Why women choose at-home abortion via teleconsultation in France: drivers of telemedicine abortion during and beyond the COVID-19 pandemic.

OBJECTIVES: In an attempt to understand the demand and main drivers of telemedicine abortion, we analysed the requests that Women on Web (WoW), an online telemedicine abortion service operating worldwide, received from France throughout 2020. METHODS: We conducted a parallel, convergent, mixed-methods study among 809 consultations received from France at WoW between 1 January and 31 December 2020. We performed a cross-sectional study of data obtained from the WoW consultation survey and a manifest content analysis of anonymised email correspondence of 140 women consulting with the WoW helpdesk from France. FINDINGS: We found that women encounter macro-level, individual-level and provider-level constraints while trying to access abortion in France. The preferences and needs over secrecy (n=356, 46.2%), privacy (n=295, 38.3%) and comfort (n=269, 34.9%) are among the most frequent reasons for women from France to choose telemedicine abortion through WoW. The COVID-19 pandemic seems to be an important driver for resorting to telemedicine (n=236, 30.6%). The lockdowns had a significant impact on the number of consultations received at WoW from France, increasing from 60 in March to 128 in April during the first lockdown and from 54 in October to 80 in November during the second lockdown. CONCLUSIONS: The demand for at-home medical abortion via teleconsultation increased in France during the lockdowns. However, drivers of telemedicine abortion are multidimensional and go beyond the conditions unique to the pandemic.

Clinical practice guidelines for contraception by the French National College of Gynecologists and Obstetricians (CNGOF).

The French College of Obstetrics and Gynecology (CNGOF) has released its first comprehensive recommendations for clinical practices in contraception, to provide physicians with an updated synthesis of the available data as a basis for their practice. The organizing committee and the working group adopted the objective methodological principles defined by the French Authority for Health (HAS) and selected 12 themes relevant to medical professionals' clinical practices concerning contraception. The available literature was screened through December 2017 and served as the basis of 12 texts, reviewed by experts and physicians from public and private practices, with experience in this field. These texts enabled us to develop evidence based, graded recommendations. Male and female sterilization, as well as the use of hormonal treatments not authorized for contraception ("off-label") were excluded from the scope of our review. Specific practical recommendations are provided for the management of contraception prescription, patient information concerning effectiveness, risks, and benefits of the different methods, patient follow-up, intrauterine contraception, emergency contraception, local and natural methods, contraception in teenagers, in women after 40, for women at high thromboembolism or cardiovascular risk, and for those at of primary cancer or relapse. The short- and mid-term future of contraception depends mainly on improving the use of currently available methods. This includes reinforced information for users and increased access to contraception for women, regardless of their social and clinical contexts. The objective of these guidelines is to aid in enabling this improvement.

[First visit for contraception]. / Première prescription d'une contraception.

The first visit for contraception essentially aims at listening and providing information and counseling. The choice of the contraceptive methods takes into account the contra-indications of the method as well as the patient personnel history, the type of demand, the needs and the fears. For young women, the most preferred choice is the combined pills, very effective and with minima sides effects but other methods (IUD, barrier methods) should be kept in mind. Observance requires proper information and reassurance on side effects particularly on menstruation disorders (amenorrhea, spotting) to avoid drop out.

Elective abortion: Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF).

The number of elective abortions has been stable for several decades. Many factors explain women's choice of abortion in cases of unplanned pregnancies. Early initiation of contraceptive use and a choice of contraceptive choices appropriate to the woman's life are associated with lower rates of unplanned pregnancies. Reversible long-acting contraceptives should be favored as first-line methods for adolescents because of their effectiveness (grade C). Ultrasound scan before an elective abortion must be encouraged but should not be obligatory (professional consensus). As soon as the embryo appears on the ultrasound scan, the date of pregnancy is estimated by measuring the crown-rump length (CRL) or, from 11 weeks on, by measuring the biparietal diameter (BPD) (grade A). Because reliability of these parameters is ±5 days, the abortion may be done if measurements are respectively less than 90 mm for CRL and less than 30 mm for BPD (professional consensus). A medically induced abortion, performed with a dose of 200 mg mifepristone combined with misoprostol, is effective at any gestational age (Level of Evidence (LE) 1). Before 7 weeks, mifepristone should be followed 24-48 h later by misoprostol, administered orally, buccally, sublingually, or even vaginally followed if needed by a further dose of 400 µg after 3 h, to be renewed if needed after 3 h (LE 1, grade A). After 7 weeks, administration of misoprostol by the vaginal, sublingual, or buccal routes is more effective and better tolerated than by the oral route (LE 1). Cervical preparation is recommended for systematic use in surgical abortions (professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 µg (grade A). Vacuum aspiration is preferable to curettage (grade B). A uterus perforated during surgical aspiration should not routinely be considered to be scarred (professional consensus). An elective abortion is not associated with a higher risk of subsequent infertility or ectopic pregnancy (LE 2). The medical consultation before an elective abortion generally does not affect the decision to end or continue the pregnancy, and most women are sufficiently certain about their choice at this time. Women appear to find the method used most acceptable and to be most satisfied when they were able to choose the method (grade B). Elective abortions are not associated with an increased rate of psychiatric disorders (LE 2). However, women with psychiatric histories are at a higher risk of psychological disorders after the occurrence of an unplanned pregnancy than women with such a history (LE 2). For surgical abortions, combined hormonal contraceptives - oral or transdermal - should be started on the day of the abortion, while the vaginal ring should be inserted 5 days afterwards (grade B). For medical abortions, the vaginal ring should be inserted in the week after mifepristone administration, while the combined contraceptives should begin the same day as the misoprostol or the day after (grade C). Contraceptive implants should be inserted on the same day as a surgical abortion, and may be inserted the day the mifepristone is administered for medical abortions (grade B and C respectively). In case of medical abortion, the implant can be inserted the same day the mifepristone is administered (grade C). Both the copper IUDs and levonorgestrel intrauterine system should be inserted on the day of the surgical abortion (grade A). After medical abortions, an IUD can be inserted in 10 days after mifepristone administration, after ultrasound scan verification of the absence of an intrauterine pregnancy (grade C).

Feasibility of self-performed urine pregnancy testing for follow-up after medical abortion.

OBJECTIVES: Medical termination of pregnancy (MToP) follow-up can be simplified by combining a clinical assessment with blood and urine human chorionic gonadotropin (hCG) measurements, the later using a low sensitivity urinary pregnancy (LSUP) testing. This study aimed to describe follow-up modalities of MToP in real-life conditions, and assess the benefit of a self-performed urine semiquantitative test in the follow-up of MToP and its feasibility, acceptability and user-friendliness as well as the women capacity to interpret it correctly. Concordance between qualitative results from LSUP test and quantitative values from the blood hCG measurement was also assessed. STUDY DESIGN: From May to November 2013, we conducted a national, prospective, observational study with 17 centres offering MToP. Pregnant women with at least 63 days of amenorrhea (DA) requesting MToP were recruited during a consultation visit for medical abortion. RESULTS: A total of 322 women were included (mean age: 28.1 ± 6.4 years). The mean term of pregnancy at the time of MToP was 44.1 ± 6.2 DA. Two regimens were mostly used: 200 and 600 mg mifepristone followed by 800 µg of misoprostol (51.5 and 33.3% of patients, respectively). 82.0% of women attended the follow-up visit (N=264), 5.0% were reached by phone and 13.0% were lost to follow-up. 86.2% of women performed blood and urine measurements, as requested, on the same day (± one day). The MToP success rate was 93.6% of women. There were two ongoing pregnancies (0.7%) and 16 retained products of conception (5.7%). The overall concordance between urine and blood hCG levels was estimated at 94.5% CI95% [90.2%; 97.4%]. According to the physician's opinion, a majority of women (89.6%) read the urine test correctly. Self-performing the LSUP test at home was found reassuring for 39.9% of women, and satisfactory for 25.8% of them, but 2.8% considered it to be alarming and 11.8% unsettling. CONCLUSION: In our study, a self-performed LSUP test showed good concordance with blood test and appeared to be relevant, efficient and safe for women to monitor MToP success.

IUD use in France: women's and physician's perspectives.

OBJECTIVE: While the intra-uterine device (IUD) is the second most popular contraceptive method in France, its use remains low among women most at risk of unintended pregnancies. Acknowledging the conjoint role of women and physicians in contraceptive decision making, we investigate the determinants of IUD use and IUD recommendations from the user and prescriber perspectives. STUDY DESIGN: Data are drawn from 2 national probability surveys (population-based and physician surveys) on sexual and reproductive health in France. The population based survey comprised 3,563 women ages 15-49 at risk of an unintended pregnancy in 2010 and the physician survey included 364 general practitioners (GPs) and 401 gynecologists practicing in private offices in 2010-2011. Analyses were performed using logistic regression models. RESULTS: Altogether, 21.4% of women were IUD users, with substantial differences by age and parity. Less than 1% of young women (<25 years) and 3% of nulliparous were current IUD users in 2010. The odds of IUD use were four times higher in women followed by a gynecologist as compared to a GP. Mirroring these results, gynecologists were more likely to recommend IUDs than GPs. Misconception about IUD risks was widespread among women and providers. Medical training and information, professional practice settings, and ever use of IUDs also informed physician's likelihood of recommending IUDs, regardless of specialty. CONCLUSIONS: The study reveals the intersection of individual and professional influences on contraceptive use patterns. The considerable age discrepancy in IUD use in France, with very few young women most at risk of an unintended pregnancy using the method, reflects a knowledge gap shared by users and providers. These findings suggest there are significant opportunities to improve contraceptive care in France. IMPLICATIONS: This study stresses the need to inform women and doctors about the benefits and risks of IUDs for all women. Substantial efforts are required to improve the medical curriculum, in order to promote evidenced based family planning counseling and provide GPs with the technical skills to insert IUDs.

Trends and determinants of use of long-acting reversible contraception use among young women in France: results from three national surveys conducted between 2000 and 2010.

OBJECTIVE: To investigate trends and determinants in the use of long-acting reversible contraceptives (LARCs), including intrauterine devices and implants, over the last decade among young women in France. DESIGN: Data drawn from three cross-sectional national probability surveys. SETTING: Not applicable. PATIENT(S): A total of 1,204 women, ages 15 to 29, who are at potential risk of an unintended pregnancy in 2000; 1,921 in 2005; and 1,281 in 2010. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Logistic regression models were used to explore trends in LARC use since 2000 and to examine determinants of LARC use in 2010. RESULT(S): A minority of women were using LARC methods, with a significant increase between 2000 and 2010, from 4.6% to 6.4%. The odds of LARC use in 2010 were higher among women 20 to 29 years, parous women, women with a history of unintended pregnancy, women in difficult financial situations, smokers, and women in the care of a gynecologist. CONCLUSION(S): This study shows that little progress has been made in LARC use among young women in France, despite these methods being widely available and reimbursed by the national health system.

Comparative study of the quality of life associated with menopause in Tunisia and France.

OBJECTIVE: Because the experience of menopause varies by ethnic group, society, and social class, we sought to compare quality of life (QoL) at menopause between Tunisian and French women. METHODS: This secondary analysis of existing data collected in two independent, cross-sectional surveys (the French GAZEL cohort and a representative sample of Tunisian women) compared both samples for six dimensions of the Women's Health Questionnaire while taking into account social and demographic characteristics and menopause status with multivariate logistic models. RESULTS: Comparison of 1,040 Tunisian women aged 45 to 64 years with 774 French women aged 48 to 53 years showed that Tunisian women had a significantly lower QoL than the French women in every dimension (low QoL for Tunisian vs French, odds ratio [95% CI]: somatic symptoms, 2.1 [1.6-2.7]; depressed mood, 3.6 [2.8-4.7]; anxiety, 2.4 [1.8-3.3]; vasomotor symptoms, 1.7 [1.3-2.3]). QoL was also lower for working-class women, but associations were weaker than for country (low QoL for working class vs middle class, odds ratio [95% CI]: somatic symptoms: 1.9 [1.5-2.4]; depressed mood, 1.5 [1.2-1.8]; anxiety, 1.8 [1.5-2.3]; vasomotor symptoms, 1.7 [1.4-2.2]). Associations between country and QoL were stronger in the working class than in the middle class. CONCLUSIONS: This epidemiological study comparing France and a North African country sheds light on the major role of country of residence, social class, and their interaction in the experience of menopause. Levels of national wealth, human development, cultural constraints, and social and gender inequality are likely to explain how country and class affect QoL.

Class, gender and culture in the experience of menopause. A comparative survey in Tunisia and France.

The experience of menopause can vary strongly from one society to another: frequency of hot flushes, other somatic and psychological symptoms, and changes in family and social relations. Several studies have shown that country of residence, country of birth, ethnicity, and social class all play roles in these variations. But few comparative anthropological studies have analysed the social processes that construct the experience of menopause or considered menopausal women's social and financial autonomy. To study the impact of the social status accorded to menopausal women and their social resources, during 2007 and 2008 we conducted a series of 75 in-depth interviews with women in different sociocultural settings: Tunisian women in Tunisia, Tunisian women in France, and French women in France, all aged from 45 to 70 years. Our methodological approach to the data included content analysis, typology development and socio-demographic analysis. Quite substantial differences appeared, as a function of social class and cultural environment. We identified three principal experiences of menopause. Tunisian working class women, in Tunisia and France, experience menopause with intense symptoms and strong feelings of social degradation. Among Tunisian middle-class women in both countries, menopause was most often accompanied by a severe decline in aesthetic and social value but few symptoms. For most of the French women, menopause involved few symptoms and little change in their social value. The distribution of types of experiences according to social but not geographic or national factors indicates that, in the populations studied here, the differences in symptoms are not biologically determined. Different experiences of menopause are linked to social class and to the degree of male domination. A given level of independence and emancipation allows women an identity beyond their reproductive function and a status unimpaired by menopause.

Introduction and provision of medical abortion: a tale of two countries in which technology is necessary but not sufficient.

INTRODUCTION: Medical abortion is one of the most important advances of the last century in the field of reproductive health. However, the introduction and use of the technology varies widely among countries. STUDY DESIGN: The article examines the commercial, political, regulatory, and legislative history of the introduction of mifepristone-misoprostol in France and the United States. RESULTS: While the introduction of the technology has been deemed a "success" in each country, existing patterns of medical research, abortion service provision and health care financing came to alter the uptake and use of medical abortion in the two countries. CONCLUSION: Proof of safety, efficacy and patient acceptability are in themselves not enough to assure successful introduction and widespread use of medical innovations. However, the case studies illustrate that there is more than one way to arrive at expansion of new technologies.

Contraception at the time of abortion: high-risk time or high-risk women?

BACKGROUND: Despite the widespread use of highly effective contraception in France, the incidence of abortion is high. A retrospective population-based cohort study was designed to analyse women's contraceptive history. METHOD: We compared the contraceptive use of 163 women, whose last pregnancy ended in abortion, 6 months before, at the time of, 1 month and 6 months after the event with that of 1787 women who had never had an abortion. RESULTS: A total of 46% of women who experienced an abortion used a highly effective form of contraception 6 months before the event (versus 76% among women who had never had an abortion, P < 0.001). This proportion dropped to 33% at the time of the abortion and increased to 71%, 1 month after. In addition, 50% of women who had an abortion had changed their contraceptive method in the 6 months before the event (compared with 16% in the 6 months before the interview in women who had not had an abortion, P < 0.001). Women with socially deprived backgrounds were less likely to use a highly effective contraception after an abortion. CONCLUSIONS: Abortion is a good opportunity for intervention, but especially so for socially disadvantaged women. It is essential to draw the attention of prescribers and women to the higher risk of contraceptive failure at the start of use of a method.