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1.
Am J Obstet Gynecol MFM ; 3(1): 100283, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33451604

RESUMO

OBJECTIVE: This study aimed to determine the optimal cervical priming regimen before surgical abortion between 14+0 and 24+0 weeks' gestation. DATA SOURCES: Embase, MEDLINE, and the Cochrane Library were searched for publications up to February 2020. Experts were consulted for any ongoing or missed trials. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials, published in English after 1985, that compared (1) mifepristone, misoprostol, and osmotic dilators against each other, alone or in combination; (2) different doses of mifepristone and misoprostol; (3) different intervals between priming and abortion; or (4) different routes of administration of misoprostol were included. METHODS: Risk of bias was assessed using the Cochrane Collaboration checklist for randomized controlled trials, and data were meta-analyzed in Review Manager 5.3. Dichotomous outcomes were analyzed as risk ratios using the Mantel-Haenszel method, and continuous outcomes were analyzed as mean differences using the inverse variance method. Fixed effects models were used when there was no significant heterogeneity (I2<50%), random effects models were used for moderate heterogeneity (I2≤50% and <80%), and evidence was not pooled when there was high heterogeneity (I2≥80%). Subgroup analyses were undertaken based on parity where available. The overall quality of the evidence was assessed using Grades of Recommendation Assessment, Development, and Evaluation. RESULTS: A total of 15 randomized controlled trials (N=2454) were included and showed decreased difficulty of procedure and/or increased cervical dilation and decreased patient acceptability with regimens that included dilators compared with those that did not include dilators; increased preoperative expulsion of the pregnancy with sublingual misoprostol and mifepristone compared with sublingual misoprostol alone; increased difficulty of procedure with dilators and misoprostol compared with dilators and mifepristone; decreased difficulty of procedure with dilators and mifepristone compared with dilators alone; and increased cervical dilation when dilators were placed the day before abortion compared with the same day. CONCLUSION: Considered alongside clinical expertise, the published data support the use of osmotic dilators, misoprostol, or mifepristone before abortion for pregnancies at 14+0 to 16+0 weeks' gestation; osmotic dilators or misoprostol for pregnancies at 16+1 to 19+0 weeks' gestation; and osmotic dilators alone or with mifepristone for pregnancies at 19+1 to 24+0 weeks' gestation. The effectiveness of pharmacologic agents alone beyond 16+0 weeks' gestation and the optimal timing of dilator placement remain important questions for future research.

2.
BMC Med Educ ; 21(1): 4, 2021 Jan 04.
Artigo em Inglês | MEDLINE | ID: mdl-33397357

RESUMO

BACKGROUND: One in three women in the United Kingdom (UK) will have an abortion before age 45, making abortion provision an essential aspect of reproductive healthcare. Despite this, abortion remains ethically contested and stigmatised, with variable teaching in UK medical schools and concerns about falling numbers of doctors willing to participate in abortion care. University College London Medical School (UCLMS) has designed practical, inclusive, teaching that aims to give students an understanding of the importance of abortion care and prepare them to be competent practitioners in this area. This study aimed to determine students' opinions of this teaching and their wider attitudes towards abortion. METHODS: We invited all 357 final-year UCL medical students to complete an online survey consisting of closed-ended questions, exploring their opinions on their abortion teaching, their personal beliefs about abortion and their future willingness to be involved in abortion care. We analysed responses using non-parametric tests. RESULTS: One hundred and forty-six questionnaires (41% response rate) showed 83% of students identified as pro-choice (agree with the right to choose an abortion). Fifty-seven percent felt they received the right amount of abortion teaching, 39% would have liked more and 4% stated they received too much. There was no correlation between students' attitudes to abortion and the rating of teaching; both pro-choice and pro-life (opposed to the right to choose an abortion) students generally rated the teaching as important and valued the range of methods used. Students requested more simulated practice speaking to patients requesting an abortion. Students with pro-life beliefs expressed lower willingness to discuss, refer, certify and provide future abortions. Students interested in careers in specialties where they may encounter abortion were more likely to be pro-choice than pro-life. CONCLUSIONS: The majority of participating UCL medical students were pro-choice and willing to be involved in future abortion care. Efforts to make teaching on abortion practical, engaging, sensitive and inclusive were appreciated. As well as preparing students to be competent and caring practitioners, the teaching appears to contribute towards them viewing abortion as an essential aspect of women's healthcare, and may contribute to destigmatising abortion.

3.
Artigo em Inglês | MEDLINE | ID: mdl-33063314

RESUMO

INTRODUCTION: The safety and acceptability of medical abortion using mifepristone and misoprostol at home at ≤9+0  weeks' gestation is well established. However, the upper gestational limit at which the procedure remains safe and acceptable at home is not known. To inform a national guideline on abortion care we conducted a systematic review to determine what gestational limit for expulsion at home offers the best balance of benefits and harms for women who are having medical abortion. MATERIAL AND METHODS: We searched Embase, MEDLINE, Cochrane Library, Cinahl Plus and Web-of-Science on 2 January 2020 for prospective and retrospective cohort studies with ≥50 women per gestational age group, published in English from 1995 onwards, that included women undergoing medical abortion and compared home expulsion of pregnancies of ≤9+0  weeks' gestational age with pregnancies of 9+1 -10+0  weeks or >10+1  weeks' gestational age, or compared the latter two gestational age groups. We assessed risk-of-bias using the Newcastle-Ottowa scale. All outcomes were meta-analyzed as risk ratios (RR) using the Mantel-Haenszel method. The certainty of the evidence was assessed using GRADE. RESULTS: Six studies (n = 3381) were included. The "need for emergency care/admission to hospital" (RR = 0.79, 95% confidence interval [CI] 0.45-1.4), "hemorrhage requiring transfusion/≥500 mL blood loss" (RR = 0.62, 95% CI 0.11-3.55), patient satisfaction (RR = 0.99, 95% CI 0.95-1.03), pain (RR = 0.91, 95% CI 0.82-1.02), and "complete abortion without the need for surgical intervention" (RR = 1.03, 95% CI 1-1.05) did not differ statistically significantly between the ≤9+0 and >9+0  weeks' gestation groups. The rates of vomiting (RR = 0.8, 95% CI 0.69-0.93) and diarrhea (RR = 0.85, 95% CI 0.73-0.99) were statistically significantly lower in the ≤9+0  weeks group but these differences were not considered clinically important. We found no studies comparing pregnancies of 9+1 -10+0  weeks' gestation with pregnancies of >10+0  weeks' gestation. The certainty of this evidence was predominantly low and mainly compromised by low event rates and loss to follow up. CONCLUSIONS: Women who are having a medical abortion and will be taking mifepristone up to and including 10+0  weeks' gestation should be offered the option of expulsion at home after they have taken the misoprostol. Further research needs to determine whether the gestational limit for home expulsion can be extended beyond 10+0  weeks.

5.
Artigo em Inglês | MEDLINE | ID: mdl-32184291

RESUMO

BACKGROUND: Abortion in the second trimester may be performed surgically or medically. The objective of this systematic review was to examine the effectiveness, safety and acceptability/satisfaction of surgical compared with medical abortion of pregnancy between 13+0 and 23+6 weeks' gestation for a new national guideline. METHODS: We searched Embase, Medline and the Cochrane Library on 4 March 2019. We included randomised controlled trials (RCTs; any size) and non-randomised comparative studies with n≥100 in each arm, published in English from 1985. Risk-of-bias was assessed using the Cochrane Collaboration checklist for RCTs. Meta-analysis of risk ratios (RRs)used the Mantel-Haenszel method. The quality of the evidence was assessed using GRADE. RESULTS: Two RCTs (n=140) were included. 'Incomplete abortion requiring surgical intervention' was clinically significantly higher with medical than surgical methods (RR=4.58, 95% CI 1.07 to 19.64). 'Abortion completed by the intended method' was statistically, but not clinically, significantly lower after medical than surgical methods, but was marked by high between-study heterogeneity (RR=0.88, 95% CI 0.79 to 0.98). To the extent that 'haemorrhage requiring transfusion/≥500 mL blood loss', 'uterine injury', 'cervical injury requiring repair' and 'infection reported within 1 month of abortion' were reported, they did not differ significantly between methods. Depending on measurement method, 'patient satisfaction/acceptability' was either clinically significantly higher or comparable after surgical than medical methods. The quality of this evidence was limited by low event rates and attrition bias. CONCLUSION: Based on this evidence and consensus, women should be offered the choice of medical or surgical methods of abortion between 13+0 and 23+6 weeks' gestation, unless not clinically appropriate.

6.
Hum Reprod Update ; 26(2): 141-160, 2020 02 28.
Artigo em Inglês | MEDLINE | ID: mdl-32096862

RESUMO

BACKGROUND: Long-acting reversible contraceptives (LARCs) are safe, effective and convenient post-abortal methods. However, there is concern that some LARCs may reduce the effectiveness of abortifacient drugs or result in other adverse outcomes. OBJECTIVE AND RATIONALE: We undertook two systematic reviews to examine the early administration of LARCs in women undergoing medical abortion with mifepristone and misoprostol. (i) For women who are having a medical abortion and who plan to use a progestogen-only contraceptive implant or injectable, does administration of the contraception at the same time as mifepristone influence the efficacy of the abortion? (Implant/injectable review). (ii) For women who have had a medical abortion, how soon after expulsion of the products of conception is it safe to insert an intrauterine contraceptive device/system? (LNG-IUS/Cu-IUD review). SEARCH METHODS: On 19 November 2018, we searched Embase Classic, Embase; Ovid MEDLINE(R) including Daily and Epub Ahead-of-Print, In-Process and Other Non-Indexed Citations; the Cochrane Library; Cinahl Plus; and Web of Science Core Collection. Eligible studies were randomised controlled trials (RCTs), in English from 1985 (Implant/injectable review) or 2007 (LNG-IUS/Cu-IUD review) onwards, conducted in women undergoing medical abortion with mifepristone and misoprostol and studying either (i) simultaneous administration of mifepristone and a progestogen-only contraceptive implant or injectable compared to administration >24 h after mifepristone, or (ii) immediate insertion of intrauterine contraception after expulsion of the products of conception compared to early insertion (≤7 days) or to delayed insertion (>7 days) or early compared to delayed insertion. One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for RCTs. All the outcomes were analysed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel-Haenszel statistical method and a fixed-effect model. The overall quality of the evidence was assessed using GRADE. OUTCOMES: Two RCTs (n = 1027) showed lower 'subsequent unintended pregnancy' rates and higher 'patient satisfaction' rates, and no other differences, after simultaneous administration of mifepristone and the implant compared to delayed administration. One RCT (n = 461) showed higher 'patient satisfaction' rates after simultaneous administration than after delayed administration of mifepristone and the injectable, but no other differences between these interventions. Three RCTs (n = 536) found no differences other than higher copper IUC uptake after early compared to delayed insertion at ≤9 weeks of gestation and higher rates of IUC expulsion, continuation and uptake after immediate compared to delayed insertion at 9+1-12+0 weeks of gestation and higher IUC continuation rates after immediate compared to delayed insertion at 12+1-20+0 weeks of gestation. The quality of this evidence ranged from very low to high and was mainly compromised by low event rates, high attrition and no blinding. WIDER IMPLICATIONS: The contraceptive implant or injectable should be offered on the day of taking mifepristone. Intrauterine methods of contraception should be offered as soon as possible after expulsion of the pregnancy.


Assuntos
Aborto Induzido , Contracepção Reversível de Longo Prazo , Cuidados Pós-Operatórios/métodos , Aborto Induzido/métodos , Aborto Induzido/estatística & dados numéricos , Feminino , Humanos , Dispositivos Intrauterinos/efeitos adversos , Dispositivos Intrauterinos/estatística & dados numéricos , Contracepção Reversível de Longo Prazo/efeitos adversos , Contracepção Reversível de Longo Prazo/métodos , Contracepção Reversível de Longo Prazo/estatística & dados numéricos , Mifepristona/uso terapêutico , Cuidados Pós-Operatórios/efeitos adversos , Cuidados Pós-Operatórios/estatística & dados numéricos , Gravidez , Gravidez não Planejada , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Fatores de Tempo , Resultado do Tratamento
7.
Artigo em Inglês | MEDLINE | ID: mdl-32029379

RESUMO

Abortion care is a fundamental part of women's reproductive health care. Surgical and medical abortion methods are safe and effective throughout the gestational age range wherein abortions are performed. Although risks increase with the gestational age of the pregnancy being terminated, rates of complications remain low and comparable between surgical and medical techniques. A high-quality abortion service should offer women a choice between abortion methods and provide the one they prefer.


Assuntos
Aborto Induzido/métodos , Aborto Induzido/tendências , Feminino , Idade Gestacional , Humanos , Gravidez , Saúde da Mulher
8.
Am J Obstet Gynecol ; 222(6): 551-563.e13, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31715147

RESUMO

OBJECTIVE: To compare the effectiveness, safety, and acceptability of in-clinic and remote/self-assessment, as well as different remote/self-assessments, for confirming the success of medical abortion at ≤10+0 weeks' gestation. DATA SOURCES: Ovid Embase Classic and Embase; Ovid MEDLINE(R) and Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations and Daily; and the Cochrane Library. We also consulted experts in this field for any ongoing or missed trials. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials published in English from 2000 onward, comparing in-clinic assessment with ultrasound to remote or self-assessment or comparing different remote or self-assessment strategies to confirm the success of medical abortion of pregnancies up to and including 10+0 weeks gestation, reporting any of the following outcomes: "missed ongoing pregnancy," "correct implementation of the follow-up strategy," patient satisfaction/preference, "adherence to follow-up strategy," "unscheduled visits/telephone calls to the abortion service," and surgical intervention. STUDY APPRAISAL AND SYNTHESIS METHODS: One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for randomized controlled trials. All outcomes were analyzed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel-Haenszel statistical method and a fixed effect model. The overall quality of the evidence was assessed using GRADE. RESULTS: Four randomized controlled trials (n = 5761) compared in-clinic to remote self-assessment and found no clinically significant differences apart from higher preference rates for remote follow-up, especially in the remote follow-up groups. The quality of this evidence was compromised by attrition, no blinding, inconsistency, indirectness, and low event rates. Two randomized controlled trials (n = 1125) compared different remote assessment strategies (using urine pregnancy tests) and also found no clinically significant differences apart from a clinically significantly lower rate of unscheduled visits to the abortion service in the remote follow-up group using a multilevel urine pregnancy test compared to remote follow-up using a high-sensitivity urine pregnancy test. The quality of this evidence was compromised by small event rates, lack of blinding, indirectness and high attrition rates. CONCLUSION: The published data support offering women who have had a medical abortion up to and including 10+0 weeks' gestation the choice of self-assessment, remote assessment, or clinic follow-up.


Assuntos
Abortivos/uso terapêutico , Aborto Induzido/métodos , Autoavaliação Diagnóstica , Cooperação do Paciente , Satisfação do Paciente , Testes de Gravidez/métodos , Assistência Ambulatorial , Feminino , Humanos , Mifepristona/uso terapêutico , Misoprostol/uso terapêutico , Preferência do Paciente , Gravidez , Primeiro Trimestre da Gravidez , Inquéritos e Questionários , Telefone , Envio de Mensagens de Texto , Resultado do Tratamento , Ultrassonografia
9.
Contraception ; 100(3): 178-181, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31102629

RESUMO

OBJECTIVE: To evaluate outcomes with mifepristone 200 mg orally followed 24-48 h later by misoprostol 800 mcg vaginally for medical abortion at 64-70 days of gestation. STUDY DESIGN: We reviewed electronic databases and medical records for medical abortion cases at 64-70 days' gestation at British Pregnancy Advisory Service clinics in England and Wales from May 2015 through October 2016. Women selected in-office follow-up or self-evaluation of abortion outcome using a checklist along with low-sensitivity urine pregnancy testing. We excluded cases in which we could not locate records and when women did not proceed with medical abortion, did not use misoprostol following mifepristone if abortion had not occurred and did not attend a scheduled follow-up assessment. We analyzed demographic characteristics, treatment outcomes and significant adverse events. We defined treatment success as complete abortion without surgical evacuation and without continuing pregnancy. RESULTS: Of 2743 cases identified, we could not locate 40 charts and excluded 30 cases, leaving a final sample of 2673. Overall, 2538 (94.9%, 95% CI 94.1-95.8) women had a successful medical abortion. Reasons for failure included continuing pregnancy (n=90, 3.4%, 95% CI 2.7-4.1), retained nonviable pregnancy (n=2, 0.1%, 95% CI 0-0.2) and incomplete abortion (n=43, 1.6%, 95% CI 1.1-2.1). Of those with continuing pregnancies, 81 underwent a uterine aspiration and 9 opted to continue the pregnancy. Thirty-five (1.3%, 95% CI 0.9-1.7) women had significant adverse events; 16 (0.6%, 95% CI 0.3-0.9) underwent an in-hospital aspiration. Pelvic infection (n=4, 0.2%) and transfusion (n=1, 0.03%) occurred rarely. CONCLUSION: Medical abortion from 64 to 70 days with mifepristone and vaginal misoprostol is effective with a low rate of serious adverse events. IMPLICATIONS: Medical abortion between 64 and 70 days of gestation may be offered on an outpatient basis using mifepristone and vaginal misoprostol. Service provision without an in-person follow-up is feasible. Not all women with a continuing pregnancy after medical abortion treatment opt to have an aspiration procedure.


Assuntos
Abortivos/administração & dosagem , Aborto Incompleto/epidemiologia , Aborto Induzido/métodos , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Abortivos/efeitos adversos , Administração Intravaginal , Administração Oral , Adolescente , Adulto , Quimioterapia Combinada , Feminino , Humanos , Pessoa de Meia-Idade , Mifepristona/efeitos adversos , Misoprostol/efeitos adversos , Satisfação do Paciente , Gravidez , Primeiro Trimestre da Gravidez , Resultado do Tratamento , Reino Unido , Adulto Jovem
10.
J Obstet Gynaecol ; 39(6): 799-804, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30999795

RESUMO

Most hospitals in Great Britain only offer a medical termination of pregnancy for a fetal anomaly (TOPFA) in the second trimester. We describe the safety and acceptability of a surgical TOPFA service delivered by an independent-sector abortion provider. Non-identifiable data for women undergoing TOPFA at British Pregnancy Advisory Service from 1 January 2015 to 31 March 2016 was extracted from existing databases. Anonymous feedback was obtained using a questionnaire. Women (n = 389) were treated along a specialised care pathway within routine abortion lists. The anomalies were chromosomal (64.0%), structural (30.8%), suspected chromosomal and/or structural or unknown (5.1%). The termination method was vacuum aspiration (41.9%) or dilation and evacuation (58.1%). No complications were reported. Feedback (173 women, 122 partners) indicated care was sensitive (99.6%), supportive (100.0%), knowledgeable (99.2%), and helpful (100.0%). Most (92.1%) reported the right amount of partner involvement. All of the respondents were likely/very likely to recommend the service. A cross-sector approach safely and satisfactorily increases the choice of TOPFA methods. Impact Statement What is already known on this subject? A surgical abortion in the first and second trimesters has been demonstrated to be safe and acceptable, if not preferable, to a medical induction for most women, including those seeking a termination of pregnancy for a foetal anomaly (TOPFA). However, most hospitals in Britain only offer a medical TOPFA in the second trimester, often due to a lack of skills to provide a surgical alternative. The lack of choice of method has a negative impact on women's experiences of TOPFA care. Independent sector abortion clinics provide the majority of surgical abortions in the second trimester in Britain, and are therefore a potential site of surgical TOPFA care. What do the results of this study add? Women and NHS service providers can be reassured that when a dedicated care pathway for TOPFA is employed in the context of routine abortion provision in the independent sector, the choice of termination method can be safely and satisfactorily increased. What are the implications of these findings for clinical practice and/or further research? The main implication is the raising of awareness among NHS providers of the availability and acceptability of this model of TOFPA service delivery, so it can become an option for more women who do not want to have a medical induction. We hope that the demonstration of some women's preferences for surgical TOPFA and the safety of this option will lead to development of this service within routine abortion lists within hospital settings. Further research could include determining the reasons why women and their partners may ultimately not choose to pursue a surgical TOPFA within the independent sector abortion service and an in-depth exploration of women's experiences of being treated within this setting.


Assuntos
Aborto Induzido/métodos , Aberrações Cromossômicas/embriologia , Anormalidades Congênitas/embriologia , Serviços de Saúde Reprodutiva , Adolescente , Adulto , Feminino , Humanos , Obstetrícia , Satisfação do Paciente , Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , Inquéritos e Questionários , Reino Unido , Adulto Jovem
11.
BMJ Sex Reprod Health ; 44(2): 114-121, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29921634

RESUMO

BACKGROUND: Incorporating thorough contraception counselling into an abortion consultation is challenging. We compared contraceptive choices and methods received between two counselling models: (1) telephone counselling separate from the abortion consultation and (2) face-to-face counselling integrated into the consultation. METHODS: We obtained de-identified data on demographic characteristics and contraceptive methods that had been chosen and received by women who had an abortion at British Pregnancy Advisory Service between 2011 and 2014 and had a choice of counselling models. We compared the characteristics of women who chose each model of counselling and the contraceptive methods they chose and received using Fisher's exact test, and used logistic regression to explore associations between counselling model and choice and receipt of Tier 1 contraceptive methods (intrauterine contraception, implant, sterilisation), controlling for covariates. RESULTS: The sample included 18 573 women. Women choosing telephone counselling were more likely to be non-White (34% vs 22%, P<0.001), to report prior difficulty obtaining contraception (40% vs 3%, P<0.001), and to have not used contraception at conception (37.1% vs 33.8%, P<0.001). Overall, 93% of women chose a contraceptive method after counselling. Telephone counselling was significantly associated with both choosing and receiving a Tier 1 method (OR 1.80, 95% CI 1.66 to 1.96 and OR 1.60, 95% CI 1.42 to 1.71, respectively). Fewer women who had telephone counselling received a less effective method (eg, condom, diaphragm) compared with those who chose integrated counselling (6.0% vs 19.2%, P<0.001). DISCUSSION: Telephone-based contraception counselling separate from the abortion consultation may serve some women better than integrated counselling, particularly those reporting past difficulty obtaining contraception.

12.
Reprod Health ; 15(1): 107, 2018 Jun 13.
Artigo em Inglês | MEDLINE | ID: mdl-29895292

RESUMO

BACKGROUND: Despite Britain, Colombia, and some Mexican states sharing a health exception within their abortion laws, access to abortion under the health exception varies widely. This study examines factors that result in heterogeneous application of similar health exception laws and consequences for access to legal abortion. Our research adds to previous literature by comparing implementation of similar abortion laws across countries to identify strategies for full implementation of the health exception. METHODS: We conducted a cross-country comparative descriptive study synthesizing data from document and literature review, official abortion statistics, and interviews with key informants. We gathered information on the use and interpretation of the health exception in the three countries from peer-reviewed literature, court documents, and grey literature. We next extracted public and private abortion statistics to understand the application of the law in each setting. We used a matrix to synthesize information and identify key factors in the use of the law. We conducted in-depth interviews with doctors and experts familiar with the health exception laws in each country and analyzed the qualitative data based on the previously identified factors. RESULTS: The health exception is used broadly in Britain, somewhat in Colombia, and very rarely in Mexican states. We identified five factors as particularly salient to application of the health exception in each setting: 1) comprehensiveness of the law including explicit mention of mental health, 2) a strong public health sector that funds abortion, 3) knowledge of and attitudes toward the health exception law, including guidelines for physicians in providing abortion, 4) dissemination of information about the health exception law, and 5) a history of court cases that protect women and clarify the health exception law. CONCLUSIONS: The health exception is a valuable tool for expanding access to legal abortion. Differences in the use of the health exception as an indication for legal abortion result in wide access for women in Britain to nearly no access in Mexican states. Our findings highlight the difference between theoretical and real access to legal abortion. The interpretation and application of the health exception law are pivotal to expanding real access to abortion.


Assuntos
Aborto Induzido/legislação & jurisprudência , Aborto Legal/legislação & jurisprudência , Comparação Transcultural , Acesso aos Serviços de Saúde/legislação & jurisprudência , Direitos Humanos , Aborto Induzido/estatística & dados numéricos , Aborto Legal/estatística & dados numéricos , Colômbia , Inglaterra , Feminino , Política de Saúde , Acesso aos Serviços de Saúde/estatística & dados numéricos , Direitos Humanos/legislação & jurisprudência , Humanos , Serviços de Saúde Materna , México , Gravidez , Reino Unido
13.
Contraception ; 2018 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-29680767

RESUMO

OBJECTIVE: To compare procedure duration, complications, and acceptability of dilation and evacuation (D&E) with and without feticide by intra-cardiac potassium chloride (KCL) injection. STUDY DESIGN: We evaluated outcomes with D&E at 18-24 weeks of gestation in the 6 months before and 6 months after removing feticide with KCL from the guidelines of a national British abortion provider. We extracted demographic and procedure-related data from medical records and electronic databases. We surveyed women undergoing D&E in both time periods about acceptability and side effects. RESULTS: We analyzed 291 cases with and 257 cases without KCL. Unadjusted mean procedure duration was shorter with KCL than without (12.7 vs. 16.1 min, respectively, p<.001). After adjustment for age, parity, Cesarean deliveries, gestational age, body mass index, surgeon, and number or duration of osmotic dilators used, KCL remained associated with a 3.5 min (95% CI 2.4-4.6) reduction in D&E duration. Uterine atony was more common with KCL than without (3% vs. 0%, respectively, p=.004), despite more frequent administration of prophylactic utero-tonics to women who received KCL (82% KCL vs. 73% no-KCL, p=.001). Women who had KCL reported more pain in the period between feticide and dilator placement and the evacuation than women who had not received feticide (49% vs. 25%, respectively, p<.001). Most women in both groups found their procedure very acceptable or acceptable (79% KCL vs. 87% no-KCL, p=.2). CONCLUSIONS: Feticide with intra-cardiac KCL reduced D&E procedure duration, but was associated with more pain and uterine atony. Treatment acceptability was high with and without feticide. IMPLICATIONS: Inducing fetal demise before dilation and evacuation with intra-cardiac potassium chloride may result in shorter operative times but does not appear to improve safety or acceptability. Level I evidence remains needed to support the use of feticide before surgical abortion.

14.
Obstet Gynecol ; 131(4): 635-641, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29528933

RESUMO

OBJECTIVE: To evaluate outcomes with simultaneous administration of mifepristone and misoprostol for medical abortion at 63 days of gestation or less in the year after its implementation in a British clinic system. METHODS: We conducted a retrospective cohort study using deidentified data from the electronic booking and complications databases and medical records of women who underwent medical abortion at British Pregnancy Advisory Service. Our primary outcome was treatment success with simultaneous dosing compared with a regimen with a 24- to 48-hour interval between medications. We defined success as complete abortion without surgical evacuation and without continuing pregnancy. To assess relative regimen effectiveness while accounting for self-assignment to simultaneous or interval dosing, we modeled the probability of treatment success using logistic regression with propensity score adjustment for demographic and clinical characteristics. Secondary outcomes were reasons for abortion failure and clinically significant adverse events (hospital admission, blood transfusion, intravenous antibiotic administration). RESULTS: Of 28,901 women treated between May 2015 and April 2016, 85% chose simultaneous dosing. Overall success rates were high with both regimens but lower with simultaneous than with interval dosing (94.5% vs 97.1%, respectively, adjusted relative risk 0.973, 95% CI 0.967-0.979). For both regimens, success rates were lower at higher gestational ages, but the relative effectiveness of simultaneous dosing did not vary significantly with gestational age (P=.268). Surgical intervention rates for continuing pregnancy were lowest at 49 days of gestation or less (1.4% simultaneous vs 0.2% interval, P<.001) and highest at 57-63 days of gestation (5.0% and 2.2%, P<.001). The rate of clinically significant adverse events was 0.2% and did not differ by regimen (P=.972). CONCLUSION: Simultaneous administration of mifepristone and misoprostol is 97% as effective as a 24- to 48-hour interval at all gestational ages 63 days or less with no increase in the risk of clinically significant adverse events. Pragmatic use of simultaneous dosing is reasonable given the small difference in effectiveness.


Assuntos
Abortivos/administração & dosagem , Aborto Induzido/métodos , Esquema de Medicação , Mifepristona/administração & dosagem , Misoprostol/administração & dosagem , Abortivos/efeitos adversos , Aborto Induzido/efeitos adversos , Adulto , Bases de Dados Factuais , Quimioterapia Combinada , Feminino , Humanos , Modelos Logísticos , Mifepristona/efeitos adversos , Misoprostol/efeitos adversos , Gravidez , Primeiro Trimestre da Gravidez , Estudos Retrospectivos , Resultado do Tratamento , Reino Unido , Adulto Jovem
15.
J Fam Plann Reprod Health Care ; 43(4): 265-268, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28698244

RESUMO

BACKGROUND: Controversy exists as to whether 'abortion or 'termination of pregnancy' should be used by health professionals during interactions with women and in published works. METHODS: Self-administered anonymous questionnaires were distributed to women attending 54 abortion clinics in Scotland, England and Wales during a 4-month period in 2015. Responses were coded and analysed using SPSS. Descriptive statistics were generated and responses compared by demographic characteristics. The main outcome measures were the proportion of respondents reporting that they found the terms 'abortion' and 'termination of pregnancy' to be distressing, and women's preferred terminology for referring to induced abortion. RESULTS: Surveys were completed by 2259 women. The mean age of the respondents was 27(range 13-51) years; 82% identified as white, 51% had children and 36% had previously undergone abortion. Thirty-five percent indicated that they found the word 'abortion' distressing compared with 18% who reported that 'termination of pregnancy' was distressing (p< 0.001). Forty-five percent of respondents expressed a preference for 'termination of pregnancy' and 12% for 'abortion'. Sixteen percent would choose either term. This pattern of results did not vary statistically by age, reproductive history, country of residence, ethnicity or level of deprivation. CONCLUSIONS: Most women seeking abortion did not find the terms 'abortion' or termination of pregnancy' distressing. When given a choice of terms, more women who expressed a preference chose 'termination of pregnancy'. Healthcare professionals should be sensitive to preferences for terminology when communicating with women seeking abortion.

16.
Contraception ; 95(6): 529-537, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-27591814

RESUMO

Five intrauterine devices (IUDs) are available in the United States: four levonorgestrel-releasing intrauterine systems (two containing 52 mg, one containing 19.5 mg and one containing 13.5 mg) and one copper-bearing device (Copper T 380A). All IUDs have very low typical-use failure rates and high acceptability ratings, yet they are used by a minority of women, with nulliparous women less likely to do so than parous women. The objective of this clinical review is to give evidence-based recommendations for the use of IUDs in nulliparous women. Intrauterine devices are safe and effective for the majority of women including those who are nulliparous, and should be routinely included in the contraception options offered to them.


Assuntos
Anticoncepção/métodos , Dispositivos Intrauterinos , Paridade , Adolescente , Adulto , Anticoncepcionais Femininos , Falha de Equipamento , Feminino , Fertilidade , Humanos , Dispositivos Intrauterinos/efeitos adversos , Dispositivos Intrauterinos de Cobre/efeitos adversos , Dispositivos Intrauterinos Medicados/efeitos adversos , Levanogestrel/administração & dosagem , Levanogestrel/efeitos adversos , Satisfação do Paciente , Gravidez , Fatores de Risco , Estados Unidos , Adulto Jovem
17.
Eur J Contracept Reprod Health Care ; 21(6): 467-473, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27701927

RESUMO

BACKGROUND: Women having a termination of pregnancy (TOP) have higher rates of Chlamydia trachomatis (CT) than the general population. In this study, we explored CT treatment and prevention in Dutch TOP clinics in comparison to that provided in Great Britain (GB). METHODS: A qualitative study including 14 semi-structured interviews with health care professionals (HCPs) in TOP clinics (the Netherlands: 9, GB: 5). Interviews were recorded, transcribed, and analysed by thematic content analysis. RESULTS: Prophylactic treatment with azithromycin is routinely prescribed after surgical TOP, but not after medical TOP ('abortion pill'). Sexually transmitted infections (STI) tests are offered to clients who are considered at high risk of having STI. Uptake varies according to health insurance coverage of STI testing. Some Dutch clinics are able to provide free testing for women under 25 years of age. Sexual health counselling is often limited to discussing birth control. The major difference between the Netherlands and GB is that GB TOP clinics more often offer free STI testing and prophylaxis to their clients. CONCLUSION: HCPs in Dutch TOP clinics consider STI testing an important part of their service, but financial barriers prevent testing on location. Dutch TOP clinics should offer STI tests to all women, and collaboration with public health services could improve STI testing and counselling for young people. Furthermore, clinics should treat all TOP clients with prophylactic azithromycin. This could prevent CT and other upper genital tract post-abortion infections.


Assuntos
Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Azitromicina/uso terapêutico , Infecções por Chlamydia , Instituições de Assistência Ambulatorial , Atitude do Pessoal de Saúde , Infecções por Chlamydia/diagnóstico , Infecções por Chlamydia/tratamento farmacológico , Infecções por Chlamydia/prevenção & controle , Chlamydia trachomatis , Feminino , Humanos , Entrevistas como Assunto , Masculino , Países Baixos , Enfermeiras e Enfermeiros/psicologia , Aceitação pelo Paciente de Cuidados de Saúde , Médicos/psicologia , Guias de Prática Clínica como Assunto , Gravidez , Pesquisa Qualitativa , Doenças Bacterianas Sexualmente Transmissíveis , Reino Unido
18.
Eur J Contracept Reprod Health Care ; 21(5): 401-7, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27539129

RESUMO

OBJECTIVES: Restrictive policies that limit access to abortion often lead women to seek services abroad. We present results from an exploratory study aimed at documenting the socio-demographic characteristics, travel and abortion-seeking experiences of non-resident women seeking abortions in the UK. METHODS: Between August 2014 and March 2015, we surveyed a convenience sample of 58 non-UK residents seeking abortions at three British Pregnancy Advisory Service (BPAS) abortion clinics in England in order to better understand the experiences of non-resident women who travel to the UK seeking abortion services. RESULTS: Participants travelled to England from 14 countries in Europe and the Middle East. Twenty-six percent of participants reported gestational ages between 14 and 20 weeks, and 14% (n = 8) were beyond 20 weeks since their last menstrual period (LMP). More women from Western Europe sought abortions beyond 13 weeks gestation than from any other region. Women reported seeking abortion outside of their country of residence for a variety of reasons, most commonly, that abortion was not legal (51%), followed by having passed the gestational limit for a legal abortion (31%). Women paid an average of £631 for travel expenses, and an average of £210 for accommodation. More than half of women in our study found it difficult to cover travel costs. CONCLUSIONS: Understanding how and why women seek abortion care far from their countries of residence is an important topic for future research and could help to inform abortion-related policy decisions in the UK and in Europe.


Assuntos
Aspirantes a Aborto , Aborto Induzido , Aborto Legal , Acesso aos Serviços de Saúde , Turismo Médico , Adolescente , Adulto , Instituições de Assistência Ambulatorial , Custos e Análise de Custo , Inglaterra , Europa (Continente) , Feminino , Idade Gestacional , Política de Saúde , Humanos , Estado Civil , Turismo Médico/economia , Pessoa de Meia-Idade , Oriente Médio , Projetos Piloto , Gravidez , Primeiro Trimestre da Gravidez , Segundo Trimestre da Gravidez , História Reprodutiva , Inquéritos e Questionários , Adulto Jovem
19.
J Fam Plann Reprod Health Care ; 41(2): 84-9, 2015 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-25201907

RESUMO

BACKGROUND AND METHODOLOGY: UK regulations on managing fetal tissue after pregnancy loss, including abortion, are underscored by the concept of 'sensitive disposal'. This involves offering women burial or cremation and, when disposal is by the health care provider, separating fetal tissue from other clinical waste before incineration. We interviewed 23 women who had undergone one or more abortions about their understanding, attitudes and experiences of fetal tissue disposal and 'sensitive disposal'. Transcripts were analysed for representative themes. RESULTS: Prior to the abortion, most participants did not give consideration to disposal methods because their focus was on ending the pregnancy. Appropriate disposal by health professionals was assumed but some women undergoing early medical abortion reported anxiety about how to manage disposal at home. The term 'sensitive disposal' was unfamiliar to most respondents. Participants generally favoured separation of fetal tissue from other clinical waste and approved of incineration as a means of destruction. Ceremonial disposal was approved of following the loss of a wanted pregnancy but not following elective abortion. Most wanted the opportunity to access information about disposal but did not favour being asked or required to make decisions about disposal. DISCUSSION AND CONCLUSIONS: Knowledge about the management of fetal tissue after abortion or the concept of 'sensitive disposal' was limited among the women we interviewed. Current guidelines appear discordant with the views of women terminating an unwanted pregnancy. Further research is needed to better inform policy on this issue.


Assuntos
Feto , Eliminação de Resíduos de Serviços de Saúde/métodos , Adolescente , Adulto , Instituições de Assistência Ambulatorial/ética , Atitude Frente a Saúde , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Pesquisa Qualitativa , Reino Unido
20.
Contraception ; 90(1): 29-35, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24815098

RESUMO

OBJECTIVES: We tested the effectiveness and feasibility of remote communication technologies to increase follow-up after early medical abortion. STUDY DESIGN: Women (n=999) were randomized to 'remote' follow-up incorporating a low-sensitivity pregnancy test and standardized symptom questionnaire administered online, by text message or telephone by a non-clinical call center operator 2 weeks after treatment, or to 'clinic-based' follow-up with ultrasound at 1 week. Women in the clinic-based group who could not return performed a high-sensitivity pregnancy test at 3 weeks and had a telephone call with clinic staff. The primary outcome was completion of follow-up. Rates of complications, acceptability and preferences were compared. RESULTS: The overall follow-up rate did not differ by group {clinic-based, 73% vs. remote, 69%; risk ratio (RR) 1.0 [95% confidence interval (CI) 0.9-1.2]}. In the clinic-based group, 83% did not return for an ultrasound scan and were followed up by phone. In the remote group, follow-up by phone or text was more successful than online (text: 75.4%; phone: 73.7%; online: 46.5%, p<.001). The proportion of women receiving additional care was 9% in the clinic-based group and was 4% in the remote group [RR 1.8 (95% CI 1.1-3.1)]. Most women found their follow-up method acceptable but would prefer follow-up by phone or text message if needed in future. CONCLUSIONS: Follow-up after medical abortion using remote communication is feasible and, for most women, preferable to a clinic visit. IMPLICATIONS: Medical abortion protocols typically use follow-up visits to ensure early identification of complications. This study demonstrates that follow-up can be achieved using remote communication technologies. This model may reduce the burden of multiple clinic visits on patients and providers.


Assuntos
Aborto Induzido/métodos , Comunicação , Anticoncepcionais Sintéticos Pós-Coito/administração & dosagem , Mifepristona/administração & dosagem , Adolescente , Adulto , Intervalos de Confiança , Feminino , Seguimentos , Humanos , Modelos Logísticos , Pessoa de Meia-Idade , Satisfação do Paciente , Gravidez , Inquéritos e Questionários , Telefone , Envio de Mensagens de Texto , Reino Unido , Adulto Jovem
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