Lindsey Carr

, outlines women’s reproductive rights and details the various reproductive health care services still available and protected by law.

The website provides helpful information about access to and coverage of various reproductive health care resources and services, including abortion care, birth control, emergency contraception, and family planning counseling.

the most comprehensive directory of trusted and verified abortion service providers in the country—where women can find verified abortion providers, resources for financial assistance, and a state-by-state guide on the current abortion laws.

This article was originally published by Contemporary OB/GYN.

Articles

The Department of Health and Human Services (HHS) launched a website Friday which offers women a comprehensive list of reproductive health care resources, services, and information.

Reproductive Health Care Website Launched by HHS

An oral presentation at the Society for Maternal-Fetal Medicine’s (SMFM) 42nd Annual Pregnancy Meeting explored possible associations with marijuana use and nausea and vomiting in early pregnancy.

Cannabis use is increasing as many states legalize marijuana. Despite recommendations from the American College of Obstetrics and Gynecology, pregnant individuals frequently use marijuana to alleviate stress, anxiety, nausea, vomiting, and pain.

 In a 2019 study, researchers conducted a test in which a “mystery caller” contacted 400 Colorado dispensaries to ask about morning sickness relief. Nearly 70% recommended cannabis use, despite a lack of scientific data.

To further investigate the use of marijuana for morning sickness, Torri D. Metz, MD, MSCR, associate professor at the University of Utah Health in Salt Lake City, Utah, along with her co-authors, led an ancillary study to evaluate whether marijuana use was in fact associated with early pregnancy nausea and vomiting. Secondarily, they wanted to learn more about antiemetic use in individuals with and without marijuana use.

The ancillary study used data from the prospective Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b), which recruited individuals from 2010 to 2013 from 8 US centers.

Metz and her team included only individuals who completed a Pregnancy-Unique Quantification of Emesis (PUQE) evaluation and consented to a frozen stored urine sample at the first study visit, which included 9,250 participants. Their primary outcome was the overall PUQE score, which involved 3 questions—how many hours in the past 12 hours have you felt nauseated? How many times in the past 12 hours have you vomited? How many times in the past 12 hours have you had retching or dry heaves?

Using the PUQE scores, they calculated nausea severity as mild, moderate, or severe—a PUQE score of 0 meant no nausea severity; A score of 1 to 6 was mild; 7 to 12 was moderate; and a score of 13 or more was qualified as severe. They also gathered antiemetic use via medical inventory that certified research staff collected at the time of the study.

Marijuana exposure was measured via biological sampling. Researchers did an immunoassay screen for 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC), followed by confirmatory testing with liquid chromatography-mass spectrometry with a cutoff at 15 ng/mL. They then quantified the THC in the urine and normalized it with urine creatinine. The team compared those with and without urine positive for THC. Multivariable logistic regression adjusted for maternal age, body mass index, prescription antiemetic use, and gestational age (P<0.05).

Researchers ultimately included 9,250 nuMoM2b participants in their analysis, 5.8% (95% CI 5.4-6.3%) of which were THC-positive (n=540). As for nausea severity, 46% (4,257) had no nausea symptoms; 38.2% (3,531) had mild nausea; and 15.8% (1,462) had moderate-to-severe nausea. The average gestational age at the first visit was between 11- and 12-week gestation.

THC-positive participants had higher rates of nausea symptoms, episodes of vomiting, and episodes of dry heaves than those who tested negative for THC (n=8,710). THC-positive participants, Metz said, were more likely to be younger, Black, live below the poverty line, and have public insurance. Interestingly, after multivariable modeling, incrementally higher THC was not significantly associated with any level of nausea (OR 1.6). 9.6% of participants reported using antiemetics at the first visit. THC-positive participants were more likely to report use of antiemetic (18 vs 12 with P<0.01).

The investigators concluded that, though they were unable to establish cause and effect through a retrospective study, they did find marijuana use to be associated with nausea and vomiting in early pregnancy. They also found that most THC-positive participants were taking only 1 antiemetic.

“Obstetricians should query about marijuana use,” Metz said, “to understand the reasons for use, and counsel [patients on] potential adverse effects. Nausea may be undertreated in early pregnancy, and we do have the opportunity to offer safe, effective alternatives.”

This article originally appeared on Contemporary Ob/Gyn.

Metz T, Allshouse A, McMillin G, et al. Association of Marijuana Use with Nausea and Vomiting of Pregnancy. Oral concurrent session. SMFM Annual Meeting. February 3, 2022.

Ko JY, Coy KC, Haight SC, et al. Characteristics of Marijuana Use During Pregnancy — Eight States, Pregnancy Risk Assessment Monitoring System, 2017. 

MMWR Morbidity and Mortality Weekly Report

. 2020;69(32):1058-1063. doi:10.15585/mmwr.mm6932a2

Dickson B, Mansfield C, Guiahi M, et al. Recommendations From Cannabis Dispensaries About First-Trimester Cannabis Use. 

. 2018;131(6):1031-1038. doi:10.1097/AOG.0000000000002619

Metz TD, Allshouse AA, McMillin GA, Silver RM, Jarlenski MP. Association of Marijuana Use with Nausea and Vomiting of Pregnancy. 

American Journal of Obstetrics and Gynecology

. 2022;226(1):S22-S23. doi:10.1016/j.ajog.2021.11.082

A presentation at the Society for Maternal-Fetal Medicine’s (SMFM) 42nd Annual Pregnancy Meeting explored possible associations with marijuana use and nausea and vomiting in early pregnancy.

Association Between Marijuana Use and Morning Sickness Symptoms Explored

The Illinois Perinatal Quality Collaborative—a statewide network of hospital teams, perinatal clinicians, public health leaders and policymakers dedicated to improving obstetric and neonatal care—launched the Mothers and Newborns Affected by Opioids (MNO) initiative in 2018. A primary goal of the MNO initiative is to increase the use of medication-assisted treatment (MAT) and recovery treatment services (RTS) in pregnant patients with opioid use disorder (OUD).

Ann Borders, MD, MPH, MSc, clinical associate professor and ILPQC executive director, Northshore University Health System, Evanston Hospital, Evanston, Illinois, led a research team to determine associations between prenatal MAT and RST and pregnancy outcomes. She presented the findings at the Society for Maternal-Fetal Medicine’s 42nd Annual Pregnancy Meeting.

Borders’ primary goal was to see what—if any—impact prenatal MAT and RTS provision had on preterm birth and higher gestational age. From 92 hospitals across Illinois, monthly key measures were reported for 2,095 patients with OUD at delivery from July 2018 to December 2020.

Researchers found that prenatal RTS and MAT, when received independently or together, were associated with lower odds of preterm birth and higher gestational age, regardless of race/ethnicity and maternal age. During the analysis period, the ILPQC facilitated collaborative learning opportunities, rapid-response data and quality improvement support, and the rates of patients receiving MAT and RTS increased from 41% to 78% and from 48% to 67%, respectively. In a subgroup analysis of patients only receiving prenatal care, researchers still found significant association between lower preterm birth and RTS or both MAT and RTS.

Borders A, Weiss D, Zumpf K, et al. Optimal prenatal opioid use disorder care is associated with improved pregnancy outcomes. Poster session. Society for Maternal-Fetal Medicine 42nd Annual Pregnancy Meeting. Virtual. February 5, 2022.

An oral concurrent session at SMFM’s 42nd Annual Pregnancy Meeting highlighted an analysis of pregnancy outcomes after optimal prenatal opioid use disorder care. 

Evaluating Pregnancy Outcomes With Optimal Prenatal Opioid Use

Twirla is an effective, low-dose contraceptive option in a non-daily, non-invasive patch. It is a once-weekly patch that contains levonorgestrel and ethinyl estradiol.

The partnership will help Americans who rely on community and public health centers get access to Twirla. Afaxys is a leading provider of innovative contraceptive options, making this partnership strategic and beneficial for all in the US family planning community.

“Afaxys and Agile Therapeutics are aligned on a mutual goal to provide reliable, affordable contraceptive access to women on their sexual and reproductive health journeys,” said Ronda Dean, President, CEO & Co-Founder of Afaxys. “We are committed to community and public health patients and providers, and this alliance will empower women with one more reliable family planning option to consider as they work with their physicians to choose the method of contraception that is right for them.”

“This strategic agreement with Afaxys, a recognized leader in the public health system, will help ensure that Twirla is available, accessible and affordable to a much broader group of patients who can benefit from it,” commented Al Altomari, Chairman and CEO of Agile Therapeutics. “We look forward to advancing women’s reproductive health together.”

“Afaxys and Agile Therapeutics are aligned on a mutual goal to provide reliable, affordable contraceptive access to women on their sexual and reproductive health journeys,” said Ronda Dean, President, CEO & Co-Founder of Afaxys. “We are committed to community and public health patients and providers, and this alliance will empower women with one more reliable family planning option to consider as they work with their physicians to choose the method of contraception that is right for them.”1

Agile Therapeutics and Afaxys Partner to Expand Access to Twirla (Levonorgestrel and Ethinyl Estradiol) Transdermal System | Agile Therapeutics. Agile Therapeutics. Published 2022. Accessed January 23, 2022. https://ir.agiletherapeutics.com/news-releases/news-release-details/agile-therapeutics-and-afaxys-partner-expand-access-twirlar

Agile Therapeutics, Inc. recently announced a new alliance with Afaxys Pharma, LLC to promote levonorgestrel and ethinyl estradiol (Twirla) transdermal system.

Afayxs, Agile Therapeutics Partner to Expand Twirla Access

The US Food & Drug Administration (FDA) granted final approval to Glenmark Pharmaceuticals (Glenmark) on Friday for its metronidazole topical gel as a generic version of Bausch Health US LLC’s MetroGel-Vaginal.

According to IQVIA sales data for the 12-month period ending in November 2021, MetroGel-Vaginal reported annual sales of approximately $60.4 million.

The global pharmaceutical company’s key therapeutic areas of focus include respiratory, dermatology, and oncology.

Glenmark’s new product adds to the firm’s growing portfolio of 173 products authorized for US distribution, with an additional 46 abbreviated new drug applications pending FDA approval.

Glenmark Pharmaceuticals Receives ANDA Approval for Metronidazole Vaginal Gel, 0.75%. News release. January 28, 2022. Accessed January 31, 2022. 

https://www.glenmarkpharma.com/sites/default/files/Glenmark-receives-ANDA-approval-for-Metronidazole-Vaginal-Gel-0-75%25_0.pdf

The drug is used to treat bacterial vaginosis and is a generic version of Bausch Health US LLC’s MetroGel-Vaginal.

FDA Approves Glenmark Pharmaceuticals Generic MetroGel

Provider bias—stereotyped and prejudiced assumptions about patients and their “best interests”—can limit patient autonomy and informed decision-making, amplify medical distrust, and deter patients from seeking care. Such bias is often amplified when patients are young, low-income, and/or Black, Indigenous, or people of color (BIPOC).

Provider bias in family planning can lead providers to: counsel patients inequitably based on demographic characteristics, neglect to assess or respect patients’ contraceptive preferences, encourage, or discourage contraceptive use, and express reluctance or refuse to or remove a LARC method at a patient’s request.

highlights how provider bias manifests in patient-provider interactions and influences contraceptive counseling. Results showed that clinicians often viewed a patient’s race/ethnicity, socioeconomic status, and age as primary challenges when providing contraceptive counseling.1

Data were based on individual interviews with 15 clinicians in South Carolina, all of whom worked in ob-gyn and provided LARC methods to Medicaid beneficiaries. The state has a nearly 35% BIPOC population and a poverty rate above the national rate, and 20% of residents are insured through Medicaid.

The interviews explored clinicians’ demographic backgrounds, medical training, current positions, patient population(s), opinions on LARC methods, and contraceptive counseling approaches. All 15 participants identified as cisgender and White/Caucasian, including 1 man and 14 women. Eleven were physicians and 4 were nurses—3 nurse practitioners and 1 registered nurse. Of all participants, 3 were residents and the remaining 12 had 5 or more years of post-residency experience. Eight participants were 40 or older, 5 were in their early 30s, and 2 were in their late 20s.

When asked about working with diverse patient populations, many clinicians referred to “cultural differences” as a primary challenge. They also illustrated difficulty in providing contraceptive counseling to adolescents and patients with negative attitudes or resistance to LARC use.

In 2 cases, clinicians ascribed their difficulties to patients’ race/ethnicity, with 1 nurse saying, “They just don’t want to listen.”

Another clinician cited patients’ low socioeconomic status as the reason for nonadherence to LARC, “My patients with less education and lower socioeconomic status can just be challenging in a way that it’s more difficult for them to be adherent.”

In their frustration with patients’ “culture,” ambivalence, distrust in their medical expertise, lack of self-efficacy and contraceptive adherence, clinicians implied that, unlike their patients, they know what is best.

The interviewer asked participants to describe a typical contraceptive-related conversation and include recent examples, to which clinicians often responded by sharing interactions with adolescent patients. In 1 response, a patient expressed concern after seeing a YouTube video about a local girl whose IUD was misplaced and dislodged, eventually going through her cervix and uterus, causing sepsis and ICU admission, where she ultimately underwent amputation. The respondent said, “17-year-old African American female, of course. Nothing ever happens exactly like that.” This statement implies that young BIPOC patients are uniquely susceptible to implausible scenarios and serious complications.

Another clinician referred to her adolescent patients. “Most of the time…they are being led by the ear of their parents,” she began, “I’m all for patient choice, but there’s also no cure for stupid…We support teenagers and then there are times when we support parents, when the teenager can’t make good decisions for themselves.”

Another clinician implied that patients’ concerns about hormonal contraception are irrational, citing “ethic components” as the primary cause. “It’s most frustrating when I hear, ‘I don’t want any hormones in me or anything foreign in me.’ [That is] the hardest part, because to me, I'm thinking, ‘Well, it's the same hormones that you have in your body circulating anyway. It's nothing,’… I think some people have their mind made up already when you start counseling them, and it's sometimes not worth it to…push through that just for the sake of getting your point across, because I think sometimes there's ethnic components to it.”

This clinician is essentially dismissing BIPOC patients’ concerns as “irrational.” Although contraceptive preferences do differ across racial and ethnic groups, the clinician’s attitude that “it’s nothing” to use hormonal contraception suggests a lack of understanding in regard to structural factors that may influence BIPOC patients.

When counseling patients who express a lack of trust in the health care system, 1 respondent fails to respectfully engage them. Her solution was to say, “I use this method, and [so do] 80% of my female ob-gyn friends who have all of the information and access about all contraceptive methods. [They] choose an IUD.” Her response is dismissive, implying that her patient’s concerns are unjustified and invalid.

The study indicates that clinicians may not consider patients’ refusal to use 

 like LARC as an assertion of agency and autonomy. Their counseling approaches did not assess or respect patients’ needs, preferences, safety concerns, or suspicions. As for counseling adolescent patients, many clinicians reinforced an imbalance of power and used their status as adults and medical experts to promote contraceptive use.

“While person-centered contraceptive counseling and shared decision-making has received significant attention, fostering clinicians’ structural competency is an important step medicine could systematically undertake to rectify provider bias,” the authors wrote.

“Contraceptive counseling informed by structural competency—that centers patients’ preferences and autonomy, regardless of clinicians’ beliefs about patients’ ‘best interests’—is better situated to realize the aims of reproductive justice for all pregnancy-capable people,” they concluded.

Mann ES, Chen AM, Johnson CL. Doctor knows best? Provider bias in the context of contraceptive counseling in the United States. 

. Published online December 2021. doi:10.1016/j.contraception.2021.11.009

Provider bias is often based on racial/ethnic, socioeconomic, and age-based assumptions.