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Many of you have already seen this widely circulated article from our June issue: "Young Adults' Contraceptive Knowledge, Norms and Attitudes: Associations with Risk of Unintended Pregnancy," by Jennifer Frost et al., of the Guttmacher Institute (click here for the news release).


In Rural Areas, Barriers to Contraceptive and Preconception Care May Be Rooted in Community Norms

Primary care physicians in rural Pennsylvania believed they played a critical role in providing contraceptive care. They reported thinking that their patients were more likely to seek such care from a primary care provider than were patients in urban settings because of a lack of specialized services in rural areas, according to "Primary Care Physicians' Perceptions of Barriers to Preventive Reproductive Health Care in Rural Communities," by Cynthia H. Chuang, of Penn State College of Medicine, et al. The authors conducted semistructured interviews with 19 rural primary care physicians in central Pennsylvania and found that the scope of contraceptive care they provided varied widely among the providers. Additionally, despite acknowledging the importance of planning for pregnancy, most providers reported that they did not routinely initiate preconception counseling for varied reasons: Some believed it was not their role, while others were uncertain of what they could bring to the discussion.

The providers felt that their own practices, combined with family planning clinics and pharmacies in their areas, provide sufficient access to contraceptive care in their communities. They suggested that lack of access was not the driving force behind rural women's low use of contraceptive and preconception services. Rather, they believed that rural community norms, which are accepting of unintended pregnancies, large families and early childbearing, are the biggest barrier to women's receipt of such care. The authors suggest that overcoming attitudes such as indifference to family planning in rural communities is essential to improving use of services. They recommend that primary care physicians take a more proactive role in promoting preventive reproductive health care to their patients.

Women Support Over-the-Counter Access to Birth Control Pills; Raise Concerns About Cost and Safety

Overall, participants report that it is relatively easy for them to obtain both prescription and nonprescription contraceptive methods, but also indicate that various barriers prevent them from using their preferred method consistently, according to "Barriers to Contraception and Interest in Over-the-Counter Access Among Low-Income Women: A Qualitative Study," by Amanda Dennis and Daniel Grossman of Ibis Reproductive Health. The authors conducted focus group discussions and in-depth interviews with 45 low-income women in Boston to explore how they access contraceptives and whether they support making oral contraceptives available over the counter. Women reported cost to be a major barrier to obtaining both prescription and nonprescription contraceptives, regardless of whether they had insurance. Some said that they had stopped using their preferred method and switched to condoms, which they could obtain at no or low cost.

Most of the women interviewed support over-the-counter access to the pill, saying that it would simplify access to the method by removing barriers such as a required clinic visit and insurance providers' restrictions on the number of packs that may be bought at once and on the timing between purchases. Although many women raised concerns about the cost of the pill if it became available over the counter, they expected that their overall out-of-pocket costs would likely decrease because they would no longer have to make an office visit to get a prescription. Additionally, many women raised concerns about the safety of over-the-counter access, particularly for young women, first time users and women with medical conditions. Interestingly, although most women thought the pill was safe enough for them to use without a provider's intervention, they had concerns about "other" women's ability to do so safely and correctly. The authors suggest that making the pill available over the counter could improve women's consistent use of this method, which could reduce unintended pregnancy and lead to improved health outcomes for mothers and their children. However, they acknowledge that over-the-counter access would not benefit women who have trouble maintaining daily pill use or women not interested in hormonal contraceptives.

Qualitative Study Suggests Teens Understand the Importance of Key Strategies for Preventing STDs, but Have Difficulty Employing Them

A sample of 37 black teens who participated in focus groups in North Carolina reported a high level of understanding of five key strategies for preventing STDs: practicing abstinence, choosing low-risk partners, discussing partners' sexual history, using condoms consistently and not having multiple partners. However, they universally perceived sex during the teen years as normal and abstinence as unrealistic, and saw the remaining strategies as difficult to implement because they relied on a partner's cooperation, according to "A Qualitative Study of Rural Black Adolescents' Perspectives on Primary STD Prevention Strategies," by Aletha Y. Akers, of the University of Pittsburgh, et al. Additionally, the teens suggested that the assumption that STD prevention is paramount when teens are making sexual decisions is incorrect. Although participants reported understanding the health risks of STDs, they considered the benefits of sex to outweigh concerns about STDs. In particular, anxiety over losing a partner was a strong barrier to prevention efforts. Instead of employing the strategies mentioned above, teens reported relying on evaluations of partners' physical appearance or sexual history to assess risk, and undergoing STD testing to identify and treat infections. The authors point out that these are ineffective practices that put teens at increased risk of STD. They suggest that counseling acknowledge the challenges faced by teens in implementing proven prevention strategies, and that prevention messages begin in early adolescence, before teens have formed beliefs that discourage risk reduction behavior. The authors note that a range of similar studies support the validity of their findings.

Financial and Logistical Barriers May Prevent Clinics from Providing Long-Acting Reversible Contraceptives Immediately Following an Abortion

In in-depth interviews, clinicians and health educators at 25 abortion practices around the country reported generally positive views about the safety and effectiveness of long-acting reversible contraceptive (LARC) methods, yet half of surveyed clinics did not offer these methods immediately following an abortion, according to "Postabortion Contraception: Qualitative Interviews on Counseling and Provision of Long-Acting Reversible Contraceptive Methods," by Jessica Morse et al., of the University of California, San Francisco. The authors conducted their study to examine why postabortion provision of LARC methods—such as the IUD and implant—is uncommon in settings serving women at elevated risk of unintended pregnancy. They found that clinicians and educators working in clinics that offered LARC methods immediately postabortion tended to have greater knowledge about these methods and to perceive fewer risks for their patients, while clinicians at practices that did not routinely offer LARC were more likely to express concern about risks such as IUD expulsion, infection or perforation. In half of practices, LARC methods were available only at a follow-up visit, rather than on the same day as abortion provision, although this delay may increase women's pregnancy risk because of interim exposure and low follow-up rates. The most commonly reported barriers to immediate postabortion LARC services were cost (to the clinic and the patient) and concerns that adding time-intensive processes for LARC counseling, consent and provision would disrupt the clinic schedule. Many clinics' decisions about whether to offer postabortion LARC services were based on administrative or logistical factors, rather than medical reasons. Morse and her colleagues suggest that making the most effective and cost-effective methods of contraception (which include LARC methods) available to women in postabortion settings will help "reduce the risk of recurring unintended pregnancy and repeat abortion." To accomplish this, they recommend further education and training for clinic staff.

Many Women Are Confident in Their Decision to Obtain An Abortion, Even Before Counseling

For nearly all abortions performed at one U.S. clinic in 2008, women reported that they were sure of their decision to have an abortion and that doing so was a better choice for them at the time than having a baby, according to "Attitudes and Decision Making Among Women Seeking Abortions at One U.S. Clinic," by Diana Greene Foster, of the University of California, San Francisco, et al. The authors analyzed data collected via precounseling needs assessment forms and clinical intake forms of about 5,100 women who sought abortions. They found that for 87% of abortions sought, women had high confidence in their decision even before receiving counseling. Some women reported lower confidence in their abortion decision, including those who were younger than age 20, were black, had less than a high school education or had a history of depression. The presence of a fetal anomaly was also linked with a reduced likelihood of confidence.

Abortion policy in the United States focuses on requirements such as waiting periods, state-mandated information and parental involvement, which are based on the premise that women are unaware of the nature of abortion and of the risks involved, and need additional time to make an informed, thoughtful decision. The authors argue that the findings of this study contradict that assumption. Rather, the authors suggest that women would benefit more from interactions with caring, nonjudgmental, trained counseling staff who can assess and respond appropriately to their individual needs.

Sexual Minorities Are at Greater Risk of STDs Than Their Heterosexual Counterparts

Across all racial and ethnic groups, women who identify themselves as bisexual or gay report higher risk sexual behaviors, including a history of multiple partners, forced sex and incarceration, and are at greater risk of acquiring an STD than are heterosexual women, according to "STD and HIV Risk Factors Among U.S. Young Adults: Variations by Gender, Race, Ethnicity and Sexual Orientation," by Sanyu Mojola and Bethany Everett of the University of Colorado, Boulder. Gay men and black men of all orientations report higher rates of STD diagnoses than heterosexual white men. The authors relied on data from Waves 3 and 4 of the National Longitudinal Study of Adolescent Health to examine the relative significance of various STD risk factors for subgroups of young adults defined simultaneously by their gender, sexual orientation, race and ethnicity.

The findings illustrate a particular vulnerability for high-risk behavior and STD diagnosis among young adults in the United States who belong to both a sexual minority group and a racial or ethnic minority group. In particular, mixed-oriented black men and women face unique sexual health challenges. The authors suggest that public health interventions be aimed at racial and ethnic minorities whose sexual identities and behaviors do not fall into neat categories, and who therefore might be missed by programs designed specifically for heterosexual women or gay men.

Additionally, you will find the following Viewpoint in this issue: Regression Analysis and Causal Inference: Cause for Concern? By Norman A. Constantine.