Social predictors of repeat adolescent pregnancy and focussed strategies

This article begins with an overview of teenage pregnancy within a social context. Data are then presented on conceptions and repeat conceptions in teenagers. Social predictors of repeat teenage pregnancy are grouped according to social ecological theory. A brief summary of prevention of teenage pregnancy in general is followed by a detailed analysis of studies of interventions designed to prevent repeat pregnancy that reached specific quality criteria. The results of some systematic reviews show no significant overall effect on repeat pregnancy, whereas others show an overall significant reduction. Youth development programmes are shown in some cases to lower pregnancy rates but in other cases to have no effect or even to increase them. Features of secondary prevention programmes more likely to be successful are highlighted

A constructivist vision of the first-trimester abortion experience

How might the abortion experience look in a world without the existing regulatory constraints? This paper critically assesses the evidence about how a high-quality abortion experience might be achieved in the first trimester. There would need to be positive obligations on states in pursuance of women’s reproductive rights. The onus would be on states and state actors to justify interferences and constraints upon a woman’s right to terminate in the first trimester of her pregnancy. In this vision, abortion is person-centred and normalized as far as possible. High-quality information about abortion would be freely available through multiple sources and in varying formats. Whenever possible, abortion would happen in a place chosen by the woman, and in the case of medical abortion, could be self-managed with excellent clinical back-up on hand should the need arise. The overarching purpose of this paper is to highlight the broader environment and framework of state obligations necessary to underpin the lived experience of abortion

Mandatory waiting periods before abortion and sterilization: theory and practice

Some laws insist on a fixed, compulsory waiting period between the time of obtaining consent and when abortions or sterilizations are carried out. Waiting periods are designed to allow for reflection on the decision and to minimize regret. In fact, the cognitive processing needed for these important decisions takes place relatively rapidly. Clinicians are used to handling cases individually and tailoring care appropriately, including giving more time for decision-making. Psychological considerations in relation to the role of emotion in decision-making, eg, regret, raise the possibility that waiting periods could have a detrimental impact on the emotional wellbeing of those concerned which might interfere with decision-making. Having an extended period of time to consider how much regret one might feel as a consequence of the decision one is faced with may make a person revisit a stable decision. In abortion care, waiting periods often result in an extra appointment being needed, delays in securing a procedure and personal distress for the applicant. Some women end up being beyond the gestational limit for abortion. Those requesting sterilization in a situation of active conflict in their relationship will do well to postpone a decision on sterilization. Otherwise, applicants for sterilization should not be forced to wait. Forced waiting undermines people’s agency and autonomous decision-making ability. Low-income groups are particularly disadvantaged. It may be discriminatory when applied to marginalized groups. Concern about the validity of consent is best addressed by protective clinical guidelines rather than through rigid legislation. Waiting periods breach reproductive rights. Policymakers and politicians in countries that have waiting periods in sexual and reproductive health regulation should review relevant laws and policies and bring them into line with scientific and ethical evidence and international human rights law

Postabortion contraception

The European Society of Contraception Expert Group on Abor tion identified as one of its priorities to disseminate up-to-date evidence-based information on postabortion contraception to healthcare providers. A concise communication was produced which summarises the latest research in an easy-to-read format suitable for busy clinicians. Information about individual methods is presented in boxes for ease of reference

Intravascular migration of contraceptive implants: two more cases

Cases: In addition to previously published case reports, further cases of intravascular migration of contraceptive implants have been identified from an information request to two national adverse reaction spontaneous reporting systems. We report on two new cases of insertion into the venous system with subsequent embolism to a pulmonary artery. Conclusion: Incorporating barium sulfate into the implant has facilitated diagnosis of these very rare adverse events with the initial diagnosis of embolism to the pulmonary arterial tree made by chest X-ray. Removal of an implant from a segmental branch of a pulmonary artery is technically challenging and not without risks. Unsuccessful removal appears to be preceded by a delay in diagnosis leading to endothelialization of the implant in the pulmonary arterial wall. Implications: Subdermal placement of contraceptive implants over the anterior surface of the biceps rather than in the sulcus between them biceps and triceps may negate this rare but reported risk

Intrauterine devices and risk of uterine perforation: current perspectives

Uterine perforation is an uncommon complication of intrauterine device insertion, with an incidence of one in 1,000 insertions. Perforation may be complete, with the device totally in the abdominal cavity, or partial, with the device to varying degrees within the uterine wall. Some studies show a positive association between lactation and perforation, but a causal relationship has not been established. Very rarely, a device may perforate into bowel or the urinary tract. Perforated intrauterine devices can generally be removed successfully at laparoscopy

On being an expert witness in sexual and reproductive health.

A new generation of expert witnesses in sexual and reproductive health is needed, including those in nursing as well as medical roles. Being an expert witness is a significant commitment alongside clinical work. Nevertheless, the work is stimulating and rewarding. Training is essential before starting medicolegal work. In particular expert witnesses need to be able to apply appropriate legal tests to the evidence, to deal with the range of expert opinion on a matter, and explain clearly what constitutes an appropriate standard of care for a clinician in their discipline and specialty. Expert witnesses must be aware of pitfalls such as being sued for substandard work and being reported to their professional regulator for straying outside their area of expertise. Expert witnesses must be truly independent and ideally their reports should be the same whoever they receive their instructions from. In addition to report writing, expert witnesses are required to comment on court documents, participate in conferences with a barrister and hold formal discussions with an opposing expert witness. Expert witnesses need to be administratively efficient and responsive. Although appearance in court is not that common, this is an essential part of the role. Apart from litigation in the civil courts, other types of case may present themselves including patent cases, work in the Court of Protection and health professionals' Fitness to Practise hearings