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Summary: Background: In the U.S. and globally, dominant metrics of contraceptive access focus on the use of certain contraceptive methods and do not address self-defined need for contraception; therefore, these metrics fail to attend to person-centeredness, a key component of healthcare quality. This study addresses this gap by presenting new data from the U.S. on preferred contraceptive method use, a person-centered contraceptive access indicator. Additionally, we examine the association between key aspects of person-centered healthcare access and preferred contraceptive method use. Methods: We fielded a nationally representative survey in the U.S. in English and Spanish in 2022, surveying non-sterile 15-44-year-olds assigned female sex at birth. Among current and prospective contraceptive users (unweighted n = 2119), we describe preferred method use, reasons for non-use, and differences in preferred method use by sociodemographic characteristics. We conduct logistic regression analyses examining the association between four aspects of person-centered healthcare access and preferred contraceptive method use. Findings: A quarter (25.2%) of current and prospective users reported there was another method they would like to use, with oral contraception and vasectomy most selected. Reasons for non-use of preferred contraception included side effects (28.8%), sex-related reasons (25.1%), logistics/knowledge barriers (18.6%), safety concerns (18.3%), and cost (17.6%). In adjusted logistic regression analyses, respondents who felt they had enough information to choose appropriate contraception (Adjusted Odds Ratio [AOR] 3.31; 95% CI 2.10, 5.21), were very (AOR 9.24; 95% CI 4.29, 19.91) or somewhat confident (AOR 3.78; 95% CI 1.76, 8.12) they could obtain desired contraception, had received person-centered contraceptive counseling (AOR 1.72; 95% CI 1.33, 2.23), and had not experienced discrimination in family planning settings (AOR 1.58; 95% CI 1.13, 2.20) had increased odds of preferred contraceptive method use. Interpretation: An estimated 8.1 million individuals in the U.S. are not using a preferred contraceptive method. Interventions should focus on holistic, person-centered contraceptive access, given the implications of information, self-efficacy, and discriminatory care for preferred method use. Funding: Arnold Ventures.

Traditional family planning research has excluded Black and Latinx leaders, and little is known about medication abortion (MA) among racial/ethnic minorities, although it is an increasingly vital reproductive health service, particularly after the fall of Roe v. Wade. Reproductive justice (RJ) community-based organisation (CBO) SisterLove led a study on Black and Latinx women’s MA perceptions and experiences in Georgia. From April 2019 to December 2020, we conducted key informant interviews with 20 abortion providers and CBO leaders and 32 in-depth interviews and 6 focus groups (n = 30) with Black and Latinx women. We analysed data thematically using a team-based, iterative approach of coding, memo-ing, and discussion. Participants described multilevel barriers to and strategies for MA access, wishing that “the process had a bit more humanity … [it] should be more holistic.” Barriers included (1) sociocultural factors (intersectional oppression, intersectional stigma, and medical experimentation); (2) national and state policies; (3) clinic- and provider-related factors (lack of diverse clinic staff, long waiting times); and (4) individual-level factors (lack of knowledge and social support). Suggested solutions included (1) social media campaigns and story-sharing; (2) RJ-based policy advocacy; (3) diversifying clinic staff, offering flexible scheduling and fees, community integration of abortion, and RJ abortion funds; and (4) social support (including abortion doulas) and comprehensive sex education. Findings suggest that equitable MA access for Black and Latinx communities in the post-Roe era will require multi-level intervention, informed by community-led evidence production; holistic, de-medicalised, and human rights-based care models; and intersectional RJ policy advocacy.

Doula support improves maternal-child health outcomes. However, during the COVID-19 pandemic, hospitals restricted the number of support people allowed during childbirth. An academic-community research team conducted 17 in-depth interviews and structured surveys with doulas in metro-Atlanta, Georgia, USA from November 2020 to January 2021. Surveys were analysed for descriptive statistics in Stata v. 14, and interviews were analysed in Dedoose using a codebook and memo-ing for thematic analysis. All 17 doulas reported COVID-19 changed their practices: most were unable to accompany clients to delivery (14), started using personal protective equipment (13), used virtual services (12), and had to limit the number of in-person prenatal/postpartum visits (11). Several attended more home births (6) because birthing people were afraid to have their babies in the hospital. Some stopped seeing clients altogether due to safety concerns (2). Many lost clientele who could no longer afford doula services, and some offered pro bono services. Most doulas pointed to restrictive hospital policies that excluded doulas and disallowed virtual support as they felt doulas should be considered a part of the team and clients should not be forced to decide between having their doula or their partner in the room. COVID-19 has severely impacted access to and provision of doula care, mostly due to economic hardship for clients and restrictive hospital policies. At the same time, doulas and their clients have been resourceful – using virtual technology, innovative payment models, and home births.

Abstract Background To examine racial/ethnic and educational inequities in the relationship between state-level restrictive abortion policies and adverse birth outcomes from 2005 to 2015 in the United States. Methods Using a state-level abortion restrictiveness index comprised of 18 restrictive abortion policies, we conducted a retrospective longitudinal analysis examining whether race/ethnicity and education level moderated the relationship between the restrictiveness index and individual-level probabilities of preterm birth (PTB) and low birthweight (LBW). Data were obtained from the 2005–2015 National Center for Health Statistics Period Linked Live Birth-Infant Death Files and analyzed with linear probability models adjusted for individual- and state-level characteristics and state and year fixed-effects. Results Among 2,250,000 live births, 269,253 (12.0%) were PTBs and 182,960 (8.1%) were LBW. On average, states had approximately seven restrictive abortion policies enacted from 2005 to 2015. Black individuals experienced increased probability of PTB with additional exposure to restrictive abortion policies compared to non-Black individuals. Similarly, those with less than a college degree experienced increased probability of LBW with additional exposure to restrictive abortion policies compared to college graduates. For all analyses, inequities worsened as state environments grew increasingly restrictive. Conclusion Findings demonstrate that Black individuals at all educational levels and those with fewer years of education disproportionately experienced adverse birth outcomes associated with restrictive abortion policies. Restrictive abortion policies may compound existing racial/ethnic, socioeconomic, and intersecting racial/ethnic and socioeconomic perinatal and infant health inequities.

Person-centered contraceptive access benefits reproductive autonomy, sexual wellbeing, menstrual regulation, and other preventive health. However, contraceptive access varies by social and geographic position, with policies either perpetuating or alleviating health inequities. We describe geographic and time-trend variation in an index from fewer (less expansive) to greater (more expansive) aggregation of U.S. state-level contraceptive access policies across 50 states and Washington, D.C. (collectively, states) from 2006 to 2021. We collected data from primary and secondary sources on 23 policies regulating contraceptive education, insurance coverage, minor’s rights, provider authority, and more. As of 2021, the most enacted policies expanded contraceptive access through: 1) prescribing authority for nurse practitioners, certified nurse-midwives (n = 50, 98 % of states), and clinical nurse specialists (n = 38, 75 %); 2) Medicaid expansion (n = 38, 75 %); 3) prescription method insurance coverage (n = 30, 59 %); and 4) dispensing authority for nurse practitioners and certified nurse-midwives (n = 29, 57 %). The average overall U.S. policy index value increased in expansiveness from 6.9 in 2006 to 8.6 in 2021. States in the West and Northeast regions had the most expansive contraceptive access landscapes (average index values of 9.0 and 8.2, respectively) and grew more expansive over time (increased by 4–5 policies). The Midwest and South had least expansive landscapes (average index values of 5.0 and 6.1, respectively). Regions with more expansive sexual and reproductive health policy environments further expanded access, whereas least expansive environments were maintained. More nuanced understanding of how contraceptive policy diffusion affects health outcomes and equity is needed to inform public health advocacy and law making.

Abstract Background Ending the HIV epidemic requires that women living with HIV (WLWH) have access to structurally competent HIV-related and other health care. WLWH may not regularly engage in care due to inadequate quality; however, women’s perspectives on the quality of care they receive are understudied. Methods We conducted 12 focus groups and three in-depth interviews with Black (90%) and Latina (11%) WLWH enrolled in the Women’s Interagency HIV Study in Atlanta, GA, Birmingham, AL, Brooklyn, NY, Chapel Hill, NC, Chicago, IL, and Jackson, MS from November 2017 to May 2018 (n = 92). We used a semi-structured format to facilitate discussions about satisfaction and dissatisfaction with health care engagement experiences, and suggestions for improvement, which were audio-recorded, transcribed, and coded using thematic analysis. Results Themes emerged related to women’s health care satisfaction or dissatisfaction at the provider, clinic, and systems levels and across Institute of Medicine-defined quality of care domains (effectiveness, efficiency, equity, patient-centeredness, safety and timeliness). Women’s degree of care satisfaction was driven by: 1) knowledge-based care resulting in desired outcomes (effectiveness); 2) coordination, continuity and necessity of care (efficiency); 3) perceived disparities in care (equity); 4) care delivery characterized by compassion, nonjudgment, accommodation, and autonomous decision-making (patient-centeredness); 5) attention to avoiding side effects and over-medicalization (safety); and 6) limited wait time (timeliness). Conclusions Quality of care represents a key changeable lever affecting engage in care among WLWH. The communities most proximally affected by HIV should be key stakeholders in HIV-related quality assurance. Findings highlight aspects of the health care experience valued by WLWH, and potential participatory, patient-driven avenues for improvement.

ObjectiveThe purpose of this study is to explore Protestant religious leaders' attitudes towards abortion and their strategies for pastoral care in Georgia, USA. Religious leaders may play an important role in providing sexual and reproductive health pastoral care given a long history of supporting healing and health promotion.MethodsWe conducted 20 in-depth interviews with Mainline and Black Protestant religious leaders on their attitudes toward abortion and how they provide pastoral care for abortion. The study was conducted in a county with relatively higher rates of abortion, lower access to sexual and reproductive health services, higher religiosity, and greater denominational diversity compared to other counties in the state. Interviews were audio-recorded, transcribed verbatim, and analyzed by thematic analysis.ResultsReligious leaders' attitudes towards abortion fell on a spectrum from "pro-life" to "pro-choice". However, most participants expressed attitudes in the middle of this spectrum and described more nuanced, complex, and sometimes contradictory views. Differences in abortion attitudes stemmed from varying beliefs on when life begins and circumstances in which abortion may be morally acceptable. Religious leaders described their pastoral care on abortion as "journeying with" congregants by advising them to make well-informed decisions irrespective of the religious leader's own attitudes. However, many religious leaders described a lack of preparation and training to have these conversations. Leaders emphasized not condoning abortion, yet being willing to emotionally support women because spiritual leaders are compelled to love and provide pastoral care. Paradoxically, all leaders emphasized the importance of empathy and compassion for people who have unplanned pregnancies, yet only leaders whose attitudes were "pro-choice" or in the middle of the spectrum expressed an obligation to confront stigmatizing attitudes and behaviors towards people who experience abortion. Additionally, many leaders offer misinformation about abortion when offering pastoral care.ConclusionThese findings contribute to limited empirical evidence on pastoral care for abortion. We found religious leaders hold diverse attitudes and beliefs about abortion, rooted in Christian scripture and doctrine that inform advice and recommendations to congregants. While religious leaders may have formal training on pastoral care in general or theological education on the ethical issues related to abortion, they struggle to integrate their knowledge and training across these two areas. Still, leaders could be potentially important resources for empathy, compassion, and affirmation of agency in abortion decision-making, particularly in the Southern United States.

BACKGROUND:Norms and stigma regarding pregnancy decisions (parenting, adoption, and abortion) are salient to maternal well-being, particularly for groups disproportionately affected by unintended pregnancy. However, there are few validated measures of individual-level perceptions of norms and stigma around pregnancy decisions. Additionally, little is known about variation in the content of norms regarding pregnancy decisions, and in stigma related to violations of these norms, across socio-demographic groups. METHODS:To create measures of perceived norms and stigma around pregnancy decisions, we developed and pre-tested 97 survey items using a mixed methods approach. The resulting survey was administered to 642 young adult women recruited from health department clinics and a public university campus in Birmingham, Alabama. Principal components factor analyses, reliability analyses, independent t-tests, and correlation analyses were conducted to establish the reliability and validity of scales. Additionally, multiple linear regression was used to identify demographic predictors of higher scale scores. RESULTS:Factor analyses revealed four subscales for each pregnancy decision: conditional acceptability, anticipated reactions, stereotypes/misperceptions, and attitudes. The total scales and their subscales demonstrated good internal reliability (alpha coefficients 0.72-0.94). The mean scores for each scale were significantly associated with each other, with related measures, and differed by sociodemographic characteristics. Specifically, in adjusted analyses, women in the university setting and White women expressed more negative attitudes and stigma around parenting. Minority women endorsed more negative norms and stigma around adoption. Finally, women from the health department, White women, and religious women expressed more negative norms and stigma around abortion. CONCLUSION:Findings suggest that our multidimensional measures have good psychometric properties in our sample of young women in the U.S. South, and highlight the importance of conceptualizing and measuring norms and stigmas around all pregnancy decisions. These scales may be of use in research on pregnancy decision-making and evaluation of stigma-reduction interventions.

Objectives. To longitudinally examine the legal landscape of laws requiring abortion patients be informed about the possibility of medication abortion (MAB) "reversal" (in quotes as it does not refer to an evidence-based medical procedure). Methods. We collected legal data on enacted state MAB-reversal laws across all 50 US states and Washington, DC, (collectively, states) from 2012 through 2021. We descriptively analyzed these laws to identify legal variation over time and geography, and conducted a content analysis to identify qualitative themes and patterns in MAB-reversal laws. Results. As of 2021, 14 states (27%)-mostly in the midwestern and southern United States-have enacted MAB-reversal laws. States largely use explicit language to describe reversal, require patients receive information during preabortion counseling, require physicians or physicians' agents to inform patients, instruct patients to contact a health care provider or visit "abortion pill reversal" resources for more information, and require reversal information be posted on state-managed Web sites. Conclusions. Reversal laws continue a dangerous precedent of using unsound science to justify laws regulating abortion access, intrude upon the patient‒provider relationship, and may negatively affect the emotional and physical health of patients seeking an MAB. ( Am J Public Health. 2023;113(2):202-212. https://doi.org/10.2105/AJPH.2022.307140).

We present a conceptual framework that highlights how unique dimensions of individual-level HIV-related stigma (perceived community stigma, experienced stigma, internalized stigma, and anticipated stigma) might differently affect the health of those living with HIV. HIV-related stigma is recognized as a barrier to both HIV prevention and engagement in HIV care, but little is known about the mechanisms through which stigma leads to worse health behaviors or outcomes. Our conceptual framework posits that, in the context of intersectional and structural stigmas, individual-level dimensions of HIV-related stigma operate through interpersonal factors, mental health, psychological resources, and biological stress pathways. A conceptual framework that encompasses recent advances in stigma science can inform future research and interventions aiming to address stigma as a driver of HIV-related health.