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The impact of Northern Ireland’s laws on women seeking abortion

Despite Northern Ireland being part of the United Kingdom, abortion remains illegal there except in very limited circumstances. Aiken and colleagues interviewed 30 women who had sought abortion by travelling to clinics in Great Britain or by using online telemedicine to self-manage a medication abortion at home. The key themes that emerged from the in-depth interviews were that there are multiple barriers to travelling for abortion services even when abortion is provided without charge, that self-management is often preferred over travel, that Customs can obstruct import of abortion medications, and that there is mistrust of the healthcare system because of fears regarding the legal obligations of healthcare professionals. Northern Ireland’s abortion laws affect the quality and safety of women’s healthcare and can have serious implications for women’s physical and emotional health. This study’s findings offer new perspectives for the debate over Northern Ireland’s abortion laws and suggest a public health rationale for decriminalising abortion. See page 3

Intimate partner violence and pregnancy decision by underprivileged women in India

Numerous factors are implicated in the high rate of unintended pregnancy in India, including lack of education, poverty, social factors such as son preference, and intimate partner violence (IPV). Dasgupta and colleagues analysed data from a large study of mothers of infants in slum communities in Mumbai, focussing on the relationship between IPV, ’external' decision-making by husbands and in-laws, and unintended pregnancy. Women who reported externally-decided pregnancies and pre-pregnancy IPV were significantly more likely to have had mistimed pregnancies than intended pregnancies, reflecting the low engagement of married women in family planning decisions. Although mistimed, the recent pregnancies were not generally reported as ’unwanted', and the authors discuss possible reasons for this finding. This study highlights the need for women’s involvement in reproductive decision-making an in formulating messages on IPV reduction when women’s healthcare services are being programmed. See page 10

Innovative approaches to safer sex: messages from imprisoned American women

For incarcerated women, transition into the community is known to be accompanied by an increased frequency of behaviour that may increase the risk of acquisition of sexually transmitted infections (STIs). Few efficacious interventions have addressed STI prevention among such women. ‘Sexual health prevention for incarcerated women: eroticizing safe sex during community re-entry’ was an exploratory qualitative study with 21 women in detention in the USA, exploring perceptions of STI prevention methods and strategies to overcome the challenges in implementing these. The authors suggest that the period prior to release and the reintegration period offer ideal opportunities for intervention. They explored narratives of sexual negotiation and challenges in the uptake of prevention strategies such as the use of condoms. The women themselves were colourfully outspoken in identifying approaches to increasing protective behaviours and the authors hope that this could inform the design of future STI prevention interventions. See page 17

A case management programme for women seeking later second trimester abortion in the USA

Abortion access has become increasingly restricted in the USA, and women requiring later second trimester abortions, particularly those in low income groups, face barriers in finding units that can accommodate their needs. Ho and colleagues reviewed data from the Massachusetts Access Programme, which was established to facilitate access to appropriate providers. The study describes core programme services as well as a patient navigator role that was identified by providers as key in sorting through the evolving abortion landscape. They conclude that the Massachusetts Access Programme is a highly acceptable, potentially replicable intervention that has shown ’some success' in improving abortion access and that their findings could shape future interventions aimed at removing barriers to abortion services. See page 23

An evaluation of the quality of online information for women seeking abortion

In developed countries, women with unwanted pregnancies will usually turn to the internet when seeking help in accessing abortion services. Sadly the information that they retrieve may be inaccurate, or unrelated to the jurisdiction in which they reside. Duffy and colleagues performed a formative evaluation of 619 abortion-related websites, of which 83 dealt with accessing services. The searches (in 2016) were performed from the perspective of users in England, Northern Ireland and the Irish Republic. The sites were evaluated using an Abortion Service Information Assessment Tool (ASIAT), developed by the authors. Fewer than one third provided information that was rated as ’good' or ’excellent'. They conclude that the needs of users must be central to the design of websites; their tool can assist organisations to identify areas for improvement in their own information. This report of a very robust study will repay detailed reading by all abortion providers. See page 32

Menstrual restriction and intimate partner violence in Nepal

In certain areas of Nepal, ’menstrual restriction' is widespread. During menstruation, women and girls must leave their home, sleep wherever they can find a place, and girls must miss schooling. In August 2017, Nepal passed a law criminalising the most restrictive forms of this practice. Nepal has also been seeking to reduce the incidence of emotional, economic or physical and sexual intimate partner violence (IPV). Cardoso and colleagues analysed data from a large randomised trial of IPV reduction to record the prevalence of menstrual restriction among married women and to examine potential associations with IPV. While the prevalence of both was high, after controlling for demographic variables no form of IPV was found to be associated with a high menstrual restriction rate. The authors conclude that the well-being of women and girls might best be served by water and sanitation programmes, which would do much to reduce menstrual stigma. See page 38

Removal of intrauterine contraception with non-visible threads

A small proportion of women using intrauterine contraception (IUC) present with threads that are not visible at the cervical os. Elizabeth Stephens reviewed a series of such women who presented at a specialist clinic for device removal. Over 90% of those who required intervention had successful IUC removal in the clinic with the aid of ultrasound and simple instrumentation. But the most interesting finding of this study was that when uterine cavity length was measured, comparison with the combined length of the devices and threads suggested that 91% of the devices had not been placed fundally at insertion. Non-fundal placement of IUC is therefore likely to be a highly significant cause of non-visible threads. The author suggests that performing an ultrasound scan immediately after IUC insertion would allow non-fundal devices to be removed and replaced, reducing the incidence and inconvenience of ’lost' threads. See page 44

A feasibility trial of a suction cervical retractor for IUD insertion

A new suction cervical retractor, the Bioceptive SCR, is a device designed to replace the standard single-tooth tenaculum to apply atraumatic traction to the cervix. A three-stage feasibility trial was conducted on this device for intrauterine device (IUD) placement. The study included a small randomised trial assessing pain scores with the SCR and a conventional tenaculum. The study showed that use of the SCR device for IUD insertion appears to be safe and clinically acceptable both for patients and providers. While there was a trend towards lower pain scores with the SCR, the study was not powered to detect statistical significance and the authors therefore suggest that further studies of the device are warranted. See page 47

Hormonal contraception reduces anaemia risk in African countries

In countries where anaemia is prevalent, the relationship between contraception use or non-use, pregnancy, lactation and anaemia is complex. Very few studies have investigated whether different contraceptive methods modify women’s anaemia risk. Using data from Africa-wide Demographic and Health Surveys, Gebremedhin and Asefa reviewed the haemoglobin status of women of over 105 000 women using various fertility regulation methods in 24 sub-Saharan countries. The association between contraception method and anaemia was assessed using a logistic regression model, adjusted for potential confounders. They showed that the use of injectables, oral contraceptives and implants is associated with reduced risk of anaemia and also that anaemia prevalence declines with longer use of injectables and oral contraceptives. The results of this study could do much to inform both health policies and family planning policies in many countries where anaemia continues to be a major problem. See page 54

An initiative to improve postpartum contraception provision in a UK hospital

Discussion and provision of contraception should be part of maternity care, both in the antenatal and postpartum periods, to enable new mothers to commence a secure, preferably long-acting, method of contraception as soon as possible. But implementing such arrangements can be difficult. In their article in this journal’s Better Way of Working series, Brammeier and colleagues describe the development and commencement of a ’postpartum family planning initiative' at the University Hospital of Wales, Cardiff, UK. The initiative has three aims - to train midwives in antenatal and postnatal contraceptive advice and care, to develop information for pregnant women on their post-natal contraceptive options and to offer contraception supplies to every maternity patient before their discharge after delivery. The information on the problems that were faced, and the ways in which they were overcome, will be of benefit to any maternity unit planning similar developments. See page 68

Advertising Standards Authority upholds complaint about contraception app’s marketing campaign

In our last issue, Hough and colleagues reported critically on the advertising methods and claims of the Natural Cycles fertility awareness app – a method popular with some women because it appears to give them more personal control over their fertility than some pharmaceutical methods. Hough submitted a complaint to the UK Advertising Standards Authority (ASA) and on 29 August 2018 the ASA concluded that the company’s claims of ‘highly accurate contraceptive app’ and ‘clinically tested alternative to birth control methods’ were indeed misleading. In their Personal View, Hough and Bryce report on the background to the ASA’s judgement, the most important feature of which was that the effectiveness of Natural Cycles had been exaggerated by the use of ’perfect use' rather than ’typical use' Pearl Index rates. Advertising content like this can now be restricted in the UK, but on a world-wide basis, internet-based misinformation will undoubtedly continue - as it does in so many other spheres. This debate emphasises how good contraception is about accurate information aswell as biological safety. Natural Cycles have been offered a right of reply. See page 71

The effects of UK immigration policies on migrants’ access to sexual and reproductive healthcare

In her insightful essay, which won the FSRH’s 2018 Margaret Jackson Prize for medical students, Isabelle Whelan reviews the ways in which the UK government’s ’hostile environment' policy threatens migrants' ability to access treatment, endangering their own health and having potential wider consequences for public health. Examples include the need for ’overseas visitors' to pay in advance for non-urgent NHS care in England and the agreement between NHS Digital and the Home Office to share confidential patient information. Whelan discusses the implications for sexual healthcare access, particularly relating to HIV, the needs of sex workers, reproductive healthcare including contraception and abortion, and late presentation for antenatal care. Her powerful conclusion is that current policies pose barriers to access to care for some of the most marginalised people in our society and that SRH staff must not be complacent in thinking that those policies will not affect their services. See page 74

Footnotes

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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