation of expedited partner therapy for the treatment of N. Gonorrhoeae and C. Trachomatis infection: Integrating mixed methods with cost- effectiveness analysis
IMPACT: This work will estimate current EPT implementation in Minnesota and provide cost-effectiv... more IMPACT: This work will estimate current EPT implementation in Minnesota and provide cost-effectiveness analyses of different implementation scenarios to inform STI treatment policy. OBJECTIVES/GOALS: This research aims to 1) assess current implementation of Expedited Partner Therapy (EPT) as treatment for C. Trachomatis (chlamydia) and N. Gonorrhoeae (gonorrhea) among healthcare providers inMinnesota and to 2) simulate the current burden of chlamydia and gonorrhea infections to test the costeffectiveness of increasing EPT implementation. METHODS/ STUDY POPULATION: We will conduct key informant interviews (KII) and an online survey of health providers across the continuum of care for chlamydia and gonorrhea treatment. Based on experience in prior studies, the KII sample size is expected to be about 15 informants. KIIs will be carried out among providers who submitted EPT protocols to the Minnesota Department of Health to understand how EPT is currently being implemented. KII results ...
Introduction: Clinical guidelines recommend cervical preparation prior to dilation and evacuation... more Introduction: Clinical guidelines recommend cervical preparation prior to dilation and evacuation (D&E). The most common method used over 16-weeks gestation is placement of osmotic dilators, which can be painful. Paracervical block is effective at decreasing pain with dilator insertion but can be painful itself. We sought to compare pain control with locally applied, patient administered lidocaine gel to lidocaine paracervical block at various time points during dilator placement prior to D&E. Methods: We conducted a non-inferiority, randomized controlled trial of women at least 18 years of age undergoing surgical abortion at 16-weeks gestation or greater at two outpatient clinics. We randomized participants to self-administer 20 mL of 2% lidocaine gel 15-30 minutes before procedure initiation or receive a 12-mL 1% lidocaine paracervical block (PCB). A 100-mm visual-analog scale (VAS) was administered to measure anticipated pain, pain with speculum insertion, tenaculum placement, cervical dilator placement (primary outcome), and speculum removal. Results: We enrolled 72 women and analyzed 69 participants (34 in the gel group, 35 in the PCB group). Socio-demographic characteristics were similar between groups. Mean gestational ages were 19+0 weeks and 19+5 weeks in the gel and PCB groups respectively. Forty-seven percent of lidocaine gel patients were parous (n=16) compared to 49% of PCB patients (n=17). VAS scores at all time points were similar between groups, with the exception of anticipated pain, which favored the gel group (p = 0.02). Mean pain scores with dilator placement were 48 ± 26 mm and 56 ± 29 mm in the gel and PCB groups respectively (p=0.24). Procedure times were approximately 2 minutes shorter in the gel group (pb0.01). Lidocaine gel was non-inferior to PCB for pain control with dilator placement by the non-inferiority margin of 15 mm with a difference in means of-8 mm (95% CI-21, 5), favoring the gel. Conclusions: Self-administration of 2% lidocaine gel prior to placement of cervical osmotic dilators for D&E is non-inferior to paracervical lidocaine block for pain control and is a promising alternative to paracervical block for pain management with osmotic dilator placement.
An emerging alternative to traditional partner management for sexually transmitted diseases (STDs... more An emerging alternative to traditional partner management for sexually transmitted diseases (STDs) is expedited partner therapy (EPT), which involves the delivery of medications or prescriptions to STD patients for their partners without the clinical assessment of the partners. The Centers for Disease Control and Prevention recently recommended EPT nationally in limited circumstances; however, its implementation may raise legal concerns. We analyzed laws relevant to the distribution of medications to persons with whom clinicians have not personally treated or established a relationship. We determined that three fourths of states or territories either expressly permit EPT or do not expressly prohibit the practice. We recommend (1) expressly endorsing EPT through laws, (2) creating exceptions to existing prescription requirements, (3) increasing professional board or association support for EPT, and (4) supporting third-party payments for partners’ medications.
Introduction Until recently, standard guidelines for provision of medication abortion (MA) requir... more Introduction Until recently, standard guidelines for provision of medication abortion (MA) required an ultrasound or pelvic exam be done prior to treatment to confirm intrauterine pregnancy and that the gestational age is within the recommended timeframe for outpatient MA. However, requiring these tests can introduce financial and logistical obstacles for patients. During the COVID-pandemic, use of “no test medication abortion” (NTMA) became more common, including in the TelAbortion study, a multicenter trial that provides MA by direct-to-patient telemedicine and mail. We compared clinical outcomes among study patients who had NTMA or who had an ultrasound or pelvic exam prior to MA. Method This prospective, observational study examined the association between use of screening ultrasound or pelvic exam and the occurrence of selected clinical events after MA. We included all participants in the TelAbortion study who were enrolled from March 25 to September 15, 2020 and who received services from a participating site that provided at least 2 NTMAs during the analysis period. The primary outcome was procedure abortion or ongoing pregnancy after MA. Other outcomes included a composite outcome of hospitalization and/or blood transfusion, ongoing pregnancy after MA, diagnosis of ectopic pregnancy after shipment of abortion medications, and receipt of clinical care after abortion medications were mailed. We compared outcomes for the 2 groups by calculating adjusted odds ratios (aORs) and corresponding 95% confidence intervals (CIs) using a logistic regression model with inverse probability weighting according to the propensity score and incorporating generalized estimating equations to adjust for clustering by study site. Propensity score weighting was done to increase comparability of the study groups with respect to age, race/ethnicity, prior pregnancies (any versus none), patient residence ≥150 miles from the study site, gestational age by date of last menstrual period, and whether patient used insurance to pay for the abortion service. Results We included 5 of the 9 participating TelAbortion sites. We analyzed outcomes among 384 TelAbortion patients, including 278 who had NTMA and 106 who had a screening ultrasound or pelvic exam before shipment of abortion medications. A procedure abortion or ongoing pregnancy after MA was reported for 16/278 (5.8%) NTMA patients compared to 2/106 (1.9%) patients who had screening ultrasound or pelvic exam (aOR = 3.23, 95% CI: 0.58–17.97). There were no diagnoses of ectopic pregnancy in either study group. Hospitalization and/or blood transfusion occurred in 2/276 (0.7%) and 1/106 (0.9%) of patients who had NTMA and screening ultrasound or pelvic exam, respectively (aOR = 1.13, 95% CI: 0.48–2.65). Ongoing pregnancy after MA was detected in 4/278 (1.4%) and 2/106 (1.9%) of patients who had NTMA and screening ultrasound or pelvic exam, respectively (aOR = 0.76, 95% CI: 0.08–7.16). More NTMA patients had unplanned clinical encounters after shipment of abortion medication (33/276, 12.0%) compared to patients who had screening ultrasound or pelvic exam (6/106, 5.7%, aOR = 2.91, 95% CI: 1.72–4.91). Of 264 patients who answered questions related to satisfaction, all 183 NTMA patients and 81 patients who had a screening ultrasound or pelvic exam reported being satisfied or very satisfied with the MA service. Conclusions Individuals who obtain NTMA may be more likely to have a procedure abortion or ongoing pregnancy and have unplanned clinical encounters following MA compared to individuals who obtain a screening ultrasound or pelvic exam. However, NTMA was not associated with an increased risk of ongoing pregnancy or of hospitalization and/or blood transfusion. Moreover, more than 94% of NTMA patients had complete abortion without a procedural intervention. NTMA could increase access to MA without serious consequences for patient safety or satisfaction.
IntroductionBarriers to long-acting reversible contraception (LARC) use in the United States have... more IntroductionBarriers to long-acting reversible contraception (LARC) use in the United States have been described in prior studies, but few have focused on women's income status. We explored associations between income status and perceived LARC barriers in a community-based sample of reproductive-aged women.MethodsNon-pregnant, heterosexually active women aged 18 to 40 years completed a cross-sectional survey at a large community event in the Midwestern U.S. in 2018. Outcome measures were comprised of 26 survey items gauging perceived barriers to LARC use (e.g., access barriers, side effects). We estimated crude and age-adjusted prevalence ratios (PRs) for each outcome by participants' income status: low-income (≤ 200% of federal poverty guideline) versus higher income.ResultsLow-income women (n = 72) were significantly more likely than higher income women (n = 183) to endorse 11 of the 26 barriers to LARC use (PR range, 1.23–7.63). Cost of LARC was the most frequently identi...
IMPORTANCE Screening for medication abortion eligibility typically includes ultrasonography or pe... more IMPORTANCE Screening for medication abortion eligibility typically includes ultrasonography or pelvic examination. To reduce physical contact during the COVID-19 pandemic, many clinicians stopped requiring tests before medication abortion and instead screened patients for pregnancy duration and ectopic pregnancy risk by history alone. However, few US-based studies have been conducted on the outcomes and safety of this novel model of care. OBJECTIVE To evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients obtaining a medication abortion without preabortion ultrasonography or pelvic examination between February 1, 2020, and January 31, 2021, at 14 independent, Planned Parenthood, academic-affiliated, and online-only clinics throughout the US. EXPOSURES Medications for abortion provided without preabortion ultrasonography or pelvic examination and dispensed to patients in person or by mail. MAIN OUTCOMES AND MEASURES Effectiveness, defined as complete abortion after 200 μg of mifepristone and up to 1600 μg of misoprostol without additional intervention, and major abortion-related adverse events, defined as hospital admission, major surgery, or blood transfusion. RESULTS The study included data on 3779 patients with eligible abortions. The study participants were racially and ethnically diverse and included 870 (23.0%) Black patients, 533 (14.1%) Latinx/Hispanic patients, 1623 (42.9%) White patients, and 327 (8.7%) who identified as multiracial or with other racial or ethnic groups. For most (2626 [69.5%]), it was their first medication abortion. Patients lived in 34 states, and 2785 (73.7%) lived in urban areas. In 2511 (66.4%) abortions, the medications were dispensed in person; in the other 1268 (33.6%), they were mailed to the patient. Follow-up data were obtained for 2825 abortions (74.8%), and multiple imputation was used to account for missing data. Across the sample, 12 abortions (0.54%; 95% CI, 0.18%-0.90%) were followed by major abortion-related adverse events, and 4 patients (0.22%; 95% CI, 0.00%-0.45%) were treated for ectopic pregnancies. Follow-up identified 9 (0.40%; 95% CI, 0.00%-0.84%) patients who had pregnancy durations of greater than 70 days on the date the mifepristone was dispensed that were not identified at screening. The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%). Effectiveness was similar when medications were dispensed in person (95.4%; 95% CI, 94.1%-96.7%) or mailed (93.3%; 95% CI, 90.7%-95.9%). CONCLUSIONS AND RELEVANCE In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination. This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.
Melinda Abernethy, MD Cynthia Abraham, MD Robert M. Abrams, MD Ovadia Abulafia, MD Ometeotl Migue... more Melinda Abernethy, MD Cynthia Abraham, MD Robert M. Abrams, MD Ovadia Abulafia, MD Ometeotl Miguel Acosta, MD C. David Adair, MD April Adams, MD Kateena Addae-Konadu, MD, PhD Marisa R. Adelman, MD Emily H. Adhikari, MD Lindsay Kennedy Admon, MD, MSc Vivian C. Aguilar, MD Francisco Aguirre, MD Alexandriah Alas, MD Catherine M. Albright, MD James M. Alexander, MD Mariam M. AlHilli, MD Rasha A. Al-Lami, MD Rebecca H. Allen, MD, MPH Amanda A. Allshouse, MS Matthew Allswede, MD Jenifer E. Allsworth, PhD Noha al-Okda, MD Meredith J. Alston, MD Roberto Altamirano-Assad, MD Anna Altshuler, MD, MPH Edwin Alexander Alvarez, MD Margarita Alvarez De La Rosa Rodríguez, MD, PhD Armando G. Amador, MD Lawrence S. Amesse, MD, PhD Cande V. Ananth, PhD, MPH James N. Anasti, MD Willie A. Andersen, MD Frank W. J. Anderson, MD, MPH Ted L. Anderson, MD, PhD William W. Andrews, PhD, MD Danielle D. Antosh, MD Linda Applegarth, EdD Joseph J. Apuzzio, MD Tarek S. Arab, MD Kavita Shah Arora, MD, MBE, MS Rohit Arora, FRCOG, MD Lily A. Arya, MD Jessica Atrio, MD Amy M. Autry, MD Adeola Awomolo, MD Ali Azadi, MD Michael M. Aziz, MD, MPH Peter Aziz, MD Shilpa Babbar, MD, MS Henrietta S. Bada, MD, MPH Jennifer L. Bailit, MD, MPH David H. Barad, MD, MS Emma Longley Barber, MD Matthew Don Barber, MD Mary Kathleen Barger, PhD Joel Barkley, MD Randall B. Barnes, MD Kurt T. Barnhart, MD, MSCE Jennifer Jo Barr, MD William H. Barth, MD Renee M. Bassaly, DO Brian T. Bateman, MD, MSc Susanne L. Bathgate, MD Ashley N. Battarbee, MD Alison Bauer, MD Melissa Evelyn Bauer, DO Samuel Thomas Bauer, MD Laxmi V. Baxi, MD James Reid Beal, PhD Cynthia Bean, MD Anitra Beasley, MD, MPH Paula Bednarek, MD Kian Behbakht, MD Sadikah Behbehani, MD Michael A. Belfort, MBBCH, MD, PhD Beryl R. Benacerraf, MD Michael Beninati, MD Kiesh A. Nicole Benn, MD, MSCTR Peter A. Benn, PhD, FACMG, DSc James E. Benson, MD Benjamin Beran, MD Alexander Berger, MD, MPH Vincenzo Berghella, MD Richard L. Berkowitz, MD Ira M. Bernstein, MD Peter S. Bernstein, MD, MPH Raymond Edward Betcher, MD Neha Bhardwaj, MD Matthew J. Bicocca, MD Joseph R. Biggio Jr, MD Caroline Billingsley, MD Natalie Blagowidow, MD Howard A. Blanchette, MD Stephanie V. Blank, MD April Bleich, MD Dorit Blickstein Matthew J. Blitz, MD, MBA Steven L. Bloom, MD Nathan R. Blue, MD Paul D. Blumenthal, MD, MPH Lori A. Boardman, MD, ScM Paul Bobby, MD Katarzyn A. Bochenska, MD Lisa M. Bodnar, PhD, MPH, RD Rupsa C. Boelig, MD Christy Marie Boraas, MD, MPH Adam F. Borgida, MD Lawrence S. Borow, MD Pietro Bortoletto, MD John Joseph Botti, MD Janet McLaren Bouknight, MD, MSCE Zachary S. Bowman, MD, PhD Angela Rodriguez Boyd, MD, PhD Sarah S. Boyd, MD Annelee Boyle, MD Antonio Braga, MD, PhD D. Ware Branch, MD Kristyn Brandi, MD Justin S. Brandt, MD Ashley R. Brant, DO, MPH Daniel M. Breitkopf, MD Erin A. Brennand, MD Molly A. Brewer, MD Wendy Brewster, MD, PhD Cynthia Brincat, MD, PhD Mikael N. Brisinger, MD Luiz Gustavo Oliveira Brito, MD, PhD Shawna Brizzolara, MD Brian Emanuel Brocato, DO Erin Christine Brousseau, MD Benjamin Patterson Brown, MD, MS Douglas N. Brown, MD Haywood L. Brown, MD Heidi Wendell Brown, MD, MAS Kevin H. Brown, MD Lance Richard Bruck, MD Mary C. Brucker, PhD, CNM Jane E. Brumbaugh, MD Cynthia G. Brumfield, MD Ann M. Bruno, MD Amy G. Bryant, MD Karen F. Buchi, MD John D. Buek, MD Emmanuel Bujold, MD, MSc, FRCSC Dana M. R. Bukhzam, MBChB, MS Jerome L. Buller, MD Marianne Louise Burda, MD, PhD Gene Burkett, MD Lindsey Ann Burnett, MD PhD Tatnai Leonor Burnett, MD Richard Michael Burwick, MD, MPH Cara Buskmiller, MD John E. Buster, MD Alexander James Butwick, MBBS, FRCA, MS John J. Byrne, MD, MPH Editorial Consultants
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