Exploring How Residents Who Partially Participate in Family Planning Training Determine Their Level of Participation

ObjectivesThe Accreditation Council for Graduate Medical Education (ACGME) requires that obstetrics and gynecology residency programs provide access to abortion training, though residents may elect to opt out of participating due to religious or moral objections. While clinical benefits of partial participation have previously been explored, our study aimed to explore how residents navigate partial participation in abortion training and determine their limits.Study DesignThis study was qualitative in nature. Between June 2010 and June 2011, we conducted 26 semi-structured phone interviews with residents who opted out of some or all of the family planning rotation at 19 programs affiliated with The Ryan Residency Training Program. Faculty directors identified eligible residents, or residents self-reported in routine program evaluation. We analyzed data using the conventional content analysis method.ResultsWe interviewed all 26 (46%) of 56 eligible residents willing to be interviewed. Three main categories constituted the general concepts concerning resident decision-making in training participation: (1) variation in timing of when residents determined the extent of participation, (2) a diversity of influences on the residents’ level of participation, and (3) the perception of support or pressure related to their participation decision.ConclusionsThe findings indicated that residents who partially participate in abortion training at programs with specialized opt-out family planning training weigh many factors when deciding under what circumstances, if any, they will provide abortions and participate in training.     

Availability and characteristics of abortion training in US ob-gyn residency programs: a national survey

Objective

To assess the availability and characteristics of abortion training in US ob-gyn residency programs.

Methods

We surveyed fourth-year residents at US residency programs by email regarding availability and type of abortion training, procedural experience and self-assessed competence in abortion skills. We conducted multivariable, ordinal logistic regression with general estimating equations to determine individual-level and resident-reported, program-level correlates of quantity of uterine evacuation procedures done during residency.

Results

Three hundred sixty-two residents provided data, representing 161 of the 240 residency programs contacted. Access to training in elective abortion was available to most respondents: 54% reported routine training—where abortion training was routinely scheduled; 30% reported opt-in training—where training was available but not routinely integrated; and 16% reported that elective abortion training was not available. Residents in programs with routine elective abortion training and those who intended to do abortions before residency did a greater number of first-trimester manual uterine aspiration and second-trimester dilation and evacuation procedures than those without routine training. Similarly, routine, integrated training, even for indications other than elective abortion, correlated with more clinical experience (all p<.01, odds ratio and confidence interval shown below).

Conclusion

There is a strong independent relationship between routine training and greater clinical experience with uterine aspiration procedures.     

Obstetrician-gynecologist experiences with abortion training: physician insights from a qualitative study

Background

Abortion is one of the most contested, yet common surgical procedures in the United States and a required component of obstetrics and gynecology resident education. Approaches to abortion training are variable.

Study Design

We conducted in-depth interviews with 30 physicians who had graduated 5–10 years prior from four US residency programs with routine abortion training. Interviews focused on their experiences with abortion during training and in practice.

Results

Graduates' positive and negative experiences demonstrated that many valued teaching about the social issues surrounding abortion as well as training in surgical skills. Respondents found training rewarding when attending physicians openly discussed their personal commitment to abortion practice, respected differences of opinions about abortion and demonstrated high regard for abortion training. Some residents who opted out of surgical training for abortion valued partially participating in the rotation.

Conclusions

Many physicians-in-training consider didactics related to the social context of care and respect for moral boundaries important components of abortion training.     

Pathways to unsafe abortion in Ghana: the role of male partners,women and health care providers

Background

Despite abortion being legal, complications from induced abortion are the second leading cause of maternal mortality in Ghana. The objective of this study was to understand the decision-making process associated with induced abortion in Ghana.

Study Design

Data were collected from female postabortion patients, male partners, family planning nurses and obstetricians/gynecologists at two teaching hospitals in Ghana using in-depth interviews and focus group discussions.

Results

While experiences differ for married and single women, men are involved in abortion decision making directly, through “orders” to abort, or indirectly, through denying responsibility for the pregnancy. Health care providers can be barriers to seeking safe abortions in this setting.

Conclusions

Women who choose to terminate a pregnancy without their male partners' knowledge should have the means (both financial and social) to do so safely. Interventions with health care providers should discourage judgemental attitudes and emphasize individually focused patient care.     

Formal training in vaccine safety to address parental concerns not routinely conducted in U.S. pediatric residency programs

Objective

To determine if U.S. pediatric residency programs provide formal training in vaccine safety to address parental vaccine concerns.

Methods

An electronic survey was mailed to all members of the Association of Pediatric Program Directors (APPD) to assess (1) if U.S. pediatric residency programs were providing formal vaccine safety training, (2) the content and format of the training if provided, and (3) interest in a training module for programs without training. Two follow-up surveys were mailed at 2 week intervals. Responses to the survey were collected at 4 weeks following the last mailing and analyzed. Logistic regression was used to assess the impact of program size on the likelihood of vaccine safety training. Pearson's chi square was used to compare programs with and without formal vaccine safety training in 5 U.S. regions.

Results

The survey was sent to 199 APPD members; 92 completed the survey (response rate 46.2%). Thirty-eight respondents (41%) had formal training in vaccine safety for pediatric residents at their programs; 54 (59%) did not. Of those that did not, the majority (81.5%) were interested in formal vaccine safety training for their residents. Of all respondents, 78% agreed that training in vaccine safety was a high priority for resident education. Thirty-five percent of all respondents agreed that local parental attitudes about vaccines influenced the likelihood of formal vaccine safety training.

Conclusion

Most pediatric residency programs surveyed do not include formal training on vaccine safety; yet, such training is supported by pediatric residency program directors as a priority for pediatric residents.     

Perceptions of home and self-injection of Sayana® Press in Ethiopia: a qualitative study

Objective

Sayana® Press,¹ a new subcutaneous formulation and presentation of a popular injectable contraceptive, has the potential to expand non-clinic access to contraception, including home and self-injection (HSI). This study collected information from potential users and stakeholders on their perceptions and preferences, the feasibility of an HSI of Sayana Press program and key policy considerations.

Study design

PATH conducted 62 interviews and 7 focus groups with family planning users, non-users, physicians, other health care providers and key informants in the Oromia region of Ethiopia. Participants watched a demonstration and tested the device on a model mid-interview. The study did not involve product use in humans.

Results

Women found the product easy to use, liked the simple design and valued the time and expense that could be saved through HSI of Sayana Press (HSI-SP). Of those with inhibitions about their ability to self-inject, most shifted their opinion favorably after demonstration. The majority of other stakeholders also supported HSI-SP and thought it could increase contraceptive use in Ethiopia, and they suggested that any successful program must include proper training and supervision, particularly regarding product storage and waste management.

Conclusion

The data provide findings to stimulate further research and support future planning. They suggest that HSI-SP may meet the needs of many women if key requirements and challenges are met. It may also be necessary to revise policies and guidelines to integrate the approach with national family planning strategies.

Implications

This study provides the first available data on perceptions, feasibility and requirements for HSI of Sayana Press in a low-resource setting. Findings provide insights that may guide future implementation strategies, strengthen non-clinic family planning access programs and stimulate continued research.     

Hospice Family Members' Perceptions of and Experiences With End-of-Life Care in the Nursing Home

Objective

Even though more than 25% of Americans die in nursing homes, end-of-life care has consistently been found to be less than adequate in this setting. Even for those residents on hospice, end-of-life care has been found to be problematic. This study had 2 research questions; (1) How do family members of hospice nursing home residents differ in their anxiety, depression, quality of life, social networks, perceptions of pain medication, and health compared with family members of community dwelling hospice patients? (2) What are family members’ perceptions of and experiences with end-of-life care in the nursing home setting?

Methods

This study is a secondary mixed methods analysis of interviews with family members of hospice nursing home residents and a comparative statistical analysis of standard outcome measures between family members of hospice patients in the nursing home and family members of hospice patients residing in the community.

Results

Outcome measures for family members of nursing home residents were compared (n = 176) with family members of community-dwelling hospice patients (n = 267). The family members of nursing home residents reported higher quality of life; however, levels of anxiety, depression, perceptions of pain medicine, and health were similar for hospice family members in the nursing home and in the community. Lending an understanding to the stress for hospice family members of nursing home residents, concerns were found with collaboration between the nursing home and the hospice, nursing home care that did not meet family expectations, communication problems, and resident care concerns including pain management. Some family members reported positive end-of-life care experiences in the nursing home setting.

Conclusion

These interviews identify a multitude of barriers to quality end-of-life care in the nursing home setting, and demonstrate that support for family members is an essential part of quality end-of-life care for residents. This study suggests that nursing homes should embrace the opportunity to demonstrate the value of family participation in the care-planning process.     

Understanding women's desires for contraceptive counseling at the time of first-trimester surgical abortion

Objective

The objective was to investigate whether or not women presenting for a first-trimester surgical abortion want to discuss contraception on the day of their procedure.

Study Design

Between October 2012 and January 2013, an anonymous self-administered survey was distributed to women receiving first-trimester surgical abortions at four northern California family planning clinics. The survey obtained demographic information about each woman and inquired about her desire for contraceptive counseling during her appointment. Results were analyzed using both univariate and multivariable regression analyses to assess trends in responses related to desire for contraceptive counseling based on demographic and other variables.

Results

Of the 199 respondents, 64% reported that they did not want to talk to a counselor or doctor about contraception on the day of their abortion. About half of the women (52%) who did not want to discuss contraception indicated they already knew what they wanted for pregnancy prevention. Of the 25% who reported that they did want to discuss contraception, the most important topic desired from the counseling was identification of methods that were easier to use than what they used previously.

Conclusion

The majority of women seeking first-trimester surgical abortion may not desire additional information about contraception on the day of the procedure.

Implications Statement

This study demonstrates that a significant proportion of women may not want contraceptive counseling on the day of a planned surgical abortion.     

Are women aware of religious restrictions on reproductive health at Catholic hospitals? A survey of women’s expectations and preferences for family planning care

Objective

To understand if women anticipate a difference in reproductive healthcare when attending a Catholic institution.

Study design

A convenience sample of reproductive-aged women in the Denver metro area completed an online survey. Women were randomized to hypothetical women’s health clinics at either a secular or Catholic hospital and asked about expectations for family planning care. Questions covered contraception and management of abnormal or unintended pregnancy. We subsequently assessed provider/site preferences for care.

Results

We analyzed 236 surveys. The majority of participants expected their gynecologist to provide all family planning services presented. The only difference based on institution was that participants randomized to the Catholic hospital were more likely to expect natural family planning advice. At least half of respondents reported they would seek care from their gynecologist for the services surveyed with the exceptions of emergency contraception and elective abortion.

Conclusions

Overall, this cohort of women did not anticipate differences in reproductive healthcare based on institution. If women who enroll at Catholic hospitals do not receive information related to potential healthcare restrictions, their ability to act as informed healthcare consumers may be constrained.

Implications

Women did not anticipate differences in reproductive healthcare based on institution type (Catholic vs. secular) and, thus, their ability to act as informed healthcare consumers may be constrained.     

Family planning intentions: a qualitative exploration of postpartum women of Mexican descent in North Carolina

Background

North Carolina has one of the fastest growing Mexican–American populations, yet health care providers have minimal information on how to address the family planning needs of this population.

Study Design

We conducted semistructured interviews with postpartum Mexican–American women, aged 18–35 years, within 1 month of delivery. Salient themes were identified, coded and analyzed.

Results

Twenty women were interviewed. The majority had firmly held family size intentions: most desired to have 2 to 4 children with 2 to 5 years between births. Partners’ preferences and the family size in which the participant was raised were factors that most influenced their family size preference. First-generation Mexican–American participants were more likely to have a partner whose intentions are influenced by the gender(s) of their children compared with participants born in Mexico. Participants desired longer intrapartum intervals for optimal infant development, with financial considerations cited less frequently.

Conclusion

Postpartum women of Mexican descent articulate consistent family planning intentions. Partners’ desires may challenge the achievement of these intentions. Providers can encourage the most effective forms of contraception to promote ideal and intended family size.     

Barriers to D&E practice among family planning subspecialists

Objective

Over 95% of all second-trimester abortions are managed by dilation and evacuation procedures (D&E) and account for nearly 9% of all abortions in the United States annually. The Fellowship in Family Planning (FFP) offers subspecialty training in abortion and contraception to obstetrician–gynecologists and family medicine physicians. Twenty years after the FFP founding, we report on the abortion practice characteristics and specific barriers these subspecialists face.

Study Design

We surveyed obstetrician–gynecologist family planning (FP) subspecialists by email regarding second-trimester abortion training and practice barriers with a focus on D&E.

Results

Our response rate was 62% (105/169) of all fellowship-affiliated physicians. Respondents were composed primarily of young women working in academic settings in the West and Northeast regions. Nearly all FP subspecialists have been trained to 24 weeks’ gestation and currently provide D&Es, with an average of nearly 200 per year. D&E practice barriers vary by geographical location and degree of “regional restrictiveness.” FP subspecialists practicing in more abortion-restrictive regions were four times more likely to report a personal main barrier (such as concern for safety) than other types of main barriers (p=.05). Providing D&Es in a hospital operating room was associated with 2.8 times higher odds of reporting an institutional or coworker main barrier (p=.02). High-volume D&E practice was associated with three times lower odds of reporting an institutional/coworker main barrier (p=.02).

Conclusions

By identifying the barriers to D&E practice experienced by FP subspecialists, we can begin to develop a coordinated approach to eradicating modifiable barriers and, ultimately, improve access for women seeking D&E services.     

Beliefs about abortion risks in women returning to the clinic after their abortions: a pilot study

Background

Misinformation regarding the risks of abortion is prevalent and commonly includes medical inaccuracies about health, depression, infertility and breast cancer. This pilot study sought to assess misinformation among abortion clients as well as the origin(s) of their abortion knowledge.

Study Design

Women who presented to the Mount Sinai School of Medicine Family Planning Division for postabortion follow-up were recruited for participation. Participants completed a researcher-administered survey regarding knowledge and beliefs about abortion.

Results

Sixty-seven women completed the survey between 1/11/10 and 8/6/12. Common sources of abortion information included clinicians (79.1%), Web sites (70.1%), friends (50.7%) and family (40.3%). Over two thirds of women (77.6%) overestimated the health risks, and close to half (43.3%) overestimated the risk of depression after a first trimester abortion.

Conclusions

Misperceptions about the health risks of abortion were prevalent among this sample. Education tools should be developed to provide accurate information about the risks of abortion.     

Evaluation of a volunteer community-based health worker program for providing contraceptive services in Madagascar

Background

Madagascar recently scaled up their volunteer community health worker (CHW) program in maternal health and family planning to reach remote and underserved communities.

Study design

We conducted a cross-sectional evaluation using a systematic sample of 100 CHWs trained to provide contraceptive counseling and short-acting contraceptive services at the community level. CHWs were interviewed on demographics, recruitment, training, supervision, commodity supply, and other measures of program functionality; tested on knowledge of injectable contraception; and observed by an expert while completing five simulated client encounters with uninstructed volunteers. We developed a CHW performance score (0–100%) based on the number of counseling activities adequately met during the client encounters and used multivariable linear regression to identify correlates of the score.

Results

CHWs had a mean performance score of 73.9% (95% confidence interval [CI]: 70.3–77.6%). More education, more weekly volunteer hours, and receiving a refresher training correlated with a higher performance score. We found no other associations between measures of the components previously identified as essential for effective CHW programs and performance score.

Conclusions

Although areas of deficiency were identified, CHWs proved capable of providing high-quality contraception services.     

Trend in the use of modern contraception in sub-Saharan Africa: does women's education matter?

Background

Existing literature revealed positive association between women's education and modern contraceptive use in sub-Saharan Africa (SSA). Overall modern contraception prevalence (MCP) and proportion of women with formal education have increased in region. However, little is known about how much the change in the prevalence of modern contraceptive methods is relative to the compositional change in population and how much of the change is actually due to increases in the number of women adopting the new behavior.

Objective(s)

This study aims to (1) describe trends in modern contraception prevalence by female education; and (2) identify the source of changes in modern contraceptive use by educational attainment (changes in structure or in population behavior).

Study Design

This is a cross-sectional study using Demographic and Health Surveys from 27 SSA countries where at least two comparable surveys have been conducted.

Results

Overall modern contraception prevalence (MCP) has increased in SSA over the study period. The ongoing increase in the contraceptive use is due to changes in behavior consistent with the ongoing family planning promotion over the past 30 years. By contrast, an increase in the proportion of women with secondary education does not explain the change in MCP in most SSA countries.

Conclusion(s)

To achieve universal access to family planning, efforts in promoting female education should be complemented with economic, cultural and geographical access to MCP. Household-based sensitization, general hospitals, mobile family planning clinics, and community-based distributors of modern contraceptive methods are key strategies to improve access to modern contraceptive use.

Implication

Findings from this study suggest that countries should combine social investments, including health services and education, with family planning programs using reproductive health services, mobile family planning clinics and community-based distributors of modern contraceptive methods. Therefore, governments' legislation measures that promote universal secondary education as well as universal access to modern contraception can be put in place.     

Twenty Years of the Ryan Residency Training Program in Abortion and Family Planning

ObjectiveTo summarize the effects of routine, opt-out abortion and family planning residency training on obstetrics and gynecology (ob-gyn) residents’ clinical skills in uterine evacuation and intentions to provide abortion care after residency.MethodsData from ob-gyn residency programs supported during the first 20 years of the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning were analyzed. Postrotation surveys assessed residents’ training experiences and acquisition of abortion care skills. Residency program director surveys assessed benefits of the training to residents and the academic department from the educators’ perspectives.ResultsA total of 2775 residents in 89 ob-gyn programs completed postrotation surveys for a response rate of 72%. During the rotation, residents – including those who only partially participated – gained exposure to and skills in first- and second-trimester abortion care. Sixty-one percent intended to provide abortion care in their postresidency practice. More than 90% of residency program directors (97.5% response rate) reported that training improved resident competence in abortion and contraception care and 81.3% reported that the training increased their own program's appeal to residency applicants.ConclusionOver 20 years, the Ryan Program has supported programs to integrate abortion training to give ob-gyn residents the skills and inspiration to provide comprehensive reproductive health care, including uterine evacuation and abortion care, in future practice. Residency program directors noted that this integrated training meets resident applicants’ expectations.ImplicationsRyan Program residents are trained to competence and are prepared, both clinically and in their professional attitudes, to care for women's reproductive health.     

Administration of the etonogestrel contraceptive implant on the day of mifepristone for medical abortion: a pilot study

Objective

We sought to determine satisfaction and continuation rates of the contraceptive implant when placed on the initial visit for first-trimester medical abortion.

Study Design

In this pilot study, we placed the implant within 15 min of mifepristone administration. We assessed satisfaction with implant placement timing, 1-year implant continuation and abortion completion.

Results

We enrolled 20 participants. Sixteen (80%) returned for follow-up, and all had complete abortion. At 1 year, of 16 participants contacted, 14 (87.5%) were satisfied with implant insertion timing, and 14 (87.5%) continued the implant.

Conclusions

Initiation of the contraceptive implant on the initial visit for medical abortion resulted in high satisfaction and continuation rates.

Implications

This pilot study provides important groundwork for future larger studies to assess initiation of the contraceptive implant on the day of mifepristone for medical abortion.     

Representation in the Care Planning Process for Nursing Home Residents With Dementia

Objectives

Federally mandated assessments of nursing home (NH) residents drive individualized care planning. Residents with cognitive impairment may not be able to meaningfully communicate their care needs and preferences during this process—a gap that may be partially addressed by involving surrogates. We describe the prevalence of family participation in the care planning process for long-stay NH residents with varying degrees of cognitive impairment.

Perceptions of family planning and abortion education at a faith-based medical school

Background

Because of religious beliefs against contraception and abortion, family planning education is limited at faith-based institutions. The purpose of this study was to assess medical students' satisfaction with family planning education at a faith-based medical school.

Study Design

A self-administered anonymous questionnaire was designed and distributed to all second- and fourth-year students (n=273) at a faith-based medical school during the 2008–2009 academic year. The questionnaire included items on adequacy of and preference for amount and content of family planning preclinical education and clinical training.

Results

A total of 220 students completed the questionnaire for a response rate of 80.6%. The majority of respondents described the preclinical education as inadequate and preferred increased content on contraception (73.9%), sterilization (68.6%) and abortion (65.2%). The majority of fourth-year students reported appropriate contraceptive clinical training (69.0%), but inadequate sterilization training (54.8%) and abortion training (71.4%) during their third-year OB/GYN clerkship. Approximately half of fourth-year students (51.8%) desired clinical abortion training.

Conclusion

The majority of students enrolled at a faith-based medical school rated their current family planning education as inadequate and desired additional opportunities.     

Observational study of the acceptability of Sayana® Press among intramuscular DMPA users in Uganda and Senegal

Background

Sayana® Press (SP), a subcutaneous formulation of depot medroxyprogesterone acetate (DMPA) in Uniject™, has potential to be a valuable innovation in family planning (FP) because it may overcome logistic and safety challenges in delivering intramuscular DMPA (DMPA IM). However, SP's acceptability is unknown. We measured acceptability of SP among DMPA IM users.

Study design

This open-label observational study was conducted in clinics in three districts in Senegal and community-based distribution services in two districts in Uganda. Experienced DMPA IM users were offered SP by community health workers (CHWs) or clinic-based providers. SP decliners were asked to discuss their reasons. Those who received SP were interviewed pre- and postinjection and 3 months later, when they were asked if they would select SP over DMPA IM if it were available.

Results

One hundred twenty women in Uganda and 242 in Senegal received SP (117 and 240 were followed up, respectively). Nine Ugandan and seven Senegalese SP decliners were interviewed. Three months after receiving SP, 84% [95% confidence interval (CI)=75%–93%] of Ugandan participants and 80% (95% CI=74%–87%) of Senegalese participants said they would select SP over DMPA IM. Main reasons for selecting SP were fewer side effects, liking the method, fast administration, less pain and method effectiveness. Thirty-four adverse events were reported but were not serious. No pregnancies were reported.

Conclusion

Current DMPA IM users in Senegal and Uganda accepted SP, and most preferred SP over DMPA IM. SP can be safely introduced into FP programs and administered by trained CHWs, with expectation of client uptake.

Implications

We found SP acceptable and safe in diverse settings among current intramuscular DMPA users, including those who received SP from CHWs. This provides evidence that SP would be used and could therefore reduce unmet family planning needs if introduced into family planning programs.