Patient and public involvement in abortion research: reflections from the Shaping Abortion for Change (SACHA) Study.

Patient and public involvement (PPI) is limited within abortion-related research. Possible reasons for this include concerns about engaging with a stigmatised patient group who value confidentiality and may be reluctant to re-engage with services. Structural barriers, including limited funding for abortion-related research, also prevent researchers from creating meaningful PPI opportunities. Here, we describe lessons learnt on undertaking PPI as part of the Shaping Abortion for Change (SACHA) Study, which sought to create an evidence base to guide new directions in abortion care in Britain.Two approaches to PPI were used: involving patients and the public in the oversight of the research and its dissemination as lay advisors, and group meetings to obtain patients' views on interpretation of findings and recommendations. All participants observed the SACHA findings aligned with their own experiences of having an abortion in Britain. These priorities aligned closely with those identified in a separate expert stakeholder consultation undertaken as part of the SACHA Study. One additional priority which had not been identified during the research was identified by the PPI participants.We found abortion patients to be highly motivated to engage in the group meetings, and participation in them actively contributed to the destigmatisation of abortion by giving them a space to share their experiences. This may alleviate any ethical concerns about conducting research and PPI on abortion, including the assumption that revisiting an abortion experience will cause distress. We hope that our reflections are useful to others considering PPI in abortion-related research and service improvement.

Patient experiences of undergoing abortion with and without an ultrasound scan in Britain.

BACKGROUND: Routine ultrasound scanning to determine gestational age and pregnancy location has long been part of pre-abortion assessment in Britain, despite not being legally required or recommended in national clinical guidelines. To support implementation of fully telemedical abortion care (implemented in Britain in April 2020), the Royal College of Obstetricians and Gynaecologists (RCOG) issued clinical guidance for an 'as-indicated' approach to pre-abortion ultrasound, removing the need for a clinic visit. We aimed to understand patient experiences of ultrasound in abortion care by conducting a qualitative study with individuals who had abortions with and without an ultrasound scan. METHODS: Between November 2021 and July 2022, we recruited patients who had a medical abortion at home without a pre-procedure ultrasound at 69 days' gestation or less at British Pregnancy Advisory Service (BPAS), and also had at least one other abortion with an ultrasound from any provider in Britain. We conducted interviews using a semi-structured interview guide to explore our participants' experiences and conducted reflexive thematic analysis. RESULTS: We recruited 24 participants and included 19 interviews in our analysis. We developed three themes from our data. These were 'Ultrasound scans and their relationship with autonomy and decision-making', 'Intrusive and out of place: the ultrasound as an inappropriate technology' and 'Towards preference-centred, quality care'. CONCLUSIONS: Further research and user-testing of strategies to improve the scan experience should be undertaken. Patient testimonies on the negative impact of ultrasound scans in abortion care should reassure providers that omitting them according to patient preference is a positive step towards providing patient-centred care.

Women's experiences of over-the-counter and prescription medication during pregnancy in the UK: findings from survey free-text responses and narrative interviews.

OBJECTIVES: To explore women's experiences of over-the-counter and prescription medication advice and use during pregnancy. DESIGN: A study design consisting of an online survey and nested in-depth interviews with a subsample of participants. We analysed data from survey free-text responses and in-depth interviews using thematic analysis. Quantitative survey data is published elsewhere. SETTING: The UK. PARTICIPANTS: Women were eligible if living in the UK, aged 16-45 years, were pregnant or had been pregnant in the last 5 years regardless of pregnancy outcome. A total of 7090 women completed the survey, and 34 women who collectively had experienced 68 pregnancies were subsequently interviewed. RESULTS: Medication prescribing and use during pregnancy was common. The prescribing, dispensing and taking of some advised medications were restricted through women's or prescribers' fear of fetal harm. Lack of adherence to national prescribing guidance, conflicting professional opinion and poor communication resulted in maternal anxiety, avoidable morbidity and women negotiating complex and distressing pathways to obtain recommended medications. In contrast, some women felt overmedicated and that pharmacological treatments were used without exploring other options first. CONCLUSION: Increased translation of national guidance into practice and greater personalisation of antenatal care are needed to improve the safety, efficacy and personalisation of prescribing in pregnancy.

Travel for later abortion in the USA: lived experiences, structural contributors and abortion fund support.

As abortion restrictions expand in the USA, pregnant people will continue to experience delays and be forced to travel for abortion. The study aims to describe later abortion travel experiences, understand structural factors influencing travel, and identify strategies to improve travel. This qualitative phenomenological study analyses data from 19 interviews with people who travelled at least 25 miles for abortion after the first trimester. Framework analysis used a structural violence lens. More than two-thirds of participants travelled interstate, and half received abortion fund support. Key considerations of travel include logistics, challenges during the journey, and physical and emotional recovery during and after travel. Restrictive laws, financial insecurity and anti-abortion infrastructure are forms of structural violence that created challenges and delays. Reliance on abortion funds facilitated access but also entailed uncertainty. Better resourced abortion funds could organise travel in advance, facilitate the travel of accompanying escorts, and tailor emotional support to reduce stress for those travelling. Clinical and practical support systems must be prepared to support people travelling for abortion, as later abortion and forced travel is increasing since the constitutional right to abortion in the USA was overturned. Findings can inform interventions to support the increasing number of people travelling for abortion.

WRISK voices: A mixed-methods study of women's experiences of pregnancy-related public health advice and risk messages in the UK.

BACKGROUND: Women receive many public health messages relating to pregnancy which are intended to improve outcomes for babies and mothers. However, negotiating the risk landscape and maternity care system can feel confusing and disempowering. Relationships between women and their healthcare providers are paramount, but they can be adversely affected by issues of trust and autonomy. METHODS: We used a nested study design including an online survey and qualitative interviews to gain an understanding of women's experiences of risk messages during pregnancy. We purposively sampled survey participants to ensure the interview population included women whose voices are seldom heard and are disproportionately impacted by poor risk communication. RESULTS: A total of 7,009 women responded to the survey, and 34 women participated in interviews. Participants received public health and risk messages from a range of sources. Data showed that women wanted a balance between a "better safe than sorry" approach and evidence-based information and advice. Women reported a discrepancy between the topics they received a lot of information on and areas in which they felt they needed more advice. Many participants said they were given conflicting advice, and the way information was delivered sometimes challenged their autonomy. We identified that younger women (<20 years old) and women with higher BMIs experienced stigmatisation in their maternity care. CONCLUSIONS: Our research shows the importance of risk communication that respects women's autonomy and trusts them to make decisions about their own pregnancy. We identified a need for a layered approach to risk communication. Whilst some women are happy to adopt precautionary behaviour without discussion, others will want a thorough examination of the evidence-base. Our findings suggest that more individualised care, continuity, and less judgement and stigmatisation from HCPs will improve experiences for women and may lead to better engagement with services.

Client perspectives on choice of abortion method in England and Wales.

INTRODUCTION: The National Institute for Health and Care Excellence, the Royal College of Obstetricians and Gynaecologists and the World Health Organization recommend that services provide a choice between medical and surgical methods of abortion. We analysed qualitative study data to examine patient perspectives on abortion method choice and barriers to meeting them. METHODS: In-depth interviews with 24 clients who had an abortion at British Pregnancy Advisory Service clinics were carried out between December 2018 and July 2019 to examine perspectives of quality of abortion care. In this article we focus on client perspectives on choice of abortion method. We performed thematic analysis of data relating to choice of abortion method, refined the analysis, interpreted the findings, and organised the data into themes. RESULTS: Participants' preferences for abortion method were shaped by prior experience of abortion, accessibility and privacy, perceptions of risk and experiences of abortion method, and information gathering and counselling. Participants' ability to obtain their preferred method was impacted by intersecting constraints such as appointment availability, service location and gestational age. CONCLUSIONS: Our findings show that many factors shape participants' preferences for abortion method. In response to the COVID-19 pandemic, some abortion services have constrained abortion method choices, with an emphasis on medical abortion and 'no-touch' care. Providers in the UK and beyond should aim to restore and expand more treatment options when the situation allows.

It's a small bit of advice, but actually on the day, made such a difference : perceptions of quality in abortion care in England and Wales.

BACKGROUND: Quality of care (QOC) is increasingly identified as an important contributor to healthcare outcomes, however little agreement exists on what constitutes quality in abortion care or the recommended indicators from the service-user perspective. Our study aimed to explore perceptions and experiences of abortion QOC in England and Wales. METHODS: We performed in-depth interviews (via phone or in-person) with participants who had an abortion at a nationwide independent sector provider in the previous 6 months. We explored their experiences of the abortion service at each point in the care pathway, their perspectives on what contributed to and detracted from the experience meeting their definitions of quality, and their reflections on different aspects of QOC. We used content analysis to generate themes. RESULTS: From December 2018 to July 2019, we conducted 24 interviews. Ten participants had a surgical and 14 had a medical abortion. Seventeen (71%) were treated in the first 12 weeks of pregnancy and 7 (29%) beyond that, with an average gestational age of 10 weeks + 5 days (range 5-23 + 6). We identified 4 major themes that contributed to participant's perception of high quality care: (1) interpersonal interactions with staff or other patients, (2) being informed and prepared, (3) participation and choices in care and (4) accessibility. Nearly all participants identified interpersonal interactions with staff as an important contributor to quality with positive interactions often cited as the best part of their abortion experience and negative interactions as the worst. For information and preparation, participant described not only the importance of being well prepared, but how incongruencies between information and the actual experience detracted from quality. Participants said that making choices about their care, for example, method of abortion, was a positive contributor. Finally, participants identified access to care, specifically in relation to waiting times and travel, as an important aspect of QOC. CONCLUSIONS: Participants situated quality in abortion care in 4 domains: interpersonal aspects of care, information and preparation, choices, and accessibility. Indicators identified can be used to develop standard metrics to ensure care meets service-user needs.

Quality of care is an important aspect of delivering healthcare in a patient-centred manner. There is a lack of agreement about what consititutes quality care for an abortion service. In our study, we interviewed 24 participants who had an abortion in the last 6 months to assess their perceptions of quality of care. Based on our analysis, we identified 4 themes that were important contributors to quality: (1) interactions with clinic staff or other patients, (2) information and preparation for the abortion, (3) making choices about care, and (4) access to abortion care. Almost all of our study participants said that positive interactions with clinic staff contributed to a quality experience. Participants wanted to be well-prepared for their abortion. They reported a negative experience when the information they were given did not match their experience. Participants felt that active participation in choices around their abortion experience improved quality. Finally, ease of access to abortion care made for a more positive experience. Abortion providers and researchers should consider using the results of our study to ensure their services meet patients' needs.

Risk messages relating to fertility and pregnancy: a media content analysis.

Background: The UK print and online media is an important channel by which scientific research is communicated to the public. Media risk messages relating to pregnancy or fertility contribute to the context of reproductive decision making, but their fidelity to the underlying science has been questioned. Method: We measured the volume, distribution and content of science-based risk headlines relating to pregnancy or fertility in the UK media over four months. We grouped headlines into unique stories and categorised them by exposure and outcome of interest. We selected four unique stories for closer content analysis and assessed their fidelity to the underlying science, with attention to the role of press releases. Results: We identified 171 headlines over four months (average 43 per month), comprising 56 unique stories. The unique stories most commonly concerned maternal risk factors (n=46) and child health outcomes (n=46). Maternal health outcomes were less frequently the focus (n=20). The most common risk factors in the media coverage were maternal food and drink (n=15), maternal medication and medical interventions (n=9), and maternal health factors (n=6). Media reports were largely faithful to press releases. Where substantive deviations from the underlying scientific study were identified, these could mostly be traced back to press releases or quotes from the study's authors. Press releases often omitted caveats which were reinstated at the media reporting stage, alongside additional expert criticism. Conclusions: Frequent science-based risk messages in the UK media frame mothers as vectors of potential harm to children, who are the focus of health outcomes. Largely, the media does not introduce misinformation, but reports press releases faithfully with additional caveats and expert commentary. Press releases fulfil an interpretative role, often omitting caveats and introducing new elements and advice to women. Their role as a bridge between scientific and lay audiences is discussed.

"Anxious and traumatised": Users' experiences of maternity care in the UK during the COVID-19 pandemic.

OBJECTIVE: The COVID-19 pandemic saw universal, radical, and ultra-rapid changes to UK National Health Services (NHS) maternity care. At the onset of the pandemic, NHS maternity services were stripped of many of the features which support woman and family centred care. In anticipation of unknown numbers of pregnant women and maternity staff potentially sick with COVID-19, services were pared back to the minimum level considered to be required to keep women and their babies safe. The aim of this survey was to understand the impact of COVID-19 public health messaging and pandemic-related service changes on users of maternity care in the UK during the pandemic. METHODS: We conducted an online survey to explore user's experiences of COVID-19 public health messaging and 'socially-distanced' maternity care across the UK. The study population consisted of women who had experienced pregnancy after the 11th March 2020 (when the WHO declared a pandemic), whether or not they were still pregnant. We collected data between June and September 2020. We used framework analysis for the free-text data and generated descriptive statistics. FINDINGS: Women were generally happy to adopt a precautionary approach and stringently social distance in the context of a relatively unknown pathogen and in an environment of extreme anxiety and uncertainty, but were acutely aware of the negative impacts. The survey found that the widespread changes to services caused unintended negative consequences including essential clinical care being missed, confusion over advice, and distress and emotional trauma for women. COVID-19 restrictions have resulted in women feeling their antenatal and postnatal care to be inadequate and has also come at great emotional cost to users. Women reported feeling isolated and sad in the postnatal period, but also frustrated and upset by a lack of staff to help them care for their new baby. KEY CONCLUSIONS: With growing evidence of the impact of the virus on pregnant women and an increased understanding of the unintended consequences of unclear public health messaging and overly precautious services, a more nuanced, evidence-based approach to caring for women during a pandemic must be prioritised. IMPLICATIONS FOR PRACTICE: All maternity services should ensure they have clear lines of communication with women to keep them updated on changing care and visiting arrangements. Services should ensure that opportunities to provide safe face-to-face care and access for birth partners and visitors are maximised.

Client satisfaction and experience of telemedicine and home use of mifepristone and misoprostol for abortion up to 10 weeks' gestation at British Pregnancy Advisory Service: A cross-sectional evaluation.

OBJECTIVE: Evaluate satisfaction and experience with telemedicine consultation and home use of mifepristone and misoprostol for abortion to 10 weeks' gestation. STUDY DESIGN: Cross-sectional evaluation of British Pregnancy Advisory Service (BPAS) clients who used mifepristone and misoprostol at home from 11 May to 10 July 2020. We sent a text message with a link to a web-survey 2 to 3 weeks postabortion. Questions assessed satisfaction and experiences with a service model including telephone consultation and provision of medicines by mail or collection from the clinic. We used bivariate and multivariate regression to explore associations between client characteristics and outcomes. Our primary outcomes were overall satisfaction (5-point Likert scale) and reported contact with a health care provider. RESULTS: A total of 1,333 clients participated. Respondents described home use of medications as "straightforward" (75.8%) and most were "very satisfied" (78.3%) or "satisfied" (18.6%) overall. Being "very satisfied" was associated with parity (aOR 1.53, 95% CI 1.09-2.14) and pain control satisfaction (aOR 2.22, 95% CI 1.44-3.44). Health care provider contact was reported by 14.7%; mainly to BPAS' telephone aftercare service (76.8%). Dissatisfaction with pain control (aOR 3.62, 95% CI 1.79-7.29) and waiting >1 week to use mifepristone (aOR3.71, 95% CI 1.48-9.28) were associated with health care provider contact. If needed in the future, most would prefer consultation by phone (74.3%) and home use of mifepristone and misoprostol (77.8%). CONCLUSIONS: Satisfaction with telemedicine and home use of mifepristone and misoprostol is high. Most clients do not need health care provider support when administering medicines at home or post abortion.

Systematic review of early abortion services in low- and middle-income country primary care: potential for reverse innovation and application in the UK context.

BACKGROUND: In the UK, according to the 1967 Abortion Act, all abortions must be approved by two doctors, reported to the Department of Health and Social Care (DHSC), and be performed by doctors within licensed premises. Removing abortion from the criminal framework could permit new service delivery models. We explore service delivery models in primary care settings that can improve accessibility without negatively impacting the safety and efficiency of abortion services. Novel service delivery models are common in low-and-middle income countries (LMICs) due to resource constraints, and services are sometimes provided by trained, mid-level providers via "task-shifting". The aim of this study is to explore the quality of early abortion services provided in primary care of LMICs and explore the potential benefits of extending their application to the UK context. METHODS: We searched MEDLINE, EMBASE, Global Health, Maternity and Infant Care, CINAHL, and HMIC for studies published from September 1994 to February 2020, with search terms "nurses", "midwives", "general physicians", "early medical/surgical abortion". We included studies that examined the quality of abortion care in primary care settings of low-and-middle-income countries (LMICs), and excluded studies in countries where abortion is illegal, and those of services provided by independent NGOs. We conducted a thematic analysis and narrative synthesis to identify indicators of quality care at structural, process and outcome levels of the Donabedian model. RESULTS: A total of 21 indicators under 8 subthemes were identified to examine the quality of service provision: law and policy, infrastructure, technical competency, information provision, client-provider interactions, ancillary services, complete abortions, client satisfaction. Our analysis suggests that structural, process and outcome indicators follow a mediation pathway of the Donabedian model. This review showed that providing early medical abortion in primary care services is safe and feasible and "task-shifting" to mid-level providers can effectively replace doctors in providing abortion. CONCLUSION: The way services are organised in LMICs, using a task-shifted and decentralised model, results in high quality services that should be considered for adoption in the UK. Collaboration with professional medical bodies and governmental departments is necessary to expand services from secondary to primary care.