Publications by authors named "Kavita Shah Arora"

57 Publications

Association of race and ethnicity with postpartum contraceptive method choice, receipt, and subsequent pregnancy.

BMC Womens Health 2021 Jan 7;21(1):17. Epub 2021 Jan 7.

Department of Bioethics, Case Western Reserve University School of Medicine, Cleveland, OH, USA.

Background: We sought to assess racial/ethnic differences in choice of postpartum contraceptive method after accounting for clinical and demographic correlates of contraceptive use.

Methods: This is a secondary analysis of a single-center retrospective cohort study examining postpartum women from 2012 to 2014. We determined the association between self-identified race/ethnicity and desired postpartum contraception, receipt, time to receipt, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery.

Results: Of the 8649 deliveries in this study, 46% were by Black women, 36% White women, 12% Hispanic, and 6% by women of other races. Compared with White women, Black and Hispanic women were more likely to have a postpartum contraception plan for all methods. After multivariable analysis, Hispanic women (relative to White women) were less likely to receive their chosen method (odds ratio [OR] 0.74, 95% confidence interval [CI] 0.64-0.87). Women of races other than Black or Hispanic were less likely to experience a delay in receipt of their desired highly-effective method compared to White women (hazard ratio [HR] = 0.70, 95% CI 0.52-0.94). There were no differences between racial/ethnic groups in terms of postpartum visit adherence. Black women were more likely to be diagnosed with a subsequent pregnancy compared to White women (OR 1.17, 95% CI 1.04-1.32).

Conclusion: Racial/ethnic variation in postpartum contraceptive outcomes persists after accounting for clinical and demographic differences. While intrinsic patient-level differences in contraceptive preferences should be better understood and respected, clinicians should take steps to ensure that the observed differences in postpartum contraceptive plan methods between racial/ethnic groups are not due to biased counseling.
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http://dx.doi.org/10.1186/s12905-020-01162-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7789754PMC
January 2021

Variation by state in Medicaid sterilization policies for physician reimbursement.

Contraception 2021 Apr 28;103(4):255-260. Epub 2020 Dec 28.

Department of Bioethics, Case Western Reserve University, Cleveland, OH, United States; Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, United States. Electronic address:

Objective: To evaluate state-level variation in Medicaid sterilization reimbursement policies for physicians in terms of policy details, flexibility, and review process.

Study Design: We reviewed state Medicaid websites and interviewed state employees to better understand reimbursement policies and implementation. We attempted to obtain policy details and instructions for physicians from all 50 state Medicaid office websites. We invited employees in all 50 state Medicaid director's offices to participate in semi-structured qualitative interviews.

Results: We were able to collect data from 48 states' websites for analysis, conducted 15 telephone interviews, and received 4 written responses from state Medicaid employees. State policies varied greatly in terms of degree of instruction available online to clinicians, number of content-related and logistical changes made compared to the federal policy, type of procedures included, corrections permitted, flexibility in terms of surgeon and procedure changes, review process, reasons for and ramifications of denial, and date of last policy revision.

Conclusion: There is need for increased transparency and instruction by state Medicaid offices as well as revision of the Medicaid policy to account for the contemporary clinical practice of female permanent contraception. Clinicians should communicate with state Medicaid employees in order to clarify important policy details and obtain greater understanding of their state's review process and ramifications to ensure their clinical practice is both correct and reimbursable.

Implications: Greater consistency between states in terms of Medicaid policy and implementation is crucial to ensuring physicians are fairly reimbursed for their work, and female permanent contraception remains an accessible contraceptive method for women.
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http://dx.doi.org/10.1016/j.contraception.2020.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7925370PMC
April 2021

COVID-19 highlights the policy barriers and complexities of postpartum sterilization.

Contraception 2021 01 15;103(1):3-5. Epub 2020 Oct 15.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, United States; Department of Bioethics, Case Western Reserve University, Cleveland, OH, United States.

Multiple barriers exist to sterilization in the postpartum period. One such barrier, the Medicaid Title XIX sterilization policy, requires publicly insured patients to complete a sterilization consent form at least 30 days prior to their scheduled procedure. While this policy was set in place in the 1970s to address the practice of coerced sterilization among marginalized women, it has served as a significant barrier to obtaining the procedure in the contemporary period. The COVID-19 pandemic has highlighted specific complexities surrounding postpartum sterilization and created additional barriers for women desiring this contraceptive method. Despite the time constraints to perform postpartum sterilization, some hospital administrators, elective officials, and state Medicaid offices deemed sterilization as "elective." Additionally, as the Center for Medicare and Medicaid Services (CMS) has revised telemedicine reimbursement and encouraged its increased use, it has provided no guidance for the sterilization consent form, use of oral consents, and change to the sterilization consent form expiration date. This leaves individual states to create policies and recommended procedures that may not be accepted or recognized by CMS. These barriers put significant strain on patients attempting to obtain postpartum sterilization, specifically for patients with lower incomes and women of color. CMS can support reproductive health for vulnerable populations by providing clear guidance to state Medicaid offices, extending the 180-day expiration of a sterilization consent form signed prior to the pandemic, and allowing for telemedicine oral consents with witnesses or electronic signatures.
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http://dx.doi.org/10.1016/j.contraception.2020.10.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557287PMC
January 2021

Ethical challenges for women's healthcare highlighted by the COVID-19 pandemic.

J Med Ethics 2021 02 12;47(2):69-72. Epub 2020 Oct 12.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA

Healthcare policies developed during the COVID-19 pandemic to safeguard community health have the potential to disadvantage women in three areas. First, protocols for deferral of elective surgery may assign a lower priority to important reproductive outcomes. Second, policies regarding the prevention and treatment of COVID-19 may not capture the complexity of the considerations related to pregnancy. Third, policies formulated to reduce infectious exposure inadvertently may increase disparities in maternal health outcomes and rates of violence towards women. In this commentary, we outline these challenges unique to women's healthcare in a pandemic, provide preliminary recommendations and identify areas for further exploration and refinement of policy.
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http://dx.doi.org/10.1136/medethics-2020-106646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551741PMC
February 2021

Ethical Implications of Donor Type for Uterus Transplantation: Why We Should Remain Wary of Using Living Donors.

Yale J Biol Med 2020 09 30;93(4):587-592. Epub 2020 Sep 30.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH.

Over the last few years, research teams have made significant advancements in treating absolute uterine factor infertility through uterus transplantation, culminating in the birth of the first US baby born from a uterus transplant in November 2017. However, studies have differed on the choice of either deceased or living donors, with some centers even exploring both methods. As researchers continue to investigate the medical feasibility of these approaches, it is also important for the medical community to consider how deceased and living uterus donation differ ethically. We argue that if living and deceased donation demonstrate equivalent clinical efficacy and the deceased donor pool is sufficient, living uterus donation should be reevaluated and may no longer be ethically justifiable.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7513439PMC
September 2020

Association between neighborhood disadvantage and fulfillment of desired postpartum sterilization.

BMC Public Health 2020 Sep 22;20(1):1440. Epub 2020 Sep 22.

Center for Health Care Research and Policy and the Departments of Medicine, and Population and Quantitative Health Sciences, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA.

Background: Adequacy of prenatal care is associated with fulfillment of postpartum sterilization requests, though it is unclear whether this relationship is indicative of broader social and structural determinants of health or reflects the mandatory Medicaid waiting period required before sterilization can occur. We evaluated the relationship between neighborhood disadvantage (operationalized by the Area Deprivation Index; ADI) and the likelihood of undergoing postpartum sterilization.

Methods: Secondary analysis of a single-center retrospective cohort study examining 8654 postpartum patients from 2012 to 2014, of whom 1332 (15.4%) desired postpartum sterilization (as abstracted from the medical record at time of delivery hospitalization discharge) and for whom ADI could be calculated via geocoding their home address. We determined the association between ADI and sterilization completion, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery via logistic regression and time to sterilization via Cox proportional hazards regression.

Results: Of the 1332 patients included in the analysis, patients living in more disadvantaged neighborhoods were more likely to be younger, more parous, delivered vaginally, Black, unmarried, not college educated, and insured via Medicaid. Compared to patients living in less disadvantaged areas, patients living in more disadvantaged areas were less likely to obtain sterilization (44.8% vs. 53.5%, OR 0.84, 95% CI 0.75-0.93), experienced greater delays in the time to sterilization (HR 1.23, 95% CI 1.06-1.44), were less likely to attend postpartum care (58.9% vs 68.9%, OR 0.86, CI 0.79-0.93), and were more likely to have a subsequent pregnancy within a year of delivery (15.1% vs 10.4%, OR 1.56, 95% CI 1.10-1.94). In insurance-stratified analysis, for patients with Medicaid, but not private insurance, as neighborhood disadvantage increased, the rate of postpartum sterilization decreased. The rate of subsequent pregnancy was positively associated with neighborhood disadvantage for both Medicaid as well as privately insured patients.

Conclusion: Living in an area with increased neighborhood disadvantage is associated with worse outcomes in terms of desired postpartum sterilization, especially for patients with Medicaid insurance. While revising the Medicaid sterilization policy is important, addressing social determinants of health may also play a powerful role in reducing inequities in fulfillment of postpartum sterilization.
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http://dx.doi.org/10.1186/s12889-020-09540-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509918PMC
September 2020

Attitudes and beliefs of obstetricians-gynecologists regarding Medicaid postpartum sterilization - A qualitative study.

Contraception 2020 Nov 25;102(5):376-382. Epub 2020 Aug 25.

Steve Hicks School of Social Work and Department of Sociology, University of Texas at Austin, Austin, TX, United States.

Objective: To explore the attitudes and beliefs of obstetrician-gynecologists in the United States (US) regarding the Medicaid postpartum sterilization policy.

Study Design: We recruited obstetrician-gynecologists practicing in ten geographically diverse US states for a qualitative study using the American College of Obstetricians and Gynecologists directory. We conducted semi-structured interviews via telephone, professionally transcribed, and analyzed using the constant comparative method and principles of grounded theory.

Results: We interviewed thirty obstetrician-gynecologists (63.3% women, 76.7% non-subspecialized, and 53.3% academic setting). Participants largely described the consent form as unnecessary, paternalistic, an administrative hassle, a barrier to desired patient care, and associated with worse health outcomes. Views on the waiting period's utility and impact were mixed. Many participants felt the sterilization policy was discriminatory. However, some participants noted the policy's importance in terms of the historical basis, used the form as a counseling tool to remind patients of the permanence of sterilization, felt the policy prompted them to counsel regarding sterilization, and protected patients in contemporary medical practice.

Conclusion: Many physicians shared concerns about the ethics and clinical impact of the Medicaid sterilization policy. Future revisions to the Medicaid sterilization policy must balance prevention of coercion with reduction in barriers to those desiring sterilization in order to maximize reproductive autonomy.

Implications: Obstetrician-gynecologists are key stakeholders of the Medicaid sterilization policy. Obstetrician-gynecologists largely believe that revision to the Medicaid sterilization policy is warranted to balance reduction of external barriers to desired care with a process that enforces the need for counseling regarding contraception and reviewing patient preference for sterilization throughout pregnancy in order to minimize regret.
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http://dx.doi.org/10.1016/j.contraception.2020.08.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606385PMC
November 2020

Implicit Bias in Counseling for Permanent Contraception: Historical Context and Recommendations for Counseling.

Health Equity 2020 17;4(1):326-329. Epub 2020 Jul 17.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA.

We provide an overview of the causes, manifestations, and potential mitigating steps regarding implicit bias in counseling for permanent contraception. The historical context of sterilization abuses and the implications of these on society's notions of fitness for parenthood are reviewed. We present contemporary examples of contraceptive coercion and discuss the impact of implicit bias from health care providers. Finally, we outline steps for ensuring a patient-centered shared decision-making ethical approach to permanent contraceptive counseling.
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http://dx.doi.org/10.1089/heq.2020.0025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410277PMC
July 2020

Perceptions and practice of state Medicaid officials regarding informed consent for female sterilization.

Contraception 2020 Nov 30;102(5):368-375. Epub 2020 Jul 30.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, United States; Department of Bioethics, Case Western Reserve University, Cleveland, OH, United States. Electronic address:

Objective: To explore the attitudes, beliefs, and interpretations of individual state Medicaid office employees regarding their state's postpartum sterilization policy and its impact on patient care.

Study Design: We invited employees in all 50 state Medicaid director's offices who self- or peer-identified as best informed about the sterilization policy to participate in semi-structured qualitative interviews. Using a pilot-tested interview guide, we transcribed, coded, and analyzed each interview. We attempted to obtain supplemental data, including relevant policy details and instructions for physicians in the state, from all 50 state Medicaid office websites.

Results: We collected data from 15 telephone interviews, four written responses, and 48 states' websites for analysis. Participants had varying responses regarding the impact of the Medicaid-mandated sterilization consent form in terms of informed consent as well as the utility and ramifications of the waiting period. State policies varied in terms of the age of consent, complexity of the form, availability of translations, use of unclear terminology, and the consent-obtaining process.

Conclusion: State Medicaid employees have differences in opinions regarding the intent of the Medicaid-mandated sterilization consent form and policies. Better understanding of the variation in individual state policies that may contribute to inequitable access to sterilization is necessary.

Implications: Provision of consistent guidelines and widespread coordination of the Medicaid sterilization policies in identified areas impacting informed consent may reduce existing obstacles and provide more equitable access to contraceptive care.
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http://dx.doi.org/10.1016/j.contraception.2020.07.092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606490PMC
November 2020

Medicaid sterilization consent forms: variation in rejection and payment consequences.

Am J Obstet Gynecol 2020 12 22;223(6):934-936. Epub 2020 Jul 22.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH; Department of Bioethics, Case Western Reserve University, Cleveland, OH.

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http://dx.doi.org/10.1016/j.ajog.2020.07.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704718PMC
December 2020

Variation in effectiveness of planned postpartum contraception at two time points from prenatal to postpartum care.

Contraception 2020 10 12;102(4):246-250. Epub 2020 Jun 12.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, United States. Electronic address:

Objective: To identify characteristics of women who have consistent plans in terms of contraceptive effectiveness from antepartum to postpartum care.

Study Design: This is a secondary analysis of a retrospective chart review of women who delivered at a single tertiary care center from 2012 to 2014. Preferred postpartum contraceptive plan was abstracted at three time points (prenatal care, hospital discharge, and outpatient postpartum care) and categorized into three tiers of effectiveness. We then examined consistency between the first two time points for the effectiveness in postpartum contraceptive method planned.

Results: Of the 8,394 women in the study cohort, 2,642 (31.5%) had a consistent postpartum contraceptive plan. Women who had a consistent plan were more likely to have higher parity (aOR 2.36, 95% CI 2.06-2.70 for parity 2+), choose highly effective methods of contraception (p < 0.001), achieve their contraception plan (adjusted odds ratio [aOR] 2.16, 95% confidence interval [95% CI] 1.85-2.52), but not more likely to have a subsequent pregnancy within 365 days of delivery (aOR 0.92, 95% CI 0.81-1.05).

Conclusion: Better understanding contraceptive decision-making as a journey and removing external barriers during that process is a necessary component of pregnancy care.

Implications: Counseling and documentation of contraceptive preferences throughout antepartum and postpartum care can help improve contraceptive outcomes.
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http://dx.doi.org/10.1016/j.contraception.2020.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7572620PMC
October 2020

Labor and Delivery Visitor Policies During the COVID-19 Pandemic: Balancing Risks and Benefits.

JAMA 2020 06;323(24):2468-2469

MetroHealth Medical Center, Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio.

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http://dx.doi.org/10.1001/jama.2020.7563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736929PMC
June 2020

In Reply.

Obstet Gynecol 2020 04;135(4):976-977

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio.

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http://dx.doi.org/10.1097/AOG.0000000000003803DOI Listing
April 2020

Factors Associated with Choice of Sterilization Among Women Veterans.

J Womens Health (Larchmt) 2020 07 4;29(7):989-995. Epub 2020 Feb 4.

Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.

We sought to compare associations of contraceptive preferences, beliefs, self-efficacy, and knowledge with use of sterilization versus other methods of contraception. This is a secondary analysis of a telephone-based survey of a nationally representative sample of women Veterans not desiring future pregnancy. Contraceptive method used at last sex was categorized as female sterilization, long-acting reversible contraception (LARC), short-acting methods, or nonprescription methods/no method. Multinomial regression models were performed to compare the association between independent variables (contraceptive preferences, beliefs, self-efficacy, and knowledge) and use of sterilization versus other contraceptive methods. Six hundred twelve women Veterans aged 18-44 years who were sexually active with men, had no history of hysterectomy or infertility, did not desire future pregnancy, and were not using male sterilization as their method of contraception were surveyed. A total of 208 women Veterans reported using female sterilization (34.0%). While method effectiveness was rated as extremely important by the majority of participants, there was no association between perceiving method effectiveness as extremely important and method selected in adjusted multinomial models. Women Veterans were more likely to use sterilization compared to hormonal methods of contraception if they reported that lack of hormones was an extremely important contraceptive method characteristic (aRRR 3.69, 95% CI 1.94-7.03). Women Veterans who strongly agreed with the belief that birth control decisions are mainly a woman's responsibility were less likely to use sterilization compared to LARC (aRRR 0.54, 95% CI 0.29-0.98). Associations between contraceptive preferences, beliefs, self-efficacy, and knowledge and use of sterilization in a population of women Veterans not desiring future pregnancy are complex, and decisions may not solely be driven by desire to select a highly effective method.
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http://dx.doi.org/10.1089/jwh.2019.8036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371549PMC
July 2020

The Association of Public Insurance with Postpartum Contraception Preference and Provision.

Open Access J Contracept 2019 19;10:103-110. Epub 2019 Dec 19.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, OH, USA.

Background: Prior studies have noted that public insurance status is associated with increased uptake of postpartum contraception whereas others have pointed to public insurance as a barrier to accessing highly effective forms of contraception.

Objective: To assess differences in planned method and provision of postpartum contraception according to insurance type.

Study Design: This is a secondary analysis of a retrospective cohort study examining postpartum women delivered at a single hospital in Cleveland, Ohio from 2012-2014. Contraceptive methods were analyzed according to Tier-based effectiveness as defined by the Centers for Disease Control and Prevention. The primary outcome was postpartum contraception method preference. Additional outcomes included method provision, postpartum visit attendance, and subsequent pregnancy within 365 days of delivery.

Results: Of the 8281 patients in the study cohort, 1372 (16.6%) were privately and 6990 (83.4%) were publicly insured. After adjusting for the potentially confounding clinical and demographic factors through propensity score analysis, public insurance was not associated with preference for a Tier 1 versus Tier 2 postpartum contraceptive method (matched adjusted odds ratio [maOR] 0.89, 95% CI 0.69-1.15), but was associated with a preference for Tier 1/2 vs Tier 3/None (maOR 1.41, 95% CI 1.17-1.69). There was no difference between women with private or public insurance in terms of method provision by 90 days after delivery (maOR 0.94, 95% CI 0.75-1.17). Public insurance status was also associated with decreased postpartum visit attendance (maOR 0.54, 95% CI 0.43-0.68) and increased rates of subsequent pregnancy within 365 days of delivery (maOR 1.29, 95% CI 1.05-1.59).

Conclusion: Public insurance status does not serve as a barrier to either the preference or provision of effective postpartum contraception. Women desiring highly- or moderately effective methods of contraception should have these methods provided prior to hospital discharge to minimize barriers to method provision.
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http://dx.doi.org/10.2147/OAJC.S231196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927572PMC
December 2019

Consent for Pelvic Examinations Under Anesthesia by Medical Students: Historical Arguments and Steps Forward.

Obstet Gynecol 2019 12;134(6):1298-1302

School of Medicine, Case Western Reserve University, and the Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio.

We provide an overview of the issue of specific consent for pelvic examinations under anesthesia performed by medical students. Arguments that have historically been made against requiring consent for such examinations are reviewed and refuted. The implications of requiring consent for examinations under anesthesia are discussed as they relate to patient autonomy, medical student education, and society at large. Finally, we outline a solution and offer sample language that balances the interests of patients, learners, and society.
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http://dx.doi.org/10.1097/AOG.0000000000003509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6905127PMC
December 2019

Desired Sterilization Procedure at the Time of Cesarean Delivery According to Insurance Status.

Obstet Gynecol 2019 12;134(6):1171-1177

Department of Obstetrics and Gynecology, MetroHealth Medical Center, the Cleveland Institute for Computational Biology, and the School of Medicine, Case Western Reserve University, Cleveland, Ohio.

Objective: To evaluate whether women with Medicaid are less likely than their privately insured counterparts to receive a desired sterilization procedure at the time of cesarean delivery.

Methods: This is a secondary analysis of a single-center retrospective cohort examining 8,654 postpartum women from 2012 to 2014, of whom 2,205 (25.5%) underwent cesarean delivery. Insurance was analyzed as Medicaid compared with private insurance. The primary outcome was sterilization at the time of cesarean delivery. Reason for sterilization noncompletion and Medicaid sterilization consent form validity were recorded. Secondary outcomes included postpartum visit attendance, outpatient postpartum sterilization, and subsequent pregnancy within 365 days of delivery.

Results: Of the 481 women included in this analysis, 78 of 86 (90.7%) women with private insurance and 306 of 395 (77.4%) women with Medicaid desiring sterilization obtained sterilization at the time of cesarean delivery (relative risk 0.85, 95% CI 0.78-0.94). After multivariable logistic regression, gestational age at delivery (1.02 [1.00-1.03]), adequacy of prenatal care (1.30 [1.18-1.43]), and marital status (1.09 [1.01-1.19]) were associated with achievement of sterilization at the time of cesarean delivery. Sixty-four (66.0%) women who desired but did not receive sterilization at the time of cesarean delivery did not have valid, signed Medicaid sterilization forms, and 10 (10.3%) sterilizations were not able to be completed at the time of surgery owing to adhesions. Sterilization during cesarean delivery was not associated with less frequent postpartum visit attendance for either the Medicaid or privately insured population. Rates of outpatient postpartum sterilization were similar among those with Medicaid compared with private insurance. Among patients who did not receive sterilization at the time of delivery, 15 patients (each with Medicaid) had a subsequent pregnancy within the study period.

Conclusion: Women with Medicaid insurance received sterilization at the time of cesarean delivery less frequently than privately insured counterparts, most commonly due to the absence of a valid Medicaid sterilization consent form as well as adhesive disease. The constraints surrounding the Medicaid form serve as a significant barrier to achieving desired sterilization.
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http://dx.doi.org/10.1097/AOG.0000000000003552DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6905118PMC
December 2019

Do Expectant Mothers' Breastfeeding Plans Influence Provider Prenatal Contraceptive Counseling?

J Hum Lact 2020 Nov 12;36(4):808-815. Epub 2019 Sep 12.

Case Western Reserve University, Cleveland, OH, USA.

Background: Breastfeeding and optimal birth spacing are associated with improved maternal and infant health outcomes worldwide. Provision of contraceptive advice that is aligned with recommendations for breastfeeding has potential to maximize maternal and infant health. Although there is broad agreement regarding the breastfeeding compatibility of specific postpartum contraceptive methods, it is not known whether maternal breastfeeding intention influences prenatal provider contraceptive counseling.

Research Aim: We aimed to determine if maternal feeding intention is considered by prenatal providers during contraceptive counseling.

Methods: This was a cross-sectional online author-created survey including all prenatal providers ( = 40) at two academic safety-net institutions in Cleveland, Ohio. Of 100 obstetrics/gynecology faculty members, 40 (40%) completed the survey, which included multiple-choice questions. Nominal and ordinal survey results were reported with percentages and frequencies, and categorical variables were compared using the Fisher exact test.

Results: Participants appropriately promoted breastfeeding-compatible postplacental intrauterine device placement, even though maternal feeding intention was specifically considered by just 12 (30%). Endorsed barriers to contraception for breastfeeding mothers included provider medical worries, patient concerns, and colleague resistance. Postplacental levonorgestrel intrauterine devices were recommended for all mothers by 92.5% of participants ( = 37). Recommendations regarding progestin-only and combined oral contraceptive pills were influenced by maternal breastfeeding versus formula-feeding intention.

Conclusion: Asking expectant women about their feeding intentions within each contraceptive discussion may create opportunities for shared decision making that can optimize perinatal outcomes for both mother and infant worldwide.
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http://dx.doi.org/10.1177/0890334419875944DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065946PMC
November 2020

Feasibility of an ethics and professionalism curriculum for faculty in obstetrics and gynecology: a pilot study.

J Med Ethics 2019 12 14;45(12):806-810. Epub 2019 Aug 14.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland Heights, Ohio, USA

Objective: There have been increased efforts to implement medical ethics curricula at the student and resident levels; however, practising physicians are often left unconsidered. Therefore, we sought to pilot an ethics and professionalism curriculum for faculty in obstetrics and gynaecology to remedy gaps in the formal, informal and hidden curriculum in medical education.

Methods: An ethics curriculum was developed for faculty within the Department of Obstetrics and Gynaecology at a tertiary care, academic hospital. During the one-time, 4-hour, mandatory in-person session, the participants voluntarily completed the Oldenburg Burnout Inventory, Handoff Clinical Evaluation Exercise, University of Missouri-Kansas City School of Medicine and overall course evaluation. Patient satisfaction survey scores in both the hospital and ambulatory settings were compared before and after the curriculum.

Results: Twenty-eight faculty members attended the curriculum. Overall, respondents reported less burnout and performed at the same level or better in terms of patient handoff than the original studies validating the instruments. Faculty rated the professionalism behaviours as well as teaching of professionalism much lower at our institution than the validation study. There was no change in patient satisfaction after the curriculum. However, overall, the course was well received as meeting its objectives, being beneficial and providing new tools to assess professionalism.

Conclusion: This pilot study suggests that an ethics curriculum can be developed for practising physicians that is mindful of pragmatic concerns while still meeting its objectives. Further study is needed regarding long term and objective improvements in ethics knowledge, impact on the education of trainees and improvement in the care of patients as a result of a formal curriculum for faculty.
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http://dx.doi.org/10.1136/medethics-2018-105189DOI Listing
December 2019

When May Government Interfere with Religious Practices to Protect the Health and Safety of Children?

Ethics Med Public Health 2018 Apr-Jun;5:86-93. Epub 2018 Jun 29.

Reproductive Biology and of Bioethics, Case Western Reserve University, Cleveland Ohio, USA, and Director of Quality, Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio, USA. Postal address: 2500 MetroHealth Drive, Suite G267, Cleveland, OH 44109, USA.

Secular states may be asked to override parental decisions based on religious beliefs when these decisions lead to concerns for the wellbeing of the child or welfare of society at large. Particular difficulties arise when goals of limited state importance to secular society conflict with practices that matter a great deal to members of religious groups. We propose a prudentially-based approach to resolving these conflicts by balancing the interests of the affected child, those close to the child, and society without compromising the child's needs. This approach acknowledges the importance of children's relational interests as members of families and religious cultures. It is compatible both with legal and bioethical practice. Decisions are contextually framed, taking into account the degree to which the state generally tolerates risks to children's health and safety. The constraints built into our approach protect against using child welfare as a pretext for attacks on minorities. Finally, use of this approach partially addresses the imprecision of other standards that have been applied to judge the appropriateness of parental decisions.
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http://dx.doi.org/10.1016/j.jemep.2018.03.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6344058PMC
June 2018

Impact of training level on postplacental levonorgestrel 52 mg intrauterine device expulsion.

Contraception 2019 02 16;99(2):94-97. Epub 2018 Nov 16.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH 44109. Electronic address:

Objective: To determine the association between provider training level and postplacental intrauterine device (IUD) outcomes following insertion instruction by email only.

Study Design: We conducted a single-center chart review of demographics, insertion and clinical outcomes within 6 months of delivery for 116 patients who underwent postplacental levonorgestrel 52 mg IUD placement from October 1, 2016, to March 31, 2017.

Results: We confirmed IUD retention, removal or expulsion in 87 of 116 (75.0%) patients by 6 months after delivery. Complete expulsion or removal for malposition occurred in 20 (23.0%) patients and more frequently after vaginal than cesarean delivery (30.2% vs. 4.2%, OR 9.93 [95% CI 1.25-78.96]) and when a postgraduate year (PGY) 1 physician placed the IUD compared to a PGY 2-4 or attending physician (37.5% vs. 14.5%, OR 3.52 [95% CI 1.25-9.94]).

Conclusion: Postplacental levonorgestrel 52 mg IUD expulsion rates are associated with provider training level as well as delivery route, though the individual association of each of these factors is difficult to ascertain given the high degree of collinearity between these two variables in our study.
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http://dx.doi.org/10.1016/j.contraception.2018.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6351181PMC
February 2019

Refusal of Vaccination: A Test to Balance Societal and Individual Interests.

J Clin Ethics 2018 ;29(3):206-216

Department of Obstetrics and Gynecology, Coney Island Hospital, Brooklyn, New York, and Department of Obstetrics and Gynecology and Department of Bioethics, Stony Brook University, Stony Brook, New York, USA.

While all states in the United States require certain vaccinations for school attendance, all but three allow for religious exemptions to receiving such vaccinations, and 18 allow for exemptions on the basis of other deeply held personal beliefs. The rights of parents to raise children as they see fit may conflict with the duty of the government and society to protect the welfare of children. In the U.S., these conflicts have not been settled in a uniform and consistent manner. We apply a test that provides a concrete and formal rubric to evaluate such conflicts. For some vaccinations, based on the individual medical characteristics of the disease and the risks of being unvaccinated, the test would suggest that permitting conscientious exemptions is ethical. However, for vaccinations protecting against other diseases that are more severe or easily transmitted, the test would suggest that the federal government may ethically impose laws that deny such exemptions.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6457107PMC
December 2018

Medicaid and receipt of interval postpartum long-acting reversible contraception.

Contraception 2019 01 5;99(1):32-35. Epub 2018 Sep 5.

Department of Obstetrics and Gynecology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH. Electronic address:

Objective: We sought to evaluate the impact of insurance type on receipt of an interval postpartum LARC, controlling for demographic and clinical factors.

Study Design: This is a retrospective cohort study of 1072 women with a documented plan of LARC for contraception at time of postpartum discharge. This is a secondary analysis of 8654 women who delivered at 20 weeks or beyond from January 1, 2012, through December 31, 2014, at an urban teaching hospital in Ohio. LARC receipt within 90 days of delivery, time to receipt, and rate of subsequent pregnancy after non-receipt were compared between women with Medicaid and women with private insurance. Postplacental LARC was not available at the time of study completion.

Results: One hundred eighty-seven of 822 Medicaid-insured and 43 of 131 privately insured women received a LARC postpartum (22.7% vs 32.8%, P=.02). In multivariable analysis, private insurance status was not significantly associated with LARC receipt (OR 1.29, 95% C.I. 0.83-1.99) though adequate prenatal care was (OR 2.33, 95% C.I. 1.42-4.00). Of women who wanted but did not receive a LARC, 208 of 635 (32.8%) Medicaid patients and 19 of 88 (21.6%) privately insured patients became pregnant within 1 year (P=.02).

Conclusion: Differences in receipt of interval postpartum LARC were not significant between women with Medicaid insurance versus private insurance after adjusting for clinical and demographic factors. Adequate prenatal care was associated with LARC receipt. Medicaid patients who did not receive a LARC were more likely to become pregnant within one year of delivery than those with private insurance.

Implications: While insurance-related barriers have been reduced given recent policy changes, access to care remains an important determinant of postpartum LARC provision and subsequent unintended pregnancy.
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http://dx.doi.org/10.1016/j.contraception.2018.08.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6289711PMC
January 2019

Obstetrician-gynecologists' counseling regarding postpartum sterilization.

Int J Womens Health 2018 13;10:425-429. Epub 2018 Aug 13.

Research Department, The American College of Obstetricians and Gynecologists, Washington, DC, USA.

Introduction: Obstetrician-gynecologists (ob-gyns) play a prominent role in counseling patients regarding sterilization, offering alternative contraception, fulfilling sterilization requests, and referring patients if unable to provide the service due to a personal moral belief. Therefore, we sought to better characterize the counseling practices of ob-gyns with respect to postpartum sterilization.

Materials And Methods: This is a prospective, electronic survey-based study of 1,000 ob-gyn members of the American College of Obstetricians and Gynecologists, half of whom are members of the Collaborative Ambulatory Research Network.

Results: A total of 188 of 957 surveyed physicians (19.6%) opened and responded to the survey, after accounting for exclusions. Age (31.9%), body mass index (28.7%), and medical history (27.1%) were the three most frequent reasons for an ob-gyn reported declining to perform sterilization in a patient requesting sterilization. Medical history (36.2%), parity (31.9%), and availability of alternative contraception (27.7%) were the three most frequent reasons that an ob-gyn reported recommending postpartum sterilization in a patient not requesting sterilization.

Conclusion: Our study has identified both medical and nonmedical factors that impact ob-gyns likelihood to recommend either toward or against postpartum sterilization. Nonmedical factors included clinical logistical issues such as availability of the operating room as well as considerations of a patient's age, parity, gestational age at delivery, and whether the husband was in agreement. Physicians should be cautious of inappropriately blending medical decision-making with paternalistic counseling.
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http://dx.doi.org/10.2147/IJWH.S169674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095126PMC
August 2018

Role of Bridge Contraception in Postpartum Long-Acting Reversible Contraception and Sterilization Fulfillment Rates.

Obstet Gynecol 2018 09;132(3):583-590

School of Medicine and the Department of Epidemiology and Biostatistics, Case Western Reserve University, and the Department of Obstetrics and Gynecology, MetroHealth Medical Center, Cleveland, Ohio.

Objective: To estimate the association of bridge contraception with interval long-acting reversible contraception (LARC) and sterilization fulfillment rates.

Methods: This is a secondary analysis of a retrospective single-center cohort chart review study examining 1,851 postpartum women who requested LARC or sterilization after discharge. Bridge contraception was requested by 597 of these women. Primary outcomes included LARC or sterilization fulfillment, time to fulfillment, postpartum visit attendance, and pregnancy within 365 days of delivery.

Results: The rate of LARC or sterilization fulfillment within 90 days of delivery was 147 of 597 (24.6%) women using bridge contraception and 287 of 1,254 (22.9%) women not using bridge contraception (P=.41). After adjusting for maternal age, parity, gestational age, mode of delivery, adequacy of prenatal care, race-ethnicity, and education level, the use of bridge contraception was associated with LARC or sterilization fulfillment (adjusted odds ratio [OR] 1.30, 95% CI 1.02-1.67). Adequacy of prenatal care and black race was associated with fulfillment. The use of bridge contraception was not associated with time to fulfillment (adjusted hazard ratio 1.17, 95% CI 0.95-1.44) or postpartum visit attendance (adjusted OR 0.97, 95% CI 0.77-1.23). The use of bridge contraception was not associated with increased pregnancy within 365 days of delivery (OR 1.00, 95% CI 0.95-1.05; adjusted OR 0.96, 95% CI 0.73-1.26).

Conclusion: Bridge contraception is associated with increased LARC and sterilization fulfillment after postpartum discharge. Long-acting reversible contraception or sterilization fulfillment after discharge occurred in less than one in four women. Strategies to improve provision of LARC or sterilization before hospital discharge are necessary.
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http://dx.doi.org/10.1097/AOG.0000000000002803DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6105446PMC
September 2018

Uterus Transplantation: The Ethics of Using Deceased Versus Living Donors.

Am J Bioeth 2018 07;18(7):6-15

b Case Western Reserve University, MetroHealth Medical Center.

Research teams have made considerable progress in treating absolute uterine factor infertility through uterus transplantation, though studies have differed on the choice of either deceased or living donors. While researchers continue to analyze the medical feasibility of both approaches, little attention has been paid to the ethics of using deceased versus living donors as well as the protections that must be in place for each. Both types of uterus donation also pose unique regulatory challenges, including how to allocate donated organs; whether the donor / donor's family has any rights to the uterus and resulting child; how to manage contact between the donor / donor's family, recipient, and resulting child; and how to track outcomes moving forward.
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http://dx.doi.org/10.1080/15265161.2018.1478018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6296249PMC
July 2018

Should Clinicians Challenge Faith-Based Institutional Values Conflicting with Their Own?

AMA J Ethics 2018 Jul 1;20(7):E630-636. Epub 2018 Jul 1.

an assistant professor of reproductive biology and bioethics at Case Western Reserve University and the director of quality in the Department of Obstetrics and Gynecology at MetroHealth Medical Center in Cleveland, Ohio, and served on the national ethics committees of both the American Medical Association and the American College of Obstetricians and Gynecologists, and serves on the board of the American Society for Bioethics and the Humanities.

Catholic health care organizations generally prohibit their employees from prescribing contraceptives for the purpose of birth control. This restriction might go against a clinician's own beliefs and the explicit wishes of a patient. In this case, Dr. N is being asked by a patient, Ms. K, to code oral contraception as treatment for acne, a noncontraceptive benefit of birth control pills, although both parties know Ms. K's primary desire is to prevent pregnancy. We examine the legal and moral arguments surrounding contraceptive provision in this case and offer guidance for how Dr. N and Ms. K might work to find a tenable solution.
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http://dx.doi.org/10.1001/amajethics.2018.630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6484439PMC
July 2018

Consenting to invasive contraceptives: an ethical analysis of adolescent decision-making authority for long-acting reversible contraception.

J Med Ethics 2018 09 14;44(9):585-588. Epub 2018 Jun 14.

Department of Bioethics, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.

Since USA constitutional precedent established in 1976, adolescents have increasingly been afforded the right to access contraception without first obtaining parental consent or authorisation. There is general agreement this ethically permissible. However, long-acting reversible contraception (LARC) methods have only recently been prescribed to the adolescent population. They are currently the most effective forms of contraception available and have high compliance and satisfaction rates. Yet unlike other contraceptives, LARCs are associated with special procedural risks because they must be inserted and removed by trained healthcare providers. It is unclear whether the unique invasive nature of LARC changes the traditional ethical calculus of permitting adolescent decision-making in the realm of contraception. To answer this question, we review the risk-benefit profile of adolescent LARC use. Traditional justifications for permitting adolescent contraception decision-making authority are then considered in the context of LARCs. Finally, analogous reasoning is used to evaluate potential differences between permitting adolescents to consent for LARC procedures versus for emergency and pregnancy termination procedures. Ultimately, we argue that the invasive nature of LARCs does not override adolescents' unique and compelling need for safe and effective forms of contraception. In fact, LARCs may oftentimes be in the best interest of adolescent patients who wish to prevent unintended pregnancy. We advocate for the specific enumeration of adolescents' ability to consent to both LARC insertion and removal procedures within state policies. Given the provider-dependent nature of LARCs and the stigma regarding adolescent sexuality, special political and procedural safeguards to protect adolescent autonomy are warranted.
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http://dx.doi.org/10.1136/medethics-2018-104855DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382463PMC
September 2018

Balancing Demand for Universally Improved Health Outcomes with Need for a Local Standard of Care.

AMA J Ethics 2018 Mar 1;20(1):261-268. Epub 2018 Mar 1.

An assistant professor of reproductive biology and bioethics at Case Western Reserve University in Cleveland, Ohio, and the director of quality in the Department of Obstetrics and Gynecology at MetroHealth Medical Center.

The United States, along with other resource-rich countries, leads global health care by advancing medical care through randomized controlled trials (RCTs). While most medical research is conducted in these resource-rich areas, RCTs, including replications of previous trials, are additionally carried out in low- and middle-income countries. On the basis of positive findings from several RCTs conducted in high-income countries, the Antenatal Corticosteroids Trial (ACT) evaluated the effectiveness of antenatal corticosteroids in reducing neonatal mortality in low- and middle-income countries. ACT, however, was undertaken in dramatically different health care infrastructures and did not confirm the results of previous studies. We argue that it is neither clinically appropriate nor ethically acceptable to extrapolate findings from one region to another without accounting for the disparate cultural values, goals of care, and health services infrastructure that impact clinical outcomes.
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http://dx.doi.org/10.1001/journalofethics.2018.20.3.stas1-1803DOI Listing
March 2018