OBJECTIVES:High-quality contraceptive counseling has been associated with increased contraceptive method satisfaction. We aimed to assess this relationship in the postpartum period and to investigate practical aspects of counseling underlying this association. STUDY DESIGN:We used data from 219 pregnant individuals aged 21-44 years contemplating tubal sterilization who were recruited to a randomized trial assessing the efficacy of the MyDecision/MiDecisión decision aid. Three months postpartum, participants rated their satisfaction with their chosen contraceptive method and their perception of contraceptive counseling encounter quality on Likert scales. Counseling quality domains included provider demonstration of respect, explanation of methods, pressure toward a method, and response to questions, as well as subjective counseling satisfaction. We used logistic regression analyses to assess the relationship between optimal counseling (both overall and in each domain) and optimal contraceptive method satisfaction, adjusting for randomization arm and demographic covariates significant in bivariate analysis. RESULTS:Participants had a mean (SD) age of 30 (5) years; 42% identified as non-Hispanic White, 25% as non-Hispanic Black, and 26% as Hispanic. Approximately one-third of participants (37%) had a tubal sterilization by study follow-up; 11% reported using no method of contraception. Many participants reported optimal contraceptive counseling (61%) and optimal method satisfaction (65%). Optimal counseling was associated with higher odds of optimal method satisfaction (aOR 1.88, 95% CI 1.03-3.46, p = 0.04). This relationship was sustained across all individual counseling quality domains. CONCLUSIONS:Patient-perceived provider demonstration of respect, discussion of contraceptive pros and cons, avoidance of pressure, and answering questions were associated with postpartum contraceptive method satisfaction.

Background: The Dobbs v. Jackson Supreme Court decision overturned Roe v. Wade and federal abortion protections, resulting in nearly half of U.S. states banning or significantly restricting abortion. Qualitative data are needed to understand how abortion restrictions influence pregnancy perceptions and experiences. Objectives: This study describes pregnancy perceptions and experiences before and after Dobbs , across states with abortion restrictions and protections, and across individual-level differences in income and age. Design and Methods: We conducted in-depth interviews with people during pregnancy ( n = 31, 28 pre- Dobbs ) and a subset of those individuals again during the postpregnancy period ( n = 14, all post- Dobbs ) from October 2021 to August 2023. All interviews were recorded, transcribed, concept mapped, and coded using MAXQDA 2022. We also conducted across-group comparisons by state abortion policy, income, and age. Results: Before Dobbs , participants described how abortion accessibility was already compromised in some states. After abortion was banned in restrictive states, participants described feeling dehumanized, criminalized, that their reproductive autonomy was constrained, and that pregnancy carried real risks to their lives. In protective states, participants were grateful they had abortion access but lacked awareness and knowledge about abortion access in other states. Participants explained that Dobbs and abortion restrictions are harming perinatal wellbeing, even for wanted pregnancies. Group comparisons demonstrated that lower income and younger people described greater impacts related to abortion availability. Conclusion: Post- Dobbs abortion restrictions are negatively impacting the mental and physical well-being of pregnant people, even those with wanted pregnancies. Dobbs could exacerbate existing health inequities for younger and lower-income people.

OBJECTIVES:We compared changes in contraceptive agency among women initiating self-injectable contraception versus other methods. STUDY DESIGN:From 2022-2024, we conducted a prospective cohort study with a convenience sample from communities and health facilities in Eastern and Northern Uganda; participants had chosen a new method within the prior two weeks. We compared changes in Agency in Contraceptive Decisions Scale scores, on a scale of 0-3, at 6 and 12 months between self-injection choosers and choosers of any other method (including provider-administered injection) using mixed effects models controlling for confounding. In three secondary analyses, we restricted the comparison group to provider-administered injectable choosers, restricted the comparison to choosers of any provider-administered method, and restricted the sample to women who used their chosen method during follow-up. RESULTS:Among 216 self-injection choosers, agency scores increased from mean= 2.65(SD=0.35) to 2.74(SD=0.31) at six months and decreased to 2.71(SD=0.32) at 12 months; scores among 1612 women choosing other methods started lower and increased more gradually from mean= 2.61(SD=0.36) at baseline to 2.63(SD=0.35) at six months and 2.67(SD=0.24) at 12 months. Interaction terms examining whether rate of change in agency differed between self-injection and other method choosers had a p-value of 0.03 at six months and 0.85 at 12 months; restricting to provider-administered injectable users or any provider-administered method users did not change results while restricting to those who used their chosen method during follow-up increased the six-month interaction term p-value to 0.20. CONCLUSION:Small improvements in agency over six months among women choosing self-injection but not other methods corroborate its empowering potential. Less difference at 12 months suggests the effect may be limited to short-term improvements or stymied by lack of external enablers. IMPLICATIONS:Greater improvement in agency over time with choosing self-injection compared to other contraceptive methods suggests self-injection may be uniquely empowering and should be offered alongside other contraceptive options. Research comparing outcomes between self-injection programmatic approaches addressing structural and social barriers would shed light on additional opportunities to help interested individuals benefit from the technology.

INTRODUCTION:Tubal sterilization is a permanent contraceptive method, yet misconceptions about its permanence are prevalent, and its history is marked by both coercion and barriers to access-particularly among Medicaid enrollees. Decision aids may help to support more informed, value-concordant decision-making. METHODS:From March 2020 to November 2023, English- and Spanish-speaking pregnant Medicaid enrollees at less than 24 weeks' gestation were randomized to either receive or not receive a novel web-based tubal sterilization decision aid. Participants completed surveys after randomization (control group) and after the decision aid (intervention group) at time point 1 (T1), in the third trimester (T2), and at 3 months postpartum (T3). Positive impacts of the decision aid on the primary outcomes of tubal sterilization knowledge and decisional conflict were previously reported. Secondary outcomes analyzed were intended contraceptive method at T1 (sterilization vs. other/no method) and satisfaction with the contraceptive decision-making process at T3. RESULTS:We included 350 pregnant Medicaid enrollees who completed surveys at T1, 301 who completed them at T2, and 286 who completed them at T3. There were no statistically significant differences between the decision aid and control groups in the intention to use tubal sterilization (55.6% vs. 61.24%; p = .238) or optimal contraceptive decision-making satisfaction (59.2% vs. 54.9%; p = .406). CONCLUSION:Although the decision aid was previously shown to improve sterilization decision quality, it did not appear to influence intended contraceptive method immediately after use of the tool during pregnancy or satisfaction with contraceptive decision-making.

OBJECTIVE:Expanding access to high-quality contraceptive care in primary care is key to achieving reproductive health equity. We assessed the impact of an equity-focused quality improvement learning collaborative (QILC) on contraceptive care at community health centers (CHCs) through innovative performance measurement. METHODS:We developed a 9-month QILC including monthly learning sessions on reproductive health equity and person-centered contraceptive care, supporting resources, peer-learning opportunities, and technical assistance. We assessed QILC impact through 3 performance measures collected prepost QILC: the Person-Centered Contraceptive Counseling (PCCC) measure that assesses contraceptive counseling; the Contraceptive Care Screening electronic clinical quality measure (eCQM) (CCS-SINC); and contraceptive use eCQM (CU-SINC). CHCs collected PCCC surveys from patients prepost QILC, and we extracted electronic health record data to calculate eCQMs. To assess intervention impact, we compared prepost PCCC scores and eCQM percentages. RESULTS:Nine CHCs participated in the QILC. Assessing contraceptive care screening, median increase in CCS-SINC was 14.4% (Interquartile range [IQR]: 7.5%-40.4%) between baseline and endline. CHCs realized an increase in CU-SINC (median relative Δ: 4.9%; IQR [3.7%-22.3%). Compared with baseline, at endline, 5 of 9 CHCs improved their PCCC score (Δ 2.1% to 26.2%) and 3 of those surpassed the 80% benchmark for high-quality care. Greater improvement in performance measure scores was noted among CHCs with leadership buy-in and lower staff turnover. CONCLUSIONS:Participation in an equity-focused and measurement-driven QILC led to improvements in person-centered contraceptive care delivery.

Sexual and reproductive health (SRH) research, programming, policy, and services have long relied on the narrow paradigm of "pregnancy intendedness and planning," including its "unintended pregnancy" measure. This framework is limited and problematic, overlooking diverse perspectives on pregnancy, structural factors, and non-parenting outcomes such as abortion and adoption. In response, we developed the Self-Assessed Pregnancy Acceptability (SAPA) framework and measure as a person-centered alternative. The SAPA framework was developed by centering the lived experiences of pregnant people in Texas, Tennessee, Pennsylvania, and California through baseline interviews shortly after pregnancy confirmation (N = 31) and follow-up post-pregnancy interviews (N = 14). Development was also informed by a diverse Expert Panel (N = 19) including reproductive justice leaders, reproductive measurement experts, and lived experience experts. Using cognitive interviews (N = 13), we refined an 11-item measure of SAPA that is currently being validated in a nationwide sample of nearly 600 people in early pregnancy. Following validation, SAPA could be integrated into national and state-level epidemiological surveillance surveys such as the National Survey of Family Growth and the Pregnancy Risk Assessment Monitoring System. This novel framework and measure offer an alternative to unintended pregnancy and contribute to an ecosystem of person-centered, rigorously developed measures of SRH equity.

PURPOSE OF REVIEW:Despite longstanding consensus that "sexual and reproductive health" are defined as more than merely the absence of disease, clinical care and research in adolescent sexual and reproductive health are generally framed in negative terms, with a focus on disease and risk rather than wellbeing, satisfaction, or other desired outcomes. Emphases on risk and risk mitigation have led to the promotion of practices and policies that undermine adolescent autonomy and the principles of reproductive justice. RECENT FINDINGS:Sexual and reproductive health care and research are evolving toward more holistic, asset-based frameworks. Clinical practice guidelines, particularly around contraceptive care, increasingly call for person-centered care. Sexual and reproductive wellbeing has been proposed as a positive outcome intended to assess fulfillment related to sexuality and reproduction. The sexual and reproductive health equity framework considers structural factors that influence health and wellbeing and calls for upending practices, policies, and systems that perpetuate injustice. SUMMARY:Adolescent sexual and reproductive health care and research must evolve to incorporate principles of reproductive justice. The concepts of sexual and reproductive health equity and sexual and reproductive wellbeing can inform our understanding of what to change and how to measure success. Pediatric clinicians should consider the unique developmental needs of adolescents as they strive to incorporate principles of justice, wellbeing, and equity into clinical care and research.

Context: Patient-centered contraceptive care prioritizes patient contraceptive needs and preferences while considering important socio-political factors. Latina/e patients desire such care but experience it inconsistently. This study explores experiences of contraceptive care using quantitative and qualitative methods, including the association between patient characteristics and receipt of patient-centered contraceptive care, among a sample of Latina/e patients in Baltimore, Maryland. Methods: We quantitatively assessed experiences of patient-centered contraceptive care among Latina/e patients ages 15-45 by using the Patient-Centered Contraceptive Counseling measure (PCCC) and a visit-satisfaction measure. Audio-recordings of visits were coded using the Four Habits Coding Scheme (4HCS), a measure of patient-centered communication between patients and clinicians. Analyses between patient characteristics and PCCC, 4HCS, and patient satisfaction scores were bivariate and exploratory. Qualitative interviews with a patient subset further characterized experiences. Results: A total of 52 visits, including patient surveys, were analyzed; a subset of 29 patients participated in interviews. A majority of patients (63.5%) reported the highest possible PCCC ratings, and 85% reported the highest level of satisfaction with their contraceptive counseling visits. Researcher-reported 4HCS scores were lower than patient-reported measures; scores for one particular habit of the 4HCS were significantly lower for Spanish-preferring and uninsured patients. The discrepancy between patient-reported PCCC and satisfaction ratings and researcher-reported 4HCS scores is contextualized by interviews in which patients reported that counseling received during the study period focused on their contraceptive preferences and involved interactions with friendly, communicative clinicians/staff, which contrasted with previous, lower quality, healthcare experiences. Conclusions: Positive experience and satisfaction ratings of Latina/e patients in the context of suboptimal patient-centered care (PCC) on audio-recordings reveal somewhat of a discrepancy between self-report and observation. Provision of contraceptive patient-centered care requires attention to both patient-reported experiences and measures using direct observations, as well as a more robust understanding of how PCC is conceptualized by patients and delivered by clinicians.

Background Choosing contraception is a highly personal, often complex decision. People with acute and chronic health conditions (eg, pulmonary embolism, diabetes, and hypertension) must deliberate additional factors including whether and to what extent a contraceptive method may affect their health conditions or interact with their medications. “My Health My Choice” (web application developed by Alfa Jango) is a web-based decision support tool designed to help patients understand their contraceptive options considering their health conditions, medications, and personal priorities. Objective We will evaluate the efficacy of “My Health My Choice” (MHMC) use among people with diverse health conditions who seek contraception in US outpatient clinics. Methods This mixed methods cluster randomized controlled trial will compare MHMC and usual contraceptive care (intervention arm) to usual contraceptive care only (control arm). Fourteen clinics that specialize in primary care or obstetrics and gynecology will be enrolled, with 7 clinics in each arm. We will enroll 726 patients (363 in each group) who (1) are 18-49 years old, (2) are able to speak and read English, (3) are seeking contraception for pregnancy prevention, and (4) have at least 1 health condition among 60 eligible health conditions and characteristics (eg, cigarette smoking and postpartum state). Aim 1 (quantitative) is to assess the primary outcome of patient-reported contraceptive nonuse (yes or no) at 3 months. Aim 2 (mixed methods) starts with a quantitative summary of patient-reported contraceptive use by method type (eg, pills and shot) and corresponding Medical Eligibility Risk Category (Category 1, 2, 3, or 4) based on the Centers for Disease Control and Prevention (CDC) US Medical Eligibility Criteria (US MEC) Contraceptive Guidelines. We will conduct exit interviews of a subsample of approximately 30 patients and 30 clinicians to qualitatively understand how MHMC and other contextual factors influenced perceptions about contraceptive risk and contraceptive decisions. Aim 3 (quantitative) is to explore patient-reported contraceptive decisional conflict (measured by the Decisional Conflict Scale) and patient-reported quality of interaction with their contraceptive provider (measured by the Interpersonal Quality of Family Planning Scale) as mediators of the effects of MHMC on the primary outcome. This paper describes the study protocol per the SPIRIT (Standard Protocol Items: Recommendations for Intervention Trials) checklist. ResultsThe National Institute of Child Health and Human Development funded this study (R01HD110570, Principal Investigator JPW) in 2023. The study team is collaborating with the DARTNet Institute (Aurora, Colorado) to enroll and prepare health clinics for trial launch. Fourteen clinics have enrolled in the trial and are in various stages of study preparation and regulatory approval. We anticipate patient enrollment to run from October 2025 to September 2028. ConclusionsThis is the first mixed methods cluster randomized controlled trial of MHMC, a novel web-based decision support tool for people with health conditions. Trial RegistrationClinicalTrials.gov NCT07075536; https://clinicaltrials.gov/study/NCT07075536 International Registered Report Identifier (IRRID)DERR1-10.2196/71101

To fill a gap in measures of empowered contraceptive decision-making, we developed the Agency in Contraceptive Decisions Scale in Uganda and Nigeria. We developed an item pool drawing on the previously published Contraceptive Agency framework. We refined items through cognitive interviews ( N  = 80) and expert feedback and piloted a reduced item pool via surveys ( N  = 3002). Exploratory factor analysis using a random half of the sample suggested a 15-item scale (Cronbach's α = 0.8) including four subscales: (1) Beliefs about Rights and Perceived Decision-making Control (α = 0.8), (2) Decision-making Self-efficacy (α = 0.8), (3) Knowledge Aligned with Preferences (α = 0.8), and (4) Control over Use or Non-use (α = 0.8). Confirmatory factor analysis with the other half of the sample supported this solution. Agency in Contraceptive Decisions Scale scores were significantly associated with scores on the contraceptive existence of choice and contraceptive exercise of choice subscales of the Women's and Girls Empowerment in Sexual and Reproductive Health Index, supporting construct validity. The 15-item Agency in Contraceptive Decisions Scale and individual subscales are valid and reliable for use in Nigeria and Uganda. This measure offers an innovative alternative for gauging the success of contraceptive programs and policies in advancing the right to empowered choices.

Performance measures are critical inputs to quality improvement efforts, enabling identification of quality gaps and allowing for monitoring of changes in quality in response to interventions. Having measures grounded in patient-centeredness is important for all quality improvement. Early contraceptive performance measures focused on contraceptive provision as a proxy for access. Concerns about these measures having the potential to inadvertently incentivize coercive practices led to the development of a patient experience measure and more person-centered measures of contraceptive access. The article reviews how these novel measures are being used to inform quality improvement in contraceptive care.

Background The evolution of medical standards in stigmatized areas like abortion is influenced by medical, political, and social factors. Self-sourcing and managing medication abortion (SSMA) is on the rise in the United States, where individuals obtain medications to end their pregnancies outside traditional medical settings. Physician attitudes towards SSMA are not well understood, despite physicians’ role in setting care standards, providing medical oversight, and de-stigmatizing healthcare both within and outside clinical environments. Materials and Methods We interviewed 40 physicians (MD/DOs) who perform abortions about their views on SSMA. We used inductive-deductive coding for transcript analysis and qualitatively assessed how attitudes shifted before and during the interviews. Results Most participants were aged 31-35 years (n=16, 40%), non-Hispanic White (n=29, 72.5%), and female (n=33, 82.5%). We oversampled family medicine-trained physicians (n=31, 78%) compared to OB/GYNs (n=9, 22.5%). Participants were from 24 states, with half from states supporting abortion rights and the other half from states with hostile or neutral stances. Half of the cohort supported SSMA, while the other half was ambivalent. Medical evidence alone did not sway physician views on SSMA; instead, participants adjusted their attitudes by clarifying their professional values, evaluating SSMA’s alignment with these values, and considering values-based frameworks as alternatives to medicalization. Discussion Although medical care is typically seen as objective and standardized, physicians’ ethics to ensure safe access to care often clash with political restrictions in this stigmatized field. Physicians are more worried about the broader structural issues related to SSMA, such as how political and social vulnerabilities could harm the most vulnerable patients, rather than the medical care itself, which they see as safe and effective, with or without physician oversight. Positive attitudes toward SSMA were strengthened by exposure to values-based frameworks that offer alternatives to strict medicalization.

To fill a gap in measures of empowered contraceptive decision-making, we developed the Agency in Contraceptive Decisions Scale in Uganda and Nigeria. We developed an item pool drawing on the previously published Contraceptive Agency framework. We refined items through cognitive interviews (N = 80) and expert feedback and piloted a reduced item pool via surveys (N = 3002). Exploratory factor analysis using a random half of the sample suggested a 15-item scale (Cronbach's α = 0.8) including four subscales: (1) Beliefs about Rights and Perceived Decision-making Control (α = 0.8), (2) Decision-making Self-efficacy (α = 0.8), (3) Knowledge Aligned with Preferences (α = 0.8), and (4) Control over Use or Non-use (α = 0.8). Confirmatory factor analysis with the other half of the sample supported this solution. Agency in Contraceptive Decisions Scale scores were significantly associated with scores on the contraceptive existence of choice and contraceptive exercise of choice subscales of the Women's and Girls Empowerment in Sexual and Reproductive Health Index, supporting construct validity. The 15-item Agency in Contraceptive Decisions Scale and individual subscales are valid and reliable for use in Nigeria and Uganda. This measure offers an innovative alternative for gauging the success of contraceptive programs and policies in advancing the right to empowered choices.

As the global community looks beyond the 2030 Sustainable Development Goals agenda, there is a critical opportunity to refine and elevate indicators focused on sexual and reproductive health and rights (SRHR) and to shift nations away from fertility and contraceptive targets. This commentary presents four key frameworks-drawn from a panel at an International Union for the Scientific Study of Population (IUSSP) meeting focused on SRHR measurements-that offer distinct yet complementary lenses for understanding and measuring reproductive choice and agency. These include the EMERGE Empowerment Framework (focused on measurement and evaluation), Patient-Centered Care (focused on clinical practice), the Human Rights Framework (focused on policy), and Reproductive Justice (focused on social change). While not an exhaustive list, these frameworks reflect a diversity of disciplinary perspectives and emphasize the importance of grounding reproductive health indicators in concepts of choice and agency. The empowerment framework centers on individual decision-making and collective action, while person-centered and rights-based approaches evaluate how health systems and policies support or constrain that agency. Reproductive justice expands the lens further, highlighting how structural inequalities shape differential access and outcomes across race, class, and other social determinants of health. Together, these frameworks underscore the need for multilevel, intersectional indicators or reproductive agency-spanning individuals, health systems, communities, and policies-to effectively guide and evaluate the impact of reproductive health programs and policies at scale.

The well-being of individuals and communities is increasingly recognized as a core objective of economic and global development policies and programs. However, existing measures of well-being neglect sexual and reproductive experiences, which are core dimensions of people's lives. While there has been increasing attention to the concept of sexual well-being, measures of sexual and reproductive health are predominantly deficit-based and ignore whether people are having positive experiences. To consider the development of a measure of sexual and reproductive well-being, a multidisciplinary and geographically diverse group of experts was convened. Outcomes of this meeting included endorsement of a draft definition of sexual and reproductive well-being, demonstrated enthusiasm and commitment to the development of a measure capturing this construct, and delineation of core considerations in the measure development process. These included considering the diversity of normative and political contexts around sexuality and reproduction, and the critical nature of meaningful community engagement when developing this measure. A pathway for measuring development was defined, with the goal of creating a concise measure assessing people's holistic experiences of sexuality and reproduction that can draw attention to and monitor the extent to which people are having the sexual and reproductive lives they wish to have.

Quality measurement often focuses solely on clinical processes and outcomes, with relative neglect of patient experience. The use of novel measurement approaches, including patient-reported outcome performance measures and electronic clinical quality measures, provide the opportunity for more nuanced and patient-centered measurement in primary care settings. In this commentary, we described the development of such measures to evaluate contraceptive care quality. Primary care is a crucial setting for delivery of contraceptive care, facilitating access in the context of longitudinal care relationships. When providing this care, it is especially critical to have attention to quality grounded in principles of person-centeredness and equity given the personal nature of reproductive health care alongside the history of reproductive oppression. The described measures provide actionable tools that can be leveraged by family medicine leaders and health systems to support quality, person-centered, and equitable contraceptive care.

INTRODUCTION:Older adults with Limited English Proficiency (LEP) comprise a disproportionate number of trauma and emergency general surgery (EGS) patients. In other settings, this group experiences barriers to communication that are likely exacerbated by acute surgical admission. Despite their likely vulnerability, this topic remains understudied. We conducted an exploratory qualitative study to understand communication of older adults with English Proficiency (EP) and LEP hospitalized for trauma or EGS. MATERIALS AND METHODS:Trauma/EGS service inpatients aged ≥65 with mild or no cognitive impairment were purposively sampled at a safety-net, level one trauma center. Semi-structured interviews were held with patients and family when present, using interpreters for LEP. Interviews transcripts were 20% triple-coded and thematically analyzed using modified grounded theory within an interpretivist paradigm. LEP transcripts were also examined for interpretation errors. RESULTS:Twenty-three patients enrolled, 8 with LEP (Spanish, Cantonese, Russian). Three themes emerged: 1. Lack of Information - both groups expressed limited knowledge of their care 2. Loss of Autonomy - both groups endorsed reliance on providers. 3. Feedback and Advocacy - Participants with EP and family members of LEP critiqued care and endorsed the importance of self-advocacy; participants with LEP were reluctant to offer critical feedback. All interviews with professional interpreters contained errors. CONCLUSIONS:Differences in EP and LEP participants' self-advocacy and critiques suggest that language proficiency and communication style contribute to communication barriers after trauma and EGS. Difficulties are likely compounded by professional interpreter errors. Our study generates foundational evidence for further exploration of these factors and their effects on patient outcomes.

Sexuality and reproduction are central to people's life experiences and their ability to thrive. Existing frameworks and measurements related to sexuality and reproduction are predominantly focused on the presence or absence of adverse outcomes, neglecting the critical question of whether people experience positive outcomes and have the sexual and reproductive lives they wish to have. The increased attention to well-being in economic, political, and health spheres presents an opportunity to define and measure the holistic construct of sexual and reproductive well-being. To this end, we engaged in an 18-month collaborative process to develop a definition of sexual and reproductive well-being, with the ultimate goal of informing the development of a measure that would be self-reported and assessed at the population level. The resulting draft definition and measure development approach will serve as the foundation for subsequent measure development. This values-driven process of defining sexual and reproductive well-being will contribute to developing a reproductive justice- and human rights-aligned measure that can illuminate the extent to which structures and systems enable optimal sexual and reproductive experiences. (Am J Public Health. 2025;115(9):1463-1471. https://doi.org/10.2105/AJPH.2025.308119).