Introducing BMJ Sexual & Reproductive Health: an international voice for sexual and reproductive health and wellbeing

We are delighted to welcome you to the first issue of BMJ Sexual & Reproductive Health (BMJ SRH), the successor to the Journal of Family Planning and Reproductive Health Care. In an editorial we introduce the new title, which reflects the journal’s intention to develop as an inclusive and scholarly voice for sexual health and wellbeing worldwide. With its shared ownership by the UK Faculty of Sexual & Reproductive Healthcare (FSRH) and BMJ Journals, BMJ SRH will welcome rigorous and thought-provoking submissions on sexual health in all its contexts, as well as showing an increasing commitment to the inclusion of patient perspectives and reflective writing to help shape our thinking. We hope that you will enjoy and contribute to the new journal. See page 3

Conscientious objection in sexual health: respecting diverse views but emphasising patients’ rights

In their editorial, the FSRH’s President and Chief Executive Officer describe the process by which the Faculty reviewed and updated its guidance for those whose personal beliefs might conflict with the provision of abortion or any method of contraception. The working group first defined essential and universal ethical principles that needed to be applied, and these led to the core principle that a patient should never be put at any disadvantage as a result of the views of any healthcare professional (HCP) they may see. So the heart of the new guideline is that the Faculty welcomes members with a range of views who are willing to show that they will put patient care first, regardless of their personal beliefs. See page 5

Contraception and gynaecological care for adolescents with disabilities

In their wide-ranging review of evidence on contraception and gynaecological care for adolescents and young women with disabilities, Dickson and colleagues remind us that such women are as likely to need contraception as their peers, and that hormonal methods may be particularly helpful for managing menstrual and cyclical problems to help improve their quality of life. They highlight the legal and ethical issues that need to be considered, particularly as this group is highly vulnerable to sexual exploitation and abuse, and the importance of multidisciplinary teamwork for recognising and addressing the concerns of the patients and their carers effectively. This review article successfully summarises the available evidence and provides very practical guidance.

In two linked commentaries, a patient’s mother describes the invaluable help she received when she met a sexual and reproductive health (SRH) consultant, and two consultant community paediatricians describe the benefits of being able to refer adolescent girls with disabilities to their local child and adolescent sexual health service. Taken together, these three articles will be of great assistance to practitioners who are faced with the complex needs of this group of young women. See pages 7, 13 and 14

British people obtain contraception from increasingly diverse sources

This sub-analysis of the 2011 Natsal-3 study yielded fascinating data regarding the provision of contraception across Britain at the turn of this decade. Data derived from the 7800 participants in the nationwide survey tell a tale of contraception provision from increasingly diverse settings. While general practice remains the venue of choice for contraceptive provision for most women, and retail venues (and pub toilet vending machines?) the means of obtaining contraception for most men, community clinics have grown as a source in the 10 years since Natsal-2. Community clinics also serve the contraceptive needs of a younger and more at-risk demographic. The diversification of contraceptive provision may be interpreted as a success of national policy objectives to increase access to contraception in the intervening decade. See page 16

IUDs for the YouTube generation

Our patients are accessing health information in myriad new ways, and YouTube’s online archive of video testimonials is an untapped, but unregulated, trove of information. Nguyen and colleagues sought to examine the accuracy of information on, and projected acceptability of, YouTube intrauterine device (IUD) user testimonials, systematically analysing the videos using a structured guide. Of 62 videos reviewed, two-thirds mentioned side effects – particularly bleeding, pain and partner sensation of the strings. About one-third of videos contained inaccurate information, and 30% were thought to project an overall negative experience. It seems that online content is generally accurate and the benefits of patient-delivered information cannot be underestimated. More regulated clinical information could be delivered in this way. See page 27

Six-week follow-up after IUC insertion was still common in USA study

Of 380 women who had intrauterine contraceptives (IUCs) inserted in this study from the University of Kansas, USA, the records of over 90% documented physician recommendations that they should return for follow-up in 6 weeks. Of those women, two-thirds returned. Excluding removals at the 6-week visit itself, the frequency of IUC removal beyond the 6-week window was the same for patients who did not attend as for those who did. Despite the recommendation by the United States Centers for Disease Control and Prevention (CDC) to abandon the follow-up visit advice, visits were still common, with no demonstrated value added. See page 32

Evaluation of counselling to include tailored use of combined oral contraception in clinical practice

The combined oral contraceptive pill (COC) is the most prescribed method of contraception in the UK, and although a variety of regimens are clinically safe, women are not routinely counselled about the choices. In this qualitative study using a structured counselling format, HCPs advised new and established COC users attending an SRH service about tailored ways of taking monophasic pills, such as a shortened pill-free interval or omitting the pill-free interval (’tricycling'), as well as the standard regimen. Nearly all patients felt it was helpful to be informed of the different ways of using the COC and 88% of HCPs did not think the consultations took significantly longer than usual. See page 36

Factors affecting condom use by people living with HIV in Malawi

Despite advances in HIV testing and antiretroviral ’Treatment as Prevention' (TasP), condoms remain an important strategy for HIV prevention in people living with, and at risk of, HIV infection. Haddad and colleagues undertook a sub-analysis of a cross-sectional survey of 470 sexually active people living with HIV in Lilongwe, Malawi. Of respondents, 38% of women and 51% of men reported consistent condom use. The ability to refuse sex without condoms was associated with condom use in both men and women. Consistent use increased with longer antiretroviral use. Using effective contraceptive methods did not alter condom use behaviours. While condom use overall was inconsistent, it is fascinating to note that in this cohort at least, the promotion of specific HIV prevention strategies, such as TasP, does not reduce other HIV prevention behaviours. An area to watch with interest. See page 42

Assessment of urinary pregnancy tests for the success of early medical abortion

Self-assessment of abortion outcome using low-sensitivity urine pregnancy tests is increasingly becoming evidence-based medical care. How can the uncomplicated nature of medical abortion be verified when many women are treated outside of healthcare facilities? Millar and Cameron from Edinburgh, UK assessed the use of two low-sensitivity urine hCG tests for verification of completeness of early medical abortion. They found that despite the tests having different methods of testing, use of a  home test combined with educating women about the symptoms of likely continuing pregnancy was very effective in detecting possible ongoing pregnancies. Their findings are important and likely to change medical practice, allowing increased individualisation of post-abortion care. See page 54

Evolution of a ‘one-stop’ outpatient MVA service for termination of pregnancy

This ’Better Way of Working' article describes a same-day manual vacuum aspiration (MVA) service, enabling access to abortion with no delay. Although developed over 40 years ago, MVA has not been widely adopted in the UK. Its convenience and cost-effectiveness are under-recognised. For women, the advantages include no need to starve or to be accompanied, low average pain scores, the option of simultaneous provision of any long-acting reversible contraceptive (LARC) method, and the ability to drive home immediately. The method was highly acceptable, with 88% of women stating they would choose this procedure again. The clinic environment and staff education are key to the success of the service. More widespread availability of this clinic model would significantly enhance choice and convenience for the 80% of women seeking abortion care by 9 weeks gestation. See page 58

A service for postnatal implant insertion by community midwives

For women who find access to contraceptive services difficult, the practicalities of the postnatal period compound the issue. In this ’Better Way of Working' article, Croan et al describe a project to avoid the need for travel to a service. Community midwives were trained for subdermal implant insertion using ethyl chloride spray as the local anaesthetic. Fitting could then be offered to women in their own homes. Discussion about this option before delivery increased acceptance of implant insertion at home in the early postnatal period. Evaluation of the procedure itself showed high acceptability and high levels of preference for home insertion in the future. Further evaluation of continuation rates is ongoing. See page 61

More haste, less speed for recovery

In her latest ’Person in Practice' article, Abi Berger reflects on how, with the healing process, all too often ’quick fixes’ are sought by both patient and clinician, when what the situation actually requires are time and patience – and adherence to the treatment plan. Dr Berger appreciates the importance of offering realistic time scales to patients, and concludes that managing expectation about time is probably more important than anything else. Extrapolating this principle to the UK’s increasingly inadequately-resourced health service, she can see the obvious benefits to be gained from having properly allocated time to see the bigger picture, to take stock and to take action earlier and in a more considered way. See page 65

Venus

Once again Venus covers a range of interesting and varied themes in her latest column. Adolescents get a look in, with items on teenage pregnancy and ‘sexting’. Featured studies highlight women’s lack of fertility awareness, the beneficial effect of breastfeeding on women’s sleep patterns, and the important finding that oral micronised progesterone reduces the rate of recurrent spontaneous preterm delivery. Men aren’t left out either, with a consideration of depressive symptoms in first-time expectant fathers during their partner’s pregnancy, and the assessment of a safer sex website that men awaiting appointments at sexual health clinics were able to access. See page 74