Contraception after abortion, miscarriage, ectopic and molar pregnancy.

Regardless of whether a pregnancy ends in abortion, miscarriage or ectopic pregnancy, fertility and sexual activity can resume quickly. For those who do not plan to become pregnant again immediately, effective contraception is therefore required. Although a contraceptive discussion and the offer to provide contraception is considered an integral part of abortion care, health care providers may not always offer this same standard of care to those whose pregnancy ends in miscarriage or ectopic due to sensitivities or assumptions around this and future fertility intentions. Yet, evidence-based recommendations support the safety of initiating contraception at these times. Provision of a chosen method of contraception may be convenient for women and valued by them. As part of holistic care, healthcare professionals who care for women around these reproductive events should therefore offer quality information on contraception and help them access their chosen method to better meet their ongoing reproductive health needs.

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.

Access to and sustainability of abortion services: a systematic review and meta-analysis for the National Institute of Health and Care Excellence-new clinical guidelines for England.

BACKGROUND: Induced abortion is a common procedure. However, there is marked variation in accessibility of services across England. Accessing abortion services may be difficult, particularly for women who live in remote areas, are in the second trimester of pregnancy, have complex pre-existing conditions or have difficult social circumstances. OBJECTIVE AND RATIONALE: This article presents a two-part review undertaken for a new National Institute of Health and Care Excellence guideline on abortion care, and aiming to determine: the factors that help or hinder accessibility and sustainability of abortion services in England (qualitative review), and strategies that improve these factors, and/or other factors identified by stakeholders (quantitative review). Economic modelling was undertaken to estimate cost savings associated with reducing waiting times. SEARCH METHODS: Ovid Embase Classic and Embase, Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R), PsycINFO, Cochrane Library via Wiley Online, Cinahl Plus and Web of Science Core Collection were searched for articles published up to November 2018. Studies were included if they were published in English after 2001, conducted in Organization for Economic Co-operation and Development (OECD) countries and were: qualitative studies reporting views of patients and/or staff on factors that help or hinder the accessibility and sustainability of a safe abortion service, or randomized or non-randomized studies that compared strategies to improve factors identified by the qualitative review and/or stakeholders. Studies were excluded if they were conducted in OECD countries where abortion is prohibited altogether or only performed to save the woman's life. One author assessed risk of bias of included studies using the following checklists: Critical Appraisal Skills Programme checklist for qualitative studies, Cochrane Collaboration quality checklist for randomized controlled trials, Newcastle-Ottawa scale for cohort studies, and Effective Practice and Organization of Care risk of bias tool for before-and-after studies.Qualitative evidence was combined using thematic analysis and overall quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Confidence in the Evidence from Reviews of Qualitative Research (CERQual). Quantitative evidence was analysed in Review Manager 5.3 and overall quality of evidence was assessed using GRADE. OUTCOMES: Eight themes (service level barriers; financial barriers; logistical barriers; personal barriers; legal and policy barriers; privacy and confidentiality concerns; training and education; community prescribing and telemedicine introduce greater flexibility) and 18 subthemes were identified from 23 papers (n = 1016) included in the qualitative review. The quality of evidence ranged from very low to high, with evidence for one theme and seven subthemes rated as high quality. Nine studies (n = 7061) were included in the quantitative review which showed that satisfaction was better (low to high quality evidence) and women were seen sooner (very low quality evidence) when care was led by nurses or midwives compared with physician-led services, women were seen sooner when they could self-refer (very low quality evidence), and clinicians were more likely to provide abortions if training used an opt-out model (very low quality evidence). Economic modelling showed that even small reductions in waiting times could result in large cost savings for services. WIDER IMPLICATIONS: Self-referral, funding for travel and accommodation, reducing waiting times, remote assessment, community services, maximizing the role of nurses and midwives and including practical experience of performing abortion in core curriculums, unless the trainee opts out, should improve access to and sustainability of abortion services.

The development of the listening in spatialised noise - universal test (LiSN-U) and preliminary evaluation in English-speaking listeners.

Objective: To create a language independent version of the Listening in Spatialised Noise - Sentences test (LiSN-S) and evaluate it in an English-speaking population.Design: Test development and normative data collection. LiSN-Universal (LiSN-U) targets consisted of CVCV pseudo-words (e.g. /mupa/). Two looped distracter tracks consisted of CVCVCVCV pseudo-words. The listener's task was to repeat back the target pseudo-words. Stimuli were presented over headphones using an iPad. Speech reception thresholds were measured adaptively. In the co-located condition all stimuli came from directly in front. In the spatially-separated condition the distracters emanated from +90° and -90° azimuth. Perceived location was manipulated using head-related transfer functions. Spatial advantage was calculated as the difference in dB between the co-located and spatially separated conditions.Study samples: Stimulus intelligibility data were collected from 20 adults. Normative data were collected from native English speakers (23 adults and 127 children).Results: Children's spatially separated, co-located, and spatial advantage results improved significantly with age. Spatial advantage was 4-6 dB larger in the LiSN-U than LiSN-S depending on age group.Conclusion: Whereas additional research in non-native English populations is required, the LiSN-U appears to be an effective tool for measuring spatial processing ability.

Midwives' experiences and views of giving postpartum contraceptive advice and providing long-acting reversible contraception: a qualitative study.

BACKGROUND: National sexual health frameworks in the UK advise that women in maternity units who are at risk of unintended pregnancy should receive contraceptive advice and supplies of the most effective long-acting reversible methods of contraception (LARC). In the UK, midwives currently deliver contraceptive advice to women following childbirth. There is a lack of information on how midwives currently view their role as provider of contraceptive advice and how they would feel about expanding this to include provision of LARC. OBJECTIVE: To explore midwives' experiences and views of giving postpartum contraceptive advice and of possible expansion of role to include provision of LARC. METHODS: Semi-structured, audio-recorded interviews were carried out with 12 midwives involved in the postpartum care of women in Edinburgh, Scotland, UK. Interviews were transcribed verbatim and analysed using thematic analysis. RESULTS: Midwives confirmed that they all routinely give contraceptive advice but that this was mostly cursory. They viewed this part of their job as of lesser importance and one that they felt inadequately trained for. Many barriers to discussing contraception were identified including lack of time and privacy, or mothers being preoccupied with concerns about their baby. Midwives expressed concern about taking on a greater role in giving contraceptive advice or providing LARC, given their current heavy workload. CONCLUSIONS: Midwives require ongoing training and support to be effective in their current role as provider of contraceptive advice. Better links between midwifery and specialist sexual and reproductive health services should therefore be encouraged, particularly if a midwife's role is expanded to include provision of contraception such as LARC.

The effect of better-ear glimpsing on spatial release from masking.

The current experiment investigated whether better-ear glimpsing can explain the spatial release achieved by normal-hearing adults when situations are high in informational masking. Both modeling and behavioral methods were used. The speech reception thresholds of 38 young adults were measured for co-located, spatially separated and two better-ear glimpsed conditions. In the better-ear glimpsed conditions the binaural signals were processed so that in each time-frequency segment, the signal with the better SNR (left or right ear) was presented diotically. To investigate the effect of widening auditory filters on better-ear glimpsing, adjacent frequency bands were combined in one of the better-ear glimpsing conditions. Twenty-two participants were tested with maskers high in informational masking, while 16 participants were tested with maskers lower in informational masking. The mean speech reception thresholds achieved in the glimpsed conditions were significantly worse than in the spatially separated condition. This suggests that better-ear glimpsing can explain some but not all of the observed spatial release from masking. The difference between performance in the spatially separated and glimpsed conditions was largest when informational masking was high, suggesting better-ear glimpsing may release energetic rather than informational masking. Reducing the number of frequency bands sampled had a small effect on performance.

The importance of interaural time differences and level differences in spatial release from masking.

Numerous studies have described improvements in speech understanding when interaural time differences (ITDs) and interaural level differences (ILDs) are present. The present study aimed to investigate whether either cue in isolation can elicit spatial release from masking (SRM) in a speech-on-speech masking paradigm with maskers positioned symmetrically around the listener. Twelve adults were tested using three presentations of the Listening in Spatialized Noise-Sentences Test, with each presentation modified to contain different interaural cues in the stimuli. Results suggest that ILDs provide a similar amount of SRM as ITDs and ILDs combined. ITDs alone provide significantly less benefit.

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.

Ongoing contraception after use of emergency contraception from a specialist contraceptive service.

BACKGROUND: A consultation for emergency contraception (EC) gives way to an opportunity to provide women with an ongoing effective method of contraception. STUDY DESIGN: A review of the case notes of women seeking EC from a large family planning clinic in Edinburgh, Scotland, was conducted to determine what percentage of women were provided with an effective method of ongoing contraception. RESULTS: Case notes of 460 women presenting for EC over a 2-year period were reviewed. Women were of mean age 26 years (range 15-49 years) and presented because they had used no contraception (47%), experienced condom failure (42%) or missed oral contraceptive pills (9%). Only 2% (n=11) were given an intrauterine device for EC. All women who had missed contraceptive pills prior to taking EC opted to continue this method. Only 23% (n=89) of women using no method or condoms at EC received supplies of an effective contraceptive method (pills, patch, injectable). Two thirds (n=263) of the women chose condoms for ongoing contraception. CONCLUSION: Research is required to develop strategies to improve the uptake of effective contraception after EC.

Listening in Spatialized Noise-Sentences Test (LiSN-S): normative and retest reliability data for adolescents and adults up to 60 years of age.

BACKGROUND: The Australian version of the Listening in Spatialized Noise-Sentences Test (LiSN-S) was originally developed to assess auditory stream segregation skills in children aged 6 to 11 yr with suspected central auditory processing disorder. The LiSN-S creates a three-dimensional auditory environment under headphones. A simple repetition-response protocol is used to assess a listener's speech reception threshold (SRT) for target sentences presented in competing speech maskers. Performance is measured as the improvement in SRT in decibels gained when either pitch, spatial, or both pitch and spatial cues are incorporated in the maskers. PURPOSE: To collect additional normative data on the Australian LiSN-S for adolescents and adults up to 60 yr of age, to analyze the effects of age on LiSN-S performance, to examine retest reliability in the older population, and to extrapolate findings from the Australian data so that the North American version of the test can also be used clinically with older adults. RESEARCH DESIGN: In a descriptive design, normative and test-retest reliability data were collected from adolescents and adults and combined with previously published data from Australian children aged 6 to 11 yr. STUDY SAMPLE: One hundred thirty-two participants with normal hearing aged 12 yr, 0 mo, to 60 yr, 7 mo, took part in the normative data study. Fifty-five participants returned between 2 and 4 mo after the initial assessment for retesting. RESULTS: Analysis of variance revealed a significant effect of age on LiSN-S performance (p < .01 for all LiSN-S measures, ηp2 ranging from 0.16 to 0.54). On the low and high cue SRT measures, planned contrasts revealed significant differences between adults and children aged 13 yr and younger, as well as between 50- to 60-yr-olds and younger adults aged 18-29 yr. Whereas there were significant differences between adults and children on the talker, spatial, and total advantage measures, there were no significant differences in performance in adults aged 18-60 yr. There was a small but significant improvement on retest ranging from 0.5 to 1.2 dB across the four LiSN-S test conditions (p ranging from .01 to <.001). However, there was no significant difference between test and retest on the advantage measures (p ranging from .143 to .768). Test-retest differences across all LiSN-S measures were significantly correlated (r ranging from 0.2 to 0.7, p ranging from .023 to <.00000001) and did not differ as a function of age (p ranging from .178 to .980). CONCLUSIONS: As there was no significant difference among adults aged 18-60 yr on the LiSN-S talker, spatial, and total advantage measures, it appears that the decline in ability to understand speech in noise experienced by 50- to 60-yr-olds is not related to their ability to use either spatial or pitch cues. This result suggests that some other factor/s contributes to the decline in speech perception in noise experienced by older adults that is reported in the literature and was demonstrated in this study on the LiSN-S low and high cue SRT measures.

The listening in spatialized noise test: an auditory processing disorder study.

The Listening in Spatialized Noise test (LISN) produces a virtual three-dimensional auditory environment under headphones. Various measures assess the extent to which either spatial, vocal, or spatial and vocal cues combined increase a listener's ability to comprehend a target story in the presence of distracter sentences, without being affected by differences between participants in variables such as linguistic skills. Ten children at risk for auditory processing disorder (APD group) were assessed on the LISN, as well as a traditional APD test battery. The APD group performed significantly more poorly on all LISN measures than 48 age-matched controls. On the spatial advantage measure, the APD group achieved a mean advantage of only 3.7 dB when the distracters were spatially separated from the target by +/-90 degrees, compared to 10.0 dB for the controls-the 6.3 dB difference significant at p < 0.000001, with nine children scoring outside the normal range. The LISN was considered a promising addition to an APD test battery.