January 1, 2019

Isabel Morgan

Isabel Morgan

Prior to her August 2018 enrollment in the doctoral program in maternal and child health at the UNC Gillings School of Global Public Health, Isabel Morgan, MSPH, led a range of research projects during her tenure at the Centers for Disease Control and Prevention (CDC). The results of three of those projects recently were published in noted journals.

Morgan’s research team — comprised of CDC colleagues Yokabed Ermias, MPH, Lauren B. Zapata, PhD, Kathryn M. Curtis, PhD, and Maura K. Whiteman, PhD – analyzed health care providers’ attitudes and practices related to providing adolescents contraception on the day of the initial health care visit. The findings, “Health Care Provider Attitudes and Practices Related to ‘Quick Start’ Provision of Combined Hormonal Contraception and Depot Medroxyprogesterone Acetate to Adolescents,” were published online Nov. 1, 2018, in the Journal of Adolescent Health.

The Quick Start approach has been successful in providing adult women with contraceptives. This study focused on adolescents, as there are limited data on health care provider attitudes on the safety of using Quick Start initiation for this population. Provider attitude is an important factor that may influence contraceptive counseling strategies and provision of contraception. The study looked at types of hormonal contraception, including combined hormonal contraception, or CHC (oral contraceptive pills, contraceptive patch, vaginal ring), and depot medroxyprogesteroneacetate (DMPA).

During 2013−2014, surveys were mailed to a random sample of 4,000 public-sector health centers that provide family planning services and 2,000 office-based physicians. The survey was a 33-item questionnaire designed to assess health care providers’ attitudes and practices related to contraceptive provision and application of federal contraceptive guidance and recommendations.

The researchers found that the majority of providers consider Quick Start initiation of CHC and DMPA safe for adolescents – 87.5 percent of public-sector providers and 80.2 percent of office-based physicians thought that same-day initiation of CHC is safe, while 80.9 percent of public-sector providers and 78.8 percent of office-based physicians believe that same-day initiation of DPMA is safe for this population.

However, the prevalence of frequent Quick Start provision was lower, particularly among office-based physicians, with 45.2 percent providing CHC and 46.9 percent providing DMPA, while 74.2 percent of their public-sector based counterparts provided CHC and 71.4 percent provided DMPA.

“Generally, providers perceive CHC and DMPA as acceptable contraceptive methods for adolescents,” said Morgan. “The study was important because it allowed us to identify provider concerns about same-day initiation of these methods to adolescents.”

The research team believes that these findings can inform guideline dissemination efforts and the development and/or updating of facility-based protocols to support Quick Start provision of CHC and DMPA to adolescents.

“Addressing Intimate Partner Violence to Improve Women’s Preconception Health” appeared online in the Nov. 10, 2018, issue of the Journal of Women’s Health. In this commentary, Morgan and her co-authors—Cheryl L. Robbins, PhD, with the CDC’s Division of Reproductive Health, and Kathleen C. Basile, PhD, with the CDC’s Division of Violence Prevention—describe the implications of intimate partner violence (IPV) on women’s health, specifically for women of reproductive age.

The researchers also discuss prevention of IPV and health care recommendations – and examine surveillance systems that capture IPV indicators among women of reproductive age.

“This commentary was a response to state health officials’ concern that the shortlist of preconception health indicators released by CDC did not contain exposure to intimate partner violence,” said Morgan. “We echo those sentiments of the importance of considering how violence and trauma impact women’s preconception health and encourage monitoring of the prevalence of IPV using available IPV surveillance systems.”

State health departments and maternal and child health researchers may use these data to identify and implement strategies to prevent IPV exposure among women of reproductive age.

Morgan was also a key member of the research team that produced “State-Identified Implementation Strategies to Increase Uptake of Immediate Postpartum Long-Acting Reversible Contraception Policies” published in the November 2018 issue of the Journal of Women’s Health.

The team also included Morgan’s CDC colleagues David A. Goodman, PhD, Charlan D. Kroelinger, PhD, and Shanna Cox, MSPH; Kristin M. Rankin, PhD, Alisa Velonis, PhD, Carla L. DeSisto, MPH, and Cameron Estrich, MPH, from the University of Illinois at Chicago’s School of Public Health; and Lisa F. Waddell, MD, MPH, Christine Mackie, MPH, and Ellen Pliska, MHS, CPH, with the Association of State and Territorial Health Officials.

With the knowledge that approximately 45 percent of pregnancies in the United States are unintended, and that long-acting reversible contraceptives (LARC)—such as intrauterine devices and contraceptive implants—are the most effective form of reversible contraception, a group of states participated in a national activity to share experiences from implementing statewide systems change.

In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum LARC Learning Community to facilitate cross-state collaboration in implementation of policies. Semi-structured interviews were conducted by the ASTHO team with 13 state team members participating in the Learning Community.

Using qualitative analysis, the state-reported domains with the most strategies were identified, including stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation.

The researchers concluded that implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, which is a public health service for preventing short intervals between births and unintended pregnancy among postpartum women.

Morgan is interested in using what she has learned from her CDC projects to inform her dissertation work.

“I am grateful for my experience in the Division of Reproductive Health and to my mentors Drs. Kathryn Curtis, Lauren Zapata, and Maura Whiteman, who challenged me to think about the public health implications and translation of our research,” she said.

Morgan plans to examine factors associated with postpartum care utilization among women with pregnancy-related complications and assess predictors in black women’s satisfaction with postpartum care services.


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