Increasing access to medical abortion

Introduction: Unsafe abortion kills approximately 47000 women per year. However, women in high resource settings may also have difficulties in accessing safe abortion facilities due to high cost, a large number of visits required or difficulty in finding an abortion provider. The object of this thesis was to examine ways to increase access to medical abortion. Materials, methods and results: Study I: Home use of misoprostol may decrease cost, the number of required visits and by attracting women who dislike hospitals. A total of 395 women with gestational age up to and including 63 days were recruited to investigate efficacy and acceptability of home use of misoprostol. Women with gestational length lower than 50 days were compared to women with gestational length of 50 days or higher. Efficacy of the procedure was high (97,5%). Overall acceptability of the procedure did not differ between the groups (p=0,36) and was not related to gestational age (p=0,097). Study II: In the second study the objective was to assess which factors had a significant influence on the acceptability of home use of misoprostol in the same group of patients. Potentially influential factors were recoded into categorical variables and evaluated using logistic regression. In the final models parity (p=0,003) and feeling calm after the administration of misoprostol (p<0,001) had a positive influence on the experience in relation to expectation whereas having a positive u-hcg test on follow up had a negative influence (p=0,003). Women who had a partner/friend present during the abortion were more likely (p=0,021) whereas women with a positive u-hcg on follow up were less likely to prefer home administration of misoprostol (p=0,002). Study III: Letrozole is an aromatase inhibitor and has been shown to increase the number of complete abortions when used with misoprostol only. A total of 16 women scheduled for surgical abortion were randomized to either pretreatment with letrozole or no pretreatment. Uterine contractility was measured before and after the cervical priming dose of misoprostol was given. The results were analyzed using repeated measures ANOVA. No difference in time to tonus increase (p=0,243), maximum tonus (p=0,953) or contractility between the two groups was detected(p=0,423). Study IV: Task shifting from physicians to midlevel providers may increase access to abortion services where physicians are scarce or unwilling to perform abortion provision. Before any examination had been made 1180 women were randomized to medical abortion provision by a physicianor nurse midwife. Both provisions were equally effective with the risk difference of 1,6% within the set margin of equivalence of 5% (p=0,027). Women randomized to nurse midwife were significantly more likely to prefer seeing a midwife again were they to have another medical abortion (p<0,001). Conclusions: This thesis shows that increased access to medical abortion can be achieved in several ways by either increasing use of home use of misoprostol, finding new drugs without previous abortion stigma to replace mifepristone or by task shifting provision of medical abortion from physicians to midlevel providers

Natural Cycles App: Contraceptive Outcomes and Demographic Analysis of UK Users

Objective: Digital fertility awareness-based contraception offers an alternative choice for women who do not wish to use hormonal methods or are unable to use hormones due to medical reasons. It is also popular among women who may be planning a pregnancy over the coming years and wish to educate themselves about their individual menstrual cycle and fertility. The aim of this study was to investigate the key demographics of current users of the Natural Cycles app and assess the effectiveness of the app at preventing pregnancy for a cohort of women from the United Kingdom. Setting: Users of the Natural Cycles mobile application. Participants: 12,247 women in the UK who used Natural Cycles as their primary method of contraception. Outcome Measures: Cohort demographics and risk of unintended pregnancy. Study Design: Observational prospective real-world cohort study. Results: Users contributed an average of 9.9 months of data for a total of 10,066 woman years of exposure. The mean age of the cohort was 30, mean BMI 23.4, the majority were in a stable relationship (83.2%) and had a university degree or higher (83%). The most common form of contraception used prior to natural cycles was combined oral contraceptive (COC)(39.3%). The one year typical use, PI was 6.1 (95% CI: 5.6, 6.6) and with perfect-use was 2.0 (95% CI: 1.3, 2.8). 13 cycle pregnancy probability was 7.1%. Age was found to be associated with contraceptive outcomes, those between 29-34 had a significantly higher pregnancy probability than those aged 34-45 (8.9% vs 5.0%; p=0.0005). In total 41.9% of users were still using the app at the end of the study. Conclusion: This is the first study which describes the use of a digital contraceptive by women in the UK. It describes the demographics of users and how they correlate with the apps effectiveness at preventing pregnancy. Its findings support previously published effectiveness rates for Natural Cycles in a number of countries

Contraceptive use in Sweden

<p>This is a database of 1000 women and their contraceptive use and experience of unintended pregnancy in Sweden 2012</p

Intrauterine mepivacaine instillation for pain relief during intrauterine device insertion in nulliparous women: a double-blind, randomized, controlled trial

OBJECTIVE:  To evaluate whether intrauterine mepivacaine instillation before intrauterine device (IUD) insertion decreases pain compared to placebo. STUDY DESIGN:  We performed a double-blind, randomized, controlled trial comparing mepivacaine 1% 10 mL versus 0.9% NaCl intrauterine instillation using a hydrosonography catheter 5 min before IUD insertion in women 18 years of age or older. Participants completed a series of 10-cm visual analogue scales (VAS) to report pain during the procedure. The primary outcome was the difference in VAS scores with IUD insertion between intervention group and placebo. Secondary outcomes included VAS before and after insertion and analgesia method acceptability. RESULTS:  We randomized 86 women in a 1:1 ratio; both groups had similar baseline characteristics. In the intention-to-treat analysis, the primary outcome, median VAS with IUD insertion, was 4.8 cm in the intervention group [n=41, interquartile range (IQR) =3.1-5.8] and 5.9 cm in the placebo group (n=40, IQR=3.3-7.5, p=.062). In the per-protocol analysis, the median VAS with IUD insertion was 4.8 cm (IQR=3.1-5.5) and 6.0 cm (IQR=3.4-7.6) for the intervention and placebo groups, respectively (p=.033). More women in the intervention group reported the procedure as easier than expected (n=26, 63.4% vs. n=15, 37.5%), and fewer reported it as worse than expected (n=3, 7.3% vs. n=14, 35%, p=.006). CONCLUSION:  Intrauterine mepivacaine instillation before IUD insertion modestly reduces pain, but the effect size may be clinically significant. IMPLICATIONS STATEMENT:  While the reduction in VAS pain scores did not meet our a priori difference of 1.3 points for clinical significance, participants' favorable subjective reaction suggests that this approach merits further study. Copyright © 2019 Elsevier Inc. All rights reserved. KEYWORDS:  Contraception; Intrauterine devices; Mepivacaine; Pain; VA

The use and access to contraception in Sweden during the COVID-19 pandemic period.

PURPOSE: Explore perceived access to, the need for, use of, and satisfaction with telemedicine services for contraceptive counselling and prescription-renewal-only during the COVID-19 pandemic, and the impact of the COVID-19 pandemic period on the choice and use of contraceptives. MATERIALS AND METHODS: Internet-based e-survey of Swedish women of fertile age, 16-49 years. RESULTS: In total, 1016 participants completed the survey. Most participants (69.7%) rated their access to contraceptive services 'as usual'. Among the remaining participants, a higher proportion rated their access as deteriorated (73.4%) compared to improved (26.6%; p &lt; 0.001). In total, 38.0% reported a need for contraceptive counselling, whereof 14.0% had used telemedicine for counselling and reported high satisfaction. Telemedicine for prescription-renewal-only was used by 15.1% of the total population. Two per cent reported use of another contraceptive than their intended, whereof long-acting reversible contraceptives were the most common intended method. The proportion of current contraceptive users was lower than in 2017 (62.4% vs 71.1%, p &lt; 0.001), and current users of long-acting reversible contraception decreased from 30.6% to 19.3% (p &lt; 0.001). CONCLUSIONS: During the COVID-19 pandemic period, most women found their access to contraceptive services unaffected, but more women felt that it had deteriorated than improved. The use of telemedicine was low, and the use of contraception overall fell. Efforts are needed to raise awareness of available services, and TM-provided interventions for maintained quality of care and informed decision-making remain to be evaluated. SHORT CONDENSATION The COVID-19 period imposed a change in contraceptive service provision, and efforts are needed to raise awareness of available services, including telemedicine. Access to all contraceptives, including LARCs, is crucial and telemedicine-provided interventions need evaluation

Effectiveness, safety and overall satisfaction of early postpartum placement of hormonal IUD compared with standard procedure : An open-label, randomized, multicenter study

Introduction In this open-label, randomized controlled, non-inferiority, multicenter study we aimed to study the risk of termination of pregnancy within 1 year postpartum, the safety profile and patient acceptability after early postpartum insertion of a hormonal intrauterine device (LNG-IUS, Mirena (R)) compared with standard placement 6-8 weeks postpartum. Material and methods April 2018 to January 2020 women with uncomplicated vaginal delivery at four urban birth centers in Sweden, were randomized to either early placement within 48 h after delivery (early group) or standard placement 6-8 weeks postpartum (standard group) of a hormonal intrauterine device. The main outcome measure was the proportion of terminations of pregnancies in each group during the first year after placement of the intrauterine device. Registration EudraCT database no. 2017-001945-29. Results The study was prematurely stopped according to the protocol due to an expulsion rate &amp;gt;20% in the early group. No pregnancies occurred. Fifty-two women were randomized to early and 49 women to standard insertion. In the early group, 23/52 (44.2%) of the intrauterine devices were expelled. After expulsion, 10 women chose to have another hormonal intrauterine device placed but still significantly fewer women (39/52, 75%, p = 0.22) in the early group used the hormonal intrauterine device method at study completion. No expulsions occurred in the standard group, but 5/49 (10.2%) requested removal and 41/49 (83.7%, p = 0.22) had used the hormonal intrauterine device method continuously for 1 year. Conclusions Early hormonal intrauterine device insertion after vaginal delivery is associated with high expulsion rates. Despite this, a high continuation rate of the hormonal intrauterine device method is seen among women once choosing the method. In the light of high continuation rates, the advantages of early insertion could balance the risk of expulsion for well-informed women.Funding Agencies|County Council of Ostergotland (ALF) [LIO-931995, LIO-794921]</p

Risk of abortion within 1-2 years after childbirth in relation to contraceptive choice: a retrospective cohort study

Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period. Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum. Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p = .005). Smoking, age amp;lt;25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk. Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth.Funding Agencies|county council of Ostergotland and county council of Stockholm</p

Risk of abortion within 1-2 years after childbirth in relation to contraceptive choice: a retrospective cohort study

Objectives: The primary objective of the study was to investigate whether the choice of long-acting reversible contraception (LARC) was associated with the risk of abortion over a period of 24 months postpartum. The secondary objective was to analyse whether other significant factors were affecting the risk of abortion during this period. Methods: In this retrospective cohort study, we analysed 11,066 women who had delivered in three Swedish cities during 2013 and 2014. Demographic and medical variables were obtained from medical records. Attendance at the postpartum visit, choice of postpartum contraception and history of abortion was noted. Logistic regression analysis was performed to assess factors associated with the risk of abortion. The main outcome measure was the proportion of women with abortion up to 24 months postpartum. Results: Data from 11,066 women were included in the final analysis. Within 12-24 months after delivery 2.5% of women had an abortion. The choice of LARC after childbirth reduced the risk of subsequent abortion (odds ratio 0.74; 95% confidence interval [CI] 0.60, 0.91; p = .005). Smoking, age amp;lt;25 years and have had a previous abortion significantly increased the risk of abortion during follow-up, whereas exclusive breastfeeding decreased the risk. Conclusions: Increasing the proportion of women who choose LARC postpartum could decrease the risk of abortion for up to 2 years after childbirth.Funding Agencies|county council of Ostergotland and county council of Stockholm</p