Abstract
Objectives
We aimed to: (a) describe current use of mifepristone for early pregnancy loss (EPL) management in Utah, (b) identify predictors of knowledge pre‐ and posteducational video, and (c) explore postvideo impacts on the likelihood to use mifepristone. Mifepristone is subject to the Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) requirements.
Methods
Between September 2020 and March 2021 we surveyed Utah clinicians from six specialties caring for people experiencing EPL, recruited through professional organizations and hospital listservs. Participants viewed a 3.5‐minute educational video on mifepristone for EPL and completed pre‐ and postvideo questionnaires. We evaluated predictors of high prevideo and improved postvideo knowledge using random forest regression conditional importance measures and partial dependency plots. We described current mifepristone use and video effects on likelihood to use mifepristone.
Results
Of 506 participants, most specialize in emergency medicine (172, 34%) and practice in private settings (253, 51%). Two‐thirds had heard of mifepristone (328/471, 70%). Of 176/471 (37%) attempting provision of mifepristone, actual provision occurred for 59% (104/176). Baseline knowledge scores were low (mean 4.81/13 [37%] correct). Predictors of high prevideo knowledge include provision or attempted provision of mifepristone, having heard of mifepristone, providing EPL management expectantly or via medication, and specialty type. Mean postvideo knowledge scores improved by 3.27 points (68% improvement, paired t‐test; 95% confidence interval 2.82–3.72, p < 0.0001). Postvideo, 66% (242/364) stated they are much more or somewhat more likely to use mifepristone, with compliance with FDA requirements cited as a barrier to utilization.
Conclusions
Among Utah providers, baseline mifepristone knowledge and use for EPL management are low. An educational video improved knowledge and likelihood of use, but FDA REMS requirements continue to be a barrier to including mifepristone in medication management of EPL.
INTRODUCTION
Each year in the United States, early pregnancy loss (EPL) occurs in approximately 10% to 30% of all pregnancies. 1 , 2 , 3 , 4 EPL is defined as pregnancy loss before 12 weeks and 6 days gestation by last menstrual period and includes inevitable and incomplete abortions, anembryonic gestation, and embryonic death. EPL treatment has become more complicated in many U.S. locations following the Supreme Court's overturning the legal right to abortion. In some states strict physician penalties for violating abortion laws have created additional concerns for managing EPL. This makes clarifying EPL treatment options even more important. People receiving the diagnosis of a nonviable pregnancy can choose among these three treatment options: expectant management, medication, or surgical (uterine aspiration). 5 , 6
For those choosing medication management, providing an evidence‐based regimen for treatment is paramount to optimize quality of care. Until 2018, clinicians providing medication management used misoprostol, a prostaglandin analog, with a success rate for complete uterine evacuation of approximately 71%. 5 A 2018 randomized control trial investigated the addition of mifepristone to misoprostol for medication management and found a higher expulsion rate in the two‐medication regimen (83.8% vs. 67.1%, risk ratio (RR) 1.25, 95% confidence interval [CI] 1.09–1.43) and significantly decreased the number of patients needing surgical uterine evacuation (8.8% vs. 23.5%, RR 0.37, 95% CI 0.21–0.68). 7 Shortly following publication of this study, the American College of Obstetricians and Gynecologists (ACOG) revised their guidelines to recommend mifepristone plus misoprostol for medication management of EPL, which is now the standard of care. 4
Although data and professional organizations support the use of mifepristone for medication management of EPL, significant implementation barriers remain, including provider knowledge and the Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) requirements. The REMS requires the prescribing provider to be registered with mifepristone's manufacturing company; administer mifepristone in a clinic, office, or hospital; provide a medication guide to the patient; and sign an FDA‐approved medication agreement form outlining the usage and potential risks of the medication, which uses language specific to induced abortion and has not been updated for use in the setting of EPL. 8 In December 2021, the FDA lifted the in‐person dispensing requirement portion of the REMS, but pharmacy dispensing remains restricted.
Many specialties and provider types care for people experiencing EPL; thus, highlighting the importance of capturing the knowledge and practices of diverse practitioners. Utah has the highest birth rate in the nation and a higher fertility rate than the national average, making EPL more common. 9 , 10 Currently, mifepristone is not widely available outside of abortion clinics in Utah, and to implement evidence‐based, quality EPL care across the state, we must educate clinicians from diverse specialties that mifepristone plus misoprostol is the standard of care and how to overcome access barriers such as the FDA REMS. What remains unknown is current knowledge and practice patterns of using mifepristone in EPL management in Utah and whether a brief educational video can improve knowledge and likelihood of use. We aimed to: (a) describe current use of mifepristone for EPL management in Utah, (b) identify predictors of knowledge pre‐ and posteducational video, and (c) explore postvideo impacts on the likelihood to use mifepristone.
METHODS
From September 2020 to March 2021, we recruited providers practicing in Utah to participate in a survey on medical management of EPL. Participants were eligible for the survey if they cared for people experiencing EPL (self‐reported, defined as counseling on or providing EPL care); had an active Utah license as a physician (MD or DO), physician assistant (PA), nurse practitioner (NP), or certified nurse midwife (CNM); and were English speaking. Recruitment efforts were targeted at obstetrics and gynecology (OBGYN), emergency medicine (EM), family medicine (FM), and women's health advanced practice clinician (APC) specialties. Exclusion criteria included not providing or counseling people about EPL care and having already completed the survey.
Participant recruitment
We recruited participants through Utah‐based email listservs including Utah state medical societies and Utah chapters of professional organizations representing physicians (n = 3 including OBGYN, EM, FM), PAs (n = 1), NPs (n = 1), and CNMs (n = 1) and hospital‐based groups including OBGYN (n = 2), EM (n = 2), FM (n = 1), and CNM (n = 2). APCs other than CNMs were included in the hospital‐based listservs under the specialty in which they practice. Listserv membership ranged from 14 to 921, except for one list of NPs not restricted to those involved in EPL management which had approximately 2700 members. Listservs were not mutually exclusive and recipients could have been on more than one list. We were not able to assess the magnitude of overlap between lists, but used the email entered for compensation to remove any duplicate entries. Recruitment emails were sent directly by the study team or listserv moderators with up to five reminder emails sent over a 7‐month period.
Participants completing all sections of the pre‐and postsurvey received a $40 Amazon gift code as compensation. The University of Utah Institutional Review Board approved the study and all participants received a consent cover letter prior to participation.
Survey and educational video development
The 51‐item, 15‐ to 20‐min survey included sections in the following order: provider clinical characteristics, EPL management practices, knowledge of mifepristone for EPL pre‐ and post–educational video, postvideo intention to use mifepristone, and demographics (full survey available upon request). We adapted survey questions from published articles on medical abortion 11 , 12 and misoprostol use 13 as well as created questions de novo to meet our objectives. Knowledge questions included basics of mifepristone mechanism of action, dosing and route, and side effects (see Appendix S1). We performed think‐aloud cognitive interviews with a diverse set of 10 reproductive health providers, which included APCs and physicians of varying specialties. 14 We then piloted the survey with 10 physicians and APCs who were familiar with mifepristone for EPL management for content validity and completion time. We provided compensation for those who participated in cognitive interviews and piloting the survey. Following the development of the surveys, we built and managed survey distribution and data collection online through the University of Utah's secure web‐based platform, Research Electronic Data Capture (REDCap). 15
We developed a 3‐min 47‐s educational video on the use of mifepristone for EPL management. We based the script on ACOG and Society of Family Planning recommendations with guidance from local content experts (DKT, LMG). The video reviewed mifepristone's mechanism of action, candidate selection, recommended medication regimen, REMS navigation, and recommended follow‐up. The University of Utah Genetic Science Learning Center created the animated video with close input of the research team. We then embedded a private YouTube link to the video immediately after the preknowledge questions in the online survey. The same survey pilot participants also reviewed the video in its final form and survey location (for the video, see Appendix S1).
Statistical analysis
We primarily aimed to assess predictors of high baseline knowledge of mifepristone for EPL management and predictors of improved knowledge after the educational video. For each outcome of interest (prevideo knowledge and change in postvideo knowledge), we measured variable importance using random forest regression. We exclude the specialties of obstetric fellowship–trained EM (n = 2) and internal medicine (n = 7) from these and future analyses due to their rarity. We also removed completed duplicate entries from the same participant and their initial survey response was used in the analysis (n = 11). We were not able to determine if a participant started the survey more than once but did not complete the entirety. Considering the likelihood of collinearity between independent variables, we used the conditional permutation algorithm, which is not as biased toward correlated variables when measuring importance as are other random forest variable importance measures. 16 We presented the order of importance of variables (metric: decrease in mean squared error) as well as partial dependency plots to show the relationship between each variable and each outcome as determined by the random forest model. The partial dependency plots show the marginal effect, or effect averaged over other model features' values, that a feature has on the predicted outcome of a machine learning model. 17 A partial dependency plot can show whether the relationship between the target and a feature is linear, monotonic, or more complex. We can use these plots to better understand the direction of each effect and assess the linearity of the independent variables. Using the order of importance, we fit nested multiple linear regression models and used the likelihood ratio test to determine a final model fit starting with the most parsimonious model. Given the exploratory nature of this analysis in which we first conducted variable selection and then model selection, p‐values should be interpreted with caution.
For participants completing the knowledge questions, if a response is missing, we assumed the participant answered incorrectly. For covariates (clinical information and demographics), we include missing values as a category in the random forest analysis and excluded it from the multiple linear regression for categorical variables and coded missing values as 0 for variables in which respondents were asked to supply the percent of time spent in various clinical settings. We additionally included tabulation of which questions were answered correctly pre‐ and postvideo as well as barriers to mifepristone use. Each knowledge question was worth one point. “Select all that apply” questions were only given a correct score if all correct options were selected and no incorrect options were selected.
Our secondary outcomes included current use of mifepristone for EPL and the effect of the video on rates of likelihood to use mifepristone in the future. We performed descriptive statistics in which we provide graphical displays of counts/percentages observed in the data.
RESULTS
Clinical characteristics and demographics
A total of 530 participants attempted the survey and 392 completed all parts (74%). After duplicates (n = 11), those who did not specify a specialty (n = 4), and internal medicine (n = 7) and obstetric‐trained FM (n = 2) specialty types were removed, a total of 506 participants attempted the survey and 368 completed all sections, rendering a final completion rate of 73%. Clinical characteristics (n = 506, 100% completion) and demographics (n = 368, 73% completion) of participants are presented in Table 1. Of those who provided demographic information, most practiced in a metropolitan or urban center (70.4%), private hospital, or clinic (51%) and specialized in EM (34%).
TABLE 1.
Clinical characteristics (n = 506) and demographics (n = 368) of respondents to a survey about mifepristone use for medication management of EPL
| Variable | |
|---|---|
| Specialty | |
| EM | 172 (34) |
| FM | 129 (25.5) |
| OBGYN | 97 (19.2) |
| Other | 55 (10.9) |
| Certified nurse midwifery | 31 (6.1) |
| Women's health | 22 (4.3) |
| Degree | |
| MD | 267 (51) |
| NP | 163 (31.1) |
| CNM | 37 (7.1) |
| DO | 36 (6.9) |
| PA | 15 (2.9) |
| Other | 6 (1.1) |
| Geographic location | |
| Metropolitan/urban (population ≥ 50,000) | 354 (70.4) |
| Micropolitan/large urbanized cluster (population 10,000‐49,999) | 99 (19.7) |
| Small town/small urbanized cluster (population 2500‐9999) | 38 (7.6) |
| Rural (population < 2500) | 11 (2.2) |
| Frontier (population < 5) | 1 (0.2) |
| Practice setting | |
| Private hospital/clinic | 253 (51) |
| Academic center | 129 (26) |
| Public hospital/clinic | 78 (15.7) |
| Federally qualified health center | 22 (4.4) |
| Other | 11 (2.2) |
| Indian Health Services or Veterans Affairs | 3 (0.6) |
| Length of time in practice posttraining (years) | |
| <5 | 171 (34.1) |
| 5–10 | 126 (25.1) |
| 10–20 | 117 (23.4) |
| >20 | 87 (17.4) |
| Gender | |
| Female | 208 (41.1) |
| Male | 153 (30.2) |
| Transgender | 0 (0) |
| Nonbinary or nonconforming | 0 (0) |
| Prefer to self‐describe | 0 (0) |
| Prefer not to answer | 7 (1.4) |
| Age (years) | 41.0 (35.0–49.0) |
Note: Data are reported as n (%) or median (IQR). Missing values: degree = 2, geographic location = 3, practice setting = 10, length of time in practice posttraining = 5, Age = 173.
Abbreviations: CNM, certified nurse midwife; FM, family medicine; EPL, early pregnancy loss; NP, nurse practitioner; OBGYN, obstetrics and gynecology; PA, physician assistant.
Current practice
Participants counseled on and provided a range of EPL management options, with surgical interventions largely performed by OBGYNs (Figure 1). On average, 70% (n = 328/471) of those participants who completed the prevideo survey had heard of mifepristone, and 37% (n = 176/471) had provided or wanted/tried to provide with only 59% (n = 104/176) of those achieving actual provision. More OBGYNs (n = 71/94, 76%) and CNMs (n = 21/31, 68%) had provided or wanted/tried to provide mifepristone than other specialties (EM, n = 39/164, 24%; and FM, n = 32/118, 27%). Of those who had tried to provide mifepristone in patient care, OBGYNs (n = 52/71, 73%), CNMs (n = 14/21, 67%), and women's health APCs (n = 7/9, 78%) were most successful with other specialties, EM and FM, dropping to 59% (n = 19/39) and 31% (n = 10/32), respectively.
FIGURE 1.
EPL management strategies counseled on and provided by specialty type. N = 368. EPL, early pregnancy loss; Fam Med, family medicine; OBGYN, obstetrics and gynecology.
Knowledge
A total of 420 participants completed the prevideo knowledge questions (83%) and 368 then completed the postvideo knowledge questions (73%). Baseline knowledge scores were low (mean 4.81/13 [37%] correct). Figure 2 includes the nine most important predictors of high prevideo knowledge. To interpret the multiple linear regression (Table 2), the estimate represents the expected increase in baseline score correct based on the presence of the listed variable. This includes past provision or attempted provision of mifepristone (estimate 1.22 [95% CI 0.46–1.98], p = 0.002), having heard of mifepristone (estimate 1.22 [95% CI 0.49–1.95], p = 0.001), provision of medication or expectant EPL management (estimate 1.19 [95% CI 0.44–1.94], p = 0.002; and estimate 1.77 [95% CI 0.71–2.83], p = 0.001, respectively), and specialty type (OBGYN estimate 2.82 [95% CI 1.90–3.74], p < 0.001; FM estimate 1.04 [95% CI 0.22–1.86], p = 0.014; CNM estimate 2.44 [95% CI 1.12–3.76], p < 0.001; and women's health APC estimate 1.88 [95% CI 0.50–3.26], p = 0.008; Figure 2, Table 2). Participants improved their knowledge score by 68% (mean improvement 3.27 points, paired t‐test; 95% CI 2.82–3.72, p < 0.0001) after viewing the video. Figure 3 presents the nine most important postvideo knowledge score improvement predictors. Low prevideo knowledge score (estimate −0.26 [95% CI −0.40 to −0.12], p < 0.001) predicted improvement in postvideo knowledge. As prevideo score is continuous, the regression shows that for each additional point in prevideo knowledge, we expect approximately a quarter of a point less improvement. Prior provision or attempted provision of mifepristone (estimate −2.05 [95% CI −3.12 to −0.98], p < 0.001) also predicted improvement in postvideo knowledge score, where those that have provided or attempted provision of mifepristone are expected to have 2‐points‐less improvement than those who have not. Over 94% (345/366) of all participants found the educational video very helpful or somewhat helpful in improving their knowledge. None rated the video as unhelpful.
FIGURE 2.
Partial dependency plots for the first nine most important predictors for total prevideo knowledge scores (%) using the random forest conditional permutation algorithm. Thirteen knowledge questions on use of mifepristone for medication management for EPL were asked prior to watching the video. N = 420. EPL, early pregnancy loss; Fam Med, family medicine; FQHC, federally qualified health center; IHS/VA, Indian Health Services/Veterans Affairs; OBGYN, obstetrics and gynecology
TABLE 2.
Multiple linear regression for pre‐educational video predictors of high baseline knowledge of mifepristone use for medication management of EPL based on the random forest regression
| Variable | Estimate (95% CI) | p‐value |
|---|---|---|
| (Intercept) | −0.79 (−2.00 to 0.42) | 0.202 |
| Has provided or wanted/tried to provide mifepristone | 1.22 (0.46 to 1.98) | 0.002 * |
| Has heard of mifepristone | 1.29 (0.49 to 1.95) | 0.001 * |
| Type of EPL management provided | ||
| Medication management, i.e., use of misoprostol +/− mifepristone | 1.19 (0.44 to 1.94) | 0.002 * |
| Expectant management, i.e., waiting for spontaneous expulsion | 1.77 (0.71 to 2.83) | 0.001 * |
| Specialty | ||
| FM | 1.04 (0.22 to 1.86) | 0.014 * |
| Certified nurse midwifery | 2.44 (1.12 to 3.76) | <0.001 * |
| OBGYN | 2.82 (1.90 to 3.74) | <0.001 * |
| Other | 0.93 (−0.37 to 2.23) | 0.164 |
| Women's health | 1.88 (0.50 to 3.26) | 0.008 * |
| Services provided at practice location: abortion care | 0.55 (−0.33 to 1.43) | 0.224 |
| Services provided by each participant: abortion care | 1.49 (0.22 to 2.76) | 0.022 * |
Note: The estimate represents the expected increase in baseline score correct based on the presence of the listed variable. N = 420.
Abbreviations: EPL, early pregnancy loss; FM, family medicine; OBGYN, obstetrics and gynecology.
*represent a significant p‐vaule.
FIGURE 3.
Partial dependency plots for the first nine most important predictors for difference between postvideo and prevideo knowledge scores (%) using the random forest conditional permutation algorithm. Thirteen knowledge questions on use of mifepristone for medication management for EPL were asked prior to watching the video. N = 368. EPL, early pregnancy loss; ER, emergency room; Fam Med, family medicine; FQHC, federally qualified health center; IHS/VA, Indian Health Services/Veterans Affairs; OBGYN, obstetrics and gynecology
Likelihood to use
After viewing the educational video, 364 participants (72%) completed questions on likelihood to use mifepristone in the future. Sixty‐six percent stated they would be much more or somewhat more likely to use mifepristone (242/364). This percentage rose to 79% if barriers, like FDA REMS requirements, were removed (288/364). After viewing the video, very few participants rated they were much less likely or somewhat less likely to use mifepristone (n = 21/364, 6%). When asked to rank the top five reasons for being unlikely to provide, 20/21 less likely to use mifepristone ranked at least one reason. Seven of 20 (35%) ranked compliance with burdensome FDA requirements in their top five, seven of 20 ranked not having enough clinical support (35%), six of 20 (30%) ranked outside their scope of practice, and six of 20 (30%) ranked risk of complications or failure most frequently.
DISCUSSION
Among Utah providers, baseline mifepristone knowledge and use for EPL management are low, and an educational video improved knowledge and likelihood of use. However, the FDA REMS requirements continue to be a barrier to including mifepristone in medication management of EPL. ACOG recommends the use of mifepristone plus misoprostol for medication management of EPL based on a 2018 landmark paper showing its effectiveness over misoprostol alone. 4 , 7 Given this recent change, few data exist regarding knowledge or likelihood of using mifepristone for this indication among providers of any specialty type. Our results provide a broad view of current practice that includes multiple specialties as well as data on mifepristone for EPL knowledge, likelihood of using mifepristone, and the effect of an educational video on these variables.
We described predictors of high baseline knowledge and of improved knowledge scores after an educational video. While predictors have not been previously described for mifepristone use for medication management of EPL, previous studies have described predictors of high baseline knowledge in respect to mifepristone use for abortion. Similar to our findings, high baseline knowledge correlates with those that are currently using mifepristone. 11 , 12 By knowing the predictors of high baseline knowledge and improvement in score, future projects aiming to implement training programs to introduce mifepristone for EPL can be targeted toward specific groups and practitioners.
One barrier to mifepristone use noted in our study is the FDA REMS. A prior study on the effects of the FDA REMS on mifepristone use for abortion or EPL management in primary care found a low proportion of providers using mifepristone for EPL (35%) and that the REMS caused unnecessary burdens for providers and patients. 18 Our study's findings are in line with this and provide further evidence for the access barriers the REMS imposes on EPL care. 19 After completion of our data collection, the FDA lifted the requirement for in‐person dispensing of mifepristone in December 2021 and is thus not reflected in these data or the educational video. Although state law and institutional policy may continue to require in‐person dispensing, this change at the federal level may lessen the burden of the FDA REMS felt by some providers offering EPL care in less restrictive states. While the FDA REMS is one of the barriers identified by participants, further research is also needed into additional barriers noted by participants.
Our study's strengths include recruitment of a diverse set of specialties and degree types, statewide involvement with representation from various practice settings, and development of a brief educational video for improving knowledge of mifepristone for medication management of EPL. The use of random forest regression feature importance allows us to assess whether variables are important regardless of a nonlinear relationship with the knowledge outcomes or complex interactions with other variables.
LIMITATIONS
Although difficult to fully generalize these results beyond Utah, the interest in adopting mifepristone for EPL by a wide variety of specialties in a state with restricted abortion access is promising for other restrictive states. We experienced a high attrition rate with each section of the survey and this is most likely due to the amount of time required to complete all the components. Even with the attrition, 73% of initial respondents completed the survey to the end. Self‐selection bias for those with prior knowledge of mifepristone and greater interest in providing this type of care is possible, but only 31% to 73% of participants by specialty type had heard of mifepristone excluding OBGYNs and CNMs (97% and 94%, respectively). We gathered these data prior to the recent U.S. Supreme Court's Dobbs decision removing the right to legal abortion. Thus, we cannot assess how the new legal environment will influence these responses. Legal limitations on abortion access with criminal penalties for physicians may create confusion on EPL management. 20 This likely increases the need for greater clarity on the safe and legal use of mifepristone for EPL management.
CONCLUSIONS
Our study found that a brief educational video improves knowledge and likelihood to use mifepristone for medication management of early pregnancy loss. Improving knowledge of mifepristone for this indication across specialties could support increased adherence to the American College of Obstetricians and Gynecologists recommended practice guidelines for management of early pregnancy loss. However, the routinization of new evidence‐based regimens in clinical medicine is a slow process, taking on average 17 years. 21 Finding a faster way to disseminate the new standard of care for medication management of early pregnancy loss is paramount to improving care for people experiencing early pregnancy loss. The widespread use of our educational tool, updated to reflect recent changes to the Food and Drug Administration's Risk Evaluation and Mitigation Strategy, across specialties in conjunction with a robust implementation science framework 22 is an important next step to promote high‐quality, evidence‐based care for medication management of early pregnancy loss.
AUTHOR CONTRIBUTIONS
Jennifer E. Kaiser and Theresa Kurtz conceived the study concept and design together. Both were integral in the analysis and interpretation of the data. Annabah Glasser provided survey support. Jennifer E. Kaiser drafted the manuscript. Theresa Kurtz, Lori M. Gawron, David K. Turok, Annabah Glasser, Benjamin J. Brintz, and Jessica N. Sanders provided critical revision of the manuscript. Lori M. Gawron, David K. Turok, and Jessica N. Sanders also provided key input on study design and data interpretation. Benjamin J. Brintz provided data analysis and interpretation.
CONFLICT OF INTEREST
The Department of Obstetrics and Gynecology at the University of Utah receives funding from Organon, Medicines 360, Sebela, and Femasys for sponsored clinical trials, for which LMG and DKT serve as site principal investigators. The other authors declare no potential conflict of interest.
Supporting information
Appendix S1.
Kaiser JE, Kurtz T, Glasser A, et al. Mifepristone for miscarriage treatment in Utah: A survey of clinician knowledge and assessment of an educational video on future use. AEM Educ Train. 2022;6:e10834. doi: 10.1002/aet2.10834
Presented at the American College of Obstetricians and Gynecologists Annual Clinical & Scientific Meeting, San Diego, CA, May 2022.
Funding informationThis project was funded by the University of Utah Department of OBGYN Research Seed Grant, 2020–2021. Use of REDCap was provided by 8UL1TR000105 (formerly UL1RR025764) NCATS/NIH. This investigation was supported by the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002538. JNS receives support from the AHRQ Award Number K01HS027220. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. This research was made possible through support from the Utah ASCENT Center for Reproductive and Sexual Health.
Supervising Editor: Dr. Anne Messman.
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Supplementary Materials
Appendix S1.