Although religious restrictions on providing contraceptive care have been documented in U.S. Catholic health care systems, it is unclear whether providers at Catholic facilities are able to address women's contraceptive needs when faced with such policies, or whether providers at Protestant and secular facilities encounter similar restrictions. Yuan Liu and colleagues explored these issues through in‐depth interviews with 28 key informants—including physicians, nurse‐midwives and nonclinical professionals—who worked in Catholic, Protestant or secular health care systems in Illinois (page 193). Interviews revealed that staff working in Protestant and secular hospitals faced few limitations on their provision of contraceptive care, whereas those working in Catholic hospitals encountered multiple barriers. Policies and enforcement practices at Catholic institutions varied, but included verbal admonishments of providers who violated church doctrine and lease agreements prohibiting contraceptive provision in secular clinics on church‐owned land. Many providers at Catholic facilities reported using work‐arounds to address women's contraceptive needs; some were told to document false diagnoses in patients’ medical records to justify the prescription of hormonal methods. Although work‐arounds were meant to overcome restrictions on care, the authors warn that such actions not only can be ethically problematic but "may inadvertently stigmatize contraception and negatively affect patient care."

Also in This Issue

• In New York City, as part of the School‐Based Health Center Reproductive Health Project (SBHC RHP), SBHCs have been providing on‐site contraceptive services since 2008 in high schools identified to have students at elevated risk of pregnancy. However, the contributions of the project to citywide teenage contraceptive use—and consequently, to reductions in teenage pregnancies, births and abortions—have not been evaluated. Rebecca Fisher and colleagues conducted an evaluation using program data and public data from the NYC Bureau of Vital Statistics and the Youth Risk Behavior Survey, as well as data on the costs of publicly funded births and abortions (page 201). They found that between 2008 and 2017, the project averted an estimated 5,376 pregnancies, 2,104 births and 3,085 abortions among students, resulting in an estimated $30.4 million in avoided costs. Notably, these averted outcomes accounted for 26–28% of the decline in New York City's teenage pregnancies, births and abortions over this period. This assessment demonstrates that access to a full range of contraceptives in high schools can reduce unplanned teenage pregnancies and lead to lower public health costs.
• About 85% of sexually active women will become pregnant within a year if they do not take steps to prevent conception, yet some women may not use contraceptives, or not use highly effective methods, because they mistakenly believe they are at little or no risk of pregnancy. To explore this issue, Laura E. Britton et al. used data from a national sample of women veterans aged 20–45 who were at risk for pregnancy, received primary care through the U.S. Veterans Affairs Healthcare System and had taken part in the Examining Contraceptive Use and Unmet Needs study (page 211). Overall, 40% of the veterans thought their likelihood of becoming pregnant during a year of unprotected sex was low, and such women were less likely than those with high perceived susceptibility to pregnancy to have used a contraceptive at last intercourse. Moreover, among contraceptive users, those with low perceived susceptibility to pregnancy were less likely to have used a highly or moderately effective method at last sex. These findings suggest that women who consider themselves at low risk for pregnancy may need assistance in making informed decisions about contraception.
• U.S. federal and clinical guidelines recommend reproductive life planning (RLP) to improve women's contraceptive choices, but the effectiveness of RLP has not been systemati­cally evaluated. To examine this issue, Cynthia H. Chuang and colleagues conducted a randomized controlled study of nearly 1,000 privately insured U.S. women aged 18–40 in 2014 who did not intend to become pregnant in the next year (page 219). Women were assigned to receive RLP, RLP with contraceptive action planning (RLP+) or information only (the control group), and contraceptive measures were assessed at six‐month intervals over a two‐year period. No differences were found between the intervention groups and the control group in overall contraceptive use, contraceptive adherence, switching to a more effective method, method satisfaction or contraceptive self‐efficacy. Despite the null findings, the authors conclude that further research on RLP is needed in other settings—such as clinics—and among alternative populations—such as publicly insured or uninsured women, low‐income women, and more racially and ethnically diverse groups.
• Adolescents who have spent time in foster care have been shown to have elevated rates of early childbirth, yet findings regarding the impact of placement type and reason and number of transitions between placements have been inconsistent. To better understand the circumstances of their time in care, Bryn King et al. conducted a latent class analysis using data from linked California birth and child welfare service records of 18,090 women who had been in foster care and may have delivered their first child between 1999 and 2010, before turning 20 (page 229). The authors identified four classes of foster youth based on age at most recent entry into care, length of this stay and placement instability. The probability of early childbirth ranged from 15% to 31% for the Earlier Entry/Low Instability and Later Entry/High Instability classes, respectively. The two conditions associated with an elevated likelihood of early childbirth were entering foster care in middle to late adolescence and placement instability, and child welfare agencies can use this knowledge to address the sexual and reproductive health care needs of foster youth.

—The Editors