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Abortion services in the UK need less hypocrisy and more acknowledgment of complexity

As 2017 gets under way, the USA swears in a new president with anti-abortion views, the UK marks 50 years since the 1967 Abortion Act, abortion remains a hot topic. Patchy access to services, inadequate training, a dwindling workforce and an unhelpful culture of exceptionalism blight UK abortion services, as highlighted by a collection of articles in this journal issue. While UK practitioners rally in new organisations and campaigns, an editorial calls for reform of its hypocritical and antiquated abortion law, but also for respectful debate which acknowledges the subject's complexity. See page 3

Iran's pronatalist policy risks disadvantaging the poorest, most

The political changes Iran has seen in recent decades make it a kind of natural experiment in family planning. An editorial by the journal’s International Advisory Editor, formerly resident in Iran, summarises the country’s family planning (FP) history in the light of an article in this issue (see page 37). Initially introduced as a maternal and child health measure, FP in Iran has always been subject to both liberal and conservative social and political influences. But a major swing to a pronatalist policy now promises to restrict access to contraception severely. The author argues that while it is government’s prerogative to legislate, it has no place in the bedrooms of the nation. See page 5

Abortion care lags behind other areas of healthcare in defining quality

How do we know what ‘good’ looks like in abortion care? This systematic review sets out to define quality in abortion care. The authors found more than 75 quality indicators proposed in the peer-reviewed and grey literature, spanning areas as diverse as policy, trained-provider availability, support for women's decision-making, and clinical safety. The diversity of indicators reflects the complexity of abortion care, but the lack of agreement and consistency between publications demonstrates the lack of a universal, translatable model. Abortion providers must drive this agenda, define what good looks like, and then hold themselves up to this standard. See page 7

Legalising abortion in Victoria has empowered women and protected clinicians, but not improved services

Some 7 years on from legislation to decriminalise abortion in Victoria, Australia, access has not improved sufficiently, according to a new qualitative study. Nineteen experts working in abortion services across the state before and after law reform were recruited into a semi-structured interview study. Themes included a lack of or delay in access to abortion after 20 weeks, and limited free surgical procedures. Both they and in their view the service users felt continuing stigma about abortion. They identify a disconnect between changes in the law and health policy change. Whilst respondents applauded the achievement of three key goals of law reform (redefining abortion as a health issue, increasing the decision-making process for women rather than doctors, and protecting clinicians performing procedures), not enough had changed to enable adequate access to services. See page 18

‘Repeat abortion’ may be a stigmatising term, best avoided

Do we categorise women seeking an abortion by their previous abortion history? A study looking at young women's abortion experiences uses participants’ own narratives to explore abortion-related stigma and influences on their post-abortion reproductive behaviour. Unsurprisingly, women's contraceptive histories and reproductive lives can be complex and the circumstances leading to the need for one abortion may differ from those in which a further abortion is requested. The authors argue that using previous abortion episodes to categorise women seeking an abortion is not helpful – indeed it may be damaging, and stigmatising. The first-person accounts in this article, particularly accounts of difficulties with contraception and of feelings of guilt, give plentiful food for thought and should give us reason to pause when we make assumptions about the young women consulting us. See page 26

LARC uptake after abortion is higher in an SRH clinic than in a hospital service

Does the place of termination have an influence on subsequent use of long-acting reversible contraception (LARC), which has been shown to reduce the risk of repeat abortion? This retrospective database survey compared the uptake of LARC in women undergoing abortion within a hospital gynaecology department and those using a community sexual and reproductive health (SRH) clinic. Women assessed and attending the SRH clinic had a higher uptake of LARC than those attending the hospital service. The reasons for this are not clear, but all services should have adequately trained staff to provide LARC before discharge after abortion. See page 31

Curbing FP in Iran puts poor women with completed families at risk

What happens when population pressures downward lead to changes in population policy and availability of reproductive health services? In Iran a new pronatalist Bill is under discussion, in an attempt to raise the national below-replacement fertility rate apparent since 2000. The study investigates who is most at risk if subsidised contraceptive methods (sterilisation, intrauterine devices, and injections) are curbed. Interviews were conducted with contraceptive users (married women aged 15–49 years) identified from a 2014 Tehran Fertility Study. It is poorer women wanting no more children that are most at risk. Couples make decisions about their own fertility. Every family and maybe especially the poor should have access to services to support their choice ‘no more children, we have enough’. Considering women's right to access reproductive health services is key to developing and implementing an appropriate population policy. See page 37

When designing services, multiple methods are needed to capture stakeholder views reliably

Using only one research tool leads to limited understanding when studying the opinions of a group of people. This study investigated stakeholder perception of FP barriers in Lilongwe District, Malawi. Five stakeholder focus groups (FGs) were followed by 960 individual interviews with women with at least one child aged under 5 years. The FGs identified lack of awareness and access; preference for traditional methods; dislike of side effects; beliefs, myths and misconceptions; and opposition by husbands. In contrast, the survey interviews found the majority were not using modern FP methods because they were not currently having sex or had had a child recently. Very few reported husband opposition or difficulty accessing services. Multiple methods of enquiry are needed to obtain a fuller picture of stakeholder perceptions for service design. Inherent contributions of different approaches need recognition, including that qualitative methods are more likely to uncover motives and reasons that are often difficult to elicit using closed quantitative interview questions. See page 44

A quarter of FSWs in sub-Saharan Africa have unmet contraceptive needs

Two articles look at sexual health in a particularly vulnerable group – female sex workers (FSWs) – on two continents. The first, looking at the prevention of mother-to-child HIV transmission in sub-Saharan Africa finds complex contraceptive goals and needs, with few easy conclusions. Using behavioural surveys and HIV counselling and testing in a respondent-driven sample, the authors found that a quarter of women had unmet contraceptive needs, and that, perhaps counterintuitively, condom use was higher with clients than with non-paying partners. See page 50

Pill use is associated with less consistent condom use in FSWs in Southern India

Meanwhile another respondent-driven HIV risk survey from Southern India found that pill use was associated with less consistent condom use with clients, though not with non-commercial sexual partners. Sterilisation, which was associated with older age, did not show the same negative association with consistent condom use. Like the African study, this one also found an unmet need for modern, spacing contraceptives. See page 60

A local protocol helped streamline management of osteoporosis risk with progestogen-only injectables

The issue of depot medroxyprogesterone acetate (DMPA) and its effect on bone mineral density (BMD), and how to manage this in clinical practice, is still uncertain. This article describes a clinician's experience of using a protocol to assess osteoporosis risk in women using injectable contraception (DMPA). The protocol is demonstrated, and a departmental audit described. The audit findings document that lowered BMD is a common finding in women using injectable contraception. This protocol has helped streamline care for patients on DMPA, and appropriate use has resulted in reassurance for some users, who can continue to use DMPA without due concern. For others it has highlighted relatively poor bone health and helped support what are probably more favourable decisions on contraceptive use. See page 67

Ignorance over cervical preparation blocks access to best treatment for mid-trimester abortion

Many UK women are denied National Health Service (NHS) access to the safest and preferred method of second-trimester surgical abortion due to misunderstood concerns about cervical damage, according to one experienced practitioner. The author summarises the evidence that dilatation and evacuation, or D&E, has a lower rate of immediate complications causing less pain and bleeding than medical induction, as well as being faster, cheaper and preferred by the majority of women. Setting this against the evidence that proper cervical preparation prevents preterm birth, he criticises poor access in the NHS, where only a single hospital offers the service up to the legal limit of 24 weeks. Instead of women being denied access to best treatment, he argues that guidance should reflect the complexity and detail of the available data. See page 70

The debate on abortion law reform needs to make space for a variety of views

The abortion debate is a complex and multifaceted one, and so unsurprisingly engenders strong feelings and opinions in those on both sides of the debate. In this issue, an SRH consultant shares her considered views on conscientious objection, a topic on which she spoke at a recent FSRH meeting on abortion law reform. Her personal view article comments on time limits, and on situations when a fetal anomaly or disability is detected, and concludes that ultimately the law must continue to balance protection of the fetus with the rights and interests of the woman with an unwanted pregnancy. Whatever one's personal views on the rights and wrongs of abortion, surely this basic premise should form a cornerstone of any abortion debate? See page 72

Self-care is hard to achieve but important for everyone

In her latest Person in Practice article, Abi Berger reflects on the importance of self-monitoring and better self-care, and the need to take time out from stressful work and life. Having observed the detrimental effects of stress and burnout in her patients over the years, the author has decided to take positive action by taking a much-needed break from her day job. Surely there's a valuable lesson here for all of us with busy lives? See page 76

A new German film confronts the sensitive question of late abortion

While book reviews feature regularly in this journal, we rarely publish film reviews, and so are particularly pleased to present an insightful and timely review of a film that has received praise at the Berlin film festival, ‘24 Weeks’ (24 Wochen). Exploring the theme of late abortion, this film complements the cluster of articles about abortion in this issue. See page 83

Venus

In her quarterly quest for interesting and relevant SRH-related research, Venus travels this time to Australia, North America and Europe. The studies she highlights include the discovery that HPV vaccination helps prevent HPV/chlamydia co-infection; the insight that Australian women lack information about medical termination, and are more likely to choose surgical abortion; and new, controversial evidence of a possible link between depression and the pill. Men get a look-in, this time, with one study reporting that obesity has a negative effect on male fertility, and the second suggesting that the long-awaited breakthrough in male contraceptive research might occur in the next decade. See page 86

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