Factors influencing the participation of pregnant and lactating women in clinical trials: A mixed-methods systematic review.

BACKGROUND: Poor representation of pregnant and lactating women and people in clinical trials has marginalised their health concerns and denied the maternal-fetal/infant dyad benefits of innovation in therapeutic research and development. This mixed-methods systematic review synthesised factors affecting the participation of pregnant and lactating women in clinical trials, across all levels of the research ecosystem. METHODS AND FINDINGS: We searched 8 databases from inception to 14 February 2024 to identify qualitative, quantitative, and mixed-methods studies that described factors affecting participation of pregnant and lactating women in vaccine and therapeutic clinical trials in any setting. We used thematic synthesis to analyse the qualitative literature and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. We compared quantitative data against the thematic synthesis findings to assess areas of convergence or divergence. We mapped review findings to the Theoretical Domains Framework (TDF) and Capability, Opportunity, and Motivation Model of Behaviour (COM-B) to inform future development of behaviour change strategies. We included 60 papers from 27 countries. We grouped 24 review findings under 5 overarching themes: (a) interplay between perceived risks and benefits of participation in women's decision-making; (b) engagement between women and the medical and research ecosystems; (c) gender norms and decision-making autonomy; (d) factors affecting clinical trial recruitment; and (e) upstream factors in the research ecosystem. Women's willingness to participate in trials was affected by: perceived risk of the health condition weighed against an intervention's risks and benefits, therapeutic optimism, intervention acceptability, expectations of receiving higher quality care in a trial, altruistic motivations, intimate relationship dynamics, and power and trust in medicine and research. Health workers supported women's participation in trials when they perceived clinical equipoise, had hope for novel therapeutic applications, and were convinced an intervention was safe. For research staff, developing reciprocal relationships with health workers, having access to resources for trial implementation, ensuring the trial was visible to potential participants and health workers, implementing a woman-centred approach when communicating with potential participants, and emotional orientations towards the trial were factors perceived to affect recruitment. For study investigators and ethics committees, the complexities and subjectivities in risk assessments and trial design, and limited funding of such trials contributed to their reluctance in leading and approving such trials. All included studies focused on factors affecting participation of cisgender pregnant women in clinical trials; future research should consider other pregnancy-capable populations, including transgender and nonbinary people. CONCLUSIONS: This systematic review highlights diverse factors across multiple levels and stakeholders affecting the participation of pregnant and lactating women in clinical trials. By linking identified factors to frameworks of behaviour change, we have developed theoretically informed strategies that can help optimise pregnant and lactating women's engagement, participation, and trust in such trials.

The prevalence of and factors associated with prior induced abortion among women who gave birth in Victoria, 2010-2019.

OBJECTIVE: To assess the prevalence of a history of induced abortion among women who gave birth in Victoria during 2010-2019; to assess the association of socio-demographic factors with a history of induced abortion. STUDY DESIGN: Retrospective cohort study; analysis of cross-sectional perinatal data in the Victorian Perinatal Data Collection (VPDC). SETTING, PARTICIPANTS: All women who gave birth (live or stillborn) in Victoria, 1 January 2010 - 31 December 2019. MAIN OUTCOME MEASURES: Self-reported induced abortions prior to the index birth; outcome of the most recent pregnancy preceding the index pregnancy. RESULTS: Of the 766 488 women who gave birth during 2010-2019, 93 251 reported induced abortions (12.2%), including 36 938 of 338 547 nulliparous women (10.9%). Women living in inner regional (adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.93-0.96) or outer regional/remote/very remote areas (aOR, 0.86; 95% CI, 0.83-0.89) were less likely than women in major cities to report induced abortions. The likelihood increased steadily with age at the index birth and with parity, and was also higher for women without partners at the index birth (aOR, 2.20; 95% CI, 2.16-2.25) and Aboriginal and Torres Strait Islander women (aOR, 1.32; 95% CI, 1.25-1.40). The likelihood was lower for women born in most areas outside Australia than for those born in Australia. The likelihood of a history of induced abortion declined across the study period overall (2019 v 2010: 0.93; 95% CI, 0.90-0.96) and for women in major cities (0.88; 95% CI, 0.84-0.91); rises in inner regional and outer regional/remote/very remote areas were not statistically significant. CONCLUSIONS: Access to abortion care in Victoria improved during 2010-2019, but the complex interplay between contraceptive use, unintended pregnancy, and induced abortion requires further exploration by remoteness of residence. Robust information about numbers of unintended pregnancies and access to reproductive health services are needed to guide national sexual and reproductive health policy and practice.

General practitioner experiences in delivering early medical abortion services to women from culturally and linguistically diverse backgrounds: A qualitative-descriptive study.

BACKGROUND AND OBJECTIVES: General practitioners (GPs) are ideally placed to deliver early medical abortion (EMA), yet little is known about how GPs deliver this care to women from culturally and linguistically diverse (CALD) backgrounds. We explored GP experiences in providing EMA to women from CALD backgrounds and their recommendations for service improvements. METHOD: This was a qualitative study involving telephone interviews with 18 Australian GPs who provide EMA to women from CALD backgrounds. Data were thematically analysed using the Capability, Opportunity and Motivation Behaviour model. RESULTS: GPs experienced challenges in communication and cultural competency when delivering EMA to women from CALD backgrounds due to insufficient training, lack of multilingual resources and difficulties accessing interpreters. In addition, the stigma surrounding abortion and concerns around reproductive coercion made engaging these women challenging. DISCUSSION: Upskilling GPs in culturally competent care, improving access to multilingual resources and enabling efficient interpreter use can optimise EMA delivery to women from CALD backgrounds.

The prevalence and variations in unintended pregnancy by socio-demographic and health-related factors in a population-based cohort of young Australian women.

OBJECTIVE: The aim of this study is to estimate the prevalence of unintended pregnancy and associated socio-demographic and health-related factors among a national cohort of young Australian women. METHODS: Secondary analysis of three waves (2013-2015) of the Australian Longitudinal Study on Women's Health new young cohort. Women born between 1989 and 1995 were recruited through internet and traditional media, and peer referral. Respondents completed a baseline web-based survey in 2013 (n=17,010) on their health and healthcare use and were followed up annually. This analysis uses data from women reporting ever having vaginal sex in waves 2 (n=9,726/11,344) and 3 (n=6,848/8,961). We assessed correlates of lifetime and recent unintended pregnancy using multivariable regression models. RESULTS: At wave 2, among women aged 19-24, lifetime prevalence of unintended pregnancy was 12.6%, rising to 81.0% among ever pregnant women. Pregnancy outcomes among women with a history of unintended pregnancy differed by geographical residence. Disparities in odds of unintended pregnancy were seen by relationship and educational status, contraceptive use, sexual coercion and risky alcohol use. CONCLUSIONS: Unintended pregnancy among young Australians is disproportionally experienced by women with structural disadvantages and exposure to sexual coercion. PUBLIC HEALTH IMPLICATIONS: Service improvements to achieve equitable distribution of contraception and abortion services must be integrated with initiatives responding to sexual coercion.

Improving rural and regional access to long-acting reversible contraception and medical abortion through nurse-led models of care, task-sharing and telehealth (ORIENT): a protocol for a stepped-wedge pragmatic cluster-randomised controlled trial in Australian general practice.

INTRODUCTION: Women living in rural and regional Australia often experience difficulties in accessing long-acting reversible contraception (LARC) and medical abortion services. Nurse-led models of care can improve access to these services but have not been evaluated in Australian general practice. The primary aim of the ORIENT trial (ImprOving Rural and regIonal accEss to long acting reversible contraceptioN and medical abortion through nurse-led models of care, Tasksharing and telehealth) is to assess the effectiveness of a nurse-led model of care in general practice at increasing uptake of LARC and improving access to medical abortion in rural and regional areas. METHODS AND ANALYSIS: ORIENT is a stepped-wedge pragmatic cluster-randomised controlled trial. We will enrol 32 general practices (clusters) in rural or regional Australia, that have at least two general practitioners, one practice nurse and one practice manager. The nurse-led model of care (the intervention) will be codesigned with key women's health stakeholders. Clusters will be randomised to implement the model sequentially, with the comparator being usual care. Clusters will receive implementation support through clinical upskilling, educational outreach and engagement in an online community of practice. The primary outcome is the change in the rate of LARC prescribing comparing control and intervention phases; secondary outcomes include change in the rate of medical abortion prescribing and provision of related telehealth services. A within-trial economic analysis will determine the relative costs and benefits of the model on the prescribing rates of LARC and medical abortion compared with usual care. A realist evaluation will provide contextual information regarding model implementation informing considerations for scale-up. Supporting nurses to work to their full scope of practice has the potential to increase LARC and medical abortion access in rural and regional Australia. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Monash University Human Research Ethics Committee (Project ID: 29476). Findings will be disseminated via multiple avenues including a knowledge exchange workshop, policy briefs, conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000086763).

Menstrual regulation: examining the incidence, methods, and sources of care of this understudied health practice in three settings using cross-sectional population-based surveys.

BACKGROUND: Menstrual regulation is a practice that may exist within the ambiguity surrounding one's pregnancy status and has been the subject of limited research. The aim of this study is to measure the annual rate of menstrual regulation in Nigeria, Cote d'Ivoire, and Rajasthan, India, overall and by background characteristics and to describe the methods and sources women use to bring back their period. METHODS: Data come from population-based surveys of women aged 15-49 in each setting. In addition to questions on women's background characteristics, reproductive history, and contraceptive experiences, interviewers asked women whether they had ever done something to bring back their period at a time when they were worried they were pregnant, and if so, when it occurred and what methods and source they used. A total of 11,106 reproductive-aged women completed the survey in Nigeria, 2,738 in Cote d'Ivoire, and 5,832 in Rajasthan. We calculated one-year incidence of menstrual regulation overall and by women's background characteristics separately for each context using adjusted Wald tests to assess significant. We then examined the distribution of menstrual regulation methods and sources using univariate analyses. Method categories included surgery, medication abortion pills, other pills (including unknown pills), and traditional or "other" methods. Source categories included public facilities or public mobile outreach, private or non-governmental facilities or doctors, pharmacy or chemist shops, and traditional or "other" sources. RESULTS: Results indicate substantial levels of menstrual regulation in West Africa with a one-year incidence rate of 22.6 per 1,000 women age 15-49 in Nigeria and 20.6 per 1,000 in Cote d'Ivoire; women in Rajasthan reported only 3.3 per 1,000. Menstrual regulations primarily involved traditional or "other" methods in Nigeria (47.8%), Cote d'Ivoire (70.0%), and Rajasthan (37.6%) and traditional or "other" sources (49.4%, 77.2%, and 40.1%, respectively). CONCLUSION: These findings suggest menstrual regulation is not uncommon in these settings and may put women's health at risk given the reported methods and sources used. Results have implications for abortion research and our understanding of how women manage their fertility.

Menstrual regulation, or bringing back a late period, is an understudied practice that women may use when they are worried they are pregnant but that may be viewed as distinct from abortion. This study seeks to measure the frequency of menstrual regulation in Nigeria, Cote d'Ivoire, and Rajasthan, India, overall and by women's characteristics and to describe the methods and sources women use. We used data from representative surveys of women aged 15­49 years old in each study setting. We asked women whether they had ever done something to bring back a late period at a time when they were worried they were pregnant, and if so, what methods and sources they used. Results indicate that menstrual regulation may be a common practice, particularly in West Africa; the observed one-year rates were 22.6 menstrual regulations per 1,000 women aged 15­49 in Nigeria and 20.6 menstrual regulations per 1000 women in Cote d'Ivoire; women in Rajasthan only reported 3.3 menstrual regulations per 1000 women per year. Menstrual regulations primarily involved traditional or "other" methods in Nigeria (47.8%), Cote d'Ivoire (70.0%), and Rajasthan (37.6%) and traditional or "other" sources (49.4%, 77.2%, and 40.1%, respectively). These findings suggest menstrual regulation is not uncommon and may put women's health at risk given the reported methods and sources used. Results have implications for abortion research and our understanding of how women manage their fertility.

Postabortion care availability, facility readiness and accessibility in Nigeria and Côte d'Ivoire.

Postabortion care (PAC) is an essential component of emergency obstetric care (EmOC) and is necessary to prevent unsafe abortion-related maternal mortality, but we know little regarding the preparedness of facilities to provide PAC services, the distribution of these services and disparities in their accessibility in low-resource settings. To address this knowledge gap, this study aims to describe PAC service availability, evaluate PAC readiness and measure inequities in access to PAC services in seven states of Nigeria and nationally in Côte d'Ivoire. We used survey data from reproductive-age women and the health facilities that serve the areas where they live. We linked facility readiness information, including PAC-specific signal functions, to female data using geospatial information. Findings revealed less than half of facilities provide basic PAC services in Nigeria (48.4%) but greater PAC availability in Côte d'Ivoire (70.5%). Only 33.5% and 36.9% of facilities with the capacity to provide basic PAC and only 23.9% and 37.5% of facilities with the capacity to provide comprehensive PAC had all the corresponding signal functions in Nigeria and Côte d'Ivoire, respectively. With regard to access, while ∼8 out of 10 women of reproductive age in Nigeria (81.3%) and Côte d'Ivoire (79.9%) lived within 10 km of a facility providing any PAC services, significantly lower levels of the population lived <10 km from a facility with all basic or comprehensive PAC signal functions, and we observed significant inequities in access for poor, rural and less educated women. Addressing facilities' service readiness will improve the quality of PAC provided and ensure postabortion complications can be treated in a timely and effective manner, while expanding the availability of services to additional primary-level facilities would increase access-both of which could help to reduce avoidable abortion-related maternal morbidity and mortality and associated inequities.

Abortion regulation in Europe in the era of COVID-19: a spectrum of policy responses.

BACKGROUND: Unprecedented public health actions restricting movement and non-COVID related health services are likely to have affected abortion care during the pandemic in Europe. In the absence of a common approach to ensure access to this essential health service, we sought to describe the variability of abortion policies during the outbreak in Europe in order to identify strategies that improve availability and access to abortion in times of public health crises. METHODS: We collected information from 46 countries/regions: 31 for which country-experts completed a survey and 15 for which we conducted a desk review. We describe abortion regulations and changes to regulations and practice during the pandemic. RESULTS: During COVID-19, abortions were banned in six countries and suspended in one. Surgical abortion was less available due to COVID-19 in 12 countries/regions and services were not available or delayed for women with COVID-19 symptoms in eleven. No country expanded its gestational limit for abortion. Changes during COVID-19, mostly designed to reduce in-person consultations, occurred in 13 countries/regions. Altogether eight countries/regions provided home medical abortion with mifepristone and misoprostol beyond 9 weeks (from 9 weeks+6 days to 11 weeks+6 days) and 13 countries/regions up to 9 weeks (in some instances only misoprostol could be taken at home). Only six countries/regions offered abortion by telemedicine. CONCLUSIONS: The lack of a unified policy response to COVID-19 restrictions has widened inequities in abortion access in Europe, but some innovations including telemedicine deployed during the outbreak could serve as a catalyst to ensure continuity and equity of abortion care.

Induced Abortion Incidence and Safety in Rajasthan, India: Evidence that Expansion of Services is Needed.

Despite induced abortion being broadly legal in India, up-to-date information on its frequency and safety is not readily available. Using direct and indirect methodological approaches, this study measures the one-year incidence and safety of induced abortions among women in the state of Rajasthan. The analysis utilizes data from a population-based survey of 5,832 reproductive aged women who reported on the abortion experiences of their closest female confidante in addition to themselves. We separately assess correlates of having a recent and most unsafe abortion using multivariable regression models. The confidante approach produced a one-year abortion incidence estimate of 23 per 1,000 women, whereas the respondent estimate is 9.5 per 1,000 women. Based on the confidante estimate, approximately 441,000 abortions occurred in Rajasthan over a year. Overall, 25 and 29 percent of respondent and confidante reported abortions were classified as most unsafe. Results suggest that abortion remains an integral component of women's fertility regulation, and that a liberal law alone is insufficient to guarantee access to safe abortion services. Existing policies on abortion in India need updating to permit task sharing in line with current recommendations to expand service delivery so that demand is met through provision of safe and accessible services.

Social network-based measurement of abortion incidence: promising findings from population-based surveys in Nigeria, Cote d'Ivoire, and Rajasthan, India.

BACKGROUND: Monitoring abortion rates is highly relevant for demographic and public health considerations, yet its reliable estimation is fraught with uncertainty due to lack of complete national health facility service statistics and bias in self-reported survey data. In this study, we aim to test the confidante methodology for estimating abortion incidence rates in Nigeria, Cote d'Ivoire, and Rajasthan, India, and develop methods to adjust for violations of assumptions. METHODS: In population-based surveys in each setting, female respondents of reproductive age reported separately on their two closest confidantes' experience with abortion, in addition to reporting about their own experiences. We used descriptive analyses and design-based F tests to test for violations of method assumptions. Using post hoc analytical techniques, we corrected for biases in the confidante sample to improve the validity and precision of the abortion incidence estimates produced from these data. RESULTS: Results indicate incomplete transmission of confidante abortion knowledge, a biased confidante sample, but reduced social desirability bias when reporting on confidantes' abortion incidences once adjust for assumption violations. The extent to which the assumptions were met differed across the three contexts. The respondent 1-year pregnancy removal rate was 18.7 (95% confidence interval (CI) 14.9-22.5) abortions per 1000 women of reproductive age in Nigeria, 18.8 (95% CI 11.8-25.8) in Cote d'Ivoire, and 7.0 (95% CI 4.6-9.5) in India. The 1-year adjusted abortion incidence rates for the first confidantes were 35.1 (95% CI 31.1-39.1) in Nigeria, 31.5 (95% CI 24.8-38.1) in Cote d'Ivoire, and 15.2 (95% CI 6.1-24.4) in Rajasthan, India. Confidante two's rates were closer to confidante one incidences than respondent incidences. The adjusted confidante one and two incidence estimates were significantly higher than respondent incidences in all three countries. CONCLUSIONS: Findings suggest that the confidante approach may present an opportunity to address some abortion-related data deficiencies but require modeling approaches to correct for biases due to violations of social network-based method assumptions. The performance of these methodologies varied based on geographical and social context, indicating that performance may be better in settings where abortion is legally and socially restricted.

Inequities in the incidence and safety of abortion in Nigeria.

Background: We know little about the frequency, correlates and conditions under which women induce abortions in Nigeria. This study seeks to estimate the 1-year induced abortion incidence and proportion of abortions that are unsafe overall and by women's background characteristics using direct and indirect methodologies. Methods: Data for this study come from a population-based, nationally representative survey of reproductive age women (15-49) in Nigeria. Interviewers asked women to report on the abortion experiences of their closest female confidante and themselves. We adjusted for potential biases in the confidante data. Analyses include estimation of 1-year induced abortion incidence and unsafe abortion, as well as bivariate and multivariate assessment of their correlates. Results: A total of 11 106 women of reproductive age completed the female survey; they reported on 5772 confidantes. The 1-year abortion incidence for respondents was 29.0 (95% CI 23.3 to 34.8) per 1000 women aged 15-49 while the confidante incidence was 45.8 (95% CI 41.0-50.6). The respondent and confidante abortion incidences revealed similar correlates, with women in their 20s, women with secondary or higher education and women in urban areas being the most likely to have had an abortion in the prior year. The majority of respondent and confidante abortions were the most unsafe (63.4% and 68.6%, respectively). Women aged 15-19, women who had never attended school and the poorest women were significantly more likely to have had the most unsafe abortions. Conclusion: Results indicate that abortion in Nigeria is a public health concern and an issue of social inequity. Efforts to expand the legal conditions for abortion in Nigeria are critical. Simultaneously, efforts to increase awareness of the availability of medication abortion drugs to more safely self-induce can help mitigate the toll of unsafe abortion-related morbidity and mortality.

Measurement of abortion safety using community-based surveys: Findings from three countries.

This study aimed to measure abortion safety in Nigeria, Cote d'Ivoire, and Rajasthan, India using population-based abortion data from representative samples of reproductive age women. Interviewers asked women separately about their experience with "pregnancy removal" and "period regulation at a time when you were worried you were pregnant", and collected details on method(s) and source(s) of abortion. We operationalized safety along two dimensions: 1) whether the method(s) used were non-recommended and put the woman at potentially high risk of abortion related morbidity and mortality (i.e. methods other than surgery and medication abortion drugs); and 2) whether the source(s) used involved a non-clinical (or no) provider(s). We combined source and method information to categorize a woman's abortion into one of four safety categories. In Nigeria (n = 1,800), 29.1% of abortions involved a recommended method and clinical provider, 5.4% involved a recommended method and non-clinical provider, 2.1% involved a non-recommended method and clinical provider, and 63.4% involved a non-recommended method and non-clinical provider. The corresponding estimates were 32.7%, 3.0%, 1.9%, and 62.4% in Cote d'Ivoire (n = 645) and 39.7%, 25.5%, 3.4%, and 31.4% in Rajasthan (n = 454). Results demonstrate that abortion safety, as measured by abortion related process data, is generally low but varies significantly by legal context. The policy and programmatic strategies employed to improve abortion safety and quality of care are likely to differ for women in different abortion safety categories.

Measuring unmet need for contraception as a point prevalence.

BACKGROUND: This study proposes a framework to address conceptual concerns with the standard indicator of unmet need for contraception. We define new point prevalence measures of current status (CS) unmet need and CS unmet demand, by linking contraceptive behaviours to pregnancy exposure and to women's future contraceptive intentions. We explore the difference between standard and CS unmet need and estimate the proportion of women with CS unmet demand, who may be more likely to adopt contraception. METHODS: We use Demographic and Health Survey data from 46 low-income and middle-income countries released between 2010 and 2018. We assess differences in women's classification between standard and CS unmet need indicators and estimate the percentage of women with CS unmet demand for contraception, defined as the percentage of women with CS unmet need who intend to use contraception in the future. FINDINGS: We find substantial country-level differences between standard and CS estimates of unmet need, ranging from -8.3% points in Niger to +11.1% points in Nepal. The average predictive value of the standard measure across the 46 countries for identifying prevalent cases of unmet need is 53%. Regardless of indicator (standard or CS), only half of women with unmet need intend to use contraception. INTERPRETATION: The results of this study suggest that the standard measure of unmet need has low predictive value in identifying women with current unmet need. Thus, the standard indicator does not reflect a prevalence estimate of unmet need.

Access, equity and costs of induced abortion services in Australia: a cross-sectional study.

OBJECTIVES: To examine access and equity to induced abortion services in Australia, including factors associated with presenting beyond nine weeks gestation. METHODS: Cross-sectional survey of 2,326 women aged 16+ years attending for an abortion at 14 Dr Marie clinics. Associations with later presentation assessed using multivariate logistic regression. RESULTS: Over a third of eligible women opted for a medical abortion. More than one in 10 (11.2%) stayed overnight. The median Medicare rebated upfront cost of a medical abortion was $560, compared to $470 for a surgical abortion at ≤9 weeks. Beyond 12 weeks, costs rose considerably. More than two-thirds (68.1%) received financial assistance from one or more sources. Women who travelled ≥4 hours (AdjOR: 3.0, 95%CI 1.2-7.3), had no prior knowledge of the medical option (AdjOR: 2.1, 95%CI 1.4-3.1), had difficulty paying (AdjOR: 1.5, 95%CI 1.2-1.9) and identified as Aboriginal and/or Torres Strait Islander (AdjOR: 2.1, 95%CI 1.2-3.4) were more likely to present ≥9 weeks. CONCLUSIONS: Abortion costs are substantial, increase at later gestations, and are a financial strain for many women. Poor knowledge, geographical and financial barriers restrict method choice. Implications for public health: Policy reform should focus on reducing costs and enhancing early access.

Advancing sexual and reproductive health and rights in low- and middle-income countries: implications for the post-2015 global development agenda.

The papers and commentaries in this special issue illuminate progress made by low- and middle-income countries towards implementation of the Programme of Action (PoA) agreed by 179 countries during the International Conference on Population and Development in Cairo in 1994. The PoA presents a path-breaking sexual and reproductive health and rights (SRHR) framework for global and national population and health policies. While progress towards implementation has been made at global, regional and national levels, continuing and new challenges require that high priority be given to SRHR for all, particularly women and girls, during the remaining months of the millennium development goals and in the United Nations post-2015 development agenda. This paper highlights three critical gaps, raised in other papers: inequalities in access to sexual and reproductive health (SRH) information and services; the widespread need to improve SRH services to meet public health, human rights and medical ethics standards for quality of care; and the absence or inadequate use of accountability mechanisms to track and remedy the other two. We discuss priority actions to achieve equality, quality and accountability in SRHR policies, programmes and services, especially those that should be included in the post-2015 development agenda.

Acceptability and use of emergency contraception among married women in Bangalore, India.

OBJECTIVE: To assess knowledge, acceptability, and use of emergency contraceptive pills (ECs) among lower-income married women in Bangalore, India. METHODS: EC counseling and supplies were offered to 322 women aged 18-25 years participating in a longitudinal reproductive health study. Participants completed interviews at enrollment and were followed for 1 year. EC acceptability and use were assessed, and factors associated with use were identified. RESULTS: 206/320 (64.4%) participants did not desire pregnancy but only 46/321 (14.3%) used an intrauterine device or contraceptive pills. Only 25 (7.8%) had heard of ECs. Overall, 123 (38.2%) participants requested advance provisions of ECs after counseling. Over a year, 37/263 (14.1%) women used ECs, usually within 3 days of unprotected sex (33 [89.2%]), and 32 (86.5%) took both pills together or 1 day apart. Thirty-six (97.3%) felt glad and 31 (83.8%) were relieved after taking ECs. Twenty-five (67.6%) women who used ECs sought permission from their husbands. The only factor associated with EC use was couples' pregnancy intentions (odds ratio 4.71; 95% confidence interval, 1.43-15.58; P≤0.01). CONCLUSION: Indian women with access to ECs generally used them correctly and found them acceptable. Efforts to expand EC knowledge and access should be coupled with efforts to promote gender equality in the reproductive sphere.