Uptake of long-acting reversible contraception after telemedicine delivered abortion during Covid-19.

BACKGROUND: During COVID-19, early medical abortion (EMA) at home in Scotland was largely delivered by telemedicine. Short-acting post-abortion contraception was provided with EMA medications, but long-acting reversible contraception (LARC) (implant, injectable and intrauterine device) required an in-person visit. We wished to assess LARC uptake following telemedicine abortion, and factors associated with method receipt. METHODS: A prospective observational cohort study of patients accessing abortion via NHS Lothian (October 2020 to February 2021). Patients were offered contraception at telemedicine consultation and their choice was recorded in their clinical notes. Those wishing LARC were directed to the service's rapid-access LARC clinic. We reviewed electronic patient records six weeks post-abortion to determine whether patients received their chosen method. RESULTS: 944 patients had an abortion; 768 (81.4%) had EMA, 131 (13.9%) had a medical or surgical abortion in hospital. The most popular contraceptive method was the progestogen-only pill (n = 324, 34%). 330 patients (35%) requested LARC but less than half (153/330; 46%) received this. Of patients choosing LARC, those who attended the clinic for a pre-abortion ultrasound, or had an abortion in hospital, were more likely to initiate LARC than those having full telemedicine EMA. Nulliparity, gestation over 7 weeks, and age under-26 years were also positively associated with initiating LARC. CONCLUSION: During COVID-19 there was demand for post-abortion LARC but less than half of patients received this by six weeks. Provision was enhanced when in-person clinical interactions took place. Interventions are required to facilitate timely access and initiation of LARC with telemedicine delivered abortion care.

Use of effective contraception following provision of the progestogen-only pill for women presenting to community pharmacies for emergency contraception (Bridge-It): a pragmatic cluster-randomised crossover trial.

BACKGROUND: Unless women start effective contraception after oral emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies. We hypothesised that pharmacist provision of the progestogen-only pill as a bridging interim method of contraception with emergency contraception plus an invitation to a sexual and reproductive health clinic, in which all methods of contraception are available, would result in increased subsequent use of effective contraception. METHODS: We did a pragmatic cluster-randomised crossover trial in 29 UK pharmacies among women receiving levonorgestrel emergency contraception. Women aged 16 years or older, not already using hormonal contraception, not on medication that could interfere with the progestogen-only pill, and willing to give contact details for follow-up were invited to participate. In the intervention group, women received a 3-month supply of the progestogen-only pill (75 µg desogestrel) plus a rapid access card to a participating sexual and reproductive health clinic. In the control group, pharmacists advised women to attend their usual contraceptive provider. The order in which each pharmacy provided the intervention or control was randomly assigned using a computer software algorithm. The primary outcome was the use of effective contraception (hormonal or intrauterine) at 4 months. This study is registered, ISRCTN70616901 (complete). FINDINGS: Between Dec 19, 2017, and June 26, 2019, 636 women were recruited to the intervention group (316 [49·6%], mean age 22·7 years [SD 5·7]) or the control group (320 [50·3%], 22·6 years [5·1]). Three women (one in the intervention group and two in the control group) were excluded after randomisation. 4-month follow-up data were available for 406 (64%) participants, 25 were lost to follow-up, and two participants no longer wanted to participate in the study. The proportion of women using effective contraception was 20·1% greater (95% CI 5·2-35·0) in the intervention group (mean 58·4%, 48·6-68·2), than in the control group (mean 40·5%, 29·7-51·3 [adjusted for recruitment period, treatment group, and centre]; p=0·011).The difference remained significant after adjusting for age, current sexual relationship, and history of effective contraception use, and was robust to the effect of missing data (assuming missingness at random). No serious adverse events occurred. INTERPRETATION: Provision of a supply of the progestogen-only pill with emergency contraception from a community pharmacist, along with an invitation to a sexual and reproductive health clinic, results in a clinically meaningful increase in subsequent use of effective contraception. Widely implemented, this practice could prevent unintended pregnancies after use of emergency contraception. FUNDING: National Institute for Health Research (Health Technology Assessment Programme project 15/113/01).

Information on early medical abortion for women using an audiovisual animation vs face-to-face consultation: A consortium randomized and quasi-randomized trial.

INTRODUCTION: There is some evidence that audiovisual formats can be an effective way of providing information about early medical abortion (EMA). A short animation (3 minutes) was developed about EMA in three languages that summarized the EMA process for use in the UK, France and Sweden. MATERIAL AND METHODS: We conducted a multicenter randomized controlled trial to compare information on EMA delivered by an animated film vs a face-to-face consultation. Women requesting EMA (≤9 weeks' gestation) from abortion clinics in Edinburgh (UK), Paris (France) and Stockholm (Sweden) were recruited. The primary outcome was women's recall of prespecified key information on EMA. Secondary outcomes were acceptability of mode of information delivery, clarity and helpfulness of information rated on a Likert scale. The study was prospectively registered with clinicaltrials.gov, ID number: NCT03417362. RESULTS: 172 women completed the study (Edinburgh = 50, Paris = 78, Stockholm = 48). There was no statistically significant difference in recall scores between the animation and standard arms in Edinburgh and Stockholm sites. However, the difference between arms at the Paris site was statistically significant (P = .007) in favor of the animation. All participants in the animation arm rated it as an acceptable way to receive information on EMA. CONCLUSIONS: A "short" audiovisual animation can adequately and acceptably deliver key information about EMA. This intervention could be used routinely to provide standardized and high-quality information to women seeking EMA.

Provision of immediate postpartum intrauterine contraception after vaginal birth within a public maternity setting: Health services research evaluation.

INTRODUCTION: Expanding access to postpartum intrauterine contraception (PPIUC) can reduce unintended pregnancies and short inter-pregnancy intervals; however, provision across Europe is limited. Our aim was to determine the feasibility, clinical outcomes and patient satisfaction of providing immediate PPIUC after vaginal birth using a health services research model. MATERIAL AND METHODS: Phased introduction of PPIUC across two Lothian maternity hospitals; all women intending vaginal birth during the study period without a contraindication to use of the method were eligible to receive PPIUC. Midwives and obstetric doctors were trained in vaginal PPIUC insertion using Kelly forceps. Women received information antenatally and had PPIUC insertion of either a levonorgestrel intrauterine system or a copper intrauterine device within 48 hours of vaginal birth. Follow-up was conducted in-person at 6 weeks postpartum and by telephone at 3, 6 and 12 months. Primary outcomes were: uptake, complications (infection, uterine perforation), expulsion and patient satisfaction at 6 weeks; and method of continuation up to 12 months. Secondary outcomes included hazard ratio for expulsion adjusted for demographic and insertion-related variables. RESULTS: Uptake of PPIUC was 4.6% of all vaginal births; 465/447 (96.1%) of those requesting PPIUC successfully received it and most chose a levonorgestrel intrauterine system (73%). At 6 weeks postpartum, the infection rate was 0.8%, there were no perforations and 98.3% of women said they would recommend the service. The complete expulsion rate was 29.8% (n = 113) and most had symptoms (n = 79). Of the additional 121 devices removed, 118 were because of partial expulsion. The rate of complete/partial expulsion was higher for insertions by midwives compared with those by doctors. The re-insertion rate after expulsion/removal was 87.6% and method continuation at 12 months was 79.6%. CONCLUSIONS: Routine PPIUC at vaginal birth is feasible. Complications were extremely rare. High expulsion rates may be observed in early stages of service introduction and with inexperienced providers. Re-insertion and therefore longer-term continuation rates of intrauterine contraception were very high. In settings with low rates of attendance for interval postpartum intrauterine contraception insertion, PPIUC could be a useful intervention to prevent unintended and closely spaced pregnancies.

Women's experiences of accessing postpartum intrauterine contraception in a public maternity setting: a qualitative service evaluation.

OBJECTIVES: The aims of the study were to explore women's experiences of an immediate postpartum intrauterine contraception (PPIUC) service recently introduced in a UK maternity setting, to identify areas for improvement and inform service provision. METHODS: Qualitative research was carried out in hospital and community maternity services in Lothian, UK. In-depth interviews were conducted with 35 women who had received PPIUC at vaginal or caesarean delivery. The interview data were analysed thematically to explore the women's experiences of PPIUC service provision. RESULTS: Women's decisions to choose PPIUC were influenced by their perception of intrauterine contraception (IUC) as a suitable and effective method and the convenience of immediate postpartum insertion. Most women were satisfied with their experience of PPIUC. Women delivering vaginally sometimes reported concerns about delays to insertion, particularly where they perceived a lack of communication from staff about when and where insertion would occur. PPIUC information was described as being difficult to absorb in the context of ante/postnatal information overload. Those receiving PPIUC at caesarean delivery sometimes expressed concerns about what post-insertion support might be available in primary care. CONCLUSION: Women typically reported satisfaction with their decision to have PPIUC. For maternity services considering introducing PPIUC, our findings reinforce the importance of anticipating and addressing implementation challenges in order to enhance women's experience of the service. These include ensuring that: clear and appropriate PPIUC information and support are provided antenatally; women are able to access PPIUC immediately after delivery; robust clinical pathways are in place to support post-insertion IUC care; and both staff and women are familiar with the clinical pathways.

Routine provision of intrauterine contraception at elective cesarean section in a national public health service: a service evaluation.

INTRODUCTION: We conducted a prospective health service evaluation to assess the feasibility and acceptability of routinely offering insertion of intrauterine contraception at cesarean section in a maternity setting in the UK. MATERIAL AND METHODS: One month before scheduled cesarean section, women were sent information about postpartum contraception including the option of insertion of an intrauterine contraception at cesarean. Women choosing intrauterine contraception (copper intrauterine device or levonorgestrel intrauterine system) were followed up in person at six weeks, and telephone contact was made at three, six and 12 months postpartum. Our main outcome measures were uptake of intrauterine contraception and complications by six weeks. Secondary outcomes were continuation and satisfaction with intrauterine contraception at 12 months. RESULTS: 120/877 women opted to have intrauterine contraception (13.7%), of which 114 were fitted. By six weeks, there were seven expulsions (6.1%). The expulsion rate by one year was 8.8%. There were no cases of uterine perforations and one case of infection (0.8%). Follow-up rates were 82.5% at 12 months, and continuation rates with intrauterine contraception at 12 months were 84.8% of those contacted. At 12 months, 92.7% of respondents asked were either 'very' or 'fairly' happy with their intrauterine contraception. CONCLUSIONS: Routine provision of intrauterine contraception at elective cesarean for women in a public maternity service is feasible and acceptable to women. It is associated with good uptake and good continuation rates for the first year. This could be an important strategy to increase use of intrauterine contraception and prevent short inter-pregnancy intervals and unintended pregnancies.

Characteristics of women who present for abortion towards the end of the mid-trimester in Scotland: national audit 2013-2014.

OBJECTIVES: Women in Scotland who request an abortion (for non-medical reasons) within the legal gestational limit (up to 24 weeks) but beyond the gestational limit of all abortion facilities in Scotland (only up to 20 weeks) must travel to England if they wish to terminate the pregnancy. We wished to determine the number and characteristics of women presenting at ≥16 weeks' gestation for abortion, and compare the characteristics of those proceeding to abortion with those continuing the pregnancy. METHODS: Over a period of 12 months we conducted a prospective audit of women presenting at ≥16 weeks' gestation to abortion services throughout Scotland. The characteristics of women proceeding to abortion and those continuing the pregnancy were compared. RESULTS: A total of 267 women presented for abortion at ≥16 weeks' gestation. Their median age was 22 years (range 14 to 47 years); 231 were from deprived areas (86.5%), 128 (47.9%) already had a child and 73 (27.3%) had previously undergone abortion. A total of 175 women (65.5%) proceeded to abortion, locally (n = 125; 46.8%) or in England (50; 18.7%). Those at ≥20 weeks' gestation were statistically more likely to continue the pregnancy than those at earlier gestations (p < 0.001). CONCLUSIONS: Relatively few women present for abortion in Scotland at ≥16 weeks' gestation. Those who are over 20 weeks' gestation and would need to travel to England for abortion are more likely to continue the pregnancy, suggesting that travel is a barrier to accessing legal abortion for this group of women. Provision of abortion services up to 24 weeks' gestation should be considered within Scotland.

Myths and misconceptions about intrauterine contraception among women seeking termination of pregnancy.

BACKGROUND: Immediate initiation of an intrauterine device (IUD) or intrauterine system (IUS) following termination of pregnancy (TOP) is associated with a significant reduction in the risk of another TOP. In spite of its high efficacy, uptake of intrauterine contraception in the UK is low. Myths and misconceptions about the method may contribute to the low uptake. STUDY DESIGN: Anonymous, self-administered questionnaire among women requesting a TOP in a hospital abortion service in Scotland, UK. METHODS: Misconceptions about intrauterine contraception were extracted from an online social networking and micro-blogging service, and from existing research to develop a questionnaire containing 12 negative statements about intrauterine contraception. Respondents indicated their level of agreement with each statement. RESULTS: A total of 106/125 (85%) women requesting a TOP completed the questionnaire. The two commonest negative statements that respondents agreed with were that the IUD/IUS 'Is painful to have inserted' (n=36; 34%) and that 'It can move around inside your body' (n=25; 23.6%). The range of women who neither agreed nor disagreed with negative statements was 26.4-56.0%. Twenty-seven (25%) women indicated that the IUD/IUS was their planned method of post-TOP contraception. CONCLUSIONS: Although myths about intrauterine contraception persist among a small proportion of women requesting a TOP, lack of knowledge about the method is also evident. The consultation prior to TOP is an important opportunity to provide accurate and quality information to women about the IUD/IUS that may serve to increase uptake and prevent repeat abortions.

A post-abortion contraception text-and-call service to support patients to access effective contraception after telemedicine abortion.

BACKGROUND: Most abortions in Scotland are conducted at home before 12 weeks' gestation using telemedicine. The volume of information given at a pre-abortion consultation may feel overwhelming and contraception may not be prioritised. Telemedicine limits immediate provision of some methods. Pathways to improve access to post-abortion contraception (PAC) are needed. METHODS: We piloted a PAC 'text-and-call' service for patients having telemedicine abortion in Edinburgh. Those agreeing to contact were sent a text message 4-6 weeks later. The message offered a follow-up telephone call with a nurse to discuss contraception. An online decision aid was used to support method selection where needed. Rapid access to the chosen method was arranged. RESULTS: During the period February-April 2022, 672 patients accessed abortion care, of whom 427 (64%) agreed to post-abortion text message contact. Most (354/427, 83%) did not respond or declined further contact, and 73/427 (17%) requested a follow-up call.Two participants did not respond to the follow-up call. Most (63/73, 86%) knew what method they wanted prior to the call. Just over half of these patients (34/73, 54%) changed to a higher-effectiveness method than they were currently using and the remainder obtained further supplies of their existing method. Eight participants had not selected a method prior to the call and received structured counselling; five chose long-acting reversible contraception (LARC) but only one subsequently initiated this. CONCLUSIONS: This PAC service was taken up by a small proportion of patients but supported a sizeable minority to connect to further contraceptive supplies, half of whom accessed more effective methods.

Abortion patients' perspectives on enhancing a telemedicine model of post-abortion contraception: a qualitative study.

BACKGROUND: Access to post-abortion contraception (PAC) is critical for reducing unintended pregnancies and supporting reproductive decision-making. Patients often face challenges in identifying, accessing and initiating their preferred contraceptive methods post-abortion. This may be particularly so with telemedicine models of care with absence of in-person appointments, and reduced opportunities to provide some contraceptive methods. This qualitative service evaluation explored patients' perspectives on PAC consultations and decision-making to inform future PAC service models in the era of telemedicine. METHODS: Qualitative interviews with 15 patients who had telemedicine medical abortion at home up to 12 weeks' gestation. Data were analysed using reflexive thematic analysis. RESULTS: Contraceptive discussions during pre-abortion consultations were valued for supporting informed choices about future contraceptive use. Decision-making was influenced by previous contraception experiences, emotional state at the time of abortion and concerns about contraceptive 'failure'. Some preferred non-hormonal methods due to past negative experiences with hormonal contraceptives. However, limited information about 'natural' contraceptive methods and concerns about discussing these with healthcare professionals were described. Barriers to accessing preferred methods, particularly long-acting reversible contraception (LARC), included reduced availability of appointments and caring responsibilities. Fast-tracked appointments for LARC fitting post-abortion were valued. The need for flexible PAC consultations and access after abortion, for example, remote consultations complemented by personalised interactions with sexual and reproductive health experts, was emphasised. CONCLUSION: The findings highlight the need for flexible and more accessible PAC service models in the era of telemedicine care to ensure timely access to preferred contraceptive methods.

Does a full bladder assist insertion of intrauterine contraception? A randomised trial.

BACKGROUND: Bladder distension is thought to cause the uterine axis to become more aligned with the cervical canal. Among women undergoing assisted conception it has been demonstrated that having a full bladder facilitates the passage of an intrauterine catheter for embryo transfer. OBJECTIVE: To determine if insertion of intrauterine contraceptive devices is easier in women who have a full bladder at the time of insertion. METHODS: 200 women requesting intrauterine contraception with a pre-filled bladder were randomised to delayed emptying (after insertion; n=100) or immediate emptying (before insertion; n=100). Comparisons were made between doctors' reported ease of insertion and women's pain scores. RESULTS: There was no significant difference with reported ease of insertion between the groups. Doctors reported that insertions were either 'very easy' or 'quite easy' in 82% and 83% of women in the immediate and delayed emptying groups, respectively (95% CIs for difference -10% to +11%). There was no significant difference in reported pain scores, with mean pain scores (out of 10) of 3.8 and 4.4 in the delayed and immediate emptying groups, respectively. CONCLUSIONS: Bladder filling does not have a significant effect on ease of insertion of an intrauterine method of contraception. Insertion is mostly associated with low levels of discomfort, even in the presence of a full bladder.

Attitudes of Scottish abortion care providers towards provision of abortion after 16 weeks' gestation within Scotland.

BACKGROUND: In Scotland, in contrast to the rest of Great Britain, abortion at gestations over 20 weeks is not provided, and provision of procedures above 16 weeks varies considerably between regions. Women at varying gestations above 16 weeks must travel outside Scotland, usually to England, for the procedure. OBJECTIVE: To determine the views of professionals working within Scottish abortion care about a Scottish late abortion service. METHODS: Delegates at a meeting for abortion providers in Scotland completed a questionnaire about their views on abortion provision over 16 weeks and their perceived barriers to service provision. RESULTS: Of 95 distributed questionnaires, 70 (76%) were analysed. Fifty-six respondents (80%) supported a Scottish late abortion service, ten (14%) would maintain current service arrangements, and five (7%) were undecided. Forty (57%) of the supporters of a Scottish service would prefer a single national service, and 16 (22%) several regional services. Perceived barriers included lack of trained staff (n = 39; 56%), accommodation for the service (n = 34; 48%), and perception of lack of support among senior management (n = 28; 40%). CONCLUSION: The majority of health professionals surveyed who work in Scottish abortion services support provision of abortion beyond 16 weeks within Scotland, and most favour a single national service. Further work on the feasibility of providing this service is required.

Assessment of a 'fast-track' referral service for intrauterine contraception following early medical abortion.

BACKGROUND: A 'fast-track' referral system for intrauterine contraception was established in 2007 between the medical abortion service at the Royal Infirmary of Edinburgh and the principal family planning clinic (FPC) in Edinburgh. METHODS: Case note review of women fast-tracked for intrauterine contraception after medical abortion between January 2007 and June 2009. Main outcome measures were numbers of women referred, attendance rates, interval to insertion, devices chosen and known complication rates. RESULTS: Of the 237 women referred, 126 (53%) attended for intrauterine contraception insertion. Attenders were slightly but significantly older than non-attenders (mean ages of 30 and 27 years, respectively; p=0.003), less likely to live in an area of deprivation (p=0.045) and were significantly more likely to have attended the FPC in the past (p<0.0001). Most attenders (90%; n=113) proceeded to have an intrauterine method inserted; 57% (n=64) chose the levonorgestrel intrauterine system and 43% (n=49) chose a copper intrauterine device. The median interval to insertion was 21 (range 0-54) days. Of those women (n=55) who attended for routine follow-up 6 weeks later (49%), there were four (7.2%) cases of expulsion, two (3.6%) requests for removal and four (7.2%) cases of suspected infection. CONCLUSIONS: Only half the women fast-tracked for intrauterine contraception actually attended and these tended to be women who were pre-existing clients of the FPC. Consideration should therefore be given to provision of immediate insertion where possible.

Comparison of unscheduled re-attendance and contraception at discharge, among women having the final stage of early medical abortion at home and those remaining in hospital.

INTRODUCTION: Throughout Great Britain, increasing numbers of women having an early medical abortion are choosing to go home soon after administration of misoprostol, to expel the pregnancy at home (early medical discharge, EMD), rather than remain upon the hospital premises (day case). However, data are lacking on how this impacts upon an abortion service in terms of unscheduled re-attendance rates and contraception provision at discharge. METHODS: A retrospective audit was carried out of women undergoing medical abortion (up to 64 days' gestation) over 9 months at a National Health Service hospital in Scotland, to determine (1) unscheduled re-attendance rates within 6 weeks of the procedure for an abortion-related complication and (2) method of contraception provided at discharge. RESULTS: Over the audit period 1128 women had an early medical abortion of whom 590 (52%) chose EMD. There was no significant difference in unscheduled re-attendance rates between EMD (n=23, 4%) and day case groups (n=20, 4%). There was no significant difference in the proportion of women in each group who left hospital with an effective method of contraception (n=362, 61% and n=355, 60% for EMD and day case groups, respectively). CONCLUSIONS: Women undergoing early medical abortion who choose to expel the pregnancy at home are no more likely to re-attend hospital with a post-abortal complication and are just as likely to receive effective contraception than those who remain on hospital premises.

Views of clinicians towards providing contraceptive advice and contraception to women following early pregnancy loss: a qualitative study.

INTRODUCTION: National guidelines advise that clinicians caring for women post-pregnancy should give women opportunities to discuss contraception, regardless of pregnancy outcome, and provide contraception to women who choose to take up a method. This study aimed to explore knowledge, views and needs of Early Pregnancy Unit (EPU) clinicians around discussing and offering contraception and discussing pregnancy intendedness with women after early pregnancy loss using a qualitative approach. METHODS: Semi-structured, audio-recorded interviews with 11 clinicians from a single regional EPU in Edinburgh, Scotland. Interviews were transcribed verbatim and analysed thematically. RESULTS: Clinicians were reluctant to discuss contraception as they believed women would find the topic overwhelming and distressing. Thoughts on discussing pregnancy intendedness were polarised; some considered it insensitive, and others essential. Barriers to discussing contraception and providing it were numerous and included time pressure, and inadequate knowledge and training on contraception. Participants suggested training on contraception, closer working with sexual and reproductive health (SRH) services, and availability of information on contraception specifically aimed at women who have experienced an early pregnancy loss could facilitate discussions and method provision. CONCLUSIONS: EPU clinicians require ongoing training and support to be effective at discussing pregnancy intendedness and discussing and providing post-pregnancy contraception. This will require close working with SRH services and development of sensitive information around contraception for women experiencing an early pregnancy loss.

Utility of a routine ultrasound for detection of ectopic pregnancies among women requesting abortion: a retrospective review.

INTRODUCTION: Routine ultrasound may be used in abortion services to determine gestational age and confirm an intrauterine pregnancy. However, ultrasound adds complexity to care and results may be inconclusive, delaying abortion. We sought to determine the rate of ectopic pregnancy and the utility of routine ultrasound in its detection, in a community abortion service. METHODS: Retrospective case record review of women requesting abortion over a 5-year period (2015-2019) with an outcome of ectopic pregnancy or pregnancy of unknown location (PUL) at a service (Edinburgh, UK) conducting routine ultrasound on all women. Records were searched for symptoms at presentation, development of symptoms during clinical care, significant risk factors and routine ultrasound findings. RESULTS: Only 29/11 381 women (0.25%, 95% CI 0.18%, 0.33%) had an ectopic pregnancy or PUL (tubal=18, caesarean scar=1, heterotopic=1, PUL=9). Eleven (38%) cases had either symptoms at presentation (n=8) and/or significant risk factors for ectopic pregnancy (n=4). A further 12 women developed symptoms during their clinical care. Of the remaining six, three were PUL treated with methotrexate and three were ectopic (salpingectomy=2, methotrexate=1). In three cases, the baseline ultrasound indicated a probable early intrauterine pregnancy. CONCLUSIONS: Ectopic pregnancies are uncommon among women presenting for abortion. The value of routine ultrasound in excluding ectopic pregnancy in symptom-free women without significant risk factors is questionable as it may aid detection of some cases but may provide false reassurance that a pregnancy is intrauterine.

Pain management for medical abortion before 14 weeks' gestation: A systematic review.

INTRODUCTION: Abortion is common worldwide and increasingly abortions are performed at less than 14 weeks' gestation using medical methods, specifically using a combination of mifepristone and misoprostol. Medical abortion is known to be a painful process, but the optimal method of pain management is unclear. We sought to identify and compare pain management regimens for medical abortion before 14 weeks' gestation. STUDY DESIGN: We conducted our search in August 2019 and included randomized controlled trials (RCT) and observational studies of any pain relief intervention (pharmacological and non-pharmacological) for mifepristone-misoprostol combination medical abortion of pregnancies less than 14 weeks' gestation. RESULTS: We included four RCTs and one observational study. Due to the heterogeneity of study designs, interventions and outcome reporting, meta-analysis was not possible. Only one study found evidence of an effect between interventions on pain score: a prophylactic dose of ibuprofen 1600mg likely reduces the pain score when compared to a dose of paracetamol 2000mg (MD 2.26/10 [CI 3-1.52 lower]). For other interventions (pregabalin 300mg vs placebo; ibuprofen 800mg vs placebo; therapeutic vs prophylactic administration of ibuprofen 800mg; ambulation vs non-ambulation during treatment) there appeared to be little to no difference with comparator. CONCLUSIONS: The findings of this review provide some support for the use of ibuprofen as a single dose given with misoprostol prophylactically, or in response to pain as needed. The optimal dosing of ibuprofen is unclear, but a single dose of ibuprofen 1600mg was shown to be effective and it was less certain whether 800mg was effective.

Perspectives of obstetricians and midwives on the provision of immediate postpartum intrauterine devices: a qualitative service evaluation.

BACKGROUND: Immediate postpartum intrauterine device (PPIUD) insertion is safe and effective but largely unavailable in Europe. Data on maternity staff views on the provision and implementation of PPIUD services are limited. The objective of this qualitative evaluation was to explore the views and experiences of obstetricians and midwives providing PPIUD within a UK maternity setting, in order to identify areas for improvement and inform service provision in other areas. METHODS: Qualitative health services research within two public maternity hospitals in Lothian (Edinburgh and surrounding region), UK. Interviews with 30 maternity staff (obstetricians n=8; midwives n=22) involved in PPIUD provision. Data were analysed thematically. RESULTS: Maternity staff were positive about the benefits of PPIUD for women. Midwives reported initial concerns about PPIUD safety, and the impact on workload; these views shifted following training, and as PPIUD was embedded into practice. Having a large pool of PPIUD-trained staff was identified as an important factor in successful service implementation. Having PPIUD 'champions' was important to address staff concerns, encourage training uptake, and advocate for the service to ensure continued resourcing. CONCLUSIONS: PPIUD in maternity services can help address unmet need for effective contraception in the immediate postpartum period. We emphasise the importance of widespread engagement around PPIUD among all healthcare professionals involved in the care of women, to ensure staff are informed and supported. Clinical champions and leaders play a key role in amplifying the benefits of PPIUD, and advancing organisational learning.

Acceptability of different mechanisms of action of contraception in women: a questionnaire survey.

BACKGROUND: The mechanism of action of a contraceptive method is an importantg consideration in a woman's choice of contraception. For the development of new methods of contraception it is important to understand the acceptability of different contraceptive mechanisms within a population. METHODS: We recruited women attending contraceptive, termination of pregnancy or postnatal care services in Hong Kong for a questionnaire survey on their acceptability of the different ways in which contraceptive methods prevent pregnancy. Univariable and multivariable analyses were used to establish factors which may predict acceptability of the mechanism of action. RESULTS: A total of 1448 women completed the survey. The acceptability of contraceptive methods that act by preventing fertilisation ranked highest (78%), followed by those that inhibit ovulation (52%), disrupt implantation (43%) and dislodge an implanted embryo (30%). A history of termination of pregnancy was associated with greater acceptance of all posited contraceptive mechanisms. There was a very low degree of agreement between the declared acceptance of the various contraceptive mechanisms and the ever use of a method with the respective mechanism of action (Cohen's kappa coefficient range 0.017-0.162). CONCLUSIONS: In this population the acceptability of contraceptive methods that act by preventing fertilisation ranked highest, followed by those that inhibit ovulation, disrupt implantation and dislodge an implanted embryo. Women who had ever had a termination of pregnancy were more likely to accept all the posited contraceptive mechanisms.

Association between menstrual cycle length and covid-19 vaccination: global, retrospective cohort study of prospectively collected data.

OBJECTIVES: To identify whether covid-19 vaccines are associated with menstrual changes in order to address concerns about menstrual cycle disruptions after covid-19 vaccination. DESIGN: Global, retrospective cohort study of prospectively collected data. SETTING: International users of the menstrual cycle tracking application, Natural Cycles. PARTICIPANTS: 19 622 individuals aged 18-45 years with cycle lengths of 24-38 days and consecutive data for at least three cycles before and one cycle after covid (vaccinated group; n=14 936), and those with at least four consecutive cycles over a similar time period (unvaccinated group; n=4686). MAIN OUTCOME MEASURES: The mean change within individuals was assessed by vaccination group for cycle and menses length (mean of three cycles before vaccination to the cycles after first and second dose of vaccine and the subsequent cycle). Mixed effects models were used to estimate the adjusted difference in change in cycle and menses length between the vaccinated and unvaccinated. RESULTS: Most people (n=15 713; 80.08%) were younger than 35 years, from the UK (n=6222; 31.71%), US and Canada (28.59%), or Europe (33.55%). Two thirds (9929 (66.48%) of 14 936) of the vaccinated cohort received the Pfizer-BioNTech (BNT162b2) covid-19 vaccine, 17.46% (n=2608) received Moderna (mRNA-1273), 9.06% (n=1353) received Oxford-AstraZeneca (ChAdOx1 nCoV-19), and 1.89% (n=283) received Johnson & Johnson (Ad26.COV2.S). Individuals who were vaccinated had a less than one day adjusted increase in the length of their first and second vaccine cycles, compared with individuals who were not vaccinated (0.71 day increase (99.3% confidence interval 0.47 to 0.96) for first dose; 0.56 day increase (0.28 to 0.84) for second dose). The adjusted difference was larger in people who received two doses in a cycle (3.70 days increase (2.98 to 4.42)). One cycle after vaccination, cycle length was similar to before the vaccine in individuals who received one dose per cycle (0.02 day change (99.3% confidence interval -0.10 to 0.14), but not yet for individuals who received two doses per cycle (0.85 day change (99.3% confidence interval 0.24 to 1.46)) compared with unvaccinated individuals. Changes in cycle length did not differ by the vaccine's mechanism of action (mRNA, adenovirus vector, or inactivated virus). Menses length was unaffected by vaccination. CONCLUSIONS: Covid-19 vaccination is associated with a small and likely to be temporary change in menstrual cycle length but no change in menses length.