- Email: [email protected]
“It’s Just a Bigger Deal”: Providers’ Perceptions and Experiences With Providing Larc To Adolescents
Poster Abstracts / J Pediatr Adolesc Gynecol 28 (2015) e41ee78
a particularly difficult time for diagnosis PCOS, making a serum marker even more desirable2. Given the known elevation of both ovarian volume and AMH in adolescence, it is our hypothesis that elevated AMH in this group is related to higher ovarian reserve as well as the higher prevalence of polycystic ovarian morphology. Methods: In this study we have used a de-identified database of young women and adolescents presenting to NIH receiving an endocrinological work up. A total of 49 subjects were analyzed 14 without PCOS and 35 who had the diagnosis. The diagnostic criteria for PCOS was defined as biochemical hyperandrogenism with associated findings of either menstrual irregularity and /or polycystic ovaries on ultrasound with other causes of hyperandrogenism excluded. A Pearson correlation test was used to analyze AMH level and ovarian volume in subjects with and without the diagnosis of PCOS. This protocol was found to be exempt from full IRB review. Results: The average age of participants was 21 ranging from 16-29. PCOS patients tended to be younger, were more likely to be Caucasian, have elevated testosterone, triglycerides and andrestienedione and LH/FSH ratio, and had lower sex hormone binding globulin than non-PCOS paticipants. There was no difference in right, left ovarian or total volume between groups (p ¼ 0.2172).AMH levels were higher in adolescents diagnosed with PCOS (10.2 6.0 vs 5.3 2.8, p ¼ 0.0025) For the entire group there was a weak positive correlation between AMH and ovarian volume (p ¼ 0.0368) There was, however, no statistically correlation between AMH levels and ovarian volume within each cohort. Conclusions: The elevation of AMH levels correlates with the diagnosis of PCOS rather than ovarian volume in young women and adolescents. This supports the hypothesis that AMH plays a role in this syndrome even in a young and adolescent population. Further study in this area may allow for improvement in diagnosis of PCOS in adolescents. Acknowledgments: Research funded by Department of Graduate Medical Education at Medstar Washington Hospital Center, Grant Number: 2014-096.
e45
Fig 1.Ă
References 1. Sahmay S, Aydin Y, Oncul M, Senturk LM: Diagnosis of Polycystic Ovary Syndrome: AMH in combination with clinical symptoms. J Assist Reprod Genet 2014; 31(2):213e20 2. Pawelczak M, Kenigsberg L, Milla S, Liu YH, Shah B: Elevated serum anti€ llerian hormone in adolescents with polycystic ovary syndrome: Mu relationship to ultrasound features. J Pediatr Endocrinol Metab 2012; 25(910):983e9
11. Labor and Delivery Outcomes Among Young Adolescents Ana J. Torvie MD, Lisa S. Callegari MD, MPH, Melissa A. Schiff MD, MPH, Katherine E. Debiec MD* University of Washington, Seattle, WA
Background: The United States has one of the highest teen pregnancy rates among industrialized nations. Little data exists regarding delivery outcomes, however, particularly in young adolescents under age 15. Our aim was to determine whether young adolescents have increased rates of cesarean section or operative vaginal delivery, as well as maternal or neonatal delivery-related morbidity, compared with older teens and young adults. Methods: We conducted a retrospective population-based cohort study using Washington State birth certificate data linked to hospital records from 1987-2009 for 26,091 nulliparas with singleton gestations between 24-43 weeks. We compared young adolescents ages 11-14 to young teens ages 15-17, older teens ages 18-19, and young adults ages 20-24. The primary outcome was method of delivery, with secondary outcomes including postpartum hemorrhage, shoulder dystocia, 3rd and 4th degree perineal lacerations, chorioamnionitis, and maternal length of stay as well as gestational age at delivery, birth weight (Figure 1), Respiratory Distress Syndrome, neonatal length of stay, and neonatal and infant death (Figure 2). We used multivariate logistic regression to assess for the association between age and delivery outcomes. Results: Adolescents ages 11-14 have lower rates of cesarean section (OR, 0.67; 95% CI, 0.58-0.78) and operative vaginal delivery (OR, 0.77; 95% CI, 0.71-0.84) than women ages 20-24. Maternal length of stay was
Fig 2.Ă
significantly increased in this youngest group for vaginal delivery (OR, 1.52; 95% CI, 1.33-1.74), and cesarean section (OR, 2.19; 95% CI, 1.64-2.92) with no significant difference in other measures of maternal morbidity or indication for cesarean section. Young adolescents have increased rates of preterm delivery (OR, 2.11; 95% CI 1.79-2.48), low and very low birth weight (OR, 2.08; 95% CI, 1.73-2.50 and OR, 3.25; 95% CI 2.22-4.77, respectively) and infant death (OR 3.09; 95% CI, 2.36-6.44). Conclusions: Young adolescents (ages 11-14) have a decreased risk of cesarean and operative vaginal delivery compared with young adult women (ages 20-24), with no difference in indication for cesarean section. Although length of stay is increased in young adolescents, maternal obstetric morbidity is otherwise similar between groups. Neonates born to young adolescent mothers are at higher risk of preterm delivery, low and very low birth weight, and death. This information will assist providers in appropriately counseling these young mothers surrounding specific risks, and in caring for them throughout the labor and delivery process. It may also inform policymakers when considering programs aimed at these youngest mothers and their babies. Acknowledgments: William O’Brien, Jan Hamanishi, BA. Financial support: Lynn S Mandel, PhD, Endowed Trainee Education and Research Award.
12. “It’s Just a Bigger Deal”: Providers’ Perceptions and Experiences With Providing Larc To Adolescents Molly K. Murphy MPH, Cindy Stoffel RN, MPH, Meghan Nolan RN, Sadia Haider MD, MPH* University of Illinois-Chicago, Chicago, Illinois
Background: Long-active reversible contraceptives (LARC) may be instrumental to lower rates of teenage pregnancy and repeat pregnancy, but LARC use among adolescents remains low. Insufficient provider knowledge and skills in LARC provision has been identified as a barrier to
e46
Poster Abstracts / J Pediatr Adolesc Gynecol 28 (2015) e41ee78
adolescent uptake of LARC, but enhancing providers’ LARC knowledge and skills will be of limited effectiveness if providers are not supported in removing context-specific barriers to LARC provision. To identify the constellation of supports and competencies required for primary care providers to negotiate barriers and provide LARC to adolescents who desire them, we conducted in-depth qualitative inquiry into providers’ experiences with and perceptions of LARC provision to adolescents. Methods: Eligible participants were purposively sampled and recruited through emailed invitations to participate, resulting in a final sample (N ¼ 16) of pediatricians (n ¼ 5), family medicine providers (n ¼ 5) and advanced practice nurses (n ¼ 6). Semi-structured interviews with participants were conducted in person, audio-recorded, transcribed and independently coded by two study team members. Coding, concept map development and thematic analysis were guided by a priori and emergent themes. Results: Thematic analysis revealed that the essential components of LARC provision are 1. provider confidence in LARC, 2. patient-centered counseling and 3. instrumental supports for LARC provision such as training on insertion. These components influence each other and the eventual provision of LARC to adolescents such that when one component is undermined or absent, the others are impacted (Figure 1). Participants’ access to essential components varied; those whose experiences and thoughts reflected more of the essential components were more likely to provide LARC regularly, be supportive of LARC adoption among adolescents, and express confidence in their LARC knowledge.
Fig 1. Concept map of adolescent LARC provision essential components.Ă
The most salient threat to LARC provision was participants’ perception that LARC is “too big a deal” to be a good method for adolescents. This perception was due to participants’ lack of experience providing LARC and resultant inability to counsel effectively and express confidence in these methods. These themes were most salient for participants who were not enthusiastic about LARC for adolescents and who had less access to instrumental supports for LARC provision. Conclusions: The essential components and attendant threats to LARC provision for adolescents exist in interdependent relationships to one another. For providers to be able to counsel effectively on LARC, they must be confident in these methods themselves and this confidence will be won, in part, by working in environments that provide instrumental and technical support to LARC provision. Interventions will be most effective by acting simultaneously on multiple aspects of the clinic environment in support of LARC provision, such that the context perpetuates support instead of barriers for LARC provision.
13. NASPAG 2015 Abstract Improving Disease-Specific Sexual And Reproductive Health Knowledge Among Adolescents With Cystic Fibrosis Zachary C. Jacobs DO, Kimberly Korn RN, BSN, CPN, Michelle Howenstine MD, Matthew C. Aalsma PhD, Rebekah L. Williams MD, MS* Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
Purpose: Cystic fibrosis (CF) has known effects on sexual and reproductive health (SRH). Research indicates that CF patients have variable understanding of these effects, and report suboptimal SRH discussions with their healthcare providers. For this study, adolescent reproductive health specialists teamed with pediatric pulmonologists to (1) assess CF specific SRH knowledge in adolescents with CF, and (2) pilot a CF-SRH educational brochure. Methods: A convenience sample of 20 participants age 12-21yrs with CF was recruited during inpatient hospitalization or outpatient CF clinic visit. Sample was stratified by gender and age, with at least 2 males and 2 females in each stage of adolescence -early (12-13yrs), middle (14-17yrs), and late (18-21yrs). Participants completed baseline gender-specific CFSRH knowledge quiz, then reviewed a “CF Sexual and Reproductive Health Information” handout. A brief semi-structured interview assessed the utility of the handout. Three days later the participant retook the CF-SRH knowledge quiz to assess knowledge improvement and retention. Descriptive statistics and paired t-tests (SPSS 21) assessed baseline versus post-handout knowledge. Results: Participants (N ¼ 10 male, 10 female) had mean age 16.4yrs. At baseline, female participants were more likely to give incorrect answers for average pubertal delay in CF (N ¼ 6), effectiveness of hormonal contraception in CF (N ¼ 6), and the difference between infertility and impotence (N ¼ 7), with this last misconception persisting on post-quiz (N ¼ 5). At baseline, male participants were more likely to give incorrect answers for average pubertal delay in CF (N ¼ 8), normal pubertal development (N ¼ 8), cause of male infertility in CF (N ¼ 7), and infertility in females with CF (N ¼ 8). On post-quiz, misconceptions about male infertility CF (N ¼ 5), and female infertility (N ¼ 5) persisted. Females had higher baseline SRH knowledge than males, and late adolescents had higher baseline SRH knowledge than early and middle adolescents. Average scores on the CF-SRH knowledge quiz improved following handout review for the total sample (65.4% vs 86.1%, p<0.05) and for all gender and adolescent stage strata. Most participants reported that healthcare providers had not discussed sexually transmitted infections (STI) or pregnancy (N ¼ 14), STI prevention (N ¼ 17), or contraception (N ¼ 16). In semi-structured interview, participants reported a desire to learn about CF-SRH via printed material and discussion with their CF or other healthcare provider. From reviewing the handout, females specifically reported learning about pregnancy complications, pubertal delay, and contraception. Conclusion: Adolescents with CF have deficiencies in their reproductive health knowledge and wish to discuss their reproductive health with healthcare providers. Partnerships between adolescent reproductive health and CF providers, and provision of a brief educational handout as a standard part of adolescent CF clinical care, may be important first steps to address this need, and could prompt improved conversations between CF patients and their care team across the reproductive lifespan.
14. Teen Acceptance of an Intrauterine Device (IUD) Service Within a School-Based Health Center Tara Stein MD, MPH, Michele St. Louis MD, Marji Gold MD* Montefiore Medical Center, Bronx, NY
Background: Despite a growing number of available contraceptive options, the rate of unintended pregnancies among adolescents in the United States remains high. Use of long-acting reversible contraceptives (LARC) is strongly recommended as a first line option for adolescents but those patients may find it difficult to obtain those services in a safe and confidential manner. We proposed to evaluate adolescents’ acceptance and use of IUD services on-site at a school-based health center (SBHC) in the Bronx, NY. Methods: We surveyed teens presenting for IUD insertion at one of our high school SBHC sites between (Figure 1) November 2010 and June 2013. Out of 139 students who came for an IUD insertion visit, 104 agreed to complete the survey. We asked the adolescents to rate their experience with the IUD insertion procedure and to describe their reasons for choosing to get the IUD at their school-based site (Figure 2). Our institutional review board approved this study.
a particularly difficult time for diagnosis PCOS, making a serum marker even more desirable2. Given the known elevation of both ovarian volume and AMH in adolescence, it is our hypothesis that elevated AMH in this group is related to higher ovarian reserve as well as the higher prevalence of polycystic ovarian morphology. Methods: In this study we have used a de-identified database of young women and adolescents presenting to NIH receiving an endocrinological work up. A total of 49 subjects were analyzed 14 without PCOS and 35 who had the diagnosis. The diagnostic criteria for PCOS was defined as biochemical hyperandrogenism with associated findings of either menstrual irregularity and /or polycystic ovaries on ultrasound with other causes of hyperandrogenism excluded. A Pearson correlation test was used to analyze AMH level and ovarian volume in subjects with and without the diagnosis of PCOS. This protocol was found to be exempt from full IRB review. Results: The average age of participants was 21 ranging from 16-29. PCOS patients tended to be younger, were more likely to be Caucasian, have elevated testosterone, triglycerides and andrestienedione and LH/FSH ratio, and had lower sex hormone binding globulin than non-PCOS paticipants. There was no difference in right, left ovarian or total volume between groups (p ¼ 0.2172).AMH levels were higher in adolescents diagnosed with PCOS (10.2 6.0 vs 5.3 2.8, p ¼ 0.0025) For the entire group there was a weak positive correlation between AMH and ovarian volume (p ¼ 0.0368) There was, however, no statistically correlation between AMH levels and ovarian volume within each cohort. Conclusions: The elevation of AMH levels correlates with the diagnosis of PCOS rather than ovarian volume in young women and adolescents. This supports the hypothesis that AMH plays a role in this syndrome even in a young and adolescent population. Further study in this area may allow for improvement in diagnosis of PCOS in adolescents. Acknowledgments: Research funded by Department of Graduate Medical Education at Medstar Washington Hospital Center, Grant Number: 2014-096.
e45
Fig 1.Ă
References 1. Sahmay S, Aydin Y, Oncul M, Senturk LM: Diagnosis of Polycystic Ovary Syndrome: AMH in combination with clinical symptoms. J Assist Reprod Genet 2014; 31(2):213e20 2. Pawelczak M, Kenigsberg L, Milla S, Liu YH, Shah B: Elevated serum anti€ llerian hormone in adolescents with polycystic ovary syndrome: Mu relationship to ultrasound features. J Pediatr Endocrinol Metab 2012; 25(910):983e9
11. Labor and Delivery Outcomes Among Young Adolescents Ana J. Torvie MD, Lisa S. Callegari MD, MPH, Melissa A. Schiff MD, MPH, Katherine E. Debiec MD* University of Washington, Seattle, WA
Background: The United States has one of the highest teen pregnancy rates among industrialized nations. Little data exists regarding delivery outcomes, however, particularly in young adolescents under age 15. Our aim was to determine whether young adolescents have increased rates of cesarean section or operative vaginal delivery, as well as maternal or neonatal delivery-related morbidity, compared with older teens and young adults. Methods: We conducted a retrospective population-based cohort study using Washington State birth certificate data linked to hospital records from 1987-2009 for 26,091 nulliparas with singleton gestations between 24-43 weeks. We compared young adolescents ages 11-14 to young teens ages 15-17, older teens ages 18-19, and young adults ages 20-24. The primary outcome was method of delivery, with secondary outcomes including postpartum hemorrhage, shoulder dystocia, 3rd and 4th degree perineal lacerations, chorioamnionitis, and maternal length of stay as well as gestational age at delivery, birth weight (Figure 1), Respiratory Distress Syndrome, neonatal length of stay, and neonatal and infant death (Figure 2). We used multivariate logistic regression to assess for the association between age and delivery outcomes. Results: Adolescents ages 11-14 have lower rates of cesarean section (OR, 0.67; 95% CI, 0.58-0.78) and operative vaginal delivery (OR, 0.77; 95% CI, 0.71-0.84) than women ages 20-24. Maternal length of stay was
Fig 2.Ă
significantly increased in this youngest group for vaginal delivery (OR, 1.52; 95% CI, 1.33-1.74), and cesarean section (OR, 2.19; 95% CI, 1.64-2.92) with no significant difference in other measures of maternal morbidity or indication for cesarean section. Young adolescents have increased rates of preterm delivery (OR, 2.11; 95% CI 1.79-2.48), low and very low birth weight (OR, 2.08; 95% CI, 1.73-2.50 and OR, 3.25; 95% CI 2.22-4.77, respectively) and infant death (OR 3.09; 95% CI, 2.36-6.44). Conclusions: Young adolescents (ages 11-14) have a decreased risk of cesarean and operative vaginal delivery compared with young adult women (ages 20-24), with no difference in indication for cesarean section. Although length of stay is increased in young adolescents, maternal obstetric morbidity is otherwise similar between groups. Neonates born to young adolescent mothers are at higher risk of preterm delivery, low and very low birth weight, and death. This information will assist providers in appropriately counseling these young mothers surrounding specific risks, and in caring for them throughout the labor and delivery process. It may also inform policymakers when considering programs aimed at these youngest mothers and their babies. Acknowledgments: William O’Brien, Jan Hamanishi, BA. Financial support: Lynn S Mandel, PhD, Endowed Trainee Education and Research Award.
12. “It’s Just a Bigger Deal”: Providers’ Perceptions and Experiences With Providing Larc To Adolescents Molly K. Murphy MPH, Cindy Stoffel RN, MPH, Meghan Nolan RN, Sadia Haider MD, MPH* University of Illinois-Chicago, Chicago, Illinois
Background: Long-active reversible contraceptives (LARC) may be instrumental to lower rates of teenage pregnancy and repeat pregnancy, but LARC use among adolescents remains low. Insufficient provider knowledge and skills in LARC provision has been identified as a barrier to
e46
Poster Abstracts / J Pediatr Adolesc Gynecol 28 (2015) e41ee78
adolescent uptake of LARC, but enhancing providers’ LARC knowledge and skills will be of limited effectiveness if providers are not supported in removing context-specific barriers to LARC provision. To identify the constellation of supports and competencies required for primary care providers to negotiate barriers and provide LARC to adolescents who desire them, we conducted in-depth qualitative inquiry into providers’ experiences with and perceptions of LARC provision to adolescents. Methods: Eligible participants were purposively sampled and recruited through emailed invitations to participate, resulting in a final sample (N ¼ 16) of pediatricians (n ¼ 5), family medicine providers (n ¼ 5) and advanced practice nurses (n ¼ 6). Semi-structured interviews with participants were conducted in person, audio-recorded, transcribed and independently coded by two study team members. Coding, concept map development and thematic analysis were guided by a priori and emergent themes. Results: Thematic analysis revealed that the essential components of LARC provision are 1. provider confidence in LARC, 2. patient-centered counseling and 3. instrumental supports for LARC provision such as training on insertion. These components influence each other and the eventual provision of LARC to adolescents such that when one component is undermined or absent, the others are impacted (Figure 1). Participants’ access to essential components varied; those whose experiences and thoughts reflected more of the essential components were more likely to provide LARC regularly, be supportive of LARC adoption among adolescents, and express confidence in their LARC knowledge.
Fig 1. Concept map of adolescent LARC provision essential components.Ă
The most salient threat to LARC provision was participants’ perception that LARC is “too big a deal” to be a good method for adolescents. This perception was due to participants’ lack of experience providing LARC and resultant inability to counsel effectively and express confidence in these methods. These themes were most salient for participants who were not enthusiastic about LARC for adolescents and who had less access to instrumental supports for LARC provision. Conclusions: The essential components and attendant threats to LARC provision for adolescents exist in interdependent relationships to one another. For providers to be able to counsel effectively on LARC, they must be confident in these methods themselves and this confidence will be won, in part, by working in environments that provide instrumental and technical support to LARC provision. Interventions will be most effective by acting simultaneously on multiple aspects of the clinic environment in support of LARC provision, such that the context perpetuates support instead of barriers for LARC provision.
13. NASPAG 2015 Abstract Improving Disease-Specific Sexual And Reproductive Health Knowledge Among Adolescents With Cystic Fibrosis Zachary C. Jacobs DO, Kimberly Korn RN, BSN, CPN, Michelle Howenstine MD, Matthew C. Aalsma PhD, Rebekah L. Williams MD, MS* Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
Purpose: Cystic fibrosis (CF) has known effects on sexual and reproductive health (SRH). Research indicates that CF patients have variable understanding of these effects, and report suboptimal SRH discussions with their healthcare providers. For this study, adolescent reproductive health specialists teamed with pediatric pulmonologists to (1) assess CF specific SRH knowledge in adolescents with CF, and (2) pilot a CF-SRH educational brochure. Methods: A convenience sample of 20 participants age 12-21yrs with CF was recruited during inpatient hospitalization or outpatient CF clinic visit. Sample was stratified by gender and age, with at least 2 males and 2 females in each stage of adolescence -early (12-13yrs), middle (14-17yrs), and late (18-21yrs). Participants completed baseline gender-specific CFSRH knowledge quiz, then reviewed a “CF Sexual and Reproductive Health Information” handout. A brief semi-structured interview assessed the utility of the handout. Three days later the participant retook the CF-SRH knowledge quiz to assess knowledge improvement and retention. Descriptive statistics and paired t-tests (SPSS 21) assessed baseline versus post-handout knowledge. Results: Participants (N ¼ 10 male, 10 female) had mean age 16.4yrs. At baseline, female participants were more likely to give incorrect answers for average pubertal delay in CF (N ¼ 6), effectiveness of hormonal contraception in CF (N ¼ 6), and the difference between infertility and impotence (N ¼ 7), with this last misconception persisting on post-quiz (N ¼ 5). At baseline, male participants were more likely to give incorrect answers for average pubertal delay in CF (N ¼ 8), normal pubertal development (N ¼ 8), cause of male infertility in CF (N ¼ 7), and infertility in females with CF (N ¼ 8). On post-quiz, misconceptions about male infertility CF (N ¼ 5), and female infertility (N ¼ 5) persisted. Females had higher baseline SRH knowledge than males, and late adolescents had higher baseline SRH knowledge than early and middle adolescents. Average scores on the CF-SRH knowledge quiz improved following handout review for the total sample (65.4% vs 86.1%, p<0.05) and for all gender and adolescent stage strata. Most participants reported that healthcare providers had not discussed sexually transmitted infections (STI) or pregnancy (N ¼ 14), STI prevention (N ¼ 17), or contraception (N ¼ 16). In semi-structured interview, participants reported a desire to learn about CF-SRH via printed material and discussion with their CF or other healthcare provider. From reviewing the handout, females specifically reported learning about pregnancy complications, pubertal delay, and contraception. Conclusion: Adolescents with CF have deficiencies in their reproductive health knowledge and wish to discuss their reproductive health with healthcare providers. Partnerships between adolescent reproductive health and CF providers, and provision of a brief educational handout as a standard part of adolescent CF clinical care, may be important first steps to address this need, and could prompt improved conversations between CF patients and their care team across the reproductive lifespan.
14. Teen Acceptance of an Intrauterine Device (IUD) Service Within a School-Based Health Center Tara Stein MD, MPH, Michele St. Louis MD, Marji Gold MD* Montefiore Medical Center, Bronx, NY
Background: Despite a growing number of available contraceptive options, the rate of unintended pregnancies among adolescents in the United States remains high. Use of long-acting reversible contraceptives (LARC) is strongly recommended as a first line option for adolescents but those patients may find it difficult to obtain those services in a safe and confidential manner. We proposed to evaluate adolescents’ acceptance and use of IUD services on-site at a school-based health center (SBHC) in the Bronx, NY. Methods: We surveyed teens presenting for IUD insertion at one of our high school SBHC sites between (Figure 1) November 2010 and June 2013. Out of 139 students who came for an IUD insertion visit, 104 agreed to complete the survey. We asked the adolescents to rate their experience with the IUD insertion procedure and to describe their reasons for choosing to get the IUD at their school-based site (Figure 2). Our institutional review board approved this study.