暂无摘要。

Etonorgestrel implant is inserted on the inner surface of the non-dominant medial upper arm in women, over the triceps area. However, this case report aims to describe an alternative insertion site for etonorgestrel implant - the medial side of the thigh - in nephropathic patients with arteriovenous fistulas undergoing hemodialysis.

We present a patient who experienced an unintended pregnancy after transitioning from the copper intrauterine device to the etonogestrel subdermal implant. When switching from contraceptive methods that do not reliably suppress ovulation, clinicians should consider backup contraception and additional counseling, depending on the specific timing of removal.

Intrauterine devices (IUDs) are a form of long-acting reversible contraception (LARC). As with all medical therapies, their use carries several risks and potential adverse effects. For patients who elect to continue IUD use, pain and irregular bleeding are the most commonly reported complications, but more serious and less common complications include expulsion, contraception failure, pelvic inflammatory disease (PID), and perforation. We report a case where a patient with a history of IUD placement in the immediate postpartum period developed significant complications including multiple intra-abdominal abscesses and pelvic inflammatory disease.

This case report highlights serious permanent sequelae of a malpositioned levonorgestrel intrauterine device. Initial cervical injury resulted in fistula formation and large hematoma eventually requiring hysterectomy. Uterine depth less than 5.5 cm should prompt timely evaluation, and immediate replacement is not advised when there is concern for injury.

UNASSIGNED: To estimate inequalities in demand for family planning satisfied with modern methods among women in Latin America and the Caribbean, with an emphasis on Brazil and Mexico, and to calculate the scenario for recovery of modern contraceptive coverage by expanding access to long-acting contraceptives (LARC) after the COVID-19 pandemic.
UNASSIGNED: National health surveys from 2006 to 2018 were used to estimate the demand for family planning satisfied with modern methods and how it was affected by the COVID-19 pandemic. The scenario included three variables: coverage, health outcomes, and costs. Considering coverage, United Nations Population Fund data were used to estimate the impact of COVID-19 on access to contraception in Latin America and the Caribbean. Health outcomes were assessed with the Impact 2 tool. Direct investment was used to evaluate cost-effectiveness.
UNASSIGNED: Substantial inequalities were found in the use of modern contraceptive methods before the pandemic. We showed the potential cost-effectiveness of avoiding maternal deaths by introducing LARCs.
UNASSIGNED: In the scenario predicted for Brazil and Mexico, the costs of modern family planning and averted disability-adjusted life years are modest. Governments in Latin America and the Caribbean should consider promoting LARCs as a highly efficient and cost-effective intervention.
UNASSIGNED: Estimar las desigualdades en la demanda de planificación familiar satisfecha con métodos anticonceptivos modernos entre las mujeres de América Latina y el Caribe, especialmente en Brasil y México, y analizar el escenario de recuperación de la cobertura de los anticonceptivos modernos mediante la ampliación del acceso a los anticonceptivos de acción prolongada tras la pandemia de COVID-19.
UNASSIGNED: Se emplearon encuestas nacionales de salud desde el año 2006 hasta el año 2018 para estimar la demanda de planificación familiar satisfecha con métodos modernos y el impacto de la pandemia de COVID-19. El escenario comprendía tres variables: cobertura, resultados en materia de salud y costos. En lo respectivo a la cobertura, se emplearon datos del Fondo de Población de las Naciones Unidas para evaluar la repercusión de la COVID-19 en el acceso a los anticonceptivos en América Latina y el Caribe. Los resultados en materia de salud se examinaron con la herramienta Impact 2. Se empleó la inversión directa para evaluar la costo-efectividad.
UNASSIGNED: Se encontraron desigualdades sustanciales en el uso de métodos anticonceptivos modernos antes de la pandemia. Se demostró la posible costo-efectividad de evitar muertes maternas mediante la introducción de anticonceptivos de acción prolongada.
UNASSIGNED: De acuerdo con el escenario previsto para Brasil y México, los costos de la planificación familiar moderna y los años de vida ajustados en función de la discapacidad evitados son moderados. Los gobiernos de América Latina y el Caribe deberían considerar la posibilidad de promover los anticonceptivos de acción prolongada como intervención sumamente eficiente y costo-efectiva.
UNASSIGNED: Estimar as desigualdades na demanda por planejamento familiar atendida por métodos contraceptivos modernos em mulheres da América Latina e do Caribe, com ênfase no Brasil e no México, e calcular o cenário de recuperação da cobertura por métodos contraceptivos modernos por meio da ampliação do acesso a métodos contraceptivos reversíveis de longa duração (LARC) após a pandemia de COVID-19.
UNASSIGNED: Foram usadas pesquisas nacionais de saúde de 2006 a 2018 para estimar a demanda por planejamento familiar atendida por métodos contraceptivos modernos e como ela foi afetada pela pandemia de COVID-19. O cenário incluiu três variáveis: cobertura, desfechos de saúde e custos. Para cobertura, os dados do Fundo de População das Nações Unidas foram usados para estimar o impacto da COVID-19 no acesso à contracepção na América Latina e no Caribe. Desfechos de saúde foram avaliados com a ferramenta Impact 2. O investimento direto foi usado para avaliar a relação custo-benefício.
UNASSIGNED: Foram constatadas desigualdades importantes no uso de métodos contraceptivos modernos antes da pandemia. Demonstramos a potencial relação custo-benefício de evitar mortes maternas mediante a introdução de LARC.
UNASSIGNED: No cenário previsto para o Brasil e o México, os custos do planejamento familiar moderno e dos anos de vida ajustados por incapacidade por ele evitados são modestos. Os governos da América Latina e do Caribe devem considerar a promoção dos LARC como uma intervenção altamente eficiente e custo-efetiva.

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

Cost can be a barrier to accessing safe and affordable contraception. Therefore, we sought to understand how the availability and utilization of a low-cost levonorgestrel intrauterine system (hormonal IUD) impacts uptake relative to other contraceptive methods. Another objective was to determine if the percentage of self-pay women who obtained a hormonal IUD changed over time. Electronic health record (EHR) data was collected from five public health organizations enrolled in the 340B drug-pricing program (30 individual health centers) from April 15, 2014, through December 31, 2017, with most sites receiving Title X funding. The study captured data before and after low-cost hormonal IUD introduction. Interview data from 28 key informants provided a deeper understanding of how trends in hormonal IUD use changed after low-cost hormonal IUD introduction. Encounters from 101,075 women were analyzed. Locally weighted scatterplot smoothing (LOWESS) trends revealed an increasing utilization for all long-acting reversible contraception (LARC) and a decreasing trend for short-acting methods. Among self-pay women, hormonal IUD uptake increased 3 percentage points (p < .001) after the introduction of low-cost hormonal IUD. Privately insured women saw a 7-percentage point increase in hormonal IUD uptake while women whose family income was greater than 200% of the federal poverty level (FPL) saw a 13.9 percentage point increase in hormonal IUD uptake. The introduction of a low-cost hormonal IUD was associated with more self-pay and low-income women accessing this method. Access to and utilization of low-cost hormonal IUDs are complicated by many factors including product availability and provider training.

Patient-centered care (PCC) is frequently recommended to improve healthcare outcomes in the United States. Despite its purported benefits, little research explores how and to what extent providers implement this model in their care. We examine such processes through the case of contraception, specifically, \"early\" removals of long-acting reversible contraception (LARC). In-depth interviews with 51 healthcare providers reveal that while providers describe embracing patient-centeredness when considering patients\' early LARC removal requests, their implementation ironically sidelines patient preferences and needs. Rather than be responsive to patients\' requests, all providers in the study resist early LARC removal by: withholding information about self-removal of intrauterine devices (IUDs); negotiating with patients to keep their device longer; setting subjective timelines to prolong LARC use; and/or engaging in delay tactics to wear down patients\' resolve for removal. Furthermore, beyond simply resisting LARC removal requests using these strategies, providers purposively employ tenets of PCC to sway patients away from removal. In other words, providers utilize PCC as a means to undermine it. Understanding how providers implement patient-centered care reveals the challenges to doing so, even in cases like early LARC removal where providers indicate patient-centeredness is a priority. It also elucidates the need for enhanced training, specificity, and institutionalization around patient-centered models of care; informs interventions that promote LARC use among patients; as well as offers opportunities for improving patient-provider exchanges generally.

BACKGROUND: Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement.
OBJECTIVE: The purpose of this study was to explore how the payer\'s costs and number of unintended pregnancies associated with a postpartum intrauterine device differed on the basis of placement timing.
METHODS: Using a decision tree model and following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing the planned approach of inpatient vs outpatient postpartum insertion. Using a 2-year time horizon, the probability and cost estimates were derived from literature review. Our primary outcome was the total accrued costs to the payer. Secondarily, we examined the rates of early repeat pregnancy and sensitivity to estimates of key inputs, including the expulsion rates and the intrauterine device cost.
RESULTS: Although an inpatient intrauterine device placement\'s upfront costs were higher, the total cost of this approach was lower. Including the costs of managing expulsions and complications, our model suggests that for every 1000 people desiring a postpartum intrauterine device, the intended inpatient intrauterine device placement resulted in total cost savings of $211,100 and the prevention of 37 additional pregnancies compared with outpatient placement. The inpatient cost savings were superior to the outpatient savings, largely because of a known high proportion not returning for outpatient placement and the resulting higher number of unintended pregnancies among the patients desiring outpatient placement. In sensitivity analyses, we found that the total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement.
CONCLUSIONS: For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (ie, \"unbundle\" from the single payment for delivery) inpatient postpartum intrauterine device placement.