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Reducing the rate of cesarean sections among women considered at low risk for delivery by that method is a goal of Healthy People 2030. Prior research suggests that perinatal mood and anxiety disorders increase the risk for cesarean section, but data are limited. This cross-sectional study of commercially insured women examined the relationship between perinatal depression and anxiety disorders and primary (first-time) cesarean section rates, using administrative claims data for US in-hospital deliveries from the period 2008-17. Of the 360,225 delivery hospitalizations among 317,802 unique women, 24.0 percent included a delivery by primary cesarean section, and 3.1 percent carried a diagnosis of depression, anxiety, or both made during the index pregnancy. Using an adjusted generalized estimating equation, we found that the predicted probability of primary cesarean section was 3.5 percentage points higher, on average, among women with these disorders compared with those without them. Our findings confirm the importance of pursuing research to identify mechanisms by which perinatal depression and anxiety disorders increase the risk for primary caesarean section among women otherwise considered at low risk for delivery by that method, as well as effective interventions.

INTRODUCTION AND HYPOTHESIS: We investigated whether factors influencing pelvic floor hiatal closure are inter-related or independent, hypothesizing that a) hiatus size is moderately correlated with levator defect, pelvic floor muscle strength, and change in hiatus size with contraction; and b) urogenital hiatus (UGH) and levator hiatus (LH) measures are similar in patients with anterior wall (AW) and posterior wall (PW) prolapse. METHODS: This cross-sectional case-control study included subjects with AW prolapse (n=50), PW prolapse (n=50), and normal support (n=50). Hiatus measurements and levator defects were assessed on MRI and vaginal closure force was measured with an instrumented speculum. Pearson correlation coefficients and simple and multivariable linear regression models were performed. RESULTS: During contraction, LH narrowed 47% more in the PW compared to AW group (p=0.001). With straining, LH lengthened 34% more in the PW than AW group (p

Key Points Question What is the prevalence of financial hardship, including unmet health care need due to cost, health care unaffordability, and general financial stress, among peripartum women in the United States? Findings This cross-sectional study of 3509 peripartum women, weighted to represent more than 1 million women, found that financial hardship was common: from 2013 to 2018, 24% reported unmet health care needs; 60%, health care unaffordability; and 54%, general financial stress. Private insurance was associated with lower odds of unmet health care need but higher odds of health care unaffordability, and lower household income was associated with higher odds of both unmet health care need and health care unaffordability. Meaning These findings suggest that financial hardship is highly prevalent among peripartum women, which should prompt policy interventions to promote the economic well-being of families., This cross-sectional study evaluates the prevalence of financial hardship, including as unmet health care need due to cost, health care unaffordability, and general financial stress, among peripartum women over time and by insurance type and income., Importance Financial hardship affects health care access and health outcomes among peripartum women. Objective To evaluate the prevalence of financial hardship among peripartum women over time and by insurance type and income. Design, Setting, and Participants This cross-sectional study included peripartum women, defined as women aged 18 to 45 years who reported being currently pregnant or pregnant in the past 12 months, who participated in the National Health Interview Survey from 2013 to 2018. Data were analyzed from January to May 2021. Exposures Current pregnancy or recent pregnancy as well as insurance type and income. Main Outcomes and Measures Three measures of financial hardship within the last year were evaluated: (1) unmet health care need due to cost (unmet need for medical care or delayed or deferred medical care due to cost); (2) health care unaffordability (worry about paying for potential medical bills or existing medical debt); and (3) general financial stress (worry about subsistence spending [eg, monthly bills, housing]). Results The study cohort included 3509 peripartum women, weighted to represent 1 050 789 women (2018: an estimated 36 045 of 184 018 [19.6%] Hispanic, 39 017 [21.2%] Black, and 97 366 [52.9%] White), with a mean (SD) age of 29 (6) years. Overall, from 2013 to 2018, 24.2% (95% CI, 22.6%-26.0%) of peripartum women reported unmet health care need, 60.0% (95% CI, 58.0%-61.9%) reported health care unaffordability, and 54.0% (95% CI, 51.5%-56.5%) reported general financial stress. The prevalence of financial hardship outcomes did not substantially change between 2013 and 2018 (unmet health care need in 2013: 27.9% [95% CI, 24.4%-31.7%]; in 2018: 23.7% [95% CI, 19.5%-28.6%]; health care unaffordability in 2013: 65.7% [95% CI, 61.1%-70.0%]; in 2018: 58.8% [95% CI, 53.4%-64.0%]; general financial stress in 2013: 60.6% [95% CI, 55.2%-65.8%]; in 2018: 53.8% [95% CI, 47.8%-59.8%]). Women with private insurance had lower odds of unmet need (adjusted odds ratio [aOR], 0.67; 95% CI, 0.52-0.87) but higher odds of health care unaffordability (aOR, 1.88; 95% CI, 1.49-2.36) compared with women with public insurance. Peripartum women with household incomes less than 400% of the federal poverty level had higher odds of unmet need (aOR, 1.50; 95% CI, 1.08-2.08) and unaffordable care (aOR, 1.98; 95% CI, 1.54-2.55) compared with those with household incomes 400% or more of federal poverty level. Conclusions and Relevance These findings suggest that financial hardship among peripartum women in the United States was common from 2013 to 2018, including 24% of pregnant and postpartum women reporting unmet health care need and 60% reporting health care unaffordability. Women with private insurance and those living on lower incomes were more likely to experience unaffordable health care than women with pubic insurance and those with higher incomes, respectively. Targeted policy interventions are needed to improve health care affordability and promote overall economic security among peripartum women.

The Affordable Care Act (ACA) requires employer-based insurance plans to cover maternity services, but plans are allowed to impose cost sharing such as copayments and deductibles for these services. This study aimed to evaluate trends in cost sharing for maternity care among working women in employer-based plans, before and after the ACA. Our data indicate that between 2008 and 2015, average out-of-pocket spending for maternity care rose among women with employer-based insurance. This increase was largely driven by increased spending among women with deductibles. When we controlled for potential confounders, we found that out-of-pocket spending was higher for lower-income working women in 2008-13, but disparities disappeared in 2014-15 because of a continued rise in spending among higher-income working women. Policies that aim to lower out-of-pocket spending for maternity care could reduce a significant financial burden on families.

BACKGROUND: In the context of a randomized controlled trial evaluating the efficacy of augmenting fluoxetine treatment in young adults with major depressive disorder (MDD) using a modified repeated partial sleep deprivation protocol contrasting two weeks of restricted time in bed (i.e., 6h TIB) to no time in bed restriction (i.e., 8h TIB) the study examines whether sleep duration and the timing of repeated partial sleep deprivation predicts patient reported affect ratings. PARTICIPANTS: Participants included 58 young adults with DSM-IV-diagnosed MDD. METHODS: Daily ratings of affect and sleep were collected during the first two weeks of initiating fluoxetine treatment, yielding 630 person-days. Actigraphy monitoring was employed to assess compliance with time in bed condition. RESULTS: Negative affect ratings and positivity ratios in the morning were more improved among participants assigned to the 6h TIB condition compared to the 8h TIB group. Participants whose bedtime was delayed by 2 hours nightly demonstrated the most significant improvement in negative affect and positivity ratio during the first two weeks of fluoxetine therapy. Moreover, the trajectory of morning negative affect ratings in the first two weeks was predictive of remission after 4 weeks of fluoxetine therapy. CONCLUSIONS: These findings suggest that monitoring changes in daily affect may be a valuable marker of early treatment response in young adults with MDD. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01545843

Background Cost sharing may impede postpartum contraceptive use. We evaluated the association between out-of-pocket costs and long-acting reversible contraceptive (LARC) insertion among commercially insured postpartum women. Methods Using the Clinformatics Data Mart, we examined out-of-pocket costs for LARC insertions at 0 to 3 and 4–60 days postpartum among women in employer-sponsored health plans from 2013 to 2016. Patient costs were estimated by summing copayment, coinsurance, and deductible payments for LARC services (device + placement). Multivariable logistic regression evaluated the association between plan cost sharing for LARC services (at least one beneficiary with >$200 cost share) and LARC insertion by 60 days postpartum (yes/no). Results We identified 396,073 deliveries among women in 51,797 employer-based plans. Overall, LARC placement by 60 days postpartum was observed after 5.2% (n = 20,604) of deliveries. Inpatient LARC insertion (n = 233; 0.06% of deliveries) was less common than outpatient LARC insertion (n = 20,375; 5.14% of deliveries). Cost sharing was observed in 23.4% of LARC insertions (inpatient IUD: median, $50.00; range, $0.93–5,055.91; inpatient implant: median, $11.91; range, $2.49–650.14; outpatient IUD: median, $25.00; range, $0.01–3,354.80; outpatient implant: median, $27.20; range, $0.18–2,444.01). Among 5,895 plans with at least one LARC insertion and after adjusting for patient age, poverty status, race/ethnicity, region, and plan type, women in plans with cost sharing of more than $200 demonstrated lower odds of LARC use by 60 days postpartum (odds ratio, 0.74; 95% confidence interval, 0.71–0.77). Conclusions Cost sharing for postpartum LARC is associated with use, suggesting that out-of-pocket costs may impede LARC access for some commercially insured postpartum women. Reducing out-of-pocket costs for the most effective forms of contraception may increase use.

INTRODUCTION AND OBJECTIVE: A wide variety of reference lines and landmarks have been used in imaging studies to diagnose and quantify posterior vaginal wall prolapse without consensus. We sought to determine which is the best system to 1) identify posterior vaginal wall prolapse and its appropriate cutoff values, and 2) assess the prolapse size. METHODS: This was a secondary analysis of sagittal maximal Valsalva dynamic MRI scans from 52 posterior-predominant prolapse cases and 60 comparable controls from ongoing research. All eight existing measurement lines and a new parameter, i.e., Exposed Vaginal Length, were measured. Expert opinions were used to score the prolapse sizes. Simple linear regressions, effect sizes, area under the curve, and Classification and Regression Tree analyses were used to compare these reference systems and determine cutoff values. Linear and ordinal logistic regression were used to assess the effectiveness of the prolapse size. RESULTS: Among existing parameters, “the Perineal Line-Internal Pubis”, a reference line from the inside of the pubic symphysis to the front tip of perineal body, (cutoff value 0.9 cm) had the largest effect size (1.61), showed the highest sensitivity and specificity to discriminate prolapse with area under the curve (0.91), and explained the most variation (68%) in prolapse size scores. The Exposed Vaginal Length (cutoff value 2.9) outperformed all the existing lines, with the largest effect size (2.09), area under the curve (0.95), and R-squared value (0.77). CONCLUSION: The Exposed Vaginal Length has slightly better performance than the best of the existing systems, both for diagnosing and quantifying posterior prolapse size. Performance characteristics and evidence-based cutoffs might be useful in clinical practice.

Background National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (ie, insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits—packages of resources and strategies to facilitate the implementation of new services—are a promising approach for guiding clinical practice change. Objective This study aimed to develop a theory-informed toolkit, evaluate the feasibility of toolkit-based implementation of immediate postpartum long-acting reversible contraception care in a single site, and refine the toolkit and implementation process for future effectiveness testing. Study Design We conducted a single-site feasibility study of the toolkit-based implementation of immediate postpartum contraception services at a large academic medical center in 2017 to 2020. Based on previous qualitative work, we developed a theory-informed implementation toolkit. A stakeholder panel selected toolkit resources to use in a multicomponent implementation intervention at the study site. These resources included tools and strategies designed to optimize implementation conditions (ie, implementation leadership, planning, and evaluation; the financial environment; engagement of key stakeholders; patient needs; compatibility with workflow; and clinician and staff knowledge, skills, and attitudes). The implementation intervention was executed from January 2018 to April 2019. Study outcomes included implementation outcomes (ie, provider perceptions of the implementation process and implementation tools [assessed via online provider survey]) and healthcare quality outcomes (ie, trends in prenatal contraceptive counseling, trends in immediate postpartum long-acting reversible contraceptive utilization [both ascertained by institutional administrative data], and the patient experience of contraceptive care [assessed via serial, cross-sectional, online patient survey items adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure]). Results In the implementation process, among 172 of 401 eligible clinicians (43%) participating in surveys, 70% were “extremely” or “somewhat” satisfied with the implementation process overall. In the prenatal contraceptive counseling, among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall throughout 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (Q4, range 30%–79%). Immediate postpartum long-acting reversible contraception utilization increased throughout the study period (before implementation, 5.46% of deliveries; during implementation, 8.95%; after implementation, 8.58%). In the patient experience of contraceptive care, patient survey respondents (response rate, 15%–29%) were largely White (344/425 [81%]) and highly educated (309/425 [73%] with at least a 4-year college degree), reflecting the study site population. Scores were poor across settings, with modest improvements in the hospital setting from 2018 to 2020 (prenatal visits, 67%–63%; hospitalization, 45%–58%; outpatient after delivery, 69%–65%). Based on these findings, toolkit refinements included additional resources designed to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care. Conclusion A toolkit-based process to implement immediate postpartum long-acting reversible contraceptive services at a single academic center was associated with high acceptability but mixed healthcare quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future research should formally test the effectiveness of the refined toolkit in a multisite, prospective trial.

Gaps and transitions (disruptions) in perinatal insurance coverage disproportionately affect indigenous, Hispanic, and black non-Hispanic women., OBJECTIVE: To measure the association between race–ethnicity and insurance status at preconception, delivery, and postpartum and the frequency of insurance gaps and transitions (disruptions) across these time points. METHODS: We conducted a cross-sectional analysis of survey data from 107,921 women in 40 states participating in the Centers for Disease Control and Prevention's Pregnancy Risk Assessment and Monitoring System from 2015 to 2017. We calculated unadjusted estimates of insurance status at preconception, delivery, and postpartum and continuity across these time points for seven racial–ethnic categories (white non-Hispanic, black non-Hispanic, indigenous, Asian or Pacific Islander, Hispanic Spanish-speaking, Hispanic English-speaking, and mixed race or other). We also examined unadjusted estimates of uninsurance at each perinatal time period by state of residence. We calculated adjusted differences in the predicted probability of uninsurance at preconception, delivery, and postpartum using logistic regression models with interaction terms for race–ethnicity and income. RESULTS: For each perinatal time point, all categories of racial–ethnic minority women experienced higher rates of uninsurance than white non-Hispanic women. From preconception to postpartum, 75.3% (95% CI 74.7–75.8) of white non-Hispanic women had continuous insurance compared with 55.4% of black non-Hispanic women (95% CI 54.2–56.6), 49.9% of indigenous women (95% CI 46.8–53.0) and 20.5% of Hispanic Spanish-speaking women (95% CI 18.9–22.2). In adjusted models, lower-income Hispanic women and indigenous women had a significantly higher predicted probability of uninsurance in the preconception and postpartum period compared with white non-Hispanic women. CONCLUSION: Disruptions in perinatal insurance coverage disproportionately affect indigenous, Hispanic, and black non-Hispanic women. Differential insurance coverage may have important implications for racial–ethnic disparities in access to perinatal care and maternal–infant health.

It was the aim to evaluate the personal preference of mode of delivery and to analyze differences between medical professionals and non-medical professionals. Interest in participating in a risk stratification system was evaluated. We hypothesized that gaining information about risk stratification provided in the survey could potentially change participants’ decision regarding the preferred mode of delivery; therefore, subjects were asked twice (before and after providing information). Five cohorts [four professionals (MP) including participants of the German Urogynecology Congress 2017, employees of two major university hospitals in Germany, and members of the German Society of Gynecology and Obstetrics, and one non-professional group (NP) including pregnant women] were invited online to participate in this survey. Vaginal delivery was the preferred mode of delivery in both groups (MP 90.4% vs. NP 88.8%; p = 0.429). MP are more likely to opt for CS due to concerns regarding pelvic floor disorders (MP 56.6% vs. NP 9.1%; p

This cross-sectional study assesses the relative rates and characteristics of early and late postpartum severe maternal morbidity overall and among racial and ethnic groups and individuals with perinatal mood and anxiety disorder.

Purpose Lung cancer has the highest mortality rate among all types of cancer in the United States. The National Lung Screening Trial demonstrated that low-dose CT for lung cancer screening decreases both lung cancer–related mortality and all-cause mortality. Currently, the only CMS-approved lung cancer screening registry is the Lung Cancer Screening Registry (LCSR) administered by the ACR. The aims of this study were to assess access to lung cancer screening services as estimated by the number and distribution of screening facilities participating in the LCSR, by state, and to evaluate state-level covariates that correlate with access. Methods The ACR LCSR list of participating lung cancer screening facilities was used as a proxy for the availability of lung cancer screening facilities in each state. Additionally, we normalized the number of facilities by state by the number of screening-eligible individuals using Behavioral Risk Factor Surveillance System data. State-level demographics were obtained from the 2015 Behavioral Risk Factor Surveillance System: poverty level, insured population, unemployed, black, and Latino. State-specific lung cancer incidence and death rates, number of active physicians per 100,000, and Medicare expenditure per capita were obtained. Linear regression models were performed to examine the influence of these state-level covariates on state-level screening facility number. QGIS, an open-source geographic information system, was used to map the distribution of lung cancer screening facilities and to estimate the nearest neighbor index, a measure of facility clustering within each state. Results As of November 18, 2016, 2,423 facilities participated in the LCSR. When adjusted by the rate of screening-eligible individuals per 100,000, the median population-normalized facility number was 15.7 (interquartile range, 10.7-19.3). There was a positive independent effect (coefficient = 12.87; 95% confidence interval, 10.93-14.8) between state-level number of screening facilities and rate of screening-eligible individuals per 100,000. There were no significant correlations between number of facilities and lung cancer outcomes, state demographic characteristics, or physician supply and Medicare expenditure. In most states, facilities are clustered rather than dispersed, with a median nearest neighbor index of 0.65 (interquartile range, 0.51-0.81). Conclusions Facility number correlated with the rate of screening-eligible individuals per 100,000, a measure of the at-risk population. Alignment of screening facility number and distribution with other clinically relevant epidemiologic factors remains a public health opportunity.

Objective To prospectively evaluate the impact of increasing levels of social media engagement on page visits and web-link clicks for content published in the Journal of the American College of Radiology . Methods A three-arm prospective trial was designed using a control group, a basic Twitter intervention group (using only the Journal's @JACRJournal Twitter account), and an enhanced Twitter intervention group (using the personal Twitter accounts of editorial board members and trainees). Overall, 428 articles published between June 2013 and July 2015 were randomly assigned to the three groups. Article-specific tweets for both intervention arms were sent between September 14, 2015, and October 28, 2015. Primary end points included article-specific weekly and monthly page visits on the journal's Elsevier website (Amsterdam, Netherlands). For the two intervention groups, additional end points included 7-day and 30-day Twitter link clicks. Results Weekly page visits for the enhanced Twitter arm (mean 18.2; 95% confidence interval [CI] 15.6-20.7) were significantly higher when compared with the weekly page visits for the control arm (mean 7.6; 95% CI 1.7-13.6). However, there was no demonstrable increase in weekly page visits (mean 9.4; 95% CI 7.4-11.5) for the basic Twitter arm compared with the control arm. No intervention effects over control, regardless of Twitter arm assignment, were demonstrated for monthly page visits. The enhanced Twitter intervention resulted in a statistically significant increase in both 7-day and 30-day Twitter link clicks compared with the basic Twitter intervention group. Conclusions An organized social media strategy, with focused social media activity from editorial board members, increased engagement with content published in a peer-reviewed radiology journal.

To determine the efficacy of physiotherapy and behavior therapy and to find specific subgroups of women with overactive bladder syndrome that might gain increased benefit from this therapy. Women with ≥10 micturitions per 24-h period were included. Six to nine therapy sessions were held within a 14-day interval. Efficacy end point was a reduction in micturitions and in episodes of nocturia. Secondary outcomes included ICIQ-OAB, ICIQ-OABqol and visual analog scales. Follow-up was 6 months. Levene test, Student’s t test, Pearson´s and Spearman’s correlations were utilized as well as the Friedman test and a multivariable-multilevel model. 32 women were included. Mean age was 51 ± 15.9 (years ± standard deviation, sd). Mean body mass index (BMI) was 24.4 ± 4.8 (kg/m2 ± sd). There was a 22.9% reduction in the number of micturitions per 24 h (11.7 ± 1.6 vs. 9.0 ± 1.3 p

The Affordable Care Act (ACA) requires employer-based insurance plans to cover maternity services, but plans are allowed to impose cost sharing such as copayments and deductibles for these services. This study aimed to evaluate trends in cost sharing for maternity care among working women in employer-based plans, before and after the ACA. Our data indicate that between 2008 and 2015, average out-of-pocket spending for maternity care rose among women with employer-based insurance. This increase was largely driven by increased spending among women with deductibles. When we controlled for potential confounders, we found that out-of-pocket spending was higher for lower-income working women in 2008-13, but disparities disappeared in 2014-15 because of a continued rise in spending among higher-income working women. Policies that aim to lower out-of-pocket spending for maternity care could reduce a significant financial burden on families.

PURPOSE: We undertook a study to assess the associations between barriers to insurance coverage for gender-affirming hormones (either lack of insurance or claim denial) and patterns of hormone use among transgender adults. METHODS: We used data from the US Transgender Survey, a large national sample of 27,715 transgender adults, collected from August to September 2015. We calculated weighted proportions and performed multivariate logistic regression analyses. RESULTS: Of 12,037 transgender adults using hormones, 992 (9.17%) were using nonprescription hormones. Among insured respondents, 2,528 (20.81%) reported that their claims were denied. Use of nonprescription hormones was more common among respondents who were uninsured (odds ratio = 2.64; 95% CI, 1.88-3.71; P

Background: Women with substance use disorders have high rates of adverse sexual and reproductive health (SRH) outcomes, including unintended pregnancy, sexually transmitted infections, and...

INTRODUCTION AND HYPOTHESIS: Childbirth pelvic floor trauma leads to pelvic floor disorders. Identification of significant injuries would facilitate intervention for recovery. Our objectives were to identify differences in pelvic floor appearance and function following delivery and identify patterns of normal recovery in women sustaining high-risk labor events. METHODS: We completed a prospective cohort study comparing women having vaginal births with risk factors for pelvic floor injury to women having cesareans. Data were collected on multidimensional factors including levator ani muscle (LA) tears. Descriptive and bivariate statistics were used to compare the groups. We identified potential markers of pelvic floor injury based on effect size. RESULTS: Eighty-two women post vaginal delivery and 30 women post cesarean enrolled. The vaginal group had decreased perineal body length between early postpartum, six weeks (p0.05). Measures of strength improved between each time point (all p

Increasing access to effective birth control after childbirth may meet many women's preferences and reduce short interpregnancy interval rates. Eliminating out-of-pocket costs for contraception has been reported to increase the use of the most effective methods among women with employer-based insurance, but the prevalence and effects of patient cost sharing for contraception have not been studied during the postpartum period.This study aimed to examine the association between cost sharing for long-acting reversible contraception and postpartum contraception use patterns and pregnancies in the 12 months after delivery.We conducted a retrospective cohort analysis of commercially insured women undergoing childbirth from 2014 to 2018 using Optum's (Eden Prairie, MN) de-identified Clinformatics Data Mart database. This large national database includes nonretired employees and their dependents who are enrolled in health insurance plans sponsored by large- or medium-sized US-based employers. Women with 12 months of continuous enrollment postpartum were included. Childbirth, pregnancy, and contraceptive method (female sterilization, long-acting reversible contraceptives, other hormonal methods, and no prescription method observed) were identified using claims data. Contraceptive use patterns were observed at 3, 6, and 12 months postpartum and adjusted for individual and plan characteristics. Median out-of-pocket costs were $0 for sterilization and other hormonal methods but nonzero for long-acting reversible contraception. We therefore used simple and multivariable logistic regressions to examine the association between plan-level cost sharing (no cost sharing, $0; low cost sharing,$0-$200; and high cost sharing, ≥$200 out-of-pocket cost) for any long-acting reversible contraceptive insertion and contraceptive use patterns and short interpregnancy interval rates, controlling for age, household income, race and ethnicity, region, and insurance plan type.Among 25,298 plans with cost sharing data, we identified 172,941 women with continuous enrollment for 12 months postpartum, including 82,500 (47.7%) in no cost sharing, 22,595 (13.1%) in low cost sharing, and 67,846 (39.2%) in high cost sharing plans. The percentage of postpartum women in the study sample using any prescription contraceptive method was 39.5% by 3 months, 43.8% by 6 months, and 46.0% by 12 months. At all time points, postpartum women in no cost sharing plans had a higher predicted probability of long-acting reversible contraceptive use (eg, at 12 months: no cost sharing, 22.0%; low cost-sharing, 17.5%; high cost sharing, 18.3%; P.001) and a lower predicted probability of no prescription method use (eg, at 12 months: no cost sharing, 51.8%; low cost sharing, 55.0%; high cost sharing, 54.9%; P.001) than those in low or high cost sharing plans. Predicted probabilities of female sterilization and other hormonal method use did not differ substantively by plan cost sharing for long-acting reversible contraception at any time point. The proportion of women experiencing a short interpregnancy interval was low (1.9% by 3 months, 1.9% by 6 months, 2.0% by 12 months) and did not differ by plan cost sharing for long-acting reversible contraception at any time point.Out-of-pocket costs for long-acting reversible contraception influence the method of contraception used by postpartum women with employer-based insurance. Eliminating financial barriers to long-acting reversible contraception access after childbirth may help women initiate their preferred method and increase the use of long-acting reversible contraceptives among interested women who otherwise might utilize less effective methods.

IMPORTANCE: Suicide deaths are a leading cause of maternal mortality in the US, yet the prevalence and trends in suicidality (suicidal ideation and/or intentional self-harm) among childbearing individuals remain poorly described. OBJECTIVE: To characterize trends in suicidality among childbearing individuals. DESIGN, SETTING, AND PARTICIPANTS: This serial cross-sectional study analyzed data from a medical claims database for a large commercially insured population in the US from January 2006 to December 2017. There were 2714 diagnoses of suicidality 1 year before or after 698 239 deliveries among 595 237 individuals aged 15 to 44 years who were continuously enrolled in a single commercial health insurance plan. Data were analyzed from October 2019 to September 2020. MAIN OUTCOMES AND MEASURES: The primary outcome was diagnosis of suicidality in childbearing individuals 1 year before or after birth based on the identification of relevant International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and ICD-10-CM diagnosis codes during at least 1 inpatient or 2 outpatient visits. RESULTS: Of 595 237 included childbearing individuals, the mean (SD) age at delivery was 31.9 (6.4) years. A total of 40 568 individuals (6.8%) were Asian, 52 613 (8.6%) were Black, 73 172 (12.1%) were Hispanic, 369 501 (63.1%) were White, and 59 383 (9.5%) had unknown or missing race/ethnicity data. A total of 2683 individuals were diagnosed with suicidality 1 year before or after giving birth for a total of 2714 diagnoses. The prevalence of suicidal ideation increased from 0.1% per 100 individuals in 2006 to 0.5% per 100 individuals in 2017 (difference, 0.4%; SE, 0.03; P

AIM This study was conducted to determine periodontal changes in postmenopausal breast cancer (BCa) survivors using aromatase inhibitors (AI) as compared to postmenopausal women without BCa. METHODS An 18-month prospective examination of periodontal health in postmenopausal women (29 receiving AI therapy; 29 women without BCa) was conducted at University of Michigan. Comprehensive periodontal examinations including alveolar bone height (ABH) were conducted at baseline, 6, 12, and 18 months. Bisphosphonate, vitamin D, and calcium supplementation were collected via chart review. Linear mixed models were utilized to investigate the relationship between AI and periodontal measures. RESULTS Aromatase inhibitor users had significantly deeper probing depths, more dental plaque and clinical attachment loss as compared to controls at the 6, 12, and 18 month study visits (p

ObjectivesThe diagnosis and treatment of Chlamydia trachomatis infection is important in preventing persistent or recurrent infection. Expedited partner therapy (EPT) is the favoured and supported method for STI treatment of the Centers for Disease Control and Prevention when the provider cannot be assured that all recent sexual partner(s) will seek therapy. EPT is legally permissible in 38 states and is endorsed by healthcare organisations to decrease the rates of chlamydia and gonorrhoea infection. Our study investigated the impact of EPT legal status (permissible, potentially allowable or prohibited) on C. trachomatis infection rates for each state.MethodsOur ecological study modelled the number of reported chlamydia cases from 2000 to 2013 as a function of year, legal status and the interaction between year and legality. We used a negative binomial regression model that included state fixed effects (including the District of Columbia) to account for both the repeated measures per state and state-specific characteristics that could not be measured for inclusion in this study. The lagged number of C. trachomatis cases was included as a covariate and each state's total population for a given year was included in the model as an exposure parameter. States were designated Y (EPT permissible), N (EPT prohibited) and M (EPT potentially allowable), and the legal status of each state could vary over time.ResultsEach legal category saw an increase in the incidence rate of C. trachomatis infection, but on average, the incidence rate for states with prohibitive EPT legislation grew significantly faster over time compared with the rate for the states where EPT was permissible. The average increase in predicted incidence rates per year for states with Y, N and M legal status were 14.1 (95% CI (12.0 to 16.2)), 17.5 (95% CI (15.9 to 19.2)) and 16.8 (95% CI (15.0 to 18.6)) cases per 100 000 persons per year, respectively, when controlling for state-specific effects.ConclusionsOur model suggests that a lack of EPT legislation is associated with an increase in STI rates. States with potentially allowable EPT legislation as of 2013 (n=8) should consider permitting EPT as a component of a multipronged strategy for treatment of sexual partners to prevent C. trachomatis infection.

This cross-sectional study assesses the association of the elimination of cost sharing for contraception under the Patient and Protection and Affordable Care Act (ACA) with birth rates by income level among commercially insured women., Key Points Question Was the elimination of cost sharing for contraception under the Patient Protection and Affordable Care Act associated with a change in birth rates among women in different income groups? Findings In this cross-sectional study, the estimated probability of birth decreased most precipitously among women in the lowest income group from 8.0% in 2014 to 6.2% in 2018. The probability of a birth also decreased significantly among women in higher income groups, but this decrease was smaller in magnitude. Meaning These findings suggest that contraception insurance coverage without consumer cost sharing may be associated with decreased income-related disparities in unintended birth rates., Importance Reducing out-of-pocket costs is associated with improved patterns of contraception use. It is unknown whether reducing out-of-pocket costs is associated with fewer births. Objective To evaluate changes in birth rates by income level among commercially insured women before (2008-2013) and after (2014-2018) the elimination of cost sharing for contraception under the Patient Protection and Affordable Care Act (ACA). Design, Setting, and Participants This cross-sectional study used data from Clinformatics Data Mart database from January 1, 2008, to December 31, 2018, for women aged 15 to 45 years who were enrolled in an employer-based health plan and had pregnancy benefits for at least 1 year. Women without household income information and women with evidence of having undergone a hysterectomy were excluded. Exposure Section 2713 of the ACA. Main Outcomes and Measures The primary outcome was the proportion of reproductive-aged women with a live birth by year (measured yearly from 2008 to 2018 [11 time points]) within 3 income categories. The secondary outcome was the distribution of contraceptive method fills in 3 categories by year: (1) most effective methods (long-acting reversible contraception or sterilization), (2) moderately effective methods (pill, patch, ring, and injectable), and (3) no prescription or surgical method. Results The analytic sample included 4 590 989 women (mean [SD] age; 30.8 [9.1] years in 2013; 3 069 053 White [66.9%]) enrolled in 47 721 health plans. A total of 500 898 participants (40.8%) resided in households with incomes less than 400% of the federal poverty level in 2013. In all 3 years (2008, 2013, and 2018), women in the lowest income category were younger than women in the other income groups (median range, 21-22 years vs 30-34 years) and in households with a higher median number of dependents (9-10 vs 2-4). There was an associated decrease in births in all income groups in the period after the elimination of out-of-pocket costs. The estimated probability of birth decreased most precipitously among women in the lowest income group from 8.0% (95% CI, 7.4%-8.5%) in 2014 to 6.2% (95% CI, 5.7%-6.7%) in 2018, representing a 22.2% decrease (P

The rising incidence rates of sexually transmitted infections in the United States highlight the need for concurrent treatment of patients and their sexual partners. Expedited partner therapy allows healthcare providers to offer antibiotic prescriptions or medications to an index patient for distribution to their sexual partner(s) without evaluating the partner. We hypothesized that there was a gap between expedited partner therapy policy at the state level and its downstream implementation by community pharmacists.The objectives of our study were to evaluate pharmacists' expedited partner therapy knowledge and practices in 41 expedited partner therapy-permissible US states, to determine whether there were differences in practice based on the length of time expedited partner therapy was permissible in the state and chlamydia incidence rates, and to measure the cost of expedited partner therapy treatment.A randomized cohort of pharmacists (n=335) was invited to complete a telephone interview from November 2017 through January 2018. Descriptive statistics were calculated and stratified by early, mid, and late expedited partner therapy-adopter status based on the year of the state's expedited partner therapy enactment and the state's chlamydia incidence rate. Fisher's exact test and 1-way analyses of variance were used to compare measures across strata.We had 143 pharmacists (42.7%) agree to complete the survey. Among our respondents, 40.6% (n=58/143) indicated that they were aware of expedited partner therapy; 14.7% (n=21/143) reported that they had ever received an expedited partner therapy prescription, and 97% (n=139/143) reported that they would dispense an expedited partner therapy prescription if they received 1 in the future. These findings were stable across the 6 strata defined by early, mid, or late expedited partner therapy-adopter and high or low incidence rates of chlamydia status. Mean cost of azithromycin 1000 mg and cefixime 400 mg for treatment of chlamydia and gonorrhea was $22.17 (95% confidence interval, 20.29-24.05) and $30.46 (95% confidence interval, 28.65-32.26), respectively.Fewer than one-half of the pharmacists were aware of expedited partner therapy. A small minority of pharmacists reported ever having received an expedited partner therapy prescription, regardless of the length of time expedited partner therapy had been legal in their states and the incidence of chlamydia. However, almost all pharmacists reported that they would dispense an expedited partner therapy prescription if they received 1. Additionally, costs were high for expedited partner therapy for self-pay patients. These data suggest that there are opportunities to increase expedited partner therapy utilization by healthcare providers, patients, and pharmacists.

RESEARCH OBJECTIVE: Policy makers, clinicians, researchers, and the general public are all paying increasing attention to disturbing trends regarding growing rates of maternal mortality. Suicide deaths are a significant contributor to maternal mortality and continue to rise. In this context, we sought to identify trends in suicidal ideation and self‐harm in a large national cohort of privately insured delivering women. STUDY DESIGN: The MAternal Behavioral Health PoLicy Evaluation (MAPLE: R01 MH120124) study uses administrative health plan data to develop predictors and health service utilization outcomes associated with suicidal ideation and self‐harm in this high‐risk patient population. We will present the baseline characteristics of our study population in addition to trends. POPULATION STUDIED: This study includes 1 750 000 privately insured delivering women between 2005 and 2017 using data from a large national database of multiple health plans. The study sample includes women aged 15‐44 continuously enrolled in a single health insurance plan for one year before and one year after delivery. We identified suicidal ideation, self‐harm, depression, and anxiety using ICD‐9 and ICD‐10 diagnosis codes. PRINCIPAL FINDINGS: We found that rates of suicidal ideation rose from 34.8 per 100 000 women in 2005 to 318.7 per 100 000 women in 2017. Rates of intentional self‐harm rose from 34.8 per 100 000 women in 2005 to 122.2 per 100 000 women in 2017. Rates of either suicidal ideation or self‐harm rose from 69.6 per 100 000 women in 2005 to 440.9 per 100 000 women in 2017. Among women with a diagnosis of perinatal depression or anxiety, rates of either suicidal ideation or self‐harm rose from 123.9 per 100 000 women in 2005 to 909.1 per 100 000 women in 2017. Among women without a diagnosis of perinatal depression or anxiety disorder (PMAD), rates of either suicidal ideation or self‐harm rose from 58.2 per 100 000 women in 2005 to 307.9 per 100 000 women in 2017. Stated another way, suicidal ideation rose over eightfold during the observation period, self‐harm increased 2.5 times, and ideation or self‐harm increased over fivefold. Among women with PMAD, ideation or self‐harm among women increased 6.3 times compared to those without PMAD, for whom ideation and self‐harm increased 4.3 times. CONCLUSIONS: Rates of suicidal ideation and self‐harm increased substantially over a thirteen‐year period. Even accounting for potential coding changes associated with conversion from diagnosis using ICD‐9 to ICD‐10, changes in access to mental health care due to mental health parity and the Affordable Care Act during the observation period, these increases remain alarming. Given that publicly insured women typically face higher rates of morbidity and mortality than do those who are privately insured, these statistics likely underrepresent the burden of severe mental distress among all perinatal women. IMPLICATIONS FOR POLICY OR PRACTICE: Policy makers, health plans, and clinicians should ensure access to screening and appropriate treatment for high‐risk delivering and postpartum women and to seek additional health system and policy avenues to mitigating this growing public health crisis. PRIMARY FUNDING SOURCE: National Institutes of Health.

Objective To assess changes in screening mammography cost sharing and utilization before and after the Affordable Care Act (ACA) and the revised US Preventive Services Task Force (USPSTF) guidelines. To compare mammography cost sharing between women aged 40 to 49 and those 50 to 74. Methods We used patient-level analytic files between 2004 and 2014 from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minnesota). We included women 40 to 74 years without a history of breast cancer or mastectomy. We conducted an interrupted time series analyses assessing cost sharing and utilization trends before and after the ACA implementation and USPSTF revised guidelines. Results We identified 1,763,959 commercially insured women aged 40 to 74 years. Between 2004 and 2014, the proportion of women with zero cost share for screening mammography increased from 81.9% in 2004 to 98.2% in 2014, reaching 93.1% with the 2010 ACA implementation. The adjusted median cost share remained $0 over time. Initially at 36.0% in 2004, screening utilization peaked at 42.2% in 2009 with the USPSTF guidelines change, dropping to 40.0% in 2014. Comparing women aged 40 to 49, 50 to 64, and 65 to 74, the proportion exposed to cost sharing declined over time in all groups. Conclusions A substantial majority of commercially insured women had first-dollar coverage for mammography before the ACA. After ACA, nearly all women had access to zero cost-share mammography. The lack of an increase in mammography use post-ACA can be partially attributed to a USPSTF guideline change, the high proportion of women without cost sharing before the ACA, and the relatively low levels of cost sharing before the policy implementation.

OBJECTIVE To evaluate changes in out-of-pocket cost for intrauterine device (IUD) placement before and after mandated coverage of contraceptive services and to examine how changes in out-of-pocket cost influence IUD insertion as a function of baseline cost. METHODS We conducted a cross-sectional pre-post analysis at the plan level using a large deidentified medical claims database to analyze our primary outcome, new IUD insertions among women enrolled in employer-sponsored health plans in 2009 and 2014, and our secondary outcome, out-of-pocket cost. Patient costs and utilization were aggregated by plan and year to conduct a plan-specific analysis. Plans were classified by mean out-of-pocket cost level: no out-of-pocket cost, low out-of-pocket cost (less than the 75th percentile), and high out-of-pocket cost (75th percentile or greater). A generalized estimating equation was used to evaluate average plan utilization of IUD services in 2009 and 2014 as a function of plan cost category and year. RESULTS Overall, average plan utilization of IUD services demonstrated a significant increase between 2009 (12.5%, 95% CI 11.6-13.4%) and 2014 (13.8%, 95% CI 13.0-14.7%; P

Introduction India has one of the lowest immunization rates worldwide despite a longstanding Universal Immunization Program (UIP) that provides free childhood vaccines. This study characterizes the predictors for under- and non-vaccination among Indian children aged 12–36 months. Methods This study utilized District Level Household and Facility Survey Data, 2008 (DLHS3), from India. DLHS3 is a nationally representative sample collected from December 2007 through December 2008; this analysis was conducted during 2014. Children's vaccination status was categorized as fully, under-, and non-vaccinated based on whether children received all, some, or none of the UIP-recommended vaccines (one dose each of bacillus Calmette–Guerin and measles, and three doses of diphtheria–pertussis–tetanus). A multinomial logistic regression model estimated the odds of under-vaccination compared with full vaccination, and odds of non-vaccination compared with full vaccination. Analytic predictors included socioeconomic, cultural, household, maternal, and childhood characteristics. Results The analysis included 108,057 children; the estimated proportions of fully, under-, and non-vaccinated children were 57%, 31%, and 12%, respectively. After adjusting for state of residence, age, gender, household wealth, and maternal education, additional significant predictors of children's vaccination status were religion, caste, place of delivery, number of antenatal care visits, and maternal tetanus vaccination, all of which demonstrated large effect sizes. Conclusions India's immunization coverage remained low in 2008, with just slightly more than half of all children aged 12–36 months fully vaccinated with UIP-recommended vaccines. A better understanding of the predictors for vaccination can help shape interventions to reduce disparities in full vaccination among children of differing demographic/cultural groups.

Aromatase inhibitor (AI) use results in low estrogen levels, which in turn affect bone mineral density (BMD). Periodontitis, alveolar bone loss, and tooth loss are associated with low BMD. The goal of this study is to assess the prevalence of periodontitis and perceived oral health and evaluate salivary biomarkers in postmenopausal women who are survivors of early-stage (I to IIIA) breast cancer (BCa) and receive adjuvant AI therapy.Participants included 58 postmenopausal women: 29 with BCa on AIs and 29 controls without BCa diagnoses. Baseline periodontal status was assessed with: 1) periodontal probing depth (PD); 2) bleeding on probing (BOP); and 3) attachment loss (AL). Demographic and dental utilization information was gathered by questionnaire. Linear regression modeling was used to analyze the outcomes.No differences were found in mean PD or number of teeth. The AI group had significantly more sites with BOP (27.8 versus 16.7; P = 0.02), higher worst-site AL (5.2 versus 4.0 mm; P0.01), and more sites with dental calculus (18.2 versus 6.4; P0.001) than controls. Linear regression adjusted for income, tobacco use, dental insurance, and previous radiation and chemotherapy exposure demonstrated that AI use increased AL by2 mm (95% confidence interval, 0.46 to 3.92). Median salivary osteocalcin and tumor necrosis factor-α levels were significantly higher in the AI group than the control group.This first investigation of the periodontal status of women initiating adjuvant AI therapy identifies this population as having an increased risk for periodontitis.

Background We sought to describe the relationship between the elimination of out-of-pocket costs and women’s use of preventive care office visits and long-acting reversible contraception after accounting for baseline levels of cost sharing. Objectives The objective of this analysis was to describe the relationship between the elimination of out-of-pocket costs and utilization of preventive care visits and long-acting reversible contraception insertion while taking baseline cost sharing levels under consideration. Study Design In 2017, we used administrative health plan data to examine changes in out-of-pocket costs and service utilization among 2,172,065 women enrolled in 15,118 employer-based health plans between 2008 and 2015. We used generalized estimating equations to examine utilization patterns. Results Women in this sample generally had low costs at baseline ($24 and $29 for preventive care visits and long-acting reversible contraception insertion, respectively). The elimination of baseline out-of-pocket costs were related to changes in the utilization of both services but more consistently for contraceptive device placement. Women whose low/moderate out-of-pocket costs were eliminated were more likely to use a preventive care office visit than women with persistent low/moderate costs (odds ratio, 1.05; 95% confidence interval, 1.04–1.05), but women with high out-of-pocket costs had lower utilization rates, even after their costs were eliminated. In contrast, the odds of having a contraceptive device placed was higher among all groups of women when out-of-pocket costs were zero, as compared with women with low/moderate costs. For instance, when compared with women with low/moderate costs, women were less likely to have a contraceptive device inserted (odds ratio, 0.92; 95% confidence interval, 0.86–0.97) when they had high costs but more likely after their costs were eliminated (odds ratio, 1.15; 95% confidence interval, 1.09–1.20). Conclusion Out-of-pocket costs were low prior to the Affordable Care Act. Eliminating costs was associated with increases in preventive service use among those with high levels of cost, but effect sizes were low, suggesting that cost is only 1 barrier. Failing to recognize that cost sharing was already low could cause us to falsely conclude that the elimination of cost sharing was ineffective.

Young women’s experiences with sexual and reproductive health (SRH) stigma may contribute to unintended pregnancy. Thus, stigma interventions and rigorous measures to assess their impact are needed. Based on formative work, we generated a pool of 51 items on perceived stigma around different dimensions of adolescent SRH and family planning (sex, contraception, pregnancy, child-bearing, abortion). We tested items in a survey study of 1,080 women ages 15 to 24 recruited from schools, health facilities, and universities in Ghana. Confirmatory factor analysis (CFA) identified the most conceptually and statistically relevant scale, and multivariable regression established construct validity via associations between stigma and contraceptive use. CFA provided strong support for our hypothesized Adolescent SRH Stigma Scale (chi-square p value < 0.001; root mean square error of approximation [RMSEA] = 0.07; standardized root mean square residual [SRMR] = 0.06). The final 20-item scale included three subscales: internalized stigma (six items), enacted stigma (seven items), and stigmatizing lay attitudes (seven items). The scale demonstrated good internal consistency (α = 0.74) and strong subscale correlations (α = 0.82 to 0.93). Higher SRH stigma scores were inversely associated with ever having used modern contraception (adjusted odds ratio [AOR] = 0.96, confidence interval [CI] = 0.94 to 0.99, p value = 0.006). A valid, reliable instrument for assessing SRH stigma and its impact on family planning, the Adolescent SRH Stigma Scale can inform and evaluate interventions to reduce/manage stigma and foster resilience among young women in Africa and beyond.

We compared two hypotheses as to why obesity is associated with stress urinary incontinence (SUI): (1) obesity increases demand on the continence system (e.g. higher cough pressure) and (2) obesity compromises urethral function and urethrovaginal support. A secondary analysis was performed using data from a case–control study of SUI in women. Measurements of urethrovaginal support (POP-Q point Aa, urethral axis), urethral function (maximal urethral closure pressure, MUCP), and measures of continence system demand (intravesical pressures at rest and during maximal cough) were analyzed. Cases and controls were divided into three body mass index (BMI) groups: normal (18.5–24.9 kg/m2); overweight (25.0–29.9 kg/m2); and obese (≥30 kg/m2). Logistic regression models where created to investigate variables related to SUI for each BMI group. Structural equation modeling was used to test the direct and indirect relationships among BMI, SUI, maximal cough pressure, MUCP, and POP-Q point Aa. The study included 108 continent controls and 103 women with SUI. MUCP was the factor most strongly associated with SUI in all BMI groups. Maximal cough pressure was significantly associated with SUI in obese women (OR 3.191, 95% CI 1.326, 7.683; p

This study evaluated Meaningful Watershed Educational Experiences (MWEEs) funded by the National Oceanic and Atmospheric Administration's Chesapeake Bay Watershed Education and Training (B-WET) grant program. It also empirically explores the relationships between predictors of environmentally responsible behavior (ERB) in the Hines, Hungerford, and Tomera (1986/1987) and Hungerford and Volk (1990) behavior models. Multilevel analyses identified associations between eight environmental stewardship characteristics, as well as between these outcomes and (1) participation in MWEEs (sample: 258 students in 20 treatment classes, 193 students in 12 comparison classes matched by grade) and (2) specific MWEE instructional practices (sample: 434 students in 29 treatment classes). Students who participated in MWEEs scored significantly higher in five of eight characteristics (i.e., knowledge of ecology, issues, and actions, individual locus of control, intention to act) than those in the comparison group. Students who were engaged in the science inquiry steps of analyzing data or reflection and those who participated in more of certain types of environmental actions also scored significantly higher in a greater number of environmental stewardship characteristics than students who did not have these experiences. Results suggest that MWEEs are likely to increase ERBs but are not reaching their full potential. Tests of the relationships between the variables in Hines et al. (1986/1987) and Hungerford and Volk (1990) models confirm that they predict a high amount of variance in intention to act and suggest that environmental stewardship characteristics are likely to interact in complex ways.

Purpose The purpose of this longitudinal study was twofold: to examine shifting from African American English (AAE) to mainstream American English (MAE) across the early elementary grades, when students are first exposed to formal instruction in reading; and to examine how metalinguistic and cognitive variables influenced the students' dialectal adaptations from AAE to MAE in a literacy context with higher expectations for MAE. Method Participants were 102 typically developing AAE-speaking students enrolled in public schools in the northern Midwest. They were enrolled in the project at kindergarten and tested 3 times a year, for 3 years. Approximately half were male and half female, and two-thirds were from low socioeconomic status homes. Results A style shifting coefficient (SSC) was created to measure amounts of dialect change between contexts and over time by individuals. Some students shifted to MAE in literacy contexts, and shifting was not related to grade. Metalinguistic skills and SSC predicted reading, and metalinguistic skills predicted the SSC at 2nd grade. The findings indicated that cognitive executive functions may contribute to the SSC. Conclusions The results provide strong support for the dialect shifting–reading achievement hypothesis and indicated that metalinguistic and perhaps executive functioning are important influences on this linguistic adaptation.

The primary objective of this study was to better understand how self-regulatory driving practices at multiple levels of driver decision making are influenced by various factors. Specifically, the study investigated patterns of tactical and strategic self-regulation among a sample of 246 Australian older drivers. Of special interest was the relative influence of several variables on the adoption of self-regulation, including self-perceptions of health, functioning, and abilities for safe driving and driving confidence and comfort.The research was carried out at the Monash University Accident Research Centre, as part of its Ozcandrive study, a partnership with the Canadian Driving Research Initiative for Vehicular Safety in the Elderly (Candrive), and in conjunction with the University of Michigan Transportation Research Institute (UMTRI). Candrive/Ozcandrive represents the first study to follow a large group of older drivers over several years and collect comprehensive self-reported and objectively derived data on health, functioning, and driving. This study used a subset of data from the Candrive/Ozcandrive study. Upon enrolling in the study, participants underwent a comprehensive clinical assessment during which data on visual, cognitive, and psychomotor functioning were collected. Approximately 4 months after study enrollment, participants completed the Advanced Driving Decisions and Patterns of Travel (ADDAPT) questionnaire, a computer-based self-regulation instrument developed and pilot-tested at UMTRI.Self-regulation among older adults was found to be a multidimensional concept. Rates of self-regulation were tied closely to specific driving situations, as well as level of decision making. In addition, self-regulatory practices at the strategic and tactical levels of decision making were influenced by different sets of factors.Continuing efforts to better understand the self-regulatory practices of older drivers at multiple levels of driver performance and decision making should provide important insights into how the transition from driving to nondriving can be better managed to balance the interdependent needs of public safety and personal mobility.

Until recently, objective data have been lacking on the extent to which older adults modify their driving by driving less or avoiding situations considered challenging; a process commonly referred to as self-regulation. Advances in technology now make it possible to examine driving exposure, patterns, and habits using low-cost global positioning system (GPS) technology to record a vehicle’s location on a continuous basis along with the date and time. The purpose of this exploratory study was to better understand the process of self-regulation among older adults by examining their trip-specific driving patterns using objectively-derived GPS measures of driving and comparing these patterns with drivers’ self-reports. The study used a sample of 156 adults age 75 or older, recruited from the greater Melbourne area of Australia as part of the Ozcandrive project, a partnership between Monash University Accident Research Centre and the Canadian Driving Research Initiative for Vehicular Safety in the Elderly (Candrive), a prospective cohort study of older drivers. Objective driving data were collected through equipment installed in participants’ personal vehicles. Participants were asked to drive as they normally would with the equipment installed in their vehicle. After approximately the first 4 months of driving with the device, data were downloaded and participants completed a computer-based questionnaire on self-regulation of driving. Results suggest that there was correspondence, albeit not perfect, between some objective driving measures and their comparable self-reported measures, but a lack of correspondence for others. For avoidance of various driving situations, comparisons were statistically significant for driving at night, driving in unfamiliar areas, and on high speed roads. For each driving situation, participants’ actual driving predicted the likelihood of reporting trying to avoid that situation, although perfect one-to-one correspondence between the self-reported and objective data on self-regulatory driving patterns was lacking. For measures of driving exposure, self-reported and objective driving exposure measures were correlated, but participants tended to underreport their average number of days per week and kilometers per week driven. This discrepancy between self-reported and objective measures is of concern as the ability to measure driving exposure not only contributes to a better understanding of the complex process of self-regulation, but is also a critical element in understanding crash risk.

Purpose The aim of this study was to determine if breast health coverage information provided by customer service representatives employed by insurers offering plans in the 2015 federal and state health insurance marketplaces is consistent with Patient Protection and Affordable Care Act (ACA) and state-specific legislation. Methods One hundred fifty-eight unique customer service numbers were identified for insurers offering plans through the federal marketplace, augmented with four additional numbers representing the Connecticut state-run exchange. Using a standardized patient biography and the mystery-shopper technique, a single investigator posed as a purchaser and contacted each number, requesting information on breast health services coverage. Consistency of information provided by the representative with the ACA mandates ( BRCA testing in high-risk women) or state-specific legislation (screening ultrasound in women with dense breasts) was determined. Results Insurer representatives gave BRCA test coverage information that was not consistent with the ACA mandate in 60.8% of cases, and 22.8% could not provide any information regarding coverage. Nearly half (48.1%) of insurer representatives gave coverage information about ultrasound screening for dense breasts that was not consistent with state-specific legislation, and 18.5% could not provide any information. Conclusions Insurance customer service representatives in the federal and state marketplaces frequently provide inaccurate coverage information about breast health services that should be covered under the ACA and state-specific legislation. Misinformation can inadvertently lead to the purchase of a plan that does not meet the needs of the insured.

It is unknown how initial cervix location and cervical support resistance to traction, which we term "apical support stiffness," compare in women with different patterns of pelvic organ support. Defining a normal range of apical support stiffness is important to better understand the pathophysiology of apical support loss.The aims of our study were to determine whether: (1) women with normal apical support on clinic Pelvic Organ Prolapse Quantification, but with vaginal wall prolapse (cystocele and/or rectocele), have the same intraoperative cervix location and apical support stiffness as women with normal pelvic support; and (2) all women with apical prolapse have abnormal intraoperative cervix location and apical support stiffness. A third objective was to identify clinical and biomechanical factors independently associated with clinic Pelvic Organ Prolapse Quantification point C.We conducted an observational study of women with a full spectrum of pelvic organ support scheduled to undergo gynecologic surgery. All women underwent a preoperative clinic examination, including Pelvic Organ Prolapse Quantification. Cervix starting location and the resistance (stiffness) of its supports to being moved steadily in the direction of a traction force that increased from 0-18 N was measured intraoperatively using a computer-controlled servoactuator device. Women were divided into 3 groups for analysis according to their pelvic support as classified using the clinic Pelvic Organ Prolapse Quantification: (1) "normal/normal" was women with normal apical (C-5 cm) and vaginal (Ba and Bp0 cm) support; (2) normal/prolapse had normal apical support (C-5 cm) but prolapse of the anterior or posterior vaginal walls (Ba and/or Bp ≥ 0 cm); and (3) prolapse/prolapse had both apical and vaginal wall prolapse (C-5 cm and Ba and/or Bp ≥ 0 cm). Demographics, intraoperative cervix locations, and apical support stiffness values were then compared. Normal range of cervix location during clinic examination and operative testing was defined by the total range of values observed in the normal/normal group. The proportion of women in each group with cervix locations within and outside the normal range was determined. Linear regression was performed to identify variables independently associated with clinic Pelvic Organ Prolapse Quantification point C.In all, 52 women were included: 14 in the normal/normal group, 11 in the normal/prolapse group, and 27 in the prolapse/prolapse group. At 1 N of traction force in the operating room, 50% of women in the normal/prolapse group had cervix locations outside the normal range while 10% had apical support stiffness outside the normal range. Of women in the prolapse/prolapse group, 81% had cervix locations outside the normal range and 8% had apical support stiffness outside the normal range. Similar results for cervix locations were observed at 18 N of traction force; however the proportion of women with apical support stiffness outside the normal range increased to 50% in the normal/prolapse group and 59% in the prolapse/prolapse group. The prolapse/prolapse group had statistically lower apical support stiffness compared to the normal/normal group with increased traction from 1-18 N (0.47 ± 0.18 N/mm vs 0.63 ± 0.20 N/mm, P = .006), but all other comparisons were nonsignificant. After controlling for age, parity, body mass index, and apical support stiffness, cervix location at 1 N traction force remained an independent predictor of clinic Pelvic Organ Prolapse Quantification point C, but only in the prolapse/prolapse group.Approximately 50% of women with cystocele and/or rectocele but normal apical support in the clinic had cervix locations outside the normal range under intraoperative traction, while 19% of women with uterine prolapse had normal apical support. Identifying women whose apical support falls outside a defined normal range may be a more accurate way to identify those who truly need a hysterectomy and/or an apical support procedure and to spare those who do not.

Background: Laboratory blood testing incurs financial costs and the blood draws can increase discomfort, yet minimal data exists regarding routine testing in gynecologic oncology surgical patients. Additionally, an increasing number of gynecologic oncology surgeries are performed via a laparoscopic approach. Thus, further investigation into perioperative laboratory testing for gynecologic oncology patients is warranted. An increasing number of gynecologic oncology surgeries are performed via a laparoscopic approach. Thus, further investigation into perioperative laboratory testing for gynecologic oncology patients is warranted. Objective: The aims of this study were (1) to evaluate the frequency and etiology of perioperative laboratory test abnormalities in patients undergoing laparoscopic and laparotomy surgery in a gynecologic oncology service, and (2) to establish an evidence-based algorithm to reduce unnecessary laboratory testing. Materials and Methods: A single-institution retrospective study was completed, investigating laparoscopic and laparotomic surgeries over 4 years. Information on preoperative and postoperative laboratory data, surgical parameters, perioperative interventions, and patient demographics was collected. Quality-assurance data were reviewed. Data were tabulated and analyzed using Statistical Product and Service Solutions (SPSS) version 22. A Student's t-test was used to test for group differences for continuous variables with equal variance, the Mann-Whitney–U test for continuous variables when unequal variance was detected, and Pearson's χ2 was used to investigate categorical variables of interest. p-Values 98% of patients underwent at least one preoperative and postoperative laboratory test, totaling 8060 preoperative and 5784 postoperative results. The laparoscopy group was significantly less likely to have postoperative metabolic abnormalities or to undergo perioperative blood transfusion. Patients taking an angiotensin-converting-enzyme inhibitor, angiotensin-II–receptor blocker, or diuretic were significantly more likely to have elevated creatinine preoperatively (odds ratio [OR]: 5.0; p

Study Objective. To determine the feasibility of using geographic information system (GIS) technology to identify geographic areas of high and low adherence to cardiovascular drug therapy for treatment of acute coronary syndrome (ACS) in patients discharged from a university-affiliated hospital. Design. Retrospective analysis. Data Source. A registry of patients admitted to and discharged from a large university-affiliated medical center for the treatment of ACS . Patients. A total of 1081 adults distributed over 300 census tracts who were discharged between April 1999 and December 2004 with a diagnosis of an ACS event of unstable angina or acute myocardial infarction. Measurements and Main Results. Data were collected on patient demographics, home addresses, and adherence to four classes of drugs—statins, angiotensin-converting enzyme inhibitors, -blockers, and aspirin—at 6–12 months after discharge for the ACS index event. A GIS program was used to map patient addresses and adherence data to geographic coordinates. Hot Spot Analysis was used to determine the existence of any spatial clustering patterns in adherence rates. The analysis was performed at the census tract level by using the percentage of nonadherent patients within a census tract to represent adherence for the people living within that tract, standardized by the number of residents in a census tract aged 40 years or older. Hot Spot Analysis identified unique geographic areas of high, neutral, and low adherence in the southeast area. Highly adherent census tracts were primarily located in and around the city where the university hospital and clinics are located. Areas of low adherence were located to the west, southwest, and southeast of the city. All other census tracts were considered neutral in adherence rates. Conclusion. Mapping geographic areas of drug adherence is feasible with use of GIS technology, with spatial mapping able to detect areas of varying levels of adherence. Future research should examine local-level factors associated with low adherence, which can be used to derive tailored, locally relevant interventions to improve long-term drug adherence.

BACKGROUND: Prolapse of the anterior and posterior vaginal walls has been generally associated with apical descent and levator ani muscle defects. However, the relative contributions of these factors to the pathophysiology of descent in the different vaginal compartments is not well understood. Furthermore, symptoms uniquely associated with prolapse in these compartments have not been well-characterized. OBJECTIVES: Compare associations between: 1) apical support, 2) levator ani muscles, and 3) pelvic floor symptoms in women with posterior-predominant prolapse, anterior-predominant prolapse, and normal support. STUDY DESIGN: This is a cross-sectional study with two case arms: 60 women with posterior prolapse, 90 with anterior prolapse, and a referent control arm with 103 asymptomatic subjects with normal support, determined from pelvic organ prolapse quantification examinations. Levator muscle defects were graded from magnetic resonance imaging. Vaginal closure forces above resting were measured with an instrumented speculum during maximal contraction. Pelvic floor symptoms were measured via the Pelvic Floor Distress Inventory – Short Form. RESULTS: Mean Point C location in controls was −6.9 cm [1.5] (mean [standard deviation]); and was higher in posterior prolapse (−4.7 cm [2.7], 2.2 cm below controls) than the anterior prolapse group (−1.2 cm [4.1]; 5.6 cm below controls, p

Objective Using our previously developed and tested Adolescent Sexual and Reproductive Health (SRH) Stigma Scale, we investigated factors associated with perceived SRH stigma among adolescent girls in Ghana. Methods We drew upon data from our survey study of 1,063 females 15-24yrs recruited from community- and clinic-based sites in two Ghanaian cities. Our Adolescent SRH Stigma Scale comprised 20 items and 3 sub-scales (Internalized, Enacted, Lay Attitudes) to measure stigma occurring with sexual activity, contraceptive use, pregnancy, abortion and family planning service use. We assessed relationships between a comprehensive set of demographic, health and social factors and SRH Stigma with multi-level multivariable linear regression models. Results In unadjusted bivariate analyses, compared to their counterparts, SRH stigma scores were higher among girls who were younger, Accra residents, Muslim, still in/dropped out of secondary school, unemployed, reporting excellent/very good health, not in a relationship, not sexually experienced, never received family planning services, never used contraception, but had been pregnant (all p-values