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PURPOSE: Black birthing parents and their newborns disproportionately experience newborn drug testing for prenatal substance exposure by health care professionals (HCPs), which contributes to Child Protective Services (CPS) reporting, family separation, and termination of parental rights. This qualitative study aims to interrogate dominant power structures by exploring knowledge, attitudes, and experiences of HCPs and CPS professionals regarding the influence of structural racism on inequities in newborn drug testing practices. METHODS: We conducted semistructured interviews with 30 physicians, midwives, nurses, social workers, and CPS professionals guided by an explanatory framework, and conducted inductive, reflexive thematic analysis. RESULTS: We identified 3 primary themes: (1) levels of racism beyond the hospital structure contributed to higher rates of drug testing for Black newborns; (2) inconsistent hospital policies led to racialized application of state law and downstream CPS reporting; and (3) health care professionals knowledge of the benefits and disproportionate harms of CPS reporting on Black families influenced their decision making. CONCLUSION: Health care professionals recognized structural racism as a driver of disproportionate newborn drug testing. Lack of knowledge and skill limitations of HCPs were barriers to dismantling power structures, thus impeding systems-level change. Institutional changes should shift focus from biologic testing and reporting to supporting the mutual needs of birthing parent and child through family-centered substance use treatment. State and federal policy changes are needed to ensure health equity for Black families and eliminate reporting to CPS for prenatal substance exposure when no concern for child abuse and neglect exists.

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Purpose: Gender-affirming hormones (hormones)-the use of sex hormones to induce desired secondary sex characteristics in transgender and nonbinary (TGNB) individuals-are vital health care for many TGNB people. Some hormone providers require a letter from a mental health provider before hormone initiation. We explore the perspectives of TGNB individuals regarding the impact of the letter requirement on their experience of care. Methods: We conducted semistructured interviews with 21 TGNB individuals who have sought or are receiving hormones. We purposively sampled respondents who were (n=12) and were not (n=8) required to provide a letter. An Advisory Board of transgender individuals guided the methodology. Interviews were transcribed verbatim and coded both inductively and deductively. Results: We identified three themes related to the letter requirement: (1) Mental health: While participants appreciated the importance of therapy, the letter requirement did not serve this purpose; (2) Trans identity: The process of obtaining a letter created doubt in participants' own transness, along with a resistance to the pathologization and conflation of mental illness with transness; and (3) Care relationships: The letter requirement negatively impacted the patient-provider relationship. Participants felt the need to self-censor or to perform a version of transness they thought the provider expected; this process decreased their trust in care professionals. Conclusion: A letter requirement did not improve mental health and had several negative consequences. Removal of this requirement will improve access to hormones and may paradoxically improve mental health.

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OBJECTIVE: Gender-affirming hormones (GAH)-the use of sex hormones to induce desired secondary sex characteristics in transgender individuals-is vital healthcare for many transgender people. Among prescribers of GAH, there is debate regarding the value of a universal requirement for an evaluation by a mental health provider prior to GAH initiation. The purpose of this qualitative study was to describe the range of attitudes and approaches to mental health evaluation among GAH providers in the United States. We analyzed the providers' attitudes and base our recommendations on this analysis. METHODS: We conducted semi-structured interviews with 18 healthcare providers who prescribe GAH across the United States. Participants were purposefully recruited using professional networks and snowball sampling to include those who require mental health evaluation and those who do not. We adapted domains from the Theoretical Domains Framework-a framework for understanding influences on health professional behavior-to inform the interviews and analysis. Guided by these domains, we iteratively coded text and identified theoretical relationships among the categories. RESULTS: While some felt a universal requirement for mental health "clearance" was necessary for the identification of appropriate candidates for GAH, others described this requirement as a form of "gatekeeping" that limits access to care. Themes we identified included providers' ability to ascertain gender identity; concern about mental illness; GAH provider and mental health provider expertise; and provider roles. All providers appreciated the potential advantages of mental health support during GAH treatment. CONCLUSION: Providers in our study practice on a continuum of care rather than adhering to strict rules about the requirement for mental health evaluation prior to GAH treatment. Where they fall on this continuum is influenced primarily by their perceptions of transgender identity and transition, and their interpretation of risk for significant mental illness and its association with transness. Providers who required universal evaluation by a mental health professional tended to hold essentialist, medicalized, and binary ideas of gender and transness.

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OBJECTIVE: We aimed to qualitatively describe the contraceptive experiences of individuals with medical conditions and develop an explanatory model of contraceptive decision-making in this context. STUDY DESIGN: We conducted 41 interviews with pre-menopausal patients with a range of medical conditions from Michigan, United States. We identified themes through open coding and comparative analysis until we reached theoretical saturation. We analyzed the themes in the context of the Health Belief Model constructs and patient autonomy. To develop the explanatory model, we qualitatively mapped out relationships between constructs and how they informed contraceptive-decision making. RESULTS: The model posits that contraceptive decisions are affected by the perceived impact of chronic disease on pregnancy, parenting, and contraceptive options. These perceptions were strongly affected by others, particularly health care providers (HCPs). Most worried that pregnancy could threaten their health, fetal health, or ability to parent. Active symptoms of chronic disease (e.g., pain, fatigue) amplified this perceived threat. Patients appreciated when their HCPs acknowledged, rather than dismissed, their concerns about contraceptive side effects that affected their chronic disease symptoms and management (e.g., headaches, worsening mood). Patients with medical contraindications to hormonal contraception and preferred to use coital-dependent methods (e.g., condoms) did not feel supported to do so by their HCPs. Patients who were Black, young, living on low-incomes, or considered medically "high risk" felt discriminated against by HCPs who limited or coerced their contraceptive decisions. CONCLUSIONS: This explanatory model synthesizes factors that underlie, constrain, or promote reproductive and contraceptive decisions and autonomy for individuals with medical conditions. IMPLICATIONS: This new explanatory model can guide the development and evaluation of interventions that support the contraceptive decisions and autonomy of individuals with medical conditions.

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OBJECTIVE: To evaluate contraceptive provision and contraceptive care quality measures for individuals who are deaf or hard of hearing and compare these outcomes to those individuals who are not. METHODS: We conducted a claims analysis with data from the 2014 Massachusetts All-Payer Claims Database. Among premenopausal enrollees aged 15-44, we determined provision of any contraception (yes or no) and provision by contraception type: prescription contraception (pills, patch, ring, injectables, or diaphragm), long-acting reversible contraceptive (LARC) devices, and permanent contraception (tubal sterilization). We compared these outcomes by deaf or hard-of-hearing status (yes or no). The odds of contraceptive provision were calculated with regression models adjusted for age, Medicaid insurance, a preventive health visit, and deaf or hard-of-hearing status. We calculated contraceptive care quality measures, per the U.S. Office of Population Health, as the percentage of enrollees who used: 1) LARC methods or 2) most effective or moderately effective methods (tubal sterilization, pills, patch, ring, injectables, or diaphragm). RESULTS: We identified 1,171,838 enrollees at risk for pregnancy; 13,400 (1.1%) were deaf or hard of hearing. Among individuals who were deaf or hard of hearing, 31.4% were provided contraception (23.5% prescription contraception, 5.4% LARC, 0.7% tubal sterilization). Individuals who were deaf or hard of hearing were less likely to receive prescription contraception (adjusted odds ratio 0.92, 95% CI 0.88-0.96) than individuals who were not deaf or hard of hearing. The percentage of individuals who were deaf or hard of hearing who received most effective or moderately effective methods was less than that for individuals who were not (24.2% vs 26.3%, P<.001). There were no differences in provision of LARC or permanent contraception by deaf and hard-of-hearing status. CONCLUSION: Individuals who were deaf or hard of hearing were less likely to receive prescription contraception than individuals who were not; factors underlying this pattern need to be examined. Provision of LARC or permanent contraception did not differ by deaf or hard-of-hearing status. These findings should be monitored and compared with data from states with different requirements for contraceptive coverage.

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OBJECTIVE: We aim to assess youth awareness of and opinions about Title X policy changes in 2019. STUDY DESIGN: We analyzed data from four open-ended questions and demographic items collected through MyVoice, a national text message survey of youth aged 14-24. We calculated descriptive statistics to summarize awareness of and opinions about Title X. We integrated the quantitative findings with qualitative themes to achieve deeper understanding of the beliefs that inform youth opinions. RESULTS: Seven hundred and fifty youth responded to the text message survey (58.0% response rate). The majority (74.9%) was unaware of recent Title X changes. Most (79.3%) were unsupportive of these changes, and a sizable portion (40%) worried these changes could impact them. Opposition to Title X changes was based upon five themes: (1) youth need to be aware of their health options, including abortion; (2) the policy will undermine reproductive rights; (3) the policy is unfair; (4) the policy is unconstitutional; (5) the policy will threaten public health and health services, including affordable and safe abortion. Those who supported Title X changes (13.8%) described moral objections to abortion and beliefs that the government should not be responsible for abortion care. CONCLUSIONS: Most youth in this sample were unsupportive of Title X changes. Limited youth awareness of Title X changes suggests that better youth outreach is needed regarding sexual and reproductive health (SRH) policies. IMPLICATIONS: Although youth represent 40% of clients who receive SRH services through Title X, more efforts are needed to inform and engage them in salient policy changes that may directly affect their SRH health and health care access.

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AIM: People with diabetes have contraceptive needs that have been inadequately addressed. The aim of this qualitative study was to develop a theoretical model that reflects contraceptive decision-making and behaviour in the setting of diabetes mellitus. METHODS: We conducted semi-structured, qualitative interviews of 17 women with type 1 or type 2 diabetes from Michigan, USA. Participants were recruited from a diabetes registry and local clinics. We adapted domains from the Health Belief Model (HBM) and applied reproductive justice principles to inform the qualitative data collection and analysis. Using an iterative coding template, we advanced from descriptive to theoretical codes, compared codes across characteristics of interest (e.g. diabetes type), and synthesized the theoretical codes and their relationships in an explanatory model. RESULTS: The final model included the following constructs and themes: perceived barriers and benefits to contraceptive use (effects on blood sugar, risk of diabetes-related complications, improved quality of life); perceived seriousness of pregnancy (harm to self, harm to foetus or baby); perceived susceptibility to pregnancy risks (diabetes is a 'high risk' state); external cues to action (one-size-fits-all/anxiety-provoking counselling vs. personalized/trust-based counselling); internal cues to action (self-perceived 'sickness'); self-efficacy (reproductive self-efficacy, contraceptive self-efficacy); and modifying factors (perceptions of biased counselling based upon one's age, race or severity of disease). CONCLUSIONS: This novel adaptation of the HBM highlights the need for condition-specific and person-centred contraceptive counselling for those with diabetes.

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BACKGROUND AND OBJECTIVES: Family physicians play an important role in delivery of family planning services, but many factors impact scope of practice. One important factor is the development of subspecialties, such as the new subspecialty within obstetrics and gynecology called complex family planning (CFP). METHODS: In 2019, we conducted a survey of family medicine department chairs as part of the Council of Academic Family Medicine Educational Research Alliance survey. We used descriptive statistics and logistic regression to test for associations between program and chair characteristics, knowledge of CFP, and attitudes regarding family planning services (complex contraceptive counseling, pregnancy options counseling, first trimester miscarriage management, and pregnancy termination). RESULTS: The survey response rate was 54% (105/193). Only 8% of respondents were aware of the CFP subspecialty. The majority of chairs considered all queried family planning services as part of family medicine's scope of practice, including pregnancy termination by medication abortion (77%) and by uterine aspiration (60%). Chairs of departments with a faculty champion in family planning had higher odds of advocating for all queried family planning services as part of family medicine scope of practice (OR 3.0, 1.1-8.2) than those without a faculty champion. CONCLUSIONS: Few chairs are aware of the new subspecialty of CFP, but most would advocate to maintain some form of abortion care in family medicine's scope of practice. Given family medicine's role in the health care safety net, supporting faculty champions in family planning is important to preserve access to family planning services for marginalized communities.

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CONTEXT: Societal views about sexuality and parenting among people with disabilities may limit these individuals' access to sex education and the full range of reproductive health services, and put them at increased risk for -unintended pregnancies. To date, however, no national population-based studies have examined pregnancy -intendedness among U.S. women with disabilities. METHODS: Cross-sectional analyses of data from the 2011-2013 and 2013-2015 waves of the National Survey of Family Growth were conducted; the sample included 5,861 pregnancies reported by 3,089 women. The proportion of pregnancies described as unintended was calculated for women with any type of disability, women with each of five types of disabilities and women with no disabilities. Multivariate logistic regression analyses were conducted to examine the relationship of disability status and type with pregnancy intendedness while adjusting for covariates. RESULTS: A higher proportion of pregnancies were unintended among women with disabilities than among women without disabilities (53% vs. 36%). Women with independent living disability had the highest proportion of unintended pregnancies (62%). In regression analyses, the odds that a pregnancy was unintended were greater among women with any type of disability than among women without disabilities (odds ratio, 1.4), and were also elevated among women with hearing disability, cognitive disability or independent living disability (1.5-1.9). CONCLUSIONS: Further research is needed to understand differences in unintended pregnancy by type and extent of disability. People with disabilities should be fully included in sex education, and their routine care should incorporate discussion of reproductive planning.

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BACKGROUND AND OBJECTIVES: Women with medical conditions are at higher risk of pregnancy-related morbidity and mortality than women without medical conditions. Thus, women who do not desire pregnancy should be offered contraceptive counseling and methods. The objective of this qualitative study was to identify potential best practices to guide primary care physicians (PCPs) in providing contraception and contraceptive counseling for women with medical conditions. METHODS: We conducted semistructured qualitative interviews of 10 PCPs who routinely provide contraception including long-acting reversible contraception (LARC). To inform the data collection and analysis, we adapted constructs from the Theoretical Domains Framework. We coded transcripts and identified themes until saturation of our theoretical constructs was achieved. RESULTS: Physician time constraints, lack of patient knowledge, and competing demands related to medical condition management were identified as barriers to contraceptive care. The study participants reported multiple strategies to mitigate these barriers. They emphasized providing reproductive health education in the context of an individual's chronic conditions and medications, educating about LARC methods, and using the US Medical Eligibility Criteria (US MEC) as a point-of-care clinical tool to guide contraceptive selection. CONCLUSIONS: The study participants (PCPs experienced in contraceptive care), described multifaceted approaches to providing contraception for women with medical conditions, including tailored contraceptive education and use of the US MEC for clinical guidance. Future research is needed to assess if such strategies can improve patient outcomes and be adopted by PCPs who have less experience with contraceptive care.

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In this article, we consider the impact of gendered language on our ability to provide inclusive care and to address health disparities experienced by transgender and nonbinary people. We posit that while obstetrician-gynecologists and others trained in women's health are already well positioned to extend care to this population, we can improve this care through simple adjustments in the framing and language we use.

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OBJECTIVE: To compare female sterilization among three mutually exclusive groups of females: 1) those without any self-reported disability, 2) those with noncognitive disabilities (sensory or physical disabilities), and 3) those with cognitive disabilities. METHODS: We conducted a secondary analysis of nationally representative data from the National Survey of Family Growth 2011-2015, which surveyed individuals aged 15-44 years in the U.S. civilian population. Disability status (self-reported) was ascertained using a standard set of questions about hearing, vision, cognitive, ambulatory, self-care, and independent living difficulties. Regression models were used to calculate odds of female sterilization, hysterectomies, and age of sterilization while accounting for sociodemographic differences. RESULTS: Female sterilization rates were higher among females with cognitive (22.1% [n=272]) and noncognitive disabilities (24.7% [n=150]) than among those without disabilities (14.8% [n=1,132]). After adjusting for sociodemographic covariates, females with cognitive disabilities had significantly higher odds of female sterilization (adjusted odds ratio [OR] 1.54, 95% CI 1.19-1.98, P<.01) and hysterectomy (adjusted OR 2.64, 95% CI 1.53-4.56, P<.001) than those without cognitive disabilities. Females with cognitive disabilities also underwent sterilization at significantly younger ages (27.3 years, 95% CI 27.0-27.6) than those with noncognitive disabilities (28.3 years, 95% CI 27.9-28.8) and those without any disability (29.8 years, 95% CI 29.5-30.0). CONCLUSION: U.S. females with cognitive disabilities were more likely to have undergone female sterilizations and hysterectomies and at younger ages than those with other disabilities or without disabilities. Drivers of these disability-related differences in female sterilization patterns must be explored.

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BACKGROUND: Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling. OBJECTIVE: The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool. METHODS: This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention. RESULTS: We are currently enrolling practices and anticipate study completion in 15 months. CONCLUSIONS: This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection. TRIAL REGISTRATION: ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8).

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CONTEXT: Women with disabilities experience a higher rate of adverse pregnancy outcomes than women without disabilities. Preventing or delaying pregnancy when that is the best choice for a woman is a critical strategy to reducing pregnancy-related disparities, yet little is known about current contraceptive use among women with disabilities. METHODS: A cohort of 545 reproductive-age women with physical disabilities (i.e., difficulty walking, climbing, dressing or bathing) or sensory disabilities (i.e., difficulty with vision or hearing) was identified from among participants in the 2011-2013 National Survey of Family Growth. Those at risk for unplanned pregnancy were categorized by whether they were using highly effective reversible contraceptive methods (IUD, implant), moderately effective ones (pill, patch, ring, injectable), less effective ones (condoms, withdrawal, spermicides, diaphragm, natural family planning) or no method. Multinomial regression was conducted to examine the association between disability and type of contraceptive used. RESULTS: Some 39% of women with disabilities were at risk of unplanned pregnancy, and 27% of those at risk were not using contraceptives. The presence of disability was associated with decreased odds of using highly effective methods or moderately effective methods, rather than less effective ones (odds ratio, 0.6 for each), but had no association with using no method. CONCLUSION: There is a significant need to reduce contraceptive disparities related to physical or sensory disabilities. Future research should explore the extent to which contraceptive use differs by type and severity of disability, as well as identify contextual factors that contribute to any identified differences.

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BACKGROUND: Female sterilization accounts for 50% of all contraceptive use in the U.S. The extent to which U.S. women with physical and/or sensory disabilities have undergone female sterilization is unknown. OBJECTIVE: Our primary objective was to determine the prevalence of sterilization for women with physical/sensory disabilities, and compare this to the prevalence for women without disabilities. We also compared use of long-acting reversible contraceptive (LARC) methods between women with and without disabilities. METHODS: We conducted a secondary analysis of data from the National Survey of Family Growth 2011-2013, a population-based survey of U.S. women aged 15-44. Bivariate comparisons between women with and without disabilities by female sterilization and LARC use were conducted using chi-square tests. Using logistic regression, we estimated the odds of female sterilization based upon disability status. RESULTS: Women with physical/sensory disabilities accounted for 9.3% of the total sample (N = 4966). Among women with disabilities only, 28.2% had undergone female sterilization, representing 1.2 million women nationally. LARC use was lower among women with disabilities than those without disabilities (5.4%, 9.3%, respectively, p < 0.01). After adjusting for age, race/ethnicity, education, insurance, marital status, parity, and self-reported health, women with disabilities had higher odds of sterilization (OR 1.36, 95% CI 1.03, 1.79). CONCLUSIONS: The odds of female sterilization is higher among women with physical/sensory disabilities than those without disabilities. Future research is necessary to understand factors contributing to this finding, including possible underutilization of LARC methods.

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BACKGROUND AND OBJECTIVES: Our study aims were to: (1) describe the scope of contraceptive methods provided by US family medicine educators and (2) assess the extent to which US family medicine educators' recommendations regarding eligibility criteria for contraceptive methods are consistent with Centers for Disease Control and Prevention (CDC) guidelines. METHODS: We contributed survey items as part of the 2014 Council of Academic Family Medicine Educational Research Alliance (CERA) omnibus survey, which is distributed annually to a national cohort of US family medicine educators. We created two summary scales, comprised of clinical scenarios, to assess the extent to which provider recommendations regarding eligibility criteria for oral contraceptive pills (OCPs, six scenarios) and the intrauterine device (IUD, eight scenarios) were consistent with CDC guidelines. RESULTS: Among the 1,054 respondents (33% response rate), 98% prescribe OCPs and 66% insert IUDs. The OCP scale mean was 4.6 ± SD 1.6 (range 0-6), and the IUD scale mean was 4.8 SD ± 2.3 (range 0-8). These scores reflect that 23% of providers' OCP recommendations and 40% of their IUD recommendations were inconsistent with CDC guidelines. CONCLUSIONS: The contraceptive recommendations of this cohort of family medicine educators only partially reflected evidence-based guidelines. More misconceptions were noted regarding eligibility criteria for the IUD than for OCPs. To avoid denying safe and effective contraception to otherwise appropriate candidates and putting women at risk of unintended pregnancy, evidence-based contraceptive recommendations must be improved among family medicine educators.

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BACKGROUND: We aimed to determine patterns of contraceptive consistency among heterosexually active, young adult women who do not desire pregnancy, and to identify factors associated with these patterns. METHODS: We analyzed longitudinal data from a population-based study of young adult women aged 18 and 19 who were representative of a single county in southeastern Michigan. Using multinomial logistic regression, we identified associations between contraceptive consistency (dependent outcome) and sociodemographic characteristics and personal factors. FINDINGS: We categorized women into three patterns of contraceptive consistency: 1) always consistent (40%; reference group), 2) sometimes consistent (49%), 3) never consistent (11%). Not being employed was associated with increased odds of being sometimes consistent (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.2) and never consistent (OR, 1.9; 95% CI, 1.1-3.4). Those who reported a grade point average of 3.0 or less were more likely to be never consistent (OR, 2.5; 95% CI, 1.2-5.3). Women in a serious relationship had a two times greater odds of being sometimes consistent. Among always consistent users, the oral contraceptive pill was most often used (55%); only 4% used the intrauterine device or implant. Sometimes consistent and never consistent users most frequently relied on condoms (35%) and withdrawal (68%), respectively. CONCLUSIONS: This analysis of longitudinal data revealed that the majority of young adult women inconsistently used short-acting or coital-specific methods; few used the most effective, long-acting methods. Interventions to improve contraceptive consistency among young adult women should include periodic assessments of personal factors (i.e., work, school, relationships) and promotion of long-acting reversible contraceptive methods when appropriate.

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BACKGROUND AND OBJECTIVES: The primary study aim was to describe patient satisfaction regarding abortion experiences in urban academic family medicine centers (FMCs). METHODS: We conducted a cross-sectional survey of 210 women obtaining a first trimester medication or aspiration abortion at four FMCs. The 32-item written survey consisted of multiple choice, open-ended questions and Likert scale measures (for satisfaction: 1=very dissatisfied, 2=somewhat dissatisfied, 3=somewhat satisfied, 4=very satisfied, for quality of care: 1=poor, 2=average, 3=good, 4=excellent). We used Fisher's exact test to examine bivariate relationships. Responses to open-ended questions were coded and categorized. RESULTS: The majority of women (93%) were very satisfied with their abortion experience in their FMC, regardless of clinical site or abortion method. Mean scores for the quality of the staff, doctor, abortion counseling, and contraceptive counseling were all at least 3.9 (out of 4). Women most commonly cited positive interactions with the staff and physicians as the best part of their experience. CONCLUSIONS: This study demonstrates that women who receive abortion services at academic FMCs are highly satisfied with their care.

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There are multiple advantages to "extended use" of the intrauterine device (IUD) use beyond the manufacturer-approved time period, including prolongation of contraceptive and non-contraceptive benefits. We performed a literature review of studies that have reported pregnancy outcomes associated with extended use of IUDs, including copper IUDs and the levonorgestrel intrauterine system (LNG-IUS). Among parous women who are at least 25 years old at the time of IUD insertion, there is good evidence to support extended use of the following devices: the TCu380A and the TCu220 for 12 years, the Multiload Cu-375 for 10 years, the frameless GyneFix® (330 mm²) for 9 years, the levonorgestrel intrauterine system 52 mg (Mirena®) for 7 years and the Multiload Cu-250 for 4 years. Women who are at least 35 years old at the time of insertion of a TCu380A IUD can continue use until menopause with a negligible risk of pregnancy. We found no data to support use of the LNG-IUS 13.5 mg (Skyla®) beyond 3 years. When counseling about extended IUD use, clinicians should consider patient characteristics and preferences, as well as country- and community-specific factors. Future research is necessary to determine the risk of pregnancy associated with extended use of the copper IUD and the LNG-IUS among nulliparous women and women less than 25 years old at the time of IUD insertion. More data are needed on the potential effect of overweight and obesity on the long-term efficacy of the LNG-IUS.

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