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, Nathan Walter, Stephanie Herold, John J. Brooks
Perspectives on Sexual and Reproductive Health; https://doi.org/10.1363/psrh.12183

Abstract:
CONTEXT Entertainment television can impact viewers' knowledge, attitudes, and reproductive health behaviors, yet little research has examined the impact of scripted abortion plotlines on viewers' abortion knowledge or social supportiveness for those having abortions. We examined the impact of an abortion storyline from Grey's Anatomy on US-based viewers. METHOD We conducted an online survey of likely Grey's Anatomy viewers prior to the episode's airing, assessing abortion ideology, knowledge, and support. After airing, we resurveyed respondents (including both those who had and had not viewed the target episode). We tested three hypotheses: episode exposure would (1) improve abortion knowledge and (2) increase support for medication abortion and decrease support for self-induced abortion, and (3) the effects on knowledge and supportive intention would be moderated by state support for abortion. We used independent samples t tests to examine hypotheses 1 and 2 and PROCESS macro to test the moderated effects (hypothesis 3). RESULTS The results of the pretest/posttest analysis indicated that exposure to the episode significantly improved medication abortion knowledge. Increases in medication abortion knowledge were tied to explicit educational dialogue and did not translate into an increase in general abortion knowledge or social supportiveness. Notably, abortion-related state policy significantly moderated the influence of exposure for respondents in states with policies favorable to abortion access. CONCLUSIONS These findings suggest that entertainment television can contribute to meaningful increases in viewers' knowledge about abortion, but that the potential for impact of entertainment-education is closely linked to episode content and moderated by state-level abortion policy.
Kathryn Kost, Guttmacher Institute, Isaac Maddow-Zimet, Ashley C. Little
Pregnancies and Pregnancy Desires at the State Level: Estimates for 2017 and Trends Since 2012; https://doi.org/10.1363/2021.33141

Abstract:
Key Points In almost all U.S. states, pregnancies reported as occurring at the right time or being wanted sooner than they occurred comprised the largest share of pregnancies in 2017, though proportions varied widely by state. The proportion of pregnancies that were wanted later or unwanted was higher in the South and Northeast than in other regions, and the proportion of pregnancies that occurred at the right time or were wanted sooner was higher in the West and Midwest. From 2012 to 2017, the wanted-later-or-unwanted pregnancy rate fell in the majority of states. However, no clear pattern emerged for any changes in the rate of pregnancies that were reported as wanted then or sooner or in the rate of those for which individuals expressed uncertainty.
Jennifer J. Frost, Jennifer Mueller, Zoe H. Pleasure
Trends and Differentials in Receipt of Sexual and Reproductive Health Services in the United States: Services Received and Sources of Care, 2006–2019; https://doi.org/10.1363/2021.33017

Abstract:
Key Points Seven in 10 U.S. women of reproductive age, some 44 million women, make at least one medical visit to obtain sexual and reproductive health (SRH) services each year. While the overall number of women receiving any SRH service remained relatively stable between 2006–2010 and 2015–2019, the number of women receiving preventive gynecologic care fell and the number receiving STI testing doubled. Disparities in use of SRH services persist, as Hispanic women are significantly less likely than non-Hispanic White women to receive SRH services, and uninsured women are significantly less likely to receive services than privately insured women. Publicly funded clinics remain critical sources of SRH care for many women, with younger women, lower income women, women of color, foreign-born women, women with Medicaid coverage and women who are uninsured especially likely to rely on publicly funded clinics. Among women who go to clinics for SRH care, two-thirds report that the clinic is their usual source for medical care. Among those relying on both private providers and public clinics, the proportion of women who reported receiving a combination of contraceptive and STI/HIV care increased between 2006–2010 and 2015–2019. Implementation of the Affordable Care Act has likely contributed to some of the changes observed in where women receive contraceptive and other SRH services and how they pay for that care: The share of women receiving contraceptive services who go to private providers rose from 69% to 77% between 2006–2010 and 2015–2019, in part because more women gained private or public health insurance coverage and there was a greater likelihood that their health insurance would cover SRH services. There was a complementary drop in the share of women receiving contraceptive services who went to a publicly funded clinic, from 27% in 2006–2010 to 18% in 2015–2019. For non-Hispanic Black women, immigrant women and uninsured women, there was no increase in the use of private providers for contraceptive care from 2006–2010 to 2015–2019. Among women served at publicly funded clinics between 2006–2010 and 2015–2019, there were significant increases in the use of both public and private insurance to pay for their care.
Rachel Murro, Guttmacher Institute, Rhea Chawla, Souvik Pyne, Shruti Venkatesh, Elizabeth Sully
Adding It Up: Investing in the Sexual and Reproductive Health of Adolescents in India; https://doi.org/10.1363/2021.32662

Akinrinola Bankole, Lisa Remez, Onikepe Owolabi, Jesse Philbin, Patrice Williams
From Unsafe to Safe Abortion in Sub-Saharan Africa: Slow but Steady Progress; https://doi.org/10.1363/2020.32446

Abstract:
This report represents the first comprehensive compilation of information about abortion in Sub-Saharan Africa and its four subregions. It offers a panorama of this hard-to-measure practice by assembling data on the incidence and safety of abortion, the extent to which the region’s laws restrict abortion, and how these laws have changed between 2000 and 2019. Many countries in this region have incrementally broadened the legal grounds for abortion, improved the safety of abortions, and increased the quality and reach of postabortion care. There is still much progress to be made, however, including enabling the region’s women to avoid unintended pregnancies and unsafe abortions. The report concludes with recommendations for a broad range of actors to improve the sexual and reproductive health and autonomy of the region’s 255 million women of reproductive age.
, Shelby N. Hickman, Sally S. Simpson
Perspectives on Sexual and Reproductive Health, Volume 52, pp 253-264; https://doi.org/10.1363/psrh.12165

Abstract:
CONTEXT Little is known about whether adolescents’ risk‐taking in areas other than sex is associated with the effectiveness of their contraceptive method use, or whether any such associations vary by race and ethnicity. METHODS Data from the 2011, 2013 and 2015 National Youth Risk Behavior Surveys were used to examine nonsexual risk behaviors and contraceptive method choice among 5,971 sexually active females aged 13–18. Risk‐taking profiles for White, Black and Hispanic adolescents were identified using latent class analysis. Multinomial logistic regression was used to estimate the associations between these risk profiles and use of less‐ or more‐effective contraceptive methods at last sexual intercourse. RESULTS Three distinct risk‐taking profiles were identified for White and Hispanic adolescents and two for Black adolescents. Compared with their counterparts in the low‐risk “abstainer” group, White adolescents in the “high substance use and violence” group were less likely to use condoms alone (relative risk, 0.4) or a prescription contraceptive paired with condoms (0.3) rather than no contraceptive at all, and more likely to use withdrawal or no method rather than condoms alone (2.4 each). However, higher risk‐taking among Whites was positively associated with using prescription contraceptives rather than condoms (1.9). Among Black and Hispanic females, lower risk‐taking was associated only with more condom use. CONCLUSIONS Future studies should examine whether interventions designed to reduce adolescent risk‐taking improve the effectiveness of contraceptive use, particularly among White females. However, efforts to increase Black and Hispanic adolescents’ use of more‐effective contraceptives should target barriers other than risk‐proneness. Perspectives on Sexual and Reproductive Health, 2020, 52(4):TK, doi:10.1363/psrh.12165
, Luciana E. Hebert, Melissa Gilliam, Robert Kaestner
Perspectives on Sexual and Reproductive Health, Volume 52, pp 227-234; https://doi.org/10.1363/psrh.12164

Abstract:
CONTEXT Although one in four U.S. women has an abortion in her lifetime, barriers to abortion persist, including distance to care. This study evaluates the association between distance to care and the abortion rate, adjusting for abortion demand. METHODS Two analyses were conducted using a data set linking provider locations and 2000–2014 county‐level abortion data for 18 states; data sources included the Census Bureau, state vital statistics offices and the Guttmacher Institute. First, a series of linear regression models were run, with and without adjustment for demographic covariates, modeling distance as both a continuous and a categorical variable. Then, an instrumental variable analysis was conducted in which being 30 or more miles from a large college‐enrolled female population younger than age 25 was used as an instrument for distance to a provider. The outcome variable for all models was abortions per 1,000 women aged 25 or older. All models were adjusted for state, year and state‐year interaction fixed effects. RESULTS Increased distance to a provider was associated with a decreased abortion rate. Each additional mile to a provider was associated with a decrease of 0.011 in the abortion rate. Compared with being within 30 miles of a provider, being between 30 and 90 miles from a provider was associated with 0.80–1.46 fewer abortions per 1,000 women. In the instrumental variable analysis, being 30 or more miles from a provider was associated with 5.26 fewer abortions per 1,000 women. CONCLUSIONS Distance to a provider may present a barrier to abortion by preventing access to care. Therefore, policies that increase travel distances have potential for harm.
, Rosalyn Schroeder, Carole Joffe
Perspectives on Sexual and Reproductive Health, Volume 52, pp 217-225; https://doi.org/10.1363/psrh.12163

Abstract:
CONTEXT The ways in which the COVID‐19 pandemic has affected abortion providers and abortion care, and the strategies clinics are adopting to navigate the pandemic, have not been well documented. METHODS In April–May 2020, representatives from 103 independent abortion clinics (i.e., those not affiliated with Planned Parenthood) completed a survey that included close‐ended questions about how the pandemic, the public health response, and designations of abortion as a nonessential service had affected their clinic, as well as open‐ended questions about the pandemic’s impact. Analyses were primarily descriptive but included an exploration of regional variation. RESULTS All U.S. regions were represented in the sample. At 51% of clinics, clinicians or staff had been unable to work because of the pandemic or public health responses. Temporary closures were more common among clinics in the South (35%) and Midwest (21%) than in the Northeast and West (5% each). More than half of clinics had canceled or postponed nonabortion services (e.g., general gynecologic care); cancelation or postponement of abortion services was less common (25–38%, depending on type) and again especially prevalent in the South and Midwest. Providers reported the pandemic had had numerous effects on their clinics, including disrupting their workforce, clinic flow and work practices; increasing expenses; and reducing revenues. State laws (including designations of abortion as nonessential) had exacerbated these difficulties. CONCLUSIONS Although independent abortion clinics have faced considerable challenges from the pandemic, most continued to provide abortion care. Despite this resiliency, additional support may be needed to ensure sustainability of these clinics.
Camille Brown, Marla E. Eisenberg, Barbara J. McMorris, Renee E. Sieving
Perspectives on Sexual and Reproductive Health, Volume 52, pp 265-273; https://doi.org/10.1363/psrh.12168

Abstract:
CONTEXT Transgender and gender‐diverse youth experience significant health disparities across numerous domains of health, including sexual health. Among general populations, parent connectedness has been strongly associated with youth sexual health. METHODS The relationships between parent connectedness and sexual health indicators were investigated among 2,168 transgender and gender‐diverse youth who participated in the 2016 Minnesota Student Survey, a statewide population‐based survey of ninth‐ and 11th‐grade students. Multivariate logistic regression models, stratified by sex assigned at birth, tested associations between parent connectedness—youth's perceptions of parent caring and parent–youth communication—and eight sexual health indicators: ever having had sex, having multiple sexual partners in the past year, pregnancy involvement, substance use at last sex, partner communication about STI prevention, partner communication about pregnancy prevention, condom use at last sex and pregnancy prevention methods at last sex. RESULTS The level of parent connectedness was inversely associated with ever having had sex, regardless of sex assigned at birth (odds ratios, 0.6–0.8). Although level of connectedness was inversely associated with having multiple sexual partners in the past year and pregnancy involvement among transgender and gender‐diverse youth assigned male at birth (0.6–0.7), these relationships were nonsignificant among transgender and gender‐diverse youth assigned female at birth. Further differences in associations between parent connectedness and four sexual risk–reduction behaviors were found between youth assigned male at birth and those assigned female. CONCLUSIONS As with other populations, parent connectedness promotes sexual health among transgender and gender‐diverse youth and may provide a point of intervention.
, Lucia Tome, Aisha Mays, Shelly Kaller, Cynthia C. Harper, Lori Freedman
Perspectives on Sexual and Reproductive Health, Volume 52, pp 245-252; https://doi.org/10.1363/psrh.12161

Abstract:
CONTEXT While community health centers (CHCs) are meeting increased demand for contraceptives, little is known about contraceptive counseling in these settings. Understanding how clinicians counsel about IUDs in CHCs, including whether they address or disregard young people's preferences and concerns during counseling, could improve contraceptive care. METHODS As part of a training program, 20 clinicians from 11 San Francisco Bay Area CHC sites who counsel young people about contraception were interviewed by telephone in 2015 regarding their IUD counseling approaches. An iterative grounded theory approach was used to analyze interview transcripts and identify salient themes related to clinicians’ contraceptive counseling, IUD removal practices and efforts to address patient concerns regarding side effects. RESULTS Most clinicians offered comprehensive contraceptive counseling and method choice. While several clinicians viewed counseling as an opportunity to empower their patients to make contraceptive decisions without pressure, they also described a tension between guiding young people toward higher‐efficacy methods and respecting patients’ choices. Many clinicians engaged in what could be considered coercive practices by trying to dissuade patients from removals within a year of placement and offering to treat or downplay side effects. CONCLUSIONS Providers try to promote their young patients’ autonomous decision making, but their support for high‐efficacy methods can result in coercive practices. More training is needed to ensure that providers employ patient‐centered counseling approaches, including honoring patient requests for removals.
Perspectives on Sexual and Reproductive Health, Volume 52, pp 197-198; https://doi.org/10.1363/psrh.12171

, Lori Freedman, Uta Landy, Callie Langton, Elizabeth Ly, Corinne H. Rocca
Perspectives on Sexual and Reproductive Health, Volume 52, pp 235-244; https://doi.org/10.1363/psrh.12162

Abstract:
CONTEXT Hospital policies and culture affect abortion provision. The prevalence and nature of colleague opposition to abortion and how this opposition limits abortion care in U.S. teaching hospitals have not been investigated. METHODS As part of a mixed‐methods study, a nationwide survey of residency and site directors at 169 accredited obstetrics‐gynecology training programs was conducted in 2015–2016, and 18 in‐depth interviews with program directors were conducted in 2014 and 2017. The prevalence and nature of interprofessional opposition were examined using descriptive statistics, and regional differences were investigated using logistic regression. A modified grounded theoretical approach was used to analyze interview data. RESULTS Among the 91% of survey respondents who reported that they or their colleagues had wanted or needed to provide abortions in the prior year, 69% faced opposition from colleagues. Most commonly, opposition came from nurses (58%), nursing administration (30%) and anesthesiologists (30%), manifesting as resistance to participating in or cooperating with procedures (51% and 38%, respectively). Fifty‐nine percent of respondents had denied care to patients in the prior year because of colleagues’ opposition. Respondents in the Midwest and South were more likely than those in the Northeast to deny abortion care to patients because of such opposition (odds ratios, 3.2 and 4.4, respectively). Interviews revealed how participants had to circumvent opposing colleagues, making abortion provision difficult and leading to delays in and, infrequently, denial of abortion care. CONCLUSIONS Interprofessional opposition to abortion is widespread in U.S. teaching hospitals. Interventions are needed that prioritize patients’ needs while recognizing the challenges hospital colleagues face in their abortion participation decisions.
Perspectives on Sexual and Reproductive Health, Volume 52, pp 191-191; https://doi.org/10.1363/psrh.12159

, Abigail S. Cutler, Nancy L. Stanwood, Kimberly A. Yonkers, Aileen M. Gariepy
Perspectives on Sexual and Reproductive Health, Volume 52, pp 161-170; https://doi.org/10.1363/psrh.12155

Abstract:
CONTEXT Research into the relationship between pregnancy intention and perinatal depression or low social support is limited. Women's perspectives on pregnancy and their associations with perinatal depression could help in developing targeted efforts for screening and intervention. METHODS In 2014–2015, 161 women seeking pregnancy testing or abortion care at clinics in New Haven, Connecticut, were surveyed. They were asked about pregnancy context (intentions, planning, wantedness, desirability, timing and happiness), and the Edinburgh Depression Screen (EDS) and the Modified Kendler Social Support Index (MKSSI) were used to identify possible antenatal depression and low social support, respectively. Multivariable logistic regression analysis was employed to examine associations between pregnancy context and these outcomes. RESULTS On average, participants were 27 years old and at nine weeks’ gestation. One‐fifth reported a previous diagnosis of depression or anxiety, and 22% and 33% screened positive for depression (EDS scores of 13 or higher and 10 or higher, respectively); 52% received low social support (MKSSI score of 3.2 or less). Regression analysis found that pregnancies described as unintended, poorly timed or undesired were associated with depression at the higher cutoff (odds ratios, 3.2–4.5); all unfavorable pregnancy measures were associated with depression at the lower cutoff. Ambivalence regarding pregnancy timing, intention, wantedness and desirability was associated with increased odds of depression by either EDS score. Unplanned pregnancies and those about which the woman was ambivalent were associated with low social support. CONCLUSIONS Findings support the need to screen women for depression early in pregnancy and to integrate assessments of pregnancy context into the evaluation of potential risk factors.
, Ian Lague, Miranda Dettmann, Marji Gold
Perspectives on Sexual and Reproductive Health, Volume 52, pp 151-159; https://doi.org/10.1363/psrh.12154

Abstract:
CONTEXT Although some family medicine residency programs include routine opt‐out training in early abortion, little is known about abortion provision by trainees after residency graduation. A better understanding of the barriers to and enablers of abortion provision by trained family physicians could improve residency training and shape other interventions to increase abortion provision and access. METHODS Twenty‐eight U.S. family physicians who had received abortion training during residency were interviewed in 2017, between two and seven years after residency graduation. The doctors, identified using databases of abortion‐trained physicians maintained by residency programs, were recruited by e‐mail. In phone interviews, they described their postresidency abortion provision experiences. All interviews were transcribed, coded and analyzed using Dedoose, and a social‐ecological framework was employed to guide investigation and analysis. RESULTS Although many of the physicians were motivated to provide abortion care, only a minority did so. Barriers to and enablers of abortion provision were found on all levels of the social‐ecological model—legal, institutional, social and individual—and included state‐specific laws and restrictions on federal funding; religious affiliation or policies prohibiting abortion within particular health systems; mentorship, colleagues’ support and the stigma of being an abortion provider; and geographic location, time management and individuals’ prioritization of abortion provision. CONCLUSIONS Clinical training alone may not be sufficient for family medicine physicians to overcome the barriers to postresidency abortion provision. To increase abortion provision and access, organizations and advocates should work to strengthen enablers of provision, such as strong mentorship and support networks.
Perspectives on Sexual and Reproductive Health, Volume 52, pp 143-143; https://doi.org/10.1363/psrh.12160

Erin E. Wingo, Jocelyn M. Wascher, Debra B. Stulberg, Lori R. Freedman
Perspectives on Sexual and Reproductive Health, Volume 52, pp 171-179; https://doi.org/10.1363/psrh.12157

Abstract:
Catholic hospitals represent a large and growing segment of U.S. health care. Because these facilities follow doctrines that restrict reproductive health services, including miscarriage management options when a fetal heartbeat is present, it is critical to understand whether and how women would want to learn about miscarriage treatment restrictions from providers. From May 2018 to January 2019, semistructured interviews were conducted with 31 women aged 21-44 who had had exposure to religious-based health care; all were drawn from a nationally representative survey sample. Participants responded to a hypothetical scenario regarding the anticipatory disclosure of miscarriage management policy during routine prenatal care. Responses were inductively coded and thematically analyzed using modified grounded theory to understand women's attitudes and considerations related to receiving anticipatory miscarriage management information. Respondents supported the routine disclosure of miscarriage management policies during prenatal care. Some expressed concern that this might increase patient anxiety during pregnancy, but most felt that the information would serve to prepare and empower patients, and likened the topic to other anticipatory health information provided during prenatal care. Identified themes related to how providers can disclose this information (including the need for a precautionary framing to reduce patient stress), sharing the rationale for institutional policy, and the importance of provider neutrality to ensure patient autonomy. To respect patient autonomy, health care providers working in Catholic hospitals should routinely discuss institutional miscarriage management policies with patients, and anticipatory counseling should give patients the balanced information they need to decide where to go for care should pregnancy complications arise.
Melissa L. Harris, Jacqueline Coombe, Peta M. Forder, Jayne C. Lucke, Deborah Bateson, Deborah Loxton
Perspectives on Sexual and Reproductive Health, Volume 52, pp 181-190; https://doi.org/10.1363/psrh.12158

Abstract:
Unintended pregnancy is common among young women. Understanding how such women use contraceptives- including method combinations-is essential to providing high-quality contraceptive care. Data were from a representative cohort of 2,965 Australian women aged 18-23 who participated in the 2012-2013 Contraceptive Use, Pregnancy Intention and Decisions baseline survey, had been heterosexually active in the previous six months, and were not pregnant or trying to conceive. Latent class analysis was employed to characterize women's contraceptive choices; multinomial logistic regression was used to evaluate correlates of membership in the identified classes. The vast majority of women (96%) reported using one or more contraceptives, most commonly short-acting hormonal methods (60%), barrier methods (38%), long-acting contraceptives (16%) and withdrawal (15%). In total, 32 combinations were reported. Four latent classes of method use were identified: no contraception (4% of women); short-acting hormonal methods with supplementation (59%, mostly the pill); high-efficacy contraceptives with supplementation (15%, all long-acting reversible contraceptive users); and low-efficacy contraceptive combinations (21%); supplementation usually involved barrier methods or withdrawal. Class membership differed according to women's characteristics; for example, women who had ever been pregnant were more likely than other women to be in the no-contraception, high-efficacy contraceptive or low-efficacy contraceptive combination classes than in the short-acting hormonal contraceptive class (odds ratios, 2.0-3.0). The complexity of women's contraceptive choices and the associations between latent classes and such characteristics as pregnancy history highlight the need for individualized approaches to pregnancy prevention and contraceptive care.
Elizabeth A. Sully, Guttmacher Institute, Ann Biddlecom, Jacqueline E. Darroch, Taylor Riley, Lori S. Ashford, Naomi Lince-Deroche, Lauren Firestein, Rachel Murro
Adding It Up: Investing in Sexual and Reproductive Health 2019; https://doi.org/10.1363/2020.31593

Abstract:
Executive Summary Sexual and reproductive health care encompasses a broad range of services that ensure people can decide whether and when to have children, experience safe pregnancy and delivery, have healthy newborns, and have a safe and satisfying sexual life. These services are important investments both because they enhance individual well-being and allow people to
Taylor Riley, Guttmacher Institute, Elizabeth A. Sully, Naomi Lince-Deroche, Lauren Firestein, Rachel Murro, Ann Biddlecom, Jacqueline E. Darroch
Adding It Up: Investing in Sexual and Reproductive Health 2019—Methodology Report; https://doi.org/10.1363/2020.31637

Perspectives on Sexual and Reproductive Health, Volume 52, pp 63-64; https://doi.org/10.1363/psrh.12153

, Yasamin Kusunoki
Perspectives on Sexual and Reproductive Health, Volume 52, pp 129-138; https://doi.org/10.1363/psrh.12149

Abstract:
CONTEXT Sexual concurrency among women is associated with increased risks of STD transmission, unintended pregnancy and sexual health disparities. Understanding the prevalence of concurrency—overlapping sexual partnerships—is imperative to reducing these disparities. METHODS Weekly, population‐representative panel data from 757 women aged 18–22, collected from 2008 to 2012 in Michigan, were drawn from the Relationship Dynamics and Social Life study. Univariate analyses assessed the prevalence of two forms of sexual concurrency. Multivariate logistic regression models investigated associations between women's social‐ecological characteristics and concurrency. RESULTS Twenty percent of women had vaginal intercourse with two partners in one week; 14% had intercourse with a second partner during an ongoing relationship. In both cases, the majority of individuals had intercourse with the second partner in one to three weeks in total. The likelihood of both types of concurrency was elevated among women who believed they should have sex with men after seeing them for a while (log‐odds, 0.27 and 0.23, respectively) and among those who were Black (0.58 and 1.02, respectively); the likelihood was reduced among women who were more willing to refuse unwanted sex (–0.10 and –0.13, respectively) and who were in exclusive, cohabiting, or married or engaged relationships (–1.82 to –2.64). Having intercourse with multiple partners in one week was also associated with receiving sex education from parents, the degree that parents and friends approved of sex, and having had early intercourse without contraception. CONCLUSIONS Sexual concurrency among young women is prevalent but intermittent, and interventions that address individuals’ social‐ecological contexts are needed to reduce negative health outcomes.
, Luciana E. Hebert, Yuan Liu, Debra B. Stulberg
Perspectives on Sexual and Reproductive Health, Volume 52, pp 107-115; https://doi.org/10.1363/psrh.12148

Abstract:
CONTEXT Abortion is generally prohibited in Catholic hospitals, but less is known about abortion restrictions in other religiously affiliated health care facilities. As religiously affiliated health systems expand in the United States, it is important to understand how religious restrictions affect the practices of providers who treat pregnant patients. METHODS From September 2016 to May 2018, in‐depth interviews were conducted with 31 key informants (clinical providers, ethicists, chaplains and health system administrators) with experience working in secular, Protestant or Catholic health care systems in Illinois. A thematic content approach was used to identify themes related to participants’ experiences with abortion policies, the role of ethics committees, the impact on patient care and conflicts with hospital policies. RESULTS Few limitations on abortion were reported in secular hospitals, while Catholic hospitals prohibited most abortions, and a Protestant‐affiliated system banned abortions deemed “elective.” Religiously affiliated hospitals allowed abortions in specific cases, if approved through an ethics consultation. Interpretation of system‐wide policies varied by hospital, with some indication that institutional discomfort with abortion influenced policy as much as religious teachings did. Providers constrained by religious restrictions referred or transferred patients desiring abortion, including for pregnancy complications, with those in Protestant hospitals having more latitude to directly refer such patients. As a result of religiously influenced policies, patients could encounter delays, financial obstacles, restrictions on treatment and stigmatization. CONCLUSIONS Patients seeking abortion or presenting with pregnancy complications at Catholic and Protestant hospitals may encounter more delays and fewer treatment options than they would at secular hospitals. More research is needed to better understand the implications for women's access to reproductive health care.
Laura D. Lindberg, Alicia VandeVusse, Jennifer Mueller, Marielle Kirstein
Early Impacts of the COVID-19 Pandemic: Findings from the 2020 Guttmacher Survey of Reproductive Health Experiences; https://doi.org/10.1363/2020.31482

Abstract:
Background The COVID-19 pandemic in the United States has quickly reshaped the American social landscape, including people’s intimate lives. This report provides an initial look at newly collected data on the emerging impact of the pandemic on women’s sexual and reproductive health (SRH) and reproductive autonomy in the United States.
, Nicole F. Kahn, Carolyn T. Halpern
Perspectives on Sexual and Reproductive Health, Volume 52, pp 97-105; https://doi.org/10.1363/psrh.12138

Abstract:
CONTEXT Intimate partner violence (IPV) among sexual minority young adults has been understudied, and victimization and perpetration estimates are needed. METHODS Data on 13,653 women and men aged 24–32 who participated in Wave 4 of the National Longitudinal Study of Adolescent to Adult Health were used to examine associations between sexual orientation and IPV perpetration and victimization in respondents’ current or most recent relationship. Logistic regression analyses were used to identify associations between respondent characteristics and three IPV categories (physical violence, threatened violence and forced sex). RESULTS Some 94% of males and 80% of females identified as 100% heterosexual; 4% of males and 16% of females as mostly heterosexual; 1% of males and 2% of females as bisexual; and 2% of males and females as either mostly homosexual or 100% homosexual. Compared with their heterosexual counterparts, mostly heterosexual women were more likely to report having perpetrated or been a victim of physical IPV (odds ratios, 1.9 and 1.6, respectively), having threatened violence (2.0) and having been a victim of threatened violence and forced sex (1.6 for each); mostly heterosexual males were more likely to have been a perpetrator or victim of physical IPV (3.1 and 1.8, respectively) and a perpetrator of forced sex and threatened violence (2.0 and 1.8, respectively). Bisexual males had elevated odds of physical violence victimization (3.3) and forced sex victimization (4.9) and perpetration (5.0). CONCLUSIONS Some sexual minority groups are disproportionately affected by IPV, indicating a need for increased prevention efforts and for studies exploring the mechanisms underlying these differences.
, Alexandra Kissling, Karen Benjamin Guzzo
Perspectives on Sexual and Reproductive Health, Volume 52, pp 117-127; https://doi.org/10.1363/psrh.12137

Abstract:
CONTEXT Female surgical sterilization is widely used in the United States. Educational differentials in sterilization are large, but poorly understood. Improved understanding of these differences is important to ensure that all women have access to the full range of contraceptive methods. METHODS Data from the National Survey of Family Growth (1973–2015) from 8,100 women aged 40–44 were used to describe trends in sterilization and other contraceptive methods by educational attainment. Demographic standardization was employed to examine how compositional changes in marital status and age at first birth contribute to aggregate changes in sterilization prevalence. RESULTS In 1982, women with a high school diploma and those with at least a bachelor's degree reported similar levels of sterilization use (38% and 32%, respectively), but by 2011–2015, prevalence had declined to 19% among college‐educated women and had increased to 44% among those with a diploma. The trend among college graduates was largely attributable to delayed fertility; all other things being equal, if their age at first birth had not increased, the prevalence of sterilization would have declined by approximately 3% instead of 14% between 1982 and 2002. Increased use of sterilization among women with a high school diploma was only weakly related to changes in birth timing and marital status. CONCLUSIONS Among women with a high school diploma, elements other than childbearing and marital status—such as contraceptive preferences and access—appeared to influence their contraceptive behavior. Sterilization differentials between high school and college graduates may reflect or exacerbate other socioeconomic disparities that affect women's health and well‐being.
Stephanie Arteaga, Margaret Mary Downey, Bridget Freihart, Anu Manchikanti Gómez
Perspectives on Sexual and Reproductive Health, Volume 52, pp 87-95; https://doi.org/10.1363/psrh.12136

Abstract:
CONTEXT The literature on reproductive decision making often focuses on women and neglects the role of men and the importance of relationship context. Research with couples is vital to understanding joint decision making regarding having children at various stages of a couple's relationship and an individual's life course. METHODS In‐depth, individual interviews were conducted with a socioeconomically, racially and ethnically diverse sample of 50 young heterosexual women and their male partners in northern California in 2015–2016. A dyadic, thematic analytic approach was used to examine whether and how prospective pregnancy intentions and current pregnancy desires are negotiated at the couple level, and how relationship dynamics influence any negotiation and decision‐making processes. RESULTS Twenty‐three couples described engaging in joint pregnancy decision making, which required purposeful communication and, for some, compromise and acceptance. For nearly all of these couples, these processes led to aligned prospective pregnancy intentions, even when current pregnancy desires differed. The remaining 27 couples described individual pregnancy decision‐making processes; many respondents reported intentions that aligned with their partner's by happenstance, despite some respondents having avoided communicating their desires to their partner. Some of these couples faced relationship difficulties, including poor communication, leading some participants to misinterpret or be unaware of their partner's pregnancy intentions and desires. CONCLUSIONS The relationship context is important in the formulation of prospective pregnancy intentions among young people. Counseling protocols, interventions and policies that attend to the complex factors that influence young couples’ pregnancy decision making are needed to better help couples attain their reproductive goals.
, Typhanye P. Dyer, MacRegga Severe, Yazmeen E. Tembunde, Kailyn E. Young, Maria R. Khan
Perspectives on Sexual and Reproductive Health, Volume 52, pp 23-30; https://doi.org/10.1363/psrh.12129

Abstract:
CONTEXT Receptive anal intercourse (RAI), which has become increasingly common among U.S. heterosexual women, is associated with STDs, including HIV, when it is unprotected and coercive. Childhood traumatic experiences may increase sexual risk behavior, but the relationship between childhood trauma and RAI among women has not been examined. METHODS Data from 4,876 female participants in Waves 1 (1994–1995), 3 (2001–2002) and 4 (2007–2008) of the National Longitudinal Study of Adolescent to Adult Health were used to examine associations between nine self‐reported childhood traumas (neglect; emotional, physical and sexual abuse; parental binge drinking and incarceration; and witnessing, being threatened with and experiencing violence) and RAI during adulthood using modified Poisson regression analysis. Whether depression, low self‐esteem, drug use, relationship characteristics or sex trade involvement mediated the relationship between trauma and RAI was also explored. RESULTS Forty percent of the sample reported having engaged in receptive anal intercourse. After adjustment for sociodemographic characteristics, eight of the nine childhood traumas were associated with increased risk of RAI (adjusted prevalence ratios, 1.2–1.5); the strongest association was with experience of violence. Each unit increase in the number of traumas yielded a 16% increase in RAI prevalence. In mediation analyses, only drug use and relationship factors slightly attenuated the association between childhood trauma and RAI (1.2 for each). CONCLUSIONS Women with a history of childhood trauma may be at increased risk of engaging in RAI, highlighting the importance of screening and trauma‐informed education in sexual health settings. Pathways linking childhood trauma and RAI among women are complex and warrant further research.
, , Justine P. Wu, Aaron B. Caughey,
Perspectives on Sexual and Reproductive Health, Volume 52, pp 31-38; https://doi.org/10.1363/psrh.12130

Abstract:
Societal views about sexuality and parenting among people with disabilities may limit these individuals' access to sex education and the full range of reproductive health services, and put them at increased risk for -unintended pregnancies. To date, however, no national population-based studies have examined pregnancy -intendedness among U.S. women with disabilities. Cross-sectional analyses of data from the 2011-2013 and 2013-2015 waves of the National Survey of Family Growth were conducted; the sample included 5,861 pregnancies reported by 3,089 women. The proportion of pregnancies described as unintended was calculated for women with any type of disability, women with each of five types of disabilities and women with no disabilities. Multivariate logistic regression analyses were conducted to examine the relationship of disability status and type with pregnancy intendedness while adjusting for covariates. A higher proportion of pregnancies were unintended among women with disabilities than among women without disabilities (53% vs. 36%). Women with independent living disability had the highest proportion of unintended pregnancies (62%). In regression analyses, the odds that a pregnancy was unintended were greater among women with any type of disability than among women without disabilities (odds ratio, 1.4), and were also elevated among women with hearing disability, cognitive disability or independent living disability (1.5-1.9). Further research is needed to understand differences in unintended pregnancy by type and extent of disability. People with disabilities should be fully included in sex education, and their routine care should incorporate discussion of reproductive planning.
, Amanda Jean Stevenson, Emily Obront, Susan Hays
Perspectives on Sexual and Reproductive Health, Volume 52, pp 15-22; https://doi.org/10.1363/psrh.12132

Abstract:
CONTEXT Most states require adolescents younger than 18 to involve a parent prior to obtaining an abortion, yet little is known about adolescents’ reasons for choosing abortion or the social support received by those who seek judicial bypass of parental consent for abortion. METHODS In‐depth interviews were conducted with 20 individuals aged 16–19 who sought judicial bypass in Texas between 2015 and 2016 to explore why they chose to get an abortion, who they involved in their decision and what their experiences of social support were. Data were analyzed thematically using stigma and social support theories. RESULTS Participants researched their pregnancy options and involved others in their decisions. They chose abortion because parenting would limit their futures, and they believed they could not provide a child with all of her or his needs. Anticipated stigma motivated participants to keep their decision private, although they desired emotional and material support. Not all male partners agreed with adolescents’ decisions to seek an abortion, and agreement by some males did not guarantee emotional or material support; some young women described their partners’ giving them the “freedom” to make the decision as avoiding responsibility. After a disclosure of their abortion decision, some participants experienced enacted stigma, including shame and emotional abuse. CONCLUSIONS Abortion stigma influences adolescents’ disclosure of their abortion decisions and limits their social support. Fears of disclosing their pregnancies and abortion decisions are justified, and policymakers should consider how laws requiring parental notification may harm adolescents. Further research is needed on adolescents’ experiences with abortion stigma.
, Alischer A. Cottrill, Eriko Kay, Elizabeth F. Janiak, Allegra R. Gordon, Jennifer Potter
Perspectives on Sexual and Reproductive Health, Volume 52, pp 7-14; https://doi.org/10.1363/psrh.12128

Abstract:
Transmasculine people-that is, individuals who were assigned female at birth and have a male or masculine gender identity-can experience unintended pregnancy. Yet research on contraception among transmasculine individuals is extremely limited. Participants were recruited online; from community-based organizations, health centers and student groups; and by chain referral. From purposive sampling, 21 transmasculine individuals aged 18-29 who resided in the greater Boston area and had had, in the last five years, a sexual partner who was assigned male at birth were selected for in-depth interviews. All interviews were conducted in person between February and May 2018 in Boston, and transcripts were analyzed using a thematic analysis approach involving inductive and deductive coding to identify themes and subthemes. Most participants believed that contraceptive use was necessary to effectively prevent pregnancy among transmasculine individuals. Their beliefs and decisions regarding contraception occurred in the context of a lack of information about contraception among transmasculine people, especially those using testosterone. Many individuals chose a contraceptive method on the basis of whether it mitigated their gender dysphoria or stopped menstruation, and said they preferred condoms and implants because these methods provided fewer reminders of their natal anatomy and were not perceived as interfering with testosterone use. Gender bias, discrimination and stigma in patient-provider interactions and health care settings negatively influenced participants' contraceptive care experiences. Health care providers and facilities should provide transmasculine people with tailored contraceptive information and care that address their specific gender-affirmation needs and contraceptive preferences in safe, inclusive and supportive clinical settings.
, Diana Greene Foster, Corinne H. Rocca
Perspectives on Sexual and Reproductive Health, Volume 52, pp 39-48; https://doi.org/10.1363/psrh.12134

Abstract:
CONTEXT Measurement of pregnancy intentions typically relies on retrospective reporting, an approach that may misrepresent the extent of unintended pregnancy. However, the degree of possible misreporting is unclear, as little research has compared prospective and retrospective reports of intention for the same pregnancies. METHODS Longitudinal data collected between 2010 and 2015 on 174 pregnancies were used to analyze the magnitude and direction of changes in intendedness (intended, ambivalent or unintended) between prospective and retrospective measurements of intendedness using versions of the London Measure of Unplanned Pregnancy (LMUP). Changes were assessed both continuously and categorically. Differences in the degree of change—by pregnancy outcome and participant characteristics—were examined using mixed-effects linear and logistic regression models. RESULTS Over two and one-half years of follow-up, 143 participants reported 174 pregnancies. Approximately half showed changes in intention between the prospective and retrospective assessments, with 38% of participants reporting increased intendedness and 10% decreased intendedness. Reported intendedness increased more among those who gave birth (mean change in continuous LMUP score, 2.2) than among those who obtained an abortion (0.7), as well as among individuals with a college degree (4.1) than among those with a high school diploma (1.2). Participants who reported recent depression or anxiety symptoms showed more stable intentions (0.02) than those who did not (2.1). CONCLUSIONS Retrospective measurement of pregnancy intentions may underestimate the frequency of unintended pregnancy, with such underestimation being greater among certain subgroups. Estimates based on retrospective reports thus may produce inaccurate impressions of intentionality. Further efforts to refine the measurement of pregnancy preferences are needed.
Perspectives on Sexual and Reproductive Health, Volume 52, pp 49-56; https://doi.org/10.1363/psrh.12131

Abstract:
The primary mission of pregnancy resource centers is to dissuade women from choosing abortion. Reproductive health and rights advocates have asserted that these centers interfere in abortion decision making. However, the reasons pregnant women go to such centers and what they experience while there have not been examined. Between June 2015 and June 2017, in-depth, semistructured phone interviews were conducted with 21 pregnant women who had presented at prenatal care clinics in southern Louisiana and Baltimore, Maryland, and who had visited a pregnancy resource center. Topics covered in the interviews included reasons for visiting a center and the experience of the visit. Transcripts were analyzed first thematically and then using grounded theory. Most of the women were low income and had not been considering abortion when they visited a pregnancy resource center. Respondents reported that they had gone to these centers for pregnancy-related services, material goods and social support. They chose these centers because the resources were free, and they were largely satisfied with their experiences. Nonetheless, their receipt of services and goods was limited and often contingent on participation in the centers' activities. Pregnancy resource centers play a role in meeting the acute material and social needs of low-income pregnant women. However, the constraints on the resources the centers offer mean that this support cannot be part of a reliable system of care. Advocates and policymakers should take a nuanced approach to regulating these centers and consider the reasons women visit them, especially low-income women.
, May Sudhinaraset, Katie Giessler, Kendall Dunlop-Korsness, Allison Stone
International Perspectives on Sexual and Reproductive Health, Volume 46, pp 1-12; https://doi.org/10.1363/46e8320

Abstract:
A growing body of evidence indicates that nonclinical health care facility staff provide support beyond their traditional roles, particularly in low- and middle-income countries. It is important to examine the role of health facility cleaners in Kenya-from their perspective-to better understand their actual and perceived responsibilities in maternity care. In-depth, face-to-face interviews using a semistructured guide were conducted with 14 cleaners working at three public health facilities in Nairobi and Kiambu Counties, Kenya, in August and September 2016. Results were coded and categorized using a thematic content analysis approach. Cleaners reported performing a range of services beyond typical maintenance responsibilities, including providing emotional, informational and instrumental support to maternity patients. They described feeling disrespected when patients were untidy or experienced bleeding; however, such examples revealed cleaners' need to better understand labor and childbirth processes. Cleaners also indicated a desire for training on interpersonal skills to improve their interactions with patients. Cleaners' direct involvement in maternity patients' care is an alarming symptom of overburdened health facilities, insufficient staffing and inadequate training. This key yet overlooked cadre of health care staff deserves appropriate support and further research to understand and alleviate health system shortcomings, and to improve the quality of maternity health care provision.
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