BMJ Sexual & Reproductive Health最新文献

Background: Access to post-abortion contraception (PAC) is critical for reducing unintended pregnancies and supporting reproductive decision-making. Patients often face challenges in identifying, accessing and initiating their preferred contraceptive methods post-abortion. This may be particularly so with telemedicine models of care with absence of in-person appointments, and reduced opportunities to provide some contraceptive methods. This qualitative service evaluation explored patients' perspectives on PAC consultations and decision-making to inform future PAC service models in the era of telemedicine.

Methods: Qualitative interviews with 15 patients who had telemedicine medical abortion at home up to 12 weeks' gestation. Data were analysed using reflexive thematic analysis.

Results: Contraceptive discussions during pre-abortion consultations were valued for supporting informed choices about future contraceptive use. Decision-making was influenced by previous contraception experiences, emotional state at the time of abortion and concerns about contraceptive 'failure'. Some preferred non-hormonal methods due to past negative experiences with hormonal contraceptives. However, limited information about 'natural' contraceptive methods and concerns about discussing these with healthcare professionals were described. Barriers to accessing preferred methods, particularly long-acting reversible contraception (LARC), included reduced availability of appointments and caring responsibilities. Fast-tracked appointments for LARC fitting post-abortion were valued. The need for flexible PAC consultations and access after abortion, for example, remote consultations complemented by personalised interactions with sexual and reproductive health experts, was emphasised.

Conclusion: The findings highlight the need for flexible and more accessible PAC service models in the era of telemedicine care to ensure timely access to preferred contraceptive methods.

Background: Abortions are common and associated with procedural pain. We aimed to evaluate benefits and harms of local anaesthesia given for pain control during surgical abortion at less than 14 weeks' gestation.

Methods: We searched a systematic review on local anaesthesia for pain control for surgical abortion at less than 14 weeks' gestation using uterine aspiration. We searched multiple databases through December 2022. We evaluated study quality using the Cochrane Risk of Bias 2 (RoB2) instrument and assessed the certainty of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Outcomes included intraoperative pain (with dilation, aspiration or procedure), patient satisfaction and adverse events.

Results: Thirteen studies with 1992 participants met the inclusion criteria and the majority were judged as low risk of bias. Intervention protocols were heterogeneous, limiting meta-analysis. A 20 mL 1% lidocaine paracervical block (PCB) reduced pain with dilation compared with sham PCB (mean difference (MD) -37.00, 95% CI -45.64 to -28.36) and aspiration (MD -26.00, 95% CI -33.48 to -18.52; 1 randomised controlled trial (RCT), n=120; high-certainty evidence). A PCB with 14 mL 1% chloroprocaine was associated with a slight reduction in pain during aspiration compared with normal saline PCB injected at two or four sites (MD -1.50, 95% CI -2.45 to -0.55; 1 RCT, n=79; high-certainty evidence). Other RCTs compared a range of local anaesthetic types, PCB techniques and topical anaesthetics. Participants reported moderately high satisfaction with any type of pain control and studies reported few adverse events that were rarely medication-related.

Conclusion: RCT evidence supports PCB efficacy but was inconsistent and of low certainty for topical anaesthesia.

Background: We describe clients in Mexico City's public abortion programme, Interrupción Legal de Embarazo (ILE), during the COVID-19 pandemic and test whether the pandemic exacerbated inequities in access.

Methods: We conducted a cohort study of all abortions in the ILE programme from 1 January 2019 to 30 June 2022. We compared patients from within and outside the Mexico City Metropolitan area (ZMVM) by pandemic stage (pre-, acute-, mid- and late-COVID periods) and assessed changes in client characteristics (adolescent age, education, weeks' gestation) by place of residence (ZMVM vs outside the ZMVM) using linear probability models clustered on state.

Results: We included 45 031 abortions. The proportion of abortions to women who travelled from outside the ZMVM decreased from 6.5% pre-COVID to 4.4%-4.8% in in the acute, mid- and late-COVID periods. The adjusted probability of being an adolescent who travelled from outside the ZMVM dropped between pre-COVID (14.4%, 95% CI 12.7% to 16.1%) and mid-COVID (9.3%, 95% CI 7.9% to 10.7%). The proportion of abortions to women with a high school education stayed fairly flat among those travelling, while it rose among those residing in the ZMVM. The adjusted probability of presenting at 11 gestational weeks or greater was higher among women residing in the ZMVM in the pre-pandemic period; this flipped during all pandemic stages, with a higher probability of presenting at 11 weeks or greater among those who travelled from outside the ZMVM.

Conclusions: The COVID-19 pandemic exacerbated existing disparities in who can access ILE services. To reduce inequities in access to essential health services, public sector abortion services should be made available in all Mexican states.

Background: Self-injectable contraceptives, namely subcutaneous depot medroxyprogesterone acetate 104 mg micronised formulation delivered via uniject system, reduce the need to travel to a facility for contraceptive access, but the initial, in-person, training may be a barrier to starting this method. This article reports on a small, exploratory pilot in Kenya to test the feasibility and acceptability of digital self-injection training.

Methods: Participants (n=11) who were currently using injectable contraceptives, intramuscular depot medroxyprogesterone acetate 150 mg injected by a healthcare worker, received digital self-injection training from a trained clinician via a WhatsApp video call. Participants administered a simulated self-injection on a model and an actual self-injection (under supervision) on themselves. The participants' self-injection proficiency, a measure of the feasibility of remote training, was documented using a checklist, and participants were administered a questionnaire about their training experience. The training was observed, and content analysis was used to understand the functionality of training.

Results: All participants were proficient when performing the self-injection on themselves after receiving the remote training and reported that the training was acceptable. A barrier to training via a video call was lack of access to quality digital devices. Eight training 'lessons learnt' emerged from the training observations.

Conclusions: Training participants to administer self-injectable contraceptives via WhatsApp video call was feasible and acceptable. Training lessons learnt offer pragmatic adaptations for communicating about a practical skill via a digital channel. Further research is needed to ascertain the efficacy of digital training for self-injection and feasibility and acceptability for wider groups.

Background: Young Australian women from culturally and linguistically diverse (CALD) backgrounds are vulnerable to unwanted pregnancy. We aimed to assess whether an online educational video, co-designed with young CALD women, can increase their contraceptive knowledge, preference for and uptake of long-acting reversible contraception (LARC).

Methods: Online advertising was used to recruit young CALD women aged 16-25 years. Participants completed the pre-video survey (S1), watched the 13-min co-designed video, then completed a survey immediately afterwards (S2) and 6 months later (S3). Outcomes were analysed using McNemar tests and multivariate logistic regression.

Results: A total of 160 participants watched the video, completed S1 and S2, and 57% of those completed S3. At S1 only 14% rated their knowledge about every contraceptive method as high. Knowledge improved at S2 for all methods (aOR 3.2, 95% CI 2.0 to 5.0) and LARC (aOR 4.7, 95% CI 2.9 to 7.5). Overall method preference for LARC increased from 2.5% (n=4) at S1 to 51% (n=82) at S2. Likelihood of using a LARC increased at S2 (aOR 3.8, 95% CI 2.6 to 5.6). The overall proportion of participants using a LARC increased from 8% at S1 to 11% at S3; however, this increase was not significant (p=0.7).

Conclusions: The significant increase in knowledge, likelihood of use, and preference for LARC underscores the potential of online video-based contraceptive education to address contraceptive knowledge gaps and challenge misconceptions about LARC held by young women. Combining contraceptive education with supports to LARC access is crucial for empowering young CALD women to make informed contraceptive decisions.