Sylvia Guendelman

Background: The number of undocumented in-transit migrant women (UITMW) traveling through Mexico to the U.S. is increasing, with longer stays in Mexico. We explore how UITMW’s sexual and reproductive health (SRH) needs and service utilization for these needs vary by time spent in Mexico and availability of instrumental social support. We also identify barriers to care and propose actionable steps to improve service delivery. Methods: We conducted a sequential quantitative–qualitative mixed-methods study in Ciudad Juárez, Mexico. It includes a secondary analysis of a 2021 survey of 252 UITMW and a primary analysis of 31 stakeholder interviews in 2023, that elaborated on the survey findings. Guided by Andersen’s Behavioral Model of Health Care Utilization, we performed bivariate analyses to assess SRH needs and service utilization by time spent in Mexico and instrumental social support. Multivariate logistic regression models estimated unadjusted (ORs), adjusted odds ratios (aORs), and 95% confidence intervals (95% CIs) to assess these associations and the modifying effect of instrumental social support. For the qualitative component, we applied a framework analysis structured around four key themes from the quantitative findings to contextualize results and identify barriers and actionable solutions. Results: Nine in ten UITMW experienced at least one SRH need, yet only 33.6% accessed SRH services. Interviewees cited fear of organized crime, government authorities, and constant mobility as key barriers. While longer stays in Mexico were initially associated with higher SRH utilization, this was no longer significant when adjusting for covariates (aOR 1.87; 95% CI 0.83–4.19). However, among women without instrumental social support, longer stays significantly increased the odds of SRH service utilization (aOR 6.99; 95% CI 1.42–34.45). This pattern may reflect greater challenges accessing care earlier in their stay. Qualitative findings suggest that instrumental social support may facilitate service utilization by enabling childcare, sharing information, and fostering connections. Conclusions: UITMW face SRH needs and multiple barriers to care while in Mexico. Utilization is particularly challenging for UITMW who experience sexual violence and lack instrumental social support. Understanding the factors influencing the health needs and SRH utilization of UITMW can help Mexico’s health system plan effective interventions.

Background: In 2018, the American College of Obstetricians and Gynecologists (ACOG) issued multiple recommendations to optimize care within the first 12 weeks postpartum. We explored the extent to which clinicians follow ACOG’s recommendations at the first postpartum visit and identified factors associated with overall adherence to clinical recommendations. Methods: Between September 2023 and February 2024, we collected data from an online survey about the care practices of 174 obstetric clinicians practicing in California. The response rate was 76%. Adherence was measured by asking the extent to which clinicians always complete care components drawn from a list of 26 of ACOG’s clinical recommendations. We used descriptive statistics and ran linear regression models to quantify the association between adherence to guidelines and years of clinical practice, proportion of patients utilizing Medi-Cal, the method of reimbursement received by the provider, perceived organizational, financial and patient barriers, duration of the visit and number of collaborations with other providers. Results: The median percentage of components checked by clinicians was 62%. Significantly higher adherence was found among clinicians with at least 12 years of practice compared with those with approximately 5 years or less and among clinicians who collaborated with 5 or more multidisciplinary providers versus fewer than 3. Adherence was also higher among clinicians who on average spent at least 30 min vs. less than 20 min with their patients and those who perceived high financial barriers to care among their patients. In contrast, clinicians who served highly mixed practices of Medi-Cal and non-Medi-Cal recipients reported lower adherence. Conclusion: We sought to understand which clinicians were more able to align their practice with ACOG guidelines at the first postpartum visit. We found that more experienced clinicians, those who simplified their practices to either all Medi-Cal or few Medi-Cal recipients, and those who collaborated more with other providers from various disciplines were best able to provide the care recommended in the guidelines. Our findings highlight where policy, resources and training are needed to improve guideline adherence and whole person care.

Background: Professional societies such as the American College of Obstetricians and Gynecologists (ACOG) promote the idea that postpartum care is an ongoing process where there is adequate opportunity to provide services and support. Nonetheless, in practice, the guidelines ask clinicians to perform more clinical responsibilities than they might be able to do with limited time and resources. Methods: We conducted an online survey among practicing obstetric clinicians (obstetrician/gynecologists (OB/GYNs), midwives, and family medicine doctors) in California about their priorities and care practices for the first postpartum visit and explored how they prioritize multiple clinical responsibilities within existing time and resources. Between September 2023 and February 2024, 174 out of 229 eligible participants completed the survey, a 76% response rate. From a list of care components, we used descriptive statistics to identify those that were highly prioritized by most clinicians and those that were considered a priority by very few and examined the alignment between prioritized components and recommended care practices. Results: Clinicians were highly invested in the care components that they rated as most important, indicating that they always check these components or assess them when they perceive patient need. Depression and anxiety, breast health/breast feeding issues, vaginal birth complications and family planning counseling were highly ranked components by all clinicians. In contrast, clinicians more often did not assess those care components that infrequently ranked highly among the priority listing, consisting mainly of social drivers of health such as screening and counseling for intimate partner violence, working conditions and food/housing insecurity. In both instances, we found little discordance between priorities and care practices. However, OB/GYNs and midwives differed in some care components that they prioritized highly. Conclusions: While there is growing understanding of how important professional society recommendations are for maternal-infant health, clinicians face barriers completing all recommendations, especially those components related to social drivers of health. However, what the clinicians do prioritize highly, they are likely to perform. Now that Medi-Cal (Medicaid) insurance is available in California for up to 12 months postpartum, there is a need to understand what care clinicians provide and what gaps remain.

Background: Limited knowledge exists about the drivers of telehealth use among obstetricians during COVID-19 in the United States. We investigated the use of live video visits by Maternal-Fetal Medicine (MFM) clinicians, the factors associated with use and interest in future use. Methods: We drew survey data from 373 clinicians on two outcomes: (1) use of any (vs. no) live video visits during COVID-19 and (2) among users, the extent of live video use. Bivariate and multivariate logistic regressions quantified the association between predisposing (demographic and practice setting characteristics) and enabling factors (prepandemic telehealth use, structural and perceived patient barriers) and each outcome. Results: During the pandemic, 88% reported any use, a jump from 29% prepandemic utilization. Users (vs. nonusers) were younger ( p = 0.02); tended to provide comprehensive prenatal care ( p = 0.01) and/or inpatient care ( p = 0.02), practice in university settings ( p = 0.01), engage in various telehealth modalities prepandemic ( p ≤ 0.01), and to perceive challenges with technical ( p < 0.01), reimbursement ( p = 0.05), and patient barriers to internet or data plan access ( p ≤ 0.001). After adjusting for covariates, only prepandemic communication through patient portal (adjusted odds ratio [aOR] = 3.85; 95% confidence interval [CI] = 1.33–11.12), perceived patient access barriers (aOR = 5.27; 95% CI = 1.95–14.23), and practice in multiple versus university settings (aOR = 0.18; 95% CI = 0.06–0.56) remained significantly associated with use. Approximately 44% were high users. Prepandemic ultrasound use (aOR = 1.92; 95% CI = 1.17–3.16), perceived patient access barriers (aOR = 1.85; 95% CI = 1.12–3.06) and Midwest versus North practice location (aOR = 0.46; 95% CI = 0.21–0.98) predicted high use. Among high users, 99% wanted to continue offering video visits. Conclusions: We found widespread use of live video obstetric care by MFM clinicians and continued interest in use postpandemic.

Background: As access barriers to in-person abortion care increase due to legal restrictions and COVID-19–related disruptions, individuals may be turning to the internet for information and services on out-of-clinic medication abortions. Google searches allow us to explore timely population-level interest in this topic and assess its implications. Objective: We examined the extent to which people searched for out-of-clinic medication abortions in the United States in 2020 through 3 initial search terms: home abortion, self abortion, and buy abortion pill online. Methods: Using the Google Trends website, we estimated the relative search index (RSI)—a comparative measure of search popularity—for each initial search term and determined trends and its peak value between January 1, 2020, and January 1, 2021. RSI scores also helped to identify the 10 states where these searches were most popular. We developed a master list of top search queries for each of the initial search terms using the Google Trends application programming interface (API). We estimated the relative search volume (RSV)—the search volume of each query relative to other associated terms—for each of the top queries using the Google Health Trends API. We calculated average RSIs and RSVs from multiple samples to account for low-frequency data. Using the Custom Search API, we determined the top webpages presented to people searching for each of the initial search terms, contextualizing the information found when searching them on Google. Results: Searches for home abortion had average RSIs that were 3 times higher than self abortion and almost 4 times higher than buy abortion pill online. Interest in home abortion peaked in November 2020, during the third pandemic wave, at a time when providers could dispense medication abortion using telemedicine and by mail. Home abortion was most frequently queried by searching for Planned Parenthood, abortion pill, and abortion clinic, presumably denoting varying degrees of clinical support. Consistently lower search popularity for self abortion and buy abortion pill online reflect less population interest in mostly or completely self-managed out-of-clinic abortions. We observed the highest interest for home abortion and self abortion in states hostile to abortion, suggesting that state restrictions encourage these online searches. Top webpages provided limited evidence-based clinical content on self-management of abortions, and several antiabortion sites presented health-related disinformation. Conclusions: During the pandemic in the United States, there has been considerably more interest in home abortions than in minimally or nonclinically supported self-abortions. While our study was mainly descriptive, showing how infrequent abortion-related search data can be analyzed through multiple resampling, future studies should explore correlations between the keywords denoting interest in out-of-clinic abortion and abortion care measures and test models that allow for improved monitoring and surveillance of abortion concerns in our rapidly evolving policy context.

Biomedical factors and social determinants of health (SDH) affect preterm birth (PTB). Given the complexity of PTB and the increasing rates in the United States, public datasets involving multicomponent variables—from biomedical to structural—can motivate novel interventions to address PTB in the US. The primary aim of this study was to develop a PTB registry based on multi-modal data collection tools that prioritize biomedical and SDH data and identify PTB phenotype (i.e. spontaneous labor, preterm premature rupture of membrane, or medically indicated). The secondary aim of this study was to execute a pilot study to assess feasibility. This study aimed to describe recruitment practices, assess data accessibility and concordance, and to provide an example of how the registry can be used to generate hypothesis and analyze data. We designed the registry through a conceptual model provided by the Dahlgren and Whitehead model of SDH using validated questionnaires and literature on PTB. The registry included a survey, interview, and medical and birth certificate abstraction. To pilot the registry, we recruited 92 participants who delivered preterm, were admitted for risk of preterm delivery, or delivered at term at an urban public hospital. Enrollment was most effective in-person and in the postpartum period. Consent to different parts of the registry was similar regardless of when participants were recruited. There was also a range of data concordance depending on the data source and chosen variable. The registry’s PTB phenotype algorithm identified the correct PTB phenotype 100% of the time. The example analysis demonstrated six unique SDH domains. Participants who delivered preterm reported an average of 11 total stressors and 19.7 protective items and 66% had a significant medical or obstetric comorbidity. Results of this study demonstrate that a PTB registry is feasible and could help advance research to prevent PTB.

BACKGROUND As access barriers to in-person abortion care increase due to legal restrictions and COVID-19–related disruptions, individuals may be turning to the internet for information and services on out-of-clinic medication abortions. Google searches allow us to explore timely population-level interest in this topic and assess its implications. OBJECTIVE We examined the extent to which people searched for out-of-clinic medication abortions in the United States in 2020 through 3 initial search terms: home abortion, self abortion, and buy abortion pill online. METHODS Using the Google Trends website, we estimated the relative search index (RSI)—a comparative measure of search popularity—for each initial search term and determined trends and its peak value between January 1, 2020, and January 1, 2021. RSI scores also helped to identify the 10 states where these searches were most popular. We developed a master list of top search queries for each of the initial search terms using the Google Trends application programming interface (API). We estimated the relative search volume (RSV)—the search volume of each query relative to other associated terms—for each of the top queries using the Google Health Trends API. We calculated average RSIs and RSVs from multiple samples to account for low-frequency data. Using the Custom Search API, we determined the top webpages presented to people searching for each of the initial search terms, contextualizing the information found when searching them on Google. RESULTS Searches for home abortion had average RSIs that were 3 times higher than self abortion and almost 4 times higher than buy abortion pill online. Interest in home abortion peaked in November 2020, during the third pandemic wave, at a time when providers could dispense medication abortion using telemedicine and by mail. Home abortion was most frequently queried by searching for Planned Parenthood, abortion pill, and abortion clinic, presumably denoting varying degrees of clinical support. Consistently lower search popularity for self abortion and buy abortion pill online reflect less population interest in mostly or completely self-managed out-of-clinic abortions. We observed the highest interest for home abortion and self abortion in states hostile to abortion, suggesting that state restrictions encourage these online searches. Top webpages provided limited evidence-based clinical content on self-management of abortions, and several antiabortion sites presented health-related disinformation. CONCLUSIONS During the pandemic in the United States, there has been considerably more interest in home abortions than in minimally or nonclinically supported self-abortions. While our study was mainly descriptive, showing how infrequent abortion-related search data can be analyzed through multiple resampling, future studies should explore correlations between the keywords denoting interest in out-of-clinic abortion and abortion care measures and test models that allow for improved monitoring and surveillance of abortion concerns in our rapidly evolving policy context.

Preterm birth (PTB; p= 0.07, 1.65 weeks, 95% CI: -3.44, 0.14). Receipt of behavioral health services was associated with a significantly later gestational age; the median difference was 5.5 weeks longer for depression symptoms, 3.5 weeks longer for high social determinants, and 6 weeks longer for depression symptoms and high social determinants. Among a cohort of high-risk pregnant women, both depression symptoms during pregnancy and co-occurring with exposure to high adverse SDH are associated with shorter gestational age at birth, after controlling for psychosocial factors. Receipt of behavioral health services may be an effective intervention to address disparities in PTB.

Background: It is now common to search for health information online. A 2013 Pew Research Center survey found that 77% of online health seekers began their query at a search engine. The widespread use of online health information seeking also applies to women’s reproductive health. Despite online interest in birth control, not much is known about related interests and concerns reflected in the search terms in the United States. Objective: In this study, we identify the top search terms on Google related to birth control in Louisiana and Mississippi and compare those results to the broader United States, examining how Google searches on birth control have evolved over time and identifying regional variation within states. Methods: We accessed search data on birth control from 2014-2018 from 2 Google application programming interfaces (APIs), Google Trends and Google Health Trends. We selected Google as it is the most commonly used search engine. We focused our analysis on data from 2017 and compared with 2018 data as appropriate. To assess trends, we analyzed data from 2014 through 2018. To compare the relative search frequencies of the top queries across Louisiana, Mississippi, and the United States, we used the Google Health Trends API. Relative search volume by designated marketing area (DMA) gave us the rankings of search volume for each birth control method in each DMA as compared to one another. Results: Results showed that when people searched for “birth control” in Louisiana and the broader United States, they were searching for information on a diverse spectrum of methods. This differs from Mississippi, where the data indicated people were mainly searching for information related to birth control pills. Across all locations, searches for birth control pills were significantly higher than any other queries related to birth control in the United States, Louisiana, and Mississippi, and this trend remained constant from 2014 to 2018. Regional level analysis showed variations in search traffic for birth control across each state. Conclusions: The internet is a growing source of health information for many users, including information on birth control. Understanding popular Google search queries on birth control can inform in-person discussions initiated by family planning practitioners and broader birth control messaging campaigns. International Registered Report Identifier (IRRID): RR2-10.2196/16543

BACKGROUND It is now common to search for health information online. A 2013 Pew Research Center survey found that 77% of online health seekers began their query at a search engine. The widespread use of online health information seeking also applies to women’s reproductive health. Despite online interest in birth control, not much is known about related interests and concerns reflected in the search terms in the United States. OBJECTIVE In this study, we identify the top search terms on Google related to birth control in Louisiana and Mississippi and compare those results to the broader United States, examining how Google searches on birth control have evolved over time and identifying regional variation within states. METHODS We accessed search data on birth control from 2014-2018 from 2 Google application programming interfaces (APIs), Google Trends and Google Health Trends. We selected Google as it is the most commonly used search engine. We focused our analysis on data from 2017 and compared with 2018 data as appropriate. To assess trends, we analyzed data from 2014 through 2018. To compare the relative search frequencies of the top queries across Louisiana, Mississippi, and the United States, we used the Google Health Trends API. Relative search volume by designated marketing area (DMA) gave us the rankings of search volume for each birth control method in each DMA as compared to one another. RESULTS Results showed that when people searched for “birth control” in Louisiana and the broader United States, they were searching for information on a diverse spectrum of methods. This differs from Mississippi, where the data indicated people were mainly searching for information related to birth control pills. Across all locations, searches for birth control pills were significantly higher than any other queries related to birth control in the United States, Louisiana, and Mississippi, and this trend remained constant from 2014 to 2018. Regional level analysis showed variations in search traffic for birth control across each state. CONCLUSIONS The internet is a growing source of health information for many users, including information on birth control. Understanding popular Google search queries on birth control can inform in-person discussions initiated by family planning practitioners and broader birth control messaging campaigns. INTERNATIONAL REGISTERED REPORT RR2-10.2196/16543