Class of 2012 Abstract / Specific Aims: During pre-hospital transport, trauma patients may be given a long-acting neuromuscular blocker (NMB) to facilitate endotracheal intubation or to prevent movement. The purpose of this study was to determine the rate of long-acting NMB use and evaluate the concurrent use of sedatives. Methods: This was a retrospective cohort study conducted in a tertiary care, academic emergency department of trauma patients aged 18-89 years who were intubated in the pre-hospital setting. The primary outcome was to determine the rate of long-acting NMB use. The use of post-intubation sedatives was compared between the groups using Wilcoxon rank-sum test or Fisher’s exact test, using an a priori alpha level of 0.05 for all analyses. Main Result: A total of 51 patients were included in final analyses. All patients received etomidate or midazolam for intubation. 86% (n=44) received succinylcholine, 10% (n=5) were given rocuronium and 4% (n=2) did not receive a NMB. After intubation, 75% (n=38) received an additional long-acting NMB to prevent movement (vecuronium (n=22) or rocuronium (n=16)) . Overall, 82% (n=42) of patients received a long-acting NMB during transport. There was no difference in the rate of post-intubation sedative use between groups (79% versus 67%, respectively, p=0.42). The long-acting NMB group received midazolam less promptly after intubation (16 versus 7 minutes, respectively, p=0.04). Conclusions: The use of long-acting NMB is common during the pre-hospital transport of trauma patients. Some of these patients may not be given sedatives or have delays in receiving sedatives following intubation and be at risk of being paralyzed without sedation.

Introuction: The sub-Saharan Africa (SSA) region is making progress in its contraceptive policies that allow for the provision of long-acting reversible contraceptives (LARC). Despite this, the overall utilisation of contraception, especially LARC is low while the burden of unintended pregnancies remains high. Unintended pregnancies pose a significant threat to global public health with far-reaching consequences. There is a need to explore all the reasons for the low uptake of effective LARC methods. The objectives of this systematic review and meta-analysis, was therefore to determine the state of knowledge, attitudes, and perceptions of LARCs among healthcare workers (HCW) in sub-Saharan Africa. Methods: A systematic review and meta-analysis were conducted of published qualitative and quantitative studies. A search strategy was developed and applied to three major databases (PubMed, Ovid (Medline), and Scopus). Studies of both a qualitative and quantitative nature were included if they assessed either the knowledge, attitude, perception or a combination of the concepts among HCWs toward a LARC method. Data were extracted using a pre-determined data extraction form to conduct a qualitative synthesis using a thematic content analysis framework using ATLAS.ti version 8. In addition to this, data was specifically extracted relating to 11 pre-determined questions to conduct proportion meta-analyses using Stata version 15. Heterogeneity was further explored using the I2-statistic and publication bias using funnel plots and Egger’s tests. Results: A total of 3616 records were screened, of which 3510 were excluded. From 106 full-text articles assessed for eligibility, 50 were included for qualitative synthesis and 21 included in the meta-analysis. From the studies, a total of 12 356 participants were included in the analysis. From the meta-analysis, the overall proportion of HCWs with training in family planning was 62% (95% CI: 48%, 76%) while 60% (95% CI: 41%, 80%) reported providing family planning counselling to their clients. Forty-one percent (95% CI: 20%, 61%) of HCWs had received IUCD insertion training with 63% (95% CI: 44%, 81%) expressing a desire for additional training. Only 27% of HCWs (95% CI: 18%, 36%) deemed IUCD appropriate for HIV-infected women. Moreover, restrictions for IUCD and injectables based on a minimum age were imposed by 56% (95% CI: 33%, 78%) and 60% (95% 41 CI: 36%, 84%) of HCWs, respectively. Lastly, minimum parity restrictions were also observed among 29% (95% CI: 9%, 50%) of HCWs for IUCDs and 36% (95% CI: 16%, 43 56%) for injectable contraceptives. Conclusion: The study revealed that there is a gap in knowledge of HCWs regarding family planning counselling and LARC provision. In addition to this, the results indicate that unnecessary provider-imposed restrictions may hinder the uptake of LARC methods by women in sub-Saharan Africa. With the deadline for the Family Planning 2020 initiative and the 2030 SDGs quickly approaching, there is a need to address these issues. / Dissertation (MSc)--University of Pretoria, 2020. / School of Health Systems and Public Health (SHSPH) / MSc (Epidemiology) / Unrestricted

Adolescent (14-17 year-olds) and young adult (18-20 year-olds) women account for a disproportionate 20% of the total number of unintended pregnancies that occur among women of all reproductive ages (14-55 year-olds) each year in the US. Nearly half (41%) of all unintended pregnancies result from the 18% of women who report inconsistent, incorrect, or no use of their contraceptive method. Evidence shows that a large proportion of these young women, especially those who are sexually active, come to the emergency department for their core sexual and reproductive health care needs. By obtaining a better understanding of the sexual and reproductive health needs and preferences of an urban population that is disproportionately low income and ethnically and racially diverse, our hope is to maximize adolescent and young adult accessibility to contraceptive services most feasible in the PED environment such as Nexplanon, in addition to the provision of comprehensive contraceptive counseling and education. OBJECTIVES: The first objective of this subgroup analysis is to determine the percentage of adolescent and young adult females presenting to an urban PED who are familiar with Nexplanon and to describe the demographic, sexual health, and contraceptive use characteristics of these young women. The second main objective of our study is to evaluate the sources of Nexplanon-related information reported by respondents familiar with Nexplanon. In addition to the main objectives, we also determine participant willingness to initiate or switch to Nexplanon® and receptivity to learning about contraceptive methods during a related or nonrelated visit to the PED. METHODS: This is a cross-sectional descriptive study using a paper-based anonymous questionnaire distributed to female patients, ages 16-21 years, presenting to a Boston urban pediatric emergency department (PED). This is a sub-group analysis of a larger study aimed at describing the contraceptive use history of young women who present to the PED. To identify if any statistically significant categorical variables existed between the two assigned groups, univariate analysis was performed using Chi-squared tests. Odds ratios with 95% confidence intervals (CIs) were obtained for the relationship between participants who have heard of Nexplanon and the three statistically significant variables: history of STDs, gravidity, and prior sexual intercourse with a male. Mean and Standard Deviation were used to describe the one continuous variable, age, followed by univariate analysis using independent t-test. Statistical significance was indicated using p-values for the categorical variables and odds ratio with 95% CI for the continuous variable—age. RESULTS: Of the 366 adolescent and young adult females included in our subgroup analysis, 230 (62.8%) indicated they were familiar with Nexplanon. We found that female participants familiar with Nexplanon were 1.3 times more likely to have had a prior STI, twice as likely to have had one or more previous pregnancies, and 3.5 times more likely to have previously engaged in sexual intercourse with a male compared to those female participants unfamiliar with Nexplanon. We also found that most (42.2%) female participants familiar with Nexplanon obtained their contraceptive information from their family and friends only, while about a third obtained their contraceptive information from medical professionals only. Among our total population of respondents, 6% (22/366) of our sub-group participants identified the contraceptive implant as their current method of contraception. Lastly, approximately 21% of female participants familiar with Nexplanon indicated current use of a long-acting reversible contraceptive method at the time of the survey. CONCLUSION: Overall, our study findings are supportive of and consistent with the provision and education of Nexplanon in the PED. This would be a crucial opportunity to provide comprehensive contraceptive counseling and convenient access to the most effective method of contraception among a population that disproportionately affected by unintended pregnancy. This can be made possible by enabling PED health care providers with the proper access to and training in Nexplanon. By adapting these patient-centered practices and techniques, the PED setting can contribute to the notable reduction in teen pregnancy seen in a variety of similar clinic-based interventions. The PED atmosphere has enormous potential to serve young women as an additional venue for contraception education and access.

The purpose of this research project is to develop a clinical practice guideline for contraceptive counseling to include long acting reversible contraceptive (LARC) recommendations for the adolescent population. LARCs, which include intrauterine devices and implants, are the top-tier contraceptive for nulliparous women yet they are only used in less than 6% of women under 19 years old. There is no LARC clinical practice guideline that addresses the adolescent’s unique developmental and psychosocial needs that arise. A clinical practice guideline with adolescent-specific recommendations will strengthen counseling especially for long-acting reversible contraceptives. The review of literature searched PubMed, CINHAL, National Guideline Clearinghouse, Google Scholar and the Cochrane Library using search terms "LARCs," and "contraceptive counseling." The search yielded over 35,000 results; titles and abstracts were reviewed using pre-determined inclusion and exclusion criteria. The final source documents included forty-eight applicable manuscripts, which were graded using the United States Preventative Task Force (USPSTF) scale. The evidence was then sorted by similar findings and practice recommendations. The findings were used to formulate practice statements, which were then input into the Bridge-wiz software. The program generated recommendations and assigned a strength rating, and the clinical practice guideline was written from these recommendations. Finally, four clinical experts were identified using snowball sampling; they each participated in the final appraisal using the AGREE II tool. Based on the analysis of the review of literature, fifteen evidenced-based recommendations emerged. The recommendation topics included: best-practices for recommending LARCs, using developmentally appropriate teaching, providing youth-friendly services, and eliminating potential barriers to LARC uptake in adolescents. There are fifteen practice recommendations that increase adolescent uptake of LARCs. Limitations for the project included the absence of an internal review committee to grade the evidence and assign a strength to each recommendation. The use of Bridge-wiz software and the USPSTF evidence scale minimized bias. Providers can facilitate use of LARCs among adolescents by using developmentally appropriate and comprehensive contraceptive counseling. If more adolescents chose a LARC as their primary form of contraception, then overall teenage pregnancies may decrease. Further research is needed to understand other barriers and possible interventions.

In the United Kingdom (UK) there is easy access to a wide range of contraceptive methods, available at no cost. In addition, oral emergency contraception (EC) (1.5 mg levonorgestrel) is now widely available from the community pharmacy. In spite of this, unintended pregnancy is common. In 2014 in England and Wales, 184,571 induced abortions were performed, and in Scotland, the corresponding figure was 11,475. Long acting reversible methods such as contraceptive implants and intrauterine contraception, are amongst the most effective methods available and National Institute for Health and Care Excellence (NICE) recommends that increased uptake can lead to fewer unintended pregnancies. However, uptake of long acting reversible contraceptive (LARC) methods remains low. The majority of women who require to use EC do so following unprotected sex or an accident with a condom. Increasingly women in Great Britain prefer to attend a pharmacy for EC rather than a sexual and reproductive health (SRH) service or general practitioner (GP). Starting an effective on-going method of contraception after EC use is clearly important if women are to avoid unintended pregnancy. Community pharmacists in the UK and most other high income countries are usually unable to provide any on-going contraception except condoms. So we have created a situation where EC is provided almost solely from settings where other more effective methods of contraception cannot be immediately provided. Novel strategies are therefore required to facilitate both uptake and continuation of the most effective methods of contraception, in order to prevent unintended pregnancy for more women. This thesis presents a mixture of biomedical, clinical and health services research to evaluate a series of strategies aimed at improving uptake of the most effective methods of contraception. Two studies investigated patient knowledge and information provision relating to contraceptive methods. The first sought to determine if women held misconceptions about intrauterine methods of contraception, and revealed that although myths persist in a small number of women, a lack of knowledge about these methods was also evident. The second study aimed to determine if the use of a digital video disc (DVD) to provide contraceptive information was acceptable and informative to women, and identified that it is, and could possibly enhance patient consultations. Studies three, four and five investigated strategies aimed at increasing the uptake of effective on-going contraception, following emergency contraception provided from a community pharmacy, and patient and health care provider attitudes to such approaches. They showed that simple interventions such as supplying one month of a progestogen only pill (POP), or offering rapid access to a family planning clinic (FPC), hold promise as strategies to increase the uptake of effective contraception after EC and that both women and clinicians were positive about such measures. Additionally, the problems encountered in conducting these studies provided valuable feedback to inform further development of research methods in the community pharmacy setting, and larger scale studies of such interventions. Community SRH services may be well placed to deliver more abortion care in the UK, and consequently this may result in greater uptake of contraception post abortion. Study six aimed to determine the views of health professionals working in SRH regarding their attitudes towards providing more abortion services and also the views of staff within one community SRH centre in Scotland where a service providing early medical abortion was due to commence. It showed there is clear support amongst health professionals in community SRH in the UK towards greater participation in provision of abortion care services.

BACKGROUND: One in ten sexually active adolescents in the United States become pregnant each year. Significant differences in unintended pregnancy and use of long-acting reversible contraceptive (LARC) methods: the sub-dermal implant, the copper intrauterine device (IUD) and hormonal IUDs, exist between socioeconomic strata as well as ethnic and racial groups. Women using LARC are 20 times less likely to experience a pregnancy than women using short-acting reversible methods. Thus, LARCs present a major opportunity for the prevention of unintended pregnancy. PURPOSE: Characterize contraceptive use, demographics, and behavioral characteristics of a novel population: young women presenting to an urban Pediatric Emergency Department (PED) in order to better understand the contraceptive needs of this population. METHODS: We characterized the current LARC usage. Using an anonymous paper-based questionnaire, we surveyed women ages 16-21 years regardless of chief complaint presenting to our PED regarding their demographics, health care access, sexual history, and history of contraceptive use. We conducted a cross-sectional analysis of demographic characteristics for current LARC and non-LARC users (n=331) using chi-squared for categorical variables and student's t-test for continuous variables. RESULTS: No significant differences were found between women currently using LARC and those not using LARC, however current LARC usage in our population was 15.8%, about three times that documented in the most recent national studies conducted in 2013. CONCLUSION: Current LARC use is particularly high in our urban PED setting. More research is necessary to determine if this is part of a larger national trend or if the early implementation of no-cost contraception in Massachusetts and changes in provider or patient attitudes towards LARC may explain the large observed difference in LARC usage.

Magister Curationis - MCur / Increasing numbers of unintended pregnancies are occurring due to contraceptive failure. Unsafe abortion remains one of the top five avoidable patient-related causes of maternal death in South Africa. There are much higher reported failure rates for short-acting methods of contraceptives than long-acting methods of contraceptives; the uptake of long-acting methods of contraception though remains low.

Introduction: Contraceptive decision-making is individual in nature and access to high-quality contraceptive care, including counseling and the full range of contraceptive methods, can help individuals achieve their personal reproductive goals and prevent unintended pregnancy. The COVID-19 pandemic disrupted provision and utilization of contraceptive counseling and contraceptive methods. Long-acting reversible contraception (LARC) methods, such as the contraceptive implant and intrauterine devices (IUDs), were particularly affected by the pandemic because they require placement by a health care provider in a clinical setting. Choose Well (CW), an ongoing statewide contraceptive access initiative in South Carolina, launched in 2017 and continues through 2022. CW aims to implement best practices of contraceptive care via training and funding for IUD and implant methods. This study examined the perceptions of access to contraceptive counseling and implant and IUD methods during the pandemic in 2020 among CW hospital partners. Methods: Data were collected in 2021 via key informant interviews with partners (n=9) at CW implementing hospitals to assess perceptions of CW activities in 2020, the first year of the COVID-19 pandemic. A semi-structured interview guide was used, and interviews were recorded, transcribed, and consensus coded. A codebook was developed based on the interview guide. Data from select questions of interest related to perceived access to contraceptive counseling, access to LARC methods, and the impact of the pandemic on contraceptive care services were analyzed for this study. Coding was conducted with NVivo software version 1.6.1. Results: Findings show that there was continued provision of contraceptive services during COVID-19 at CW partner hospitals, including an increase in access to contraceptive counseling and LARCs in 2020. The most prevalent facilitator for increased access to contraceptive counseling and LARCs at CW partner hospitals was having key personnel available such as physicians and Obstetrics (OB) navigators. Expanded access to outpatient sites was also noted as a facilitator of contraceptive counseling. Advertising and wide-spread patient education, buy-in and engagement from staff were additional facilitators for the increased access to LARCs. Considering the context of the COVID-19 pandemic, patients wanting to quickly leave the hospital and challenges with staffing contributed to an overall decline in access in some hospital locations. Challenges with staffing included not being able to receive training and nurses being overworked and overburdened. Conclusion: While COVID-19 has posed challenges to contraceptive care service provision, most individuals perceived an increase in access to contraceptive counseling and LARCs at CW partner hospitals. Hospital partners have continued to provide contraceptive services during COVID-19. The findings suggest the success of the CW initiative in increasing access to contraceptive services, particularly during COVID-19 through key facilitators. Staffing positions such as OB Navigators should be funded and maintained to increase access to contraceptive care services in hospital inpatient settings. Coordinating care between hospital inpatient and outpatient settings is similarly important for widespread patient education about contraceptive care services.

Objective: State medicaid programs provide access to effective contraception for people with lower incomes. This study examined contraception use and pregnancy among reproductive-age women enrolled in the South Carolina Medicaid, by eligibility program and socio-demographic sub-groups. Methods: A retrospective cohort of women aged 15–45 who were newly eligible for South Carolina Medicaid from 2012 to 2016 was examined. Log-binomial regression and average marginal effects assessed relationships between contraception use and pregnancies ending in live and non-live births. Contraception was categorized as permanent, long acting reversible contraception (LARC), short-acting hormonal contraception (SAC), or no contraceptive claims. Women with family planning or full-benefit medicaid coverage were included. Results: Approximately 11% of women used LARC methods, 41% used SAC methods, and 46% had no evidence of contraceptive claims. Method utilization varied by eligibility program, race/ethnicity and age. The likelihood of pregnancy was lower among SAC users and lowest among LARC users compared to women with no evidence of contraception across all three programs (family planning APR = 0.44; 95% CI 0.41–0.49 and APR = 0.13, 95% CI 0.10–0.17; Low income families APR = 0.82; 95% CI 0.77–0.88 and APR = 0.33, 95% CI 0.28–0.38; Partners for Healthy Children APR = 0.72; 95% CI 0.68–0.77 and APR = 0.35, 95% CI 0.30–0.43, respectively). Non-Hispanic Black and Hispanic teens were less likely to experience a pregnancy than non-Hispanic white teens. Conclusions for Practice: The likelihood of pregnancy was lower among women using SAC methods and markedly lower among women using LARC. Variation in contraceptive use among racial/ethnic groups was noted despite Medicaid coverage. As new policies and initiatives emerge, these findings provide important context for understanding the role of Medicaid programs in reducing financial barriers to contraceptive services and ensuring access to effective contraception, while fostering reproductive health autonomy among women.

Patient-centered contraceptive care is key for ensuring that individuals achieve their personal reproductive goals. Despite public health efforts, preventing undesired pregnancies and improving maternal and child health outcomes remains unresolved in the United States (US). In Tennessee (TN), the rate of unintended pregnancies remains higher than the national rate (32.4% vs. 30.3%). Long-acting reversible contraceptives (LARCs) are 99% effective in preventing undesired pregnancies; however, uptake remains low in rural and underserved communities. Previous research has provided some insight into women’s perceptions of LARCs; however, those guided by conceptual frameworks to understand the multiple influences that impact perceptions towards LARCs, especially among rural regions, are scarce. This multimethod qualitative study explored multiple influences that impact northeast Tennessee women’s perceptions and attitudes toward LARCs using the Socio-ecological Model (SEM) as a guiding framework. The qualitative study comprised six focus groups and seven individual interviews of women aged 18-44, not pregnant, and current residents of five Counties in Northeast TN. Participants’ demographics were captured through an anonymous survey administered through REDCap. Qualitative data from these sessions were recorded via Zoom, an online audio/video conferencing platform. Each interview and focus group lasted 60 to 90 minutes. Focus group and interview data were combined, transcribed, and uploaded into NVivo for thematic analysis. A priori list of codes identified from the constructs of the SEM was initially used to deductively code the data. Subsequently, the data were analyzed inductively for new codes and themes that did not apply to the a priori categories. Quotations that were representative of or inconsistent with the codes of interest were identified. Fifteen themes and 20 sub-themes were identified using the SEM; On the intrapersonal level of the SEM, participants’ attitudes towards a method, perception of method features, and perceived side effects were identified as themes that delineate influences on their LARC utilization. On the interpersonal level, perception of partner support, perceived support from peer/social networks, and provider trust were themes that describe influences on participants’ LARC utilization. On the community level, the cost of the method, access to information, perceived accessibility to a method, social services, and cultural norms themes were identified as influences on participants’ use of LARCs. On the organizational level, the availability of preferred methods in a clinic, the need for multiple clinic visits to enable the use of a method, and provider counseling practices were salient themes impacting LARC utilization. On the policy level, insurance, and billing policies, sex education policies were identified as impacting LARC utilization. The study presents multi-layered influences on LARC utilization among Northeast TN women, highlighting the utility of the SEM in understanding factors that influence contraceptive use. Findings are critical for programming as they highlight the areas of influence that can be addressed to increase LARC uptake and enable women in rural and underserved regions of the US to achieve personal reproductive goals.