Medical abortion at 13 or more weeks gestation provided through telemedicine: A retrospective review of services.

OBJECTIVES: To evaluate medical abortion effectiveness and safety in women at 13 or more weeks gestation provided care through Women on Web's telemedicine service. STUDY DESIGN: We conducted a retrospective case study of abortions at 13 or more weeks gestation provided by Women on Web between 2016 and 2019. Women received mifepristone and misoprostol or misoprostol alone for abortion. We extracted demographic characteristics and outcome data for cases with pregnancy continuation outcomes. RESULTS: We identified 144 women who used medical abortion at 13 or more weeks; 131 (91%) provided abortion outcome data. Almost all, 118 (90%) received mifepristone and misoprostol. The population had an average age of 26 ± 5.8 years, 102 (78%) reported a gestational age of 13 to 15 weeks, 114 (87%) had experienced prior pregnancy, and represented all world regions. Overall, 13 (10%) women reported a continuing pregnancy, with 5 (5%) among women 13 to 15 weeks and 8 (28%) among those ≥16 weeks (p = 0.001); 38 (29%) reported adverse events (heavy bleeding, fever), 53 (43%) sought additional care from a health provider, and 18% of all cases received treatment with D&C/aspiration. CONCLUSIONS: Efficacy of self-administered medical abortion decreases as gestational age increases, risking continuation of pregnancy. Provision through telemedicine at 13 to 15 weeks appears safe and effective. IMPLICATIONS: Limited data suggest that medical abortion through telemedicine services may be a safe option through 15 weeks gestation in settings where there is ready access to the formal health system. More research with adequate sample sizes and high rates of follow-up is needed to inform on the safety of telemedicine for pregnancies 13 weeks and greater.

Abortion knowledge, attitudes and experiences among adolescent girls: a review of the literature.

Adolescent girls comprise a considerable proportion of annual abortion deaths, worldwide, with 15% of all unsafe abortions taking place among girls under 20 years of age. Despite recent global attention to the health and welfare of adolescent girls, little is known about their abortion experience, particularly of those under the age of 15 years. This review examines existing peer-reviewed and grey literature on abortion-related experiences of adolescent girls, paying particular attention to girls ages 10-14. In December 2019, the authors conducted a comprehensive search of five major online resource databases, using a two-part keyword search strategy for articles from 2003 to 2019. Of the original 3,100+ articles, 1,228 were individually screened and 35 retained for inclusion in the analysis. Findings show that while adolescent girls may have knowledge of abortion in general, they lack specific knowledge of sources of care and delay care-seeking due to the fear of stigma, lack of resources and provider bias. Adolescent girls do not experience higher rates of physical complications compared to older cohorts, but they are at risk of psychosocial harm. For girls ages 10-14, abortion experience may be compounded by pregnancy due to sexual abuse or transactional sex, and they face even more barriers to care than older adolescents in terms of provider bias and lack of agency. Adolescents have unique needs and experiences around abortion, which should be accounted for in programming and advocacy. Adolescent girls need information about safe abortion at an early age and a responsive and stigma-free health system.

Retraction Note: Factors associated with induced abortion in Nepal: data from a nationally representative population-based cross-sectional survey.

The authors have retracted this article [1] because it contains significant conceptual and textual overlap with unpublished work from another group. Suresh Mehata, Jamie Menzel, Erin Pearson and Kathryn Andersen agree with this retraction. Navaraj Bhattarai, Sharad Kumar Sharma and Mukta Shah did not respond to correspondence regarding this retraction.

Unintended Consequences of mHealth Interactive Voice Messages Promoting Contraceptive Use After Menstrual Regulation in Bangladesh: Intimate Partner Violence Results From a Randomized Controlled Trial.

BACKGROUND: Mobile phones for health (mHealth) hold promise for delivering behavioral interventions. We evaluated the effect of automated interactive voice messages promoting contraceptive use with a focus on long-acting reversible contraceptives (LARCs) among women in Bangladesh who had undergone menstrual regulation (MR), a procedure to "regulate the menstrual cycle when menstruation is absent for a short duration." METHODS: We recruited MR clients from 41 public- and private-sector clinics immediately after MR. Eligibility criteria included having a personal mobile phone and consenting to receive messages about family planning by phone. We randomized participants remotely to an intervention group that received at least 11 voice messages about contraception over 4 months or to a control group (no messages). The primary outcome was LARC use at 4 months. Adverse events measured included experience of intimate partner violence (IPV). Researchers recruiting participants and 1 analyst were blinded to allocation groups. All analyses were intention to treat. The trial is registered with ClinicalTrials.gov (NCT02579785). RESULTS: Between December 2015 and March 2016, 485 women were allocated to the intervention group and 484 to the control group. We completed follow-up on 389 intervention and 383 control participants. Forty-eight (12%) participants in the intervention group and 59 (15%) in the control group reported using a LARC method at 4 months (adjusted odds ratio [aOR] using multiple imputation=0.95; 95% confidence interval [CI]=0.49 to 1.83; P=.22). Reported physical IPV was higher in the intervention group: 42 (11%) intervention versus 25 (7%) control (aOR=1.97; 95% CI=1.12 to 3.46; P=.03) when measured using a closed question naming acts of violence. No violence was reported in response to an open question about effects of being in the study. CONCLUSIONS: The intervention did not increase LARC use but had an unintended consequence of increasing self-reported IPV. Researchers and health program designers should consider possible negative impacts when designing and evaluating mHealth and other reproductive health interventions. IPV must be measured using closed questions naming acts of violence.

Definitions, measurement and indicator selection for quality of care in abortion.

Little consensus exists about how to measure quality of care in abortion. Our purpose is to (a) provide common language for healthcare quality definitions, frameworks and measurement; (b) synthesize literature about quality measurement in abortion; and (c) present criteria for quality metric development. Quality includes effectiveness, patient centeredness, timeliness, efficiency and equity of care. Information about structure, process and outcomes of care is used to measure quality. We do not have good evidence about expected population-level health and behavioral outcomes associated with improving abortion service quality. Abortion patients overwhelmingly report high satisfaction with services, but it is not clear if their satisfaction indicates high-quality care. Guidance exists for quality metric selection; measures must focus on priority topics, be scientifically sound and be feasible. Technical quality standards and clinical guidelines exist, but we lack a standard set of quality metrics. Partners in the Abortion Service Quality Initiative (https://asq-initiative.org/) are collaborating to develop the first-ever global standard for measuring abortion service quality in low- and middle-income countries, both in and out of health care facilities. Standardized and validated quality metrics would move our field forward and contribute to quality improvement activities and, ultimately, to improved health outcomes for women and families. IMPLICATIONS: We define quality of health care, synthesize the evidence about quality of care in abortion and advocate for standardized and validated quality metrics to improve health outcomes for women.

Factors associated with induced abortion in Nepal: data from a nationally representative population-based cross-sectional survey.

BACKGROUND: Despite the legalization of abortion services in 2002, unsafe abortion (abortion services conducted by persons lacking necessary skill or in substandard settings or both) continues to be a public health concern in Nepal. There is a lack of national research exploring the characteristics of women who choose to have an abortion. This study assessed abortion in Nepal and its correlates using data from a nationally representative population-based cross-sectional survey. METHODS: We employed data from the Nepal Demographic and Health Survey 2016. Sample selection was based on stratified two-stage cluster sampling in rural areas and three-stage sampling in urban areas. The primary outcome is report of induced abortion in the 5 years preceding the survey, as recorded in the pregnancy history. All values were weighted by sample weights to provide population-level estimates. Bivariate and multivariate logistic regressions were performed using STATA 14 considering cluster sampling design. RESULTS: A total of 12,862 women of reproductive age (15-49 years) were interviewed. Overall, 4% (95% CI: 3.41-4.29) reported an abortion within the last 5 years (and less than 1% had had more than one abortion during that time). A higher proportion of women aged 20-34 years (5.7%), women with primary education (5.1%), women aware of abortion legalization (5.5%), and women in the richest wealth quintile (5.4%) had an abortion in the past 5 years. Compared to women aged < 20 years, women aged 20-34 years had higher odds (AOR: 5.54; 95% CI: 2.87-10.72) of having had an abortion in the past 5 years. Women with three or more living children had greater odds (AOR: 2.24; 95% CI: 1.51-3.31) of having had an abortion than women with no living children. The odds of having an abortion in the past 5 years increased with each wealth quintile, with the richest wealth quintile having almost three-fold greater odds of having had an abortion. No significant association was observed between having an abortion and the ecological zone and place of residence. CONCLUSION: This nationally representative study shows that abortion is associated with women's age, knowledge of abortion legality, wealth status, number of living children, and caste/ethnicity. Targeted interventions to young women, those in the poorest wealth quintile, women from Terai caste groups, and those who reside in Province 2 would be instrumental to address disproportional access to abortion services. Overall, strengthening contraceptive provision and abortion education programs would be cornerstone to improving the health of women and girls in Nepal.

Prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among young women (24 and below) in Nepal: Strategy in the search for improvements.

INTRODUCTION: Postabortion contraceptive use differs across countries, suggesting the need for country-level research to identify barriers and suggest appropriate interventions. This study aimed to identify the prevalence and correlates of postabortion long-acting reversible contraceptive (LARC) use among women aged 24 or younger in Nepal. METHODS: This is a cohort study using Health Management Information System (HMIS) data where individual case records of women seeking induced abortion or postabortion care were documented using structured HMIS 3.7 records. Analysis was performed on the individual case records of 20,307 women 24 years or younger who received induced abortion or postabortion care services in the three-year period from July 2014 to June 2017 at 433 public and private health facilities. FINDINGS: Overall, LARC uptake during the study period was 11% (IUD: 3% and implant: 8%). The odds of LARC acceptance was higher for young women (24 and below) who belonged to Brahmin/Chhetri (AOR = 1.23; 95% CI: 1.02-1.47) and Janajatis (AOR = 1.20; 95% CI: 1.01-1.43) as compared to Dalits; young women who had an induced abortion (AOR = 3.75; 95% CI: 1.75-8.06) compared with postabortion care; and those receiving service from public sector health facilities (AOR = 4.00; 95% CI: 2.06-7.75) compared with private sector health facilities. CONCLUSION: The findings from this study indicate the need to focus on barriers to acceptance of LARC among several groups of young women (24 and below) receiving abortion care in Nepal: Dalits, Madhesis and Muslims; nulliparous women; and those receiving services at private sector health facilities.

Is Abortion Included in Maternal and Child Health Curricula in the United States?

Purpose The purpose of this study is to assess whether Maternal and Child Health (MCH) graduate programs address abortion content in their programs' foundational courses, elective courses, and general curricula. Description Between January and March 2017, we conducted a descriptive study with faculty from the 13 Centers of Excellence in Maternal and Child Health Education, Science and Practice (COEs). We reviewed syllabi and discussed foundational and elective course content via email and key informant interviews with COE faculty. We categorized abortion coverage in foundational courses as "transparent" or "tangential" depending on inclusion of the word "abortion" in course syllabi. We identified electives addressing abortion as "electives including abortion" and courses that focus on abortion as "abortion-specific electives." Assessment Evidence demonstrated that most programs do not transparently address abortion in required course curricula. Only one of 13 COEs transparently addresses abortion in the foundational course(s); seven COEs tangentially include abortion in foundational courses; and all programs address abortion in some capacity though no standard exists to ensure its inclusion. Despite barriers, including avoidance of controversy and fear of losing funding, COEs could address abortion by establishing shared curricular standards, facilitating values clarification and attitude transformation activities, utilizing information-sharing networks, strengthening relationships between MCH programs and abortion-related organizations, and using professional societies. The scope of our study does not allow us to conclude why abortion content is lacking nor the quality of current content. Conclusion MCH programs should transparently incorporate abortion content in foundational and electives courses to educate students on how to engage with complex and sometimes stigmatized public health issues.

Determination of medical abortion success by women and community health volunteers in Nepal using a symptom checklist.

BACKGROUND: We sought to determine if female community health volunteers (FCHVs) and literate women in Nepal can accurately determine success of medical abortion (MA) using a symptom checklist, compared to experienced abortion providers. METHODS: Women undergoing MA, and FCHVs, independently assessed the success of each woman's abortion using an 8-question symptom checklist. Any answers in a red-shaded box indicated that the abortion may not have been successful. Women's/FCHVs' assessments were compared to experienced abortion providers using standard of care. RESULTS: Women's (n = 1153) self-assessment of MA success agreed with abortion providers' determinations 85% of the time (positive predictive value = 90, 95% CI 88, 92); agreement between FCHVs and providers was 82% (positive predictive value = 90, 95% CI 88, 92). Of the 92 women (8%) requiring uterine evacuation with manual vacuum aspiration (n = 84, 7%) or medications (n = 8, 0.7%), 64% self-identified as needing additional care; FCHVs identified 61%. However, both women and FCHVs had difficulty recognizing that an answer in a red-shaded box indicated that the abortion may not have been successful. Of the 453 women with a red-shaded box marked, only 35% of women and 41% of FCHVs identified the need for additional care. CONCLUSION: Use of a checklist to determine MA success is a promising strategy, however further refinement of such a tool, particularly for low-literacy settings, is needed before widespread use.

Values clarification workshops to improve abortion knowledge, attitudes and intentions: a pre-post assessment in 12 countries.

BACKGROUND: Women's access to abortion care is often denied or hampered due to a range of barriers, many of which are rooted in abortion stigma. Abortion values clarification and attitude transformation (VCAT) workshops are conducted with abortion providers, trainers, and policymakers and other stakeholders to mitigate the effects of abortion stigma and increase provision of and access to abortion care. This study assesses changes in knowledge, attitudes, and behavioral intentions of VCAT workshop participants. METHODS: Pre- and post-workshop surveys from 43 VCAT workshops conducted in 12 countries in Asia, Africa, and Latin America between 2006 and 2011 were analyzed to assess changes in three domains: knowledge, attitudes and behavioral intentions related to abortion care. A score was created for each domain (range: 0-100), and paired t-tests or Wilcoxon matched-pairs signed-ranks tests were used to test for significant differences between the pre- and post-workshop scores overall and by region and participant type (providers, trainers, and policymakers/other stakeholders). We also assessed changes in pre- and post-workshop scores for participants with the lowest knowledge and negative attitudes on the pre-workshop survey. RESULTS: Overall, the mean knowledge score increased significantly from 49.0 to 67.1 (p < 0.001) out of a total possible score of 100. Attitudes and behavioral intentions showed more modest, but still statistically significant improvements between the pre- and post-workshop surveys. The mean attitudes score increased from 78.2 to 80.9 (p < 0.001), and the mean behavioral intentions score rose from 82.2 to 85.4 (p = 0.03). Among participants with negative attitudes pre-workshop, most shifted to positive attitudes on the post-workshop survey, ranging from 35.2% who switched to supporting unrestricted access to second-trimester abortion to 90.9% who switched to feeling comfortable working to increase access to contraceptive services in their country. Participants who began the workshop with the lowest level of knowledge experienced the greatest increase in mean knowledge score from 20.0 to 55.0 between pre- and post-workshop surveys (p < 0.001). CONCLUSIONS: VCAT workshop participants demonstrated improvements in knowledge, attitudes, and behavioral intentions related to abortion care. Participants who entered the workshops with the lowest levels of knowledge and negative attitudes had the greatest gains in these domains.

What contraception do women use after abortion? An analysis of 319,385 cases from eight countries.

Contraception is an essential element of high-quality abortion care. However, women seeking abortion often leave health facilities without receiving contraceptive counselling or methods, increasing their risk of unintended pregnancy. This paper describes contraceptive uptake in 319,385 women seeking abortion in 2326 public-sector health facilities in eight African and Asian countries from 2011 to 2013. Ministries of Health integrated contraceptive and abortion services, with technical assistance from Ipas, an international non-governmental organisation. Interventions included updating national guidelines, upgrading facilities, supplying contraceptive methods, and training providers. We conducted unadjusted and adjusted associations between facility level, client age, and gestational age and receipt of contraception at the time of abortion. Overall, postabortion contraceptive uptake was 73%. Factors contributing to uptake included care at a primary-level facility, having an induced abortion, first-trimester gestation, age ≥25, and use of vacuum aspiration for uterine evacuation. Uptake of long-acting, reversible contraception was low in most countries. These findings demonstrate high contraceptive uptake when it is delivered at the time of the abortion, a wide range of contraceptive commodities is available, and ongoing monitoring of services occurs. Improving availability of long-acting contraception, strengthening services in hospitals, and increasing access for young women are areas for improvement.

Developing mHealth Messages to Promote Postmenstrual Regulation Contraceptive Use in Bangladesh: Participatory Interview Study.

BACKGROUND: Abortions are restricted in Bangladesh, but menstrual regulation is an approved alternative, defined as a procedure of regulating the menstrual cycle when menstruation is absent for a short duration. Use of contraception after menstrual regulation can reduce subsequent unintended pregnancy, but in Bangladesh, the contraceptive method mix is dominated by short-term methods, which have higher discontinuation and failure rates. Mobile phones are a channel via which menstrual regulation clients could be offered contraceptive support after leaving the clinic. OBJECTIVE: This study aimed to support the development of a mobile phone intervention to support postmenstrual regulation family planning use in Bangladesh. It explored what family planning information women want to receive after having a menstrual regulation procedure, whether they would like to receive this information via their mobile phone, and if so, what their preferences are for the way in which it is delivered. METHODS: We conducted participatory interviews with 24 menstrual regulation clients in Dhaka and Sylhet divisions in Bangladesh. Women were recruited from facilities in urban and peri-urban areas, which included public sector clinics supported by Ipas, an international nongovernmental organization (NGO), and NGO clinics run by Marie Stopes. Main themes covered in the interviews were factors affecting the use of contraception, what information and support women want after their menstrual regulation procedure, how respondents would prefer to receive information about contraception, and other key issues for mobile health (mHealth) interventions, such as language and privacy. As part of the in-depth interviews, women were shown and played 6 different messages about contraception on the research assistant's phone, which they were given to operate, and were then asked to give feedback. RESULTS: Women were open to both receiving messages about family planning methods on their mobile phones and talking to a counselor about family planning methods over the phone after their menstrual regulation. Women most commonly wanted information about the contraceptive method they were currently using and wanted this information to be tailored to their particular needs. Women preferred voice messages to text and liked the interactive voice message format. When asked to repeat and identify the main points of the messages, women demonstrated good understanding of the content. Women did not seem too concerned with privacy or with others reading the messages and welcomed including their husbands in speaking to a counselor. CONCLUSIONS: This study found that menstrual regulation clients are very interested in receiving information on their phones to support family planning use and wanted more information about the method of contraception they were using. Participatory voicemail was the preferred modality.

What Factors Contribute to Postabortion Contraceptive Uptake By Young Women? A Program Evaluation in 10 Countries in Asia and sub-Saharan Africa.

BACKGROUND: Unintended pregnancy disproportionately affects young women and adolescents in developing countries. The abortion care setting offers a unique opportunity for adolescents and young women to access a full range of contraceptive services. This evaluation assesses the factors that influence contraceptive uptake among adolescents and young women seeking abortion care in health facilities. METHODS: Following provider training, we analyzed client log book data from 921,918 abortion care cases in 4,881 health facilities in 10 countries from July 2011 through June 2015. Log book data included client characteristics such as age, pregnancy gestation, type of service provided, and contraceptive method provision. Health facility characteristics were obtained through administration of a site baseline form prior to initiation of programmatic support by Ipas, an international NGO. Programmatic support included integration of postabortion contraceptive services with abortion care, improvements in commodities logistics, health worker training, upgraded recordkeeping, and post-training follow-up with providers and sites to solve problems and improve performance. We analyzed abortion cases by 3 age categories, ≤19 years, 20-24 years, and ≥25 years, and conducted unadjusted and adjusted analyses for the primary outcomes of interest: receipt of a contraceptive method at the time of care; type of contraceptive method selected; and the client, clinical care, and facility characteristics associated with contraceptive uptake. RESULTS: Overall, 77% of women left the facility with a contraceptive method. The majority (84%) of contraceptive acceptors selected a short-acting method, especially oral contraceptives. In the adjusted model, women ≤19 were less likely to choose a method than women 25 years or older (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.79 to 0.96). Adolescents and young women were also significantly less likely to choose a long-acting, reversible contraceptive than those ages 25 or older (≤19 years: OR, 0.59; 95% CI, 0.52 to 0.67; 20-24 years: OR, 0.68; 95% CI, 0.63 to 0.73). Women treated by an Ipas-trained provider were significantly more likely to select postabortion contraception than women treated by non-Ipas-trained providers (OR, 1.37; 95% CI, 1.20 to 1.57). CONCLUSIONS: Programmatic support to health systems, including provider training in contraceptive counseling and provision, was associated with women's higher acceptance of postabortion contraception. However, gaps remained for young women, especially adolescents, who were significantly less likely than older women to accept postabortion contraception. Health systems and facilities should pay increased attention to meeting the contraceptive needs of young women and adolescents.

Service Delivery Correlates of Choosing Short-Acting Contraceptives at the Time of Uterine Evacuation in Bangladesh.

CONTEXT: The World Health Organization recommends that contraceptives be offered on the day of a uterine evacuation procedure (i.e., induced abortion or postabortion care for an incomplete abortion). Short-acting methods can be initiated on the day of the uterine evacuation, regardless of procedure type. METHODS: Survey data from a facility-based sample of 479 Bangladeshi women aged 18-49 who did not intend to become pregnant in the four months following their uterine evacuation were used to examine women's choice of short-acting contraceptive methods (pill, condoms or injectable). Service delivery correlates of contraceptive choice were identified using sequential logistic regression models. RESULTS: Seventy-three percent of women chose a short-acting contraceptive method on the day of their uterine evacuation. The odds that a woman chose a short-acting method, rather than no method, were lower among those who had had a medication abortion (odds ratio, 0.1) or dilatation and curettage (0.3) than among those who had had a vacuum aspiration. The likelihood that a woman chose a specific type of short-acting method varied according to the type of uterine evacuation she had had, the facility level and the governmental or nongovernmental entity that managed the facility. CONCLUSIONS: Uterine evacuation service delivery characteristics may act as barriers to women's choosing a contraceptive method following an abortion. Training and monitoring providers may help ensure that all uterine evacuation clients have access to the full range of contraceptive information and services and that their choices, rather than service delivery factors, drive postabortion contraceptive use.

Improving health worker performance of abortion services: an assessment of post-training support to providers in India, Nepal and Nigeria.

BACKGROUND: Health worker performance has been the focus of numerous interventions and evaluation studies in low- and middle-income countries. Few have examined changes in individual provider performance with an intervention encompassing post-training support contacts to improve their clinical practice and resolve programmatic problems. This paper reports the results of an intervention with 3471 abortion providers in India, Nepal and Nigeria. METHODS: Following abortion care training, providers received in-person visits and virtual contacts by a clinical and programmatic support team for a 12-month period, designed to address their individual practice issues. The intervention also included technical assistance to and upgrades in facilities where the providers worked. Quantitative measures to assess provider performance were established, including: 1) Increase in service provision; 2) Consistent service provision; 3) Provision of high quality of care through use of World Health Organization-recommended uterine evacuation technologies, management of pain and provision of post-abortion contraception; and 4) Post-abortion contraception method mix. Descriptive univariate analysis was conducted, followed by examination of the bivariate relationships between all independent variables and the four dependent performance outcome variables by calculating unadjusted odds ratios, by country and overall. Finally, multivariate logistic regression was performed for each outcome. RESULTS: Providers received an average of 5.7 contacts. Sixty-two percent and 46% of providers met measures for consistent service provision and quality of care, respectively. Fewer providers achieved an increased number of services (24%). Forty-six percent provided an appropriate postabortion contraceptive mix to clients. Most providers met the quality components for use of WHO-recommended abortion methods and provision of pain management. Factors significantly associated with achievement of all measures were providers working in sites offering community outreach and those trained in intervention year two. The number of in-person contacts was significantly associated with achievement of three of four measures. CONCLUSION: Post-training support holds promise for strengthening health worker performance. Further research is needed to compare this intervention with other approaches and assess how post-training contacts could be incorporated into current health system supervision.

Using automated voice messages linked to telephone counselling to increase post-menstrual regulation contraceptive uptake and continuation in Bangladesh: study protocol for a randomised controlled trial.

BACKGROUND: Adoption of modern contraceptive methods after menstrual regulation (MR) is thought to reduce subsequent unwanted pregnancy and abortion. Long-acting reversible contraceptives (LARCs) are highly effective at reducing unintended pregnancy, but uptake in Bangladesh is low. Providing information on the most effective methods of contraception increases uptake of more effective methods. This protocol describes a randomised controlled trial of an intervention delivered by mobile phone designed to support post-MR contraceptive use in Bangladesh. METHODS: This is a multi-site single blind individual randomised controlled trial. At least 960 women undergoing MR procedures at selected facilities will be recruited after their procedure by female research assistants. Women will be randomised into the control or intervention group with a 1:1 ratio. All participants will receive usual clinic care, including contraceptive counselling and the telephone number of a non-toll-free call centre which provides counselling on MR and contraception. During the 4 months after their MR procedure, intervention participants will be sent 11 recorded interactive voice messages to their mobile phone about contraception with a focus on their chosen method and LARCs. Each message allows the participant to connect directly to the call centre. The intervention is free to the user. The control group will receive no messages delivered by mobile phone. All participants will be asked to complete an in-person questionnaire at recruitment and follow-up questionnaires by telephone at 2 weeks, 4 months and 12 months after their MR. The primary outcome for the trial will be self-reported LARC use 4 months post-MR. Secondary outcomes include LARC use at 2 weeks and 12 months post-MR, use of any effective modern contraceptive method at 2 weeks, 4 months and 12 months post-MR, and contraceptive discontinuation, contraceptive method switching, pregnancy, subsequent MR and experience of violence during the 12 month study period. DISCUSSION: Mobile phones offer a low-cost mechanism for providing individualised support to women with contraception outside of the clinic setting. This study will provide information on the effects of such an intervention among MR clients in Bangladesh. TRIAL REGISTRATION: Trial registered with clinicaltrials.gov Registration number: NCT02579785 Date of registration: 16th October 2015.

Determination of medical abortion eligibility by women and community health volunteers in Nepal: A toolkit evaluation.

OBJECTIVE: To determine if pregnant, literate women and female community health volunteers (FCHVs) in Nepal can accurately determine a woman's eligibility for medical abortion (MA) using a toolkit, compared to comprehensive abortion care (CAC) trained providers. STUDY DESIGN: We conducted a prospective diagnostic accuracy study in which women presenting for first trimester abortion, and FCHVs, independently assessed each woman's eligibility for MA using a modified gestational dating wheel to determine gestational age and a nine-point checklist of MA contraindications or cautions. Ability to determine MA eligibility was compared to experienced CAC-providers using Nepali standard of care. RESULTS: Both women (n = 3131) and FCHVs (n = 165) accurately interpreted the wheel 96% of the time, and the eligibility checklist 72% and 95% of the time, respectively. Of the 649 women who reported potential contraindications or cautions on the checklist, 88% misidentified as eligible. Positive predictive value (PPV) of women's assessment of eligibility based on gestational age was 93% (95% CI 92, 94) compared to CAC-providers' (n = 47); PPV of the medical contraindications checklist and overall (90% [95% CI 88, 91] and 93% [95% CI 92, 94] respectively) must be interpreted with caution given women's difficulty using the checklist. PPV of FCHVs' determinations were 93% (95% CI 92, 94), 90% (95% CI 89,91), and 93% (95% CI 91, 94) respectively. CONCLUSION: Although a promising strategy to assist women and FCHVs to assess MA eligibility, further refinement of the eligibility tools, particularly the checklist, is needed before their widespread use.

Integrating postabortion care, menstrual regulation and family planning services in Bangladesh: a pre-post evaluation.

BACKGROUND: In Bangladesh, abortion is restricted except to save the life of a woman, but menstrual regulation is allowed to induce menstruation and return to non-pregnancy after a missed period. MR services are typically provided through the Directorate General of Family Planning, while postabortion care services for incomplete abortion are provided by facilities under the Directorate General of Health Services. The bifurcated health system results in reduced quality of care, particularly for postabortion care patients whose procedures are often performed using sub-optimal uterine evacuation technology and typically do not receive postabortion contraceptive services. This study evaluated the success of a pilot project that aimed to integrate menstrual regulation, postabortion care and family planning services across six Directorate General of Health Services and Directorate General of Family Planning facilities by training providers on woman-centered abortion care and adding family planning services at sites offering postabortion care. METHODS: A pre-post evaluation was conducted in the six large intervention facilities. Structured client exit interviews were administered to all uterine evacuation clients presenting in the 2-week data collection period for each facility at baseline (n = 105; December 2011-January 2012) and endline (n = 107; February-March 2013). Primary outcomes included service integration indicators such as provision of menstrual regulation, postabortion care and family planning services in both facility types, and quality of care indicators such as provision of pain management, provider communication and women's satisfaction with the services received. Outcomes were compared between baseline and endline for Directorate General of Family Planning and Directorate General of Health Services facilities, and chi-square tests and t-tests were used to test for differences between baseline and endline. RESULTS: At the end of the project there was an increase in menstrual regulation service provision in Directorate General of Health Services facilities, from none at baseline to 44.1% of uterine evacuation services at endline (p < 0.001). The proportion of women accepting a postabortion contraceptive method increased from 14.3% at baseline to 69.2% at endline in Directorate General of Health Services facilities (p = 0.006). Provider communication and women's rating of the care they received increased significantly in both Directorate General of Health Services and Directorate General of Family Planning facilities. CONCLUSIONS: Integration of menstrual regulation, postabortion care and family planning services is feasible in Bangladesh over a relatively short period of time. The intervention's focus on woman-centered abortion care also improved quality of care. This model can be scaled up through the public health system to ensure women's access to safe uterine evacuation services across all facility types in Bangladesh.

An exploration of the socio-economic profile of women and costs of receiving abortion services at public health facilities of Madhya Pradesh, India.

BACKGROUND: Maternal mortality, which primarily burdens developing countries, reflects the greatest health divide between rich and poor. This is especially pronounced for access to safe abortion services which alone avert 1 of every 10 maternal deaths in India. Primarily due to confidentiality concerns, poor women in India prefer private services which are often offered by untrained providers and may be expensive. In 2006 the state government of Madhya Pradesh (population 73 million) began a concerted effort to ensure access to safe abortion services at public health facilities to both rural and urban poor women. This study aims to understand the socio-economic profile of women seeking abortion services in public health facilities across this state and out of pocket cost accessing abortion services. In particular, we examine the level of access that poor women have to safe abortion services in Madhya Pradesh. METHODS: This study consisted of a cross-sectional client follow-up design. A total of 19 facilities were selected using two-stage random sampling and 1036 women presenting to chosen facilities with abortion and post-abortion complications were interviewed between May and December 2014. A structured data collection tool was developed. A composite wealth index computed using principal component analysis derived weights from consumer durables and asset holding and classified women into three categories, poor, moderate, and rich. RESULTS: Findings highlight that overall 57% of women who received abortion care at public health facilities were poor, followed by 21% moderate and 22% rich. More poor women sought care at primary level facilities (58%) than secondary level facilities and among women presenting for postabortion complications (67%) than induced abortion. Women reported spending no money to access abortion services as abortion services are free of cost at public facilities. However, poor women spend INR 64 (1 USD) while visiting primary level facilities and INR 256 (USD 4) while visiting urban hospitals, primarily for transportation and food. CONCLUSIONS: Improved availability of safe abortion services at the primary level in Madhya Pradesh has helped meeting the need of safe abortion services among poor, which eventually will help reducing the maternal mortality and morbidity due to unsafe abortion.