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Despite promising products, no male hormonal contraceptives have reached the market
Despite media interest, progress in developing new reversible male contraception has been slow. Trials of a self-administered gel combination of testosterone and the progestogen Nestorone are underway, while novel long-acting steroids with both androgenic and progestogenic activity are also in early clinical trials. The non-hormonal approach offers certain advantages, with potential sites of action on spermatogenesis, sperm maturation in the epididymis or at the vas, but such products are only in preclinical testing. Surveys indicate willingness among men and their partners to use a new male method, but they are still waiting for that opportunity. See page 236
Women are underadvised and underinformed about interpregnancy intervals
Interpregnancy intervals (IPIs) are important in preventing adverse obstetric outcomes. But do women know what is the ideal length of IPI, and understand the consequences of a short IPI? Yang and colleagues undertook a prospective questionnaire-based study of 467 pregnant women (of whom 344 were pregnant following a live birth) at two hospitals in Sydney, Australia to find out. 20.9% had an IPI of <12 months, of whom only 7.5% believed this was ideal, while the remainder stated their ideal IPI was >12 months (52.3%) or they had no ideal IPI (40.3%). An IPI <12 months was associated with younger age but not ethnicity, relationship status, education, religion, parity or previous mode of delivery. Worryingly, less than half of the respondents reported receiving advice about IPI or postnatal contraception from a healthcare provider, and the authors recommend that this needs to be addressed. See page 249
Too few teenage mothers receive the postpartum contraception they want
Access to postpartum contraception is a challenge, particularly for vulnerable groups. Gallagher and colleagues evaluated the impact of antenatal contraceptive counselling and the provision of postpartum contraception for 118 first-time teenage mothers enrolled with a Family Nurse Partnership (FNP) programme in Scotland. Using self-administered questionnaires and interviews with FNP clients, 81% agreed that it was helpful to receive antenatal contraceptive counselling, and just over two-thirds were planning to use a LARC method, of which 80% expressed a wish to receive contraception before leaving the hospital. Of the subset questioned 10 days postpartum, only 32% said they had received contraception from the hospital. FNP nurses attributed this figure to heavy workloads in maternity departments, and expressed frustration when contraception was not provided. See page 243
Lifting restriction on abortion for fetal anomaly is not linked to increased second-trimester abortion in Mexico
How are second-trimester abortion services used? Alexander and colleagues analysed data from 2007 to 2015 to examine temporal and geographical trends among 145 956 second-trimester abortions in public hospitals across Mexico. Higher odds of second-trimester abortions were observed for women living in highly marginalised compared with less marginalised municipalities, while living in Mexican states with fetal anomaly exception to abortion restrictions was not associated with higher utilisation of second-trimester abortion services. To improve health outcomes for Mexican women, especially the most vulnerable, the authors encourage the implementation of current legal exceptions and an emphasis on training healthcare providers. See page 283
Sexual minority groups face the highest sexual health risks among among Chinese students
Underage sexual intercourse, multiple sexual partners, and intercourse without condoms are risks that disproportionately affect the health of sexual minorities. Tang and colleagues focused on China to examine the distribution of sexual minority groups, associations with high-risk sexual behaviours and symptoms of sexually transmitted infections (STIs). Of the 17 966 respondents from 130 Chinese colleges to an internet-based questionnaire, homosexual males were more likely to have their sexual debut with a non-regular partner (OR 4.79, 95% CI 3.38 to 6.78), have their sexual debut before the age of 18 years (OR 1.92, 95% CI 1.34 to 2.76) and not use condoms for most episodes of sexual intercourse (OR 1.47, 95% CI 1.00 to 2.17). These results were similar for homosexual females. A positive association between sexual orientation and having symptoms of STIs (OR 1.49, 95% CI 1.02 to 2.18) was found among homosexual males. That sexual minority groups among Chinese college students are at greater risk of engaging in high-risk sexual behaviours and having STI symptoms should prompt greater focus on this population. See page 255
Women report less pain and bleeding with the mini IUD than with standard IUDs
Copper intrauterine devices (IUDs) are less popular in the UK than in other European countries. Standard-sized T-shaped IUDs are the most effective types of copper-containing IUDs, while a small-sized IUD is also available. But is there a difference between them when it comes to discontinuation rates? The clinical records of 67 women fitted with mini IUDs and 63 women fitted with standard-sized IUDs over a 3-year period were compared. At 1 year, twice as many standard IUD users (32%, n=20) had had their IUD removed compared with mini IUD users (15%, n=10). Complaints of pain and bleeding were twice as high (70%, n=14) for women who discontinued the standard IUD compared with the mini IUD (30%, n=3). This study should prompt further research into the association between size and discontinuation of IUDs. See page 263
Unmet demand for family planning methods in Lebanon persists despite free access
In Lebanon, research on the national prevalence of contraceptive use is scarce. El Khoury and Salameh measured the current Lebanese national prevalence of FP uptake among women and men of reproductive age, and assessed barriers for unmet need. Their cross-sectional survey on a nationally representative sample of 825 married women (aged 15–49 years) and men of reproductive age (aged 18+ years) found that the current prevalence of contraceptive use is 55.6%, the total demand for FP is 67%, and the percentage of satisfied demand for FP is 83%. Knowledge, access and attitudes to FP were favourable, yet there was clear stagnation in the rate of contraception use over the past four decades. The major factors hindering the use of FP methods in Lebanon were found to be religion, age and lower education levels. National-level interventions are recommended to encourage couples to use modern FP methods. See page 269
An expanded SRH role for community pharmacists helps reduce teenage pregnancy
In Wales, free EC supplied by community pharmacists (CPs) has helped to bring down high teenage pregnancy rates since 2011. Mantzourani and colleagues examined 5 years of data from this EC service to understand how it is used and has changed over time. They found that women aged between 13 and 59 years were accessing the service, and almost half (47.9%) of requests were because no contraception had been used during intercourse, with a strong and positive association for teenagers and women aged 40+ years. A growing percentage of CP consultations were accompanied by further sexual health advice, but reduced availability of CP services on Sundays proved a barrier to timely EC access. The study deemed the CP service’s contribution to reducing teenage conceptions and termination rates a success, and the authors propose an expanded role for CPs in also providing regular contraception. See page 275
The psychological consequences of abortion remain underexplored
Despite scattered research, and politicised assertion on the psychological impacts of abortion, there has been no study of the history of psychological knowledge production on the topic. Macleod and colleagues performed a content analysis and narrative review of psychology journals, looking at the politics of location and representation of abortion in the 1970s and 2000s. Including literature from South Africa to the USA, this article charts the psychological impact of abortions performed under safe conditions, both benign and traumatic, but finds little coverage of unsafe abortion in the literature. The authors call for more nuanced and contextualised research on the psychology of both safe and unsafe abortion. See page 290
Home EMA in Scotland since legalisation has increased with undiminished success
In October 2017, Scotland made it legal for women up to 9+6 weeks' gestation to self-administer misoprostol at home for early medical abortion (EMA), 24–48 hours after receiving mifepristone in the clinic. Finch and colleagues’ prospective observational study evaluated the impact of this legislation on uptake and success rates of EMA. Two cohorts of women from the 6 months prior and 6 months following the introduction of home misoprostol were studied to measure uptake and success of EMA, as well as provision of LARC after EMA. They found a statistically significant increase in the uptake of EMA from 64.9% women in the first study period to 71.8% in the second study period. The success rate of EMA showed no statistically significant difference (99.3% in clinic and 98.9% at home) and both groups were equally likely to be provided with LARC. This is good news for other countries planning similar legislation. See page 296
New midwife contraceptive champions in Lothian prove popular among patients and professionals
The challenge of increasing uptake of postpartum contraception requires a multidisciplinary team effort. Gallimore and colleagues evaluated the acceptability of hospital and community midwives holding a new contraceptive champion role in NHS Lothian, Scotland. Five contraceptive champions underwent semi-structured interviews after the first 6 months in their role. All participants expressed increased confidence in their knowledge of postnatal contraception. The positive reception of contraceptive champions by patients, midwives themselves and their healthcare colleagues suggests this may be an effective model for other National Health Service (NHS) trusts. See page 309
Expanding the second-trimester abortion service in Hackney proves popular and safe
Limited availability of surgical abortions within the NHS compromises access, particularly for women requiring surgical abortions in their second trimester. Babra and colleagues reviewed Homerton University Hospital’s (HUH) abortion service after it expanded to accept out-of-area referrals, and began providing surgical abortions up to 24 weeks' gestation. Within a year, the service had received 75 referrals, with a majority of these patients electing for surgical abortions via cervical dilatation and evacuation. This article emphasises the safety of, and demand for, surgical abortions in the second trimester, and recommends that services similar to HUH’s are developed elsewhere. See page 305
Person in practice
In this issue’s Person in Practice column, Abi Berger shares reflections on the changeless things patients need from their general practitioners, in a changing world of healthcare delivery: clear appointment times which are respected, and person-to-person contact. Oh, and a bit of humour helps. See page 302
Venus
Venus brings us a combination of novelty and reassurance: a new contraceptive smartphone app is being marketed, while it seems that menstrual cup use may increase the risk of IUD expulsion, and Ceftriaxone is beating Gentamicin in gonorrhoea treatment. Reassuringly, she also brings us evidence that Depot Medoxyprogesterone acetate users have no increased risk of HIV acquisition, and that Ulipristal acetate emergency contraception does compromise established pregnancies. See page 315
Footnotes
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
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