Publications by authors named "Lisa H Harris"

60 Publications

Beyond Abortion: The Consequences of Overturning .

Am J Bioeth 2022 Jun 2:1-13. Epub 2022 Jun 2.

University of Virginia.

The upcoming U.S. Supreme Court decision in has the potential to eliminate or severely restrict access to legal abortion care in the United States. We address the impact that the decision could have on abortion access and its consequences beyond abortion care. We posit that an abortion ban would, in effect, mean that anyone who becomes pregnant, including those who continue a pregnancy and give birth to healthy newborns and those with pregnancy complications or adverse pregnancy outcomes will become newly vulnerable to legal surveillance, civil detentions, forced interventions, and criminal prosecution. The harms imposed by banning or severely restricting abortion access will disproportionately affect persons of color and perpetuate structural racism. We caution that focusing on as a decision that only protects ending a pregnancy ignores the protection that the decision also affords people who want to continue their pregnancies. It overlooks the ways in which overturning will curtail fundamental rights for all those who become pregnant and will undermine their status as full persons meriting Constitutional protections. Such a singular focus inevitably obscures the common ground that people across the ideological spectrum might inhabit to ensure the safety, health, humanity, and rights of all people who experience pregnancy.
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http://dx.doi.org/10.1080/15265161.2022.2075965DOI Listing
June 2022

Navigating Loss of Abortion Services - A Large Academic Medical Center Prepares for the Overturn of .

Authors:
Lisa H Harris

N Engl J Med 2022 06 11;386(22):2061-2064. Epub 2022 May 11.

From the Departments of Obstetrics and Gynecology and Women's and Gender Studies, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1056/NEJMp2206246DOI Listing
June 2022

Balancing enhanced contraceptive access with risk of reproductive injustice: A United States comparative case study.

Contraception 2022 Apr 16. Epub 2022 Apr 16.

University of Michigan Department of Obstetrics and Gynecology, Ann Arbor, MI, United States; University of Michigan Department of Women's and Gender Studies, Ann Arbor, MI, United States.

Objective: We aimed to examine how peripartum contraceptive care quality improvement efforts address or perpetuate reproductive health injustices.

Study Design: We conducted a comparative case study of inpatient postpartum contraceptive care implementation in 2017 to 2018, using key informant interviews at 11 United States hospitals. After our primary analysis revealed tensions between enhancing access to contraceptive care and patient-centeredness, we conducted the current inductive content analysis guided by 4 questions developed post-hoc: (1) What are healthcare workers' aspirations for contraceptive quality improvement programs? (2) What are healthcare workers' biases regarding peripartum contraceptive care delivery? (3) Do care delivery processes center patients' needs? (4) Do healthcare workers recognize and engage with structural inequities?

Results: Seventy-eight key informants (i.e., clinicians, operations staff, administrators) participated. In nine study sites, we observed evidence of interviewees both mitigating and perpetuating reproductive injustice. Many aspired to provide compassionate, patient-centered care, avoid paternalism, and foster patient autonomy. Simultaneously, interviewees demonstrated biases, including implicit subscription to an ideology of stratified reproduction, stereotyping, and "othering." Even when interviewees endorsed goals of patient-centeredness, care delivery processes sometimes prioritized healthcare systems' needs, and patients were not included on quality improvement teams. Many interviewees recognized structural inequities as driving health outcome disparities, yet relied on individual-level solutions like long-acting reversible contraception, and not structural-level interventions, to address them.

Conclusion: Alongside enthusiasm for delivering compassionate care exist biases, missed opportunities to center patients, and lack of curiosity about the appropriateness of solving structural-level problems with individual-level solutions.

Implications: Our findings call for individual and institutional self-reflection, partnership with patients and communities, and other intentional efforts to mitigate potential for harm in initiatives enhancing access to contraceptive care.
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http://dx.doi.org/10.1016/j.contraception.2022.04.004DOI Listing
April 2022

Leveraging Administrative Claims to Understand Disparities in Gender Minority Health: Contraceptive Use Patterns Among Transgender and Nonbinary People.

LGBT Health 2022 04 17;9(3):186-193. Epub 2022 Mar 17.

Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA.

Transgender people face disparities in access to reproductive and sexual health services; however, differences in receipt of contraceptive services have not been quantified. We compare contraceptive patterns between cisgender women and trans masculine people in insurance claims databases. We analyzed 2014-2018 Truven MarketScan data, using diagnostic and procedural codes to identify sex assigned at birth, and existing coding methodology to identify transgender and nonbinary people. We compared contraceptive patterns between cisgender women and trans masculine people aged 15-49 in Medicaid and commercial databases. We identified 4700 people in the commercial and 1628 people in the Medicaid databases as trans masculine. Trans masculine people were prescribed fewer oral contraceptive pills (Medicaid: 17.44%, commercial: 16.62%) compared to cisgender women (Medicaid: 24.96%, commercial: 27.85%), less long-acting reversible contraception (LARC) use (Medicaid: 7.62%, commercial: 7.49% vs. Medicaid: 12.79%, commercial: 8.51%), had more hysterectomies (Medicaid: 5.77%, commercial: 8.45% vs. Medicaid: 2.15%, commercial: 2.48%), and less evidence of any contraception (Medicaid: 34.21%, commercial: 32.28% vs. Medicaid: 46.80%, commercial: 39.81%). Hysterectomies and LARC use varied by insurance type. We found significant differences in contraceptive patterns between trans masculine people and cisgender women. Data suggest potential differences in hysterectomy occurrences by trans masculine people, and long-acting reversible contraceptive use by cisgender women, in Medicaid versus commercial insurance cohorts. Appropriate counseling, insurance coverage, and removal of structural barriers are needed to ensure adequate access to contraception methods for people of all genders-regardless of whether they are being employed for contraception, menstrual management, or gender affirmation.
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http://dx.doi.org/10.1089/lgbt.2021.0303DOI Listing
April 2022

Addressing Abortion Provider Stigma: A Pilot Implementation of the Providers Share Workshop in Sub-Saharan Africa and Latin America.

Int Perspect Sex Reprod Health 2020 04 30;46:35-50. Epub 2020 Apr 30.

Professor, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI.

Context: In much of Sub-Saharan Africa and Latin America, abortion is legally restricted, and abortion providers experience stigma and legal jeopardy. The Providers Share Workshop group intervention has been shown to reduce provider stigma in the United States, but has not been evaluated in other settings.

Methods: In 2014-2015, the Providers Share Workshop was adapted and piloted among 59 abortion caregivers from three Sub-Saharan African countries and 93 caregivers from seven Latin American countries. Survey data collected before, directly following and six months after each workshop measured stigma, attitudes, and legal safety and advocacy engagement, using original items and adapted scales. Univariate analyses and baseline pairwise correlations were used to measure changes in outcomes over time, and between demographic characteristics and outcomes. Mixed-effects linear regressions and multivariable models controlling for demographics were used to assess changes in outcomes over time.

Results: Six months after workshop participation, total abortion stigma had decreased among caregivers in Sub-Saharan Africa and in Latin America (beta coefficients, -0.2 and -0.4, respectively). Unfavorable attitudes had decreased in Africa (-0.2) but not in Latin America, where attitudes were favorable to start; emotional exhaustion and depersonalization also had decreased in Africa (-2.9 and -1.2), and legal safety had increased (0.8). Increased total abortion stigma was negatively associated with legal safety, in both Africa and Latin America (-1.9 and -0.6), and with legal advocacy in Africa (-1.5).

Conclusions: The Providers Share Workshop is a promising intervention to support the abortion care workforce in Sub-Saharan African and Latin American settings.
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http://dx.doi.org/10.1363/46e8720DOI Listing
April 2020

South African abortion attitudes from 2007-2016: the roles of religiosity and attitudes toward sexuality and gender equality.

Women Health 2020 08 6;60(7):806-820. Epub 2020 Apr 6.

Sociology, University of Michigan , Ann Arbor, Michigan, USA.

Abortion is legal in South Africa, but negative abortion attitudes remain common and are poorly understood. We used nationally representative South African Social Attitudes Survey data to analyze abortion attitudes in the case of fetal anomaly and in the case of poverty from 2007 to 2016 (n = 20,711; ages = 16+). We measured correlations between abortion attitudes and these important predictors: religiosity, attitudes about premarital sex, attitudes about preferential hiring and promotion of women, and attitudes toward family gender roles. Abortion acceptability for poverty increased over time (b = 0.05, < .001), but not for fetal anomaly (b = -0.008, = .284). Highly religious South Africans reported lower abortion acceptability in both cases (Odds Ratio (OR) = 0.85, = .015; OR = 0.84, = .02). Premarital sex acceptability strongly and positively predicted abortion acceptability (OR = 2.63, < .001; OR = 2.46, < .001). Attitudes about preferential hiring and promotion of women were not associated with abortion attitudes, but favorable attitudes about working mothers were positively associated with abortion acceptability for fetal anomaly ((OR = 1.09, = .01; OR = 1.02, = .641)). Results suggest negative abortion attitudes remain common in South Africa and are closely tied to religiosity, traditional ideologies about sexuality, and gender role expectations about motherhood.
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http://dx.doi.org/10.1080/03630242.2020.1746951DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8988310PMC
August 2020

Complications of Unsafe and Self-Managed Abortion.

N Engl J Med 2020 03;382(11):1029-1040

From the Department of Obstetrics and Gynecology and the Department of Women's Studies, University of Michigan, Ann Arbor (L.H.H.); and the Department of Obstetrics, Gynecology, and Reproductive Sciences, Advancing New Standards in Reproductive Health (ANSIRH), and the Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco (D.G.).

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http://dx.doi.org/10.1056/NEJMra1908412DOI Listing
March 2020

Attitudes toward abortion, social welfare programs, and gender roles in the U.S. and South Africa.

Crit Public Health 2020 19;30(4):441-456. Epub 2019 Apr 19.

Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA.

Public abortion attitudes are important predictors of abortion stigma and accessibility, even in legal settings like the U.S. and South Africa. With data from the U.S. General Social Survey and South African Social Attitudes Survey, we used ordinal logistic regressions to measure whether abortion acceptability (in cases of poverty and fetal anomaly) is related to attitudes about social welfare programs and gender roles, then assessed differences by race/ethnicity and education. Social welfare program attitudes did not correlate with abortion acceptability in the U.S., but in South Africa, greater support for income equalization (OR: 0.59, 95% CI: 0.41-0.85) and increased government spending on the poor (OR: 0.66, 95% CI: 0.49-0.91) correlated with lower abortion acceptability in circumstances of poverty. This was significant for Black African and higher educated South Africans. In the U.S., egalitarian gender role attitudes correlated with higher acceptability of abortion in circumstances of poverty (OR: 1.18, 95% CI: 1.03-1.36) and fetal anomaly (OR: 1.15, 95% CI: 1.01-1.31). This was significant for White and less educated Americans. In South Africa, egalitarian gender role attitudes correlated with higher abortion acceptability for fetal anomaly (OR: 1.12, 95% CI: 1.01-1.25) overall and among Black and less educated respondents, but among non-Black South Africans they correlated with higher abortion acceptability in circumstances of poverty. These results suggest abortion attitudes are distinctly related to socioeconomic and gender ideology depending one's national context, race/ethnicity, and socioeconomic status. Reducing abortion stigma will require community-based approaches rooted in intersectional reproductive justice frameworks.
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http://dx.doi.org/10.1080/09581596.2019.1601683DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8975127PMC
April 2019

Stigma and abortion complications: stories from three continents.

Sex Reprod Health Matters 2019 Nov;27(3):1688917

Professor, University of Michigan, Department of Obstetrics and Gynecology, Department of Women's Studies, Ann Arbor, MI, USA.

Complications from abortion, while rare, are to be expected, as with any medical procedure. While the vast majority of serious abortion complications occur in parts of the world where abortion is legally restricted, legal access to abortion is not a guarantee of safety, particularly in regions where abortion is highly stigmatised. Women who seek abortion and caregivers who help them are universally negatively "marked" by their association with abortion. While attention to abortion stigma as a sociological phenomenon is growing, the clinical implications of abortion stigma - particularly its impact on abortion complications - have received less consideration. Here, we explore the intersections of abortion stigma and clinical complications, in three regions of the world with different legal climates. Using narratives shared by abortion caregivers, we conducted thematic analysis to explore the ways in which stigma contributes, both directly and indirectly, to abortion complications, makes them more difficult to treat, and impacts the ways in which they are resolved. In each narrative, stigma played a key role in the origin, management and outcome of the complication. We present a conceptual framework for understanding the many ways in which stigma contributes to complications, and the ways in which stigma and complications reinforce one another. We present a range of strategies to manage stigma which may prove effective in reducing abortion complications.
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http://dx.doi.org/10.1080/26410397.2019.1688917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887980PMC
November 2019

Trusted Colleagues or Incompetent Hacks? Development of the Attitudes About Abortion-Providing Physicians Scale.

Womens Health Issues 2020 Jan - Feb;30(1):16-24. Epub 2019 Oct 23.

Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, Ann Arbor, Michigan.

Background: Many physicians who provide abortion care report feeling marginalized within medicine. Because abortion care can require consultation with many types of physicians, physician opinions of providers may have implications for quality of care. However, no measure of physicians' attitudes about abortion-providing colleagues currently exists.

Methods: We developed a 24-item pool to measure perceptions of the motivations, competence, and standing within the medical profession of physicians who provide abortion care. We administered the survey to a sample of 1,640 faculty physicians at a Midwestern teaching hospital. We used Stata SE/14.0 for all analyses.

Results: Our response rate was 34% (n = 560), comparable with other studies of physicians. Exploratory factor analysis resulted in a three-factor solution: opinion, motivations, and competence. The scale demonstrated good internal consistency. Attitudes were largely favorable: 84% of participants agreed that abortion providers provide necessary care for women and 81% felt that abortion providers contribute positively to society. Compared with those who felt abortion should be illegal in all circumstances, attitudes were more favorable among those who felt that abortion should be legal. We observed an inverse relationship between religious attendance and attitudes. Participants with children held more favorable attitudes compared with those without children.

Conclusions: The Attitudes About Abortion-Providing Physicians Scale captures physicians' perceptions of their abortion-providing colleagues along three important dimensions: opinion, motivations, and competence. This sample of physicians held generally favorable views of their colleagues who provide abortion care.
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http://dx.doi.org/10.1016/j.whi.2019.09.002DOI Listing
July 2020

Bridging the Expertise of Advocates and Academics to Identify Reproductive Justice Learning Outcomes.

Teach Learn Med 2020 Jan-Mar;32(1):11-22. Epub 2019 Jul 11.

Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, Michigan, USA.

: Reproductive justice (RJ) is defined by women of color advocates as the right to have children, not have children and parent children while maintaining reproductive autonomy. In the United States, physicians have been complicit in multiple historical reproductive , involving coercive sterilization of thousands of people of color, low income, and disabilities. Currently, reproductive injustices continue to occur; however, physicians have no formal RJ medical education to address injustices. The objective of this study was to engage leading advocates within the movement using a Delphi method to identify critical components for such a curriculum. : In 2016, we invited 65 RJ advocates and leaders to participate in an expert panel to design RJ medical education. A 3-round Delphi survey was distributed electronically to identify content for inclusion in an RJ curriculum. In the next 2 survey rounds, experts offered feedback and revisions and rated agreement with including content recommendations in the final curriculum. We calculated descriptive statistics to analyze quantitative data. A team with educational expertise wrote learning outcomes based on expert content recommendations. : Of the 65 RJ advocates and leaders invited, 41 participated on the expert panel of the Delphi survey. In the first survey, the expert panel recommended 58 RJ content areas through open-ended response. Over the next 2 rounds, there was consensus among the panel to include 52 of 58 of these areas in the curriculum. Recommended content fell into 11 broad domains: access, disparities, and structural competency; advocacy; approaches to reproductive healthcare; contemporary law and policy; cultural safety; historical injustices; lesbian, gay, bisexual, transgender, queer/questioning, and intersex health; oppression, power, and bias training; patient care; reproductive health; and RJ definitions. The 97 learning outcomes created from this process represented both unique and existing educational elements. : A collaborative methodology infused with RJ values can bridge experts in advocacy and academics. New learning outcomes identified through this process can enhance medical education; however, it is just as important to consider education in RJ to care as it is knowledge about that care. We must explore the pedagogic process of RJ medical education while considering that expertise in this area may exist outside of the medical community and thus there is a need to partner with RJ advocates. Finally, we expect to use innovative teaching methods to transform medical education and achieve an RJ focus.
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http://dx.doi.org/10.1080/10401334.2019.1631168DOI Listing
June 2020

Abortion and Women's Physical Health: An Issue for All Physicians.

Ann Intern Med 2019 08 11;171(4):287-288. Epub 2019 Jun 11.

University of Michigan, Ann Arbor, Michigan (L.H.H., V.D.).

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http://dx.doi.org/10.7326/M19-1740DOI Listing
August 2019

Conscience reconsidered: The moral work of navigating participation in abortion care on labor and delivery.

Soc Sci Med 2019 07 23;232:181-189. Epub 2019 Mar 23.

University of Michigan, Ann Arbor, Center for Bioethics and Social Sciences in Medicine, USA; University of Michigan, Ann Arbor, Department of Obstetrics & Gynecology, USA; University of Michigan, Ann Arbor, Department of Women's Studies, USA.

How do caregivers make decisions about participating in morally contested care, such as abortion? Debates about conscience in the delivery of health care generally assume that participation decisions stem from religious beliefs and moral values. Few studies have examined this question in the context of everyday practice. Drawing on 50 interviews with the staff of a labor and delivery unit offering abortion care-including nurses, maternal-fetal medicine specialists, obstetrics and gynecology residents, and anesthesiologists-we show that respondents have varied definitions of "participation" in abortion care and that participation decisions are driven by an array of factors beyond personal beliefs. We present a conceptual model of "moral work" that shows conscience to be an emerging, iterative process influenced not only by beliefs-religious and non-religious-but also by personal and work experiences and social and institutional contexts. Our study brings new insights into understanding conscience and participation in contested care.
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http://dx.doi.org/10.1016/j.socscimed.2019.03.034DOI Listing
July 2019

The Power and Limits of Classification - A 32-Year-Old Man with Abdominal Pain.

N Engl J Med 2019 May;380(20):1885-1888

From the Institute for Healthcare Policy and Innovation (D.S.), the Departments of Obstetrics and Gynecology (D.S., L.H.H.) and Anthropology (E.F.S.R.), and the Medical Scientist Training Program (H.K.), University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1056/NEJMp1811491DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395710PMC
May 2019

Looking back while moving forward: a justice-based, intersectional approach to research on contraception and disability.

Contraception 2019 05 11;99(5):267-271. Epub 2019 Feb 11.

Georgia State University.

For the first time in the 21st century, we have an emerging body of research regarding contraceptive use among adult women with disabilities in the United States. We highlight key findings from population-based analyses that found higher odds of female sterilization and lower odds of long-acting reversible contraception use among women with disabilities compared to their peers without disabilities. We consider potential reasons underlying these differences, including discriminatory attitudes and policies that restrict the sexual and reproductive autonomy of people with disabilities. We advocate for a justice-based, intersectional approach to research on contraception and disability with the aim of promoting the reproductive autonomy of people with disabilities.
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http://dx.doi.org/10.1016/j.contraception.2019.01.006DOI Listing
May 2019

and unmet family planning need among Sub-Saharan African adolescents: the role of sexual and reproductive health stigma.

Qual Res Med Healthc 2018 May;2(1):55-64

University of Michigan, Women's Hospital, Ann Arbor, USA.

Adolescent pregnancy contributes to high maternal mortality rates in Sub-Saharan Africa. We explored stigma surrounding adolescent sexual and reproductive health (SRH) and its impact on young Ghanaian women's family planning (FP) outcomes. We conducted in-depth, semi-structured interviews with 63 women ages 15-24 recruited from health facilities and schools in Accra and Kumasi, Ghana. Purposive sampling provided diversity in reproductive/relationship/socioeconomic/religious characteristics. Using both deductive and inductive approaches, our thematic analysis applied principles of grounded theory. Participants described adolescent SRH experiences as cutting across five stigma domains. First, identified non-marital sex and its consequences (pregnancy, childbearing, abortion, sexually transmitted infections) as , , and , resulting in labeling. Second, entailed gossip, marginalization, and mistreatment from all community members, especially healthcare workers. Third, young sexually active, pregnant, and childbearing women experienced as , and . Fourth, were used to avoid/reduce stigma. Fifth, was achieved through social support. Collectively, SRH stigma precluded adolescents' use of FP methods and services. Our resulting conceptual model of adolescent SRH stigma can guide health service, public health, and policy efforts to address unmet FP need and de-stigmatize SRH for young women worldwide.
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http://dx.doi.org/10.4081/qrmh.2018.7062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6292434PMC
May 2018

Factors associated with sexual and reproductive health stigma among adolescent girls in Ghana.

PLoS One 2018 2;13(4):e0195163. Epub 2018 Apr 2.

Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States of America.

Objective: Using our previously developed and tested Adolescent Sexual and Reproductive Health (SRH) Stigma Scale, we investigated factors associated with perceived SRH stigma among adolescent girls in Ghana.

Methods: We drew upon data from our survey study of 1,063 females 15-24yrs recruited from community- and clinic-based sites in two Ghanaian cities. Our Adolescent SRH Stigma Scale comprised 20 items and 3 sub-scales (Internalized, Enacted, Lay Attitudes) to measure stigma occurring with sexual activity, contraceptive use, pregnancy, abortion and family planning service use. We assessed relationships between a comprehensive set of demographic, health and social factors and SRH Stigma with multi-level multivariable linear regression models.

Results: In unadjusted bivariate analyses, compared to their counterparts, SRH stigma scores were higher among girls who were younger, Accra residents, Muslim, still in/dropped out of secondary school, unemployed, reporting excellent/very good health, not in a relationship, not sexually experienced, never received family planning services, never used contraception, but had been pregnant (all p-values <0.05). In multivariable models, higher SRH stigma scores were associated with history of pregnancy (β = 1.53, CI = 0.51,2.56) and excellent/very good self-rated health (β = 0.89, CI = 0.20,1.58), while lower stigma scores were associated with older age (β = -0.17, 95%CI = -0.24,-0.09), higher educational attainment (β = -1.22, CI = -1.82,-0.63), and sexual intercourse experience (β = -1.32, CI = -2.10,-0.55).

Conclusions: Findings provide insight into factors contributing to SRH stigma among this young Ghanaian female sample. Further research disentangling the complex interrelationships between SRH stigma, health, and social context is needed to guide multi-level interventions to address SRH stigma and its causes and consequences for adolescents worldwide.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0195163PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880390PMC
July 2018

Divisions, New and Old - Conscience and Religious Freedom at HHS.

Authors:
Lisa H Harris

N Engl J Med 2018 Apr 14;378(15):1369-1371. Epub 2018 Mar 14.

From the Departments of Obstetrics and Gynecology and Women's Studies, University of Michigan, Ann Arbor.

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http://dx.doi.org/10.1056/NEJMp1801154DOI Listing
April 2018

Harm Reduction for Abortion in the United States.

Obstet Gynecol 2018 04;131(4):621-624

University of Michigan Medical School, the Department of Obstetrics and Gynecology, Michigan Medicine, and the Department of Women's Studies, University of Michigan, Ann Arbor, Michigan.

Access to abortion in the United States has eroded significantly. Accordingly, there is a growing movement to empower women to self-induce abortion. To date, physicians' roles and responsibilities in this changing environment have not been defined. Here, we consider a harm reduction approach to first-trimester abortion as a way for physicians to honor clinical and moral obligations to care for women, negotiate ever-increasing abortion restrictions, and support women who consider abortion self-induction. Harm reduction approaches to abortion have been successfully implemented in a range of countries around the world and typically take the form of teaching women how to use misoprostol. When women self-administer misoprostol, rather than resort to other means such as self-instrumentation or abdominal trauma, to end a pregnancy, maternal mortality falls. There are clinical and ethical benefits as well as limitations to a harm reduction approach to abortion in U.S.

Settings: Its legal implications for patients and physicians are unclear. Ultimately, we suggest that despite its limitations, a harm reduction approach may help both physicians and patients.
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http://dx.doi.org/10.1097/AOG.0000000000002491DOI Listing
April 2018

Evaluation of Abortion Stigma in the Workforce: Development of the Revised Abortion Providers Stigma Scale.

Womens Health Issues 2018 Jan - Feb;28(1):59-67. Epub 2017 Nov 11.

University of Michigan, Department of Obstetrics & Gynecology, Ann Arbor, Michigan.

Objectives: We report on the development of a scale measuring abortion providers' experiences of stigma.

Study Design: Using previous measures, qualitative data, and expert review, we created a 49-item question pool. We administered questions to 315 abortion providers before participation in the Providers Share Workshop. We explored the factor structure and item quality using exploratory factor analysis. We assessed reliability using Cronbach's alpha. To test construct validity, we calculated Pearson's correlation coefficients between the stigma scales, the Maslach Burnout Inventory, and the K10 measure of psychological distress. We used Stata SE/12.0 for analyses.

Results: Factor analysis revealed a 35-item, five-factor model: worries about disclosure, internalized states, social judgment, social isolation, and discrimination (Cronbach's alphas 0.79-0.94). Our stigma measure was correlated with psychological distress (r = 0.40; p < .001), and with Maslach Burnout Inventory's emotional exhaustion (r = 0.27; p < .001), and depersonalization (0.23; p < .001) subscales, and was inversely correlated with Maslach Burnout Inventory's personal accomplishment subscale (r = -0.15; p < .05).

Conclusions: Psychometric analysis of this scale reveals that it is a reliable and valid tool for measuring stigma in abortion providers, and may be helpful in evaluating stigma reduction programs.
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http://dx.doi.org/10.1016/j.whi.2017.10.004DOI Listing
September 2018

Sexual Health Care Services among Young Adult Sexual Minority Women.

Sex Res Social Policy 2017 Sep 30;14(3):345-357. Epub 2017 Mar 30.

Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA.

Young adult sexual minority women (YSMW) are at elevated risk for negative reproductive health outcomes, yet are less likely than heterosexual peers to utilize preventive health care. Medical and public health policy organizations advocate sexual orientation disclosure ("coming out") to health care providers as a strategy for increasing service utilization among YSMW. Limited research explores relationships between disclosure and receipt of sexual health services. YSMW (N=285) ages 21-24 participated in an online survey assessing their health behaviors and care utilization. We employed multivariable logistic regression models to examine the association between receipt of sexual health services and sexual orientation disclosure to provider, after adjusting for sociodemographic covariates. Thirty-five percent of YSMW were out to their provider. Less than half the sample had received Pap screening or STI testing in the previous year; approximately 15% had received at least one dose of the HPV vaccination. Disclosure was associated with increased likelihood of Pap screening (OR=2.66, p<.001) and HPV vaccination (OR=4.30, p<.001), but was not significantly associated with STI testing. Promoting coming out to providers may be a promising approach to increase sexual health care use among YSMW. Future research should explore causal relationships between these factors.
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http://dx.doi.org/10.1007/s13178-017-0277-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5626006PMC
September 2017

Dangertalk: Voices of abortion providers.

Soc Sci Med 2017 07 3;184:75-83. Epub 2017 May 3.

University of Michigan, Ann Arbor, Dept. of Obstetrics & Gynecology, USA; University of Michigan, Ann Arbor, Dept. of Women's Studies, USA.

Researchers have described the difficulties of doing abortion work, including the psychosocial costs to individual providers. Some have discussed the self-censorship in which providers engage in to protect themselves and the pro-choice movement. However, few have examined the costs of this self-censorship to public discourse and social movements in the US. Using qualitative data collected during abortion providers' discussions of their work, we explore the tensions between their narratives and pro-choice discourse, and examine the types of stories that are routinely silenced - narratives we name "dangertalk". Using these data, we theorize about the ways in which giving voice to these tensions might transform current abortion discourse by disrupting false dichotomies and better reflecting the complex realities of abortion. We present a conceptual model for dangertalk in abortion discourse, connecting it to functions of dangertalk in social movements more broadly.
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http://dx.doi.org/10.1016/j.socscimed.2017.05.001DOI Listing
July 2017

Development and Validation of a Scale to Measure Adolescent Sexual and Reproductive Health Stigma: Results From Young Women in Ghana.

J Sex Res 2018 01 7;55(1):60-72. Epub 2017 Mar 7.

f Health Services Research Division, Department of Obstetrics and Gynecology , University of Michigan.

Young women's experiences with sexual and reproductive health (SRH) stigma may contribute to unintended pregnancy. Thus, stigma interventions and rigorous measures to assess their impact are needed. Based on formative work, we generated a pool of 51 items on perceived stigma around different dimensions of adolescent SRH and family planning (sex, contraception, pregnancy, childbearing, abortion). We tested items in a survey study of 1,080 women ages 15 to 24 recruited from schools, health facilities, and universities in Ghana. Confirmatory factor analysis (CFA) identified the most conceptually and statistically relevant scale, and multivariable regression established construct validity via associations between stigma and contraceptive use. CFA provided strong support for our hypothesized Adolescent SRH Stigma Scale (chi-square p value < 0.001; root mean square error of approximation [RMSEA] = 0.07; standardized root mean square residual [SRMR] = 0.06). The final 20-item scale included three subscales: internalized stigma (six items), enacted stigma (seven items), and stigmatizing lay attitudes (seven items). The scale demonstrated good internal consistency (α = 0.74) and strong subscale correlations (α = 0.82 to 0.93). Higher SRH stigma scores were inversely associated with ever having used modern contraception (adjusted odds ratio [AOR] = 0.96, confidence interval [CI] = 0.94 to 0.99, p value = 0.006). A valid, reliable instrument for assessing SRH stigma and its impact on family planning, the Adolescent SRH Stigma Scale can inform and evaluate interventions to reduce/manage stigma and foster resilience among young women in Africa and beyond.
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http://dx.doi.org/10.1080/00224499.2017.1292493DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901672PMC
January 2018

Stressful Life Events Around the Time of Unplanned Pregnancy and Women's Health: Exploratory Findings from a National Sample.

Matern Child Health J 2017 06;21(6):1336-1348

Department of Obstetrics and Gynecology, L4000 Women's Hospital, 1500 East Medical Center Dr., University of Michigan, Ann Arbor, MI, 48109, USA.

Objective Little is known about how women's social context of unintended pregnancy, particularly adverse social circumstances, relates to their general health and wellbeing. We explored associations between stressful life events around the time of unintended pregnancy and physical and mental health. Methods Data are drawn from a national probability study of 1078 U.S. women aged 18-55. Our internet-based survey measured 14 different stressful life events occurring at the time of unintended pregnancy (operationalized as an additive index score), chronic disease and mental health conditions, and current health and wellbeing symptoms (standardized perceived health, depression, stress, and discrimination scales). Multivariable regression modeled relationships between stressful life events and health conditions/symptoms while controlling for sociodemographic and reproductive covariates. Results Among ever-pregnant women (N = 695), stressful life events were associated with all adverse health outcomes/symptoms in unadjusted analyses. In multivariable models, higher stressful life event scores were positively associated with chronic disease (aOR 1.21, CI 1.03-1.41) and mental health (aOR 1.42, CI 1.23-1.64) conditions, higher depression (B 0.37, CI 0.19-0.55), stress (B 0.32, CI 0.22-0.42), and discrimination (B 0.74, CI 0.45-1.04) scores, and negatively associated with ≥ very good perceived health (aOR 0.84, CI 0.73-0.97). Stressful life event effects were strongest for emotional and partner-related sub-scores. Conclusion Women with adverse social circumstances surrounding their unintended pregnancy experienced poorer health. Findings suggest that reproductive health should be considered in the broader context of women's health and wellbeing and have implications for integrated models of care that address women's family planning needs, mental and physical health, and social environments.
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http://dx.doi.org/10.1007/s10995-016-2238-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5444959PMC
June 2017

Abortion attitudes among South Africans: findings from the 2013 social attitudes survey.

Cult Health Sex 2017 Aug 19;19(8):918-933. Epub 2017 Jan 19.

b Population Studies Center , University of Michigan , Ann Arbor , MI , USA.

Abortion is legal in South Africa, but over half of abortions remain unsafe there. Evidence suggests women who are (Black) African, of lower socioeconomic status, living with HIV, or residents of Gauteng, KwaZulu-Natal, or Limpopo provinces are disproportionately vulnerable to morbidity or mortality from unsafe abortion. Negative attitudes toward abortion have been documented in purposively sampled studies, yet it remains unclear what attitudes exist nationally or whether they differ across sociodemographic groups, with implications for inequities in service accessibility and health. In the current study, we analysed nationally representative data from 2013 to estimate the prevalence of negative abortion attitudes in South Africa and to identify racial, socioeconomic and geographic differences. More respondents felt abortion was 'always wrong' in the case of family poverty (75.4%) as compared to foetal anomaly (55%), and over half of respondents felt abortion was 'always wrong' in both cases (52.5%). Using binary logistic regression models, we found significantly higher odds of negative abortion attitudes among non-Xhosa African and Coloured respondents (compared to Xhosa respondents), those with primary education or less, and residents of Gauteng and Limpopo (compared to Western Cape). We contextualise and discuss these findings using a human rights-based approach to health.
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http://dx.doi.org/10.1080/13691058.2016.1272715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849464PMC
August 2017

Capsules From the Medical Care Section of APHA: Call to the Public Health Clinical Community to Practice Conscientious Provision of Abortion Care.

Med Care 2016 12;54(12):1033-1034

*Department of Obstetrics and Gynecology †Department of Women's Studies, University of Michigan, L4000 Women's Hospital, Ann Arbor, MI ‡Trust Women/Silver Ribbon Campaign, Center for Policy Analysis, San Francisco, CA.

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http://dx.doi.org/10.1097/MLR.0000000000000673DOI Listing
December 2016

Women's Preferred Sources for Primary and Mental Health Care: Implications for Reproductive Health Providers.

Womens Health Issues 2017 Mar - Apr;27(2):196-205. Epub 2016 Nov 4.

Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan; Program on Women's Health Care Effectiveness Research, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.

Purpose: To describe women's preferences for reproductive health providers as sources of primary and mental health care.

Methods: This is secondary data analysis of the Women's Health Care Experiences and Preferences Study, an Internet survey conducted in September 2013 of 1,078 women aged 18 to 55 randomly sampled from a U.S. national probability panel. We estimated women's preferred and usual sources of care (reproductive health providers, generalists, other) for various primary care and mental health care services using weighted statistics and multiple logistic regression.

Main Findings: Among women using health care in the past 5 years (n = 981), 88% received primary and/or mental health care, including a routine medical checkup (78%), urgent/acute (48%), chronic disease (27%), depression/anxiety (21%), stress (16%), and intimate partner violence (2%) visits. Of those, reproductive health providers were the source of checkup (14%), urgent/acute (3%), chronic disease (6%), depression/anxiety (6%), stress (11%), and intimate partner violence (3%) services. Preference for specific reproductive health-provided primary/mental health care services ranged from 7% to 20%. Among women having used primary/mental health care services (N = 894), more women (1%-17%) preferred than had received primary/mental health care from reproductive health providers. Nearly one-quarter (22%) identified reproductive health providers as their single most preferred source of care. Contraceptive use was the strongest predictor of preference for reproductive health-provided primary/mental health care (odds ratios range, 2.11-3.30).

Conclusions: Reproductive health providers are the sole source of health care for a substantial proportion of reproductive-aged women-the same groups at risk for unmet primary and mental health care needs. Findings have implications for reproductive health providers' role in comprehensive women's health care provision and potentially for informing patient-centered, integrated models of care in current health systems.
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http://dx.doi.org/10.1016/j.whi.2016.09.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357444PMC
December 2017

The Effect of Lesbian, Gay, Bisexual, and Transgender-Related Legislation on Children.

J Pediatr 2016 11 26;178:5-6.e1. Epub 2016 Aug 26.

Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI.

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http://dx.doi.org/10.1016/j.jpeds.2016.08.028DOI Listing
November 2016

Experiences With the Providers Share Workshop Method: Abortion Worker Support and Research in Tandem.

Qual Health Res 2016 Nov 19;26(13):1823-1837. Epub 2016 Aug 19.

1 University of Michigan, Ann Arbor, Michigan, USA.

Abortion providers work in an environment characterized by the stresses of the helping professions as well as by the marginalization and devaluation that accompany work in a stigmatized field. We created the Providers Share Workshop (PSW), a five-session workshop carried out at seven abortion care sites around the United States, to support workers and better understand the complexities of working in abortion care. Qualitative analysis suggests that the experience of participating in the workshop fosters connection, and that the group process creates unique data about the abortion care team. Taken together, these results show that PSW fulfills the dual role of a supportive group intervention-helping create connections and foster resilience-and a research tool, producing rich, multi-perspective narratives of the abortion provision team. This method provides useful insight into supporting abortion care workers specifically, and may also prove useful in the study and support of other stigmatized workers generally.
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http://dx.doi.org/10.1177/1049732316661166DOI Listing
November 2016

The Paradigm of the Paradox: Women, Pregnant Women, and the Unequal Burdens of the Zika Virus Pandemic.

Am J Bioeth 2016 05;16(5):1-4

c Schools of Medicine and Nursing , University of Virginia.

The Zika pandemic provides biomedical scientists, clinicians, public health advocates, and governments a unique opportunity to advance reproductive justice by addressing the paradoxes outlined in this essay. The circumstances in which pregnancies occur are morally relevant to women’s reproductive life decisions, to the provision of reproductive health care, and to the development of reproductive health policy. Whether the Zika pandemic might foster context-driven reproductive pandemic planning and response is yet to be determined. Maintaining the status quo will surely increase a range of global health disparities and further stratify reproduction, producing predictable and preventable outcomes in which some people receive the necessary care and resources to achieve family building while others are neglected. Women and men should be able to count on biomedical researchers to answer the questions that need answering without undue influence from political agendas. Women should be able to continue pregnancies and count on public health assistance and help for children with Zika-related disabilities, or prevent or end a Zika-affected pregnancy. Pandemic responses that don’t further these ends are morally unacceptable.
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http://dx.doi.org/10.1080/15265161.2016.1177367DOI Listing
May 2016
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