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Home use of misoprostol in England is supported by evidence
In England, women seeking medical abortion are required to make two trips to the clinic, the first to receive mifepristone, and the second to receive misoprostol. This regimen places barriers in their way, particularly in rural locations or if they have work or childcare commitments. Taking misoprostol in the clinic also means that some will start to abort on their way home. In their editorial, Lord and his co-authors, who include the FSRH and RCOG Presidents, describe how re-interpretation of the 1967 Abortion Act in Scotland and Wales has changed policy to allow the use of misoprostol at home. They argue that simple action by the UK Health Minister to designate the home as an eligible site for misoprostol administration would also permit change of policy in England. Such action would pave the way for a service that is both evidence-based and responsive to women’s needs. See page 155
Developing patient-based quality indicators in abortion research and practice
Safety and effectiveness are two key indicators of the quality of abortion care worldwide. But people’s experiences accessing and engaging with services go beyond these two important domains. Darney and colleagues' editorial discusses additional measures of quality, including interpersonal experiences and clinical practices. They propose the development of quality of care metrics that are evidence-based and validated to reflect the perspectives of patients. This article challenges us to think beyond the ‘safe versus unsafe’ dichotomy in abortion research and practice, and to address other important aspects of the patient experience. See page 159
Sex robots and health
Sex robots (’sexbots') are anthropomorphic devices created for sexual gratification. Despite their fictional representation in films and in television series such as Westworld, they are no longer the stuff of fiction alone. In their eye-opening but objective editorial, Cox-George and Bewley assess evidence for potential health implications of the expanding sexbot industry. They found no reports of primary health data, but important themes emerged on reviewing available information and in discussion with experts from various specialties. They conclude that as there is a lack of evidence for alleged health benefits of sexbots, they should not be used clinically until such benefits have been tested in properly conducted research. See page 161
Influence of women’s relationships on contraceptive choice
The third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3) produced a prodigious volume of data, aspects of which have been reported in this journal and elsewhere. Understanding influences on choice is essential in offering contraception that is suitable to users' lifestyles, and therefore more likely to be continued. Firman and colleagues now report on their deeper analysis of data from Natsal-3. In looking at the type of contraceptive method used, they found a stronger association with duration of a relationship than with its participant-defined status, particularly among younger women. The results suggest that asking about partnership characteristics, including duration, may help providers support women in their use of contraception by considering their priorities and preferences at different life stages. See page 165
Young cancer patients’ decisions on preserving their fertility
Health professionals are challenged by a growing number of young long-term cancer survivors who must plan for their future fertility. To learn more about such women’s information needs, Tschudin and colleagues conducted an online questionnaire study of women with cancer types or treatments that had potentially affected their reproductive function. ’Decisional conflict' regarding fertility preservation was very high, but was significantly lower among those where the risk of infertility had been discussed with a health professional, if they had undergone any fertility-preserving procedures, and following university education. The authors make a plea for the provision of appropriate information to all women diagnosed with cancer in their fertile lifespan. The factors they identified will undoubtedly help in the development of suitable decision aids for female cancer patients. See page 175
Women’s voices on abortion in Ireland
On 25 May 2018, citizens of the Irish Republic voted overwhelmingly to repeal the Eighth Amendment of their constitution which effectively prohibited abortion. Yet for years Irish women have obtained safe abortions by travelling to clinics abroad, or more recently by illegally sourcing drugs online for medical abortion. Last year, Aiken and colleagues investigated such women’s experiences using semi-structured in-depth interviews. Key themes that emerged included lack of support in the Irish healthcare system before and after abortion, shame and stigma induced by laws and attitudes, and desperation while searching for access to safe abortion. Self-managing medication abortion at home was preferred by some to travelling abroad. This study’s findings, which this journal published online before the recent referendum, may have contributed to objective discourse on the needs and attitudes of Irish women with unwanted pregnancies. See page 181
Advance notice of contraceptive availability at surgical abortion
This pilot randomised controlled trial assessed the impact of an informational telephone call prior to the surgical abortion visit on patient contraceptive knowledge. Women were randomised to an intervention telephone message or a control message without contraceptive information. The intervention call improved knowledge that long-acting reversible contraception (LARC) is available immediately after surgical abortion. The study demonstrated that abortion patients have baseline misconceptions about short-acting reversible contraception (SARC) and LARC, particularly regarding the availability, safety and effectiveness of LARC. Women in the control arm believed that SARC was safer to initiate post-abortion and more effective at preventing pregnancy. There is potential for a simple and acceptable intervention to address common misconceptions that may contribute to a low uptake of LARC at surgical abortion. See page 187
Illegal abortion in Haiti needs educational interventions
Haiti has the highest maternal mortality rate in the Western hemisphere and abortion there is strictly illegal. In their mixed-methods study, Berry-Bibee and colleagues conducted interviews about abortion practices with women and with women’s health providers. They then surveyed women in, or soon after, a pregnancy of ≤20 weeks’ gestation and obtained more information from women who had tried to induce abortion in that pregnancy. The picture that emerged was of widespread knowledge of misoprostol for self-managed abortion, but much poorer knowledge of the safest management options. Significantly, men played key roles in abortion decision-making and in accessing misoprostol. The authors conclude that public health efforts in Haiti should follow a model of harm reduction and of education about post-abortion contraception, but that efforts should be made to increase access to safer abortion services for all women. See page 193
Malaysian doctors' knowledge, and practice regarding IUD use
While copper intrauterine devices (IUDs) are known to be highly effective, safe and economical long-acting contraceptives, they are little-used in Malaysia. To try to establish the reasons for this, Chew and colleagues surveyed doctors in general and gynaecological practice in Kuala Lumpur and found that only 45% of private doctors and 63% of government doctors believed that IUDs are an effective contraceptive method. Almost 30% were unaware of the use of IUDs for emergency contraception (EC). Doctors working in the government sector had significantly higher knowledge scores than private doctors. Their conclusions are universally true: ongoing training and supervision are needed to reduce knowledge deficiency, but translating evidence from clinical trials into daily practice is no easy task. See page 200
Young women’s thoughts on LARCs and pregnancy intention
LARCs are highly effective, yet uptake remains relatively low in young women, despite high unintended pregnancy rates. Coombe et al conducted qualitative interviews with 15 young women to explore the relationship between pregnancy intention and LARC use. They found that while women who had plans for future pregnancy often considered LARCs as part of their plans, women who were more ambivalent with regard to pregnancy were less likely to use LARCs. A key reason for this was that LARCs require fitting and removal by a medical professional and thus leave less room for inconsistent use or ‘accidents’, which may work more consistently with women’s ambivalence regarding pregnancy intention. This study offers new, woman-centred insights into the complex relationship between pregnancy intention and LARC use. See page 207
Time to re-think COC regimens
Seven ’pill-free' days are a legacy of the introduction of combined oral contraception (COC) over 50 years ago. But in their comprehensive and persuasive review, MacGregor and Guillebaud point out that those 7 days are in fact a ’contraceptive-free interval' (CFI), with the risk of escape ovulation if resumption of pill-taking is delayed, as it commonly is through forgetfulness or unavailability of pills. In addition to potentially reducing the risk of pill failure, shortening or eliminating the CFI leads to reduction of hormone withdrawal symptoms, fewer days of bleeding per year, and reduction in the need for EC. In addition to awakening prescribers to the benefits of non-standard regimens, perhaps this review will persuade manufacturers to market licensed preparations more suitable for the second half-century of COC. See page 214
Simple reminders of best practice guidelines could reduce NHS costs
Unnecessary laboratory tests contribute to the financial strain on an under-funded National Health Service (NHS). In this Better Way of Working article, Viney and Mansour describe how a simple intervention at an integrated sexual health service reduced unnecessary mid-stream urine culture requests for suspected urinary infections. The authors reminded clinical staff of best practice by emailing them the guidelines and displaying laminated copies on all urinalysis machines. This simple, low-cost intervention led to a 66% reduction in unnecessary requests and saved their service £2060 per year. See page 221
Loss of children after sterilisation in India
In his heartfelt Personal View, Pavan Pandey draws attention to the fact that female sterilisation is the most common method of family planning for couples in India with two or more children. Sadly, child mortality rates in India remain higher than in many other countries and it is not uncommon for couples to suffer child loss after sterilisation. Such couples are often poor or illiterate, and while adoption or assisted reproduction technologies might offer hope elsewhere, in practice they are unavailable to these unfortunate people. Pandey makes a strong case for the Indian government to offer greater access to sterilisation reversal. But he also makes the important point that greater availability of long-acting contraceptive methods would reduce his country’s dependence on sterilisation for contraception. See page 223
Most people find the idea of change challenging. In her latest Person in Practice article, Abi Berger reflects on her recent move to another GP practice. Looking back on the experience, she is aware that she went through the classic stages of change, but that this process required her to first give herself permission to make that change. A thought-provoking article that will resonate with both healthcare professionals and patients. See page 226
Venus takes her customary stroll through the SRH literature, searching out interesting articles for journal readers’ education and edification. Themes include analgesia in early medical abortion, young men’s role in pregnancy prevention via EC provision, intrauterine contraception following caesarean section, increasing adolescent gender identity service referrals, and facilitating stigma and discrimination detection in bisexuals. A varied selection of articles indeed! See page 232
Competing interests None declared.
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