Supporting Patient-centered Communication on Adolescent Sexual and Reproductive Health—Perspectives to Build an Appointment Planning Tool

Study Objective: Input from adolescents and healthcare providers is needed to develop electronic tools that can support patient-centered sexual and reproductive (SRH) care. This study explores facilitators and barriers to patient-centered communication in the context of developing an electronic appointment planning tool to promote SRH communication in clinic settings.Design: In-depth interviews were conducted to explore what constitutes adolescent-friendly SRH care and communication, as well as on the design of the appointment planning tool. Interviews were coded iteratively, and analyzed using the software Atlas.TI v8.Setting: An adolescent primary care clinic, and a pediatric and adolescent gynecology clinic.Participants: Adolescent girls (N=32; ages 14-18) and providers who care for adolescent girls (N=10).Main Outcome Measures: Thematic analyses explored facilitators/barriers to SRH communication and care and preferences for the tool.Results: Facilitators identified by adolescents and providers included: direct patient/provider communication; adolescent-driven decision-making regarding care and contraceptive choice; supplementing clinic visits with electronic resources; and holistic care addressing physical, mental, and social needs. Barriers identified by participants included: limited time for appointments; limited adolescent autonomy in appointments; and poor continuity of care when adolescents cannot see the same provider. Given the complexity of issues raised, adolescents and providers were interested in developing an appointment planning tool to guide communication during appointments, and contributed input on its design. The resulting Appointment Planning Tool app pilot is in progress.Conclusions: Qualitative interviews with adolescents and providers offer critical insights for the development and implementation of mobile health (mHealth) tools that can foster patient-centered care.     

Committee Opinion No. 419: Coercion Free Contraceptive Care

ObjectiveTo provide guidance on culturally competent contraception counselling that is free of coercion and promotes shared decision-making and patient autonomy.Target populationIndividuals of reproductive age who seek contraception or counselling for family planning.OptionsContraception counselling is provided within a rights-based family planning framework, where the individual's beliefs, culture, preferences, and ability to use the chosen method are respected.OutcomesTo promote patient autonomy in decision-making surrounding family planning, including the right to access and use their contraceptive method of choice, to decline contraception or use less effective methods of contraception, and to freely choose to discontinue a method of contraception, as well as the right to unbiased, non-coercive contraception counselling and evidence-based information from their health care providerBenefits, Harms, and CostsImplementation of these recommendations would reduce real or perceived coercive contraceptive care, particularly among vulnerable populations, resulting in improved patient autonomy and a better patient experience in health care settings.EvidenceDatabases searched: MEDLINE, Cochrane, PubMed, and CanLII. Medical terms used: contraception, family planning services, informed consent, coercion, decision making, sterilization, permanent contraception, counselling. Legal terms searched: forced sterilization, and aboriginal. Initial search conducted in 2020 and updated in 2021.Intended AudienceThis committee opinion is intended for health care providers (obstetricians, gynaecologists, family physicians, general surgeons, nurse practitioners, nurses, midwives, undergraduate/postgraduate medical trainees, and other health care providers) who provide sexual and reproductive health services.     

Fertility Preservation after a Cancer Diagnosis: A Systematic Review of Adolescents', Parents', and Providers’ Perspectives,Experiences, and Preferences

Study ObjectiveSurvival into adulthood is now a reality for many adolescents facing cancer. Fertility preservation (FP) is rapidly advancing, but oncology providers and health systems struggle to incorporate the newest FP technologies into the clinical care of adolescents. Our objective was to systematically review and synthesize the available data regarding the perspectives, experiences, and preferences of adolescents, parents, and oncology providers about FP to inform clinical implementation of FP technologies.Design, Setting, Participants, Interventions, and Main Outcome MeasuresFive electronic databases (PubMed, Embase, Web of Knowledge, Cumulative Index to Nursing and Allied Health Literature, PsychInfo) were systematically searched for studies published between January 1999 and May 2014. Adolescents were defined as 12-18 years at the time of diagnosis or designated as pubertal/postpubertal and younger than 18 years of age. Studies were assessed for methodological quality, data were extracted using a standardized form, and results were synthesized using guidelines for a narrative syntheses of quantitative and qualitative data.ResultsIn total, 1237 records were identified, with 22 articles, representing 17 unique studies that met the inclusion criteria. The following topics were consistently observed across studies and populations: (1) fertility in trust; (2) decision-making challenges; (3) provider knowledge and practices; and (4) discrepancies between desired and actual experiences.ConclusionDespite the challenges associated with a new cancer diagnosis, adolescents and parents value the opportunity to discuss fertility concerns and preservation options. Providers play an important role in addressing these topics for families and efforts should be made to incorporate FP discussions into routine cancer care for all adolescents, with attention paid to the unique needs of adolescents and their parents.     

Unmet Needs and Experiences of Adolescent Girls with Heavy Menstrual Bleeding and Dysmenorrhea: A Qualitative Study

Study ObjectiveTo identify and examine the key areas of need and explore the experiences of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea.Design and SettingQualitative interview study using semi-structured interviews. Gynaecology outpatient clinic at The Royal Children's Hospital, Melbourne, Australia.ParticipantsAdolescent girls (12-18 years; mean age, 14.8 ± 1.5 years) presenting with heavy menstrual bleeding and/or dysmenorrhea at the clinic (N = 30).Interventions and Main Outcome MeasuresIn-depth semi-structured interviews were conducted between May and August 2018. Interview data were thematically analyzed using a grounded theory approach. Themes covered experiences and unmet needs of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea.ResultsA total of 12 themes were identified, and covered the impact of symptoms, experiences, and/or unmet needs of these adolescents. Key themes highlighting experiences and unmet needs related to (1) coordination of healthcare, (2) day-to-day coping, (3) school, and (4) information surrounding menstrual issues. From these themes, 7 unmet needs emerged and were organized under 3 key areas of need: (1) treatment, management, and care, (2) improvements in the school environment, and (3) menstrual health as a gendered issue.ConclusionMenstrual concerns can have a profound physical and psychosocial impact on adolescents. Effective school-based menstrual education programs may be key in reducing stigma, fear, and shame surrounding menstruation, in teaching positive management strategies and in encouraging adolescents to seek help for their menstrual concerns.     

A Qualitative Study of Factors That Influence Contraceptive Choice among Adolescent School-Based Health Center Patients

Study ObjectiveLong-acting reversible contraceptive (LARC) methods can prevent teen pregnancy yet remain underutilized by adolescents in the United States. Pediatric providers are well positioned to discuss LARCs with adolescents, but little is known about how counseling should occur in pediatric primary care settings. We explored adolescent womens' attitudes and experiences with LARCs to inform the development of adolescent-centered LARC counseling strategies.DesignQualitative analysis of one-on-one interviews.SettingParticipants were recruited from 2 urban school-based, primary care centers.ParticipantsThirty adolescent women aged 14-18 years, diverse in race/ethnicity, and sexual experience.InterventionsInterviews were audio-recorded, transcribed, and coded using inductive and deductive coding.Main Outcome MeasureMajor themes were identified to integrate LARC-specific adolescent preferences into existing counseling approaches.ResultsParticipants (mean age, 16.2 years; range, 14-18 years) represented a diverse range of racial and/or ethnic identities. Half (15/30) were sexually active and 17% (5/30) reported current or past LARC use. Five themes emerged regarding key factors that influence LARC choice, including: (1) strong preferences about device-specific characteristics; (2) previous exposure to information about LARCs from peers, family members, or health counseling sessions; (3) knowledge gaps about LARC methods that affect informed decision-making; (4) personal circumstances or experiences that motivate a desire for effective and/or long-acting contraception; and (5) environmental constraints and supports that might influence adolescent access to LARCs.ConclusionWe identified 5 factors that influence LARC choice among adolescent women and propose a framework for incorporating these factors into contraceptive counseling services in pediatric primary care settings.     

Healthcare Clinician and Staff Perspectives on Facilitators and Barriers to Ideal Sexual Health Care to High-Risk Depressed Young Women: A Qualitative Study of Diverse Clinic Systems

Study ObjectiveThis study identified clinician and clinic staff perspectives on facilitators and barriers to providing sexual and reproductive health (SRH) care to depressed young women, a population at increased risk for adverse SRH outcomes.DesignWe conducted in-person semi-structured qualitative interviews, which were audio-recorded, transcribed, and coded by two researchers. We used thematic analysis to identify themes pertaining to care facilitators and barriers within a socio-ecological framework.SettingThis study was conducted in seven diverse clinics in the U.S. New England region.ParticipantsParticipants were 28 clinicians and staff (4/clinic), including behavioral health clinicians (n = 9), nurse practitioners (n = 7), nurses (n = 3), medical doctors (n = 3), administrative associates (n = 2), practice managers (n = 2), family planning counselor (n = 1), and medical assistant (n = 1).Main Outcome MeasuresWe queried how clinicians and clinic staff identify and manage depression and sexual risk, and what they perceive as facilitators and barriers affecting provision of ideal SRH care to depressed young women.ResultsThemes represented facilitators of and barriers to providing ideal SRH care to high-risk depressed young women at five socio-ecological levels: individual (facilitator: trust in providers; barrier: stigma experiences), interpersonal/provider (facilitator: frequent patient–provider communication; barrier: lack of time during clinic visits to build trust), clinic (facilitator: integration of care; barrier: lack of scheduling flexibility), organization/community (facilitator: training for providers; barrier: funding constraints), and macro/societal (facilitator: supportive policies; barrier: mental health stigma).ConclusionOptimizing SRH care to high-risk depressed young women necessitates attention to factors on all socio-ecological levels to remove barriers and bolster existing facilitators of care.     

Patient-Centered Contraceptive Counseling: Evidence to Inform Practice

Patient centeredness is an increasingly recognized aspect of quality health care. The application of this framework to contraceptive counseling and care has not been well described. We propose a definition of patient-centered contraceptive counseling that focuses on and prioritizes each patient’s individual needs and preferences regarding contraceptive methods and the counseling experience. Guided by this definition, we review recent research that has advanced our understanding of how patient-centered contraceptive counseling can be delivered in practice, focusing on how women decide on a contraceptive method, their preferences for counseling, and their experiences with counseling. This research provides evidence that women have diverse preferences around attributes of their contraceptive methods and value personal, supportive relationships with their family planning providers that focus on their individual preferences. We discuss the implications of this research for practice and review recent interventions that incorporate patient centeredness to varying degrees.     

Congress Calendar

Abstract

Background The mere availability of family planning (FP) services is not sufficient to improve reproductive health; services must also be of adequate quality. The introduction of new contraceptive methods is a means of improving quality of care. The Standard Days Method (SDM) is a new fertility-awareness-based contraceptive method that has been successfully added to reproductive health care services around the world.

Content Framed by the Bruce-Jain quality-of-care paradigm, this paper describes how the introduction of SDM in developing country settings can improve the six elements of quality while contributing to the intrinsic variety of available methods. SDM meets the needs of women and couples who opt not to use other modern methods. SDM providers are sensitised to the potential of fertility-awareness-based contraception as an appropriate choice for these clients. SDM requires the involvement of both partners and thus offers a natural entry point for providers to further explore partner communication, intimate partner violence, condoms, and HIV/STIs.

Conclusion SDM introduction broadens the range of FP methods available to couples in developing countries. SDM counselling presents an opportunity for FP providers to discuss important interpersonal and reproductive health issues with potential users.     

Prioritizing the sexual and reproductive health and rights of adolescent girls and young women within HIV treatment and care services in emergency settings: a girl-centered agenda

Background

The integration of family planning (FP) and HIV-related services is common in sub-Saharan Africa. Little research has examined how FP quality of care differs between integrated and non-integrated facilities. Using nationally representative data from Malawi and Tanzania, we examined how HIV integration was associated with FP quality of care.

Methods

Data were drawn from Service Provision Assessments (SPAs) from Malawi (2013–2014) and Tanzania (2014–2015). The analytic sample was restricted to lower-level facilities in Malawi (n = 305) and Tanzania (n = 750) that offered FP services. We matched SPA measures to FP quality of care indicators in the Quick Investigation of Quality (QIQ). We conducted bivariate and multivariate analyses of 22 QIQ indicators to examine how integration status was related to individual QIQ indicators and overall FP quality of care at the facility- and client-level.

Results

The prevalence of HIV integration in Malawi (39%) and Tanzania (38%) was similar. Integration of HIV services was significantly associated (p < 0.05) with QIQ indicators in Malawi (n = 3) and Tanzania (n = 4). Except for one negative association in Tanzania, all other associations were positive. At the facility-level, HIV integration was associated with increased odds of being at or above the median in FP quality of care in Malawi (adjusted odd ratio (OR) = 2.24; 95% confidence interval (CI) = 1.32, 3.79) and Tanzania (adjusted OR = 2.10; 95% CI = 1.37, 3.22). At the client-level, HIV integration was not associated with FP quality of care in either country.

Conclusion

Based on samples in Malawi and Tanzania, HIV integration appears to be beneficially associated with FP quality of care. Using a spectrum of FP quality of care indicators, we found little evidence to support concerns that HIV integration may strain facilities and providers, and adversely impact quality outcomes. Rather, it appears to strengthen FP service delivery by increasing the likelihood of stocked FP commodities and achievement of other facility-level quality indicators, potentially through HIV-related supply chains. Further research is needed to assess FP quality of care outcomes across the various platforms of FP integration found in sub-Saharan Africa.

     

Luxation antérieure d’un utérus rétroversé incarcéré à 21 semaines d’aménorrhée : à propos d’un cas

BackgroundAn incarcerated uterus refers to the retroversion of a pregnant uterus within the pelvis due to the absence of a forward tilt at the end of the first trimester. An incarcerated uterus that is overlooked or only discovered perpartum can cause severe obstetrical complications. Several authors have shared their experience with uterine incarceration management at 12, 14, and 16 weeks of amenorrhea.CaseOur report concerns a case of uterine incarceration management at 21 weeks of amenorrhea, achieved by way of a specific anesthesia protocol and the positioning of the patient, which allowed the disimpaction of the uterus with the help of external maneuvers. No recurrence was observed.ConclusionUterine incarceration management is possible beyond 16 weeks of amenorrhea.     

Care providers’ views and experiences of postnatal care in private hospitals in Victoria,Australia

Objectivein Australia, as in other developed countries, women have consistently reported lower levels of satisfaction with postnatal care compared with antenatal and intrapartum care. However, in Victoria Australia, women who receive private hospital postnatal care have rated their care more favourably than women who received public hospital care. This study aimed to gain a further understanding of this by exploring care providers’ views and experiences of postnatal care in private hospitals.Designqualitative design using semi-structured interviews and thematic analysis.Settingprivate maternity hospitals in Victoria, Australia.Participantseleven health-care providers from three metropolitan and one regional private hospital including eight midwives (two maternity unit managers and six clinical midwives) and three obstetricians.Findingstwo global themes were identified: ‘Constrained Care’ and ‘Consumer Care’. ‘Constrained care’ demonstrates the complexity of the provision of postnatal care and encompasses midwives’ feelings of frustration with the provision of postnatal care in a busy environment complicated by staffing difficulties, a lack of continuity and the impact of key players in postnatal care (including visitors, management and obstetricians). ‘Consumer care’ describes care providers’ views that women often approach private postnatal care as a consumer, which can impact on their expectations and satisfaction with postnatal care. Despite these challenges, care providers, particularly midwives, highly valued (and generally enjoyed working in) postnatal care.Key conclusionsthis study, along with other Australian and international studies, has identified that hospital postnatal care is complex and characterised by multiple barriers which impact on the provision of quality postnatal care. Further research is needed to evaluate routine postnatal practices and continuity of care within the postnatal period. In-depth qualitative studies investigating women's expectations and experiences of postnatal care in both the public and private sector are also needed.     

The Sexuality of Adolescents and Young Women With MRKH Syndrome: A Qualitative Study

BackgroundVaginal agenesis, most commonly referred as Mayer–Rokitansky–Küster–Hauser (MRKH) Syndrome, is mostly diagnosed as primary amenorrhea in teenage girls; although there is plenty of literature concerning the formation of a neovagina, limited research has focused on the psychological burden of this diagnosis to the girls.AimTo enlighten health providers into the finer aspects of sexuality through the own words and experiences of girls with MRKH under our care.MethodsWomen currently undergoing vaginal dilation or who had completed vaginal dilation within the past year were recruited from February 2019 to January 2020. A gynecologist with training in Sexual Medicine conducted a semistructured interview, which was recorded and then transcribed to identify common themes among interviewees.OutcomesThe main outcome explored was the narrative experiences of women with MRKH.Results7 women participated, with a mean age of 19.7 (range 17–22 years). None of the girls felt stigmatized, however one reported significant distress at diagnosis, stemming from the attitude of health care professionals and exacerbated by an earlier age at disclosure. All girls accepted that VDT was successful, when it was initiated after they had felt sexual interest and arousal. Exact quantification of the vaginal length at onset, worried 4 as they felt pressurized to achieve a specific length. A few girls reported anxiety over sharing the diagnosis with an intimate partner. All of them pretended at some point to have menses. Childbearing was an important issue for most of the interviewees, but it did not concern them for the time being. All girls had supporting families. However, 5 did not want to share information about VDT with them. One girl reported that openness in discussing genital anatomy, VDT and sexuality, helped her both in completing treatment and adapting in a sexual relationship.Clinical ImplicationsA multidisciplinary team should aim for age-appropriate disclosure and consultation and guide women through VDT and their sexual relations.Strengths and LimitationsThis is a thorough account of women's perceptions regarding VDT and sexuality in MRKH. However, our conclusions may be limited by the small number of participants.ConclusionGradual provision of information at disclosure and adjusted timing at VDT may reduce stress in girls with MRKH.Tsitoura A, Michala L. The Sexuality of Adolescents and Young Women With MRKH Syndrome: A Qualitative Study. J Sex Med 2021;18:2012–2019.     

Humanitarian migrant women's experiences of maternity care in Nordic countries: A systematic integrative review of qualitative research

BackgroundMaternal morbidity and sub-optimal maternity care are more common in humanitarian migrants in comparison to country-born population in the Nordic countries. Statistical reviews on the issue are plenty, whereas little synthesis on humanitarian migrants’ lived experiences exists.AimThis systematic integrative literature review investigated humanitarian migrant women's experiences on maternity care in Nordic countries, aiming to address possible hindrances for optimal care.MethodsElectronic search in PubMed, CINAHL, SocIndex, Scopus, PsycINFO and Web of Science yielded 474 papers. PICoS inclusion and exclusion criteria were used. Critical appraisal was conducted utilising 32-item COREQ tool. The findings of the review articles were synthesised through thematic analysis.FindingsTen qualitative studies were included in the review. Altogether 198 women in Sweden, Norway and Finland had participated interviews or focus group discussions. Analysis of the women's reported experiences of care emerged three themes: Diminished negotiation power on care, Sense of insecurity, and Experienced care-related discrimination.Key conclusionHumanitarian migrant women's maternal morbidity and sub-optimal care has multiple potential explanations, and their experiences of care reflect those earlier reported.Implications for practiceRecommendations for tackling the addressed hindrances are: (1) enabling humanitarian migrant women's negotiation power by acknowledging their vulnerability but also competency, (2) increasing the sense of security, and (3) improving care providers’ cultural competence.     

Current practice of preconception care by primary caregivers in the Netherlands

Objectives: Over the past decade the value of preconception care (PCC) consultations has been acknowledged. Investments have been made to promote delivery and uptake of PCC consultations in the Dutch primary care setting. We assessed current activities, perceptions and prerequisites for delivery of PCC in primary care. Methods: A questionnaire was compiled and distributed by mail or e-mail among 1682 general practitioners (GPs) and 746 midwives in the Netherlands between 2013 and 2014. Results: The questionnaire was completed by 449 GPs and 250 midwives. While GPs and midwives were frequently asked about preconception risks, explicit requests by patients for a PCC consultation were less frequent. Although caregivers gave information on preconception risk factors, only a minority recommended PCC in the form of a dedicated consultation. Such consultations occurred infrequently. Risk factor assessment varied between GPs and midwives. Respondents’ perceptions of PCC consultations, however, were generally positive. A small proportion believed that PCC medicalised pregnancy, and recognised barriers in actively raising the topic of patients’ pregnancy wishes. More training, staff, promotion of PCC and adequate reimbursement were prerequisites for future delivery. GPs differed in their opinion of whether they or midwives were primarily responsible for PCC consultations. Midwives, however, saw themselves as responsible for providing PCC consultations. Conclusions: Primary care is underserving prospective parents with regards to PCC consultations. Targets to increase delivery of systematic PCC are: (1) promotion during routine care; (2) increased use of tools; (3) increased collaboration among primary caregivers; (4) reduction of caregivers’ negative perceptions; and (5) tailoring PCC consultations to suit women’s preferences.