Towards evidence-based reform of abortion law in the Isle of Man

The Isle of Man is a self-governing British Crown dependency, located between Great Britain and Ireland in more ways than one. Many of its laws are entirely local, and abortion is available only in very restricted circumstances. Women seeking abortion therefore either travel abroad, or self-source abortion medication. In 2017, a general practitioner member of the island’s parliament was granted leave to introduce a bill to liberalise abortion and the government asked for evidence on which any new legislation could be based. In their Editorial, Aiken and colleagues describe how they compiled data on the demographics, circumstances and needs of Manx women who seek abortions to inform and guide the policy debate, paving the way for abortion law reform that is based firmly on evidence of its necessity. See page 77

Intrauterine contraception in the spotlight

Intrauterine contraception (IUC) has long been known to be highly effective, convenient, safe, long-acting and easily reversible. So it is surprising that in the UK, where IUC is available cost-free to women, it is chosen by only a small proportion of women requiring contraception. Some of the challenges in increasing IUC acceptability and implementation are highlighted in three articles in this issue. See pages 82, 90 and 97

Perspectives on barriers to IUC uptake in UK general practice

Hoggart and colleagues set out to clarify the barriers to greater acceptance of IUC in primary care in two linked articles resulting from their study conducted in South East England. In the first article they report on interviews with 30 women who had never used IUC. The themes that emerged were then used to construct a survey of almost 1200 women, 73% of whom had never used IUC. Among the interview group, a major concern was the long duration of effectiveness of IUC, with failure to realise that devices could be removed at any time for restoration of fertility. Numerous concerns were endorsed by the ‘never-users’ in the survey, the most common being dislike of having a device inside the body and worries about painful IUC fitting and unpleasant removal.

The second article reports on a survey of general practices to establish attitudes to IUC. This was followed by detailed interviews with practitioners. There was discordance between practitioners’ knowledge of women’s medical eligibility for IUC use and the likelihood of recommending IUC to a full range of potential users. The in-depth interviews indicated that practitioners’ risk aversion and limited training, together with their assessments that women are uninterested in IUC, may lead to under-use of this important contraceptive method. The authors have developed an aide-memoire for use by practitioners providing contraception advice, which they hope will contribute to narrowing the gap between knowledge and practice in IUC provision. See pages 82 and 90

Community SRH practitioners’ views on postpartum IUC

Immediate postpartum intrauterine contraception (PPIUC) provision is known to be safe and effective and is supported by a recent FSRH guideline, Contraception After Pregnancy. But PPIUC is still not available routinely in the UK. Cooper and colleagues distributed a questionnaire to attendees at two UK sexual health conferences, focusing on views on PPIUC, the perceived role of sexual health providers in PPIUC services, and potential challenges anticipated in providing PPIUC aftercare. Overall, the respondents, while positive towards PPIUC implementation, perceived their role predominantly in aftercare. The knowledge that community medical support will be available may support PPIUC implementation in UK maternity units. See page 97

Prenatal ’Centering group' care appears to enhance uptake of postnatal contraception

The postpartum period is a crucial time to initiate effective contraception, but unfortunately this often does not occur. In her retrospective cohort study, Smith found that compared with traditional care, women participating in ‘Centering group’ prenatal care were more likely to use postpartum contraception, particularly long-acting reversible contraception (LARC) methods. This was most pronounced in women aged 20–24 years. Compared with conventional antenatal care, ‘Centering group’ care is said to encourage group communication . Undoubtedly this will not suit all women. A future prospective randomised study may better define the strengths of this model. See page 103

Teaching family planning policy to health professionals in developing countries

‘Blended learning’ describes an education programme combining online digital media with more traditional classroom methods. Limaye and colleagues set out to ascertain whether this might be the answer to delivering training on legislative and policy requirements in family planning for recipients of US aid, many of whom work in remote settings. Some 660 learners from 44 countries completed an online survey assessing the knowledge imparted by several training methods. Knowledge retention was higher in the group that utilised blended learning when compared with those using online-only methods. Blended approaches appear to help learners consolidate their knowledge. See page 109

Telephone contraception counselling in abortion care

It can be difficult to provide enough time for adequate contraception counselling during an abortion consultation. The UK’s largest abortion service offers clients the options of discussing contraception with a nurse at the consultation, or telephone-based contraception counselling beforehand. Lohr and colleagues assessed the outcomes of over 18 000 consultations, approximately two-thirds being face-to-face and the remainder by telephone. Women choosing telephone counselling were significantly more likely to report having had difficulty in obtaining contraception in the past and not having used a method of contraception at conception. But they were also more likely to choose and receive a LARC method. In the context of abortion care, telephone-based contraception counselling may serve some women better than conselling at consultation, and these  findings support setting up a randomised comparison between the two approaches. See page 114

‘Termination of pregnancy’ may be used  to avoid  abortion stigma

Abortion stigma may be experienced both by those who undergo abortion and by those who provide it. The term ‘termination of pregnancy’ is often used instead of ‘abortion’ in UK guidelines and service provision. Yet little is known about how abortion providers view these terms and why they might choose one over the other when communicating with patients. Kavanagh and colleagues conducted a survey of 90 abortion providers in Scotland and 19 in-depth interviews at a single clinic site, exploring perceptions and usage of  each term. Some 28% of surveyed abortion providers found the term ‘abortion’ distressing, which raises important questions about how providers perceive and deal with abortion stigma, and how their language choices might impact patient care and patient experience.  See page 122

The impact of laws regulating abortion provision in the USA

In the USA, Targeted Regulation of Abortion Providers (TRAP) legislation is common and can impose extensive and sometimes costly requirements on abortion providers and facilities, potentially leading to barriers to care. Austin and Harper conducted a systematic review of the literature on TRAP laws and their impact on abortion trends and women’s health. Only  six studies met their rigorous inclusion criteria and the designs and measured outcomes varied, making comparison difficult. Nevertheless, there was evidence that some of the laws may be associated with reductions  in abortion rates in certain states. Further research is needed to gain better understanding of the impact of TRAP laws on women’s health outcomes.

In their accompanying Commentary, Liang and Acharya make the important point that TRAP laws, whether or not known by that acronym, are not solely a US phenomenon and that the impact of legislative restrictions on abortion services elsewhere should also be investigated. They conclude that as abortion is known to be safe in deregulated settings, it is very unlikely that extensive regulation, as seen in TRAP laws, will be found to have any beneficial impact on women’s health.  See pages 128 and 134

Telephone counselling for subdermal implants and IUC

This Better Way of Working article describes a trial of a telephone counselling clinic as an alternative to in-clinic counselling for women interested in a subdermal implant or IUC. Patients who completed feedback stated that telephone counselling was convenient, that they felt equipped with knowledge and prepared for their procedure, and would recommend the service to a friend. Practitioners also supported this change and contributed useful suggestions for improving the patient experience, including identifying situations in which a telephone appointment might not be appropriate.  See page 136

The personal impact of a newspaper ’sting' operation

In 2012 consultant gynaecologist Claudine Domoney and two other doctors found themselves the subjects of a newspaper article alleging that they were prepared to offer illegal gender-selective abortions. In an interview with Dr Kate Womersley, Ms Domoney describes her reactions to the article and the surrounding furore, and her experience of the pressure of subsequent tribunal hearings. While ultimately exonerated and able to return to full medical practice, she is only too aware of the stress that other doctors who do not have the benefits of an established career, seniority and strong support from colleagues must go through in similar circumstances. She is particularly concerned by the ongoing case of Dr Hadiza Bawa-Garba, a paediatric trainee found guilty of manslaughter, who lacked the support structures from which Ms Domoney benefitted.  See page 139

Sexual and reproductive health and rights: a major goal for developing countries

In their Personal View article, Sundewall and Poku face the fact that the targets of the 2030 Sustainable Development Goals that were adopted by the United Nations in 2015 are likely to be commitments that are aspirational rather than compulsory. They argue that one of the most far-reaching and indeed sustainable investments that could be salvaged for improving health in developing countries would be a concerted effort to improve sexual and reproductive health and rights (SRHR), the concept of human rights applied to sexuality and reproduction. In numerous examples they show  how such rights could be implemented, and at low cost. The establishment of Universal Health Coverage as a human right would facilitate promotion of SRHR in countries where the introduction of such rights has traditionally met resistance. This is a thought-provoking article that will repay being read in detail. See page 142

Continual honing of listening and reflective skills benefits practice

The importance of listening to patients and really hearing what they are saying is highlighted in this issue’s Person in Practice column. Investigating a patient complaint led Abi Berger to reflect on how the case evolved, and how her reflections continue to influence her practice. Since healthcare professionals must now include evidence of reflection in their appraisal portfolios, she reminds us that even experienced practitioners may be able to learn lessons from younger colleagues, who become accustomed to reflecting on practice early in their training, and as a consequence are more comfortable with this important skill. See page 144

Venus

Venus has been busy once again, scouring the scientific literature to find articles that journal readers might not have encountered in their general reading. Two findings with wide-reaching implications for SRH practice are that there are definite cost savings associated with the early diagnosis of HIV, and evidence from a systematic review that non-rifamycin antibiotics do not interfere with the action of combined hormonal contraceptives. Three items focus on women’s general wellbeing, including ensuring that menopause-related challenges are accounted for in the workplace, raising awareness that lifestyle choices can impact on female sexual wellbeing, and finally that a cup of herbal tea can ease mastalgia. See page 152