The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries.

Previous studies have found high levels of unintended pregnancy among female sex workers (FSW), but less attention has been paid to their abortion practices and outcomes. This study is the first to investigate abortion-related mortality among FSW across eight countries: Angola, Brazil, Democratic Republic of Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa. The Community Knowledge Approach (CKA) was used to survey a convenience sample of FSW (n = 1280). Participants reported on the deaths of peer FSW in their social networks during group meetings convened by non-governmental organisations (n = 165 groups, conducted across 24 cities in 2019). Details on any peer FSW deaths in the preceding five years were recorded. The circumstances of abortion-related deaths are reported here. Of the 1320 maternal deaths reported, 750 (56.8%) were due to unsafe abortion. The number of abortion-related deaths reported was highest in DRC (304 deaths reported by 270 participants), Kenya (188 deaths reported by 175 participants), and Nigeria (216 deaths reported by 312 participants). Among the abortion-related deaths, mean gestational age was 4.6 months and 75% occurred outside hospital. Unsafe abortion methods varied by country, but consumption of traditional or unknown medicines was most common (37.9% and 29.9%, respectively). The 750 abortion-related deaths led to 1207 children being left motherless. The CKA successfully recorded a stigmatised practice among a marginalised population, identifying very high levels of abortion-related mortality. Urgent action is now needed to deliver comprehensive sexual and reproductive healthcare to this vulnerable population, including contraption, safe abortion, and post-abortion care.

The impact of COVID-19 lockdown on abortion care: a time series analysis of data from Marie Stopes Nepal.

The COVID-19 pandemic significantly impacted sexual and reproductive health and rights. Nepal implemented a nationwide lockdown in March 2020, limiting population movement and service access. The 36 clinics run by Marie Stopes Nepal (MSN) closed for varying periods at the beginning of lockdown. This study assesses the impact of lockdown and associated clinic closures on abortion services within MSN's network. An interrupted time-series analysis of clinic-level MSN data compared abortion service use in the pre-closure and post-reopening periods, focusing on the following outcomes: number of abortion care visits, proportion of abortion-related visits, gestational age at time of abortion care and demographics of patients accessing abortion care. Subsequent meta-analyses combined clinic-level results to generate outcome-specific pooled effect estimates. As MSN clinics reopened, during ongoing wider lockdown, weekly visits for abortion care decreased by 37% on average, but abortion increased as a proportion of services post-reopening (OR: 1.53) compared with pre-closure, with no evidence of a change in the proportion of higher gestation abortions. The demographic profile of abortion care clients was altered, with post-reopening clients more likely to have completed primary education (OR: 1.54) and be aged 25 years or older (OR: 1.31) compared with pre-closure clients. COVID-19 lockdown and associated clinic closures reduced the absolute number of abortion services provided within MSN's network, impacting the composition of service provision. Reductions in safe abortion and wider SRH access will have wide-ranging consequences, curtailing crucial reproductive rights. Policy-makers must ensure ongoing abortion access to protect rights and ensure access.

Implementation research to accelerate scale-up of national screen and treat strategies towards the elimination of cervical cancer.

BACKGROUND: Cervical cancer is a significant public health problem, with 570,000 new cases and 300,000 deaths of women per year globally, mostly in low- and middle-income countries. In 2018 the WHO Director General made a call to action for the elimination of cervical cancer as a public health problem. MAIN BODY: New thinking on programmatic approaches to introduce emerging technologies and screening and treatment interventions of cervical precancer at scale is needed to achieve elimination goals. Implementation research (IR) is an important yet underused tool for facilitating scale-up of evidence-based screening and treatment interventions, as most research has focused on developing and evaluating new interventions. It is time for countries to define their specific IR needs to understand acceptability, feasibility, and cost-effectiveness of interventions as to design and ensure effective implementation, scale-up, and sustainability of evidence-based screening and treatment interventions. WHO convened an expert advisory group to identify priority IR questions for HPV-based screening and treatment interventions in population-based programmes. Several international organizations are supporting large scale introduction of screen-and-treat approaches in many countries, providing ideal platforms to evaluate different approaches and strategies in diverse national contexts. CONCLUSION: For reducing cervical cancer incidence and mortality, the readiness of health systems, the reach and effectiveness of new technologies and algorithms for increasing screening and treatment coverage, and the factors that support sustainability of these programmes need to be better understood. Answering these key IR questions could provide actionable guidance for countries seeking to implement the WHO Global Strategy towards cervical cancer elimination.

Safety, Quality, and Acceptability of Contraceptive Implant Provision by Community Health Extension Workers versus Nurses and Midwives in Two States in Nigeria.

Task sharing is a strategy with potential to increase access to effective modern contraceptive methods. This study examines whether community health extension workers (CHEWs) can insert contraceptive implants to the same safety and quality standards as nurse/midwives. We analyze data from 7,691 clients of CHEWs and nurse/midwives who participated in a noninferiority study conducted in Kaduna and Ondo States, Nigeria. Adverse events (AEs) following implant insertions were compared. On the day of insertion AEs were similar among CHEW and nurse/midwife clients-0.5 percent and 0.4 percent, adjusted odds ratio (aOR) 0.92 (95 percent CI 0.38-2.23)-but noninferiority could not be established. At follow-up 6.6 percent of CHEW clients and 2.1 percent of nurse/midwife clients experienced AEs. There was strong evidence of effect modification by State. In the final adjusted model, odds of AEs for CHEW clients in Kaduna was 3.34 (95 percent CI 1.53-7.33) compared to nurse/midwife clients, and 0.72 (95 percent CI 0.19-2.72]) in Ondo. Noninferiority could not be established in either State. Implant expulsions were higher among CHEW clients (142/2987) compared to nurse/midwives (40/3517). Results show the feasibility of training CHEWs to deliver implants in remote rural settings but attention must be given to provider selection, training, supervision, and follow-up to ensure safety and quality of provision.

Treading the Thin Line: Pharmacy Workers' Perspectives on Medication Abortion Provision in Lusaka, Zambia.

CONTEXT: Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies. METHODS: We conducted 16 in-depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka. RESULTS: We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers' motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion, and level of desperation. CONCLUSION: These findings highlight how pharmacy staff informally determine women's abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion.

Acceptability of no-test medical abortion provided via telemedicine during Covid-19: analysis of patient-reported outcomes.

INTRODUCTION: The English government approved both stages of early medical abortion (EMA), using mifepristone and misoprostol under 10 weeks' gestation, for at-home use on 30 March 2020. MSI Reproductive Choices UK (MSUK), one of the largest providers of abortion services in England, launched a no-test telemedicine EMA pathway on 6 April 2020. The objectives of this study were to report key patient-reported outcome measures and to assess whether our sample was representative of the whole population receiving no-test telemedicine EMA. METHODS: A sample of all MSUK's telemedicine EMA patients between April and August 2020 were invited to opt in to a follow-up call to answer clinical and satisfaction questions. A total of 1243 (13.7% of all telemedicine EMAs) were successfully followed-up, on average within 5 days post-procedure. RESULTS: Patients reported high confidence in telemedicine EMA and high satisfaction with the convenience, privacy and ease of managing their abortion at home. The sample responding were broadly equivalent to the whole population receiving telemedicine. No patient reported that they were unable to consult privately. The majority (1035, 83%) of patients reported preferring the telemedicine pathway, with 824 (66%) indicating that they would choose telemedicine again if COVID-19 were no longer an issue. CONCLUSIONS: Telemedicine EMA is a valued, private, convenient and more accessible option that is highly acceptable for patients seeking an abortion, especially those for whom in-clinic visits are logistically or emotionally challenging. Evidence that this pathway would be a first choice again in future for most patients supports the case to make telemedicine EMA permanent.

Getting more than "claps": incentive preferences of voluntary community-based mobilizers in Tanzania.

BACKGROUND: Marie Stopes Tanzania works with a voluntary cadre of 66 community-based mobilizers (CBMs), who are tasked with raising awareness, generating demand and providing referral to potential clients for family planning, comprehensive post-abortion care and cervical cancer screening. CBMs extend the reach of urban clinics to peri-urban communities, enhancing access to sexual and reproductive health services. In an effort to optimize performance of CBMs, a study was conducted to explore the drivers of CBM motivation and inform the design of an incentive scheme. METHODS: Three focus group discussions with 17 CBMs and 11 interviews with CBM supervisors and managers were conducted in three clinics and the head office. After thematic analysis of transcripts, findings on motivational factors were discussed in a reflection workshop and informed the development of a discrete choice experiment (DCE) involving 61 CBMs as respondents. The DCE included eight choice questions on two incentive schemes, each consisting of five attributes related to remuneration, training, supervision, benefits and identification. For each attribute, different incentive options were presented, based on the outcomes of the qualitative assessment. The DCE results were analysed using conditional logistic regression. RESULTS: A variety of factors motivated CBMs. Most CBMs were motivated to conduct their work because of an intrinsic desire to serve their community. The most mentioned extrinsic motivational factors were recognition from the community and supervisors, monthly allowance, availability of supporting materials and identification, trainings, supervision and feedback on performance. Recommendations for improvement were translated into the DCE. Incentive attributes that were found to be significant in DCE analysis (p < 0.05), in preference order, were carrying an ID card, bi-monthly training, supervision conducted via both monthly meetings at clinics and visits from the head office, and a monthly flat rate remuneration (over pay for performance). CONCLUSION: Despite the recognition that being a CBM is voluntary, incentives, especially those of non-financial nature, are important motivators. Incentive schemes should include basic compensation with a mix of other incentives to facilitate CBMs' work and enhance their motivation. Programme designs need to take into account the voices of community-based workers, to optimize their performance and service delivery to communities they serve.

Contraceptive use and discontinuation among women in rural North-West Tanzania.

INTRODUCTION: Existing estimates of contraceptive use in Tanzania rely on cross-sectional or retrospective study designs. This study used a 2-year, retrospective, month-by-month calendar of contraceptive utilization among women aged 15-49 years. METHODS: We estimated the median duration of contraceptive use, factors associated with use, and contraceptive discontinuation rates in sexually active women, using life tables and Cox proportional hazard model. RESULTS: A total of 5416 women contributed to the analysis in the study. Of the 5416 women, 942 (17%) had never had sex, 410 (7.6%) had no sexual partner in the last year. Among the 5416 women, 4064 were sexually active during the period, 814 (21.1%) were pregnant or amenorrheic, 610 (15.0%) were using contraception, and 1203 (29.6%) did not want to get pregnant but were not using contraception. In the 1813 women who wanted to avoid pregnancy, contraceptive use was lower among women over 35 years compared to younger ones (OR = 0.28, 95%CI: 0.19, 0.41), and in HIV positive women (OR = 0.89, 95%CI: 0.60-1.32). On the other hand, use was higher among women who were married/living together compared to unmarried ones (OR = 2.23, 95% CI: 1.54, 3.23). Using a 2-year retrospective contraceptive calendar, 1054 women reported contraceptive use, 15.8% discontinued within 6 months and 30.5% discontinued within 12 months. Higher rates of contraceptive discontinuation were observed among women who used pills (OR = 1.86, 95%CI: 1.25, 2.77) or injections (OR = 2.04, 95%CI: 1.59, 2.61) compared to those who used implants. CONCLUSION: Contraceptive use was significantly associated with age, education and parity, but not with HIV status. HIV status, number of living children and education are not statistically associated with discontinuation of contraceptive use Pills and injections had the highest rates of discontinuation. Wider choice and greater accessibility of long-acting contraceptive methods with better effectiveness and convenience may serve women better. Furthermore, special efforts may be needed to remove barriers to contraceptive use amongst younger women.

Drug Seller Provision Practices and Knowledge of Misoprostol in Bangladesh.

CONTEXT: In Bangladesh, prior to the availability of the approved combination regimen of mifepristone and misoprostol for menstrual regulation (MR), drug seller provision of misoprostol-only regimens for MR without a prescription was widespread but service quality was poor. Examining provider practices relating to misoprostol-only provision in Bangladesh may increase understanding of misoprostol use and provision in other low-resource, legally restrictive settings. METHODS: In 2013-2014, a countrywide cross-sectional knowledge, attitudes and practice survey was conducted among 777 randomly selected drug sellers; data were analyzed descriptively. Logistic regression was used to test the associations between exposure to three interventions designed to improve drug seller practice (nongovernmental organization [NGO]-led training, a call center and in-shop training from pharmaceutical company representatives) and correct knowledge of the misoprostol-only MR regimen. RESULTS: Almost all (97%) of the drug sellers reported providing medications intended for MR; misoprostol-only was more commonly sold than the combination regimen (96% vs. 26%). Nine percent had received NGO-led training, 62% had received in-shop training from a pharmaceutical company representative and 27% had used the call center. Overall, 19% of drug sellers knew the correct misoprostol-only MR regimen, and 74% wanted more information about this regimen. Correct regimen knowledge was positively associated with receipt of NGO training and call center utilization (odds ratios, 2.0 and 1.9, respectively). CONCLUSIONS: NGO-led training and call centers should be considered in other settings in which misoprostol alone is provided off-label for pregnancy termination.

RESUMEN Contexto: En Bangladesh, antes de que el régimen combinado de mifepristona y misoprostol fuera aprobado para la regulación menstrual (RM), la provisión sin receta de regímenes de misoprostol solo para RM por parte de vendedores de medicamentos estuvo muy generalizada, pero la calidad de servicio era deficiente. Examinar las prácticas de los proveedores relacionadas con la provisión de misoprostol solo en Bangladesh podría aumentar la comprensión sobre el uso y la provisión de misoprostol en otros entornos de bajos recursos restringidos legalmente. Métodos: Entre 2013 y 2014, se realizó una encuesta transversal de conocimientos, actitudes y prácticas en todo el país entre 777 vendedores de medicamentos seleccionados al azar; los datos fueron analizados descriptivamente. Se utilizó regresión logística para evaluar las asociaciones entre la exposición a tres intervenciones diseñadas para mejorar las prácticas de los vendedores de medicamentos (capacitación conducida por una organización no gubernamental [ONG], un centro de atención telefónica y capacitación en el negocio por parte de representantes de las compañías farmacéuticas), así como el conocimiento correcto del régimen de misoprostol solo usado para RM. Resultados: Casi la totalidad (97%) de los vendedores de medicamentos informaron que estaban vendiendo medicamentos para RM; que la venta de misoprostol solo era más común que el régimen combinado (96% vs 26%). El nueve por ciento había recibido capacitación impartida por ONG, el 62% había recibido capacitación en su negocio de un representante de una compañía farmacéutica y el 27% había utilizado el centro de llamadas. En general, el 19% de los vendedores de medicamentos conocía el régimen correcto de RM basado en misoprostol solo y el 74% quería más información sobre ese régimen. El conocimiento correcto del régimen se asoció positivamente con la recepción de capacitación de las ONG y la utilización del centro de atención telefónica (razón de probabilidades, 2.0 y 1.9, respectivamente). Conclusiones: La capacitación conducida por ONG y el uso del centro de atención telefónica deberían considerarse en otros entornos restringidos en los que el misoprostol solo se proporciona sin autorización para la interrupción del embarazo.

RÉSUMÉ Contexte: Au Bangladesh, avant la disponibilité du traitement homologué au mifépristone associé au misoprostol pour la régulation menstruelle (RM), la prestation par les vendeurs de médicaments des traitements de RM au misoprostol seul sans ordonnance était répandue, mais la qualité du service était faible. L'examen des pratiques de prestation relatives à la fourniture de misoprostol seul au Bangladesh peut aider à mieux cerner l'usage et l'offre de ce médicament dans d'autres contextes à faibles ressources soumis à des lois restrictives. Méthodes: En 2013­2014, une étude transversale sur les connaissances, les attitudes et les pratiques à l'échelle du pays a été menée auprès de 777 vendeurs de médicaments sélectionnés aléatoirement, pour analyse descriptive des données. La régression logistique a servi au test des associations entre l'exposition à trois interventions conçues pour améliorer la pratique des vendeurs de médicaments (formation sous la conduite d'organisations non gouvernementales [ONG], établissement d'un centre d'appels et formation par des représentants de laboratoires pharmaceutiques) et la connaissance correcte du traitement de RM à base de misoprostol seul. Résultats: Presque tous les vendeurs de médicaments (97%) ont déclaré vendre des médicaments destinés à la RM. Le misoprostol seul était vendu plus fréquemment que le traitement d'association (96% vs 26%). Neuf pour cent avaient bénéficié d'une formation par une ONG, 62% d'une formation locale assurée par un représentant de laboratoire pharmaceutique et 27% avaient eu recours au centre d'appels. Globalement, 19% des vendeurs avaient une connaissance correcte du traitement de RM à base de misoprostol seul et 74% désiraient plus d'information à ce sujet. La connaissance correcte du traitement était associée positivement à l'obtention d'une formation par une ONG et au recours au centre d'appels (RC, 2,0 et 1,9, respectivement). Conclusions: La formation sous la conduite d'une ONG et l'établissement d'un centre d'appels doivent être envisagés dans d'autres contextes sujets à une législation restrictive dans lesquels le misoprostol seul est proposé hors indication pour l'interruption d'une grossesse.

Unintended Consequences of mHealth Interactive Voice Messages Promoting Contraceptive Use After Menstrual Regulation in Bangladesh: Intimate Partner Violence Results From a Randomized Controlled Trial.

BACKGROUND: Mobile phones for health (mHealth) hold promise for delivering behavioral interventions. We evaluated the effect of automated interactive voice messages promoting contraceptive use with a focus on long-acting reversible contraceptives (LARCs) among women in Bangladesh who had undergone menstrual regulation (MR), a procedure to "regulate the menstrual cycle when menstruation is absent for a short duration." METHODS: We recruited MR clients from 41 public- and private-sector clinics immediately after MR. Eligibility criteria included having a personal mobile phone and consenting to receive messages about family planning by phone. We randomized participants remotely to an intervention group that received at least 11 voice messages about contraception over 4 months or to a control group (no messages). The primary outcome was LARC use at 4 months. Adverse events measured included experience of intimate partner violence (IPV). Researchers recruiting participants and 1 analyst were blinded to allocation groups. All analyses were intention to treat. The trial is registered with ClinicalTrials.gov (NCT02579785). RESULTS: Between December 2015 and March 2016, 485 women were allocated to the intervention group and 484 to the control group. We completed follow-up on 389 intervention and 383 control participants. Forty-eight (12%) participants in the intervention group and 59 (15%) in the control group reported using a LARC method at 4 months (adjusted odds ratio [aOR] using multiple imputation=0.95; 95% confidence interval [CI]=0.49 to 1.83; P=.22). Reported physical IPV was higher in the intervention group: 42 (11%) intervention versus 25 (7%) control (aOR=1.97; 95% CI=1.12 to 3.46; P=.03) when measured using a closed question naming acts of violence. No violence was reported in response to an open question about effects of being in the study. CONCLUSIONS: The intervention did not increase LARC use but had an unintended consequence of increasing self-reported IPV. Researchers and health program designers should consider possible negative impacts when designing and evaluating mHealth and other reproductive health interventions. IPV must be measured using closed questions naming acts of violence.

Title Correction: Using a Call Center to Reduce Harm From Self-Administration of Reproductive Health Medicines in Bangladesh: Interrupted Time-Series.

[This corrects the article DOI: 10.2196/12233.].

Using a Call Center to Reduce Harm From Self-Administration of Reproductive Health Medicines in Bangladesh: Interrupted Time-Series.

BACKGROUND: Annually, there are approximately 25 million unsafe abortions, and this remains a leading cause of maternal morbidity and mortality. In settings where abortion is restricted, women are increasingly able to self-manage abortions by purchasing abortion medications such as misoprostol and mifepristone (RU-486) from pharmacies or other drug sellers. Better availability of these drugs has been shown to be associated with reductions in complications from unsafe abortions. In Bangladesh, abortion is restricted; however, menstrual regulation (MR) was introduced in the 1970s as an interim method of preventing pregnancy. Pharmacy provision of medications for MR is widespread, but customers purchasing these drugs from pharmacies often do not have access to quality information on dosage and potential complications. OBJECTIVE: This study aimed to describe a call center intervention in Bangladesh, and assess call center use over time and how this changed when a new MR product (combined mifepristone-misoprostol) was introduced into the market. METHODS: In 2010, Marie Stopes Bangladesh established a care provider-assisted call center to reduce potential harm from self-administration of MR medications. The call center number was advertised widely in pharmacies and on MR product packaging. We conducted a secondary analysis of routine data collected by call center workers between July 2012 and August 2016. We investigated the reported types of callers, the reason for call, and reported usage of MR products before and after November 2014. We used an interrupted time series (ITS) analysis to formally assess levels of change in caller characteristics and reasons for calling. RESULTS: Over the 4-year period, 287,095 calls about MR were received and the number of users steadily increased over time. The most common callers (of 287,042 callers) were MR users (67,438, 23.49%), their husbands (65,999, 22.99%), pharmacy workers (65,828, 22.93%), and village doctors (56,036, 19.52%). Most MR calls were about misoprostol, but after November 2014, a growing proportion of calls were about the mifepristone-misoprostol regimen. The most common reasons (of 287,042 reasons) for calling were to obtain information about the regimen (208,605, 72.66%), to obtain information about side effects (208,267, 72.54%), or to report side effects (49,930, 17.39%). The ITS analyses showed that after November 2014, an increasing number of calls were from MR users who had taken the complete regimen (P=.02 and who were calling to discuss reported side effects (P=.01) and pain medication (P=.01), and there were fewer calls asking about dosages (P<.001). CONCLUSIONS: The high call volume suggests that this call center intervention addressed an unmet demand for information about MR medications from both MR users and health care providers. Call center interventions may improve the quality of information available by providing information directly to MR users and drug sellers, and thus reducing the potential harm from self-management of MR medications.

A longitudinal review of national HIV policy and progress made in health facility implementation in Eastern Zimbabwe.

BACKGROUND: In recent years, WHO has made major changes to its guidance on the provision of HIV care and treatment services. We conducted a longitudinal study from 2013 to 2015 to establish how these changes have been translated into national policy in Zimbabwe and to measure progress in implementation within local health facilities. METHODS: National HIV programme policy guidelines published between 2003 and 2013 (n = 9) and 2014 and 2015 (n = 5) were reviewed to assess adoption of WHO recommendations on HIV testing services, prevention of mother-to-child transmission (PMTCT) of HIV, and provision of antiretroviral therapy (ART). Changes in local implementation of these policies over time were measured in two rounds of a survey conducted at 36 health facilities in Eastern Zimbabwe in 2013 and 2015. RESULTS: High levels of adoption of WHO guidance into national policy were recorded, including adoption of new recommendations made in 2013-2015 to introduce PMTCT Option B+ and to increase the threshold for ART initiation from CD4 ≤ 350 cells/mm3 to ≤ 500 cells/mm3. New strategies to implement national HIV policies were introduced such as the decentralisation of ART services from hospitals to clinics and task-shifting of care from doctors to nurses. The proportions of health facilities offering free HIV testing and counselling, PMTCT (including Option B+) and ART services increased substantially from 2013 to 2015, despite reductions in numbers of health workers. Provision of provider-initiated HIV testing remained consistently high. At least one test-kit stock-out in the prior year was reported in most facilities (2013: 69%; 2015: 61%; p = 0.44). Stock-outs of first-line ART and prophylactic drugs for opportunistic infections remained low. Repeat testing for HIV-negative individuals within 3 months decreased (2013: 97%; 2015: 72%; p = 0.01). Laboratory testing remained low across both survey rounds, despite policy and operational guidelines to expand coverage of diagnostic services. CONCLUSIONS: Good progress has been made in implementing international guidance on HIV service delivery in Zimbabwe. Further novel implementation strategies may be needed to achieve the latest targets for universal ART eligibility.

Setting the research agenda for induced abortion in Africa and Asia.

Provision of safe abortion is widely recognized as vital to addressing the health and wellbeing of populations. Research on abortion is essential to meet the UN Sustainable Development Goals. Researchers in population health from university, policy, and practitioner contexts working on two multidisciplinary projects on family planning and safe abortion in Africa and Asia were brought together for a workshop to discuss the future research agenda on induced abortion. Research on care-seeking behavior, supply of abortion care services, and the global and national policy context will help improve access to and experiences of safe abortion services. A number of areas have potential in designing intervention strategies, including clinical innovations, quality improvement mechanisms, community involvement, and task sharing. Research on specific groups, including adolescents and young people, men, populations affected by conflict, marginalized groups, and providers could increase understanding of provision, access to and experiences of induced abortion. Methodological and conceptual advances, for example in the measurement of induced abortion incidence, complications, and client satisfaction, conceptualizations of induced abortion access and care, and methods for follow-up of patients who have induced abortions, will improve the accuracy of measurements of induced abortion, and add to understanding of women's experiences of induced abortions and abortion care.

Medical Abortion Provision by Pharmacies and Drug Sellers in Low- and Middle-Income Countries: A Systematic Review.

We undertook a systematic review to assess 1) the level and quality of pharmacy and drug shop provision of medical abortion (MA) in low- and middle-income countries (LMICs) and 2) interventions to improve quality of provision. We used standardized terms to search six databases for peer-reviewed and grey literature. We double-extracted data using a standardized template, and double-graded studies for methodological quality. We identified 22 studies from 16 countries reporting on level and quality of MA provision through pharmacies and drug sellers, and three intervention studies. Despite widespread awareness and provision of MA drugs, even in legally restricted contexts, most studies found that pharmacy workers and drug sellers had poor knowledge of effective regimens. Evidence on interventions to improve pharmacy and drug shop provision of MA was limited and generally low quality, but indicated that training could be effective in improving knowledge. Programmatic attention should focus on the development and rigorous evaluation of innovative interventions to improve women's access to information about MA self-management in low-and middle-income countries.

Feasibility of assessing the safety and effectiveness of menstrual regulation medications purchased from pharmacies in Bangladesh: a prospective cohort study.

OBJECTIVE: To assess the feasibility of following up women who purchase mifepristone+misoprostol or misoprostol-only from pharmacies in order to measure the safety and effectiveness of self-administration of menstrual regulation. STUDY DESIGN: A prospective cohort study followed women purchasing mifepristone+misoprostol or misoprostol-only from pharmacies in Bangladesh. Participants were recruited by pharmacy workers either in person or indirectly via the purchaser of the drugs. End users were contacted by phone 2 weeks after recruitment, screened and interviewed. RESULTS: Study recruitment rates by pharmacy workers were low (30%, 109 of 642 women informed about the study), but 2-week follow-up rates were high (87%). Of the 109 end users interviewed, 87 purchased mifepristone+misoprostol and 20 misoprostol-only, while 2 women did not know what drugs they had purchased. Mean self-reported number of weeks of pregnancy was 5.7 weeks. Information provision by pharmacy workers was inadequate (40.4% received none, 8.7% received written information or pictures). A total of 80.5% of mifepristone+misoprostol users were sold the correct regimen versus 9 out of 20 misoprostol-only users. A total of 68.8% did not report experiencing any complications (70.0% misoprostol-only; 69.0% mifepristone+misoprostol users, p=1.0). A total of 94.3% of mifepristone+misoprostol users and 75% of misoprostol-only users reported that they were not pregnant at day 15 (p=.020). However, 7.3% of all users sought additional treatment. CONCLUSIONS: Challenges in assessing outcomes of self-managed menstrual regulation medications purchased from pharmacies must be overcome through further development of this methodology. Interventions are urgently needed to ensure that women have access to correct dosages, accurate information and necessary referrals. IMPLICATIONS: This paper assesses the outcomes of women who self-manage menstrual regulation medications purchased from pharmacies. The methodology requires further development, but our study provides preliminary positive evidence on the safety and effectiveness of self-management despite low information provision from pharmacy workers.

Using automated voice messages linked to telephone counselling to increase post-menstrual regulation contraceptive uptake and continuation in Bangladesh: study protocol for a randomised controlled trial.

BACKGROUND: Adoption of modern contraceptive methods after menstrual regulation (MR) is thought to reduce subsequent unwanted pregnancy and abortion. Long-acting reversible contraceptives (LARCs) are highly effective at reducing unintended pregnancy, but uptake in Bangladesh is low. Providing information on the most effective methods of contraception increases uptake of more effective methods. This protocol describes a randomised controlled trial of an intervention delivered by mobile phone designed to support post-MR contraceptive use in Bangladesh. METHODS: This is a multi-site single blind individual randomised controlled trial. At least 960 women undergoing MR procedures at selected facilities will be recruited after their procedure by female research assistants. Women will be randomised into the control or intervention group with a 1:1 ratio. All participants will receive usual clinic care, including contraceptive counselling and the telephone number of a non-toll-free call centre which provides counselling on MR and contraception. During the 4 months after their MR procedure, intervention participants will be sent 11 recorded interactive voice messages to their mobile phone about contraception with a focus on their chosen method and LARCs. Each message allows the participant to connect directly to the call centre. The intervention is free to the user. The control group will receive no messages delivered by mobile phone. All participants will be asked to complete an in-person questionnaire at recruitment and follow-up questionnaires by telephone at 2 weeks, 4 months and 12 months after their MR. The primary outcome for the trial will be self-reported LARC use 4 months post-MR. Secondary outcomes include LARC use at 2 weeks and 12 months post-MR, use of any effective modern contraceptive method at 2 weeks, 4 months and 12 months post-MR, and contraceptive discontinuation, contraceptive method switching, pregnancy, subsequent MR and experience of violence during the 12 month study period. DISCUSSION: Mobile phones offer a low-cost mechanism for providing individualised support to women with contraception outside of the clinic setting. This study will provide information on the effects of such an intervention among MR clients in Bangladesh. TRIAL REGISTRATION: Trial registered with clinicaltrials.gov Registration number: NCT02579785 Date of registration: 16th October 2015.