Decision-making in case of an unintended pregnancy: an overview of what is known about this complex process.

Introduction: Unintended pregnancies are a worldwide health issue, faced each year by one in 16 people, and experienced in various ways. In this study we focus on unintended pregnancies that are, at some point, experienced as unwanted because they present the pregnant person with a decision to continue or terminate the pregnancy. The aim of this study is to learn more about the decision-making process, as there is a lack of insights into how people with an unintended pregnancy reach a decision. This is caused by 1) assumptions of rationality in reproductive autonomy and decision-making, 2) the focus on pregnancy outcomes, e.g. decision-certainty and reasons and, 3) the focus on abortion in existing research, excluding 40% of people with an unintended pregnancy who continue the pregnancy. Method: We conducted a narrative literature review to examine what is known about the decision-making process and aim to provide a deeper understanding of how persons with unintended pregnancy come to a decision.Results: Our analysis demonstrates that the decision-making process regarding unintended pregnancy consists of navigating entangled layers, rather than weighing separable elements or factors. The layers that are navigated are both internal and external to the person, in which a 'sense of knowing' is essential in the decision-making process. Conclusion: The layers involved and complexity of the decision-making regarding unintended pregnancy show that a rational decision-making frame is inadequate and a more holistic frame is needed to capture this dynamic and personal experience.

Navigating a maze: Midwives' identity response to the enactment of an abortion law in Chile.

BACKGROUND: Chilean midwives have been identified as essential for successfully implementing an abortion law, a practice which could potentially be understood as contradicting their central mission. Nevertheless, to date, there has been no investigation into how Chilean midwives have incorporated induced abortion care provision into their professional identity. OBJECTIVE: To elucidate how Chilean midwives understand and provide abortion care and how they have (re)defined their professional identity to include induced abortion care. This article reports the findings of the second part of this aim. METHODS: This study was underpinned by a constructivist grounded theory methodology informed by a reproductive justice and feminist perspective. Midwives from Chile who have cared for women undergoing abortion were invited to participate in the study. After purposive and theoretical sampling, fifteen midwives were recruited. FINDINGS: Midwives' identity is woman-centred, with high value placed on their role protecting life. These two aspects of midwives' identity are in contradiction when providing abortion care. Midwives' identity results from and informs midwives' practice. Midwifery regulation influences both practice and identity. The model 'Navigating a maze' explains the interaction of these three elements. CONCLUSION: Midwives' identity response to the enactment of the Chilean abortion law is an example of how professional identity must navigate regulation and practice to make sense of its purpose. In light of this study's findings, the current tension experienced in midwives' identity should be carefully attended to prevent adverse outcomes for midwives and the Chilean population.

Chilean midwives' experiences while providing induced abortion care after the enactment of a law decriminalising abortion.

INTRODUCTION: The recent change in Chilean legislation towards abortion enabled midwives to include the care of women having an induced abortion within their scope of practice. However, midwives' identity could be strained by induced abortion care provision as it is contrary to midwives' traditional role. Considering this, the aim of the study was to elucidate how Chilean midwives understand and provide abortion care. METHODS: A constructivist grounded theory study was conducted using online semi-structured in-depth interviews. Midwives were purposively sampled considering maximum variation criteria and then theoretical sampling occurred. Saturation was achieved with fifteen interviews. Interviews were conducted in Spanish and then translated into English. Constant comparison analysis generated categories. Data were managed using NVivo 12. All interviewees provided their consent to be part of this study. RESULTS: This article reports on the experiences of nine midwives who had provided lawful induced abortion care in Chile. The experiences of these midwives were grouped into two major categories: 'Defining a position towards abortion' and 'Abortion care is emotional labour'. CONCLUSION: Midwives can successfully provide abortion care despite being challenged by certain areas of it. Considering the high demand for emotional labour in abortion care, efforts should be made to increase midwives' emotional self-regulation skills. Likewise, organisations should strengthen and implement their offer of well-being and emotional self-care support to midwives.

Medication abortion during the COVID-19 pandemic in France: A research based on the French national health insurance database.

OBJECTIVES: During the COVID-19 pandemic in France, abortion was recognized as an essential service that cannot be delayed, and such care was therefore presumed to be maintained. The aim is to analyze the changes in the practice of abortion in 2020 to identify the consequences of the two lockdowns and the effects of the extension of the legal time limit. METHODS: We analyzed the data collected by the French national health insurance system, which covers 99% of the population. All women who had an elective abortion, either surgical or with medication, in France in 2019 and 2020 were included in the study. Trend changes in abortions were analyzed by comparing the ratio of the weekly number of abortions in 2020 with the weekly number in 2019. RESULTS: Both 2020 lockdowns were followed by a drop in abortions, particularly after the first and stricter lockdown. This may be explained not by an abrupt shutdown of access to abortion services, but rather by a decrease in conceptions during the lockdown weeks. The decrease was more marked for surgical abortions than for medication abortions in a hospital setting, and less so for medication abortions in non-hospital settings. Moreover, the proportion of the latter type of abortions continued to increase, showing the reinforcement of a previous trend. CONCLUSIONS: Our findings indicate that expanding the legal time limit for abortion, diversifying the settings where abortions can be performed and the range of abortion providers help to facilitate access to this fundamental reproductive care.

Selective feticide in dichorionic diamniotic (DCDA) twins complicated with previable premature rupture of membrane before 24 weeks may be a safe therapeutic alternative to ongoing pregnancy.

BACKGROUND: To date, there are no clinical guidelines for dichorionic diamniotic (DCDA) twins complicated with previable premature rupture of membrane (PV-ROM) before 24 weeks of gestation. The typical management options including expectant management and/or pregnant termination, induce the risks of fetal mortality and morbidity. OBJECTIVE: To explore the feasibility selective feticide in DCDA twins complicated with PV-ROM. STUDY DESIGN: A Retrospective cohort study, enrolling 28 DCDA twins suffering from PV-ROM in a tertiary medical center from Jan 01 2012 to Jan 01 2022. The obstetric outcome was compared between selective feticide group and expectant management group. RESULTS: There were 12 cases managed expectantly and 16 underwent selective feticide. More cases suffered from oligohydramnios in expectant management group compared to selective feticide group (P = 0.008). Among 13 cases with ROM of upper sac, the mean gestational age at delivery was (33.9 ± 4.9) weeks in the selective feticide group, which was significantly higher than that in the expectant management (P = 0.038). Five fetuses (83.3%) with selective feticide delivered after 32 weeks, whereas only one (14.3%) case in expectant management group (P = 0.029). However, in the subgroup with ROM of lower sac, no significant difference of the mean gestation age at delivery between groups and none of cases delivered after 32 weeks. CONCLUSION: There was a trend towards an increase in latency interval in DCDA twins with PV-ROM following selective feticide, compared to that with expectant management. Furthermore, selective feticide in cases with PV-ROM of upper sac has a favorable outcome.

Abortion care at 20 weeks and over in Victoria: a thematic analysis of healthcare providers' experiences.

BACKGROUND: In many countries, abortions at 20 weeks and over for indications other than fetal or maternal medicine are difficult to access due to legal restrictions and limited availability of services. The Abortion and Contraception Service at the Royal Women's Hospital in Victoria, Australia is the only service in the state that provides this service. The views and experiences of these abortion providers can give insight into the experiences of staff and women and the abortion system accessibility. The aim of this study was to examine health providers' perceptions and experiences of providing abortion care at 20 weeks and over for indications other than fetal or maternal medicine, as well as enablers and barriers to this care and how quality of care could be improved in one hospital in Victoria, Australia. METHODS: A qualitative study was conducted at the Abortion and Contraception Service at the Royal Women's Hospital. Participants were recruited by convenience and purposive sampling. Semi-structured interviews were conducted one-on-one with participants either online or in-person. A reflexive thematic analysis was performed. RESULTS: In total, 17 healthcare providers from medicine, nursing, midwifery, social work and Aboriginal clinical health backgrounds participated in the study. Ultimately, three themes were identified: 'Being committed to quality care: taking a holistic approach', 'Surmounting challenges: being an abortion provider is difficult', and 'Meeting external roadblocks: deficiencies in the wider healthcare system'. Participants felt well-supported by their team to provide person-centred and holistic care, while facing the emotional and ethical challenges of their role. The limited abortion workforce capacity in the wider healthcare system was perceived to compromise equitable access to care. CONCLUSIONS: Providers of abortion at 20 weeks and over for non-medicalised indications encounter systemic enablers and barriers to delivering care at personal, service delivery and healthcare levels. There is an urgent need for supportive policies and frameworks to strengthen and support the abortion provider workforce and expand provision of affordable, acceptable and accessible abortions at 20 weeks and over in Victoria and in Australia more broadly.

Low-concentration exogenous 3-indoleacetic acid improves fruit-setting rate of Marsdenia tenacissima by inhibiting the expression of embryo abortion-related genes.

Marsdenia tenacissima is a medicinal plant characterized by many flowers, few fruits, and a low fruit-setting rate. Exogenous auxins can improve the fruit-setting rate of plants; however, their impacts on M. tenacissima and regulatory mechanisms remain unclear. In this study, we conducted a field experiment to determine the fruit-setting rate, seed-setting rate, fruit size, and changes in transcriptional expression of related genes by spraying 10 and 50 mg·L-1 of 3-indoleacetic acid (IAA). The control plants were sprayed with distilled water. Our results indicated that the fruit-setting rate was 0.15 when treated with 10 mg·L-1 of IAA, which was 2.76-fold higher than that of the control. Compared with that of the control, the number of differentially expressed genes (DEGs) regulated by 10 mg·L-1 of IAA was 28.6-fold higher than that regulated by 50 mg·L-1 of IAA. These DEGs were closely related to hormone metabolism and fruit development. By transcriptome analysis, spraying 10 mg·L-1 of IAA increased the expressions of STP6, MYB17, and LAX3 and reduced those of CXE18, ILR1-like 3, and SAUR50; this possibly affected the ovule, embryo, and fruit development, thereby elevating the fruit-setting rate of M. tenacissima. Our results indicated that low IAA concentration increased the fruit-setting rate of M. tenacissima, providing theoretical and practical support for promoting the seed yield of M. tenacissima.

Effects of aromatherapy on patient satisfaction with procedural abortion at less than 10 weeks' gestation: A randomized controlled trial.

OBJECTIVES: This study aimed to compare satisfaction with procedural abortion prior to 10 weeks' gestation in patients randomized to lavender essential oil aromatherapy vs placebo (jojoba oil). STUDY DESIGN: This randomized trial compared lavender aromatherapy vs placebo in patients undergoing procedural abortion <10 weeks' gestation. Participants self-administered and inhaled oil during their procedures. Our primary outcome was composite mean score on the Iowa Satisfaction with Anesthesia Scale. Participants completed the State-Trait Anxiety Inventory, a visual analog scale reporting maximum procedural pain, and reported postprocedure aromatherapy acceptability. RESULTS: We analyzed 112 participants randomized to aromatherapy (n = 57) vs placebo (n = 55). Baseline characteristics were similar between groups. We found no difference in overall satisfaction (mean Iowa Satisfaction with Anesthesia Scale scores aromatherapy: 0.72 ± 0.96 vs placebo: 0.46 ± 0.98, p = 0.17) or maximum procedural pain (median visual analog scale score aromatherapy: 65 [range: 4-95] vs placebo: 63 [range: 7-97], p = 0.91). Independent predictors of satisfaction included the use of oral sedation (B: 0.36; 95% CI: 0.04-0.69), state anxiety (B: -0.45; 95% CI: -0.79 to -0.10), and maximum procedural pain (B: -0.17; 95% CI: -0.25 to -0.09). The aromatherapy participants were significantly more likely to have found inhaling scented oil helpful during their procedure (71.9% vs 45.5%; p = 0.005) and would recommend it to a friend who needed a procedural abortion (86.0% vs 56.4%; p = 0.0005) compared to those in the placebo group. Additionally, patients in the aromatherapy group were significantly more likely to agree with the statement, "If I need another procedural abortion, I would want to inhale scented oil during my procedure" (87.7% vs 70.9%; p = 0.03). CONCLUSIONS: The adjunctive use of lavender aromatherapy during first-trimester procedural abortion does not improve satisfaction with anesthesia but is highly valued by patients. IMPLICATIONS: Oral opioids as an adjunct to standard analgesics during procedural abortion (ibuprofen and paracervical block) do not decrease pain, and nonopioid options are lacking. Given current limited anesthesia options, aromatherapy could serve as an affordable and acceptable nonopioid adjunct to current standard of care during procedural abortion. GOV IDENTIFIER: NCT04969900.

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.

Ethics, Abortion Access, and Emergency Care Post-Dobbs: The Gray Areas.

Clinical management of emergency pregnancy care, such as ectopic pregnancy or heavy bleeding with pregnancy of unknown location, includes upholding legal and ethical standards. For health care providers unwilling to provide evidence-based life-saving abortion care due to personal beliefs, clear guidance dictates disclosure of these limitations to the patient and colleagues, followed by immediate referral for appropriate care. However, this decision-making pathway may not be engaged due to a variety of factors: providers' beliefs preclude adherence to referral responsibilities, political discourse confuses patients as to their options and rights, and a constantly changing state and national legal landscape leads providers to question their ability to practice to their full scope of clinical care. Although this disruption of evidence-based standard of care existed pre-Dobbs, the moral disorder is now heightened. This Clinical Rounds highlights a patient vignette describing the risks of abortion restrictions for patients and providers alike, particularly when an individual provider's concerns for violating institutional guidelines sets a precedent for nursing response and forecloses on collaborative input or ethics consultation. The history of physician-only abortion exceptionalism and exclusion of nurses and midwives despite a significant history of nurses and midwives in abortion care grounds an argument for focusing on the impact of unethical and substandard care on the interprofessional care team leading to moral distress and negative patient outcomes. Patient-centered models of care, such as frameworks common in nursing and midwifery, offer opportunities to consider how all providers practicing to their full scope in interprofessional and collaborative ways, such as in emergency rooms and labor departments, might mitigate obstructions to abortion care that risk pregnant people's lives.

Midwifery and APRN Scope of Practice in Abortion Care in the Early Post-Roe Era: Everything Old Is New Again.

Over the past 10 years, there has been a rapid expansion of legal and legislative changes in abortion care provision for advanced practice clinicians (APCs), including nurse practitioners, midwives, and physician associates (formerly physician assistants), with most of that expansion occurring in the last several years. This expansion has occurred via several routes (eg, legislative, popular vote, court decision, attorney general opinion), and the patchwork of legal statuses nationally creates confusion for clinicians who are unclear on current regulations. This review explores the historical context of abortion practice for APCs, as well as the primary philosophical and legal concepts relevant to this role development. Since 2012, the number of states permitting abortion practice by APCs has more than quintupled, and the changes to abortion law in the United States in the wake of the 2022 Supreme Court decision in the case of Dobbs v. Jackson Women's Center creates a new imperative to understand the role of APCs in accessing abortion care. Additionally, although the research on abortion safety for APC abortion providers is well-established, the physician-centered paradigm of abortion care has limited the ability of APCs to develop expertise in this essential public and clinical health service.

Privileging Midwives for Abortion Care.

Since the US Supreme Court overturned Dobbs v Jackson, expanded access to abortion has been critical. Abortion is safe, and related complications are rare. The safety of abortion provision by advanced practice clinicians (APCs) is well documented. Despite the increase in targeted restrictions for patients and clinicians in many states post-Dobbs, in recent years there have been meaningful gains in recognition and codification of abortion as part of an expanded scope of practice for APCs. Thus, creating a formal written pathway for midwives to obtain privileges in abortion provision could also improve abortion access. In New York City's public health care system, the largest in the United States, midwives provide a significant portion of perinatal and gynecologic care. Yet, until recently, a process to privilege midwives in the provision of abortion services did not exist. In response, midwives and physicians at a large New York City hospital system sought key stakeholder support to develop a pathway for certified nurse-midwives and certified midwives, licensed midwives in New York state, to obtain the necessary training needed for independent abortion provision. This article describes the development of a midwifery-led pilot program to improve abortion access by increasing the availability of trained midwifery abortion providers, along with the results of staff meetings exploring attitudes toward abortion care by APCs. We report our safety statistics from this pilot program and share existing evidence for safety of abortion provision by midwives and other APCs.

The forgotten girls: the state of evidence for health interventions for pregnant adolescents and their newborns in low-income and middle-income countries.

Every year, an estimated 21 million girls aged 15-19 years become pregnant in low-income and middle-income countries (LMICs). Policy responses have focused on reducing the adolescent birth rate whereas efforts to support pregnant adolescents have developed more slowly. We did a systematic review of interventions addressing any health-related outcome for pregnant adolescents and their newborn babies in LMICs and mapped its results to a framework describing high-quality health systems for pregnant adolescents. Although we identified some promising interventions, such as micronutrient supplementation, conditional cash transfers, and well facilitated group care, most studies were at high risk of bias and there were substantial gaps in evidence. These included major gaps in delivery, abortion, and postnatal care, and mental health, violence, and substance misuse-related outcomes. We recommend that the fields of adolescent, maternal, and sexual and reproductive health collaborate to develop more adolescent-inclusive maternal health care and research, and specific interventions for pregnant adolescents. We outline steps to develop high-quality, evidence-based care for the millions of pregnant adolescents and their newborns who currently do not receive this.

"I would love for there not to be so many hoops ": recommendations to improve abortion service access and experiences made by Indigenous women and 2SLGTBQIA+ people in Canada.

Acknowledging the barriers in accessing sexual and reproductive health services that disproportionately impact Indigenous women and 2SLGTBQIA+ people, coupled with the lack of knowledge surrounding Indigenous peoples' experiences with abortion, we present qualitative findings from a pilot study investigating Indigenous experiences of accessing abortion services in Canada. We focus on findings related to participant recommendations for improving safety and accessibility of abortion services made by and for Indigenous people in Canada. Informed by an Indigenous Advisory Committee consisting of front-line service providers working in the area of abortion service access and/ or support across Canada, the research team applied an Indigenous methodology to engage with 15 Indigenous people across Canada utilising a conversational interview method, between September and November 2021. With representation from nine provinces and territories across Canada, participants identified with Anishinaabe, Cree, Dene, Haudenosaunee, Inuit, Métis and/ or Mi'kmaq Nations. Five cross-cutting recommendations emerged, including: (1) location, comfort, and having autonomy to choose where the abortion takes place; (2) holistic post-abortion supports; (3) accessibility, availability, and awareness of non-biased and non-judgemental information; (4) companionship, advocacy, and logistical help before and during the abortion from a support person; and (5) cultural safety and the incorporation of local practices and knowledges. Recommendations demonstrate that Indigenous people who have experienced an abortion carry practical solutions for removing barriers and improving access to abortion services in the Canadian context.

Midwives Safeguarding Abortion Access: Establishing Medication Abortion Services.

The abortion access landscape for patients has changed dramatically in the wake of the US Supreme Court Dobbs v. Jackson Women's Health Organization decision in June of 2022. In response, the Division of Midwifery at Baystate Medical Center in Springfield, Massachusetts, began a medication abortion service for both established patients and those who may seek care from out of state. This service increases access to abortion care now while also providing the clinical experience needed for student nurse-midwives to become future abortion providers. This article outlines the steps taken to implement a medication abortion service and ways it can be adopted by other midwifery practices. Strategies to address possible clinical, administrative, and logistical challenges are addressed. Finally, this article is a call to action because midwives are well qualified to provide high quality, safe, and comprehensive medication abortion within the midwifery model of care.

Roots, Leaves, and Flowers: A Narrative Review of Herbs and Botanicals Used for Self-Managed Abortion in Asia and the Pacific.

Abortion has existed throughout history, often outside of formal health care systems. This type of care, now called self-managed abortion, has historically been achieved in part through botanicals and traditional medicines. Their use continues into the modern day, especially in Asia, Hawai'i, and other Pacific Islands, where indigenous medicine traditions practice alongside allopathic medicine. Many of these botanicals, such as papaya leaves, hibiscus flowers, and young ki, and traditional medicines, such as tianhuafen, yuanhua, and Shenghua Decoction, have undergone scientific and clinical investigation of their potential abortifacient and antifertility action. The incidence of self-managed abortion with such abortifacients in countries with severe abortion restrictions are only estimates, leading to the possibility that legal rulings and societal pressures may cause underreporting. The Asian American, Native Hawaiian, and Pacific Islander communities in the United States also suffer from a lack of abortion access in addition to unique health disparities and barriers to reproductive health care. As difficulties in abortion access increases due to the Supreme Court decision in Dobbs v. Jackson Women's Health Organization, some may seek or even prefer self-managed abortion through traditional methods that have been passed down in their communities. Midwives and other health care providers may then be contacted during this process. This narrative review provides an overview of the literature on the use of botanicals, herbs, and traditional medicines used for self-managed abortion, specifically in Asia, Hawai‧i, and other Pacific Islands. Their implications for practice for providers in the United States and further opportunities for research are also presented.

Midwifery care for late termination of pregnancy: Integrative review.

Midwives provide reproductive healthcare to women, including during termination of pregnancy (TOP) after 12 weeks (late TOP). Their expertise, knowledge and woman-centred care approach sees them ideally placed for this role. However, the medical, social and emotional complexities of late TOP can cause midwives significant distress. An integrative review methodology was used to examine the research on midwifery care for late TOP and identify support strategies and interventions available to midwives in this role. Five databases and reference lists were searched for relevant studies published between 2000 and 2021. A total of 2545 records were identified and 24 research studies included. Synthesis of research findings resulted in three themes: Positive aspects, negative aspects and carers need care. Midwives reported a high level of job satisfaction when caring for women during late TOP. Learning new skills and overcoming challenges were positive aspects of their work. Yet, midwives felt unprepared to deal with challenging aspects of late TOP care such as the grief and the psychological burden of the role. Caring for the baby with dignity had both positive and negative aspects. Midwives relied predominantly on close colleagues for help and debriefing as they felt poorly supported by management, judged by co-workers and lacked appropriate support to reduce the emotional effects of late TOP care. Midwives need support, although current evidence has not identified the most appropriate and effective strategy to support them in this role.

"I suppose we've all been on a bit of a journey": a qualitative study on providers' lived experiences with liberalised abortion care in the Republic of Ireland.

The aim of this study was to explore service providers' lived experiences with abortion care in the Republic of Ireland following liberalisation in 2018 via public referendum. Data were collected using semi-structured interviews conducted between February 2020 and March 2021. Thirteen interviews were completed with providers who were directly involved in caring for patients accessing liberalised abortion care in the Republic of Ireland. The sample includes six general practitioners, three midwives, two obstetricians, and two nurses. Interpretative phenomenological analysis identified five super-ordinate themes in the providers' lived experiences: (1) public reactions to liberalised abortion care; (2) lessons from the service implementation; (3) getting involved in abortion care; (4) moments of moral doubt; and (5) remaining committed to the provision of care. Following liberalisation, providers recalled isolated experiences with anti-abortion sentiments, particularly from those who continue to oppose abortion care. They believed that implementation has been mostly successful in delivering a safe, robust, and accessible service in general practice, though identified ongoing challenges in Irish hospitals. Personally, the providers supported access to care and began providing because they perceived a duty to facilitate access to care. Many, however, reported occasional moral doubts about their work. Despite these, none had considered leaving abortion care and all were proud of their work. They said that patients' stories were a constant reminder about the importance of safe abortion care. Further work is required to ensure that abortion is fully integrated and normalised and that all providers and patients have access to supports.

The association between abortion restrictions and patient-centered care for early pregnancy loss at US obstetrics-gynecology residency programs.

BACKGROUND: Early pregnancy loss is a common medical problem, and the recommended treatments overlap with those used for induced abortions. The American College of Obstetricians and Gynecologists recommends the incorporation of clinical and patient factors when applying conservative published imaging guidelines to determine the timing of intervention for early pregnancy loss. However, in places where abortion is heavily regulated, clinicians who manage early pregnancy loss may cautiously rely on the strictest criteria to differentiate between early pregnancy loss and a potentially viable pregnancy. The American College of Obstetricians and Gynecologists also notes that specific treatment modalities that are frequently used to induce abortion, including the use of mifepristone in medical therapy and surgical aspiration in an office setting, are cost-effective and beneficial for patients with early pregnancy loss. OBJECTIVE: This study aimed to determine how US-based obstetrics and gynecology residency training institutions adhere to the American College of Obstetricians and Gynecologists recommendations for early pregnancy loss management, including the timing and types of interventions, and to evaluate the relationship with institutional and state abortion restrictions. STUDY DESIGN: From November 2021 to January 2022, we conducted a cross-sectional study of all 296 US-based obstetrics and gynecology residency programs by emailing them and requesting that a faculty member complete a survey about early pregnancy loss practices at their institution. We asked about location of diagnosis, use of imaging guidelines before offering intervention, treatment options available at their institution, and program and personal characteristics. We used chi-square tests and logistic regressions to compare the availability of early pregnancy loss care based on institutional indication-based abortion restrictions and state legislative hostility to abortion care. RESULTS: Of the 149 programs that responded (50.3% response rate), 74 (49.7%) reported that they did not offer any intervention for suspected early pregnancy loss unless rigid imaging criteria were met, whereas the remaining 75 (50.3%) programs reported that they incorporated imaging guidelines with other factors. In an unadjusted analysis, programs were less likely to incorporate other factors with imaging criteria if they were in a state with legislative policies that were hostile toward abortion (33% vs 79%; P<.001) or if the institution restricted abortion by indication (27% vs 88%; P<.001). Mifepristone was used less often in programs located in hostile states (32% vs 75%; P<.001) or in institutions with abortion restrictions (25% vs 86%; P<.001). Similarly, office-based suction aspiration use was lower in hostile states (48% vs 68%; P=.014) and in institutions with restrictions (40% vs 81%; P<.001). After controlling for program characteristics, including state policies and affiliation with family planning training programs or religious entities, institutional abortion restrictions were the only significant predictor of rigid reliance on imaging guidelines (odds ratio, 12.3; 95% confidence interval, 3.2-47.9). CONCLUSION: In training institutions that restrict access to induced abortion based on indication for care, residency programs are less likely to holistically incorporate clinical evidence and patient priorities in determining when to intervene in early pregnancy loss as recommended by the American College of Obstetricians and Gynecologists. Programs in restrictive institutional and state environments are also less likely to offer the full range of early pregnancy loss treatment options. With state abortion bans proliferating nationwide, evidence-based education and patient-centered care for early pregnancy loss may also be hindered.

Shoutai Wan regulates glycolysis imbalance at the maternal-fetal interface in threatened abortion mice.

ETHNOPHARMACOLOGICAL RELEVANCE: Threatened abortion is a common disease among women of childbearing age. Its high incidence rate and unclear etiology, seriously threaten women's physical and mental health. Shoutai Wan (STW) is a traditional Chinese medicine decoction for treating abortion. It has a long history of treating threatened abortion by tonifying the kidney and calming the fetus. However, the mechanism of STW remains unclear. AIM OF STUDY: To study the mechanism and potential benefit of STW in pregnant mice with hydrocortisone and mifepristone-induced threatened abortion. MATERIALS AND METHODS: The STW compounds were identified using gas chromatography-mass spectrometry analysis. STW-H, STW-M, or STW-L was separately given 3 mg/ml, 1.5 mg/ml and 0.75 mg/ml STW in the morning, and 2 mg/ml hydrocortisone in the afternoon from gestation day (D) 1-9 and once with 0.4 mg/kg mifepristone on D10. Didroxyprogesterone (0.1 mg/ml) and equal dose pure water were used to replace STW in didroxyprogesterone (DYD) group and model group respectively. The control group used pure water to replace STW, hydrocortisone, and mifepristone. We performed morphological and histological analyses of the maternal-fetal interface on day 10. RESULTS: The embryo loss rate in the STW-H and DYD groups was lower than that in the model group. Hematoxylin and eosin (HE) staining suggested that the morphology of maternal-fetal interface was improved in the STW-H and DYD groups. Immunohistochemical (IHC), Quantitative Reverse Transcription Polymerase Chain Reactionstaining (qRT-PCR), and Western blot (WB) results indicated that HIF-1α expression in the maternal-fetal interface of the STW-H and DYD groups was higher than that in model group. The activities of HK, PKM, LDH and the concentration of lactic acid in the STW-H and DYD groups were higher than those in model group. Furthermore, the protein and mRNA levels of HK2, PKM2, LDHA, MCT4, and GPR81 were higher in the STW-H and DYD groups than those in the model group. CONCLUSIONS: STW can reduce the pregnancy loss rate by regulating the glycolysis balance at the maternal-fetal interface of kidney deficiency threatened abortion model mice.