Are unmet needs driving requests for Medical Assistance in Dying (MAiD)? A qualitative study of Canadian MAiD providers.

In this study, 20 medical assistance in dying (MAiD) providers were interviewed about their experience when assessing patients with unmet needs, including medical, financial or social needs. Collectively they had experience with over 3700 MAiD assessments and found that unmet needs were rare. In the cases where patients had unmet needs, these were usually related to loneliness and poverty. This led to the ethical dilemma of providers deciding to honor their wishes for MAiD, knowing that some of their suffering was due to society's failure to provide for them.

Comparing telemedicine to in-clinic medication abortions induced with mifepristone and misoprostol.

OBJECTIVE: The objective was to compare the practical aspects of providing medication abortions through telemedicine and in-person clinic visits so that clinics can use this information when planning to add this service. STUDY DESIGN: We conducted a comparative retrospective chart review comparing telemedicine medication abortions to a control group matched for date seen. We extracted and compared demographics, use of dating ultrasound, outcomes and unscheduled visits or communications with staff and physicians. RESULTS: During the study period, we provided 4340 medication abortions, of which 182 (4.2%) were provided through by telemedicine; 199 patients met the criteria to be in the control group. The mean age was 28.7 years for telemedicine patients and 28.1 years for in-person patients (p = .38). The mean gestational ages were also similar, 48.2 days for telemedicine patients and 46.5 days for in-person patients (p = .03). Only 33 (18.1%) of telemedicine patients had dating ultrasounds compared to 199 (100%) of in-clinic patients (p < .001). The proportions of documented completed abortions (164/182, 90.1% and 179/199, 89.9%, p = .76) were similar, as were the proportions of aspirations for completion (6/182, 3.3% and 9/199, 4.5%, p = .54) and the proportions lost to follow-up (5.5% and 6.6%, p = .66). There were 10 complications in each group (5.5% of telemedicine patients and 5.0% of in-clinic patients) (p > 0.5). Unscheduled communications with office assistants were greater in the telemedicine patients than the in-person patients (84/182, 46.2% vs. 43/199, 21.6% in-person, p < .001). CONCLUSION: We found that telemedicine patients required more unscheduled communications and received ultrasounds far less often compared to in-clinic patients. IMPLICATIONS: We could provide telemedicine without the need for ultrasound to most women. Larger studies without routine ultrasound use are needed to validate our findings. Unscheduled communication with clinic staff was more frequent with telemedicine medication abortion patients. This information may help clinics when planning to add this service.

Suicide vs medical assistance in dying (MAiD): A secondary qualitative analysis.

This is a secondary analysis of three qualitative studies about MAiD in which researchers asked about the differences between suicide and MAiD. In all, researchers interviewed 52 Canadians; 7 were people who had requested MAiD and had been found ineligible, 6 were MAiD providers and 39 were socially and economically marginalized. The overwhelming response was that MAiD is better than suicide in the context of suffering at the end of life. Whereas these people perceived suicide as uncertain, difficult, and something that was usually done alone and without support, they thought MAiD was certain, painless, and more socially acceptable.

Misperceptions about the risks of abortion in women presenting for abortion.

OBJECTIVE: Misinformation about the risks and sequelae of abortion is widespread. The purpose of this study was to examine whether women having an abortion who believe that there should be restrictions to abortion (i.e., that some other women should not be allowed to have an abortion) also believe this misinformation about the health risks associated with abortion. METHODS: We carried out a cross-sectional survey of women presenting consecutively for an abortion at an urban abortion clinic in Vancouver, British Columbia, between February and September 2012. RESULTS: Of 1008 women presenting for abortion, 978 completed questionnaires (97% response rate), and 333 of these (34%) favoured abortion restrictions. More women who favoured restrictions believed that the health risk of an abortion was the same as or greater than the health risk of childbirth (84.2% vs. 65.6%, P < 0.001), that abortion caused mental health problems (39.1% vs. 28.3%, P < 0.001), and that abortion caused infertility (41.7% vs. 21.9%, P < 0.001). Using multivariate logistic regression analyses, believing that abortion should not be restricted was found to be a significantly correlated with correct answers about health risks, mental health problems, and infertility. CONCLUSION: Misinformed beliefs about the risks of abortion are common among women having an abortion. Women presenting for abortion who favoured restrictions to abortion have more misperceptions about abortion risks than women who favour no restrictions.

Objectif : La désinformation au sujet des risques et des séquelles de l'avortement est généralisée. Cette étude avait pour objectif de tenter de déterminer si les femmes subissant un avortement qui estiment que des restrictions devraient être imposées en matière d'avortement (c.-à-d. qui estiment que certaines autres femmes ne devraient pas avoir le droit de subir un avortement) sont susceptibles de croire cette désinformation au sujet des risques pour la santé qui sont associés à l'avortement. Méthodes : Nous avons mené un sondage transversal auprès des femmes s'étant consécutivement présentées à une clinique urbaine d'avortement de Vancouver, en Colombie-Britannique, entre février et septembre 2012, en vue d'y obtenir un avortement. Résultats : Des 1 008 femmes s'étant présentées à cette clinique en vue d'y obtenir un avortement, 978 ont rempli le questionnaire (taux de réponse de 97 %) et 333 d'entre elles (34 %) favorisaient l'imposition de restrictions en matière d'avortement. Un nombre supérieur de femmes favorisant l'imposition de restrictions estimaient que les risques pour la santé associés à l'avortement étaient égaux ou supérieurs aux risques pour la santé associés à l'accouchement (84,2 % vs 65,6 %, P < 0,001), que l'avortement causait des problèmes de santé mentale (39,1 % vs 28,3 %, P < 0,001) et que l'avortement causait l'infertilité (41,7 % vs 21,9%, P < 0,001). En utilisant des analyses de régression logistique multivariées, nous avons constaté que le fait d'estimer que l'avortement ne devrait pas faire l'objet de restrictions était en corrélation significative avec l'offre de réponses exactes au sujet des risques pour la santé, des problèmes de santé mentale et de l'infertilité. Conclusion : Les opinions erronées au sujet des risques de l'avortement sont courantes chez les femmes qui subissent un avortement. Les femmes cherchant à obtenir un avortement qui favorisent l'imposition de restrictions à l'avortement sont plus susceptibles d'avoir des perceptions erronées, au sujet des risques de l'avortement, que les femmes qui ne favorisent pas l'imposition de telles restrictions.

Invited commentary: How can we reconcile the findings of Keyes et al.'s study with the experience of our patients in clinical practice?

Although the accompanying study by Keyes et al. (Am J Epidemiol. 2013;178(9):1378-1388) shows us that women currently using hormonal contraception (HC) have better scores on the Center for Epidemiologic Studies Depression Scale and report fewer suicide attempts, it does not show us that HC protects women from mood disorders or that HC is free of the mood-related side effects which cause high rates of discontinuation. The groups compared in the Keyes et al. study were different in many ways; the women using HC were younger, were more likely to engage in positive health behaviors, and had lower depression scores at each prior interview. Women with mood disorders are more likely to avoid or discontinue HC and more likely to experience worsening mood while on HC. The negative mood-related side effects experienced by women using HC (irritability and lability) are not captured by a screening tool for clinical depression, such as the depression scale used in this study. The database used in this study was longitudinal and multiwave, so the authors could have compared changes in depressive symptoms among women who switched from hormonal to nonhormonal contraceptive methods (and vice versa) across different waves. Only if the same women experienced greater levels of depressive symptoms after discontinuing HC and fewer symptoms when they restarted HC could we conclude that HC may protect women from mood disorders.

Can we safely avoid fasting before abortions with low-dose procedural sedation? A retrospective cohort chart review of anesthesia-related complications in 47,748 abortions.

BACKGROUND: Some licensing authorities require fasting before abortions under intravenous sedation to avoid aspiration of gastric contents. This study was conducted to estimate the incidence of anesthesia-related complications in women undergoing abortions without preprocedure fasting. STUDY DESIGN: This is a retrospective cohort chart review of patients having abortions with both fentanyl and midazolam at two urban free-standing abortion clinics with routine policy of advising women to eat a light meal before the procedure. RESULTS: There were no reports of anesthesia-related complications in the 47,748 charts reviewed from 1998 to 2010. Applying Hanley's formula for rare events that have not occurred, the upper 95% confidence interval for the true incidence of anesthesia-related complications for women having abortion under low-dose procedural sedation without fasting was estimated to be 0.00006%. CONCLUSIONS: This large retrospective cohort chart review identified no complications related to low-dose procedural sedation in over 47,000 consecutive nonfasting patients having abortions through 18 weeks' gestation. Eliminating the requirement to fast would decrease unnecessary stress and unpleasant symptoms without increase in the anesthesia-related complications for women having abortions.

Why are response rates in clinician surveys declining?

OBJECTIVE: To understand why response rates in clinician surveys are declining. DESIGN: Cross-sectional fax-back survey. SETTING: British Columbia. PARTICIPANTS: Random sample of family physicians and all gynecologists in the College of Physicians and Surgeons of British Columbia's registry. MAIN OUTCOME MEASURES: Accuracy of the College of Physicians and Surgeons of British Columbia's registry, and the prevalence and characteristics of physicians with policies not to participate in any surveys. RESULTS: Of 542 physicians who received surveys, 76 (14.0%) responded. On follow-up we found the following: the College of Physicians and Surgeons of British Columbia's registry was inaccurate for 94 (17.3%) listings; 14 (2.6%) physicians were away; 100 (18.5%) were not eligible; and 197 (36.3%) had an office policy not to participate in any surveys. Compared with the respondents, physicians with an office policy not to participate in any surveys were more likely to be men, less likely to be white, more likely to have urban-based practices, and more likely to have been in practice for more than 15 years. CONCLUSION: Many physicians have an office policy not to participate in any surveys. Owing to the trend of lower response rates, recommendations of minimum response rates for clinician surveys by many journals might need to be reassessed.

Does using tampons or menstrual cups increase early IUD expulsion rates?

BACKGROUND: Many intrauterine device (IUD) users utilize intravaginal menstrual cups or tampons during menses, but no studies have investigated the impact this practice may have on IUD expulsions. STUDY DESIGN: Retrospective chart survey. RESULTS: Of the 930 women having IUDs placed and reporting menstrual protection, 10.3% (96) used menstrual cups, 74.2% (690) used tampons, and 43.2% (402) used pads (many women reported using more than one method). In the 743 women with adequate follow-up information, there was a full or partial expulsion (i.e., part of the IUD in the cervical canal) rate of 2.5% (27) during the first 6 weeks after insertion. There was no difference in the women using cups, tampons or pads (confidence intervals overlap). CONCLUSIONS: From this study, there is no evidence that women who report using menstrual cups or tampons for menstrual protection had higher rates of early IUD expulsion.

Characteristics of women who experience mood and sexual side effects with use of hormonal contraception.

OBJECTIVE: To describe the characteristics of women who experience sexual and mood side effects associated with use of hormonal contraception, and to compare them with women who do not. METHODS: We conducted a questionnaire survey of women presenting for primary care or to a reproductive health clinic. The women were asked if they had specific side effects with use of hormonal contraception in the domains of sexual desire, arousability, or irritability. The characteristics of women who reported such symptoms were compared with those who did not. RESULTS: Of the 1311 women recruited (mean age 28 years), 978 (77%) had previously used hormonal contraception. Of these women, 482 (51%) said they had at least one mood side effect and 358 (38%) said they had at least one sexual side effect. Using logistic regression, we found that women complaining of mood side effects were more likely to be unmarried (P = 0.02) and to be Caucasian or South Asian (P = 0.002) than women without such complaints. Women complaining of sexual side effects were more likely than those without sexual side effects to be younger (P = 0.04), to have more education (P = 0.04), and to be Caucasian or South Asian (P = 0.07). Women who complained of sexual side effects were also more likely than others to complain of mood and physical side effects (P < 0.001). CONCLUSION: Understanding the characteristics of women who report mood and sexual side effects with use of hormonal contraception may be useful when counselling women about contraception. It is important for women to choose contraception that not only is effective but also does not complicate their emotional and sexual lives.

Women's experience of viewing the products of conception after an abortion.

BACKGROUND: The objectives of this study were to assess perceptions of women viewing the products of conception after abortion and to assess the feasibility of offering this choice. STUDY DESIGN: Women presenting for abortion at two abortion clinics were given a questionnaire asking if they wished to view the products of conception. A second questionnaire was given to women who had viewed products of conception about their perceptions. Clinic staff members were interviewed after completion of the study. RESULTS: The study revealed that 152/508 (28.7%) of women having abortions chose to view the products of conception and 98/122 (83.1%) found that viewing did not make it harder emotionally. Older women and those who had children were less likely to want to view products of conception (p=.037) and more likely to find it harder if they did (p=.05). All 11 clinic staff members interviewed were positive about offering this service. CONCLUSIONS: It is feasible to offer women having abortions the choice to view the products of conception and for most, viewing does not make it emotionally harder for them.

Women's perceptions about seeing the ultrasound picture before an abortion.

OBJECTIVES: To gain a better understanding of women's perceptions and experiences of viewing the ultrasound (US) before an abortion. METHODS: This mixed-methods study included questionnaires and interviews. Women presenting for medical and surgical abortion at two urban abortion clinics completed questionnaires asking if they wished to view the US image and those women who had done so answered questions about their perceptions. A randomly selected ten women were interviewed six weeks later about their perceptions. The interviews were audio-taped, transcribed and analysed for salient themes. RESULTS: The 350 participants had a mean age of 27.6 years, 0.68 births, and were at a mean of 49.1 days gestation at the time of the procedure. Most women (254/350, 72.6%) chose to view the US and 179/219 (86.3%) found it a positive experience. Older women and those who had children were less likely to want to view the US image (p = 0.001). All ten interviewees recommended that this choice be offered to every woman and recommended more communication between care providers and patients at the time of the US. None of the women changed her mind about having the abortion after having seen the US. CONCLUSIONS: Offering the choice to view the ultrasound is both feasible and beneficial to women having abortions. Our findings support those of the only other study published on the subject.

Contraceptive failure related to estimated cycle day of conception relative to the start of the last bleeding episode.

BACKGROUND: The objective of this study was to estimate the menstrual cycle day of conception in women presenting for abortion. STUDY DESIGN: This was a retrospective chart survey in two urban free-standing abortion clinics. RESULTS: There were 913 charts reviewed of women presenting for an abortion at less than 63 days' gestation as determined by endovaginal ultrasound who were "sure" of the date of their last normal menstrual period. The estimated mean cycle day of conception determined by sonographically estimating length of gestation was 14.6. There were 26 (26.3%) of 99 women using cyclic hormonal contraception who conceived before 10 days after the onset of withdrawal bleeding compared to 100 (14.7%) of 679 who conceived before 10 days after the onset of their last menstrual period who were using all other forms of contraception, including "none" (p=.005). No other differences in the proportions conceiving early in the cycle were observed with respect to age, ethnicity or obesity. CONCLUSION: These data suggest that there is a sizeable subset of women who ovulate earlier after onset of withdrawal bleeding when using 21/7 hormonal contraceptives than after onset of menses when not using hormonal contraception. It is possible that women using hormonal contraceptives may have a higher risk of pregnancy if they ovulate sooner after the onset of bleeding.

Comparing continuation rates and side effects of hormonal contraceptives in East Asian and Caucasian women after abortion.

BACKGROUND: The purpose of this study was to determine whether East Asian women had more side effects and a higher discontinuation rate than Caucasian women when choosing to use hormonal contraceptives. STUDY DESIGN: This was an observational cohort study of usual care using questionnaires for 2 months after being given hormonal contraceptives following an abortion in Vancouver, Canada. RESULTS: In the first month, 73 (64.4%) of the 110 East Asian and 86 (80.4%) of the 107 Caucasian women took any of the sample provided (p=.020). In the second month, 52 (47.3%) of the East Asian and 62 (57%) of the Caucasian women used the prescription to buy and take their hormonal contraception (p=.12). Total side effects were similar, but there was more nausea in the East Asian women (23.3% vs. 8.1%) (p=.03) and more acne in the Caucasian women (8.2% vs. 20.9%) (p=.05). CONCLUSIONS: There may be both physiological and cultural differences leading East Asian women to use less hormonal contraception.