Texas Policy Evaluation Project
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Related Publications (selected)

*Contact Laura Dixon, TxPEP Media Liaison, to request a PDF of any of these articles.

2017  -  2016  -  2015  -  2014  -  2013  -  2012

BMJExperiences of Women in Ireland who Accessed Abortion by Travelling Abroad or by Using Abortion Medication at Home: A Qualitative Study

Aiken, A. R. A., Johnson, D. M., Broussard, R. K., Padron, E. (2018). Experiences of women in Ireland who accessed abortion by travelling abroad or by using abortion medication at home: A qualitative study. BMJ Sexual and Reproductive Health.

Abstract: Background: The Republic of Ireland has one of the world’s most restrictive abortion laws, allowing abortion only to preserve a pregnant woman’s life. We examined the impact of the law on women’s options for accessing abortion, their decision-making regarding whichpathway to follow, and their experiences with their chosen approach. Methods: We conducted semi-structured in-depth interviews with 38 women who had either travelled abroad to access abortion in a clinic or had self-managed a medical abortion at home using online telemedicine, between 2010 and 2017. We coded interview transcripts according to an iteratively developed coding guide and performed a thematic analysis to identify key themes. Results: We identified four key themes: (1) self-managing a medical abortion at home using online telemedicine can be a preference over travelling abroad to access abortion services; (2) regardless of the pathway chosen, women experience a lack of pre- and post-abortion support in the Irish healthcare system; (3) feelings of desperation while searching for safe abortion care can lead to considering or attempting dangerous methods; and (4) Irish abortion law and attitudes have impacts beyond physical health considerations, engendering shame and stigma. Conclusions: Despite the country’s restrictive abortion law, women in Ireland do obtain abortions, using methods that are legal and safe elsewhere. However, the law negatively impacts women’s ability to discuss their options with their healthcare professionals and to seek follow-up care, and can have serious implications for their physical and emotional health. This study’s findings provide evidence to inform public and policy discourse on Ireland’s abortion laws.

2017

social science medicineThe Socio-Political Context of Migration and Reproductive Health Disparities: The Case of Early Sexual Initiation Among Mexican-Origin Immigrant Young Women

Coleman-Minahan, K. (2017). The socio-political context of migration and reproductive health disparities: The case of early sexual initiation among Mexican-origin immigrant young women. Social Science & Medicine, 180, 85-93. 

Available online through ScienceDirect

Abstract: Prior research often explains the lower risk of early sexual initiation among foreign-born Mexican-origin young women by a patriarchal and sexually conservative “traditional Latino culture.” This definition overlooks structural factors such as exploitation of migrant workers, and conflates gender inequality and sexual expectations. I use an intersectional framework and the theory of gender and power to explore how gender inequality and sexual expectations are both influenced by structural factors and affect reproductive health outcomes. I integrate data from qualitative interviews with 21 first and second generation Mexican-origin women in 2013–2014 with data from discrete time hazard models with 798 Mexican-origin young women in the National Longitudinal Study of Adolescent to Adult Health. Qualitative results demonstrate that gender inequality and sexual expectations in Mexican-origin immigrant households are associated with structural factors. Gender inequality occurs more often in households with family instability, greater poverty, and among parents who migrated independently. Qualitative data also demonstrate that parental gendered expectations are sometimes at odds to what parents are actually doing in the household. Finally, contrary to assumptions that a patriarchal “traditional Latino culture” protects against early sexual initiation, qualitative and multivariate quantitative data suggest that household gender inequality increases risk of early sexual initiation. These findings challenge the utility of a culturalist approach that views culture as determining health behavior among immigrants and demonstrate the need to incorporate an intersectional framework that includes structural factors. This approach may reduce stereotypes and identify meaningful interventions to reduce reproductive health disparities.

Journal Family PlanningSexual and Reproductive Health Under the Trump Presidency: Policy Change Threatens Women in the USA and Worldwide

Grossman, D. (2017). Sexual and reproductive health under the Trump presidency: Policy change threatens women in the USA and worldwide. Journal of Family Planning and Reproductive Health Care, 43, 89-91. 

Available online through BMJ

This editorial from TxPEP investigator Daniel Grossman focuses on concerns from a medical and public health perspective regarding President Trump's policy initiatives affecting abortion, contraception, maternity care, and more. The editorial touches on the Global Gag Rule, appointment of Supreme Court justices, the potential reversal of Roe v. Wade, the defunding of Planned Parenthood, the potential repeal of the ACA, and more. The editorial concludes by calling for physicians to be a voice in favor of evidence-based health care.

2016

Women and HealthA Socio-Ecological Approach for Examining Factors Related to Contraceptive Use Among Recent Latina Immigrants in an Emerging Latino State

White, K., Ocampo, M., & Scarinci, I. C. (2016). A socio-ecological approach for examining factors related to contraceptive use among recent Latina immigrants in an emerging Latino state. Women & Health, 57(7), 872-889. 

Available online through PubMed

Abstract: Using the Social Ecological Model, the individual, partner, social, and structural factors related to recent Latina immigrants' contraceptive use in an emerging immigrant community were explored. During September 2013-January 2014, door-to-door sampling was used in Birmingham, Alabama to recruit Latina immigrants who had lived in the United States (U.S.) for less than 5 years. Ten women with foreign-born children and 10 with only U.S.-born children completed in-depth interviews about their contraceptive use following migration. Women's narratives revealed interrelated barriers to using highly effective contraception after migrating to the U.S. Women had nuanced concerns about using hormonal contraception, which, when combined with other factors, led them to rely on condoms and withdrawal. Limited partner communication was a barrier to effective method use for some women, but partner attitudes that women should be responsible for contraception were less important. Weak female networks made it difficult for immigrants to learn about the U.S. health-care system, especially those with only U.S.-born children. Even once women accessed services, a full range of highly effective methods was not available or affordable. In emerging communities, integrated strategies that address immigrants' need for information and ensure access to affordable contraception would help women achieve their reproductive life goals.

Journal of Marriage and Family Anticipated Emotions About Unintended Pregnancy in Relationship Context: Are Latinas Really Happier?

Aiken, A. R., & Trussell, J. (2016). Anticipated emotions about unintended pregnancy in relationship context: Are Latinas really happier? Journal of Marriage and Family, 79(2), 356-371.

Available online through Wiley Online Library

Abstract: This study examined differences in women's anticipated emotional orientations toward unintended pregnancy by relationship status and race and ethnicity. Data from a prospective survey of 437 women aged 18 to 44 years who intended no more children for at least 2 years were analyzed along with 27 in-depth interviews among a diverse subsample. Cohabiting women and women in romantic relationships not living together were less likely to profess happiness (odds ratio = 0.42, p < .05, odds ratio = 0.25, p < .01, respectively), even when partners' intentions and feelings were controlled. The most prominent factor underlying negative feelings was partners' anticipated lack of engagement with the emotional, physical, and financial toll of unintended childbearing. Contrary to conventional wisdom regarding the “Hispanic paradox,” foreign-born and U.S.-born Latinas were no more likely to profess happiness than non-Hispanic Whites or Blacks. Moreover, foreign-born Latinas whose survey responses indicated happiness often revealed highly negative feelings at in-depth interview, citing pressure to conform to sociocultural norms surrounding motherhood and abortion.

Women's Health IssuesExperiences Accessing Abortion Care in Alabama Among Women Traveling for Services

White, K., Demartelly, V., Grossman, D., & Turan, J. M. (2016). Experiences accessing abortion care in Alabama among women traveling for services. Women’s Health Issues, 26(3), 298-304. 

Available online through ScienceDirect

Abstract: Background: In Alabama, more than one-half of reproductive-aged women live in counties without an abortion provider. State regulations require in-person counseling (or confirmed receipt of materials sent by certified mail) followed by a 48-hour waiting period. We explored the impact of this service and policy environment on experiences accessing abortion care for women traveling long distances to clinics. Methods: We conducted in-depth interviews with 25 women who traveled more than 30 miles to an Alabama clinic providing abortion care between July and September 2014. Women were interviewed by telephone at least 1 day after their consultation, procedure, or follow-up visit. We used content analysis methods to code and analyze interview transcripts. Findings: Almost all women found a clinic by searching online or talking to others in their social networks who had abortions. These strategies did not always direct women to the closest clinic, and some described searches that yielded inaccurate information. The majority of women did not believe an in-person consultation visit was necessary and found it to be burdensome because of the extra travel required and long waits at the clinic. Two-thirds of the women were unable to schedule their abortion 48 hours later owing to work schedules or because appointments were offered only once a week, and four women were delayed until their second trimester even though they sought services earlier in pregnancy. Conclusions: It is often difficult for women in communities without an abortion provider to find and access timely abortion care. Efforts are needed to make abortion more accessible and prevent further restrictions on services.

ContraceptionFamily Planning Policy in the United States: The Converging Politics of Abortion and Contraception

Aiken, A. R., & Scott, J. G. (2016). Family planning policy in the United States: The converging politics of abortion and contraception. Contraception, 93(5), 412-420. 

Available online through ScienceDirect

Abstract: Objectives: Following decades of mainstream bipartisan support, contraception has reemerged as a controversial political issue in the United States. At the same time, opposition to abortion has intensified. State legislatures across the country have enacted highly visible policies limiting access to family planning. Perhaps the most striking example occurred in 2011 in Texas, when legislators instituted unprecedented requirements on abortion providers and cut public funding for contraception by two thirds. Yet, despite popular interpretations of this phenomenon as a simple byproduct of increasing partisan divisions, little is understood about the factors underlying such policy shifts. Study design: We fit Bayesian ideal-point models to analyze correlation patterns in record-vote data in the Texas House of Representatives in the 2003 and 2011 Legislatures. Both sessions had large Republican majorities and saw the passage of restrictive abortion bills, but they differed markedly with respect to public funding for contraception. Results: We demonstrate that variation in voting on family-planning issues cannot be fully attributed to partisanship in either session. However, the politics of abortion and contraception have converged over time, and — at least for Democrats — the correlation between constituency characteristics and voting behavior on family-planning legislation is markedly higher in 2011 than in 2003. These shifts have been partly driven by legislators from high-poverty, majority Latino districts near the US–Mexico border. Conclusions: Recent dramatic shifts in family-planning policy go beyond simple partisan divisions. As the politics of abortion and contraception have converged, policies that are increasingly hostile to reproductive health and that disproportionately affect low-income minority women have emerged. Implications: Recent shifts in family-planning policy restrict women's access to contraception and abortion, yet little research has examined why such shifts are occurring. This paper analyzes factors underlying voting behavior on restrictive policies in Texas. Identification of these factors helps us to better understand the current political climate surrounding our field.

Journal of Health CarePerceived Interest in Vasectomy among Mexican-Origin Women and Their Partners in a Community with Limited Access to Female Sterilization

Hubert, C., White, K., Hopkins, K., Grossman, D., & Potter, J. E. (2016). Perceived interest in vasectomy among Latina women and their partners in a community with limited access to female sterilization. Journal of Health Care for the Poor and Underserved, 27(2), 762-777. 

Available online through Project MUSE

Abstract: The low prevalence of vasectomy among Latino men in the United States is often attributed to cultural characteristics despite limited evidence supporting this hypothesis. We assessed male partners’ perceived willingness to undergo vasectomy through surveys with 470 Mexican-origin women who did not want more children in El Paso, Texas. Overall, 32% of women reported that their partner would be interested in getting a vasectomy. In multivariable analysis, completing high school (OR=2.03 [1.05, 3.95]), having some college education (OR=2.97 [1.36, 6.48]) or receiving US government assistance (OR=1.95 [1.1, 3.45]) was associated with partners’ perceived interest. Additionally, we conducted two focus groups on men’s knowledge and attitudes about vasectomy with partners of a subsample of these women. Despite some misperceptions, male partners were willing to get a vasectomy, but were concerned about cost and taking time off work to recover. Health education and affordable vasectomy services could increase vasectomy use among Mexican-origin men.

Perspectives on Sexual and Reproductive HealthRethinking the Pregnancy Planning Paradigm: Unintended Conceptions or Unrepresentative Concepts?

Moreau, C. (2016). Rethinking the pregnancy planning paradigm: Unintended conceptions or unrepresentative concepts? Perspectives on Sexual and Reproductive Health, 48(3), 147-151. 

Available online through Wiley Online Library

Abstract: Approximately half of pregnancies occurring each year in the United States are unintended: They either occurred too soon or were not intended at any time. This commonly cited statistic is testament to the dominance of unintended pregnancy as a public health benchmark for measuring and improving women's reproductive health. In addition to its use as a public health metric, this timing-based definition of unintended pregnancy is reflected in pregnancy planning paradigms in clinical practice. According to these paradigms, women are expected to map out their intentions regarding whether and when to conceive, and to formulate specific plans to follow through on their intentions. What can researchers, public health practitioners and clinicians engaged in efforts to reduce unintended pregnancy and improve pregnancy outcomes do in response to these limitations? As a first step, we propose a conceptual model that integrates insights from recent research and provides a framework for informing women-centered approaches to preventing undesired pregnancies and improving outcomes.

NEJMRequests for Abortion in Latin America Related to Concern About Zika Virus Exposure

Aiken, A. R., Scott, J. G., Gomperts, R., Trussell, J., Worrell, M., & Aiken, C. E. (2016). Requests for abortion in Latin America related to concern about Zika virus exposure. New England Journal of Medicine, 375(4), 396-398. 

Available online through New England Journal of Medicine

Abstract: With the rapid emergence of Zika virus throughout Latin America and its association with microcephaly, requests for access to abortion medications through online telemedicine have increased in countries where access to safe abortion is not universally available. On November 17, 2015, the Pan American Health Organization (PAHO) issued an epidemiologic alert regarding Zika virus in Latin America. Several countries subsequently issued health advisories, including cautions about microcephaly, declarations of national emergency, and unprecedented warnings urging women to avoid pregnancy. Yet in most Latin American countries, abortion is illegal or highly restricted, leaving pregnant women with few options.

Perspectives on Sexual and Reproductive HealthSocial Norms and Stigma Around Unintended Pregnancy and Pregnancy Options: A Qualitative Study of Young Adult Women in Alabama

Smith, W., Turan, J. M., White, K., Stringer, K. L., Helova, A., Simpson, T., & Cockrill, K. (2016). Social norms and stigma regarding unintended pregnancy and pregnancy decisions: A qualitative study of young women in Alabama. Perspectives on Sexual and Reproductive Health, 48(2), 73-81. 

Available online through PubMed

Abstract: Context: Social norms and stigma may play important roles in reproductive health behavior and decision making among young women in the U.S. South, who disproportionately experience unintended pregnancies. No research has described the presence and manifestations of social norms and stigmas associated with unintended pregnancy and related decision making from the perspective of this population. Methods: Six focus groups and 12 cognitive interviews were conducted between December 2013 and July 2014 with 46 low-income women aged 19-24 living in Birmingham, Alabama; respondents were recruited from two public health department centers and a community college. Semistructured interview guides were used to facilitate discussion about social perceptions of unintended pregnancy and related pregnancy decisions. Sessions were audio-recorded, and transcripts were analyzed using a theme-based approach. Results: Participants described community expectations that pregnancy occur in the context of monogamous relationships, in which both partners are mature, educated and financially stable. However, respondents reported that unintended pregnancy outside of these circumstances was common, and that the community expected young women faced with unintended pregnancies to bear and raise their children. Women who chose to do so were viewed more positively than were women who chose abortion or adoption. The community generally considered these alternatives to parenting unacceptable, and participants discussed them in terms of negative labels, social judgment and nondisclosure. Conclusions: Findings suggest a need to reduce stigma and create a social environment in which young women are empowered to make the best reproductive decisions for themselves.

EJGOWeekend Working: A Retrospective Cohort Study of Maternal and Neonatal Outcomes in a Large NHS Delivery Unit

Aiken, C. E., Aiken, A. R., Scott, J. G., Brockelsby, J. C., & Trussell, J. (2016). Weekend working: A retrospective cohort study of maternal and neonatal outcomes in a large NHS delivery unit. European Journal of Obstetrics & Gynecology and Reproductive Biology, 199, 5-10. 

Available online through ScienceDirect

Abstract: Objectives: Mandatory weekend working for NHS consultants is currently the subject of intense political debate. The Secretary of State for Health's proposed 7-day contract policy is based on the claim that such working patterns will improve patient outcomes. We evaluate this claim by taking advantage of as-if-at-random presentation of women for non-elective deliveries throughout the week. We examine (i) whether consultants currently perform fewer deliveries during weekends versus weekdays, and (ii) whether adverse outcomes increase during weekends. Study design: We conducted a retrospective cohort study using data on all non-elective deliveries from January 2008 to December 2013 in a large UK obstetrics centre (n = 27,466). We used Pearson's chi-squared tests to make direct comparisons of adverse outcome rates during weekdays versus weekends. Outcomes included: estimated maternal blood loss ≥1.5 l; severe perineal trauma; delayed neonatal respiration; umbilical arterial pH <7.1; and critical incidents at delivery. Results: Consultants currently perform the same proportion of non-elective deliveries on weekends and weekdays (2.3% versus 2.6%, p = 0.25). We found no increase in any adverse maternal or neonatal outcomes during weekends versus weekdays, despite high statistical power to detect such differences. Moreover, adverse outcomes are no higher during periods of the weekend when consultants are not routinely present compared to equivalent periods during weekdays. Conclusions: Under current working arrangements, women who would benefit from consultant-led delivery are equally likely to receive one on weekends compared to weekdays. Weekend delivery has no effect on maternal or neonatal morbidity. Adopting mandatory 7-day contracts is unlikely to make any difference to either consultant-led delivery during weekends or to patient outcomes.

2015

Social Science and Medicine A Blessing I Can’t Afford: Factors Underlying the Paradox of Happiness About Unintended Pregnancy

Aiken, A., Dillaway, C., & Mevs-Korff, N. (2015). A blessing I can't afford: Factors underlying the paradox of happiness about unintended pregnancy. Social Science & Medicine, 132, 149-155.

Available online through ScienceDirect

Abstract: An unresolved paradox in the measurement and interpretation of unintended pregnancy is that women frequently report feeling happy about pregnancies they also classify as unintended (i.e. they have incongruent intentions and feelings). This study explores the underlying reasons why women profess such happiness and how these relate to their motivations to avoid pregnancy. Between September 2013 and February 2014, semi-structured in-depth interviews were conducted with 27 women (8 white, 19 Latina) selected from a longitudinal study measuring prospective pregnancy intentions and feelings among 403 women in Austin, Texas. Women were selected for interview on the basis of wanting no more children and consistently professing either happiness (n = 17) or unhappiness (n = 10) at the prospect of pregnancy. Interviews were coded and analyzed following the principles of grounded theory. We found that it is possible for women to express happiness at the idea of pregnancy while simultaneously earnestly trying to prevent conception. Happiness at the idea of an unintended pregnancy was explained as the result of deep and heartfelt feelings about children taking precedence over practical considerations, the perception that the psychosocial stress resulting from another child would be low, and the ability to rationalize an unintended pregnancy as the result of fate or God's plan. The major exception to the sincerity of professed happiness was that conveyed as a result of social pressure despite truly negative feelings, predominantly expressed by foreign-born Latina women. Overall, equating incongruence with ambivalence about avoiding conception may undermine the sincerity of women's intentions and their desires for highly-effective contraception. At the same time, unintended pregnancies that are greeted with happiness may have different implications for maternal and child health outcomes compared to pregnancies that are greeted with unhappiness. Identifying which unintended pregnancies are most likely to result in adverse outcomes is a target for future research.

Contraception Journal imageAbortion Access and State Variation in Observed Unintended Pregnancy

Stevenson, A. J., & Potter, J. E. (2015). Abortion access and state variation in observed unintended pregnancy. Contraception, 92(3), 227-233. 

Available online through ScienceDirect

Abstract: Objective: The state-level proportion of pregnancies that are unintended is an important social and public health indicator, and comparisons between states inform policy discussions. Unintended pregnancy is measured as a composite of abortions and unintended births, each of which is measured with error. We investigate whether between-state differences in abortion access and demand may bias comparisons between states’ unintended pregnancy proportions when pregnancy intentions are misreported. Study design: We algebraically specify the model currently used to estimate unintended pregnancy, extend it to include underreporting, and simulate the impact of underreporting on observed unintended pregnancy. Comparing the impact of underreporting across states, we identify levels of underreporting at which between-state comparisons are compromised. Results: We find that underreporting of unintended pregnancies could bias between-state comparisons when reporting of unintended pregnancies is less than 90–95%. Conclusion: Current methods for estimating state-level unintended pregnancy proportions may underestimate unintended pregnancy to a greater degree in places with less abortion, and between-state comparisons may be biased. Estimates of state-level unintended pregnancy proportions would be more comparable if adjustment for completeness of retrospective underreporting were included in the estimation process. Implications: Estimates of unintended pregnancy should be adjusted for nonsampling error and include variances based on sampling and nonsampling error in order to permit robust comparisons between states, between populations, and across time. More research on the fidelity of retrospective reporting of pregnancy intention would facilitate this endeavor.

American Journal of Medical Sciences

Comparison of Self-Rated Health Among Latina Immigrants in a Southern U.S. City and a National Sample

White, K., & Scarinci, I. C. (2015). Comparison of self-rated health among Latina Immigrants in a Southern U.S. city and a national sample. The American Journal of the Medical Sciences, 350(4), 290-295. 

Available online through PubMed

Abstract: Background: In the United States, Latinos often report fair/poor self-rated health, which is an indicator for increased morbidity and mortality. Foreign-born Latinos in new immigrant destinations, such as the south, may rate their health more poorly than their counterparts elsewhere in the United States, because of the factors associated with migration and settlement in these communities. Methods: The authors assessed foreign-born Latinasʼ self-rated health in Birmingham, Alabama (n = 765), and compared it with that of foreign-born Latinas in the National Health Interview Survey (NHIS; n = 8,746). Birmingham participants were matched to Latinas in the NHIS using propensity scores. The authors examined factors associated with reporting worse health using ordered logistic regression and inverse probability of treatment weights. Results: After propensity score matching, 47.6% of foreign-born Latinas in the Birmingham study reported their health as fair/poor compared with 17.9% of foreign-born Latinas in the NHIS (P < 0.001). The association between being Mexican born versus from other countries with poorer health was stronger in the Birmingham study (odds ratio4.46 [95% CI1.91–10.4]) than in the NHIS (odds ratio1.09 [95% CI1.08–1.09]). Shorter durations of U.S. residence were associated with better health for Latinas in the NHIS but not those in Birmingham. Conclusions: In this study of Latina immigrants in a new settlement community in the south, women reported worse health than foreign-born Latinas in other U.S. regions, suggesting they may be at increased risk of adverse health outcomes. Future studies are needed to better understand the factors associated with these differences to reduce morbidity and mortality burdens.

ContraceptionContinuing Pregnancy After Mifepristone and ‘Reversal’ of First-Trimester Medical Abortion: A Systematic Review

Grossman, D., White, K., Harris, L., Reeves, M., Blumenthal, P., Winikoff, B., & Grimes, D. (2015). Continuing pregnancy after mifepristone and "reversal" of first-trimester medical abortion: A systematic review. Contraception, 92(3), 206-211. 

Available online through ScienceDirect

Abstract: Objective: We conducted a systematic review of the literature on the effectiveness of medical abortion "reversal" treatment. Since the usual care for women seeking to continue pregnancies after ingesting mifepristone is expectant management with fetal surveillance, we also performed a systematic review of continuing pregnancy after mifepristone alone. Study design: We searched PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus and the Cochrane Library for articles published through March 2015 reporting the proportion of pregnancies continuing after treatment with either mifepristone alone or after an additional treatment following mifepristone aimed at reversing its effect. Results: From 1115 articles retrieved, 1 study met inclusion criteria for abortion reversal, and 13 studies met criteria for continuing pregnancy after mifepristone alone. The one report of abortion reversal was a case series of 7 patients receiving varying doses of progesterone in oil intramuscularly or micronized progesterone orally or vaginally; 1 patient was lost to follow-up. The study was of poor quality and lacked clear information on patient selection. Four of six women continued the pregnancy to term [67%, 95% confidence interval (CI) 30-90%]. Assuming the lost patient aborted resulted in a continuing pregnancy proportion of 57% (95% CI 25-84%). The proportion of pregnancies continuing 1-2 weeks after mifepristone alone varied from 8% (95% CI 3-22%) to 46% (95% CI 37-56%). Continuing pregnancy was more common with lower mifepristone doses and advanced gestational age. Conclusions: In the rare case that a woman changes her mind after starting medical abortion, evidence is insufficient to determine whether treatment with progesterone after mifepristone results in a higher proportion of continuing pregnancies compared to expectant management.

Obstetrics and GynecologyContraception After Delivery and Short Interpregnancy Intervals Among Women in the United States

White, K., Teal, S. B., & Potter, J. E. (2015). Contraception after delivery and short interpregnancy intervals among women in the United States. Obstetrics & Gynecology, 125(6), 1471-1477. 

Available online through LWW Journals

Abstract: Our objective was to investigate women's patterns of contraceptive use after delivery and the association between method use and risk of pregnancy within 18 months. We used the 2006–2010 National Survey of Family Growth to examine women's contraceptive use after delivery and at 3, 6, 12, and 18 months after giving birth. The sample included 3,005 births that occurred within 3 years of the survey date and for which information on contraceptive use was available. We estimated multivariable-adjusted Cox regression models to assess the association between women's method use and risk of pregnancy within 18 months after delivery. We also examined the percentage of pregnancies occurring 18 months or less after the index birth that were unintended.

Contraception Journal imageDid Increasing Use of Highly Effective Contraception Contribute to Declining Abortions in Iowa?

Biggs, M., Rocca, C., Brindis, C., Hirsch, H., & Grossman, D. (2015). Did increasing use of highly effective contraception contribute to declining abortions in Iowa? Contraception, 91(2), 167-173. 

Available online through ScienceDirect

Abstract: Background: Between 2006 and 2008, Iowa increased access to family planning services through a Medicaid expansion and a privately funded initiative. During this same time, Iowa expanded access to abortion through telemedicine provision of medical abortion. Despite increased access to abortion services, abortions in Iowa have declined. This study assessed whether increased provision of long-acting reversible contraception (LARC) may have contributed to the abortion decline. Study design: We analyzed abortion data from Iowa vital statistics and LARC use data from 14 family planning agencies’ records (N= 544,248) for the years 2005 to 2012. Mixed-effects logistic regression analyses assessed whether changes in the percentage of LARC users were associated with subsequent reductions in abortion across the state. Results: From 2005 to 2012, the number of family planning clients using LARC increased from 539 to 8603 (less than 1% to 15%); the number of resident abortions decreased from 5198 to 3887 (8.7 per 1000 women aged 15–44 to 6.7). There were reduced odds of abortion (adjusted odds ratio, 0.96; 95% confidence interval: 0.94–0.97) with increased LARC use. Conclusions: Declines in abortion followed increases in LARC use in Iowa.

ContraceptionDo As We Say, Not As We Do: Experiences of Unprotected Intercourse Reported by Members of the Society of Family Planning

Aiken, A. R., & Trussell, J. (2015). Do as we say, not as we do: Experiences of unprotected intercourse reported by members of the Society of Family Planning. Contraception, 92(1), 71-76. 

Available online through ClinicalKey

Abstract: Objectives: We examine the lifetime and past-year prevalence and circumstances of unprotected intercourse among members of the Society of Family Planning (SFP), a professional reproductive health organization in the United States. Study design: We invited the membership of SFP ( n = 477) via email to participate in an anonymous online survey. The response rate was 70% ( n = 340). We asked whether respondents had ever and in the past year had unprotected vaginal intercourse when not intending a pregnancy and, if so, how many times, under what circumstances, and at what age the first time. We then asked about unprotected vaginal, anal, or oral intercourse ever and in the past year under three different scenarios relating to sexually transmitted infections (STIs): (1) partner STI status unknown, respondent STI-free; (2) partner known infected, respondent STI-free; (3) partner STI-free, respondent STI status unknown or known infected. Each scenario included questions about the number of times, applicable circumstances, and age at first time. Results: Forty-six percent of respondents had ever had unprotected vaginal intercourse when not intending pregnancy, 7% within the past year. Sixty percent had ever had unprotected vaginal, anal, or oral intercourse with a partner whose STI status was unknown, 12% within the past year. Four percent had ever had unprotected intercourse with a partner known to have STI, and 8%, with an STI-free partner when they themselves either had an STI or did not know their STI status. Conclusions: Ever having taken a risk with respect to pregnancy and/or STIs is common among our sample of reproductive health professionals. Implications Most reproductive healthcare professionals in our sample have taken sexual risks in their lifetime and a small proportion has done so in the past year. These findings could inform counseling by encouraging healthcare professionals to reflect upon their own experiences when developing strategies to promote safe sex among their patients.

Women's Health IssuesGeographic Variation in Characteristics of Postpartum Women Using Female Sterilization

White, K., Potter, J., & Zite, N. (2015). Geographic variation in characteristics of postpartum women using female sterilization. Womens Health Issues, 25(6), 628-633. 

Available online through ScienceDirect

Abstract: Background: Southern states have higher rates of female sterilization compared with other areas of the United States, and the reasons for this are not well understood. We examined whether low-income and racial/ethnic minority women, who were previous targets of coercive practices, disproportionately report using sterilization in the South. Methods: We used data from 12 states participating in the Pregnancy Risk Assessment Monitoring System that collected information on women's contraceptive method use between 2006 and 2009. We categorized states according to geographic region: South, Midwest/West, and Northeast. Within each region, we computed the percentage of women using sterilization according to their demographic and obstetric characteristics and estimated multivariable-adjusted prevalence ratios to evaluate whether the same characteristics were associated with sterilization use. Findings: The percentage of postpartum women using sterilization ranged from 5.0% to 9.9% in the Northeast, 8.9% to 10.6% in the Midwest/West, and 11.6% to 22.4% in the South. Women in nearly all subgroups in Southern states were more likely to use sterilization than women in the Northeast. After multivariable adjustment, there were no differences in the prevalence of sterilization for Blacks compared with Whites in the Northeast (0.76; 95% CI, 0.55–1.06), Midwest/West (0.91; 95% CI, 0.80–1.04), and South (0.96; 95% CI, 0.85–1.07). Women with Medicaid-paid deliveries (vs. private insurance) had a higher prevalence of sterilization in all regions (p < .05). Conclusions: These findings do not indicate that low-income and racial/ethnic minority women in the South use sterilization at disproportionately higher rates compared with other regions, and suggest that other differences, such as social norms and family planning policies, may contribute to this geographic variation.

Perspectives on Sexual and Reproductive HealthHappiness About Unintended Pregnancy and its Relationship to Contraceptive Desires Among a Predominantly Latina Cohort

Aiken, A. R. (2015). Happiness about unintended pregnancy and its relationship to contraceptive desires among a predominantly Latina cohort. Perspectives on Sexual and Reproductive Health, 47(2), 99-106.

Available online through Wiley Online Library

Abstract: Context: Women frequently profess happiness about unintended pregnancies; such incongruence is associated with use of less effective contraceptive methods and inconsistent or incorrect method use. Yet, the methods women use may differ from those they desire. Methods: Data on 578 women were drawn from a prospective survey of postpartum women aged 18–44 recruited from three hospitals in Texas between 2012 and 2014. Jonckheere-Terpstra tests were used to compare women's feelings about a future pregnancy with their childbearing intentions. Fisher-Freeman-Halton tests compared distributions of contraceptive methods currently used and desired by women who professed happiness about a future unintended pregnancy, as well as distributions of desired methods by women's reported feelings. Results: The proportion of women who reported happiness about a future pregnancy was 59% among those intending to wait two or three years for another child, 46% among those intending to wait four or more years, and 36% among those intending to have no more children. Among women who professed happiness, a greater proportion desired to use a highly effective contraceptive method than were currently using one (72% vs. 15% among those intending no more children; 55% vs. 23% among those intending to wait at least four years; and 36% vs. 10% among those intending to wait two or three years). Across intention categories, the types of methods desired did not differ by whether women professed happiness or unhappiness. Conclusions: Women who profess happiness about a future unintended pregnancy may nonetheless desire highly effective contraceptive methods.

Obstetrics and GynecologyIncidence of Emergency Department Visits and Complications After Abortion

Upadhyay, U. D., Desai, S., Zlidar, V., Weitz, T. A., Grossman, D., Anderson, P., & Taylor, D. (2015). Incidence of emergency department visits and complications after abortion. Obstetrics & Gynecology, 125(1), 175-183. 

Available online through Obstetrics & Gynecology

Abstract: To conduct a retrospective observational cohort study to estimate the abortion complication rate, including those diagnosed or treated at emergency departments (EDs). Using 2009-2010 abortion data among women covered by the fee-for-service California Medicaid program and all subsequent health care for 6 weeks after having an abortion, we analyzed reasons for ED visits and estimated the abortion-related complication rate and the adjusted relative risk. Complications were defined as receiving an abortion-related diagnosis or treatment at any source of care within 6 weeks after an abortion. Major complications were defined as requiring hospital admission, surgery, or blood transfusion. A total of 54,911 abortions among 50,273 fee-for-service Medi-Cal beneficiaries were identified. Among all abortions, 1 of 16 (6.4%, n=3,531) was followed by an ED visit within 6 weeks but only 1 of 115 (0.87%, n=478) resulted in an ED visit for an abortion-related complication. Approximately 1 of 5,491 (0.03%, n=15) involved ambulance transfers to EDs on the day of the abortion. The major complication rate was 0.23% (n=126, 1/436): 0.31% (n=35) for medication abortion, 0.16% (n=57) for first-trimester aspiration abortion, and 0.41% (n=34) for second-trimester or later procedures. The total abortion-related complication rate including all sources of care including EDs and the original abortion facility was 2.1% (n=1,156): 5.2% (n=588) for medication abortion, 1.3% (n=438) for first-trimester aspiration abortion, and 1.5% (n=130) for second-trimester or later procedures. Abortion complication rates are comparable to previously published rates even when ED visits are included and there is no loss to follow-up.

Journal of PerinatologyMaternal and Fetal Outcomes Following Unplanned Conversion to General Anesthetic at Elective Cesarean Section

Aiken, C. E., Aiken, A. R., Cole, J. C., Brockelsby, J. C., & Bamber, J. H. (2015). Maternal and fetal outcomes following unplanned conversion to general anesthetic at elective cesarean section. Journal of Perinatology, 35(9), 695-699. 

Available online through Journal of Perinatology

Abstract: Objective: To investigate risk factors predicting unplanned conversion to general anesthesia during elective cesarean section, and to examine maternal and fetal outcomes associated with unplanned conversion compared with other modes of anesthesia. Study Design: A retrospective cohort at a UK center (2008 to 2013). Women (4337) underwent elective cesarean section. Delivery outcomes were compared according to anesthesia type using logistic regression. Result: Women (1.6%) underwent unplanned conversion to general anesthetic. Unplanned conversion was associated with higher parity (odds ratio (OR) 3.82, confidence interval (CI; (1.58 to 9.62)) and maternal age 40 (OR 4.40, CI (1.08 to 29.88)). Compared with spinal anesthetic, unplanned conversion was associated with increased likelihood of maternal hemorrhage 1.5 l (OR 5.74, CI (1.90 to 14.01)) and delayed neonatal respiration (OR 4.76, CI (1.76 to 11.05)). Adverse outcomes were not significantly more likely compared with planned general anesthetic. Conclusion: Higher parity and maternal age are risk factors for unplanned conversion to general anesthetic. There is no increase in the likelihood of adverse outcomes with unplanned versus planned general anesthetic.

AIDS Care Providers’ Perspectives on Male Involvement in Family Planning in the Context of Family Planning/HIV Integration in Nyanza, Kenya

Newmann, S. J., Mishra, K., Onono, M., Bukusi, E. A., Cohen, C. R., Gage, O., . . . Grossman, D. (2014). Provider’s perspectives on male involvement in family planning in the context of a cluster-randomized controlled trial evaluating integrating family planning into HIV care in Nyanza Province, Kenya. AIDS Care, 27(1), 31-37. 

Available online through Hindawi

Abstract: Objective. To inform an intervention integrating family planning into HIV care, family planning (FP) knowledge, attitudes and practices, and perspectives on integrating FP into HIV care were assessed among healthcare providers in Nyanza Province, Kenya. Methods. Thirty-one mixed-method, structured interviews were conducted among a purposive sample of healthcare workers (HCWs) from 13 government HIV care facilities in Nyanza Province. Structured questions and case scenarios assessed contraceptive knowledge, training, and FP provision experience. Open-ended questions explored perspectives on integration. Data were analyzed descriptively and qualitatively. Results. Of the 31 HCWs interviewed, 45% reported previous FP training. Few providers thought long-acting methods were safe for HIV-positive women (19% viewed depot medroxyprogesterone acetate as safe and 36% viewed implants and intrauterine contraceptives as safe); fewer felt comfortable recommending them to HIV-positive women. Overall, providers supported HIV and family planning integration, yet several potential barriers were identified including misunderstandings about contraceptive safety, gendered power differentials relating to fertility decisions, staff shortages, lack of FP training, and contraceptive shortages. Conclusions. These findings suggest the importance of considering issues such as patient flow, provider burden, commodity supply, gender and cultural issues affecting FP use, and provider training in FP/HIV when designing integrated FP/HIV services in high HIV prevalence areas.

Journal of Adolescent HealthWomen’s Perspectives on Age Restrictions for Over-the-Counter Access to Oral Contraceptives in the United States

Grindlay, K., & Grossman, D. (2015). Women's perspectives on age restrictions for over-the-counter access to oral contraceptives. Journal of Adolescent Health, 56(1), 38-43. 

Available online through ScienceDirect

Abstract: Purpose: There is a growing movement for an over-the-counter (OTC) oral contraceptive (OC) in the United States. This study aimed to explore women's views regarding an age restriction for an OTC OC. Methods: From November to December 2011, we administered a nationally representative survey of U.S. women aged 18-44 years who were at risk of unintended pregnancy to explore their opinions of an age restriction for an OTC OC. A total of 2,046 women completed the survey. Weighted proportions were calculated, and logistic regression was used to identify covariates associated with supporting an age restriction. Chi-square tests of potential advantages and disadvantages of OTC access to OCs by support for an age restriction were also performed. Results: Overall, 26% of respondents supported an age restriction for an OTC OC; 28% were against an age restriction, and 46% were unsure. In multivariable analysis controlling for overall support for OTC access to OCs and for other covariates, women were more likely to support an age restriction for an OTC OC if they had less than a high school degree (odds ratio [OR], 2.5), a high school degree (OR, 1.6), or some college (OR, 1.6) compared with a college degree; if they were married compared with never married (OR, 2.1); and if they lived in the Midwest (OR, 2.1) or South (OR, 2.1) compared with the West. Conclusions: A minority of women support an age restriction. Women's concerns about a potential OTC OC should be addressed through education and ongoing research.

2014

JHCPUChanges in Use of County Public Health Services Following Alabama’s Immigration Law

White, K., Blackburn, J., Manzella, B., Welty, E., & Menachemi, N. (2014). Changes in use of county public health services following implementation of Alabama’s immigration law. Journal of Health Care for the Poor and Underserved, 25(4), 1844-1852. 

Available online through PubMed

Abstract: Several states have enacted legislation restricting undocumented immigrants' access to publicly funded health benefits not protected by federal law. Using electronic health records from 140,856 county health department visits, we assessed the monthly change in Latino patients' visits compared to non-Latinos 12 months before and after implementation of Alabama's immigration law. We used ICD-9 diagnosis codes to determine whether visits included services exempt under the law: immunizations, testing and treatment for sexually transmitted infections (STIs) and communicable diseases, and family planning. Differences between groups in the mean percent change were assessed with t-tests. Among children younger than 18 years, there were no significant differences by ethnicity. Visits among Latino adults decreased by 28% for communicable diseases, 25% for STIs, and 13% for family planning; this was significantly different from changes among non-Latino adults (p <.05). State-level legislation may reduce immigrants' access to protected benefits, which could adversely affect the broader public's health.

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

White, K., Yeager, V. A., Menachemi, N., & Scarinci, I. C. (2014). Impact of Alabama’s immigration law on access to health care among Latina immigrants and children: Implications for national reform. American Journal of Public Health, 104(3), 397-405. 

Available online through American Journal of Public Health

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

NEJM cover imageMedicaid Policy on Sterilization — Anachronistic or Still Relevant?

Borrero, S., Zite, N., Potter, J. E., & Trussell, J. (2014). Medicaid policy on sterilization — anachronistic or still relevant? New England Journal of Medicine, 370(2), 102-104. 

Available online through the New England Journal of Medicine

Abstract: Female sterilization, typically accomplished by means of tubal ligation, is a widely used method of contraception that is highly effective at preventing unintended pregnancy. Yet there appears to be unmet demand for the procedure in certain segments of the U.S. population. Specifically, low-income women and women from minority racial and ethnic groups may face substantial system-level barriers to obtaining a desired sterilization procedure. One such barrier is the federal policy regarding Medicaid-funded sterilizations. Although this policy was designed to protect vulnerable populations, we believe that it does not effectively fulfill that intention — in fact, it restricts the reproductive autonomy of the women it intends to serve. With the upcoming Medicaid expansions, the number of women affected by these barriers could increase substantially.

F1000Recent Advances in Contraception

Aiken, A., & Trussell, J. (2014). Recent advances in contraception. F1000Prime Reports, 6, 113.

Available online through PubMed

Abstract: Focusing on intrauterine contraceptives (IUC), contraceptive implants, and emergency contraceptives, we review recent advances in contraceptive development and discuss progress in policies to improve access to the most effective methods. We report on the shift in practice towards routinely providing IUCs and implants to young and nulliparous women, prompted in part by the reduced diameter of the insertion tube for the Mirena IUC and the development of a smaller IUC called Skyla. Additionally, we describe the new SCu300A intrauterine ball and the development of an implant called Nexplanon, which comes with a preloaded inserter. We also discuss the efficacy of ulipristal acetate versus levonorgestrel for emergency contraception, especially for women who weigh more than 75 kg. Finally, in light of the increasing interest in providing IUCs and implants to women in the immediate postpartum and post-abortion periods, we consider the rationale for this change in practice and review the progress that has been made so far in the United States.

ContraceptionReconsidering Racial/Ethnic Differences in Sterilization in the United States

White, K., & Potter, J. E. (2014). Reconsidering racial/ethnic differences in sterilization in the United States. Contraception, 89(6), 550-556. 

Available online through ScienceDirect

Abstract: Objective: Cross-sectional studies have found that low-income and racial/ethnic minority women are more likely to use female sterilization and less likely to rely on a partner’s vasectomy than women with higher incomes and whites. However, studies of pregnant and postpartum women report that racial/ethnic minorities, particularly low-income minority women, face greater barriers in obtaining a sterilization than do whites and those with higher incomes. In this paper, we address this apparent contradiction by examining the likelihood a woman gets a sterilization following each delivery, which removes from the comparison any difference in the number of births she has experienced. Study Design: Using the 2006–2010 National Survey of Family Growth, we fit multivariable-adjusted logistic and Cox regression models to estimate odds ratios and hazard ratios for getting a postpartum or interval sterilization, respectively, according to race/ethnicity and insurance status. Results: Women’s chances of obtaining a sterilization varied by both race/ethnicity and insurance. Among women with Medicaid, whites were more likely to use female sterilization than African Americans and Latinas. Privately insured whites were more likely to rely on vasectomy than African Americans and Latinas, but among women with Medicaid-paid deliveries reliance on vasectomy was low for all racial/ethnic groups. Conclusions: Low-income racial/ethnic minority women are less likely to undergo sterilization following delivery compared to low-income whites and privately insured women of similar parities. This could result from unique barriers to obtaining permanent contraception and could expose women to the risk of future unintended pregnancies. Implications: Low-income minorities are less likely to undergo sterilization than low-income whites and privately insured minorities, which may result from barriers to obtaining permanent contraception, and exposes women to unintended pregnancies.

Contraception Journal imageVariation in Postpartum Contraceptive Method Use: Results from the Pregnancy Risk Assessment Monitoring System (PRAMS)

White, K., Potter, J. E., Hopkins, K., & Grossman, D. (2014). Variation in postpartum contraceptive method use: Results from the Pregnancy Risk Assessment Monitoring System (PRAMS). Contraception, 89(1), 57-62. 

Available online through ScienceDirect and as a public access version

Abstract: Objective:The National Survey of Family Growth has been a primary data source for trends in US women’s contraceptive use. However, national-level data may mask differences in contraceptive practice resulting from variation in local policies and norms. Study Design: We used the Pregnancy Risk Assessment Monitoring System, a survey of women who are 2–4 months postpartum. Information on women’s current method was available for 18 reporting areas from 2000 to 2009. Using the two most recent years of data, we computed the weighted proportion of women using specific contraceptive methods according to payment for delivery (Medicaid or private insurance) and examined differences across states. We used log binomial regression to assess trends in method use in 8 areas with consecutive years of data. Results: Across states, there was a wide range of use of female sterilization (7.0–22.6%) and long-acting reversible contraception (LARC; 1.9–25.5%). Other methods, like vasectomy and the patch/ring, had a narrower range of use. Women with Medicaid-paid deliveries were more likely to report female sterilization, LARC and injectables as their method compared to women with private insurance. LARC use increased ≥ 18% per year, while use of injectables and oral contraceptives declined by 2.5–10.6% annually. Conclusions: The correlation in method-specific prevalence within states suggests shared social and medical norms, while the larger variation across states may reflect both differences in norms and access to contraception for low-income women. Surveys of postpartum women, who are beginning a new segment of contraceptive use, may better capture emerging trends in US contraceptive method mix. Implications: There is considerable variation in contraceptive method use across states, which may result from differences in state policies and funding for family planning services, local medical norms surrounding contraceptive practice, and women’s and couples’ demand or preference for different methods.

2013

Perspectives coverAre Latina Women Ambivalent About Pregnancies They Are Trying to Prevent? Evidence from the Border Contraceptive Access Study

Aiken, A. R., & Potter, J. E. (2013). Are Latina women ambivalent about pregnancies they are trying to prevent? Evidence from the Border Contraceptive Access Study. Perspectives on Sexual and Reproductive Health, 45(4), 196-203.

Available online through Wiley Online Library

Abstract: Context: Women's retrospective reports of their feelings about a pregnancy and of its intendedness are often inconsistent, particularly among Latinas. Interpretation of this incongruence as ambivalence overlooks the possibility that happiness about the prospect of pregnancy and desire to prevent pregnancy need not be mutually exclusive. Methods: Data from the 2006–2008 Border Contraceptive Access Study—a prospective study of 956 Latina oral contraceptive users aged 18–44 in El Paso, Texas—were used to compare women's planned pill use and childbearing intentions with their feelings about a possible pregnancy. Associations between women's feelings and their perceptions of their partner's feelings were examined using logistic regression. Prospective and retrospective intentions and feelings were compared among women who became pregnant during the study. Results: Forty-one percent of women who planned to use the pill for at least another year and 34% of those who wanted no more children said they would feel very or somewhat happy about becoming pregnant in the next three months. Perceiving that a male partner would feel very upset about a pregnancy was negatively associated with happiness about the pregnancy among both women who planned to continue pill use and those who wanted no more children (coefficients, –4.4 and −3.9, respectively). Of the 36 women who became pregnant during the study, 24 reported feeling very happy about the pregnancy in retrospect, while only 14 had prospectively reported feeling happy about a possible pregnancy. Conclusion: Intentions and happiness appear to be distinct concepts for this sample of Latina women.

AJPHChanges in Service Delivery Patterns after Introducing Telemedicine Provision of Medical Abortion in Iowa

Grossman, D., Grindlay, K., Buchacker, T., Potter, J., & Schmertmann, C. (2010). Changes in service delivery patterns after launching telemedicine provision of medication abortion in Iowa. Contraception, 82(2), 205-206. 

Available online through PubMed

Abstract: Objectives: We assessed the effect of a telemedicine model providing medical abortion on service delivery in a clinic system in Iowa. Methods: We reviewed Iowa vital statistic data and billing data from the clinic system for all abortion encounters during the 2 years prior to and after the introduction of telemedicine in June 2008 (n?=?17?956 encounters). We calculated the distance from the patient's residential zip code to the clinic and to the closest clinic providing surgical abortion. Results: The abortion rate decreased in Iowa after telemedicine introduction, and the proportion of abortions in the clinics that were medical increased from 46% to 54%. After telemedicine was introduced, and with adjustment for other factors, clinic patients had increased odds of obtaining both medical abortion and abortion before 13 weeksE gestation. Although distance traveled to the clinic decreased only slightly, women living farther than 50 miles from the nearest clinic offering surgical abortion were more likely to obtain an abortion after telemedicine introduction. Conclusions: Telemedicine could improve access to medical abortion, especially for women living in remote areas, and reduce second-trimester abortion.

Obstetrics and GynecologyHospital Variation in Postpartum Tubal Sterilization Rates in California and Texas

Potter, J., Stevenson, A., White, K., Hopkins, K., & Grossman, D. (2012). Hospital variation in postpartum tubal sterilization rates in California and Texas. Contraception, 86(3), 322. 

Available online through PubMed

Abstract: Objective:To estimate variation across hospitals in the rate of postpartum sterilization. Methods:All hospitals with deliveries in California and Texas in 2009 were included. Proportion of live singleton deliveries with postpartum sterilization was calculated by hospital, insurance status (Medicaid compared with private insurance), type of delivery, and state. Results:Within each insurance status in California and Texas, we found wide variations across hospitals in postpartum tubal sterilization rates. This variability was not explained by disparities in hospital cesarean delivery rates. Some, but not all, of this variation was attributable to the absence of sterilizations in Catholic hospitals. Overall, postpartum tubal sterilization rates were higher in Texas than in California (10.2% compared with 6.7%), and this difference was found among both public insurance and private insurance patients. Interval sterilizations were more frequent in California, but the difference was not large enough to offset the difference in postpartum sterilization. Conclusions:The variation in postpartum tubal sterilization rates across hospitals is substantial and exists even among hospitals without religious affiliations. Large-scale studies are needed to assess the demand for, and the barriers to, obtaining postpartum sterilization

Journal of Health CareHypertension Among Oral Contraceptive Users in El Paso, Texas

White, K., Potter, J. E., Hopkins, K., Amastae, J., & Grossman, D. (2013). Hypertension among oral contraceptive users in El Paso, Texas. Journal of Health Care for the Poor and Underserved, 24(4), 1511-1521. 

Available online through PubMed

Abstract: On the U.S.-Mexico border, residents frequently cross into Mexico to obtain medications or medical care. We previously reported relatively high prevalence of hypertension among Latina oral contraceptive users in El Paso, particularly those obtaining pills over the counter (OTC) in Mexico. Here, we examine factors associated with having hypertension among 411 OTC users and 399 clinic users. We also assess hypertension awareness and interest in using blood pressure kiosks. Women age 35 to 44 and who had BMI ≥ 30 kg/m2 had higher odds of having hypertension. 59% of hypertensive women had unrecognized hypertension, and 77% of all participants would use a blood pressure kiosk; there were no significant differences between clinic and OTC users. Alternative approaches to increase access to health screenings are needed in this setting, where OTC pill use among women with unrecognized hypertension confers unique health risks.

ContraceptionInterest in Over-the-Counter Access to Oral Contraceptives Among Women in the United States

Grossman, D., Grindlay, K., Li, R., Potter, J. E., Trussell, J., & Blanchard, K. (2013). Interest in over-the-counter access to oral contraceptives among women in the United States. Contraception, 88(4), 544-552. 

Available online through ScienceDirect

Abstract: Background: A growing body of evidence indicates that over-the-counter (OTC) access to oral contraceptive pills (OCPs) is safe and effective. Study Design: We performed a nationally representative survey of adult women at risk of unintended pregnancy using a probability-based online panel. In November–December 2011, 2046 eligible women completed the survey. Weighted proportions were calculated, and logistic regression was used to identify covariates associated with support for and interest in using an OTC OCP. Results: A total of 62.2% said they were strongly (31.4%) or somewhat (30.9%) in favor of OCPs being available OTC. A total of 37.1% of participants reported being likely to use OCPs if available OTC, including 58.7% of current users, 28.0% using no method and 32.7% using a less effective method. Covariates associated with a higher odds of reporting interest in using OTC OCPs were younger age; being divorced, being separated or living with a partner (versus married); being uninsured or having private insurance (versus public insurance); living in the south (versus northeast); and current use of OCPs or less effective methods, or nonuse of contraception (versus use of another hormonal method or intrauterine device). Among respondents who said they were likely to use OTC OCPs, the highest amount they were willing to pay was on average $20. Conclusions: US women are supportive of OTC access to OCPs, and many would obtain refills OTC or start using OCPs if they were available OTC.

Women's Health IssuesKnowedge and Attitudes about Long-Acting Reversible Contraception among Latina Women Who Desire Sterilization

White, K., Hopkins, K., Potter, J. E., & Grossman, D. (2013). Knowledge and attitudes about long-acting reversible contraception among Latina women who desire sterilization. Womens Health Issues, 23(4). 

Available online through ScienceDirect

Abstract: Background: There is growing interest in increasing the use of long-acting reversible contraception (LARC), and suggestions that such methods may serve as an alternative to sterilization. However, there is little information about whether women who do not want more children would be interested in using LARC. Methods: We conducted semistructured interviews with 120 parous Latina women in El Paso, Texas, who wanted a sterilization but had not obtained one. We assessed women’s awareness of and interest in using the copper intrauterine device (IUD), levonorgestrel intrauterine system (LNG-IUS), and etonogestrel implant. Findings: Overall, 51%, 23%, and 47% of women reported they had heard of the copper IUD, LNG-IUS, and implant, respectively. More women stated they would use the copper IUD (24%) than the LNG-IUS (14%) or implant (9%). Among women interested in LARC, the most common reasons were that, relative to their current method, LARC methods were more convenient, effective, and provided longer-term protection against pregnancy. Those who had reservations about LARC were primarily concerned with menstrual changes. Women also had concerns about side effects and the methods’ effectiveness in preventing pregnancy, preferring to use a familiar method. Conclusions: Although these findings indicate many Latina women in this setting do not consider LARC an alternative to sterilization, they point to an existing demand among some who wish to end childbearing. Efforts are needed to improve women’s knowledge and access to a range of methods so they can achieve their childbearing goals.

Culture Health Sexuality Knowledge and Beliefs about Reproductive Anatomy and Physiology among Mexican-Origin Women in the U.S.-- Implications for Effective Oral Contraceptive Use

Shedlin, M., Amastae, J., Potter, J. E., Hopkins, K., & Grossman, D. (2013). Knowledge and beliefs about reproductive anatomy and physiology among Mexican-origin women in the USA: Implications for effective oral contraceptive use. Culture, Health & Sexuality, 15(4), 466-479. 

Available online through PubMed

Abstract: Inherent in many reproductive health and family planning programmes is the problematic assumption that the body, its processes and modifications to it are universally experienced in the same way. This paper addresses contraceptive knowledge and beliefs among Mexican-origin women, based upon data gathered by the qualitative component of the Border Contraceptive Access Study. Open-ended interviews explored the perceived mechanism of action of the pill, side-effects, non-contraceptive benefits, and general knowledge of contraception. Findings revealed complex connections between traditional and scientific information. The use of medical terms (e.g. 'hormone') illustrated attempts to integrate new information with existing knowledge and belief systems. Conclusions address concerns that existing information and services may not be sufficient if population-specific knowledge and beliefs are not assessed and addressed. Findings can contribute to the development of effective education, screening and reproductive health services.

Demographic ResearchPatterns of Contraceptive Use among Mexican-Origin Women

White, K., & Potter, J. E. (2013). Patterns of contraceptive use among Mexican-origin women. Demographic Research, 28, 1199-1212. 

Available online through Demographic Research

Abstract: Background: Mexican women in the United States (US) have higher rates of fertility compared to other ethnic groups and women in Mexico. Whether variation in women’s access to family planning services or patterns of contraceptive use contributes to this higher fertility has received little attention. Objective: We explore Mexican women’s contraceptive use, taking into account women’s place in the reproductive life course. Methods: Using nationally representative samples from the US (National Survey of Family Growth) and Mexico (Encuesta National de la Dinámica Demográfica), we compared the parity-specific frequency of contraceptive use and fertility intentions for non-migrant women, foreign-born Mexicans in the US, US-born Mexicans, and whites. Results: Mexican women in the US were less likely to use IUDs and more likely to use hormonal contraception than women in Mexico. Female sterilization was the most common method among higher parity women in both the US and Mexico, however, foreign-born Mexicans were less likely to be sterilized, and the least likely to use any permanent contraceptive method. Although foreign-born Mexicans were slightly less likely to report that they did not want more children, differences in method use remained after controlling for women’s fertility intentions

Contraception Journal imagePotential Unintended Pregnancies Averted and Cost Savings Associated with a Revised Medicaid Sterilization Policy

Borrero, S., Zite, N., Potter, J. E., Trussell, J., & Smith, K. (2013). Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy. Contraception, 88(6), 691-696. 

Available online through ScienceDirect

Abstract: Objective: Medicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers. Study Design: We constructed a cost-effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a postpartum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively. Results: With the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved. Conclusion: A revised Medicaid sterilization policy could potentially honor women’s reproductive decisions, reduce the number of unintended pregnancies and save a significant amount of public funds. Implication: Compared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly funded, postpartum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to cost savings of $215 million each year.

Population StudiesThe Impact of Out-Migration of Men on Fertility and Marriage in the Migrant Sending States of Mexico, 1995-2000

White, K., & Potter, J. E. (2013). The impact of outmigration of men on fertility and marriage in the migrant-sending states of Mexico, 1995–2000. Population Studies, 67(1), 83-95. 

Available online through PubMed

Abstract: Using the 2000 Mexican Census, we examined whether the level of migration was associated with total fertility and the proportion of women married in 314 municipalities from seven traditional sending states. Across these municipalities, we observe lower fertility in higher-migration areas. Municipalities in the quartile with the highest levels of migration have total fertility more than half a child lower than municipalities in the lowest migration quartile. However, there are no differences in marital fertility by level of migration, indicating that lower proportions of women married account for lower total fertility in high-migration municipalities. In municipal-level regression models, lower sex ratios are associated with a lower proportion of women married, while there is an inverse association between education and marriage. The level of migration also has an independent association with marriage, suggesting that there may be changing ideas surrounding family formation in high-migration areas.

Journal of Applied Research on Children The Influence of Race/Ethnicity and Gender on Attitudes Surrounding Contraceptive Responsibility: Do Latino Adolescents Differ From Other Groups?

White, K., Hopkins, K., & Schiefelbein, E. (2013). Attitudes surrounding contraceptive responsibility: Do Latino youth differ from other groups? The Journal of Applied Research on Children, 4(2), 8. 

Available online through National Center for Biotechnology Information

Abstract: Recent estimates demonstrate that more than 75% of young women and men ages 15 to 19 used contraception at first sex and their most recent intercourse. However, there are notable disparities in contraceptive use by race/ethnicity. Female and male Latino adolescents are less likely than African American and white teens to report contraceptive use at first sex. In addition, Latino adolescents are less likely to report using condoms at last intercourse (54.9%) compared to African Americans (62.4%) and whites (63.3%) and were also less likely than whites to state they used hormonal methods (14.0% compared to 29.3% among whites). These lower rates of contraceptive use may be due, in part, to differences in attitudes about contraceptive decision-making. Several studies have noted that Latinos report that women are primarily responsible for contraception and preventing pregnancy, which is associated with less effective method use compared to when both partners are responsible for deciding on contraception. However, it is not clear whether attitudes placing responsibility for contraceptive use on women are more widely endorsed among Latinos compared to other racial/ethnic groups. Some of these studies have only included Latinos, and others that assessed attitudes across racial/ethnic groups found few differences. Additionally, little is known about the underlying beliefs and values that shape ideas about which partner or partners have responsibility for contraception and how these might vary by race/ethnicity. Such information is important in order to identify target areas for interventions that promote shared decision-making, and therefore increase effective use of contraception. In this study, we explore youths’ attitudes toward contraceptive responsibility. The specific questions we address are: Which partner is usually responsible for contraception and why? How do these attitudes and beliefs vary, if at all, across racial/ethnic groups and gender? To answer these questions we used data collected from focus groups with Latino, African American and white young women and men. Focus groups are particularly well-suited for the study of this topic because they highlight values and norms within groups sharing similar characteristics, as well as identify beliefs underlying attitudes and behaviors.

2012

Contraception Journal imageContraindications to Progestin-only Oral Contraceptive Pills among Reproductive-aged Women

White, K., Potter, J., Hopkins, K., Fernandez, L., Amastae, J., & Grossman, D. (2012). Contraindications to progestin-only oral contraceptive pills among reproductive-aged women. Contraception, 86(3), 199-203.

Available online through ScienceDirect

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

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

Potter, J. E., White, K., Hopkins, K., Mckinnon, S., Shedlin, M. G., Amastae, J., & Grossman, D. (2012). Frustrated demand for sterilization among low-income Latinas in El Paso, Texas. Perspectives on Sexual and Reproductive Health, 44(4), 228-235. 

Available online through Wiley Online Library

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

Contraception Journal imageReproductive Health Preventive Screening Among Clinic vs. Over-the-Counter Oral Contraceptive Users

Hopkins, K., Grossman, D., White, K., Amastae, J., & Potter, J. E. (2012). Reproductive health preventive screening among clinic vs. over-the-counter oral contraceptive users. Contraception, 86(4), 376-382. 

Available online through ScienceDirect

Abstract: Background: Interest is growing in moving oral contraceptives over-the-counter (OTC), although concerns exist about whether women would continue to get preventive health screening. Study Design: We recruited cohorts of US-resident women who obtained oral contraceptives from US family planning clinics (n=532) and OTC from pharmacies in Mexico (n=514) and interviewed them four times over 9 months. Based on self-reports of having a Pap smear within 3 years or ever having had a pelvic exam, clinical breast exam and testing for sexually transmitted infections (STIs), we assessed the prevalence of preventive screening using Poisson regression models. Results: The prevalence of screening was high for both groups (>88% for Pap smear, pelvic exam and clinical breast exam and >71% for STI screening), while the prevalence ratios for screening were higher for clinic users, even after multivariable adjustment. Conclusions: Results suggest that most women would obtain reproductive health preventive screening if oral contraceptives were available OTC, and also highlight the need to improve access to preventive screening for all low-income women.

Obstetrics and GynecologyContraindications to Combined Oral Contraceptives Among Over-the-Counter Compared With Prescription Users

Grossman, D., White, K., Hopkins, K., Amastae, J., Shedlin, M., & Potter, J. (2011). Contraindications to combined oral contraceptives among over-the-counter compared with prescription users. Obstetrics and Gynecology, 117(3), 558-565. 

Available online through PubMed

Abstract: Objective: To compare the estimated proportion of contraindications to combined oral contraceptives (COCs) between women living in El Paso, Texas, obtaining COCs in US public clinics versus over the counter (OTC) in Mexican pharmacies. Methods: We recruited a cohort of 501 El Paso resident women who obtained COCs over the counter (OTC) in Mexico and 514 women who obtained COCs from family planning clinics in El Paso.  Based on self-report of WHO category 3 and 4 contraindications and interviewer-measured blood pressure, we estimated the proportion of contraindications and, using multivariable-adjusted logistic regression, identified possible predictors of contraindications. Results: The estimated proportion of any category 3 or 4 contraindication was 18%.  Relative contraindications (category 3) were more common among OTC users (13% vs 9% among clinic users, p=0.006).  Absolute contraindications (category 4) were not different between the groups (5% for clinic users vs 7% for OTC users, p=0.162).  Hypertension was the most prevalent contraindication (8%).  After multivariable adjustment, OTC users had higher odds of being contraindicated compared to clinic users (OR 1.59, 95% CI: 1.11-2.29).  Women age 35 years or older (OR 5.30, 95% CI: 3.59-7.81) and those with body mass index ≥ 30.0 kg/m2 (OR 2.24, 95% CI: 1.40-3.56) also had higher odds of being contraindicated. Conclusions: Relative COC contraindications are more common among OTC users in this setting.  Research is needed to determine whether checklists can be used to accurately identify contraindications when women obtain COCs OTC.  Progestin-only pills might be a better candidate for the first OTC product given their fewer contraindications.