The prevalence of and factors associated with prior induced abortion among women who gave birth in Victoria, 2010-2019.

OBJECTIVE: To assess the prevalence of a history of induced abortion among women who gave birth in Victoria during 2010-2019; to assess the association of socio-demographic factors with a history of induced abortion. STUDY DESIGN: Retrospective cohort study; analysis of cross-sectional perinatal data in the Victorian Perinatal Data Collection (VPDC). SETTING, PARTICIPANTS: All women who gave birth (live or stillborn) in Victoria, 1 January 2010 - 31 December 2019. MAIN OUTCOME MEASURES: Self-reported induced abortions prior to the index birth; outcome of the most recent pregnancy preceding the index pregnancy. RESULTS: Of the 766 488 women who gave birth during 2010-2019, 93 251 reported induced abortions (12.2%), including 36 938 of 338 547 nulliparous women (10.9%). Women living in inner regional (adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.93-0.96) or outer regional/remote/very remote areas (aOR, 0.86; 95% CI, 0.83-0.89) were less likely than women in major cities to report induced abortions. The likelihood increased steadily with age at the index birth and with parity, and was also higher for women without partners at the index birth (aOR, 2.20; 95% CI, 2.16-2.25) and Aboriginal and Torres Strait Islander women (aOR, 1.32; 95% CI, 1.25-1.40). The likelihood was lower for women born in most areas outside Australia than for those born in Australia. The likelihood of a history of induced abortion declined across the study period overall (2019 v 2010: 0.93; 95% CI, 0.90-0.96) and for women in major cities (0.88; 95% CI, 0.84-0.91); rises in inner regional and outer regional/remote/very remote areas were not statistically significant. CONCLUSIONS: Access to abortion care in Victoria improved during 2010-2019, but the complex interplay between contraceptive use, unintended pregnancy, and induced abortion requires further exploration by remoteness of residence. Robust information about numbers of unintended pregnancies and access to reproductive health services are needed to guide national sexual and reproductive health policy and practice.

Intimate partner violence and severe acute maternal morbidity in the intensive care unit: A case-control study in Peru.

BACKGROUND: Intimate partner violence is a prevalent public health issue associated with all-cause maternal mortality. This study investigated the relationship between intimate partner violence, severe acute maternal morbidity in the intensive care unit (ICU), and neonatal outcomes. METHODS: This was a prospective case-control study in a hospital in Lima, Peru, with 109 cases (maternal ICU admissions) and 109 controls (obstetric patients not admitted to the ICU). Data were collected through face-to-face interviews and medical record review. Partner violence was assessed using the World Health Organization instrument. Multivariate logistic regression was used to model the association between intimate partner violence and severe acute maternal morbidity. RESULTS: There was a significantly higher rate of intimate partner violence both before and during pregnancy among cases (58.7%) than controls (27.5%). In multivariate analysis, intimate partner violence both before and during pregnancy (aOR 3.83 (95% CI: 1.99-7.37)), being married (3.86 (1.27-11.73)), having <8 antenatal care visits (2.78 (1.14-6.80)), and having previous abortions (miscarriage, therapeutic, or unsafe) (1.69 (1.13-2.51)) were significantly associated with severe acute maternal morbidity. The ICU admission rate was 18.8 (per 1000 live births), and ICU maternal mortality was 1.7%. The perinatal mortality rate was higher in cases (9.3%) than in controls (1.8%). CONCLUSIONS: Intimate partner violence was associated with an increased risk of severe acute maternal morbidity. This suggests a more severe impact of intimate partner violence on pregnancy than has been previously identified. Inquiring about intimate partner violence during prenatal visits may prevent further harm to the mother-baby dyad.

Maternal and child health nurse screening and care for mothers experiencing domestic violence (MOVE): a cluster randomised trial.

BACKGROUND: Mothers are at risk of domestic violence (DV) and its harmful consequences postpartum. There is no evidence to date for sustainability of DV screening in primary care settings. We aimed to test whether a theory-informed, maternal and child health (MCH) nurse-designed model increased and sustained DV screening, disclosure, safety planning and referrals compared with usual care. METHODS: Cluster randomised controlled trial of 12 month MCH DV screening and care intervention with 24 month follow-up. The study was set in community-based MCH nurse teams (91 centres, 163 nurses) in north-west Melbourne, Australia. Eight eligible teams were recruited. Team randomisation occurred at a public meeting using opaque envelopes. Teams were unable to be blinded. The intervention was informed by Normalisation Process Theory, the nurse-designed good practice model incorporated nurse mentors, strengthened relationships with DV services, nurse safety, a self-completion maternal health screening checklist at three or four month consultations and DV clinical guidelines. Usual care involved government mandated face-to-face DV screening at four weeks postpartum and follow-up as required. Primary outcomes were MCH team screening, disclosure, safety planning and referral rates from routine government data and a postal survey sent to 10,472 women with babies ≤ 12 months in study areas. Secondary outcomes included DV prevalence (Composite Abuse Scale, CAS) and harm measures (postal survey). RESULTS: No significant differences were found in routine screening at four months (IG 2,330/6,381 consultations (36.5 %) versus CG 1,792/7,638 consultations (23.5 %), RR = 1.56 CI 0.96-2.52) but data from maternal health checklists (n = 2,771) at three month IG consultations showed average screening rates of 63.1 %. Two years post-intervention, IG safety planning rates had increased from three (RR 2.95, CI 1.11-7.82) to four times those of CG (RR 4.22 CI 1.64-10.9). Referrals remained low in both intervention groups (IGs) and comparison groups (CGs) (<1 %). 2,621/10,472 mothers (25 %) returned surveys. No difference was found between arms in preference or comfort with being asked about DV or feelings about self. CONCLUSION: A nurse-designed screening and care model did not increase routine screening or referrals, but achieved significantly increased safety planning over 36 months among postpartum women. Self-completion DV screening was welcomed by nurses and women and contributed to sustainability. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12609000424202, 10/03/2009.

Emergency contraception in Australia: the desired source of information versus the actual source of information.

OBJECTIVE: To determine long-term trends in emergency contraception (EC) management by general practitioners in Australia. DESIGN, SETTING AND PARTICIPANTS: Data from April 2000 to March 2012 were drawn from the BEACH (Bettering the Evaluation and Care of Health) program, a continuous cross-sectional survey of GP activity. We analysed consultations involving EC management, unwanted pregnancy management and emergency contraceptive pill (ECP) prescribing per 1000 GP encounters with women aged 14-54 years. Summary statistics were calculated with 95% confidence intervals. RESULTS: In 2000-2001, GPs managed EC problems at a rate of 5.50 per 1000 encounters (95% CI, 4.37-6.63). From 2004, after the ECP became available over the counter (OTC) in pharmacies, EC management, which includes ECP prescription, progressively declined. By 2011-2012, only 1.43 EC problems were managed per 1000 encounters (95% CI, 0.84-2.02) and only 0.48 ECP prescriptions were provided per 1000 encounters (95% CI, 0.14-0.82). Yet the management rate of unwanted pregnancy problems stayed relatively constant (rate in 2000-2001, 0.95 per 1000 encounters; 95% CI, 0.40-1.50; rate in 2011-2012, 0.88 per 1000 encounters; 95% CI, 0.41-1.36). CONCLUSION: Low rates of EC management by GPs since ECP became available OTC suggest that women may be obtaining information on EC elsewhere. Further investigation is needed to uncover the sources of this information and its acceptability and application by Australian women.

What do Australian primary care clinicians need to provide long-acting reversible contraception and early medical abortion? A content analysis of a virtual community of practice.

BACKGROUND: Uptake of long-acting reversible contraception (LARC) is lower in Australia compared with other high-income countries, and access to early medical abortion (EMA) is variable with only 11% of general practitioners (GPs) providing EMA. The AusCAPPS (Australian Contraception and Abortion Primary Care Practitioner Support) Network is a virtual community of practice established to support GPs, nurses and pharmacists to provide LARC and EMA in primary care. Evaluating participant engagement with AusCAPPS presents an opportunity to understand clinician needs in relation to LARC and EMA care. METHODS: Data were collected from July 2021 until July 2023. Numbers of online resource views on AusCAPPS were analysed descriptively and text from participant posts underwent qualitative content analysis. RESULTS: In mid-2023 AusCAPPS had 1911 members: 1133 (59%) GPs, 439 (23%) pharmacists and 272 (14%) nurses. Concise point-of-care documents were the most frequently viewed resource type. Of the 655 posts, most were created by GPs (532, 81.2%), followed by nurses (88, 13.4%) then pharmacists (16, 2.4%). GPs most commonly posted about clinical issues (263, 49% of GP posts). Nurses posted most frequently about service implementation (24, 27% of nurse posts). Pharmacists posted most about health system and regulatory issues (7, 44% of pharmacist posts). CONCLUSIONS: GPs, nurses and pharmacists each have professional needs for peer support and resources to initiate or continue LARC and EMA care, with GPs in particular seeking further clinical education and upskilling. Development of resources, training and implementation support may improve LARC and EMA provision in Australian primary care.

Intimate partner violence and the association with very preterm birth.

BACKGROUND: Intimate partner violence is a major public health problem. It occurs commonly in pregnancy, resulting in adverse events for women and their fetus or children. The objective of this study was to examine the association between intimate partner violence and very preterm birth. METHODS: This population-based, case-control study was conducted in Victoria, Australia, from 2002 to 2004. Interviews were conducted with 603 women who had a singleton very preterm birth (20-31 weeks' gestation), 770 women who had a singleton term birth (37 or more completed weeks' gestation), 139 women who had a very preterm twin birth, and 214 women who had a term twin birth. Intimate partner violence was measured using the Composite Abuse Scale, and questions were also asked about fear of partners and violence from others. RESULTS: Prevalence of intimate partner violence in the past 12 months was 14.9 percent in singleton case women, 11.7 percent in singleton control women, 9.5 percent in twin case women, and 14.7 percent in twin control women. Fear of a previous partner and reporting similar violence experience with someone else were more likely in singleton births (AOR = 1.36; 95% CI 1.03, 1.79) and (AOR = 1.44; 95% CI 1.12, 1.86), respectively. No differences between twin case women and twin control women were observed. When the precipitating cause of very preterm birth was investigated, antepartum hemorrhage was significantly associated with intimate partner violence and all its subscales. CONCLUSIONS: The heterogeneity of causes of very preterm birth may explain the lack of association found with intimate partner violence in pregnancy. Pregnant women have a significant risk of intimate partner violence, which should be a serious concern for all care providers.

Pharmacy dispensing of abortion pills in Ghana: experiences of pharmacy workers and users.

BACKGROUND: Self-managed medical abortions are generally safe; however, pharmacy provision of abortion pills is against the Ghanaian abortion law. Nevertheless, evidence shows increasing numbers of women use it. An understanding of the influence of the law on pharmacies dispensing abortifacients and women who needed hospital care after using these pills is lacking. This study aimed to address this gap. METHODS: We conducted 26 interviews with eight pharmacy workers and 18 women who sought hospital care after using abortion pills. Study participants were recruited from private pharmacies and hospitals within the Ashanti Region of Ghana between June 2017 and March 2018. We employed phenomenology in analysing the data. RESULTS: Results show that criminalising medical abortion care from pharmacies does not stop abortions but rather drives it to be provided without oversight. It also denied pharmacy workers formal training in medical abortion care, resulting in situations where they failed to provide correct dosage information, used their discretion in determining the price of abortifacients and to whom they would dispense the pills. For women, it contributed to limited interaction with providers and an inability to insist on their rights even in instances where the pills were sold at exorbitant prices. CONCLUSIONS: Due to the increasing numbers of Ghanaian women using medical abortion pills from pharmacies, although it is illegal, the ideal would be for medical abortion pills to be made legally available through pharmacies. Given that this may not occur in the short term, an immediate solution would be to upskill pharmacy workers.

The prevalence and variations in unintended pregnancy by socio-demographic and health-related factors in a population-based cohort of young Australian women.

OBJECTIVE: The aim of this study is to estimate the prevalence of unintended pregnancy and associated socio-demographic and health-related factors among a national cohort of young Australian women. METHODS: Secondary analysis of three waves (2013-2015) of the Australian Longitudinal Study on Women's Health new young cohort. Women born between 1989 and 1995 were recruited through internet and traditional media, and peer referral. Respondents completed a baseline web-based survey in 2013 (n=17,010) on their health and healthcare use and were followed up annually. This analysis uses data from women reporting ever having vaginal sex in waves 2 (n=9,726/11,344) and 3 (n=6,848/8,961). We assessed correlates of lifetime and recent unintended pregnancy using multivariable regression models. RESULTS: At wave 2, among women aged 19-24, lifetime prevalence of unintended pregnancy was 12.6%, rising to 81.0% among ever pregnant women. Pregnancy outcomes among women with a history of unintended pregnancy differed by geographical residence. Disparities in odds of unintended pregnancy were seen by relationship and educational status, contraceptive use, sexual coercion and risky alcohol use. CONCLUSIONS: Unintended pregnancy among young Australians is disproportionally experienced by women with structural disadvantages and exposure to sexual coercion. PUBLIC HEALTH IMPLICATIONS: Service improvements to achieve equitable distribution of contraception and abortion services must be integrated with initiatives responding to sexual coercion.

Enhanced maternal and child health nurse care for women experiencing intimate partner/family violence: protocol for MOVE, a cluster randomised trial of screening and referral in primary health care.

BACKGROUND: Intimate partner violence (IPV) can result in significant harm to women and families and is especially prevalent when women are pregnant or recent mothers. Maternal and child health nurses (MCHN) in Victoria, Australia are community-based nurse/midwives who see over 95% of all mothers with newborns. MCHN are in an ideal position to identify and support women experiencing IPV, or refer them to specialist family violence services. Evidence for IPV screening in primary health care is inconclusive to date. The Victorian government recently required nurses to screen all mothers when babies are four weeks old, offering an opportunity to examine the effectiveness of MCHN IPV screening practices. This protocol describes the development and design of MOVE, a study to examine IPV screening effectiveness and the sustainability of screening practice. METHODS/DESIGN: MOVE is a cluster randomised trial of a good practice model of MCHN IPV screening involving eight maternal and child health nurse teams in Melbourne, Victoria. Normalisation Process Theory (NPT) was incorporated into the design, implementation and evaluation of the MOVE trial to enhance and evaluate sustainability. Using NPT, the development stage combined participatory action research with intervention nurse teams and a systematic review of nurse IPV studies to develop an intervention model incorporating consensus guidelines, clinical pathway and strategies for individual nurses, their teams and family violence services. Following twelve months' implementation, primary outcomes assessed include IPV inquiry, IPV disclosure by women and referral using data from MCHN routine data collection and a survey to all women giving birth in the previous eight months. IPV will be measured using the Composite Abuse Scale. Process and impact evaluation data (online surveys and key stakeholders interviews) will highlight NPT concepts to enhance sustainability of IPV identification and referral. Data will be collected again in two years. DISCUSSION: MOVE will be the first randomised trial to determine IPV screening effectiveness in a community based nurse setting and the first to examine sustainability of an IPV screening intervention. It will further inform the debate about the effectiveness of IPV screening and describe IPV prevalence in a community based post-partum and early infant population. TRIAL REGISTRATION: ACTRN12609000424202.

Three Delays Model applied to prevention of unsafe abortion in Ghana: a qualitative study.

BACKGROUND: Unsafe abortion is an important public health problem in Ghana, making significant contributions to the morbidity and mortality of reproductive-aged women. Although mostly used in explaining mortality associated with perinatal care, recent calls for research on induced abortion in Africa suggest that the Three Delays Model could be used to enhance understanding of women's experiences and access to induced abortion care. METHODS: We conducted 47 face-to-face interviews with women who had experienced unsafe abortions, with formal abortion providers (abortion providers in hospitals) and with informal and non-legal abortion providers (pharmacy workers and herb sellers). Study participants were recruited from selected hospitals, community pharmacies and markets within the Ashanti region of Ghana. We drew on phenomenology to analyse the data. FINDINGS: The first delay (in seeking care) occurred because of women's poor knowledge of pregnancy, the influence of religion, and as a result of women underestimating the seriousness of abortion complications. Factors including cost, provider attitudes, stigma, and the proximity of pharmacies to women's homes delayed their access to safe abortion and resulted in their experience of the second delay (in reaching a healthcare facility). The third delay (in receiving appropriate care) was a result of hospitals' non-prioritisation of abortion complications and a shortage of equipment, resulting in long hospital waiting times before treatment. CONCLUSION: This study has shown the value of the Three Delays Model in illustrating women's experiences of unsafe abortions and ways of preventing the first, second and third delays in their access to care.

The power of social connection and support in improving health: lessons from social support interventions with childbearing women.

BACKGROUND AND OBJECTIVE: Social support interventions have a somewhat chequered history. Despite evidence that social connection is associated with good health, efforts to implement interventions designed to increase social support have produced mixed results. The aim of this paper is to reflect on the relationship between social connectedness and good health, by examining social support interventions with mothers of young children and analysing how support was conceptualised, enacted and valued, in order to advance what we know about providing support to improve health. CONTEXT AND APPROACH: First, we provide a brief recent history of social support interventions for mothers with young children and we critically examine what was intended by 'social support', who provided it and for which groups of mothers, how support was enacted and what was valued by women. Second, we examine the challenges and promise of lay social support approaches focused explicitly on companionship, and draw on experiences in two cluster randomised trials which aimed to improve the wellbeing of mothers. One trial involved a universal approach, providing befriending opportunities for all mothers in the first year after birth, and the other a targeted approach offering support from a 'mentor mother' to childbearing women experiencing intimate partner violence. RESULTS: Interventions providing social support to mothers have most often been directed to women seen as disadvantaged, or 'at risk'. They have also most often been enacted by health professionals and have included strong elements of health education and/or information, almost always with a focus on improving parenting skills for better child health outcomes. Fewer have involved non-professional 'supporters', and only some have aimed explicitly to provide companionship or a listening ear, despite these aspects being what mothers receiving support have said they valued most. Our trial experiences have demonstrated that non-professional support interventions raise myriad challenges. These include achieving adequate reach in a universal approach, identification of those in need of support in any targeted approach; how much training and support to offer befrienders/mentors without 'professionalising' the support provided; questions about the length of time support is offered, how 'closure' is managed and whether interventions impact on social connectedness into the future. In our two trials what women described as helpful was not feeling so alone, being understood, not being judged, and feeling an increased sense of their own worth. CONCLUSION AND IMPLICATIONS: Examination of how social support has been conceptualised and enacted in interventions to date can be instructive in refining our thinking about the directions to be taken in future research. Despite implementation challenges, further development and evaluation of non-professional models of providing support to improve health is warranted.

Ethical complexities of screening for depression and intimate partner violence (IPV) in intervention studies.

BACKGROUND: Intervention studies for depression and intimate partner violence (IPV) commonly incorporate screening to identify eligible participants. The challenge is that current ethical evaluation is largely informed by the four principle approach applying principles of beneficence, non-maleficence, and respect for justice and autonomy. We examine three intervention studies for IPV, postnatal depression (PND) and depression that used screening from the perspective of principlism, followed by the perspective of a narrative and relational approach. We suggest that a narrative and relational approach to ethics brings to light concerns that principlism can overlook. DISCUSSION: The justification most commonly used to incorporate screening is that the potential benefits of identifying intervention efficacy balance the risk of individual harm. However, considerable risks do exist. The discovery of new information may result in further depression or worries, people might feel burdened, open to further risk, unsure of whether to disclose information to family members and disappointed if they are allocated to a control group. This raises questions about study design and whether the principle of equipoise remains an adequate justification in studies with vulnerable groups. In addition, autonomy is said to be respected because participants give informed consent to participate. However, the context of where recruitment is undertaken has been shown to influence how people make decisions. SUMMARY: The four principles have been subjected to criticisms in recent years but they remain prominent in public health and medical research. We provide a set of simple, interrogative questions that are narrative and relationally driven which may assist to further evaluate the potential impacts of using screening to identify eligible research participants in intervention studies. A narrative and relational based approach requires seeing people as situated within their social and cultural contexts, and as existing within relationships that are likely to be affected by the results of screening information.

Mothers' AdvocateS In the Community (MOSAIC)--non-professional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomised trial in primary care.

BACKGROUND: Effective interventions to increase safety and wellbeing of mothers experiencing intimate partner violence (IPV) are scarce. As much attention is focussed on professional intervention, this study aimed to determine the effectiveness of non-professional mentor support in reducing IPV and depression among pregnant and recent mothers experiencing, or at risk of IPV. METHODS: MOSAIC was a cluster randomised trial in 106 primary care (maternal and child health nurse and general practitioner) clinics in Melbourne, Australia. 63/106 clinics referred 215 eligible culturally and linguistically diverse women between January 2006 and December 2007. 167 in the intervention (I) arm, and 91 in the comparison (C) arm. 174 (80.9%) were recruited. 133 (76.4%) women (90 I and 43 C) completed follow-up at 12 months. INTERVENTION: 12 months of weekly home visiting from trained and supervised local mothers, (English & Vietnamese speaking) offering non-professional befriending, advocacy, parenting support and referrals. MAIN OUTCOME MEASURES: Primary outcomes; IPV (Composite Abuse Scale CAS) and depression (Edinburgh Postnatal Depression Scale EPDS); secondary measures included wellbeing (SF-36), parenting stress (PSI-SF) and social support (MOS-SF) at baseline and follow-up. ANALYSIS: Intention-to-treat using multivariable logistic regression and propensity scoring. RESULTS: There was evidence of a true difference in mean abuse scores at follow-up in the intervention compared with the comparison arm (15.9 vs 21.8, AdjDiff -8.67, CI -16.2 to -1.15). There was weak evidence for other outcomes, but a trend was evident favouring the intervention: proportions of women with CAS scores ≥ 7, 51/88 (58.4%) vs 27/42 (64.3%) AdjOR 0.47, CI 0.21 to 1.05); depression (EPDS score ≥ 13) (19/85, 22% (I) vs 14/43, 33% (C); AdjOR 0.42, CI 0.17 to 1.06); physical wellbeing mean scores (PCS-SF36: AdjDiff 2.79; CI -0.40 to 5.99); mental wellbeing mean scores (MCS-SF36: AdjDiff 2.26; CI -1.48 to 6.00). There was no observed effect on parenting stress. 82% of women mentored would recommend mentors to friends in similar situations. CONCLUSION: Non-professional mentor mother support appears promising for improving safety and enhancing physical and mental wellbeing among mothers experiencing intimate partner violence referred from primary care. TRIAL REGISTRATION: ACTRN12607000010493http://www.anzctr.org.au.

MOSAIC (MOthers' Advocates In the Community): protocol and sample description of a cluster randomised trial of mentor mother support to reduce intimate partner violence among pregnant or recent mothers.

BACKGROUND: Intimate partner violence (IPV) is prevalent globally, experienced by a significant minority of women in the early childbearing years and is harmful to the mental and physical health of women and children. There are very few studies with rigorous designs which have tested the effectiveness of IPV interventions to improve the health and wellbeing of abused women. Evidence for the separate benefit to victims of social support, advocacy and non-professional mentoring suggested that a combined model may reduce the levels of violence, the associated mental health damage and may increase a woman's health, safety and connection with her children. This paper describes the development, design and implementation of a trial of mentor mother support set in primary care, including baseline characteristics of participating women. METHODS/DESIGN: MOSAIC (MOtherS' Advocates In the Community) was a cluster randomised trial embedded in general practice and maternal and child health (MCH) nursing services in disadvantaged suburbs of Melbourne, Australia. Women who were pregnant or with infants, identified as abused or symptomatic of abuse, were referred by IPV-trained GPs and MCH nurses from 24 general practices and eight nurse teams from January 2006 to December 2007. Women in the intervention arm received up to 12 months support from trained and supported non-professional mentor mothers. Vietnamese health professionals also referred Vietnamese women to bilingual mentors in a sub-study. Baseline and follow-up surveys at 12 months measured IPV (CAS), depression (EPDS), general health (SF-36), social support (MOS-SF) and attachment to children (PSI-SF). Significant development and piloting occurred prior to trial commencement. Implementation interviews with MCH nurses, GPs and mentors assisted further refinement of the intervention. In-depth interviews with participants and mentors, and follow-up surveys of MCH nurses and GPs at trial conclusion will shed further light on MOSAIC's impact. DISCUSSION: Despite significant challenges, MOSAIC will make an important contribution to the need for evidence of effective partner violence interventions, the role of non-professional mentors in partner violence support services and the need for more evaluation of effective health professional training and support in caring for abused women and children among their populations. TRIAL REGISTRATION: ACTRN12607000010493.

The emergency contraceptive pill rescheduled: a focus group study of women's knowledge, attitudes and experiences.

BACKGROUND AND METHODOLOGY: The levonorgestrel-containing emergency contraceptive pill (ECP), amongst other strategies, has the potential to assist in reducing unintended pregnancy and abortion rates. Since the rescheduling of the ECP in January 2004 to over-the-counter (OTC) status from pharmacies in Australia, there is little information about Australian women's ECP knowledge, attitudes or practice. The aim of the study was to explore Australian women's knowledge of, attitudes towards and experiences of using the ECP, particularly since it has been available OTC. This paper reports a qualitative study using six focus groups, which were conducted between February and June 2007 in four Australian states with 29 women aged 16-29 years. RESULTS: Participants had a lack of specific knowledge about the ECP. Most were positive about the ECP being available OTC, however some expressed concerns about younger women misusing it. Women's experiences obtaining the ECP from the pharmacy were both positive and negative. Most women said they would use the ECP again if required and would recommend it to a friend. Pharmacists were seen as important suppliers of the ECP but women felt it was not their role to provide advice about contraception or sexually transmitted infections. DISCUSSION AND CONCLUSIONS: The findings from this study confirm views from other studies, which suggest that although women have some concerns in relation to OTC supply of the ECP, they believe that the deregulation of the ECP is a positive step. The data also suggest that women need to be provided with more information and education about the ECP.

Factors associated with induced abortion over time: secondary data analysis of five waves of the Australian Longitudinal Study on Women's Health.

OBJECTIVE: A trend analysis of associations with induced abortion. METHODS: Secondary analysis of the 1973/78 cohort of the Australian Longitudinal Study of Women's Health of women responding to two or more consecutive surveys out of five (N=9,042), using generalised estimating equations. RESULTS: New abortions dropped from 7% to 2% at surveys 4 and 5. By survey 5, 16% of respondents reported abortions, only 2% of them new. Women aged in their twenties were more likely to terminate a pregnancy if they reported less-effective contraceptives (aOR2.18 CI 1.65-2.89); increased risky drinking (aOR1.65 CI 1.14-2.38); illicit drugs ≤12 months (aOR3.09 CI 2.28-4.19); or recent partner violence (aOR2.42 CI 1.61-3.64). By their thirties, women were more likely to terminate if they reported violence (aOR2.16 CI 1.31-3.56) or illicit drugs <12 months (aOR2.69 CI 1.77-4.09). Women aspiring to be fully- (OR1.58 CI 1.37-1.83) or self-employed (OR1.28 CI 1.04-1.57), with no children (OR1.41 CI 1.14-1.75) or further educated (OR 2.08 CI 1.68-2.57) were more likely to terminate than other women. CONCLUSIONS: Abortion remains strongly associated with factors affecting women's control over reproductive health such as partner violence and illicit drug use. Implications for public health: Healthcare providers should inquire about partner violence and illicit drug use among women seeking abortion, support women experiencing harm and promote effective contraception.

Depression and termination of pregnancy (induced abortion) in a national cohort of young Australian women: the confounding effect of women's experience of violence.

BACKGROUND: Termination of pregnancy is a common and safe medical procedure in countries where it is legal. One in four Australian women terminates a pregnancy, most often when young. There is inconclusive evidence about whether pregnancy termination affects women's rates of depression. There is evidence of a strong association between partner violence and depression. Our objective was to examine the associations with depression of women's experience of violence, pregnancy termination, births and socio-demographic characteristics, among a population-based sample of young Australian women. METHODS: The data from the Younger cohort of the Australian Longitudinal Study on Women's Health comprised 14,776 women aged 18-23 in Survey I (1996) of whom 9683 aged 22-27 also responded to Survey 2 (2000). With linked data, we distinguished terminations, violence and depression reported before and after 1996.We used logistic regression to examine the association of depression (CES-D 10) as both a dichotomous and linear measure in 2000 with pregnancy termination, numbers of births and with violence separately and then in mutually adjusted models with sociodemographic variables. RESULTS: 30% of young women were depressed. Eleven percent (n = 1076) reported a termination by 2000. A first termination before 1996 and between 1996 and 2000 were both associated with depression in a univariate model (OR 1.37, 95%CI 1.12 to 1.66; OR 1.52, 95%CI 1.24 to 1.87). However, after adjustment for violence, numbers of births and sociodemographic variables (OR 1.22, 95%CI 0.99 to 1.51) this became only marginally significant, a similar association with having two or more births (1.26, 95%CI. 1.00 to 1.58). In contrast, any form of violence but especially that of partner violence in 1996 or 2000, was significantly associated with depression: in univariate (OR 2.31, 95%CI 1.97 to 2.70 or 2.45, 95% CI 1.99 to 3.04) and multivariate models (AOR 2.06, 95%CI 1.74 to 2.43 or 2.12, 95%CI 1.69 to 2.65). Linear regression showed a four fold greater effect of violence than termination or births. CONCLUSION: Violence, especially partner violence, makes a significantly greater contribution to women's depression compared with pregnancy termination or births. Any strategy to reduce the burden of women's depression should include prevention or reduction of violence against women and strengthening women's sexual and reproductive health to ensure that pregnancies are planned and wanted.

Impact of violence against women on severe acute maternal morbidity in the intensive care unit, including neonatal outcomes: a case-control study protocol in a tertiary healthcare facility in Lima, Peru.

INTRODUCTION: Preventing and reducing violence against women (VAW) and maternal mortality are Sustainable Development Goals. Worldwide, the maternal mortality ratio has fallen about 44% in the last 25 years, and for one maternal death there are many women affected by severe acute maternal morbidity (SAMM) requiring management in the intensive care unit (ICU). These women represent the most critically ill obstetric patients of the maternal morbidity spectrum and should be studied to complement the review of maternal mortality. VAW has been associated with all-cause maternal deaths, and since many women (30%) endure violence usually exerted by their intimate partners and this abuse can be severe during pregnancy, it is important to determine whether it impacts SAMM. Thus, this study aims to investigate the impact of VAW on SAMM in the ICU. METHODS AND ANALYSIS: This will be a prospective case-control study undertaken in a tertiary healthcare facility in Lima-Peru, with a sample size of 109 cases (obstetric patients admitted to the ICU) and 109 controls (obstetric patients not admitted to the ICU selected by systematic random sampling). Data on social determinants, medical and obstetric characteristics, VAW, pregnancy and neonatal outcome will be collected through interviews and by extracting information from the medical records using a pretested form. Main outcome will be VAW rate and neonatal mortality rate between cases and controls. VAW will be assessed by using the WHO instrument. Binary logistic followed by stepwise multivariate regression and goodness of fit test will assess any association between VAW and SAMM. ETHICS AND DISSEMINATION: Ethical approval has been granted by the La Trobe University, Melbourne-Australia and the tertiary healthcare facility in Lima-Peru. This research follows the WHO ethical and safety recommendations for research on VAW. Findings will be presented at conferences and published in peer-reviewed journals.