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Background: Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Li

OBJECTIVE: This study was undertaken to assess the acceptability of levonorgestrel emergency contraception (EC). STUDY DESIGN: We examined attitudes and use patterns among 1950 women in a randomized trial evaluating access to EC through advance provision, pharmacies, or clinics. RESULTS: Most women considered EC to be safe (92%) and effective (98%). Compared with women with clinic access, women with direct pharmacy access were no more likely to use EC within 24 hours (odds ratio [OR] = 1.65, 95% CI = 0.82-3.30) or to report it very convenient (OR = 1.41, 95% CI = 0.77-2.56). However, women with advance provisions were more likely to use EC promptly (OR = 2.43, 95% CI = 1.24-4.80) and report high convenience (OR = 4.25, 95% CI = 2.32-7.76). Advance provision increased use by all women, whereas pharmacy access increased use only among condom users. Inconvenience and fear of side effects were common reasons for nonuse. CONCLUSION: Women viewed EC favorably. Advance provision improved promptness and convenience of use overall, while pharmacy access benefited specific populations. [ABSTRACT FROM AUTHOR]

The recent U.S. Supreme Court decision cannot take obstetricians and gynecologists back to 1972, because abortion practice, training, and research have made 50 years of progress. During this past half century, safe and effective medication and surgical abortion have helped millions of patients, thousands of obstetrician-gynecologists have been trained in more than 100 programs, and thousands of clinical, epidemiologic, and sociologic studies have demonstrated the importance of abortion to personal and public health. Obstetrician-gynecologists must support one another in amending or defying laws that subvert the principles of medical practice, training, and evidence., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2022 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Study Objective: Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs., Design: Secondary analysis of a cluster-randomized provider educational trial., Setting: Forty US-based reproductive health centers., Participants: We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care., Interventions: The parent study assessed the effect of provider training on evidence-based contraceptive counseling., Main Outcome Measures: We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations., Results: Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98)., Conclusion: In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners., (Copyright © 2020 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Maternal mortality is falling in most of the world's countries, but, for 20 years, the United States has seen no reduction. Over this period, a dozen countries in various stages of development, all spending much less than the United States on health, achieved their United Nations' Millennium Development Goal of 2015 (Millennium Development Goal 5: improve maternal health), with substantial reductions in maternal mortality rates. To consider whether interventions successful in reducing global maternal mortality rates could help the United States to lower its rate, the American College of Obstetricians and Gynecologists, at the 2018 International Federation of Gynecology and Obstetrics' Rio de Janeiro World Congress, convened a panel of the presidents and representatives from five national societies with wide maternal mortality rate ranges and health expenditures and whose national societies had focused on reducing maternal mortality for Millennium Development Goal 5. They identified expanded access to reproductive health care, particularly contraception and safe abortion, as key interventions that had proven effective in decreasing maternal mortality rates worldwide.

Objective: The objective was to evaluate amenorrhea patterns and predictors of amenorrhea during the first year after levonorgestrel 52 mg intrauterine system (IUS) placement., Study Design: This cohort analysis includes 1714 nulliparous and parous women who received a Liletta® levonorgestrel 52 mg IUS in a multicenter trial to evaluate efficacy and safety for up to 8 years. Participants maintained a daily diary with bleeding information. We assessed bleeding patterns in 90-day intervals; amenorrhea was defined as no bleeding or spotting in the preceding 90 days. We employed multivariable regression to identify predictors of amenorrhea at 12 months. The predictor analysis only included women not using a levonorgestrel IUS in the month prior to study enrollment., Results: In the month before enrollment, 148 and 1566 women, respectively, had used and not used a levonorgestrel IUS. Prior users averaged 50±19 months of use before IUS placement; 38.4% of these women reported amenorrhea at 12 months. Amenorrhea rates for non-prior-users at 3, 6, 9 and 12 months were 0.2%, 9.1%, 17.2% and 16.9%, respectively. During the first 12 months, 29 (1.7%) women discontinued for bleeding irregularities; no women discontinued for amenorrhea. The only significant predictor of amenorrhea at 12 months was self-reported baseline duration of menstrual flow of fewer than 7 days vs. 7 or more days (18.2% vs. 5.2%, adjusted odds ratio 3.70 [1.69, 8.07]). We found no relationships between 12-month amenorrhea rates and age, parity, race, body mass index, baseline flow intensity or hormonal contraception use immediately prior to IUS placement., Conclusions: Amenorrhea rates during the first year of levonorgestrel 52 mg IUS use are similar at 9 and 12 months. Amenorrhea at 12 months is most common among women with shorter baseline duration of menstrual flow., Implications Statement: This information provides more data for clinicians when counseling women about amenorrhea expectations, especially since women seeking a levonorgestrel 52 mg IUS for contraception are different than women desiring treatment for heavy menstrual bleeding. Amenorrhea at 12 months is most common among women with shorter baseline duration of menstrual flow., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Expanding access to medication abortion through pharmacies is a promising avenue to reach women with safe and convenient care, yet no pharmacy provision interventions have been evaluated. This observational non-inferiority study investigated the effectiveness and safety of mifepristone-misoprostol medication abortion provided at pharmacies, compared to government-certified public health facilities, by trained auxiliary nurse-midwives in Nepal., Methods: Auxiliary nurse-midwives were trained to provide medication abortion through twelve pharmacies and public facilities as part of a demonstration project in two districts. Eligible women were ≤63 days pregnant, aged 16-45, and had no medical contraindications. Between 2014-2015, participants (n = 605) obtained 200 mg mifepristone orally and 800 μg misoprostol sublingually or intravaginally 24 hours later, and followed-up 14-21 days later. The primary outcome was complete abortion without manual vacuum aspiration; the secondary outcome was complication requiring treatment. We assessed risk differences by facility type with multivariable logistic mixed-effects regression., Results: Over 99% of enrolled women completed follow-up (n = 600). Complete abortions occurred in 588 (98·0%) cases, with ten incomplete abortions and two continuing pregnancies. 293/297 (98·7%) pharmacy participants and 295/303 (97·4%) public facility participants had complete abortions, with an adjusted risk difference falling within the pre-specified 5 percentage-point non-inferiority margin (1·5% [-0·8%, 3·8%]). No serious adverse events occurred. Five (1.7%) pharmacy and two (0.7%) public facility participants experienced a complication warranting treatment (aRD, 0.8% [-1.0%-2.7%])., Conclusions: Early mifepristone-misoprostol abortion was as effective and safe when provided by trained auxiliary nurse-midwives at pharmacies as at government-certified health facilities. Findings support policy expanding provision through registered pharmacies by trained auxiliary nurse-midwives to improve access to safe care.

Background: In 2013, California passed Assembly Bill (A.B.) 2348, approving registered nurses (RNs) to dispense patient self-administered hormonal contraceptives and administer injections of hormonal contraceptives. The Family Planning, Access, Care and Treatment (Family PACT) program, which came into effect in 1997 to expand low-income, uninsured California resident access to contraceptives at no cost, is one program in which qualified RNs can dispense and administer contraceptives., Aims: The aims of this study were to (a) describe utilization of RN visits within California's Family PACT program and (b) evaluate the impact of RN visits on client birth control acquisition during the first 18 months after implementation of A.B. 2348 (January 1, 2013 to June 30, 2014)., Methods: A descriptive observational design using administrative databases was used. Family PACT claims were retrieved for RN visits and contraception. Paid claims for contraceptive dispensing and/or administration visits by physicians, nurse practitioners, certified nurse midwives, and physician assistants were compared before and after the implementation of A.B. 2348 at practice sites where RN visits were and were not utilized. Contraceptive methods and administration procedures were identified using Healthcare Common Procedure Coding System codes, National Drug Codes, and Common Procedural Terminology codes. Claims data for healthcare facilities were abstracted by site location based on a unique combination of National Provider Identifier (NPI), NPI Owner, and NPI location number., Results: RN visits were found mainly in Northern California and the Central Valley (73%). Sixty-eight percent of RN visits resulted in same-day dispensing and/or administration of hormonal (and/or barrier) methods. Since benefit implementation, RN visits resulted in a 10% increase in access to birth control dispensing and/or administration visits. RN visits were also associated with future birth control acquisition and other healthcare utilization within the subsequent 30 days., Discussion: RN visits, though underutilized across the state, have resulted in increased access to contraception in some communities, an effect that may continue to grow with time and can serve as a model for other states.

Objective: The objective was to monitor the effectiveness of the etonogestrel implant clinical training program through a voluntary active monitoring program (AMP)., Study Design: US health care providers underwent mandatory training by the manufacturer on etonogestrel implant insertion, localization and removal. After training, health care providers could enroll in a voluntary AMP to provide outcome data to meet a postmarketing commitment of the manufacturer with the US Food and Drug Administration (FDA). Those who volunteered completed and faxed forms to the manufacturer after implant insertion and removal detailing the procedure and device-related outcomes, including insertion-, localization- or removal-associated events. Experts reviewed outcome data quarterly, which the Sponsor then reported to the FDA., Results: Among 42,337 health care providers completing the training program, 4294 (10.1%) volunteered to participate in the AMP. The 26,198 forms submitted over 6.4 years included more insertion (n=20,497) forms than removal forms (n=5701). The volunteers reported 646 events on 566 (2.2%) forms related to insertion (n=197), localization (n=34), removal (n=357) and "other" (n=58). Clinically important events included noninsertion (n=4), serum etonogestrel positive but implant not found (n=1), and possible nerve (n=66) or vascular (n=5) injury. The reports did not include any insertion-, localization- or removal-associated hospitalizations. Eight (0.14%) removal reports described referral for surgical implant removal., Conclusion: Events related to insertion, localization or removal of the etonogestrel implant are uncommon among US providers who received mandatory training in the use of the implant., Implications: This report presents results from the first mandatory US contraceptive training program. Health care providers volunteered to report information about etonogestrel implant insertion, localization and removal. Although the data do not demonstrate whether a mandatory program improves outcomes, they elucidate the utility and real-life experience that clinical training programs can provide., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: The majority of pregnancies during adolescence are unintended, and few adolescents use long-acting reversible contraception (LARC) due in part to health care providers' misconceptions about nulliparous women's eligibility for the intrauterine device. We examined differences in LARC counseling, selection, and initiation by age and parity in a study with a provider's LARC training intervention., Methods: Sexually active women aged 18-25 years receiving contraceptive counseling (n = 1,500) were enrolled at 20 interventions and 20 control clinics and followed for 12 months. We assessed LARC counseling and selection, by age and parity, with generalized estimated equations with robust standard errors. We assessed LARC use over 1 year with Cox proportional hazards models with shared frailty for clustering., Results: Women in the intervention had increased LARC counseling, selection, and initiation, with similar effects among older adolescent and nulliparous women, and among young adult and parous women. Across study arms, older adolescents were as likely as young adults to receive LARC counseling (adjusted odds ratio [aOR] = .85; 95% confidence interval [CI]: .63-1.15), select LARC (aOR = .86; 95% CI: .64-1.17), and use LARC methods (adjusted hazard ratio [aHR] = .94; 95% CI: .69-1.27). Nulliparous women were less likely to receive counseling (aOR = .57; 95% CI: .42-.79) and to select LARC (aOR = .53; 95% CI: .37-.75) than parous women, and they initiated LARC methods at lower rates (aHR = .65; 95% CI: .48-.90). Nulliparous women had similar rates of implant initiation but lower rates of intrauterine device initiation (aHR = .59; 95% CI: .41-.85)., Conclusions: Continued efforts should be made to improve counseling and access to LARC methods for nulliparous women of all ages., (Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: We determined whether public funding for contraception was associated with long-acting reversible contraceptive (LARC) use when providers received training on these methods., Methods: We evaluated the impact of a clinic training intervention and public funding on LARC use in a cluster randomized trial at 40 randomly assigned clinics across the United States (2011-2013). Twenty intervention clinics received a 4-hour training. Women aged 18 to 25 were enrolled and followed for 1 year (n = 1500: 802 intervention, 698 control). We estimated the effects of the intervention and funding sources on LARC initiation with Cox proportional hazards models with shared frailty., Results: Women at intervention sites had higher LARC initiation than those at control (22 vs 18 per 100 person-years; adjusted hazard ratio [AHR] = 1.43; 95% confidence interval [CI] = 1.04, 1.98). Participants receiving care at clinics with Medicaid family planning expansion programs had almost twice the initiation rate as those at clinics without (25 vs 13 per 100 person-years; AHR = 2.26; 95% CI = 1.59, 3.19). LARC initiation also increased among participants with public (AHR = 1.56; 95% CI = 1.09, 2.22) but not private health insurance., Conclusions: Public funding and provider training substantially improve LARC access.

Background: Unintended pregnancy remains a serious public health challenge in the USA. We assessed the effects of an intervention to increase patients' access to long-acting reversible contraceptives (LARCs) on pregnancy rates., Methods: We did a cluster randomised trial in 40 reproductive health clinics across the USA in 2011-13. 20 clinics were randomly assigned to receive evidence-based training on providing counselling and insertion of intrauterine devices (IUDs) or progestin implants and 20 to provide standard care. Usual costs for contraception were maintained at all sites. We recruited women aged 18-25 years attending family planning or abortion care visits and not desiring pregnancy in the next 12 months. The primary outcome was selection of an IUD or implant at the clinic visit and secondary outcome was pregnancy within 12 months. We used generalised estimating equations for clustered data to measure the intervention effect on contraceptive selection, and used survival analysis to assess pregnancy rates., Findings: Of 1500 women enrolled, more at intervention than control sites reported receiving counselling on IUDs or implants (565 [71%] of 797 vs 271 [39%] of 693, odds ratio 3·8, 95% CI 2·8-5·2) and more selected LARCs during the clinic visit (224 [28%] vs 117 [17%], 1·9, 1·3-2·8). The pregnancy rate was lower in intervention group than in the control group after family planning visits (7·9 vs 15·4 per 100 person-years), but not after abortion visits (26·5 vs 22·3 per 100 person-years). We found a significant intervention effect on pregnancy rates in women attending family planning visits (hazard ratio 0·54, 95% CI 0·34-0·85)., Interpretation: The pregnancy rate can be reduced by provision of counselling on long-term reversible contraception and access to devices during family planning counselling visits., Funding: William and Flora Hewlett Foundation., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: This article presents the extent to which providers enrolled in California's Family Planning, Access, Care, and Treatment (Family PACT) program offer contraceptive methods onsite, thus eliminating one important access barrier. Family PACT has a diverse provider network, including public-sector providers receiving Title X funding, public-sector providers not receiving Title X funding, and private-sector providers. We explored whether Title X funding enhances providers' ability to offer contraceptive methods that require specialized skills onsite., Methods: Data were derived from 1,072 survey responses to a 2010 provider-capacity survey matched by unique identifier to administrative claims data., Results: A significantly greater proportion of Title X-funded providers compared to non-Title X public and private providers offered onsite services for the following studied methods: intrauterine contraceptives (90% Title X, 51% public non-Title X, 38% private); contraceptive implants (58% Title X, 19% public non-Title X, 7% private); vasectomy (8% Title X, 4% public non-Title X, 1% private); and fertility-awareness methods (69% Title X, 55% public non-Title X, 49% private) (all p<0.0001). The association between onsite provision and Title X funding remained after stratifying individually by clinic specialty, facility capacity to provide reproductive health services (based on staffing), and rural/urban location., Conclusions: Extra funding for publicly funded family-planning programs, through mechanisms such as Title X, appears to be associated with increased onsite access to a wide range of contraceptive services, including those that require special skills and training.

Background: Abortion was legalized in Nepal in 2002, following advocacy efforts highlighting high maternal mortality from unsafe abortion. We sought to assess whether legalization led to reductions in the most serious maternal health consequences of unsafe abortion., Methods: We conducted retrospective medical chart review of all gynecological cases presenting at four large public referral hospitals in Nepal. For the years 2001-2010, all cases of spontaneous and induced abortion complications were identified, abstracted, and coded to classify cases of serious infection, injury, and systemic complications. We used segmented Poisson and ordinary logistic regression to test for trend and risks of serious complications for three time periods: before implementation (2001-2003), early implementation (2004-2006), and later implementation (2007-2010)., Results: 23,493 cases of abortion complications were identified. A significant downward trend in the proportion of serious infection, injury, and systemic complications was observed for the later implementation period, along with a decline in the risk of serious complications (OR 0.7, 95% CI 0.64, 0.85). Reductions in sepsis occurred sooner, during early implementation (OR 0.6, 95% CI 0.47, 0.75)., Conclusion: Over the study period, health care use and the population of reproductive aged women increased. Total fertility also declined by nearly half, despite relatively low contraceptive prevalence. Greater numbers of women likely obtained abortions and sought hospital care for complications following legalization, yet we observed a significant decline in the rate of serious abortion morbidity. The liberalization of abortion policy in Nepal has benefited women's health, and likely contributes to falling maternal mortality in the country. The steepest decline was observed after expansion of the safe abortion program to include midlevel providers, second trimester training, and medication abortion, highlighting the importance of concerted efforts to improve access. Other countries contemplating changes to abortion policy can draw on the evidence and implementation strategies observed in Nepal.

Past US FDA decisions about emergency contraception (EC) have been subject to undue political influence, and last year's barring of over-the-counter access to Plan B One-Step(®) for those under the age of 17 years is no exception. The US Department of Health and Human Services cited insufficient data on EC use for females aged 11-12 years. These youngest adolescents, however, rarely need EC: data from California (USA) show that in 2009, fewer than one in 10,000 females under the age of 13 years received EC. Maintaining barriers to safe and effective EC is not medically necessary and conflicts with national goals to decrease teenage and unintended pregnancies.

Background: Publicly funded family planning services play an important role in reducing unintended pregnancy by providing access to effective contraception. We assessed whether California family planning providers receiving federal Title X funds are more likely to offer on-site long-acting reversible contraception (LARC) methods than those who do not receive these funds., Study Design: Using 2009 administrative data, we examined on-site utilization of LARC by clinic type (Title X public, non-Title X public, or private) and constructed beta-binomial logistic regression models., Results: The odds of on-site LARC services in non-Title X public and private providers were decreased by 35% [Odds Ratio (OR)=0.65, 95% confidence interval (CI) 0.54-0.79] and 61% [OR=0.39, 95% CI 0.32-0.47], respectively, compared to those of Title X providers after controlling for clinic size, urban/rural location, and proportion of teen, African-American, and Latina clients., Conclusions: On-site utilization of LARC is a potential quality indicator for family planning programs. Title X resources are associated with increased use of LARC., (Published by Elsevier Inc.)

Background and Objectives: Family physicians and obstetrician-gynecologists provide much of contraceptive care in the United States and have a shared goal in preventing unintended pregnancy among patients. We assessed their competency to offer women contraceptives of the highest efficacy levels., Methods: We conducted a national probability survey of family physicians and obstetrician-gynecologists (n=1,192). We measured counseling and provision practices of intrauterine contraception and used multivariable regression analysis to evaluate the importance of evidence-based knowledge to contraceptive care., Results: Family physicians reported seeing fewer contraceptive patients per week than did obstetrician-gynecologists and were less likely to report sufficient time for counseling. While 95% of family physicians believed patients were receptive to learning about intrauterine contraception, fewer than half offered counseling or the method. Only half were trained to competence to offer intrauterine contraception, while virtually all obstetrician-gynecologists were. Both family physicians and obstetrician-gynecologists were unlikely to have adequate knowledge of the women who would be good candidates for intrauterine contraception-as gauged by the Centers for Disease Control and Prevention Medical Eligibility Criteria for contraception-and consequently did not offer the method to a wide range of eligible patients., Conclusions: Most family physicians providing contraceptive care were not offering methods with top-tier effectiveness, although they reported interest in updating contraceptive skills through training. Obstetrician-gynecologists had technical skills to offer intrauterine contraception but still required education on patient selection. Greater hands-on training opportunities for family physicians, and complementary education on eligible method candidates for obstetrician-gynecologists, can increase access to intrauterine contraception by women seeking contraceptive care.

Background: Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers' views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care., Methods: To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data., Results: Overall, participants had positive views of abortion legalization - many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment., Conclusions: Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications.

The use of performance indicators has the potential to improve service quality and avert costs, yet such indicators have typically not been used to assess family planning and reproductive health services. An exception is California's Family PACT (Planning, Access, Care, and Treatment) Program, a statewide family planning and reproductive health services program. Our study assessed whether the behavior of providers participating in this program was influenced by performance reports that used both quality improvement and utilization management indicators. We examined three indicators in each category from 2005 to 2009 and found that change occurred in five of six indicators among private providers and in three of six indicators among public providers. Chlamydia screening rates in women age twenty-five and younger, for example, increased significantly among both private and public providers. Despite the challenges enumerated in this article, we conclude that the methodology used in the program could serve as a starting point for the development of a uniform set of provider-focused reproductive health quality and utilization reports that could be instituted by state family planning programs, state Medicaid programs and health plans, and other health care delivery systems.

Objective: To estimate the number of unintended pregnancies averted through the provision of family planning services to low income women in Family PACT, California's Medicaid waiver program., Study Design: We use a Markov model to estimate the number of pregnancies in the absence of Family PACT based on the contraceptive method mix used before program enrollment, and pregnancies in the presence of the program, based on method dispensing claims., Results: Nearly 1 million (998,084) women were provided with contraceptives in Family PACT in 2007. Contraceptive services averted over an estimated 286,700 unintended pregnancies including 122,000 abortions, 133,000 unintended births, and over 40,000 births among teens., Conclusion: This conservative measure of the effect of Family PACT on unintended pregnancies indicates the benefit of expanding access to contraceptive services, an example for other states considering expanding access to family planning services through a state plan amendment under health care reform., (Copyright © 2011 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

The University of California, San Francisco, initiated a Fellowship in Family Planning in 1991, and since then 23 academic teaching hospitals across the country have adopted the 2 year program model for training obstetrician-gynecologist physicians in a subspecialty focused on contraception and abortion. The program follows a curriculum that includes clinical practice, research, and international work. This review includes information about the Fellowship in Family Planning as well as research opportunities available from academia, independent foundations, and government related sources., (Copyright © 2011 Mosby, Inc. All rights reserved.)

The adoption of Title X in 1971 provided for public funding for family planning in the United States but funding from this program has not kept pace with demand for contraceptives. In 1997, The California Department of Public Health established the Family Planning, Access, Care, and Treatment (PACT) Program, a public-private partnership to meet the needs of Californians, including about a half-million adolescents, who did not have access to contraceptive services. The program has saved the state billions of dollars in maternity and abortion costs, dramatically reduced teen pregnancy rates, and serves as a good example for other states., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: The study was conducted to estimate the long-term costs for implementing citizenship documentation requirements in a Medicaid expansion program for family planning services in Oregon., Study Design: A decision-analytic model was developed using two perspectives: the state and society. Our primary outcome was future reproductive health care costs due to pregnancy in the next 5 years. A Markov structure was utilized to capture multiple future pregnancies. Model inputs were retrieved from the existing literature and local hospital and Medicaid data related to reimbursements. One-way and multi-way sensitivity analyses were conducted. A Monte Carlo simulation was performed to simultaneously incorporate uncertainty from all of the model inputs., Results: Screening for citizenship results in a loss of $3119 over 5 years ($39,382 vs. $42,501) for the state and $4209 for society ($63,391 compared to $59,182) for adult women. Among adolescents, requiring proof of identity and citizenship results in a loss of $3123 for the state ($39,378 versus $42,501) and $4214 for society ($63,391 instead of $59,177)., Conclusion: Screening for citizenship status in publicly funded family planning clinics leads to financial losses for the state and society., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Sex-selective abortion is expressly prohibited in Nepal, but limited evidence suggests that it occurs nevertheless. Providers' perspectives on sex-selective abortion were examined as part of a larger study on legal abortion in the public sector in Nepal., Methods: In-depth interviews were conducted with health care providers and administrators providing abortion services at four major hospitals (n = 35), two in the Kathmandu Valley and two in outlying rural areas. A grounded theory approach was used to code interview transcripts and to identify themes in the data., Results: Most providers were aware of the ban on sex-selective abortion and, despite overall positive views of abortion legalization, saw sex selection as an increasing problem. Greater availability of abortion and ultrasonography, along with the high value placed on sons, were seen as contributing factors. Providers wanted to perform abortions for legal indications, but described challenges identifying sex-selection cases. Providers also believed that illegal sex-selective procedures contribute to serious abortion complications., Conclusion: Sex-selective abortion complicates the provision of legal abortion services. In addition to the difficulty of determining which patients are seeking abortion for sex selection, health workers are aware of the pressures women face to bear sons and know they may seek unsafe services elsewhere when unable to obtain abortions in public hospitals. Legislative, advocacy, and social efforts aimed at promoting gender equality and women's human rights are needed to reduce the cultural and economic pressures for sex-selective abortion, because providers alone cannot prevent the practice., (Copyright © 2011 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Intrauterine progestins have many important current and potential gynecologic applications. This article describes the evidence for use of intrauterine progestin for common gynecologic conditions beyond its important role in contraception. The pharmacology of and selection criteria for use of the levonorgestrel intrauterine device is discussed, and the evidence for use of intrauterine progestin delivery for menorrhagia, endometriosis management, uterine fibroids, adenomyosis and endometrial hyperplasia is reviewed.

Intrauterine progestins, progesterone receptor modulators, and antagonists have many important current and potential gynecologic applications. This article will describe the evidence for use of intrauterine progestin for common gynecologic conditions beyond its important role in contraception. We will review the evidence for use of intrauterine progestin delivery for menorrhagia, endometriosis management, adenomyosis treatment, uterine fibroids, endometrial hyperplasia, and its concurrent use in women on hormone replacement therapy or tamoxifen., (Copyright (c) 2010 Mosby, Inc. All rights reserved.)

Objective: To estimate the costs of expanding Emergency Medicaid coverage to include postpartum contraception., Methods: A decision-analytic model was developed using three perspectives: the hospital, state Medicaid programs, and society. Our primary outcome was future reproductive health care costs due to pregnancy in the next 5 years. A Markov structure was use to analyze the probability of pregnancy over a 5-year time period. Model inputs were retrieved from the existing literature and local hospital and Medicaid data related to reimbursements. One-way and multiway sensitivity analyses were conducted. A Monte Carlo simulation was performed to incorporate uncertainty from all of the model inputs simultaneously., Results: Over a 5-year period, provision of contraception would save society $17,792 per woman in future pregnancy costs and incur a loss of $367 for hospitals. In states in which 49% of immigrants remain in the area for 5 years, such a program would save state Medicaid $108 per woman., Conclusion: Under federal regulations, new immigrants are restricted to acute, hospital-based care only. Failure to provide the option of contraception postpartum results in increased costs for society and states with long-term immigrants.

Background: A formulation of depot medroxyprogesterone acetate (DMPA) has been developed that allows subcutaneous injection (104 mg/0.65 mL; DMPA-SC) and achieves highly effective contraception with a similar tolerability profile to intramuscular DMPA (150 mg/mL; DMPA-IM)., Study Design: This randomized, evaluator-blinded study was designed to compare efficacy, safety, and user satisfaction in women receiving DMPA-SC (n=266) or DMPA-IM (n=268) for 2 years with an option to continue for a third year. The primary objectives were to evaluate bone mineral density (BMD) changes and contraceptive efficacy after 2 years., Results: A total of 225 women completed the first 2 years of this study (DMPA-SC, n=116; DMPA-IM, n=109). After 2 years of DMPA use, BMD loss was marginally smaller in the DMPA-SC group than in the DMPA-IM group at both the total hip (-3.3% and -3.6%, respectively) and lumbar spine (-4.3% and -5.0%, respectively). In those women who received DMPA during the third year, there were no statistically significant differences in BMD loss between DMPA-SC and DMPA-IM groups at the end of Year 3. Recovery of BMD was observed in the small subpopulation of women who had discontinued DMPA-SC or DMPA-IM after the second year. The 2-year treatment-failure cumulative pregnancy rate was 0% in the DMPA-SC group and 0.8% (95% confidence interval, 0.00-2.37%) in the DMPA-IM group (life-table method). Adverse events were similar in the two groups except that injection site reactions were more common in the DMPA-SC group., Conclusion: DMPA-SC is an effective and well-tolerated contraceptive option, providing comparable efficacy and BMD safety to DMPA-IM.

Background: The study was conducted to assess the continuation and patient satisfaction with intrauterine contraception (IUC) insertion immediately after elective abortion in the first and second trimesters in an urban, public hospital-based clinic., Study Design: A cohort of 256 women who elected to have insertion of a copper-T IUC (CuT380a) or a levonorgestrel-releasing IUC (LNG-IUC) were followed postoperatively by phone calls or chart review to evaluate satisfaction and continuation with the method., Results: Of our 256 subjects, 123 had first-trimester abortions and 133 had second-trimester abortions (14 or more weeks). Median time to follow-up was 8 weeks (range 7-544 days). Nineteen discontinuations occurred: eight (6.5%, 95% CI 2.8-12.4%) following first-trimester and 11 (8.3%, 95% CI 4.2-14.3%) following second-trimester abortion (p=.6). Five women reported expulsion; one (0.8%, 95% CI 0.0-4.4%) in the first-trimester group and four (3.0%, 95% CI 0.8-7.5%) in the second-trimester group. (p=.4) Seven infections resulting in discontinuation occurred (2.7%, 95% CI 1.1-5.6%); none were positive for gonorrhea or chlamydia at time of insertion. No perforations occurred. Nearly all (93.8%) of the women were satisfied with IUC. Rates of satisfaction between women after first- and second-trimester abortions were equal., Conclusion: In an urban clinic, IUC has high initial continuation and high patient satisfaction when inserted immediately following either first- or second-trimester abortions.