Foregrounding pain in self-managed early medication abortion: a qualitative study.

OBJECTIVE: To explore experiences of pain in the context of early medical abortion (EMA) in the UK and to guide best practice around anticipatory guidance on pain. METHODS: From late 2020 to early 2021, we recruited individuals from across the UK who had undergone abortion during the COVID-19 pandemic to participate in in-depth, semi-structured telephone interviews. A storytelling approach was used and data were analysed thematically using NVivo 12 software. RESULTS: Focused coding and thematic analysis addressed accounts of pain, which were prominent in many interviews. We constructed the following subthemes: expected pain is manageable for some; the problem with unexpected pain; pain (co)produces fear; and problematising 'period-like pain'. The key issue which our analysis draws out is that while EMA pain experience might vary, for some it may be much worse than anticipated. Moreover, the common trope of likening it to 'period pain' can be misleading and a source of additional uncertainty at a potentially already challenging time. CONCLUSIONS: For some individuals, pain experienced in EMA will be severe and/or worse than expected. Insufficient preparation for pain can result in extremely negative experiences of EMA. Alongside development of improved analgesia, improvements should be made to anticipatory guidance on pain, particularly for those self-manging EMA at home. Framings of 'period-like pain' do not clarify expectations and should be avoided.

Young women's fertility knowledge: partial knowledge and implications for contraceptive risk-taking.

BACKGROUND: There is a lack of research on young women's fertility knowledge and awareness. This has implications for contraceptive risk-taking, including the use of emergency hormonal contraception (EHC). By drawing on two research studies, this article shows how greater fertility knowledge could benefit young women in terms of pregnancy prevention. METHODS: We draw on two qualitative research studies ('fertility study' and 'abortion study') resulting in a composite sample of 46 interviews with women aged 16-24 years. Focused secondary analysis was undertaken looking specifically at fertility knowledge in relation to contraceptive behaviour. FINDINGS: A lack of accurate knowledge about the menstrual cycle was evident in two ways. Young women drew conclusions about their invulnerability to pregnancy if previous unprotected sexual intercourse (UPSI) had not resulted in pregnancy. Additionally, although participants were aware of EHC, there was no awareness of when it might fail other than after a certain time limit. CONCLUSIONS: Young women would benefit from a more nuanced understanding of fertility. Episodes of UPSI that do not result in pregnancy can encourage a belief that 'it won't happen to me', and this has implications for taking chances with contraception. Partial knowledge about the effectiveness of EHC may also lead to unintended pregnancy. Calculating the number of hours following UPSI generates overreliance on what is only one of the factors determining the effectiveness of EHC. Information regarding the link between EHC and failure rates near the day of ovulation needs to be more widely publicised.

Provider-based barriers to provision of intrauterine contraception in general practice.

OBJECTIVES: Intrauterine contraception (IUC) is highly effective, safe and long-lasting, but is not a popular method of contraception among British women. This study examined barriers to the uptake of IUC in general practice in England. METHOD: A sequential mixed-method approach to explore the views of practitioners regarding the provision of IUC. We e-surveyed 208 practitioners from 69 practices in a region of England and subsequently interviewed 14 practitioners from eight practices. RESULTS: Just under half of general practitioners (GPs) (46.8%; 58/124), and only 8.2% (4/49) of nurses reported being trained to fit IUC. Lack of knowledge of IUC was a barrier to fitting, and also to recommending IUC, especially by practitioners who were not trained to fit. There was discordance between reported knowledge of eligibility for IUC and the likelihood of recommending IUC. Respondents were less likely to recommend IUC to young, nulliparous women, women who had experienced a previous ectopic pregnancy, a recent sexually transmitted infection (STI), or an abnormal cervical smear. The qualitative data indicate that risk aversion and limited training, together with practitioners' assessments that women are uninterested, may lead to IUC being precluded as a suitable method. CONCLUSIONS: Increased practitioner education, for those not trained to fit IUC, may remove a barrier to the uptake of IUC in general practice. More research is required on the discordance between the practitioners' views on the characteristics of women considered suitable for IUC, and the criteria set out in the UK Medical Eligibility Criteria (UKMEC) guidelines.

"I think maybe 10 years seems a bit long." Beliefs and attitudes of women who had never used intrauterine contraception.

AIM: To explore, in a general practice setting, the concerns, beliefs and attitudes about intrauterine contraception (IUC) reported by women, who had never used the methods. METHODS: We used a sequential mixed-method (QUAL/quant) approach. A pragmatic, self-selecting sample of 30 women, aged 18-46 years, who had never used IUC), was recruited through seven general practices in South East England. Themes arising from qualitative interviews were used to construct a quantitative survey, completed by a pragmatic sample of 1195 women, aged 18-49 years, attending 32 general practices in the same region, between February and August 2015. RESULTS: Qualitative themes were concerns about the long-acting nature of IUC, concerns about body boundaries, and informal knowledge of IUC, especially 'friend of a friend' stories. Women were not sure if the devices can be removed before their full 5- or 10-year duration of use, and felt that these timeframes did not fit with their reproductive intentions. Quantitative survey data showed that the most commonly endorsed concerns among never-users were painful fitting (55.8%), unpleasant removal of the device (60.1%), and concern about having a device 'inside me' (60.2%). CONCLUSIONS: To facilitate fully informed contraceptive choice, information provided to women considering IUC should be tailored to more fully address the concerns expressed by never-users, particularly around the details of insertion and removal, and concerns about the adverse, long-term effects of the device. Women need to be reassured that IUC can be removed and fertility restored at any time following insertion. TRIAL REGISTRATION: Trial registration NIHR CRN portfolio; 15912.

'Repeat abortion', a phrase to be avoided? Qualitative insights into labelling and stigma.

BACKGROUND: In recent years there has been growing international interest in identifying risk factors associated with 'repeat abortion', and developing public health initiatives that might reduce the rate. This article draws on a research study looking at young women's abortion experience in England and Wales. The study was commissioned with a specific focus on women who had undergone more than one abortion. We examine what may influence women's post-abortion reproductive behaviour, in addition to exploring abortion-related stigma, in the light of participants' own narratives. STUDY DESIGN: Mixed-methods research study: a quantitative survey of 430 women aged 16-24 years, and in-depth qualitative interviews with 36 women who had undergone one or more abortions. This article focuses on the qualitative data from two subsets of young women: those we interviewed twice (n=17) and those who had experienced more than one unintended/unwanted pregnancy (n=15). RESULTS: The qualitative research findings demonstrate the complexity of women's contraceptive histories and reproductive lives, and thus the inherent difficulty of establishing causal patterns for more than one abortion, beyond the obvious observation that contraception was not used, or not used effectively. Women who had experienced more than one abortion did, however, express intensified abortion shame. CONCLUSIONS: This article argues that categorising women who have an abortion in different ways depending on previous episodes is not helpful. It may also be damaging, and generate increased stigma, for women who have more than one abortion.

Hormonal contraception and regulation of menstruation: a study of young women's attitudes towards 'having a period'.

BACKGROUND: Irregular bleeding is one of the most common side effects of hormonal contraception and a key reason for the discontinuation of hormonal methods. STUDY DESIGN: A qualitative study in which 12 young women volunteered to be interviewed in depth, along with six focus group discussions (23 participants). The study had two main research objectives: to document and investigate what young women think and feel about menstruation and contraception, and to explore young women's preferences regarding the intersection of contraceptives and bleeding patterns. RESULTS: Although participants held a broad view that menstruation can be an inconvenience, they did ascribe positive values to having a regular bleed. Bleeding was seen as a signifier of non-pregnancy and also an innate part of being a woman. A preference for a 'natural' menstruating body was a strong theme, and the idea of selecting a hormonal contraceptive that might stop the bleeding was not overly popular, unless the young woman suffered with painful natural menstruation. Contraceptives that mimicked the menstrual cycle were acceptable to most, suggesting that cyclic bleeding still holds a symbolic function for women. CONCLUSIONS: When counselling young women about the effect of different contraceptive modalities on their bleeding, practitioners should explore how the women feel about their bleeding, including how they might feel if their bleeding stopped or if they experienced erratic bleeding patterns. Practitioners also need to recognise the subjective understanding of the 'natural body' as held by some women, and in these cases to support them in their seeking out of non-hormonal methods of contraception.

"I think it depends on the body, with mine it didn't work": explaining young women's contraceptive implant removal.

BACKGROUND: Our study was conducted to learn more about why some young women (under 24) request "early" removal of the subdermal contraceptive implant (implant). STUDY DESIGN: A qualitative study in which 20 young women were interviewed in-depth, along with nine health providers of the implant. This paper concentrates on the findings from the interviews with young women. RESULTS: Overwhelmingly, the reason given for removal was intolerable side effects, the most common being bleeding irregularities. Other hormonal side effects mentioned were mood swings, headaches and weight gain; and it was often a combination of factors that brought participants to a "tipping point" at which their negative experiences outweighed the positive attributes of the implant. Many participants felt that they had not been sufficiently warned about all possible side effects, and some were frustrated by delays encountered after they requested removal. CONCLUSION: Women need to be made aware of all possible side effects and be given more support once the implant is in place. In supporting women's contraceptive choice, clinicians need to accept that some women are unable to tolerate the implant and that encouraging retention without dealing with distressing side effects may be counterproductive.

Young women's experiences of side-effects from contraceptive implants: a challenge to bodily control.

In the UK, long-acting reversible contraceptives have been welcomed by sexual health policy-makers and many practitioners as a particularly effective way of preventing unintended pregnancy, especially teenage conception. However, little is known about women's individual experiences of these forms of contraception beyond limited data on retention rates and reasons for discontinuation. The main aims of this research were to gain a fuller understanding of why some young women have their implants removed, and what may help them maintain this method of contraception if they wish to do so. The contraceptive choices of 20 young women (aged 16-22) who had chosen the implant, and later discontinued it, were examined. They had experienced unacceptable side effects that they attributed to the implant, and interpreted as a threat to their bodily control, which they were not prepared to tolerate. These feelings were exacerbated if they then encountered delays after requesting removal. Although they remained concerned to avoid unintended pregnancy, they generally moved to a less reliable form of contraception following implant removal and felt discouraged from trying other long-acting contraception. We suggest that principles of contraceptive choice should include facilitating the discontinuation of unsatisfactory methods; implant removal should therefore be readily available when requested, regardless of the length of time the implant has been in place. Long-acting forms of contraception do not suit all women, and will not obviate the need for other forms of reproductive control, including legal abortion.