Women’s Preferences for the Location of Abortion Services: A Pilot Study in Two Chicago Clinics

Between July and December 2006, 209 women at a university-based primary care center and a freestanding abortion clinic completed a verbally administered questionnaire in which they were asked their preference for the location of early abortion services. Sixty women seeking primary care services at the university-based clinic and 149 women seeking first-trimester abortion services at an abortion clinic completed the questionnaire. Sixty-seven percent (67%) of women surveyed at the university-based primary care facility and 69% at the abortion clinic indicated a preference for abortion services from their regular health care provider. A statistically significant association (P = 0.002) was found between comfort speaking with a regular health care provider about pregnancy prevention and preference for the provision of abortion services from a regular health care provider. Women may feel more comfortable undergoing an early abortion procedure with a provider with whom they have an established relationship. The integration of early abortion services into primary care practice may increase continuity of care among women seeking an abortion.     

Miscommunication between healthcare providers and patients may result in unplanned pregnancies

Our objective was to examine the impact of prior healthcare provider counseling on previous use of contraception and knowledge of emergency contraception in women seeking surgical abortion. We performed a retrospective analysis of 342 patient charts from women seeking an office abortion in a private practice setting from January 1999 to June 2001. Data extracted included demographic information, primary method of contraception over the preceding few months, compliance with that method, contraceptive history, knowledge of emergency contraception and postabortion contraception. Patients were primarily white (69%) and unmarried (63%) and had private insurance that covered abortion services (72%). Only 19% of women were using a birth control method with no recognized potential failure. Twenty-two percent of women were using their birth control method correctly but experienced an event that put them at risk for pregnancy, 32% were using their birth control method incorrectly and 27% were using no birth control method at all. Miscommunication between patients and their healthcare provider(s) negatively affected use of a primary contraceptive method in 14% of patients. Of the 77% of women who did not know about emergency contraception, nearly two thirds had an identifiable event for which emergency contraception could have been used. Healthcare providers may contribute to the occurrence of unintended pregnancy if they provide poor medical advice or miscommunicate with patients.     

Lack of family planning leading to induced abortion in rural Greece

29 (31%) of the 94 mothers interviewed in a domiciliary study of the use of mother and child health services in rural northwest Greece reported they had undergone an induced abortion. Most of these women, between 30-40 years of age, had at least 2 children. There was no correlation with the mother's literacy, father's occupation, and family's socioeconomic situation. The rate of abortion reported in this study is consistent with the findings of other Greek studies in urban settings. In the current study it was difficult to identify the exact time when women had undergone the abortion as the topic was delicate. Yet, all women were prompt and sincere in their answers and willing to share their anxieties and their fears about possible effects on subsequent pregnancies. The women had gone to considerable efforts to obtain an induced abortion. These included the inconvenience of going to a doctor in the main town (40 miles away) and incurring travel costs as well as the cost of the operation, which is currently about 10,000 drachmas. Few women (36%) were using any contraceptive method. The 36% included 27% who used condoms and coitus interruptus, 7% the rhythm method, and 2% all 3 methods. Only a few of the more educated women had heard or read about other methods. All of the women were concerned about the risk of becoming pregnant when they used no method or a risky method. In Greece induced abortion is clearly a response to unwanted pregnancies, which follow the lack of family planning or birth spacing services. The government introduced legislation concerning the provision of family planning services in 1980, but the provision of these services has been very slow. Currently, only a few family planning clinics are operational and mainly in the large cities. 1 way to make some progress may be to develop interest in the provision of more appropriate primary health care and more appropriate training of doctors and other health workers. There are few experienced doctors practicing in rural Greece at this time. The key person for providing family planning care could be the rural midwife who is already a respected provider of family advice in the community. Needed is an active program to expand the provision of family planning services to the rural areas of Greece. Contraceptive services must be provided to enable people to limit the size of their family to the size they want without having to resort to abortion. It is time for health care providers to stop saying that what is needed is family planning education and to start providing the actual services.     

Patterns of ambulatory care for AIDS patients, and association with emergency room use.

OBJECTIVE. We examined the association of patterns of ambulatory care for AIDS patients with any use of the emergency room (ER) and the monthly rate of ER visits in the six months after AIDS diagnosis. DATA SOURCES/STUDY SETTING. The study population was obtained from the New York State Medicaid HIV/AIDS Research Data Base and includes patients diagnosed with AIDS from 1983 to 1990. DATA COLLECTION/EXTRACTION METHODS. To examine patterns of care and ER use not leading to hospitalization, we studied patients who survived at least six months after their first AIDS-defining diagnosis. The data base included person level information on visits to different provider sites and patient demographic and clinical characteristics. STUDY DESIGN. We defined the dominant provider as the site delivering the majority of ambulatory care for patients with a minimum of four ambulatory visits in the six months after AIDS diagnosis. Dominant providers were classified by specialty and setting: generalist physician; general medicine clinic; AIDS specialty clinic; and other specialty clinic or physician (e.g., cardiology). Patients without a dominant provider were grouped into those with four or more visits and those with fewer than four visits. Regression analysis was used to estimate relationships between ER use and patterns of ambulatory care and patient demographic and severity of illness characteristics. PRINCIPAL RESULTS. The study population included 9,155 AIDS patients aged 13 to 60 years at diagnosis, continuously Medicaid-enrolled, and surviving at least six months after AIDS diagnosis. Among those with four or more visits (56 percent), over 70 percent had a dominant provider. Overall, 39 percent of the study population visited the ER while, in the group with four or more visits, 53 percent of those without a dominant provider had an ER visit. Patients without a dominant provider were estimated to have 32 percent higher odds of ER use than patients with a dominant provider. Among patients with a dominant provider, patients with a generalist or primary care clinic dominant site of care were estimated respectively to have 18 percent and 23 percent lower odds than patients with an AIDS specialty clinic as the dominant site of care. Drug users had higher odds of ER use, as did women. CONCLUSIONS. In this Medicaid AIDS population, a dominant provider delivering the majority of a patient's care was associated with less use of the ER by the patient. Among patients with a dominant provider, ER use was lowest for those with a primary care provider. Further examination of the type and availability of ambulatory services in AIDS specialty clinics and primary care settings, as well as more detailed information on patient characteristics, may reveal reasons for these patterns of ER use.     

Patients' attitudes and experiences related to receiving contraception during abortion care

BackgroundHigh risk for additional unintended pregnancies among abortion patients makes the abortion care setting an ideal one for facilitating access to contraception. This study documents attitudes of abortion patients about contraceptive services during their receipt of abortion services and identifies patient characteristics associated with desire for contraception and interest in using a long-acting reversible contraceptive method (LARC).Study DesignStructured surveys were administered to 542 patients at five US abortion-providing facilities between March and June of 2010. Supplementary information was collected from 161 women who had had abortions in the past 5 years through an online survey.ResultsAmong abortion patients, two thirds reported wanting to leave their appointments with a contraceptive method and 69% felt that the abortion setting was an appropriate one for receiving contraceptive information. Having Medicaid and having ever used oral contraceptives were predictive of wanting to leave with a method. Women having a second or higher-order abortion were over twice as likely as women having a first abortion to indicate interest in LARC, while black women were half as likely as white women to indicate this interest.ConclusionMany women are interested in learning about and obtaining contraceptive methods, including LARC, in the abortion care setting.     

Ensuring high-quality primary care for women: predictors of success.

BACKGROUND: Provider gender, provider specialty, and clinic setting affect quality of primary care delivery for women, but previous research has not examined these factors in combination. The purpose of this study is to determine whether separate or combined effects of provider gender, availability of gynecologic services from the provider, and women's clinic setting improve patient ratings of primary care. METHODS: Women veterans receiving care in women's clinics or traditional primary care at 10 Veteran's Affair (VA) medical centers completed a mailed questionnaire (N = 1321, 61%) rating four validated domains of primary care (preference for provider, communication, coordination, and accumulated knowledge). For each domain, summary scores were calculated and dichotomized into perfect score (maximum score) versus other. Multiple logistic regressions were used to estimate the probability of a perfect score in each domain while controlling for patient characteristics and site. RESULTS: Female provider was significantly associated with perfect ratings for communication and coordination. Providing gynecologic care was significantly associated with perfect ratings for male and female providers. Patients who used a women's clinic and had a female provider who gave gynecologic care had perfect or nearly perfect ratings for preference for provider, communication, and accumulated knowledge. CONCLUSION: Gynecologic services are linked to patient ratings of primary care separate from and in synergy with the effect of female provider. Male and female providers should consider offering routine gynecologic services or working in coordination with a setting that provides gynecologic services. Health care evaluations should assess scope of services for provider and practice.     

The accessibility of abortion services in the United States, 2001

CONTEXT: A woman's ability to obtain an abortion is affected both by the availability of a provider and by accessrelated factors such as cost, convenience, gestational limits and the provision of early medical abortion services.
METHODS: In 2001-2002, The Alan Guttmacher Institute surveyed all known abortion providers in the United States, collecting information on their delivery of abortion services and on the number of abortions performed.
RESULTS: A minority of abortion providers offer services before five weeks from the last menstrual period (37%) or after 20 weeks (24% or fewer), but the proportions have increased since 1993. Providers estimate that one-quarter of women having abortions in nonhospital facilities travel 50 miles or more for services, and that 7% are initially unsure of their abortion decision. The majority of providers (59%) say that these clients usually receive abortions during a single visit. An average self-paying client was charged $372 for a surgical abortion at 10 weeks in 2001, up from $319 in 1997; only 26% of clients receive services billed directly to public or private insurance. Early medical abortions are becoming increasingly available but are more expensive than surgical abortions. More than half (56%) of providers experienced antiabortion harassment in 2000, but types of harassment other than picketing have declined since 1996.
CONCLUSIONS: Abortion at very early and late gestations and early medical abortion are more available than before, but charges have increased and antiabortion picketing remains at high levels. Thus, many women still face substantial barriers to obtaining an abortion.     

Determinants of demand: method selection and provider preference among US women seeking abortion services

BACKGROUND: Medication abortion has the potential to increase abortion availability, primarily through new provider networks; however, without a better understanding of how and why women make decisions regarding both their abortion method and their provider, expansion efforts may be misguided and valuable resources may be wasted. STUDY DESIGN: We undertook an exploratory study to investigate method and provider preferences. Semistructured one-on-one interviews were conducted with 205 abortion clients at three family planning clinics. RESULTS: Study participants greatly preferred the clinic setting for their abortion; the majority of women in the study would not have gone to their regular physician if they had been given the option. In addition, method choice trumps provider choice for the majority of women who would have preferred their regular provider. Participants who chose the aspiration procedure were more likely to have previous knowledge about the medication method. Travel time was not a predictor of preferring one's regular physician over the clinic. CONCLUSIONS: Expanding provider networks via the private sector is unlikely to be a panacea. In addition to these efforts, more attention may need to be paid to addressing logistic barriers to access. Physicians offering abortion services need to let their patients know they offer such services prior to their patients' need for them. Questions remain regarding the information being circulated about medication abortion.     

Association Between Availability of Women's Health Services and Women Veterans' Care Experiences

IntroductionFew studies have focused on determinants of women's ratings of care experiences in primary care. We assessed associations between availability of women's health services and women veterans' ratings of care experiences.MethodsIn a cross-sectional analysis, we linked Fiscal Year (FY) 2017 (October 1, 2016, to September 30, 2017) survey data from 126 Veterans Health Administration (VA) primary care leaders to 4,254 women veterans' ratings of care from VA's Survey of Healthcare Experiences of Patients-Patient Centered Medical Home (FY 2017). The dependent variables were ratings of optimal access (appointments, information), care coordination, comprehensiveness (behavioral health assessment), patient–provider communication, and primary care provider. Key independent variables were number of women's health services 1) routinely available all weekday hours (compared with some hours or not available) and 2) available in VA general primary care vs. other arrangements. In multilevel logistic regression models, we adjusted for patient-, facility-, and area-level characteristics.ResultsA greater number of women's health services routinely available in VA primary care was associated with a higher likelihood of optimal ratings of care coordination (adjusted odds ratio [AOR], 1.06; 95% confidence interval [CI], 1.01–1.10), provider communication (AOR, 1.08; 95% CI, 1.002–1.16), and primary care provider (AOR, 1.07; 95% CI, 1.02–1.13). A greater number of services available in VA primary care was associated with a lower likelihood of optimal ratings for access (AOR, 0.94; 95% CI, 0.88–0.99).ConclusionFor the most part, routine availability of women's health services in VA primary care clinics enhanced women's healthcare experiences. These empirical findings offer healthcare leaders evidence-based approaches for improving women's care experiences.     

Patients' attitudes and experiences related to receiving contraception during abortion care

Background

High risk for additional unintended pregnancies among abortion patients makes the abortion care setting an ideal one for facilitating access to contraception. This study documents attitudes of abortion patients about contraceptive services during their receipt of abortion services and identifies patient characteristics associated with desire for contraception and interest in using a long-acting reversible contraceptive method (LARC).

Study Design

Structured surveys were administered to 542 patients at five US abortion-providing facilities between March and June of 2010. Supplementary information was collected from 161 women who had had abortions in the past 5 years through an online survey.

Results

Among abortion patients, two thirds reported wanting to leave their appointments with a contraceptive method and 69% felt that the abortion setting was an appropriate one for receiving contraceptive information. Having Medicaid and having ever used oral contraceptives were predictive of wanting to leave with a method. Women having a second or higher-order abortion were over twice as likely as women having a first abortion to indicate interest in LARC, while black women were half as likely as white women to indicate this interest.

Conclusion

Many women are interested in learning about and obtaining contraceptive methods, including LARC, in the abortion care setting.     

Transaction costs of access to health care: Implications of the care-seeking pathways of tuberculosis patients for health system governance in Nigeria

Health care costs incurred prior to the appropriate patient–provider transaction (i.e., transaction costs of access to health care) are potential barriers to accessing health care in low- and middle-income countries. This paper explores these transaction costs and their implications for health system governance through a cross-sectional survey of adult patients who received their first diagnosis of pulmonary tuberculosis (TB) at the three designated secondary health centres for TB care in Ebonyi State, Nigeria. The patients provided information on their care-seeking pathways and the associated costs prior to reaching the appropriate provider. Of the 452 patients, 84% first consulted an inappropriate provider. Only 33% of inappropriate consultations were with qualified providers (QP); the rest were with informal providers such as pharmacy providers (PPs; 57%) and traditional providers (TP; 10%). Notably, 62% of total transaction costs were incurred during the first visit to an inappropriate provider and the mean transaction costs incurred was highest with QPs (US$30.20) compared with PPs (US$14.40) and TPs (US$15.70). These suggest that interventions for reducing transaction costs should include effective decentralisation to integrate TB care with services at the primary health care level, community engagement to address information asymmetry, enforcing regulations to keep informal providers within legal limits and facilitating referral linkages among formal and informal providers to increase early contact with appropriate providers.     

Mental Health Screening Results Associated with Women Veterans' Ratings of Provider Communication,Trust, and Care Quality

Background

Identifying factors influencing patient experience and communication with their providers is crucial for tailoring comprehensive primary care for women veterans within the Veterans Health Administration. In particular, the impact of mental health (MH) conditions that are highly prevalent among women veterans is unknown.

Antenatal contraception — simple,feasible, but is it safe and ethical in resource-poor environments?

In developing countries, antenatal care is used by more women than any other reproductive health services available and many women who receive antenatal care will not receive intrapartum care by a trained provider and even fewer will receive postnatal care. At present, antenatal care provides contraceptive counselling but not contraceptive provision. An important reason for this is the perceived absence of a suitable method that could be distributed or started during antenatal care. In this article, we discuss the available options. We conclude that antenatal insertion of subdermal contraceptive implants is very likely to be safe and ethically defensible where access to contraceptive services is poor.     

It Is Time to Integrate Abortion Into Primary Care

The Roe v Wade decision made safe abortion available but did not change the reality that more than 1 million women face an unwanted pregnancy every year. Forty years after Roe v Wade, the procedure is not accessible to many US women.The politics of abortion have led to a plethora of laws that create enormous barriers to abortion access, particularly for young, rural, and low-income women. Family medicine physicians and advanced practice clinicians are qualified to provide abortion care.To realize the promise of Roe v Wade, first-trimester abortion must be integrated into primary care and public health professionals and advocates must work to remove barriers to the provision of abortion within primary care settings.THE 1973 ROE V WADE decision1 removed many legal obstacles to abortion and was a public health watershed. The availability of safe abortion services led to dramatically decreased rates of maternal morbidity and mortality in the United States,2 as in most countries that have removed legal impediments to abortion care.According to the most recent available data, approximately 1.2 million women obtain safe, legal abortions from skilled clinicians in the United States every year.3 The political debate over abortion has largely ignored the public health fact that the Roe v Wade decision did not create or change the need for abortion; legalization simply made abortion safe. Maternal death from unsafe abortion in the United States became a negligible statistic after 1973. Abortion is now one of the safest medical procedures available; only 0.3% of abortion patients experience a complication that requires hospitalization.4Unwanted pregnancy continues to be a reality of women’s lives. One in three women in the United States will seek an abortion before she is aged 45 years.3 For these women, restrictive laws driven by ideology, not science, are undermining the promise of Roe v Wade in many parts of the country. State restrictions—including waiting periods, parental consent requirements for minors, lack of insurance coverage or Medicaid coverage for abortion, and expensive and unnecessary building requirements for facilities that provide abortions—create almost insurmountable barriers to access, especially for rural, young, and low-income women. There are ever-increasing restrictions passed at the state and federal levels, and antiabortion activists have directed a relentless campaign of violence and harassment at clinics and clinicians who provide the service. Many medical residencies lack training opportunities, leading to a lack of skilled abortion providers. The cumulative result of these regulations, the harassment, and the lack of training is a shrinking number of sites that offer abortion services.Specialized abortion clinics performed 70% of all abortions in 2008,3 yet the hostile political climate those opposed to abortion have created is forcing the numbers of these clinics to decline every year. The number of abortion providers has declined dramatically, from 2908 in 1982 to 1787 in 2005. Eighty-seven percent of all US counties lacked an abortion provider in 2008; 35% of US women live in those counties.3Abortion services are concentrated in cities.3 Almost all nonmetropolitan counties (which is 97% of all US counties) lack an abortion provider.3 In eight states (Arkansas, Idaho, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, and Wyoming) there are abortion clinics in only one city in the entire state. The result of the shortage of providers is that although abortion is one of the most common medical procedures performed in the United States, in many areas of the country women must travel for hours and deal with long delays to get the reproductive health care they need.Primary care clinicians provide personalized continuous preventative health care to patients throughout their reproductive years. Physician assistants, nurse midwives, and nurse practitioners (collectively, advanced practice clinicians, or APCs) and family physicians provide the majority of well-woman care to patients throughout the country. The skills needed to provide abortions—including the ability to assess gestational age, provide counseling, provide medications, perform manual or electric vacuum aspiration, and conduct postabortion follow-up—are in the scope of practice of primary clinicians. Many primary care clinicians who specialize in women’s health have specialized training. They perform suturing, colposcopy, intrauterine device insertions, endometrial biopsy, and gynecological care; and prescribe medications for family planning. These skills are comparable to those required to perform a first-trimester abortion.The provision of first-trimester abortion care is clearly within the scope of practice of primary care clinicians. In fact, since 1973 physician assistants have provided abortions in Montana and Vermont. Beginning in the early 1990s, advocates and professional groups came together to begin state-by-state advocacy to clarify the laws and scope of practice issues and promote the involvement of APCs in abortion care. APCs have been legally recognized as competent to substitute for physicians in the performance of many tasks.5 Several studies6,7 have compared complication rates and patient satisfaction between abortions physicians provide and those APCs provide. These studies consistently show that APCs with the requisite skills, training, and experience are fully competent to provide medical and first-trimester surgical abortions safely. As a result of state-by-state advocacy, APCs are now providing medication abortion in 18 states. APCs provide aspiration abortions in Montana, New Hampshire, Oregon, and Vermont.Additionally, APCs are providing aspiration abortion in California through a five-year demonstration project (Health Workforce Pilot Project No. 171) under the auspices of the University of California, San Francisco. Nurse practitioners, certified nurse midwives, and physician assistants have been trained to provide first-trimester aspiration abortion, and the project is being carefully evaluated. To date, 41 APCs at sites across California have been trained through the project. Nearly 8000 patients have received abortion care from these trained nurse practitioners, certified nurse midwives, and physician assistants. The project has conducted a study to compare the outcomes of these early abortions that APCs performed to a comparable number that physicians performed. The data show similar rates of high patient satisfaction and low complications in both groups.8Nurse practitioners, certified nurse midwives, and physician assistants have been increasing their commitment to abortion care, and there has also been remarkable advocacy among family medicine physicians. Several organizations (e.g., the Reproductive Health Access Project and the Center for Reproductive Health Education in Family Medicine [RHEDI]) have worked to increase training in abortion procedures in family medicine residency programs and to increase advocacy among family medicine professional organizations. Family physicians currently provide abortions at many of the freestanding clinics around the United States. Studies have shown that abortion care that family doctors provide have low rates of complication9,10 and that many patients would prefer to get their abortion from their family physician.11As more primary care clinicians are being trained and expressing interest in providing abortions, new technologies are making it possible for women to diagnose and end their pregnancies earlier. Inexpensive and accurate pregnancy tests now allow many women to determine whether they are pregnant within two weeks after unprotected intercourse. Advances in ultrasound have made it possible to confirm a pregnancy very early on. These advances have contributed to women in the first trimester coming in earlier to end an unwanted pregnancy. Eighty-eight percent of women who have abortions get the procedure in the first 12 weeks of pregnancy, and 61.8% of women have their abortion before the ninth week.4 All these women could be treated in a primary care setting.Yet most of the primary care clinicians who currently provide abortions do so at freestanding abortion sites.3 Too often when a patient seeks an abortion from her primary care clinician at her medical home, she is referred to another health care provider,12 even though trained family medicine doctors, nurse practitioners, certified nurse midwives, and physician assistants can provide first-trimester abortions. Although there are certainly primary care clinicians who do not want to provide abortions to their patients, many qualified and trained clinicians are willing but unable to offer this care because of burdensome, politically motivated restrictions that are not derived from science, public health considerations, or good medicine.Family medicine practices and physicians and community health centers are key health access points for low-income and rural women. Community health centers are the medical and health care home for more than 20 million people nationally, and community health center patients are disproportionately low income, uninsured or publicly insured, and minority.13 If abortion care were available in these centers and in family medicine practices, more women would be able to end their unwanted pregnancies without having to travel hundreds of miles or face delays that push them into getting abortions later in their pregnancy.Unfortunately, most federally qualified community health centers do not offer abortion services because of the Hyde Amendment, a legislative provision barring the use of federal funds to pay for abortions. Additionally, many of the federally qualified community health centers rely on malpractice coverage from the federal government, which does not cover abortion care. Family doctors who want to provide early abortion care in their practices must purchase extremely expensive obstetrical coverage, even though many other procedures routinely performed in family medicine have a higher complication rate than do first-trimester abortion procedures. APCs face other barriers; in many states, APCs are prevented from providing abortions or are limited to providing only medication abortion because of laws promoted by those who seek to restrict abortion access and because of resistance to expanding the scope of APCs’ practice to include abortion care.14The World Health Organization recently issued technical and policy guidelines for safe abortion worldwide. The guidelines state,

Both vacuum aspiration and medical abortion can be provided at the primary care level on an outpatient basis and do not require advanced technical knowledge or skills, expensive equipment such as ultrasound, or a full complement of hospital staff (e.g., anaesthesiologist). 15

The United States needs to step up to the World Health Organization standard. Health care reform has identified the importance of promoting high-quality, continuous, accessible, and cost-effective care in primary care settings. It is time for the promise of legal abortion to be available to every woman in the United States, rural or urban, low-income or middle class. Public health professionals and advocates must work together to find strategies to expand access to abortion by removing restrictions on the primary care clinicians who are trained and willing to provide the service. Forty years after Roe v Wade, it is time to integrate first-trimester abortion into primary care.     

What contraception do women use after abortion? An analysis of 319,385 cases from eight countries

Contraception is an essential element of high-quality abortion care. However, women seeking abortion often leave health facilities without receiving contraceptive counselling or methods, increasing their risk of unintended pregnancy. This paper describes contraceptive uptake in 319,385 women seeking abortion in 2326 public-sector health facilities in eight African and Asian countries from 2011 to 2013. Ministries of Health integrated contraceptive and abortion services, with technical assistance from Ipas, an international non-governmental organisation. Interventions included updating national guidelines, upgrading facilities, supplying contraceptive methods, and training providers. We conducted unadjusted and adjusted associations between facility level, client age, and gestational age and receipt of contraception at the time of abortion. Overall, postabortion contraceptive uptake was 73%. Factors contributing to uptake included care at a primary-level facility, having an induced abortion, first-trimester gestation, age ≥25, and use of vacuum aspiration for uterine evacuation. Uptake of long-acting, reversible contraception was low in most countries. These findings demonstrate high contraceptive uptake when it is delivered at the time of the abortion, a wide range of contraceptive commodities is available, and ongoing monitoring of services occurs. Improving availability of long-acting contraception, strengthening services in hospitals, and increasing access for young women are areas for improvement.     

The role of trust in use of preventive services among low-income African-American women

BACKGROUND: This study explored factors that predict higher trust in primary care providers, and examined the role of patient trust on the use of preventive services for low-income African-American women. METHODS: We conducted a cross-sectional, population-based telephone survey of 961 African-American women over age 40 in Washington, DC. Two dimensions of trust were examined: overall trust in one's regular primary care provider, and trust that the regular provider had no financial conflict of interest. Self-reported use of mammography, Pap tests, clinical breast exams, colorectal cancer screening, blood pressure, height and weight measurement, diet counseling, and depression screening, as delivered by one's primary care provider, were assessed. An index summarizing overall use of these interventions was the main outcome variable. RESULTS: More than two-thirds of respondents reported high trust in their physician. Older respondents (>65) were more trusting of their physicians overall than were younger respondents (P < 0.01). Primary care characteristics (continuity of care, accessibility of the practice, coordination of specialty care by one's regular provider) were more strongly associated with having high trust than were sociodemographic, health status, and insurance characteristics. Higher trust was significantly associated with greater use of recommended preventive services (OR: 2.3, 95% CI: 1.3, 4.0), controlling for the effects of insurance status, primary care, and patient characteristics. CONCLUSIONS: Trust is associated with use of recommended preventive services in low-income African-American women. Stronger patient-provider relationships, with high levels of trust, may indirectly lead to better health through adherence to recommended preventive services for low income African-American women.     

Associations Between Abortion Services and Acceptance of Postabortion Contraception in Six Indian States

Women receiving induced abortions or postabortion care are at high risk of subsequent unintended pregnancy, and intervals of less than six months between abortion and subsequent pregnancy may be associated with adverse outcomes. This study highlights the prevalence and attributes of postabortion contraceptive acceptance from 2,456 health facilities in six major Indian states, among 292,508 women who received abortion care services from July 2011 through June 2014. Eighty‐one percent of the women accepted postabortion contraceptive methods: 53 percent short‐term, 11 percent intrauterine devices, and 16 percent sterilization. Postabortion contraceptive acceptance was highest among women who were aged 25 years and older, received first‐trimester services, received induced abortion, attended primary‐level health facilities, and had medical abortions. Doctors receiving post‐training support were more likely to offer contraceptives, but no association was observed between such support and acceptance of IUDs or sterilization. Comprehensive service‐delivery interventions, including ensuring availability of skilled providers and contraceptive commodities, offering clinical mentoring for providers, identifying and addressing provider bias, and improving provider counseling skills, can increase postabortion contraceptive acceptance and reduce unintended pregnancy.     

Family planning clinic patients: their usual health care providers, insurance status, and implications for managed care.

PURPOSE: To understand the extent to which family planning clinic patients have health insurance or access to other health care providers, as well as their preferences for clinic versus private reproductive medical care. METHOD: An anonymous self-report questionnaire was administered at three Planned Parenthood clinics in Los Angeles County to 780 female patients aged 12-49 years. Dependent variables included insurance status, usual source of care, and a battery of questions regarding the importance of confidentiality. RESULTS: A total of 356 adolescents (aged 12-19 years) and 424 adults (aged 20-49 years) completed the survey in 1994. Fifty-nine percent of adolescents and 53% of adults had a usual source of care other than the clinic. The majority of each group reported some degree of continuity of care in their usual provider setting. Nearly half (49%) of all adolescents had health insurance compared with 27% of adults. Adolescents cited not wanting to involve family members as the primary reason for not using their usual providers, whereas adults were more likely to cite being uninsured. The majority of both adult and adolescent patients indicate they would prefer the clinic over private health care if guaranteed health care that was free, confidential, or both. CONCLUSION: Despite many patients' having health insurance and other sources of health care, family planning clinics were primarily chosen because of cost and confidentiality. Their reasons for preferring clinics may continue despite changes in access to insurance or efforts to incorporate similar reproductive services into mainstream health care provider systems. Making public or private health care funds available to family planning clinics through contracts or other mechanisms may facilitate patients' access to essential services and reduce potential service duplication.