March 2022: Power Updates Edition
There are plenty of articles, publications, and stories published every month. To help you distinguish fact from fiction, save time in your already busy day, and share news you may not have otherwise seen, here are 12 stories from the last month we thought you might find interesting:
The COVID-19 pandemic accelerated the incorporation of telehealth into many aspects of health care, including reproductive health care. Many advocates for telehealth cite its convenience and accessibility for visits focused on contraceptive counseling, but less data is available regarding the quality of telehealth contraception counseling in comparison to traditional in-office counseling. This study found that demographics data was overall similar between both groups. There were no significant differences between the types of contraception ultimately chosen between the two groups of study participants, including permanent sterilization. The authors did find, however, that patients in the telehealth group were more likely to have had previous experience with telehealth and report favorable impressions of telehealth. These findings suggest that high quality contraception counseling is feasible through telehealth visits, especially for patients who already feel favorably towards telehealth.
This study examined data from a single health plan in California to look at people age 10 to 50 who filled at least once birth control prescription between January 2017 and September 2018. It compared pregnancy rates, rates of emergency contraceptive (EC) use, and contraceptive refills more than a year after the initial prescription. Nearly 1,700 people were identified as receiving a prescription for a 12-month supply of hormonal birth control. More than 350,000 people were identified as receiving a prescription for a less than 12-month supply. Those with the 12-month supply were less likely to receive EC or get pregnant and more likely to refill their prescription than those with a less than one year supply. The results indicate that offering a 12-month supply of birth control may reduce the unplanned pregnancy rate.
Using data from the 2017 Behavioral Risk Factor Surveillance Survey this study found that having health insurance increased the odds of using a method of birth control. Those who have a primary provider were more likely to use a prescription method, and therefore more likely to use a more effective method. The paper’s authors note that this relationship is especially important to keep in mind during policy debates around increasing insurance access and decreasing access barriers.
The Bridge-it Study aimed to improve birth control uptake by distributing the progestogen-only pill alongside rapid access to a sexual and reproductive health clinic to women who sought EC at a community pharmacy. Results showed that implementation of this practice is acceptable to pharmacist and clinic staff, however only a few participants attended a clinic and people reported that pre-existing barriers to receiving sexual and reproductive health care such as a lack of staff were still present. The authors conclude that while there’s potential to increase contraceptive use by providing progestogen-only pills alongside EC in pharmacies, more thought needs to be given to overcoming barriers to accessing clinic health care.
Pregnancy and Birth
In the United States, approximately 1.5% pregnant patients per year experience severe maternal morbidity (SMM), defined as a complication during pregnancy or postpartum that causes significant maternal harm or risk of death. Chronic disease, having Medicaid or no insurance, and/or identification as a racial or ethnic minority all have been shown to increase the risk of SMM. While preconception care has been suggested as a mechanism for reducing SMM, its benefit has not been definitively shown. The authors examined the correlations between demographic factors, preventative health care in the year prior to conception, and SMM as defined by the CDC’s International Classification of Diseases. In more than 1.5 million unique births, the authors found that 1.74% of births were affected by death or SMM and if transfusion alone was excluded, 0.63% were affected by SMM. Consistent with existing data, patients from racial and ethnic minorities were more likely to experience SMM, along with older patients, patients with short interval pregnancies, patients with a history of SMM, and patients with medical comorbidities. However, the authors found that receiving any preconception care, particularly contraception services, was associated with decreased risk of SMM. Preconception care was also associated with decreased SMM among patients with comorbidities such as chronic hypertension, diabetes, and chronic kidney disease.
Early identification of pregnancy may improve health outcomes for pregnant patients, either by facilitating earlier entry to prenatal care, or, for patients who opt for abortion, by reducing the costs of abortion care and lowering the chances of complications. However, approximately 25% of pregnant patients do not discover pregnancy until later than seven to eight weeks. And pregnancies among adolescents, Black and Latinx patients, and/or patients who describe their pregnancies as unintended are all more likely to be identified later. This survey examined how the use of home pregnancy tests contributed to pregnancy awareness. Seventy-four percent of respondents presenting to care who suspected pregnancy took a home test before presenting to care, but only 65% of adolescents did so. Overall, those testing at home identified their pregnancy on average 10 days earlier than those who did not. Of those not testing at home, the most common reasons given were distrust of the test’s accuracy and difficulty accessing a test. The authors conclude that despite the availability of home pregnancy testing, early gestational age abortion bans will still predominantly affect already marginalized patient populations that face barriers to test procurement and use.
Texas Senate Bill 8 (SB 8) is currently the most restrictive state-level abortion law in the United States. This brief from the University of Texas at Austin’s Texas Policy Evaluation Project (TxPEP) used data from August 1 and December 31, 2021 to better who is traveling out of state to receive abortion care and understand the challenges people face as they do so. Among other results, the Project found:
- Abortions in Texas fell by around 50% in the month after SB 8’s passage compared to the same month the year before, but this trend did not continue in the other four months looked at.
- Nearly 1,400 Texas residents are forced to travel out of state every month for abortion care. Nearly three-quarters of these people travel to either Oklahoma or New Mexico. Oklahoma has only four abortion facilities while New Mexico has only seven.
- Commonly reported obstacles to obtaining an abortion include: visiting a “pregnancy resource center” on accident, being unable to get an appointment in-state within the legal timing, health care providers being reluctant to provide out-of-state information, and having trouble finding an appointment at a facility out-of-state.
This study looked at Mississippi residents who received abortion care at 12 weeks or more from one of 12 of 14 facilities in Mississippi, Alabama, Louisiana, or Tennessee in 2018 to better understand the relationship between the accessibility of abortion care and a person’s economic situation. Data showed that of the nearly 4,500 people who obtained an abortion, 59% lived 50 or more miles from a facility and 60% were able to find care within the state. However, those who obtained an abortion at 16 weeks gestation or later had to travel a median distance of 143 miles one way compared to less than 70 miles one way travel for those at 15 weeks or less. Overall, results show that those living in communities with less access to health care and those with less economic means are more likely to be disproportionately affected by restrictive abortion laws.
Medication abortion with misoprostol and mifepristone, is FDA-approved for use up to ten weeks of pregnancy. Since the FDA’s approval in 2000, medication abortion has accounted for an increasingly higher proportion of abortions in the US. In 2017, 39% of abortions were medication abortions, in 2020 that figure jumped to 54% with medication abortions now accounting for more than half of all abortions in the US In this analysis, the Guttmacher Institute writes about how this increase signifies not only the growing acceptance of medication abortion by providers and patients, but also that this method now has 20 years of data showing its safety and effectiveness. The authors caution that these reasons also account for anti-abortion efforts targeted around medication abortion.
Sexual and Reproductive Health
One Key Question® (OKQ) provides a framework for health care providers, social service providers, and champions to routinely ask their patients about pregnancy desires and goals and offer personalized counseling and care based on their response. This study explored the experiences of OBGYNs and clinic staff who have implemented OKQ to understand potential barriers and facilitators. Clinicians reported concern that asking OKQ at every patient visit could distract from the visit agenda or create a time constraint. However, participants did not report any major implementation impacts on clinic workflow and 95% agreed or strongly agreed that OKQ addressed an important clinical need.
Racial health inequities have a particular impact on the reproductive health of Black women in the United States. While the impact of systemic racism is known to contribute to a number of poor maternal and neonatal health outcomes in obstetrics, racial health inequities extend beyond obstetrics to nearly every reproductive health domain. In this study the authors sought to better characterize the lived experience of racism and its associated effects in the field of reproductive health care. In interviews with 21 participants age 18-45 who self-identified as Black and were assigned female at birth, the authors identified a number of themes common. Participants described several aspects of societal systemic racism that impacted their reproductive health care, including early sexualization of Black women and girls, heightened awareness of reproductive health disparities, and the impact of a known history of reproductive oppression in the US. Participants reported examples of anti-Black racism within the health care system, including the absence of shared-decision making, stereotyping, and invalidation and dismissal by health care providers. Finally, many participants discussed actions that they themselves took to counterbalance racism within the health care system, including seeking providers of color, enlisting advocates outside the system, seeking care only when desperate, and heightening their symptoms.
The Kaiser Family Foundation analyzed state-level policies on family planning service coverage under Medicaid. As states have “considerable discretion” when it comes to Medicaid eligibility criteria, managed care enrollment, and payment structures, the results varied. However, four themes emerged around birth control, STIs including HIV, breast and cervical cancers, and increasing care access. Key takeaways to broadening access include increasing interest in provision of a one-year supply of contraception, authorizing and reimbursing pharmacists for providing prescription contraception, increasing coverage for contraceptives provided via telehealth apps, and inclusion of family planning services in managed care capitation rates.