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Open Access Publications from the University of California

Scholarly Works (32 results)

  • Thesis
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UC Berkeley Electronic Theses and Dissertations (2015)

In spite of an expanding menu of contraceptive options, women in the United States (US) continue to experience high rates of unintended pregnancy, with 50% of all pregnancies being unintended. Unintended pregnancy has been associated with a number of adverse health outcomes for mothers and their children and results in significant financial cost to society. While the root causes of unintended pregnancy are likely complex and multi-factorial, the direct cause of an unintended pregnancy is sexual activity coupled with contraceptive misuse, failure or nonuse altogether. Although most women who do not wish to become pregnant have at some point used contraception, nonuse and inconsistent use of contraception in any given year is common. Thus, at its most proximal level, reducing unintended pregnancy requires increasing and improving contraceptive use among women and couples that want to avoid pregnancy.

This research focuses on contraceptive method choice as a critical decision because the method used by a woman has implications for how well she is able to prevent an unintended pregnancy. Further, dissatisfaction with the contraceptive methods women use is high, highlighting the importance of assisting women with choosing methods that meet their needs. Contraceptive method choice is a highly individualized decision made in the context of a woman’s life circumstances. This decision can be complex and involves a number of considerations that can affect a woman’s ability to successfully use the method. Given that the most commonly used and most effective methods require a prescription and/or an interaction with a health care provider in the US, factors related to the health care system influence the methods women choose. There is a need to develop patient-centered interventions that can assist women in choosing a contraceptive method that best meets their individual needs.

This dissertation presents the findings of three interrelated studies related to women’s contraceptive method choice. The first paper presents the findings of a critical literature review of the role of the US health care system in impacting women’s contraceptive method choice. In this study, I identified a comprehensive set of factors related to the health care system, such as the provision of specific services by providers, that are associated with contraceptive method choice. The second paper examined a component of the contraceptive choice decision-making process by assessing the importance women assign to several contraceptive attributes when choosing a method. This quantitative analysis tested hypotheses to determine if the importance women assigned to various contraceptive attributes aligned with the methods they chose. Finally, in the third paper, I explored patient perceptions of a contraceptive decision support tool that can be used in clinical settings to help women choose contraceptive methods. Specifically, this qualitative study used semi-structured interviews to describe patients’ perception of the value and utility of the tool in order to understand the mechanisms through which these tools have an impact on contraceptive method choice.

    Cover page: Women’s Contraceptive Method Choice in the United States: The Role of the Health Care System, the Importance of Contraceptive Attributes, and Exploring the Potential for a Decision Support Intervention in the Clinical Setting
    • Article
    • Peer Reviewed
    UC Berkeley Previously Published Works (2015)

    Objective

    Increasing use of long-acting methods of contraception, such as intrauterine devices (IUDs), has been recognized as a promising strategy to reduce the incidence of unintended pregnancy. While men may play an important role in promoting or discouraging contraceptive use, very little research has examined men's knowledge of and attitudes toward IUDs.

    Study design

    We used data from the 903 men included in the 2009 National Survey of Reproductive and Contraceptive Knowledge to examine their awareness and knowledge of IUDs and other contraceptive methods by several individual-level characteristics.

    Results

    Men's awareness and perceived knowledge of IUDs is low in comparison to condoms and birth control pills. Men's perceived knowledge of IUDs was lower than their objective knowledge, as measured by true/false questions about IUDs, suggesting that men may be more knowledgeable of IUDs than they perceive. In the multivariate models, men who were uninsured [adjusted odds ratio (AOR), 0.4; 95% confidence interval (CI), 0.2-0.6], identified as Christian (AOR, 0.6; 95% CI, 0.3-1.0) and who had never had a sexual health visit (AOR, 0.6; 95% CI, 0.4-1.0) were less likely to have heard of IUDs. Among men who had heard of the method, Hispanic men were less likely (AOR, 0.2; 95% CI, 0.1-0.5) to be more knowledgeable of the method.

    Conclusion

    Young men report low awareness of IUDs in comparison to other methods, and this varies by demographic characteristics including health insurance status. Family planning programs should consider targeted knowledge promotion for young men, with a focus on contraceptive methods besides condoms and oral contraception.

    Implications

    Male partners are influential in contraceptive use, yet little research has examined their IUD knowledge. Our findings indicate that healthcare providers may play important role in increasing young men's knowledge of contraceptive methods, including IUDs. This study highlights the need to better incorporate young men into contraception research and programs.
      Cover page: Young men’s awareness and knowledge of intrauterine devices in the United StatesCreative Commons 'BY-NC-ND' version 4.0 license
      • Article
      • Peer Reviewed
      UC Berkeley Previously Published Works (2023)
      Available research suggests that patients with diabetes do not regularly receive preconception counseling, but information on patients' experiences of counseling is scant. We conducted a qualitative study involving semi-structured interviews with 22 patients between October 2020 and February 2021. Pregnant patients with preexisting diabetes were recruited from a specialty diabetes and pregnancy clinic at a large academic medical center in Northern California. Interviews were transcribed, coded, and analyzed using an inductive and deductive content analysis approach. A total of 27% reported they did not have any pregnancy-related discussions with a health care provider before pregnancy. Of those that did, many sought out counseling; this was often connected to how "planned" the pregnancy was. Few participants, nearly all with type 1 diabetes, reported having a formal preconception care visit. Participants described receiving information mostly about the risks associated with diabetes and pregnancy. While participants who sought out counseling generally reported their providers were supportive of their desire for pregnancy, there were a few exceptions, notably all among patients with type 2 diabetes. The varied experiences of participants indicate gaps in the delivery of pre-pregnancy counseling to patients with diabetes and suggest counseling may vary based on diabetes type. There are opportunities to improve the patient-centeredness of counseling.
        Cover page: Experiences of Preconception Counseling among Pregnant Women with Preexisting Diabetes: Opportunities to Improve Patient-Centered Care
        • Article
        • Peer Reviewed
        UC Berkeley Previously Published Works (2018)

        Context

        Research on predictors of clinical outcomes usually focuses on the impact of individual patient factors, despite known relationships between neighborhood environment and health.

        Objective

        To determine whether US census information on where a patient resides is associated with diabetes development among patients with prediabetes.

        Design

        Retrospective cohort study of all 157,752 patients aged 18 years or older from Kaiser Permanente Northern California with laboratory-defined prediabetes (fasting plasma glucose, 100 mg/dL-125 mg/dL, and/or glycated hemoglobin, 5.7%-6.4%). We assessed whether census data on education, income, and percentage of households receiving benefits through the US Department of Agriculture's Supplemental Nutrition Assistance Program (SNAP) was associated with diabetes development using logistic regression controlling for age, sex, race/ethnicity, blood glucose levels, and body mass index.

        Main outcome measure

        Progression to diabetes within 36 months.

        Results

        Patients were more likely to progress to diabetes if they lived in an area where less than 16% of adults had obtained a bachelor's degree or higher (odds ratio [OR] =1.22, 95% confidence interval [CI] = 1.09-1.36), where median annual income was below $79,999 (OR = 1.16 95% CI = 1.03-1.31), or where SNAP benefits were received by 10% or more of households (OR = 1.24, 95% CI = 1.1-1.4).

        Conclusion

        Area-level socioeconomic and food assistance data predict the development of diabetes, even after adjusting for traditional individual demographic and clinical factors. Clinical interventions should take these factors into account, and health care systems should consider addressing social needs and community resources as a path to improving health outcomes.
          Cover page: Using Neighborhood-Level Census Data to Predict Diabetes Progression in Patients with Laboratory-Defined Prediabetes
          • Article
          • Peer Reviewed
          UC Berkeley Previously Published Works (2023)

          Background

          Language barriers play significant roles in quality of healthcare. Limited studies have examined the relationships between Spanish language and quality of intrapartum care. The objective was to determine the association between primary Spanish language and quality of intrapartum care so as to further inform best practices for non-English speaking patients in the labor and delivery setting.

          Methods

          We used the 2016 Listening to Mothers in California survey data, which included a statewide representative sample of women who gave birth in hospitals. Our analytical sample included 1202 Latina women. Multivariable logistic regression was used to examine the association between primary language (monolingual English vs. monolingual Spanish vs. bilingual Spanish/English) and perceived discrimination due to language, perceived pressure for medical interventions, and mistreatment during labor, adjusting for maternal sociodemographics and other maternal and neonatal factors.

          Results

          Over one-third of the study population spoke English (35.6%), less than one-third spoke Spanish (29.1%), and greater than one-third spoke bilingual Spanish/English (35.3%). Overall, 5.4% of Latina women perceived discrimination due to language spoken, 23.1% perceived pressure for any medical intervention, and 10.1% experienced either form of mistreatment. Compared to English-speakers, Spanish-speakers were significantly more likely to report discrimination due to language (aOR 4.36; 95% CI 1.15-16.59), but were significantly less likely to experience pressure for certain medical interventions (labor induction or cesarean delivery) during labor (aOR 0.34; 95% CI 0.15-0.79 for induction; aOR 0.44; 95% CI 0.18-0.97 for cesarean delivery). Bilingual Spanish/English-speakers also significantly reported discrimination due to language to a lesser extent than monolingual Spanish-speakers (aOR 3.37; 95% CI 1.12-10.13). Any form of Spanish language (monolingual or bilingual) was not significantly associated with mistreatment.

          Conclusions

          Spanish language may contribute to experiences of discrimination during intrapartum care among Latina women. Future research is needed to explore perceptions of pressure, discrimination and mistreatment, among patients with limited English proficiency.
            Cover page: Association between primary Spanish language and quality of intrapartum care among Latina women: a secondary analysis of the Listening to Mothers in California survey
            • Article
            • Peer Reviewed
            UC Berkeley Previously Published Works (2018)

            Background

            Contraceptive nonadherence is an important contributor to unintended pregnancy in the United States. While the elimination of patient cost sharing has been cited as means to improve contraceptive access, little is known about the relationship between cost sharing and ongoing adherence and continuation of chosen methods. The purpose of this study was to examine the relationship between copayment amount and adherence to pharmacy-dispensed contraception in young women.

            Methods

            We conducted a retrospective cohort study of 39,142 women ages 19-29 with a new prescription for the contraceptive pill, patch, or ring at Kaiser Permanente Northern California during 2011-2014. We examined 12-month nonadherence as measured by timely prescription refills and used multivariable Cox proportional hazards models to assess the association between copayment amount and the risk of nonadherence.

            Results

            Ninety-four percent of women used the pill, and 6% used the patch or ring. Forty percent of patients had no copayment and 25% had a copayment of ≥$30. Nearly 75% of women were nonadherent during the study period. In 2013 and 2014, women with a copayment had a 9% increased risk of nonadherence (adjusted hazard ratio, 1.09; 95% confidence interval, 1.04, 1.14) compared with women with no copayment.

            Conclusions

            Prescription copayments may serve as a barrier to adherence of pharmacy-dispensed contraception. Given recent changes to Affordable Care Act contraceptive coverage requirement, these findings can be used to support state-level and health system-level policies for no-cost contraception, and to determine the potential public health impact of this policy change.
              Cover page: The Relationship Between Prescription Copayments and Contraceptive Adherence in a New-user Cohort
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2022)

              Objective

              Among women initiating new prescription contraception, we investigated the relationship between recent depression and a range of contraceptive behaviors.

              Study design

              We used medical and pharmacy records of 52,325 women ages 19 to 29 who initiated prescription contraception (pills, patches or rings, injectables, and long-acting reversible contraceptives) in 2014-2016 at a large integrated healthcare system in Northern California. Women had continuous enrollment for a year before and after initiating, and no records of prescription contraceptive use in the year before initiating. Depression in the year prior to initiation was dichotomized into (1) no depression indicator (reference group) or (2) depression diagnosis or redeemed antidepressant. Multinomial logistic regression models examined the associations between depression and method type initiated, and contraceptive patterns, timing of discontinuation, inconsistent use, and switching methods over a year after initiating, adjusting for sociodemographics and testing for interactions between depression and having a recent birth or abortion.

              Results

              Women with recent depression were more likely to initiate methods other than the pill, and the association was stronger for patches or rings vs pills among those with a recent birth compared to those without. Among women initiating all methods and the pill, those with depression were more likely to discontinue their method, use it inconsistently, and switch from it than use it continuously for a year.

              Conclusion

              Women with recent depression were less likely to initiate the pill; and when the pill was initiated, those with depression were more likely to discontinue use, use it inconsistently, and switch from it.

              Implications

              Women with recent depression indicators should be followed closely to ensure they have the support they need to meet their reproductive goals. Those who wish to avoid pregnancy may benefit from methods that do not require daily use.
                Cover page: The association between depression and contraceptive behaviors in a diverse sample of new prescription contraception users.
                • Article
                • Peer Reviewed
                UC Berkeley Previously Published Works (2023)

                Objectives

                Community 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.

                Methods

                In 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.

                Results

                SisterWeb 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.

                Conclusions

                Results 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.
                  Creative Commons 'BY-NC-ND' version 4.0 license
                  • Article
                  • Peer Reviewed
                  UC Berkeley Previously Published Works (2022)

                  Purpose

                  This commentary proposes a new direction to train the MCH workforce by leveraging today's rapidly changing innovation and technology to address persistent health inequities.

                  Description

                  We outline the creation of an MCH technology and innovation training pipeline developed by harnessing creative funding opportunities, diversifying training modalities, and expanding partnerships beyond traditional academic-practice partners, that be replicated and adapted by other academic programs.

                  Assessment

                  Technology and innovation will continue to be a growing intersection between health and equity, and we must create a robust pipeline of MCH leaders prepared to collaborate with entrepreneurial and innovation leaders.

                  Conclusion

                  Technology offers an important opportunity to improve MCH outcomes and reduce disparities, but only if we train the MCH workforce to seize these opportunities.
                    Cover page: Emerging Technology: Preparing Tomorrow's MCH Workforce to Innovate for Equity
                    • Article
                    • Peer Reviewed
                    UC Berkeley Previously Published Works (2023)

                    Objective

                    Describe 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 design

                    We 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.

                    Results

                    Nearly 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.

                    Conclusions

                    This 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.

                    Implications

                    This 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.
                      Creative Commons 'BY-NC-ND' version 4.0 license
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