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BackgroundThere is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit.MethodsDevelopment of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed.ResultsThis guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections.ConclusionsIn this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.

PurposeIn an effort to address persistent inequities in maternal and infant health, policymakers and advocates have pushed to expand access to doula care. Several states, including California, now cover doula services through Medicaid. As coverage expands, research on the impact of doula care will likely increase. To develop best practices for research, it is critical to engage community doulas, clients, and other key stakeholders.DescriptionOur overarching goal was to build capacity for future doula- and client-centered research on community doula care. First, we established a Steering Committee with members from seven relevant stakeholder groups: community doulas, former or potential doula clients, clinicians, payers, advocates, researchers, and public health professionals. Second, we conducted a needs assessment to identify and understand stakeholders' needs and values for research on community doula care. Findings from the needs assessment informed our third step, conducting a research prioritization to develop a shared research agenda related to community doula care with the Steering Committee. We adapted the Research Prioritization by Affected Communities protocol to guide this process, which resulted in a final list of 21 priority research questions. Lastly, we offered a training to increase capacity among community doulas to engage in research on community doula care.AssessmentOur findings provide direction for those interested in conducting research on doula care, as well as policymakers and funders.ConclusionThe findings of our stakeholder-engaged process provide a roadmap that will lead to equity-oriented research centering clients, doulas, and their communities.

ObjectiveDescribe the prevalence of considering, wanting, and not obtaining a wanted abortion among a nationally representative sample of 15-44 year olds in the United States who had ever been pregnant.Study designWe analyzed data from ever-pregnant respondents (unweighted n = 1789) from a larger online survey about contraceptive access using the nationally representative AmeriSpeak panel. Among those not obtaining wanted abortions, weighted frequencies for sociodemographic characteristics and reasons for not getting the abortion are presented.ResultsNearly 6% of the full sample reported having wanted an abortion they did not obtain. In open-ended responses, respondents most frequently reported individual reasons (43.8%) for not getting an abortion (e.g., changing their mind; personal opposition) and financial, logistical, or informational barriers (24.7%) likely related to policy. A quarter (24.1%) of the sample reported a past abortion. Among those who reported no past abortions, about one-fifth had considered abortion in the past, and 6.8% had wanted or needed one. Among those reporting no prior abortions who had considered abortion, only a third (34.3%) also report ever wanting or needing one.ConclusionsThis study begins to quantify the experience, even before the Supreme Court's 2022 decision in Dobbs v. Jackson Women's Health Organization, of being unable to obtain a wanted abortion. Additionally, findings suggest that people in a national sample will answer questions about whether and why they did not obtain a wanted abortion.ImplicationsThis study provides the first known national estimates of lifetime history of not getting a wanted abortion. Survey questions can be used for future research. Prospective and ongoing measurement of the inability to get a wanted abortion could be one part of documenting the effects of Dobbs on abortion access.

Despite the importance of respectful pregnancy care, birthing people experience high rates of mistreatment in clinical settings in the United States. In light of persistent racialized maternal and infant health inequities, doula care is increasingly promoted as an intervention. Limited research has examined healthcare providers’ experiences with doulas. As part of an evaluation of community doula programs in San Francisco, California, we interviewed physicians (n ​= ​11), certified nurse-midwives (n ​= ​7), and nurses (n ​= ​10) who worked in hospitals and clinics where doula clients receive care. Using reflexive thematic analysis, we identified two themes around how providers perceive doulas to affect pregnancy-related care. First, providers described doulas fostering accountability at multiple levels. Providers described how their personal sense of accountability to patients increased in the presence of doulas; at times, this mitigated racism and implicit bias in clinical settings. Additionally, through the partnership between the community doula organization and local hospitals, doulas engaged in bidirectional feedback with providers, creating opportunities for institutional-level accountability. Second, providers perceived doulas to bridge gaps in care for pregnant and birthing people by providing services, such as continuous labor support, that are not realistic for clinicians to provide. This analysis contributes to the broader literature on doula care by describing mechanisms through which doulas improve pregnancy-related care. Doulas may be critical for birthing people who are most likely to experience mistreatment due to racism and other dimensions of oppression. Future research should explore facilitators and barriers to developing partnerships between clinical sites and doula organizations and the long-term effects of these partnerships on health equity.

ProblemIn the United States, Black women are disproportionately impacted by inequities in maternal health.BackgroundCommunity doula support may improve birth outcomes and experiences, including lower rates of preterm birth and low birthweight and increases in positive birthing experiences. Few studies have explored client experiences with doula care, specifically community doula care.AimTo explore Black doula clients' motivations for seeking and experiences with community doula care.MethodsData are from a mixed methods process evaluation of an organization providing free community doula services in San Francisco, California. We conducted two rounds of qualitative interviews with doula clients who identified as Black or Pacific Islander between August 2019 and March 2020. Interviews explored clients' knowledge of, experiences with, and motivations for seeking doula care and their perceptions of the services they received. We utilized a Rapid Assessment Process to synthesize findings and thematic analysis.FindingsClients' motivations for seeking doula care included general lack of support and knowledge of mistreatment experienced by Black women in hospital settings. Doulas provided support in the form of information about the perinatal period and clients' rights, advocacy in hospital settings, and connection to resources beyond pregnancy and birth. Some clients described doulas as helping them stay focused and make decisions during difficult labor experiences and described positive birth experiences despite experiencing complications.ConclusionCommunity doulas play an instrumental role in the birth experiences of Black women and birthing people. Efforts should be made to expand access to this needed support via policy and hospital practices.

Objective: Patients with abdominal aortic aneurysm (AAA) may be treated with endovascular intervention or open surgical repair. Despite the possibility of a retroperitoneal approach for open surgery, many surgeons prefer a transperitoneal approach. Transperitoneal aortic exposure may be done by longitudinal or transverse incisions. Transverse incisions are thought to be less painful and have less perioperative complications as compared to longitudinal midline incisions, but the reports to this effect are not conclusive. To address the lack of data comparing perioperative outcomes in aortic surgery incisions, our center conducted a retrospective study. Our aim was to generate concrete evidence regarding the choice of incision and its impact on surgical outcomes, filling a crucial gap in existing knowledge. Materials and Methods: Fifty-two consecutive cases were selected from our institute’s database who underwent elective open AAA repair, with 26 cases each in longitudinal and transverse incision group. Data were analyzed to compare the effects of type of incision for abdominal aortic surgery on the duration of ventilatory requirements and intensive care unit (ICU) stay, postoperative ileus, perioperative analgesia requirement, and the duration of hospital stay in these patient groups. Results: Baseline characteristics and comorbidities of the study population were comparable. Postoperative hospital stays were notably shorter for patients with transverse incisions than those with longitudinal incisions. The transverse incision group also exhibited a statistically significant reduction in postoperative ileus development. However, no significant differences were observed between the two study groups in terms of ventilatory requirements, postoperative analgesia needs, and ICU stays. Conclusion: The ongoing discourse in the literature surrounding the incision choices find support in our study, indicative of advantages of transverse incisions that include lower postoperative ileus and shorter hospital stays. However, no clear benefits were observed regarding postoperative ventilation and analgesic requirements. Study limitations underscore the necessity for future prospective research with larger samples and longer follow-ups, yet the findings suggest that transverse incisions may offer improved perioperative outcomes, potentially easing financial strains on patients and health-care systems through reduced hospitalization durations.

INTRODUCTION: The COVID-19 pandemic resulted in major disruptions in all aspects of human life including a decline of medical services utilized during 2020. An analysis of the impact of COVID-19 pandemic showed an 18.7% reduction in utilization patterns of interventional techniques in managing chronic pain in the Medicare population from 2019 to 2020. However, specific changes in utilization patterns of facet joint interventions have not been studied. Thus, we sought to assess the utilization patterns including an update of facet joint interventions from 2018 to 2020, with analysis of the impact of COVID-19 pandemic in managing chronic spinal pain utilizing facet joint interventions in the fee-for-service Medicare population of the United States. METHODS: The present investigation was designed to assess utilization patterns and variables of facet joint interventions, in managing chronic spinal pain from 2010 to 2020 in the fee-for-service (FFS) Medicare population in the United States (US), and how the COVID-19 pandemic impacted these utilization patterns. Data for the analysis were obtained from the master database from the Centers for Medicare & Medicaid Services (CMS) physician/supplier procedure summary from 2000 to 2020. RESULTS: Results of this analysis showed significant impact of COVID-19 with overall decrease of 18.5% of all facet joint interventions per 100,000 Medicare population compared to 20.2 and 20.5% decrease for lumbar and cervical facet joint injections, 15 and 13.1% decrease per 100,000 Medicare population of lumbosacral and cervicothoracic facet joint neurolysis procedures. The results are significant in that comparative analysis from 2000 to 2010 and 2010 to 2019 showing an annual increase of 14.4 vs. 2.2%, illustrating a decelerating pattern. There were also significant growth patterns noted with decreases in facet joint injections and nerve blocks compared to facet joint neurolytic procedures. CONCLUSIONS: This analysis shows a significant effect of COVID-19 producing an overall decrease in utilization of facet joint interventions relative to pre-COVID data. Further, the analysis demonstrates continued deceleration of utilization patterns of facet joint interventions compared to the periods of 2000-2010 and 2010-2019.

BackgroundThe Healthy People initiative is a national effort to lay out public health goals in the United States every decade. In its latest iteration, Healthy People 2030, key goals related to contraception focus on increasing the use of effective birth control (contraceptive methods classified as most or moderately effective for pregnancy prevention) among women at risk of unintended pregnancy. This narrow focus is misaligned with sexual and reproductive health equity, which recognizes that individuals’ self-defined contraceptive needs are critical for monitoring contraceptive access and designing policy and programmatic strategies to increase access. ObjectiveWe aimed to compare 2 population-level metrics of contraceptive access: a conventional metric, use of contraceptive methods considered most or moderately effective for pregnancy prevention among those considered at risk of unintended pregnancy (approximating the Healthy People 2030 approach), and a person-centered metric, use of preferred contraceptive method among current and prospective contraceptive users. MethodsWe used nationally representative data collected in 2022 to construct the 2 metrics of contraceptive access; the overall sample included individuals assigned female at birth not using female sterilization or otherwise infecund and who were not pregnant or trying to become pregnant (unweighted N=2760; population estimate: 43.9 million). We conducted a comparative analysis to examine the convergence and divergence of the metrics by examining whether individuals met the inclusion criteria for the denominators of both metrics, neither metric, only the conventional metric, or only the person-centered metric. ResultsComparing the 2 approaches to measuring contraceptive access, we found that 79% of respondents were either included in or excluded from both metrics (reflecting that the metrics converged when individuals were treated the same by both). The remaining 21% represented divergence in the metrics, with an estimated 5.7 million individuals who did not want to use contraception included only in the conventional metric denominator and an estimated 3.5 million individuals who were using or wanted to use contraception but had never had penile-vaginal sex included only in the person-centered metric denominator. Among those included only in the conventional metric, 100% were content nonusers—individuals who were not using contraception, nor did they want to. Among those included only in the person-centered metric, 68% were currently using contraception. Despite their current or desired contraceptive use, these individuals were excluded from the conventional metric because they had never had penile-vaginal sex. ConclusionsOur analysis highlights that a frequently used metric of contraceptive access misses the needs of millions of people by simultaneously including content nonusers and excluding those who are using or want to use contraception who have never had sex. Documenting and quantifying the gap between current approaches to assessing contraceptive access and more person-centered ones helps clearly identify where programmatic and policy efforts should focus going forward.

BackgroundContraceptive choice is central to reproductive autonomy. The internet, including social networking sites like Reddit, is an important resource for people seeking contraceptive information and support. A subreddit dedicated to contraception, r/birthcontrol, provides a platform for people to post about contraception.ObjectiveThis study explored the use of r/birthcontrol, from the inception of the subreddit through the end of 2020. We describe the web-based community, identify distinctive interests and themes based upon the textual content of posts, and explore the content of posts with the most user engagement (ie, "popular" posts).MethodsData were obtained from the PushShift Reddit application programming interface from the establishment of r/birthcontrol to the start date of analysis (July 21, 2011, to December 31, 2020). User interactions within the subreddit were analyzed to describe community use over time, specifically the commonality of use based on the volume of posts, the length of posts (character count), and the proportion of posts with any and each flair applied. "Popular" posts on r/birthcontrol were determined based on the number of comments and "scores," or upvotes minus downvotes; popular posts had 9 comments and a score of ≥3. Term Frequency-Inverse Document Frequency (TF-IDF) analyses were run on all posts with flairs applied, posts within each flair group, and popular posts within each flair group to characterize and compare the distinctive language used in each group.ResultsThere were 105,485 posts to r/birthcontrol during the study period, with the volume of posts increasing over time. Within the time frame for which flairs were available on r/birthcontrol (after February 4, 2016), users applied flairs to 78% (n=73,426) of posts. Most posts contained exclusively textual content (n=66,071, 96%), had comments (n=59,189, 86%), and had a score (n=66,071, 96%). Posts averaged 731 characters in length (median 555). "SideEffects!?" was the most frequently used flair overall (n=27,530, 40%), while "Experience" (n=719, 31%) and "SideEffects!?" (n=672, 29%) were most common among popular posts. TF-IDF analyses of all posts showed interest in contraceptive methods, menstrual experiences, timing, feelings, and unprotected sex. While TF-IDF results for posts with each flair varied, the contraceptive pill, menstrual experiences, and timing were discussed across flair groups. Among popular posts, intrauterine devices and contraceptive use experiences were often discussed.ConclusionsPeople commonly wrote about contraceptive side effects and experiences using methods, highlighting the value of r/birthcontrol as a space to post about aspects of contraceptive use that are not well addressed by clinical contraceptive counseling. The value of real-time, open-access data on contraceptive users' interests is especially high given the shifting landscape of and increasing constraints on reproductive health care in the United States.

BackgroundBeginning in March 2020, health care systems in the United States restricted the number of support people who could be present during pregnancy-related care to reduce the spread of COVID-19. We aimed to describe how SisterWeb, a community-based doula organization that employs Black, Pacific Islander, and Latinx doulas in San Francisco, California, adapted to the COVID-19 pandemic.MethodsAs part of process and outcome evaluations conducted through an academic-community partnership, we interviewed SisterWeb doulas, mentors, and leaders in 2020, 2021, and 2022 (n=26 interviews). We identified preliminary themes using the Rapid Assessment Process and then conducted thematic analysis of data related to COVID-19.ResultsSisterWeb leadership remained committed to safeguarding doulas by shifting to virtual support until doulas were onboarded as benefitted employees. Doulas reported hospital policies impacted clients' pregnancy-related care. Initially, doulas adapted to virtual support by connecting with clients more frequently through phone and text. When permitted to meet in person, doulas adjusted to client preference. Finally, as the pandemic impacted doulas' well-being, they turned to mentors for emotional support.Discussion and health equity implicationsThis analysis contributes to a growing body of literature describing doulas' experiences during the pandemic. By shifting to virtual support, SisterWeb leaders prioritized the health, safety, and financial stability of doulas, who were members of communities disproportionately impacted by COVID-19. Our findings suggest that public health guidance, organizational COVID-19 precautions, and hospital policies hindered SisterWeb's goal of ensuring clients receive equitable medical care. In addition, we found that emotional support for doulas is vital to their work.

ObjectivesCommunity doulas, who provide culturally concordant, nonclinical support during and after pregnancy, are increasingly promoted as an evidence-based intervention to advance birth equity. As valued members of their communities, community doulas often provide extensive physical and emotional pregnancy, birth, and postpartum support at low or no cost to clients. However, neither community doulas' scope of work nor the distribution of time among their different work activities has been clearly defined or enumerated; therefore, this project sought to describe the work activities and time use of doulas in one community-based doula organization.MethodsIn a quality improvement project, we reviewed case management system client data and collected 1 month of time diary data from eight doulas employed full-time at SisterWeb San Francisco Community Doula Network. We calculated descriptive statistics for activities community doulas reported in their time diaries and each visit/interaction logged in the case management system.ResultsSisterWeb doulas spent about half of their time in direct client care. For every hour that doulas spent with a client in prenatal and postpartum visits, on average, they spent an additional 2.15 h communicating with and supporting their clients in other ways. Overall, we estimate that SisterWeb doulas spend an average of 32 h providing care for a client receiving the standard course of care, including intake, prenatal visits, support during childbirth, and postpartum visits.ConclusionsResults highlight the wide variety of work that SisterWeb community doulas do beyond direct client care. Acknowledgment of community doulas' broad scope of work and appropriate compensation for all activities is necessary if doula care is to be advanced as a health equity intervention.