BMJ Sexual & Reproductive Health最新文献

Introduction: Physical pain is known to be a common feature of sexual and reproductive healthcare (SRH) encounters for women and other people with a uterus. Our aim was to understand experiences of painful procedures in SRH care and to identify priorities for change.

Methods: In January 2025, we conducted an online qualitative survey of people with lived experience of painful SRH procedures. Focused coding and thematic data analysis was supported by Nvivo 14.

Results: Analysis of the 149 qualitative responses highlighted four key thematic areas: how painful procedures felt at the time; how they made participants feel in the longer term; the impact on decisions around future procedures; and what, from participants' perspectives, could be done differently. Our results illustrate the impacts of pain in the short and longer term, as well as ways in which painful experiences can shape future engagement with SRH care. Specifically, they highlight the distress, fear and distrust of health professionals and services which these experiences can generate.

Conclusions: While best practice guidance exists for some potentially painful SRH procedures, women and other people with a uterus in the UK continue to report highly negative experiences. Trauma-informed approaches - recognising the role of past experiences and supporting compassionate, respectful patient interactions - could improve training and awareness among health professionals, and broader shifts in attitudes and practice.

Objective: Intrauterine device (IUD) user rates remain below 5% in low-income countries yet fertility after first-trimester abortions returns within 2 weeks. IUDs provide effective contraception. This study set out to explore the risk factors for IUD expulsion after medical management of first-trimester incomplete abortions.

Design: Prospective cohort study SETTING: Multicentre study at five public health facilities in central Uganda.

Participants: 1050 women with first-trimester incomplete abortion managed with misoprostol, recruited on giving informed consent.

Intervention: After selecting either copper or levonorgestrel (LNG) IUDs, participants were randomised to early (within 1 week) or standard (at 2-4 weeks) insertion and assessed on IUD expulsion 6 months later.

Main outcome measures: Primary outcome was IUD expulsion rates at 6 months. Secondary outcomes were risk factors for IUD expulsions.

Results: Between 8 July 2023 and 31 May 2024, 532 (50.7%) participants chose LNG IUDs, 488 (46.5%) chose copper IUDs, while 30 (2.9%) participants chose not to use IUDs. The IUD expulsion rate was 4.6% (95% CI 3.48 to 6.07). IUD expulsion was significantly associated with low overall satisfaction with IUD insertion procedure and use (adjusted odds ratio (aOR)=7.99, 95% CI 4.83 to 13.22, p<0.001), anxiety during the IUD insertion (aOR=4.28, 95% CI 1.09 to 16.85, p=0.038), use of ultrasound at follow-up (aOR=8.41, 95% CI 4.56 to 15.5, p<0.001) and breastfeeding at the time of IUD insertion (aOR=1.48, 95% CI 0.26 to 4.98, p=0.042).

Conclusion: Offering IUD insertion immediately after medical management of first-trimester incomplete abortion is associated with low expulsion rates and should be offered as a safe choice.

Background: Respondent-driven sampling (RDS) is a social network sampling technique used to study hidden behaviours. We used web-based RDS (webRDS) to estimate the prevalence of self-managed abortion (SMA) outside the formal healthcare system in Argentina where abortion was legalised in 2020, but access remains uneven.

Methods: A cross-sectional web survey (February-May 2024) among individuals aged 16-49 years, ever pregnant, and residing in Argentina. Our primary outcome was the proportion of SMA occurring outside the formal healthcare system. Estimates were generated using the RDS II estimator.

Results: Seven recruitment chains generated 2437 participants (mean of 19.8 recruitment waves, the longest being 51). We filtered for suspected repeat and ineligible participation and generated RDS estimates for the remaining 1340 participants. The estimated personal network size was 4.9; participants knew an average of 2.7 peers with abortion experience. An estimated 17.1% reported ≥1 abortion, ever in life. Among these, an estimated 20.7% (95% CI 14.2 to 28.0) reported an SMA outside the formal healthcare system; 65.3% before and 24.7% after the legal reform. An estimated 42.2% completed the SMA alone. Reported advantages included autonomy in timing and setting, and support person choice. Disadvantages included concerns about pill quality and uncertainties around the process.

Conclusions: A substantial proportion of women in Argentina with abortion experience have had an SMA outside the formal healthcare system, including post-legalisation. Our findings highlight the need to better address the preferences and needs of those facing unintended pregnancy and the potential of webRDS to study SMA.

Objective: To examine geographical variation in utilisation of hormonal long-acting reversible contraceptives (LARCs), namely the hormonal intrauterine device (IUD) and implant.

Study design: Cross-sectional study of Australian women aged 15-54 years using Pharmaceutical Benefits Scheme (PBS) dispensing data from 2018 to 2021. We calculated age-standardised rates of LARC dispensing per 1000 women across each Statistical Area Level 3 (SA3) according to remoteness and socioeconomic status (SES) indices. Differences between minimum and maximum rates of LARC utilisation in SA3s were used to determine magnitude of variation.

Results: Between 2018 and 2021, hormonal IUD dispensing rates increased from 18.4 to 21.6 per 1000 women in major cities, 25.2 to 30.6 per 1000 in inner regional, 25.4 to 28.7 per 1000 in outer regional, and 17.7 to 20.0 per 1000 in remote areas. This corresponded to decreases in implant dispensing rates from 14.6 to 12.6 per 1000 women in major cities, 25.3 to 23.1 per 1000 in inner regional, 28.0 to 25.3 per 1000 in outer regional, and 20.7 to 19.6 per 1000 in remote areas. Rates of LARC utilisation varied considerably across SA3s, ranging from 10.9 to 37.8 per 1000 women. Increasing SES was associated with increasing hormonal IUD rates in major cities (incidence rate ratio (IRR) 1.06, 95% CI 1.04 to 1.08), inner regional (IRR 1.06, 95% CI 1.03 to 1.09) and remote (IRR 1.44, 95% CI 1.12 to 1.85) areas, but decreasing implant rates in major cities (IRR 0.89, 95% CI 0.86 to 0.91) and inner regional areas (IRR 0.91, 95% CI 0.88 to 0.94).

Conclusion: Given observed variation in LARC utilisation, efforts to identify and address barriers towards more equitable access to LARC methods appear warranted.

Objectives: To evaluate and compare self-managed abortion (SMA) user-reported quality of care between users accessing a safe abortion hotline versus proprietary patent medicine vendors (PPMVs) that provide medicines to rural communities in Nigeria, and identify factors associated with increases in total quality scores and key indicators of abortion access and information provision.

Methods: We leveraged exit surveys and 30-day follow-up data collected from users of a safe abortion hotline and PPMVs in Nigeria used to develop the Abortion Care Quality Tool (ACQTool). We used bivariate statistics to compare 17 user-reported quality indicators across six domains and eight abortion outcomes, by care source (hotline vs PPMV). We used multivariable linear regression to identify factors associated with total quality scores and multivariable logistic regression to identify factors associated with abortion affordability and preparedness for a complication, controlling for user sociodemographic characteristics.

Results: Hotline users (n=182; 40.8%) scored higher than PPMV users (n=264; 59.2%) on 9 of 17 quality indicators, particularly in the decision-making and information provision domains. Mean total quality score was significantly higher for hotline users (16.53 vs 14.53; p<0.001). Hotline users were associated with an increase of 1.87 points in the total quality and higher odds (aOR=3.23; 95% CI 1.07 to 12.02) of feeling prepared if a complication occurred, but had lower odds (aOR=0.10; 95% CI 0.05 to 0.21) of indicating the abortion was affordable, adjusting for sociodemographic factors.

Conclusions: This study highlights the high overall quality of abortion care from both hotlines and PPMVs but identifies key areas for improvement, such as affordability for hotline users and decision and information support for PPMV users.

Background: National guidance emphasises the importance of offering women requesting abortion timely access to care and choices about abortion method. Women with complex health needs face particular challenges due to restrictions in where their procedure can be safely performed. In England, a specialised commissioned service operates, offering care in five National Health Service (NHS) centres.

Methods: A service evaluation collecting clinical and patient-reported data from 277 women attending (a) an NHS specialist abortion service and (b) a local abortion service for low-risk women at the same NHS provider during 2023/2024 in the North East of England.

Results: Clinical outcomes were similar between groups. Women accessing the specialist service had higher gestation at abortion (+14 days, 95% CI 6.0 to 22.0), waited longer between referral and procedure (+8.0 days, 95% CI 7.0 to 10.0), were less likely to have accessed their preferred abortion method (-37.4%, 95% CI -49.3 to-25.5), travelled for longer (+30.0 min, 95% CI 20.0 to 50.0), spent more money to access care (+£22.2, 95% CI 9.0 to 45.0) and were more likely to report financial hardship as a consequence (+27.6%, 95% CI 13.3 to 41.9). This group also rated their pre-hospital care lower and described specific challenges about their care.

Conclusions: While specialised abortion services for women with complex health needs have improved opportunities to access safe care, differences remain in important elements of the service. This creates disparities in relation to timely access, experience and choice of abortion method. Streamlining referral mechanisms between providers may reduce delay and improve efficiency and consistency. Services should consider how to support women who need to travel to access care.

Introduction: Women with intellectual disability often have limited knowledge and decision-making input regarding their contraception use. This study aimed to examine and compare the prevalence of any and specific contraceptive use in women with intellectual disability and matched comparators.

Methods: This was a retrospective, population-based, cohort study of women with intellectual disability and matched comparators aged 15-49 years in New South Wales, Australia in 2001-2018 using linked administrative datasets. Outcomes included overall and annual prevalence of any and specific contraceptive use calculated using person-years. We used a generalised linear model to examine the association between intellectual disability status and any contraceptive use.

Results: Women with intellectual disability were slightly more likely to use contraception overall (26.8% vs 23.9%), with different patterns of prevalence by age. The contraceptive pill accounted for 48.9% of overall contraceptive use in women with intellectual disability and 58.1% in comparators. Contraceptive injection showed increased prevalence in women with intellectual disability (20.4% vs 4.8%), while hormonal intrauterine device use showed decreased prevalence (11.2% vs 18.3%). Annual prevalence graphs showed a larger increase in contraceptive implant use in women with intellectual disability over time. The model showed a significant association between intellectual disability and any contraception use after controlling for covariates (relative rate 1.15, 95% CI 1.12 to 1.17).

Conclusions: The tendency towards contraceptives that require minimal active management may reduce opportunities for decision-making involvement. We recommend the development of better information and support for women with intellectual disability to enable access to a wider range of contraceptive options and achieve greater agency in reproductive health.

Background: Cervical cancer is predominantly caused by infection with high-risk human papillomavirus (HPV). Prevention efforts rely on vaccination and cervical screening. This study aimed to determine HPV vaccination and in-date cervical screening rates among women seeking abortion to determine whether this care setting could provide an opportunity to deliver catch-up prevention services.

Methods: Retrospective database study examining HPV vaccination and cervical screening coverage among women accessing abortion in Edinburgh, Scotland, UK from October to December 2024. National Health Service electronic systems recording HPV vaccinations and the Scottish Cervical Call Recall System were examined together with clinical records to determine if an in-person clinical visit was made as part of care.

Results: Some 798 individuals presented for abortion over the study period (n=297, ≤25 years and n=501, >25 years). Of those aged ≤25 years reviewed for HPV vaccination, 161/297 (54.2%) were vaccinated, 37 (12.5%) were unvaccinated and 99 (33.3%) had no record of vaccination status. Of the 501 women of cervical screening age >25 years, 289 (57.7%) were up to date, 70 (14%) were overdue and 142 (28.3%) had never been screened. Of the 37 unvaccinated individuals, 29 (78.4%) attended the clinic in person as did 158 (74.5%) of the 212 overdue/never-screened women.

Conclusions: A significant proportion of those individuals who present for abortion are not vaccinated against HPV or up to date with cervical screening. Three-quarters of this group made an in-person visit, indicating an opportunity for delivering cervical cancer preventative services in the future. Future research is required to determine the feasibility of HPV vaccination and cervical screening in this setting.

Objective: To assess the efficacy and safety of emergency contraception (EC) interventions.

Methods: Literature published until 28 December 2024 was retrieved from nine databases. Randomised controlled trials (RCTs) evaluating the efficacy of copper or levonorgestrel intrauterine devices (Cu-IUDs or LNG-IUDs), oral levonorgestrel (LNG), mifepristone (MFP), ulipristal acetate (UPA) and oral EC plus cyclooxygenase inhibitor (COX) were considered eligible. A Bayesian network meta-analysis was conducted to evaluate the relative risk (RR) with a 95% credible interval (CrI) for efficacy and adverse events. Evidence certainty was graded using the CINeMA GRADE application. Pairwise meta-analyses, robustness analyses and Bayesian meta-regressions were conducted to verify the reliability of the results.

Results: Of 17 244 studies, 92 involving 37 260 women were included. With robustness verified, the Cu-IUD was the most effective EC treatment. No significant differences in EC efficacy were observed between LNG-IUD and all other treatments, but with low- or very-low-certainty evidence. With acceptable adverse events, co-treatment with LNG and COX (LNG-COX) was more efficacious than single-dose (RR=0.112, 95%CrI: 0.005, 0.686) or double-dose LNG (RR=0.095, 95%CrI: 0.004, 0.605) with high certainty. MFP (25 mg) and UPA had comparable EC efficacy (RR=0.782, 95%CrI: 0.425, 1.433), whereas MFP tended to induce advancement of the subsequent menstrual period.

Conclusions: Although the efficacy of LNG-COX was confirmed by high-certainty evidence, large-scale validation trials are required before it can be recommended clinically. Owing to within-study bias and imprecision, large RCTs are strongly recommended to assess the efficacy of ECs for interventions without direct comparisons.

Trial registration number: CRD42024627671.