Associations between the COVID-19 pandemic and women's fertility intentions: a multi-country, cross-sectional (I-SHARE) study.

INTRODUCTION: The COVID-19 pandemic, together with the subsequent social distancing measures, could lead to shifts in family and fertility planning. This study aimed to explore the associations between the COVID-19 pandemic and changes in fertility intentions among an international sample of reproductive-aged women. METHODS: A multi-country, cross-sectional study based on data from 10 672 women aged 18-49 years who participated in the International Sexual Health And REproductive Health (I-SHARE) study, which organised an international online survey between July 2020 and February 2021. Factors associated with changes in fertility intentions were explored using multinomial probit regression models. Cluster-robust standard errors were used to calculate model parameters. RESULTS: Of 10 672 included reproductive-aged women, 14.4% reported changing their fertility intentions due to the pandemic, with 10.2% postponement and 4.2% acceleration. Women who had ever been isolated/quarantined were more likely to postpone their fertility intentions (adjusted odds ratio (AOR)=1.41; 95% CI 1.18 to 1.69) compared with those who had not; women who lived with a steady partner were more likely to want children sooner (AOR=1.57; 95% CI 1.10 to 2.23) compared with those who did not; and those who reported a higher frequency of getting angry, feeling frustrated, or worrying about their finances were more likely to postpone their fertility intentions. The main findings were robust in the sensitivity analyses. CONCLUSIONS: Most women who changed fertility intentions because of the pandemic have postponed intentions to expand their families. The pandemic-induced exposures were associated with these postponements.

Adherence to Modern Contraceptives Among Female Refugee Adolescents in Northern Uganda: A Prospective Single Cohort Study.

Background: Contraceptive adherence is the current and consistent use of a contraceptive method as prescribed by a health worker or family planning provider so as to prevent pregnancy. Globally, adherence is lowest among adolescents. This has greatly contributed to the high burden of adolescent pregnancies. Adherence and reasons for discontinuation among refugee adolescents are poorly understood. The aim of this study was to determine the rates and predictors of adherence to modern contraceptives among female refugee adolescents in northern Uganda. Methods: This was a prospective single cohort study, nested into a randomised controlled trial (RCT) assessing the effect of peer counselling on acceptance of modern contraceptives. The RCT was conducted among female refugee adolescents in Palabek refugee settlement, northern Uganda. The study involved 272 new starters of modern contraceptives who were followed up for six months from May 2019 to January 2020. The outcome was measured at one, three, and six months after receiving a contraceptive method, and the predictors of adherence were determined using Generalised Estimating Equations (GEE). Data were analysed using STATA version 14.0. Results: Adherence rates were low and reduced over time. By the end of the six months, only 44% of the participants were using a contraceptive method. Participants using long-acting reversible contraceptives (LARC) were more likely to adhere compared to those who were using short-acting reversible contraceptives (SARC) (OR: 3.37, 95% CI: 1.914-5.937, p<0.001). Conclusion: Adherence to modern contraceptives was low, leaving adolescents at risk of unintended pregnancies. Participants using LARC were more likely to adhere than those using SARC. Interventions addressing fear of side effects and partner prohibition should be studied and implemented to enable adherence to modern contraceptives.

Implementing the QUALI-DEC project in Argentina, Burkina Faso, Thailand and Viet Nam: a process delineation and theory-driven process evaluation protocol.

The project 'Quality Decision-making by women and providers' (QUALI-DEC) combines four non-clinical interventions to promote informed decision-making surrounding mode of birth, improve women's birth experiences, and reduce caesarean sections among low-risk women. QUALI-DEC is currently being implemented in 32 healthcare facilities across Argentina, Burkina Faso, Thailand, and Viet Nam. In this paper, we detail implementation processes and the planned process evaluation, which aims to assess how and for whom QUALI-DEC worked, the mechanisms of change and their interactions with context and setting; adaptations to intervention and implementation strategies, feasibility of scaling-up, and cost-effectiveness of the intervention. We developed a project theory of change illustrating how QUALI-DEC might lead to impact. The theory of change, together with on the ground observations of implementation processes, guided the process evaluation strategy including what research questions and perspectives to prioritise. Main data sources will include: 1) regular monitoring visits in healthcare facilities, 2) quantitative process and output indicators, 3) a before and after cross-sectional survey among post-partum women, 4) qualitative interviews with all opinion leaders, and 5) qualitative interviews with postpartum women and health workers in two healthcare facilities per country, as part of a case study approach. We foresee that the QUALI-DEC process evaluation will generate valuable information that will improve interpretation of the effectiveness evaluation. At the policy level, we anticipate that important lessons and methodological insights will be drawn, with application to other settings and stakeholders looking to implement complex interventions aiming to improve maternal and newborn health and wellbeing.Trial registration: ISRCTN67214403.

The impact of third-party authorization requirements on abortion-related outcomes: a synthesis of legal and health evidence.

OBJECTIVES: This review synthesizes legal and health evidence to demonstrate the health and human rights impacts of third-party authorization requirements (TPAs) on abortion seekers. RESULTS: The synthesized evidence substantiates the pre-existing position in international human rights law that requirements that abortion be authorized by third parties like parents, spouses, committees, and courts create barriers to abortion, should not be introduced at all, or should be repealed where they exist. CONCLUSIONS: The review establishes that rights-based regulation of abortion should not impose TPAs in any circumstances. Instead, the provision and management of abortion should be treated in a manner cognizant with the general principles of informed consent in international human rights law, presuming capacity in all adults regardless of marital status and treatment sought, and recognizing the evolving capacity of young people in line with their internationally-protected rights.

Implementing medical abortion through telemedicine in Colombia: a qualitative study.

The non-governmental organisation Profamilia developed and implemented medical abortion through telemedicine in response to the Covid-19 pandemic. This service is now integrated as an alternative to in-person care and available to abortion-seekers across Colombia. Previous research has emphasised bottlenecks in abortion provision, but less is known about implementation processes and experiences. We assessed the feasibility and acceptability of telemedicine for medical abortion from the perspectives of key informants involved in the implementation in Colombia. We conducted 15 in-depth interviews with healthcare professionals, coordinators and support staff implementing telemedicine for medical abortion in the early phase of implementation, between March and October 2021. We analysed the data using the framework method and applied the normalisation process theory in our analysis and interpretation of findings. Our findings show that strong leadership, organisational efforts on pre-implementation training, monitoring and evaluation, and collaboration between diversely skilled and experienced providers are essential for successful implementation. Participants were generally positive towards the use of telemedicine for medical abortion; concerns related to effectiveness, safety and safeguarding existed mainly among providers with less clinical experience. We identified contextual barriers, such as social opposition, regulatory barriers, providers' unavailability, and poor phone and internet connections in rural areas, which impacted the feasibility of the intervention negatively. In conclusion, to ensure stakeholders' buy-in and for the service to reach all abortion seekers in need, future implementation endeavours must address concerns about safety and effectiveness, and tackle identified contexual barriers.Plain Language SummaryIn telemedicine for medical abortion, all or some components of abortion care, such as initial consultations, home delivery of abortion medication, and post-abortion follow up are provided with the use of telecommunications. Telemedicine for medical abortion has been shown to be a safe and effective form of service delivery.In this study, we interviewed 15 healthcare providers and staff involved in the implementation of a telemedicine service for medical abortion in Colombia to determine whether they deemed the service to be acceptable and feasible. We found that collaboration between providers of different backgrounds and levels of experience, appropriate training and strong leadership were key factors for successfully implementing the service. However, some healthcare providers, especially those with less clinical experience, were concerned that telemedicine for medical abortion may not be safe and may risk the health and well-being of abortion-seekers. Further, social opposition to abortion, unclear regulation and limited access to technology were identified as barriers that need to be addressed to ensure the service reaches all abortion-seekers in need.In conclusion, despite contextual barriers and some provider's concerns about medical safety, telemedicine for medical abortion was viewed as a positive and feasible form of service delivery in Colombia.

The Impact of 'conscientious objection' on abortion-related outcomes: A synthesis of legal and health evidence.

The World Health Organization (WHO) and international human rights bodies have long urged states to take steps to ensure that 'conscientious objection' does not undermine access to abortion in practice. This review uses an established methodology to identify and integrate evidence of the health and human rights impacts of the practice of conscientious objection/refusal. The evidence identified in this review suggests strongly that conscientious objection negatively affects the rights of abortion seekers and has negative implications for the rights of non-objecting health workers. This is exacerbated in situations where an exercise of 'conscience' goes beyond 'opting out' of providing care and extends into seeking to prevent abortion through dissuasion, misinformation, misdirection, delay, and sometimes abuse. The insights from this review suggest that states must take better and further action to centre abortion seekers in the regulation of conscientious objection, and to prevent and ensure accountability for rights-limiting manifestations of conscience that go beyond opting out of direct provision of abortion care in non-emergency settings.

Intimate Partner Violence During COVID-19 Restrictions: A Study of 30 Countries From the I-SHARE Consortium.

Intimate partner violence (IPV) causes substantial physical and psychological trauma. Restrictions introduced in response to the COVID-19 pandemic, including lockdowns and movement restrictions, may exacerbate IPV risk and reduce access to IPV support services. This cross-sectional study examines IPV during COVID-19 restrictions in 30 countries from the International Sexual HeAlth and REproductive Health (I-SHARE) study conducted from July 20th, 2020, to February, 15th, 2021. IPV was a primary outcome measure adapted from a World Health Organization multicountry survey. Mixed-effects modeling was used to determine IPV correlates among participants stratified by cohabitation status. The sample included 23,067 participants from 30 countries. A total of 1,070/15,336 (7.0%) participants stated that they experienced IPV during COVID-19 restrictions. A total of 1,486/15,336 (9.2%) participants stated that they had experienced either physical or sexual partner violence before the restrictions, which then decreased to 1,070 (7.0%) after the restrictions. In general, identifying as a sexual minority and experiencing greater economic vulnerability were associated with higher odds of experiencing IPV during COVID-19 restrictions, which were accentuated among participants who were living with their partners. Greater stringency of COVID-19 restrictions and living in urban or semi-urban areas were associated with lower odds of experiencing IPV in some settings. The I-SHARE data suggest a substantial burden of IPV during COVID-19 restrictions. However, the restrictions were correlated with reduced IPV in some settings. There is a need for investing in specific support systems for survivors of IPV during the implementation of restrictions designed to contain infectious disease outbreaks.

The impact of criminalisation on abortion-related outcomes: a synthesis of legal and health evidence.

Abortion is criminalised to at least some degree in most countries. International human rights bodies have recognised that criminalisation results in the provision of poor-quality healthcare goods and services, is associated with lack of registration and unavailability of essential medicines including mifepristone and misoprostol, obstructs the provision of abortion information, obstructs training for abortion provision, is associated with delayed and unsafe abortion, and does not achieve its apparent aims of ether protecting abortion seekers from unsafe abortion or preventing abortion. Human rights bodies recommend decriminalisation, which is generally associated with reduced stigma, improved quality of care, and improved access to safe abortion. Drawing on insights from reproductive health, law, policy, and human rights, this review addresses knowledge gaps related to the health and non-health outcomes of criminalisation of abortion. This review identified evidence of the impacts of criminalisation of people seeking to access abortion and on abortion providers and considered whether, and if so how, this demonstrates the incompatibility of criminalisation with substantive requirements of international human rights law. Our analysis shows that criminalisation is associated with negative implications for health outcomes, health systems, and human rights enjoyment. It provides a further underpinning from empirical evidence of the harms of criminalisation that have already been identified by human rights bodies. It also provides additional evidence to support the WHO's recommendation for full decriminalisation of abortion.

Impact of the COVID-19 pandemic on access to and utilisation of services for sexual and reproductive health: a scoping review.

INTRODUCTION: The COVID-19 pandemic has negatively impacted health systems globally and widened preexisting disparities. We conducted a scoping review on the impact of the COVID-19 pandemic on women and girls' access to and utilisation of sexual and reproductive health (SRH) services for contraception, abortion, gender-based and intimate partner violence (GBV/IPV) and sexually transmitted infections (STIs). METHODS: We systematically searched peer reviewed literature and quantitative reports, published between December 2019 and July 2021, focused on women and girls' (15-49 years old) access to and utilisation of selected SRH services during the COVID-19 pandemic. Included studies were grouped based on setting, SRH service area, study design, population and reported impact. Qualitative data were coded, organised thematically and grouped by major findings. RESULTS: We included 83 of 3067 identified studies and found that access to contraception, in-person safe abortion services, in-person services for GBV/IPV and STI/HIV testing, prevention and treatment decreased. The geographical distribution of this body of research was uneven and significantly less representative of countries where COVID-19 restrictions were very strict. Access was limited by demand and supply side barriers including transportation disruptions, financial hardships, limited resources and legal restrictions. Few studies focused on marginalised groups with distinct SRH needs. CONCLUSION: Reports indicated negative impacts on access to and utilisation of SRH services globally, especially for marginalised populations during the pandemic. Our findings call for strengthening of health systems preparedness and resilience to safeguard global access to essential SRH services in ongoing and future emergencies.

Comparison of the effectiveness and safety of treatment of incomplete second trimester abortion with misoprostol provided by midwives and physicians: a randomised, controlled, equivalence trial in Uganda.

BACKGROUND: To address the knowledge gaps in the provision of post-abortion care by midwives for women in the second trimester, we investigated the effectiveness and safety of treatment for incomplete second trimester abortion with misoprostol, comparing care provision by midwives with that provided by physicians in Uganda. METHODS: Our multicentre, randomised, controlled, equivalence trial undertaken in 14 health facilities in Uganda recruited women with incomplete abortion of uterine size 13-18 weeks. We randomly assigned (1:1) women to clinical assessment and treatment by either midwife or physician. The randomisation sequence was computer generated, in blocks of four to 12, and stratified for study site. Participants received sublingual misoprostol (400 µg once every 3 h for up to five doses). The study was not concealed from the health-care providers and study participants. Primary outcome was complete abortion within 24 h that did not require surgical evacuation. Analysis was per-protocol and intention to treat; the intention-to-treat population consisted of women who were randomised, received at least one dose of misoprostol, and reported primary outcome data, and the per-protocol population excluded women with unexplained discontinuation of treatment. We used generalised mixed-effects models to obtain the risk difference. The predefined equivalence range was -5% to 5%. The trial was registered at ClinicalTrials.gov, NCT03622073. FINDINGS: Between Aug 14, 2018, and Nov 16, 2021, 1191 eligible women were randomly assigned to each group (593 women to the midwife group and 598 to the physician group). 1164 women were included in the per-protocol analysis, and 530 (92%) of 577 women in the midwife group and 553 (94%) of 587 women in the physician group had a complete abortion within 24 h. The model-based risk difference for the midwife versus physician group was -2·3% (95% CI -4·4 to -0·3), and within our predefined equivalence range (-5% to 5%). Two women in the midwife group received blood transfusion. INTERPRETATION: Clinical assessment and treatment of second trimester incomplete abortion with misoprostol provided by midwives was equally effective and safe as when provided by physicians. In low-income settings, inclusion of midwives in the medical management of uncomplicated second trimester incomplete abortion has potential to increase women's access to safe post-abortion care. FUNDING: Swedish Research Council and THRiVE-2.

The impact of mandatory waiting periods on abortion-related outcomes: a synthesis of legal and health evidence.

This review follows an established methodology for integrating human rights to address knowledge gaps related to the health and non-health outcomes of mandatory waiting periods (MWPs) for access to abortion. MWP is a requirement imposed by law, policy, or practice, to wait a specified amount of time between requesting and receiving abortion care. Recognizing that MWPs "demean[] women as competent decision-makers", the World Health Organization recommends against MWPs. International human rights bodies have similarly encouraged states to repeal and not to introduce MWPs, which they recognize as operating as barriers to accessing sexual and reproductive healthcare. This review of 34 studies published between 2010 and 2021, together with international human rights law, establishes the health and non-health harms of MWPs for people seeking abortion, including delayed abortion, opportunity costs, and disproportionate impact. Impacts on abortion providers include increased workloads and system costs.

The impact of 'grounds' on abortion-related outcomes: a synthesis of legal and health evidence.

Where abortion is legal, it is often regulated through a grounds-based approach. A grounds-based approach to abortion provision occurs when law and policy provide that lawful abortion may be provided only where a person who wishes to have an abortion satisfies stipulated 'grounds', sometimes described as 'exceptions' or 'exceptional grounds'. Grounds-based approaches to abortion are, prima facie, restrictive as they limit access to abortion based on factors extraneous to the preferences of the pregnant person. International human rights law specifies that abortion must be available (and not 'merely' lawful) where the life or health of the pregnant woman or girl is at risk, or where carrying a pregnancy to term would cause her substantial pain or suffering, including but not limited to situations where the pregnancy is the result of rape or incest or the pregnancy is not viable. However, international human rights law does not specify a grounds-based approach as the way to give effect to this requirement. The aim of this review is to address knowledge gaps related to the health and non-health outcomes plausibly related to the effects of a grounds-based approach to abortion regulation. The evidence from this review shows that grounds have negative implications for access to quality abortion and for the human rights of pregnant people. Further, it shows that grounds-based approaches are insufficient to meet states' human rights obligations. The evidence presented in this review thus suggests that enabling access to abortion on request would be more rights-enhancing than grounds-based approaches to abortion regulation.

The impact of provider restrictions on abortion-related outcomes: a synthesis of legal and health evidence.

Many components of abortion care in early pregnancy can safely be provided on an outpatient basis by mid-level providers or by pregnant people themselves. Yet, some states impose non-evidence-based provider restrictions, understood as legal or regulatory restrictions on who may provide or manage all or some aspects of abortion care. These restrictions are inconsistent with the World Health Organization's support for the optimization of the roles of various health workers, and do not usually reflect evidence-based determinations of who can provide abortion. As a matter of international human rights law, states should ensure that the regulation of abortion is evidence-based and proportionate, and disproportionate impacts must be remedied. Furthermore, states are obliged take steps to ensure women do not have to undergo unsafe abortion, to reduce maternal morbidity and mortality, and to effectively protect women and girls from the physical and mental risks associated with unsafe abortion. States must revise their laws to ensure this. Where laws restrict those with the training and competence to provide from participating in abortion care, they are prima facie arbitrary and disproportionate and thus in need of reform. This review, developed by experts in reproductive health, law, policy, and human rights, examined the impact of provider restrictions on people seeking abortion, and medical professionals. The evidence from this review suggests that provider restrictions have negative implications for access to quality abortion, contributing inter alia to delays and recourse to unsafe abortion. A human rights-based approach to abortion regulation would require the removal of overly restrictive provider restrictions. The review provides evidence that speaks to possible routes for regulatory reform by expanding the health workforce involved in abortion-related care, as well as expanding health workers' roles, both of which could improve timely access to first trimester surgical and medical abortion, reduce costs, save time, and reduce the need for travel.

This review identifies evidence of the impacts of provider restrictions on people seeking to access abortion and on abortion providers. It pursues a methodology designed to ensure the full integration of public health and human rights standards developed by the research team and published elsewhere. The evidence from this review points clearly to provider restrictions having negative implications for health outcomes, health systems, and human rights. This is especially important as international guidance provided by the WHO indicates best practice in provision and management of abortion and shows clearly that undue provider restrictions are not justified by reference to the nature and complexity of abortion.

Effect of peer counselling on acceptance of modern contraceptives among female refugee adolescents in northern Uganda: A randomised controlled trial.

BACKGROUND: The unmet need for contraceptives among refugee adolescents is high globally, leaving girls vulnerable to unintended pregnancies. Lack of knowledge and fear of side effects are the most reported reasons for non-use of contraceptives amongst refugee adolescents. Peer counselling, the use of trained adolescents to offer contraceptive counselling to fellow peers, has showed effectiveness in increasing use of contraceptives in non-refugee adolescent resarch. OBJECTIVE: To determine the effect of peer counselling on acceptance of modern contraceptives among female refugee adolescents in northern Uganda. METHODS: A randomised controlled trial carried out in Palabek refugee settlement in northern Uganda, May to July 2019. Adolescents were included if they were sexually active or in any form of union, wanted to delay child bearing, and were not using any contraceptives. A total of 588 consenting adolescents were randomised to either peer counselling or routine counselling, the standard of care. RESULTS: Adolescents who received peer counselling were more likely to accept a contraceptive method compared to those who received routine counselling (PR: 1·24, 95% CI: 1·03 to 1·50, p = 0·023). Adolescents whose partners had attained up to tertiary education were more likely to accept a method than those whose partners had secondary or less education (PR: 1·45, 95% CI: 1·02 to 2·06, p = 0·037). In both groups, the most frequently accepted methods were the injectable and implant, with the commonest reasons for non-acceptance of contraception being fear of side effects and partner prohibition. CONCLUSION: Our data indicates that peer counselling has a positive effect on same day acceptance of modern contraceptives and should therefore be considered in future efforts to prevent adolescent pregnancies in refugee settings. Future peer counselling interventions should focus on how to effectively address adolescents' fear of side effects and partner prohibition, as these factors continue to impede decision making for contraceptive uptake.

Abortion hotlines around the world: a mixed-methods systematic and descriptive review.

Barriers to access abortion services globally have led to the development of alternative methods to assist and support women who seek an abortion. One such method is the use of hotlines, currently utilised globally for abortion care. This review aimed to understand (1) how abortion hotlines facilitate access to abortion; and (2) how women and stakeholders describe the impact of hotlines on abortion access. Published quantitative and qualitative studies and grey literature were systematically reviewed alongside an identification and description of abortion hotlines in the public domain. Our findings highlight that the existence of abortion hotlines is highly context-dependent. They may exist either as an independent community-based model of care, or as part of formal care pathways within the health system. Hotlines operating in contexts with legal restrictions seem to be broader in scope and will use innovative approaches to adapt to their setting and reach hard-to-reach populations. All the abortion hotlines that provided information on a data extraction form used evidence-based guidelines but women seeking medical abortion still struggle to access quality medications. There is limited data in general on abortion hotlines, especially on the user and provider experience. Abortion hotlines have the potential to facilitate access to safe abortion care through evidence-based information and to decrease maternal mortality and morbidity from unsafe abortions for women and girls globally.

Integrating rights and evidence: a technical advance in abortion guideline development.

As part of its core work, the WHO generates, translates and disseminates knowledge, including through guideline development. In recent years, substantial work has been undertaken to revise the Evidence to Decision framework in order to fully integrate inter alia human rights. This paper describes an innovative methodological approach taken by the authors to inform law and policy recommendations for the forthcoming third edition of the Safe Abortion: Technical and Policy Guidance for Health Systems. The methodology described here effectively integrates human rights protection and enjoyment as part of health outcomes and analysis, ensuring that subsequent recommendations are consistent with international human rights standards. This will allow guideline users to make informed decisions on interventions, including legal and policy reform, to fulfil relevant human rights including the right to health.

How task-sharing in abortion care became the norm in Sweden: A case study of historic and current determinants and events.

We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife-provided abortion care in Sweden. Identified facilitating factors were: (1) the historical role and high status of Swedish midwives; (2) Swedish research and development of medical abortion that enabled an enlarged clinical role for midwives; (3) collaborations between individual clinicians and researchers within the professional associations, and the autonomy of clinical units to implement changes in clinical practice; (4) a historic precedent of changes in abortion policy occurring without prior official or legal sanction; (5) a context of liberal abortion laws, secularity, gender equality, public support for abortion, trust in public institutions; and (6) an increasing global interest in task-shifting to increase access and reduce costs. Identified barriers/risks were: (1) the lack of systems for monitoring and evaluation; and (2) a loss of physician competence in abortion care.

Modern contraceptive use among female refugee adolescents in northern Uganda: prevalence and associated factors.

BACKGROUND: Adolescent pregnancies are persistently high among refugees. The pregnancies have been attributed to low contraceptive use in this population. The aim of this study was to determine the prevalence and factors associated with modern contraceptive use among female refugee adolescents in northern Uganda. METHODS: This was a cross sectional study using both descriptive and analytical techniques. The study was carried out in Palabek refugee settlement in Northern Uganda from May to July 2019. A total of 839 refugee adolescents who were sexually active or in-union were consecutively enrolled. Interviewer administered questionnaires were used for data collection. RESULTS: Modern contraceptive prevalence was 8.7% (95% CI: 7.0 to 10.8). The injectable was the most commonly used modern contraceptive method [42.5% (95% CI: 31.5 to 54.3)], and most of the participants had used the contraceptives for 6 months or less (59.7%). Reasons for not using modern contraceptives included fear of side effects (39.3%), partner prohibition (16.4%), and the desire to become pregnant (7.0%). Participants who were married (OR = 0.11, 95% CI: 0.04 to 0.35, p < 0.001), cohabiting (OR = 0.43, 95% CI: 0.20 to 0.93, p = 0.032) or having an older partner (OR = 0.93, 95% CI: 0.86 to 0.99, p = 0.046) were less likely to use modern contraceptives. CONCLUSION: Modern contraceptive use among female refugee adolescents was very low, and few reported a desire to become pregnant, leaving them vulnerable to unplanned pregnancies. Least likely to use modern contraceptives were participants who were married/cohabiting and those having older partners implying a gender power imbalance in fertility decision making. There is an urgent need for innovations to address the gender and power imbalances within relationships, which could shape fertility decision-making and increase modern contraceptive use among refugee adolescents.

Online access to abortion medications: a review of utilization and clinical outcomes.

We performed a search in PubMed and Web of Science on the self-use of abortion medication after online access. Studies published between January 1, 1995, and March 31, 2019, were considered. We included studies of online services that were (i) led by healthcare staff (n = 14), (ii) led by non-healthcare staff (n = 4), and (iii) providing noninteractive access (n = 17). Our outcomes were utilization (frequency and demand for services), acceptability for women, safety, and success rate. Key findings: Women are increasingly using the Internet to access abortion medication. Available services are of varying quality. Women accessing noninteractive services report feelings of distress related to the lack of medical guidance, and the demand for interactive guidance through the abortion process is high. Women using services led by healthcare staff report high rates of satisfaction and similar rates of clinical outcomes as those of in-person abortion care.

A systematic review of the effectiveness, safety, and acceptability of medical management of intrauterine fetal death at 14-28 weeks of gestation.

BACKGROUND: Optimal dose, interval, and administration route of misoprostol with added benefit of mifepristone for management of second trimester intrauterine fetal death (IUFD) are not established. OBJECTIVES: To assess effectiveness, safety, and acceptability of medical management of second trimester IUFD. SEARCH STRATEGY: Research databases from January 2006 to October 2018. SELECTION CRITERIA: Randomized controlled trials with IUFD cases at 14-28 weeks of gestation. DATA COLLECTION AND ANALYSIS: We screened and extracted data, assessed risk of bias, conducted analyses, and assessed overall certainty of the evidence. MAIN RESULTS: Sixteen trials from 1695 citations. When misoprostol is used alone, 400 µg is more effective than 200 µg (RR 0.78; 95% CI, 0.66-0.92, moderate certainty evidence); the sublingual route is more effective than the oral route (RR 0.88; 95% CI, 0.70-1.11, low certainty evidence). There may be little to no difference between the sublingual and vaginal route (RR 0.93; 95% CI, 0.85-1.03, low certainty evidence). Certainty of evidence related to mifepristone-misoprostol regimens and safety and acceptability is very low. CONCLUSIONS: Misoprostol 400 µg every 4 hours, sublingually or vaginally, may be effective. We cannot draw conclusions about safety and acceptability, or about the added benefits of mifepristone.