OBJECTIVE: To characterize county-level differences in pregnancy-related mortality as a function of sociospatial indicators. METHODS: We conducted a cross-sectional multilevel analysis of all pregnancy-related deaths and all live births with available ZIP code or county data in the Pregnancy Mortality Surveillance System during 2011-2016 for non-Hispanic Black, Hispanic (all races), and non-Hispanic White women aged 15-44 years. The exposures included 31 conceptually-grounded, county-specific sociospatial indicators that were collected from publicly available data sources and categorized into domains of demographic; general, reproductive, and behavioral health; social capital and support; and socioeconomic contexts. We calculated the absolute difference of county-level pregnancy-related mortality ratios (deaths per 100,000 live births) per 1-unit increase in the median absolute difference between women living in counties with higher compared with lower levels of each sociospatial indicator overall and stratified by race and ethnicity. RESULTS: Pregnancy-related mortality varied across counties and by race and ethnicity. Many sociospatial indicators were associated with county-specific pregnancy-related mortality ratios independent of maternal age, population size, and Census region. Across domains, the most harmful indicators were percentage of low-birth-weight births (absolute ratio difference [RD] 6.44; 95% CI 5.36-7.51), percentage of unemployed adults (RD 4.98; 95% CI 3.91-6.05), and food insecurity (RD 4.92; 95% CI 4.14-5.70). The most protective indicators were higher median household income (RD -2.76; 95% CI -3.28 to -2.24), percentage of college-educated adults (RD -2.28; 95% CI -2.81 to -1.75), and percentage of owner-occupied households (RD -1.66; 95% CI -2.29 to -1.03). The magnitude of these associations varied by race and ethnicity. CONCLUSION: This analysis identified sociospatial indicators of pregnancy-related mortality and showed an association between pregnancy-related deaths and place of residence overall and stratified by race and ethnicity. Understanding county-level context associated with pregnancy-related mortality may be an important step towards building public health evidence to inform action to reduce pregnancy-related mortality at local levels.

BACKGROUND: The U.S. pregnancy-related mortality ratio has not improved over the past decade and includes striking disparities by race/ethnicity and by state. Understanding differences in pregnancy-related mortality across and within urban and rural areas can guide the development of interventions for preventing future pregnancy-related deaths. OBJECTIVE: We sought to compare pregnancy-related mortality across and within urban and rural counties by race/ethnicity and age. STUDY DESIGN: We conducted a descriptive analysis of 3,747 pregnancy-related deaths during 2011-2016 (the most recent available) with available ZIP code or county data in the Pregnancy Mortality Surveillance System, among Hispanic and non-Hispanic White, Black, American Indian/Alaska Native, and Asian/Pacific Islander women ages 15-44 years. We aggregated data by U.S. county and grouped counties per the National Center for Health Statistics Urban-Rural Classification Scheme for Counties. We used R statistical software, epitools, to calculate the pregnancy-related mortality ratio (number of pregnancy-related deaths per 100,000 live births) for each urban-rural grouping, obtain 95% confidence intervals, and perform exact tests of ratio comparisons using the Poisson distribution. RESULTS: Of the total 3,747 pregnancy-related deaths analyzed, 52% occurred in large metro counties and 7% occurred in noncore (rural) counties. Large metro counties had the lowest pregnancy-related mortality ratio (14.8, 95% CI: 14.2-15.5) while noncore counties had the highest (24.1, 95% CI: 21.4-27.1), including for most race/ethnicity and age groups. Pregnancy-related mortality ratio age disparities increased with rurality. Women ages 25-34 years and ages 35-44 years living in noncore counties had pregnancy-related mortality ratios 1.5 and 3 times higher, respectively, than women of the same age groups in large metro counties. Within each urban-rural category, pregnancy-related mortality ratios were higher among non-Hispanic Black women compared to non-Hispanic White women. Non-Hispanic American Indian/Alaska Native pregnancy-related mortality ratios in small metro, micropolitan, and noncore counties were 2-3 times that of non-Hispanic White women in the same areas. CONCLUSION: Although more than half of pregnancy-related deaths occurred in large metro counties, the pregnancy-related mortality ratio rose with increasing rurality. Disparities existed among urban-rural categories, including by age group and by race/ethnicity. Geographic location is an important context for initiatives to prevent future deaths and eliminate disparities. Further research is needed to better understand reasons for the observed urban-rural differences and to guide a multifactorial response to reduce pregnancy-related deaths.

OBJECTIVE: Increasingly, states authorize pharmacists to prescribe hormonal contraception to patients without a prescription from another healthcare provider. The purpose of this review is to investigate pharmacist and patient perspectives on pharmacist-prescribed contraception in the United States. Study Design We searched Medline, Embase, PsycInfo, CINAHL, Scopus, and the Cochrane Library from inception through July 10, 2019. We included qualitative and mixed-methods studies, quantitative surveys, observational studies, and randomized trials in the United States. Risk of bias was assessed using tools for quantitative and qualitative studies. RESULTS: Fifteen studies met inclusion criteria, including studies on pharmacists and student pharmacists (n=9), patients (n=5), and both (n=1). Study samples ranged from local to national. Studies had moderate to high risk of bias, primarily due to low response rates and lack of validated instruments. Most pharmacists (57-96%) across four studies were interested in participating in pharmacist-prescribed contraception services. Among patients, 63-97% across three studies supported pharmacist-prescribed contraception, and 38-68% across four studies intended to participate in these services. At least half of pharmacists across four studies felt comfortable prescribing contraception, though pharmacists identified additional training needs. Pharmacists and patients identified several reasons for interest in pharmacist-prescribed contraception services, including increasing patient access, reducing unintended pregnancies, and offering professional development for pharmacists. They also identified barriers, including payment, time and resource constraints, liability, and patient health concerns. CONCLUSIONS: Most pharmacists and patients across 15 studies were interested in expanded access to contraception through pharmacist-prescribed contraception. Findings on facilitators and barriers may inform implementation efforts. Implications Pharmacist-prescribed contraception is a strategy to expand patient access to contraception. Reducing barriers to implementation could improve participation among pharmacists and patients.

PROBLEM/CONDITION: Since 1969, CDC has conducted abortion surveillance to document the number and characteristics of women obtaining legal induced abortions in the United States. PERIOD COVERED: 2016. DESCRIPTION OF SYSTEM: Each year, CDC requests abortion data from the central health agencies of 52 reporting areas (the 50 states, the District of Columbia, and New York City). The reporting areas provide this information voluntarily. For 2016, data were received from 48 reporting areas. Abortion data provided by these 48 reporting areas for each year during 2007-2016 were used in trend analyses. Census and natality data were used to calculate abortion rates (number of abortions per 1,000 women aged 15-44 years) and ratios (number of abortions per 1,000 live births), respectively. RESULTS: A total of 623,471 abortions for 2016 were reported to CDC from 48 reporting areas. Among these 48 reporting areas, the abortion rate for 2016 was 11.6 abortions per 1,000 women aged 15-44 years, and the abortion ratio was 186 abortions per 1,000 live births. From 2015 to 2016, the total number of reported abortions decreased 2% (from 636,902), the abortion rate decreased 2% (from 11.8 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 1% (from 188 abortions per 1,000 live births). From 2007 to 2016, the total number of reported abortions decreased 24% (from 825,240), the abortion rate decreased 26% (from 15.6 abortions per 1,000 women aged 15-44 years), and the abortion ratio decreased 18% (from 226 abortions per 1,000 live births). In 2016, all three measures reached their lowest level for the entire period of analysis (2007-2016). In 2016 and throughout the period of analysis, women in their 20s accounted for the majority of abortions and had the highest abortion rates. In 2016, women aged 20-24 and 25-29 years accounted for 30.0% and 28.5% of all reported abortions, respectively, and had abortion rates of 19.1 and 17.8 abortions per 1,000 women aged 20-24 and 25-29 years, respectively. By contrast, women aged 30-34, 35-39, and >/=40 years accounted for 18.0%, 10.3%, and 3.5% of all reported abortions, respectively, and had abortion rates of 11.6, 6.9, and 2.5 abortions per 1,000 women aged 30-34, 35-39, and >/=40 years, respectively. From 2007 to 2016, the abortion rate decreased among women in all age groups. In 2016, adolescents aged <15 and 15-19 years accounted for 0.3% and 9.4% of all reported abortions, respectively, and had abortion rates of 0.4 and 6.2 abortions per 1,000 adolescents aged <15 and 15-19 years, respectively. From 2007 to 2016, the percentage of abortions accounted for by adolescents aged 15-19 years decreased 43%, and the abortion rate decreased 56%. This decrease in abortion rate was greater than the decreases for women in any older age group. In contrast to the percentage distribution of abortions and abortion rates by age, abortion ratios in 2016 and throughout the entire period of analysis were highest among adolescents and lowest among women aged 25-39 years. Abortion ratios decreased from 2007 to 2016 for women in all age groups. In 2016, almost two-thirds (65.5%) of abortions were performed at </=8 weeks' gestation, and nearly all (91.0%) were performed at </=13 weeks' gestation. Fewer abortions were performed between 14 and 20 weeks' gestation (7.7%) or at >/=21 weeks' gestation (1.2%). During 2007-2016, the percentage of abortions performed at >13 weeks' gestation remained consistently low (8.2%-9.0%). Among abortions performed at </=13 weeks' gestation, the percentage distributions of abortions by gestational age were highest among those performed at </=6 weeks' gestation (35.0%-38.4%). In 2016, 27.9% of all abortions were performed by early medical abortion (a nonsurgical abortion at </=8 weeks' gestation), 59.9% were performed by surgical abortion at </=13 weeks' gestation, 8.8% were performed by surgical abortion at >13 weeks' gestation, and 3.4% were performed by medical abortion at >8 weeks' gestation; all other methods were uncommon (0.1%). Among those that were eligible for early medical abortion on the basis of gestational age (i.e., performed at </=8 weeks' gestation), 41.9% were completed by this method. In 2016, women with one or more previous live births accounted for 59.0% of abortions, and women with no previous live births accounted for 41.0%. Women with one or more previous induced abortions accounted for 43.1% of abortions, and women with no previous abortions accounted for 56.9%. Deaths of women associated with complications from abortion are assessed as part of CDC's Pregnancy Mortality Surveillance System. In 2015, the most recent year for which data were reviewed for abortion-related deaths, two women were identified to have died as a result of complications from legal induced abortion and for one additional death, it was unknown whether the abortion was induced or spontaneous. INTERPRETATION: Among the 48 areas that reported data every year during 2007-2016, decreases in the total number, rate, and ratio of reported abortions resulted in historic lows for the period of analysis for all three measures of abortion. PUBLIC HEALTH ACTION: The data in this report can help program planners and policymakers identify groups of women with the highest rates of abortion. Unintended pregnancy is the major contributor to induced abortion. Increasing access to and use of effective contraception can reduce unintended pregnancies and further reduce the number of abortions performed in the United States.