Expanding access to postpartum contraception.

PURPOSE OF REVIEW: Women are particularly vulnerable to unintended pregnancy in the 12 months following a birth. Improving access to postpartum contraception within maternity settings can prevent unintended and closely spaced births, improving the health of mother and child. This review will summarize the recent research in postpartum contraception (PPC), building on existing knowledge and developments in this field. RECENT FINDINGS: Current models of postpartum contraceptive provision may not adequately meet women's needs. The COVID-19 pandemic led to changes in postpartum contraceptive provision, with an increasing emphasis placed on maternity services. Antenatal contraceptive discussion is associated with increased postpartum contraceptive planning and uptake of methods after birth. Digital health interventions may be a useful tool to support information about contraception. The most effective long-acting reversible contraceptive (LARC) methods, such as the intrauterine device (IUD) and implant, can be challenging to provide in the maternity setting because of availability of trained providers. Postpartum IUD insertion remains relatively under-utilized, despite evidence supporting its safety, efficacy and cost-effectiveness. SUMMARY: Antenatal information needs to be partnered with access to the full range of methods immediately after birth to reduce barriers to PPC uptake. Training and education of maternity providers is central to successful implementation of PPC services.

DigiSpan: Development and Evaluation of a Computer-Based, Adaptive Test of Short-Term Memory and Working Memory.

PURPOSE: This article describes DigiSpan, a new computer-controlled auditory test of forward and reverse digit span, designed to be administered by clinicians, and presents normative and test-retest reliability data for adults. METHOD: DigiSpan mimics conventional live-voice tests in that it commences with trials that ascend in length until a stopping criterion is met, giving rise to a conventional scaled score. It then administers five additional adaptive trials, the length of which depends on the correctness of the response to the previous trial. Each of these two segments of the measurement gives rise to a scaled score. The ascending and adaptive scores are averaged to give an overall score and subtracted to produce an internal measure of consistency, and hence reliability. Young adults with an Mage of 25 years (N = 163) were tested, of whom 65 were retested on a separate day. RESULTS: The scaled scores from the conventional ascending trials were highly consistent with existing normative data based on live-voice tests. Combination of the conventional scaled score with a scaled score based on the adaptive trials led to 44% reduction in error variance for forward memory span and 20% reduction for reverse memory span. The average of these (32%) is similar to but (insignificantly) less than the 42% reduction in error variance that can be predicted based on adding the five adaptive trials. CONCLUSIONS: Replacing live-voice production of digits by a clinician with recorded, computer-controlled production has not affected the difficulty of the test. Adding five additional trials around the sequence length that a test participant can just remember has produced a decrease in measurement error. In addition, the availability of separate scaled scores for the ascending and adaptive phases enables the reliability of the combined score to be checked, for both forward and reverse measurements. The combination of standardized delivery, increased accuracy, internal reliability check, and fast automated scoring makes the test highly suitable for clinical use.

Variations in sexual and reproductive health services for the provision of comprehensive contraceptive and abortion services across Europe: A questionnaire-based study commissioned by the European Board and College of Obstetrics & Gynaecology (EBCOG) and European Society of Contraception (ESC).

A questionnaire-based study was jointly organised by European Board and College of Obstetrics and Gynaecology and European Society of Contraception to evaluate the current status as regards access and quality of care regarding contraception, abortion care, and pre-conceptional counselling and care among the 26 European countries. There are considerable variations among these countries as regards the provision of contraceptive services and abortion care. There is ample room for improvement through European training and education programs. However, the most important difference is the absence of a comprehensive network of healthcare providers in various countries to deliver these services at different points of access. There is notable absence of educational programs and instructional materials tailored specifically for nurses and midwives in several countries. This deficiency impedes the professional development and skills enhancement of these healthcare professionals, potentially compromising the quality of healthcare services provided to women in these countries.

How can patient experience of abortion care be improved? Evidence from the SACHA study.

BACKGROUND: Models of abortion care have changed significantly in the last decade, most markedly during the COVID-19 pandemic, when home management of early medical abortion with telemedical support was approved in Britain. OBJECTIVE: Our study aimed to examine women's satisfaction with abortion care and their suggestions for improvements. DESIGN: Qualitative, in-depth, semi-structured interviews. METHODS: A purposive sample of 48 women with recent experience of abortion was recruited between July 2021 and August 2022 from independent sector and National Health Service abortion services in Scotland, Wales and England. Interviews were conducted by phone or via video call. Women were asked about their abortion experience and for suggestions for any improvements that could be made along their patient journey - from help-seeking, the initial consultation, referral, treatment, to aftercare. Data were analyzed using the Framework Method. RESULTS: Participants were aged 16-43 years; 39 had had a medical abortion, 8 a surgical abortion, and 1 both. The majority were satisfied with their clinical care. The supportive, kind and non-judgmental attitudes of abortion providers were highly valued, as was the convenience afforded by remotely supported home management of medical abortion. Suggestions for improvement across the patient journey centred around the need for timely care; greater correspondence between expectations and reality; the importance of choice; and the need for greater personal and emotional support. CONCLUSION: Recent changes in models of care present both opportunities and challenges for quality of care. The perspectives of patients highlight further opportunities for improving care and support. The principles of timely care, choice, management of expectations, and emotional support should inform further service configuration.

How can patients' experience of abortion care in Britain be improved?Provision of abortion care and support in Britain has changed in recent decades. The COVID-19 pandemic also brought called for new ways of managing early medical abortions, at home, with remote support. We wanted to know how women in Britain felt about this kind of abortion care, and what ideas they had to make it better. Between July 2021 and August 2022, we spoke with 48 women who had recently had an abortion in Scotland, Wales and England. Some received got care from independent clinics, and some from the National Health Service (NHS). We talked to them over the phone or through video calls. We asked about their experiences, and what could be done to improve different parts of their care journey ­ from looking fo asking for help, the first appointment, the treatment, to the follow-up care. Most women generally felt satisfied with how they were taken care of by the medical staff. They appreciated the supportive, kind and non-judgmental attitude of the health professionals providing abortion care. They also liked the convenience of telemedicine and remote care, which made it easier to have a medical abortion at home. The changes in provision of abortion care and support have mostly had positive effects on women's experience. Yet the feedback from women interviewed shows that there are still more opportunities to make improvements, focusing on prompt care, offering choices of abortion method and location, managing expectations better, and providing more emotional support. These principles should guide how services are set up in the future.

Timing of Coronavirus Disease 2019 (COVID-19) Vaccination and Effects on Menstrual Cycle Changes.

OBJECTIVE: To assess whether menstrual cycle timing (follicular or luteal phase) of coronavirus disease 2019 (COVID-19) vaccine administration is associated with cycle length changes. METHODS: We used prospectively collected (2021-2022) menstrual cycle tracking data from 19,497 reproductive-aged users of the application "Natural Cycles." We identified whether vaccine was delivered in the follicular or luteal phase and also included an unvaccinated control group. Our primary outcome was the adjusted within-individual change in cycle length (in days) from the average of the three menstrual cycles before the first vaccination cycle (individuals in the unvaccinated control group were assigned a notional vaccine date). We also assessed cycle length changes in the second vaccination cycle and whether a clinically significant change in cycle length (8 days or more) occurred in either cycle. RESULTS: Most individuals were younger than age 35 years (80.1%) and from North America (28.6%), continental Europe (33.5%), or the United Kingdom (31.7%). In the vaccinated group, the majority received an mRNA vaccine (63.8% of the full sample). Individuals vaccinated in the follicular phase experienced an average 1-day longer adjusted cycle length with a first or second dose of COVID-19 vaccine compared with their prevaccination average (first dose: 1.00 day [98.75% CI, 0.88-1.13], second dose: 1.11 days [98.75% CI, 0.93-1.29]); those vaccinated in the luteal phase and those in the unvaccinated control group experienced no change in cycle length (respectively, first dose: -0.09 days [98.75% CI, -0.26 to 0.07], second dose: 0.06 days [98.75% CI, -0.16 to 0.29], unvaccinated notional first dose: 0.08 days [98.75% CI, -0.10 to 0.27], second dose: 0.17 days [98.75% CI, -0.04 to 0.38]). Those vaccinated during the follicular phase were also more likely to experience a clinically significant change in cycle length (8 days or more; first dose: 6.8%) than those vaccinated in the luteal phase or unvaccinated (3.3% and 5.0%, respectively; P <.001). CONCLUSION: COVID-19 vaccine-related cycle length increases are associated with receipt of vaccination in the first half of the menstrual cycle (follicular phase).

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.

Using telemedicine to improve early medical abortion at home (UTAH): a randomised controlled trial to compare telemedicine with in-person consultation for early medical abortion.

OBJECTIVES: To compare telephone consultations with in-person consultations for the provision of medical abortion (using mifepristone 200 mg and misoprostol 800 µg). We hypothesised that telemedicine consultations would be non-inferior to in-person consultations with a non-inferiority limit of 3%. DESIGN: Randomised controlled trial with 1:1 allocation. SETTING: Community abortion service housed within an integrated sexual and reproductive health service in Edinburgh, UK. PARTICIPANTS: The trial began on 13 January 2020, but was stopped early due to COVID-19; recruitment was suspended on 31 March 2020, and was formally closed on 31 August 2021. A total of 125 participants were randomised, approximately 10% of the total planned, with 63 assigned to telemedicine and 62 to in-person consultation. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome: efficacy of medical abortion, defined as complete abortion without surgical intervention. SECONDARY OUTCOMES: satisfaction with consultation type, preparedness, unscheduled contact with care, complication rate, time spent in clinical contact and uptake of long-acting contraception. RESULTS: Primary outcome was available for 115 participants (lost-to-follow-up telemedicine=2, in-person=8), secondary outcomes were available for 110 participants (n=5 and n=10 in telemedicine and in-person groups did not complete questionnaires). There were no significant differences between groups in treatment efficacy (telemedicine 57/63 (90.5%), in-person 48/62 (77.4%)). However, non-inferiority was not demonstrated (+3.3% in favour of telemedicine, CI -6.6% to +13.3%, lower than non-inferiority margin). There were no significant differences in most secondary outcomes, however, there was more unscheduled contact with care in the telemedicine group (12 (19%) vs 3 (5%), p=0.01). The overall time spent in clinical contact was statistically significantly lower in the telemedicine group (mean 94 (SD 24) vs 111 (24) min, p=0.0005). CONCLUSIONS: Telemedicine for medical abortion appeared to be effective, safe and acceptable to women, with less time spent in the clinic. However, due to the small sample size resulting from early cessation, the study was underpowered to confirm this conclusion. These findings warrant further investigation in larger scale studies. TRIAL REGISTRATION NUMBER: NCT04139382.

Expanding community pharmacists' scope of practice in relation to contraceptive counselling and referral: a protocol for a pragmatic, stepped-wedge, cluster randomised trial (ALLIANCE).

INTRODUCTION: Improving access to effective contraception has the potential to reduce unintended pregnancy and abortion rates. Community pharmacists could play an expanded role in contraceptive counselling and referral to contraceptive prescribers particularly when women are already attending community pharmacy to obtain emergency contraceptive pills (ECPs) or to have medical abortion (MA) medicines dispensed. The ALLIANCE trial aims to compare the subsequent uptake of effective contraception (hormonal or intrauterine) in women seeking ECP or MA medicines, who receive the ALLIANCE community pharmacy-based intervention with those who do not receive the intervention. METHODS AND ANALYSIS: ALLIANCE is a stepped-wedge pragmatic cluster randomised trial in Australian community pharmacies. The ALLIANCE intervention involves community pharmacists delivering structured, patient-centred, effectiveness-based contraceptive counselling (and a referral to a contraceptive prescriber where appropriate) to women seeking either ECPs or to have MA medicines dispensed. Women participants will be recruited by participating pharmacists. A total of 37 pharmacies and 1554 participants will be recruited. Pharmacies commence in the control phase and are randomised to transition to the intervention phase at different time points (steps). The primary outcome is the self-reported use of effective contraception at 4 months; secondary outcomes include use of effective contraception and the rate of pregnancies or induced abortions at 12 months. A process and economic evaluation of the trial will also be undertaken. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Monash University Human Research Ethics Committee (#34563). An explanatory statement will be provided and written consent will be obtained from all participants (pharmacy owner, pharmacist and women) before their commencement in the trial. Dissemination will occur through a knowledge exchange workshop, peer-reviewed journal publications, presentations, social media and conferences. TRIAL REGISTRATION NUMBER: ACTRN12622001024730.

Impact of coronavirus disease 2019 (COVID-19) vaccination on menstrual bleeding quantity: An observational cohort study.

OBJECTIVE: To assess whether coronavirus disease 2019 (COVID-19) vaccination impacts menstrual bleeding quantity. DESIGN: Retrospective cohort. SETTING: Five global regions. POPULATION: Vaccinated and unvaccinated individuals with regular menstrual cycles using the digital fertility-awareness application Natural Cycles°. METHODS: We used prospectively collected menstrual cycle data, multivariable longitudinal Poisson generalised estimating equation (GEE) models and multivariable multinomial logistic regression models to calculate the adjusted difference between vaccination groups. All regression models were adjusted for confounding factors. MAIN OUTCOME MEASURES: The mean number of heavy bleeding days (fewer, no change or more) and changes in bleeding quantity (less, no change or more) at three time points (first dose, second dose and post-exposure menses). RESULTS: We included 9555 individuals (7401 vaccinated and 2154 unvaccinated). About two-thirds of individuals reported no change in the number of heavy bleeding days, regardless of vaccination status. After adjusting for confounding factors, there were no significant differences in the number of heavy bleeding days by vaccination status. A larger proportion of vaccinated individuals experienced an increase in total bleeding quantity (34.5% unvaccinated, 38.4% vaccinated; adjusted difference 4.0%, 99.2% CI 0.7%-7.2%). This translates to an estimated 40 additional people per 1000 individuals with normal menstrual cycles who experience a greater total bleeding quantity following the first vaccine dose' suffice. Differences resolved in the cycle post-exposure. CONCLUSIONS: A small increase in the probability of greater total bleeding quantity occurred following the first COVID-19 vaccine dose, which resolved in the cycle after the post-vaccination cycle. The total number of heavy bleeding days did not differ by vaccination status. Our findings can reassure the public that any changes are small and transient.

Self-reported contraceptive use and satisfaction among women accessing telemedicine medical abortion at the onset of the COVID-19 pandemic at 3-6-month follow-up.

BACKGROUND: Changes in legislation due to COVID-19 led to the introduction of telemedicine for early medical abortion (EMA) at home in Scotland. The opportunity to provide contraception at presentation may be more limited with this model of care. We compared contraceptive use immediately post-abortion with 3-6 months later to determine if contraceptive needs were being met. METHODS: We contacted 579 women by telephone call or text message who agreed to be involved in a service evaluation of telemedicine EMA in NHS Lothian at 3-6 months post-abortion. A research nurse administered a questionnaire on the women's current contraception use. The research nurses also offered women support in switching or initiating contraception via the abortion service if desired. RESULTS: The response rate to the contact was 57% (331/579). Under a third of the women (30%, 98/331) were using the progestogen-only pill (POP) at 3-6 month follow-up, a significant decrease (p<0.00) compared with 65% (215/331) who were provided with POP at the time of abortion. Thirty-nine women (12%) were provided with contraception through this telephone contact, leading to a significant increase in the proportion using subdermal implants, the progestogen injectable or intrauterine contraception. CONCLUSIONS: This study shows that there was a decrease in the use of the POP 3-6 months after telemedicine EMA during the COVID-19 pandemic. Telephone contact at 3-6 months to facilitate obtaining contraception may be a promising strategy to improve access to effective methods with this model of abortion care.

The development of the Language-Independent Speech in Noise and Reverberation test (LISiNaR) and evaluation in listeners with English as a second language.

OBJECTIVE: Create a language-independent, ecologically valid auditory processing assessment and evaluate relative stimuli intelligibility in native and non-native English speakers. DESIGN: The Language-Independent Speech in Noise and Reverberation Test (LISiNaR) targets comprised consonant-vowel (CVCV) pseudo-words. Distractors comprised CVCVCVCV pseudo-words. Stimuli were presented over headphones using an iPad either face-to-face or remotely. Scoring occurred adaptively to establish a participant's speech reception threshold in noise (SRT). The listening environment was simulated using reverberant and anechoic head-related transfer functions. In four test conditions, targets originated from 0°. Distractors originated from either ±90°, ±67.5° and ±45° (spatially separated) or 0° azimuth (co-located). Reverberation impact (RI) was calculated as the difference in SRTs between the anechoic and reverberant conditions and spatial advantage (SA) as the difference between the spatially separated and co-located conditions. STUDY SAMPLE: Young adult native speakers of Australian (n = 24) and Canadian (25) and non-native English speakers (34). RESULTS: No significant effects of language occurred for the test conditions, RI or SA. A small but significant effect of delivery mode occurred for RI. Reverberation impacted SRT by 5 dB relative to anechoic conditions. CONCLUSION: Performance on LISiNaR is not affected by the native language or accent of groups tested in this study.

A systematic review of randomised controlled trials of the effects of digital health interventions on postpartum contraception use.

BACKGROUND: Digital health interventions (DHI) have been used to enhance the uptake of postpartum contraception and reduce unmet contraception needs. We conducted a systematic review of the effectiveness of DHI on postpartum contraceptive use and repeated pregnancy. METHOD: We searched MEDLINE, Embase, Global Health, CINAHL and Cochrane CENTRAL (January 1990-July 2020). Randomised controlled trials (RCTs) of DHI promoting contraception among pregnant or postpartum women were included. Two researchers screened articles and extracted data. We assessed the risk of bias, certainty of evidence (CoE) and conducted meta-analyses following Cochrane guidance. RESULTS: Twelve trials with 5527 women were included. Interventions were delivered by video (four trials), mobile phone counselling (three trials), short message services (SMS) (four trials) and computer (one trial). During pregnancy or the postpartum period, mobile phone counselling had an uncertain effect on the use of postpartum contraception (risk ratio (RR) 1.37, 95% CI 0.82 to 2.29, very low CoE); video-based education may moderately improve contraception use (RR 1.48, 95% CI 1.01 to 2.17, low CoE); while SMS education probably modestly increased contraception use (RR 1.12, 95% CI 1.01 to 1.23, moderate CoE). Mobile phone counselling probably increased long-acting reversible contraception (LARC) use (RR 4.23, 95% CI 3.01 to 5.93, moderate CoE). Both mobile phone counselling (RR 0.27, 95% CI 0.01 to 5.77, very low CoE) and videos (RR 1.25, 95% CI 0.24 to 6.53, very low CoE) had uncertain effects on repeated pregnancy. CONCLUSIONS: During pregnancy or in the postpartum period, videos may moderately increase postpartum contraception use and SMS probably modestly increase postpartum contraception use. The effects of DHI on repeated pregnancy are uncertain. Further well-conducted RCTs of DHI would strengthen the evidence of effects on contraception use and pregnancy.

Very early medical abortion: treatment with mifepristone and misoprostol before ultrasonographic visualisation of an intrauterine pregnancy.

INTRODUCTION: Abortion providers may be reluctant to commence abortion before ultrasound evidence of intrauterine pregnancy (IUP) due to concerns of missed ectopic pregnancy. In 2017, very early medical abortion (VEMA) was introduced at an abortion service in Edinburgh, UK. Following ultrasound, patients without confirmed IUP, and without symptoms or risk factors for ectopic pregnancy, could commence treatment immediately after baseline serum-human chorionic gonadotrophin (hCG) measurement, and return for follow-up serum-hCG a week later to determine treatment success (≥80% decline from baseline). This study aimed to compare clinical outcomes between two pathways: (1) VEMA; and (2) standard-of-care delayed treatment where treatment is only commenced on IUP confirmation by serial serum-hCG monitoring and/or repeat ultrasound. METHODS: A retrospective database review was conducted of VEMA eligible patients from July 2017 to December 2021. Study groups were determined by patient preference. Records were searched for abortion outcomes, duration of care, number of appointments (clinic visits, ultrasounds, serum-hCG) and clinical data entries. RESULTS: Of 181 patients included, 77 (43%) chose VEMA and 104 (57%) chose delayed treatment. 11/181 (6.1%) were lost to follow-up. Cohort ectopic prevalence was 4.4% and was not statistically different between groups (2.6% vs 5.8%, VEMA vs delayed group, respectively, p=0.305), as with complete abortion rates (93.3% vs 97.6%, p=0.256). All VEMA group ectopics were detected on the seventh day (from initial visit) while time-to-diagnosis for delayed group ectopics ranged from 7 days to 3 weeks. VEMA patients had significantly reduced duration of care (12 vs 21 days, p<0.001), number of visits (2 vs 3, p<0.001), ultrasounds (1 vs 2, p<0.001) and data entries (6 vs 9, p<0.001). CONCLUSIONS: VEMA is safe, effective and reduces the duration of care, number of appointments and clinical administrative time. It should be offered to medically eligible patients.

Association between menstrual cycle length and covid-19 vaccination: global, retrospective cohort study of prospectively collected data.

OBJECTIVES: To identify whether covid-19 vaccines are associated with menstrual changes in order to address concerns about menstrual cycle disruptions after covid-19 vaccination. DESIGN: Global, retrospective cohort study of prospectively collected data. SETTING: International users of the menstrual cycle tracking application, Natural Cycles. PARTICIPANTS: 19 622 individuals aged 18-45 years with cycle lengths of 24-38 days and consecutive data for at least three cycles before and one cycle after covid (vaccinated group; n=14 936), and those with at least four consecutive cycles over a similar time period (unvaccinated group; n=4686). MAIN OUTCOME MEASURES: The mean change within individuals was assessed by vaccination group for cycle and menses length (mean of three cycles before vaccination to the cycles after first and second dose of vaccine and the subsequent cycle). Mixed effects models were used to estimate the adjusted difference in change in cycle and menses length between the vaccinated and unvaccinated. RESULTS: Most people (n=15 713; 80.08%) were younger than 35 years, from the UK (n=6222; 31.71%), US and Canada (28.59%), or Europe (33.55%). Two thirds (9929 (66.48%) of 14 936) of the vaccinated cohort received the Pfizer-BioNTech (BNT162b2) covid-19 vaccine, 17.46% (n=2608) received Moderna (mRNA-1273), 9.06% (n=1353) received Oxford-AstraZeneca (ChAdOx1 nCoV-19), and 1.89% (n=283) received Johnson & Johnson (Ad26.COV2.S). Individuals who were vaccinated had a less than one day adjusted increase in the length of their first and second vaccine cycles, compared with individuals who were not vaccinated (0.71 day increase (99.3% confidence interval 0.47 to 0.96) for first dose; 0.56 day increase (0.28 to 0.84) for second dose). The adjusted difference was larger in people who received two doses in a cycle (3.70 days increase (2.98 to 4.42)). One cycle after vaccination, cycle length was similar to before the vaccine in individuals who received one dose per cycle (0.02 day change (99.3% confidence interval -0.10 to 0.14), but not yet for individuals who received two doses per cycle (0.85 day change (99.3% confidence interval 0.24 to 1.46)) compared with unvaccinated individuals. Changes in cycle length did not differ by the vaccine's mechanism of action (mRNA, adenovirus vector, or inactivated virus). Menses length was unaffected by vaccination. CONCLUSIONS: Covid-19 vaccination is associated with a small and likely to be temporary change in menstrual cycle length but no change in menses length.

Pain management for medical abortion before 14 weeks' gestation: A systematic review.

INTRODUCTION: Abortion is common worldwide and increasingly abortions are performed at less than 14 weeks' gestation using medical methods, specifically using a combination of mifepristone and misoprostol. Medical abortion is known to be a painful process, but the optimal method of pain management is unclear. We sought to identify and compare pain management regimens for medical abortion before 14 weeks' gestation. STUDY DESIGN: We conducted our search in August 2019 and included randomized controlled trials (RCT) and observational studies of any pain relief intervention (pharmacological and non-pharmacological) for mifepristone-misoprostol combination medical abortion of pregnancies less than 14 weeks' gestation. RESULTS: We included four RCTs and one observational study. Due to the heterogeneity of study designs, interventions and outcome reporting, meta-analysis was not possible. Only one study found evidence of an effect between interventions on pain score: a prophylactic dose of ibuprofen 1600mg likely reduces the pain score when compared to a dose of paracetamol 2000mg (MD 2.26/10 [CI 3-1.52 lower]). For other interventions (pregabalin 300mg vs placebo; ibuprofen 800mg vs placebo; therapeutic vs prophylactic administration of ibuprofen 800mg; ambulation vs non-ambulation during treatment) there appeared to be little to no difference with comparator. CONCLUSIONS: The findings of this review provide some support for the use of ibuprofen as a single dose given with misoprostol prophylactically, or in response to pain as needed. The optimal dosing of ibuprofen is unclear, but a single dose of ibuprofen 1600mg was shown to be effective and it was less certain whether 800mg was effective.

Uptake of long-acting reversible contraception after telemedicine delivered abortion during Covid-19.

BACKGROUND: During COVID-19, early medical abortion (EMA) at home in Scotland was largely delivered by telemedicine. Short-acting post-abortion contraception was provided with EMA medications, but long-acting reversible contraception (LARC) (implant, injectable and intrauterine device) required an in-person visit. We wished to assess LARC uptake following telemedicine abortion, and factors associated with method receipt. METHODS: A prospective observational cohort study of patients accessing abortion via NHS Lothian (October 2020 to February 2021). Patients were offered contraception at telemedicine consultation and their choice was recorded in their clinical notes. Those wishing LARC were directed to the service's rapid-access LARC clinic. We reviewed electronic patient records six weeks post-abortion to determine whether patients received their chosen method. RESULTS: 944 patients had an abortion; 768 (81.4%) had EMA, 131 (13.9%) had a medical or surgical abortion in hospital. The most popular contraceptive method was the progestogen-only pill (n = 324, 34%). 330 patients (35%) requested LARC but less than half (153/330; 46%) received this. Of patients choosing LARC, those who attended the clinic for a pre-abortion ultrasound, or had an abortion in hospital, were more likely to initiate LARC than those having full telemedicine EMA. Nulliparity, gestation over 7 weeks, and age under-26 years were also positively associated with initiating LARC. CONCLUSION: During COVID-19 there was demand for post-abortion LARC but less than half of patients received this by six weeks. Provision was enhanced when in-person clinical interactions took place. Interventions are required to facilitate timely access and initiation of LARC with telemedicine delivered abortion care.

Pain management for medical abortion before 14 weeks' gestation.

BACKGROUND: Abortion is common worldwide and increasingly abortions are performed at less than 14 weeks' gestation using medical methods, specifically using a combination of mifepristone and misoprostol. Medical abortion is known to be a painful process, but the optimal method of pain management is unclear. We sought to identify and compare pain management regimens for medical abortion before 14 weeks' gestation.  OBJECTIVES: Primary objective To determine if there is evidence of superiority of any particular pain relief regimen in the management of combination medical abortion (mifepristone + misoprostol) under 14 weeks' gestation (i.e. up to 13 + 6 weeks or 97 days). Secondary objectives To compare the rate of gastrointestinal side effects resulting from different methods of analgesia To compare the rate of complete abortion resulting from different methods of analgesia during medical abortion To determine if the induction-to-abortion interval is associated with different methods of analgesia To determine if any method of analgesia is associated with unscheduled contact with the care provider in relation to pain. SEARCH METHODS: On 21 August 2019 we searched CENTRAL, MEDLINE, Embase, CINAHL, LILACs, PsycINFO, the World Health Organization International Clinical Trials Registry and ClinicalTrials.gov together with reference checking and handsearching of conference abstracts of relevant learned societies and professional organisations to identify further studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and observational studies (non-randomised studies of interventions (NRSIs)) of any pain relief intervention (pharmacological and non-pharmacological) for mifepristone-misoprostol combination medical abortion of pregnancies less than 14 weeks' gestation. DATA COLLECTION AND ANALYSIS: Two review authors (JRW and MA) independently assessed all identified papers for inclusion and risks of bias, resolving any discrepancies through discussion with a third and fourth author as required (CM and SC). Two review authors independently conducted data extraction, including calculations of pain relief scores, and checked for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included four RCTs and one NRSI. Due to the heterogeneity of study designs, interventions and outcome reporting, we were unable to perform meta-analysis for any of the primary or secondary outcomes in this review. Only one study found evidence of an effect between interventions on pain score: a prophylactic dose of ibuprofen 1600 mg likely reduces the pain score when compared to a dose of paracetamol 2000 mg (mean difference (MD) 2.26 out of 10 lower, 95% confidence interval (CI) 3.00 to 1.52 lower; 1 RCT 108 women; moderate-certainty evidence). There may be little to no difference in pain score when comparing pregabalin 300 mg with placebo (MD 0.5 out of 10 lower, 95% CI 1.41 lower to 0.41 higher; 1 RCT, 107 women; low-certainty evidence).  There may be little to no difference in pain score when comparing ibuprofen 800 mg with placebo (MD 1.4 out of 10 lower, 95% CI 3.33 lower to 0.53 higher; 1 RCT, 61 women; low-certainty evidence). Ambulation or non-ambulation during medical abortion treatment may have little to no effect on pain score, but the evidence is very uncertain (MD 0.1 out of 5 higher, 95% CI 0.26 lower to 0.46 higher; 1 NRSI, 130 women; very low-certainty evidence). There may be little to no difference in pain score when comparing therapeutic versus prophylactic administration of ibuprofen 800 mg (MD 0.2 out of 10 higher, 95% CI 0.41 lower to 0.81 higher; 1 RCT, 228 women; low-certainty evidence).   Other outcomes of interest were reported inconsistently across studies. Where these outcomes were reported, there was no evidence of difference in incidence of gastrointestinal side effects, complete abortion rate, interval between misoprostol administration to pregnancy expulsion, unscheduled contact with a care provider, patient satisfaction with analgesia regimen nor patient satisfaction with abortion experience overall. However, the certainty of evidence was very low to low. AUTHORS' CONCLUSIONS: The findings of this review provide some support for the use of ibuprofen as a single dose given with misoprostol prophylactically, or in response to pain as needed. The optimal dosing of ibuprofen is unclear, but a single dose of ibuprofen 1600 mg was shown to be effective, and it was less certain whether 800 mg was effective. Paracetamol 2000 mg does not improve pain scores as much as ibuprofen 1600 mg, however its use does not appear to cause greater frequency of side effects or reduce the success of the abortion. A single dose of pregabalin 300 mg does not affect pain scores during medical abortion, but like paracetamol, does not appear to cause harm. Ambulation or non-ambulation during the medical abortion procedure does not appear to affect pain scores, outcomes, or duration of treatment and so women can be advised to mobilise or not, as they wish. The majority of outcomes in this review had low- to very low-certainty evidence, primarily due to small sample sizes and two studies at high risk of bias. High-quality, large-scale RCT research is needed for pain management during medical abortion at gestations less than 14 weeks. Consistent recording of pain with a validated measure would be of value to the field going forward.