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Background: In March 2020, all levels of government introduced various strategies to reduce the impact of the COVID-19 pandemic. The purpose of this study was to document how the experience of providing medical assistance in dying (MAiD) changed during the COVID-19 pandemic. Methods: We conducted a qualitative study using semistructured interviews with key informants in Canada who provided or coordinated MAiD before and during the COVID-19 pandemic. We interviewed participants from April to June 2020 by telephone or email. We collected and analyzed data in an iterative manner and reached theme saturation. Our team reached consensus on the major themes and subthemes. Results: We interviewed 1 MAiD coordinator and 15 providers, including 14 physicians and 1 nurse practitioner. We identified 4 main themes. The most important theme was the perception that the pandemic increased the suffering of patients receiving MAiD by isolating them from loved ones and reducing available services. Providers were distressed by the difficulty of establishing rapport and closeness at the end of life, given the requirements for physical distancing and personal protective equipment. They were concerned about the spread of SARS-CoV-2, and found it difficult to enforce rules about distancing and the number of people present. Logistics and access to MAiD became more difficult because of the new restrictions, but there were many adaptations to solve these problems. Interpretation: Providers and coordinators had many challenges in providing MAiD during the COVID-19 pandemic, including their perception that the suffering of their patients increased. Some changes in how MAiD is provided that have occurred during the pandemic, including more telemedicine assessments and virtual witnessing, are likely to remain after the pandemic and may improve service.

Introduction Cannabis is reported to enhance sexual function; yet, previous studies have shown that physiological and subjective indices of sexual arousal and motivation were associated with decreased availability of circulating endocannabinoid concentrations. Aim To explain this contradiction, we evaluated which aspects of sexual experience were enhanced or diminished by cannabis use. Methods We used an online questionnaire with a convenience sample of people who had experience with cannabis. We asked questions regarding various aspects of sexual experience and whether they are affected by cannabis. We also asked about sexual dysfunction. Main Outcome Measure Aspects of participant sexual experience enhanced by cannabis. Results We analyzed results from 216 questionnaires completed by people with experience using cannabis with sex. Of these, 112 (52.3%) said they used cannabis to alter their sexual experience. Eighty-two participants (38.7%) said sex was better, 34 (16.0%) said it was better in some ways and worse in others, 52 (24.5%) said it was sometimes better, and only 10 (4.7%) said it was worse. Of 202 participants, 119 (58.9%) said cannabis increased their desire for sex, 149 of the 202 participants (73.8%) reported increased sexual satisfaction, 144 of 199 participants (74.3%) reported an increased sensitivity to touch, and 132 of 201 participants (65.7%) reported an increased intensity of orgasms. Out of 199 participants, 139 (69.8%) said they could relax more during sex, and 100 of 198 participants (50.5%) said they were better able to focus. Of the 28 participants who reported difficulty reaching orgasm, 14 said it was easier to reach orgasm while using cannabis, but only 10 said that sex was better. Clinical Implications The information in this study helps clarify which aspects of sexual function can be improved or interfered with by cannabis use. Strengths & Limitations We asked about specific sexual effects of cannabis and were therefore able to understand the paradox of how cannabis can both improve and detract from sexual experience. Limitations of this study include bias that may have been introduced because the sample included only people who responded to the advertisements; it may not represent the general population of people who use cannabis. Moreover, over one-third of our sample said they use cannabis daily and so represent heavier than average users. Conclusion Many participants in our study found that cannabis helped them relax, heightened their sensitivity to touch, and increased intensity of feelings, thus enhancing their sexual experience, while others found that cannabis interfered by making them sleepy and less focused or had no effect on their sexual experience.

This is a secondary analysis of three qualitative studies about MAiD in which researchers asked about the differences between suicide and MAiD. In all, researchers interviewed 52 Canadians; 7 were people who had requested MAiD and had been found ineligible, 6 were MAiD providers and 39 were socially and economically marginalized. The overwhelming response was that MAiD is better than suicide in the context of suffering at the end of life. Whereas these people perceived suicide as uncertain, difficult, and something that was usually done alone and without support, they thought MAiD was certain, painless, and more socially acceptable.

Background Some licensing authorities require fasting before abortions under intravenous sedation to avoid aspiration of gastric contents. This study was conducted to estimate the incidence of anesthesia-related complications in women undergoing abortions without preprocedure fasting. Study Design This is a retrospective cohort chart review of patients having abortions with both fentanyl and midazolam at two urban free-standing abortion clinics with routine policy of advising women to eat a light meal before the procedure. Results There were no reports of anesthesia-related complications in the 47,748 charts reviewed from 1998 to 2010. Applying Hanley's formula for rare events that have not occurred, the upper 95% confidence interval for the true incidence of anesthesia-related complications for women having abortion under low-dose procedural sedation without fasting was estimated to be 0.00006%. Conclusions This large retrospective cohort chart review identified no complications related to low-dose procedural sedation in over 47,000 consecutive nonfasting patients having abortions through 18 weeks' gestation. Eliminating the requirement to fast would decrease unnecessary stress and unpleasant symptoms without increase in the anesthesia-related complications for women having abortions.

Objectives Use of an intrauterine contraceptive device (IUD) has not been recommended to nulliparous women in the past. There is now good evidence that there is no increased risk of pelvic inflammatory disease or infertility in nulliparas who use IUDs and the recommendations have changed. Our objective was to understand more about the motivations and experience of nulliparous women using IUDs. Methods This was a mixed method study. First, we asked 44 nulliparous women who had had an IUD inserted within the previous six months about their reasons for seeking the IUD, their history with other forms of contraception, their perception of the insertion experience, and their feelings after insertion. Questionnaires were then distributed to 154 nulliparous women presenting for IUDs, asking about their past experience with hormonal contraception. Results The main theme arising from the interviews was a desire to avoid hormonal contraception. Other reasons for choosing the IUD were greater contraceptive effectiveness than other methods, convenience of use, and lower cost. Responses to the questionnaire indicated that 138 women (89.7%) had used hormonal contraception in the past and, of those, 98 (63.0%) complained of mood side effects, 64 (41.6%) of sexual side effects, and 64 (41.6%) of physical side effects. Conclusion The most important motivation for nulliparous women in this study to choose IUDs was to avoid the potential or actual side effects of hormonal contraception. Despite experiencing some discomfort at the time of insertion, this group of nulliparous women was very positive about using IUDs for contraception.

The objective of this study was to estimate the menstrual cycle day of conception in women presenting for abortion.This was a retrospective chart survey in two urban free-standing abortion clinics.There were 913 charts reviewed of women presenting for an abortion at less than 63 days' gestation as determined by endovaginal ultrasound who were "sure" of the date of their last normal menstrual period. The estimated mean cycle day of conception determined by sonographically estimating length of gestation was 14.6. There were 26 (26.3%) of 99 women using cyclic hormonal contraception who conceived before 10 days after the onset of withdrawal bleeding compared to 100 (14.7%) of 679 who conceived before 10 days after the onset of their last menstrual period who were using all other forms of contraception, including "none" (p=.005). No other differences in the proportions conceiving early in the cycle were observed with respect to age, ethnicity or obesity.These data suggest that there is a sizeable subset of women who ovulate earlier after onset of withdrawal bleeding when using 21/7 hormonal contraceptives than after onset of menses when not using hormonal contraception. It is possible that women using hormonal contraceptives may have a higher risk of pregnancy if they ovulate sooner after the onset of bleeding.

Background The prevalence of self-identified chronic pain in Canadian adults is approximately one in five people. Marginalization and addictions have been shown to complicate chronic pain in vulnerable populations. This study aimed to understand the experience of chronic pain among female Survival Sex Workers in Vancouver's downtown eastside (DTES). Methods This study used an exploratory qualitative analysis with in-depth, semi-structured interviews. Members of PACE Society who self-identified as a current or former Survival Sex Worker and who had a chronic pain experience known to PACE support workers were invited to participate. Interviews were conducted, audio recorded and transcribed. The investigators met to read the transcripts and discuss emerging themes. The process continued until no new themes were observed. Results Participants ranged in age from 42 to 56 years old and all self- identified as females and Survival Sex Workers. Eleven of thirteen interviews were analyzed for themes. Drug use for pain management, both prescribed and illicit, was the most important theme. Poverty, the need to continue working and the lack of stable housing were barriers to adequately addressing the source of chronic pain. Participants felt judged for living in the downtown eastside, being a drug user and/or being Aboriginal and only two participants had been referred to a pain specialist. All participants were involved in support networks made up of other Sex Workers and all spoke of a sense of community and survival. Conclusions Our study emphasizes the complex nature of chronic pain and addictions among a uniquely marginalized population. The study is unique in that it contributes the perspectives of a traditionally “hard-to-reach” population and demonstrates that Sex Workers should not only participate in but should lead development and implementation of research and programs for managing chronic pain in the setting of addiction.

Objective To characterize method-related discontinuation rates and acceptability over 1 year of SCu380A use. Study design Women enrolled into this prospective pilot study underwent SCu380A placement by a single clinician with follow-up at 6–8 weeks and at 3, 6, 9 and 12 months. Outcome measures included reasons for discontinuation and satisfaction. Results Fifty-one women had a 12-mm-diameter intrauterine ball (IUB; SCu380A) inserted by a single clinician (EW). Postinsertion ultrasonography showed all the devices to be correctly placed. By 8 weeks, there were 9 expulsions and 2 removals for symptoms. By 12 months, there were 14 expulsions (27%), 8 removals for symptoms (16%), 1 pregnancy and 7 lost to follow-up. Of the remaining 21 women, 15 said that they were satisfied. Conclusion The high rate of expulsions and removals for symptoms in the first year indicates that this device, as presently designed, is unacceptable as an alternative to the currently available copper intrauterine devices. Implications More research is needed before we know if it is the spherical design, the size of the device or some other factor that led to the high expulsion rate. There are currently three different IUBs (12, 15 and 18 mm) approved and being investigated.

Objective To compare the efficacy, adverse effects and acceptability of the three most common misoprostol regimens used with mifepristone for medical abortion. Design Randomised nonblinded trial. Setting Three clinics associated with major research universities in Canada; two in major urban areas and one in a periurban area. Population Women of reproductive age. Methods Consenting women presenting for abortion services with gestations less than 56 days and who met inclusion criteria were given 200 mg mifepristone orally and then randomised into three misoprostol study groups: (group I) 400 micrograms of oral misoprostol, (group II) 600 micrograms of oral misoprostol, and (group III) 800 micrograms of vaginal misoprostol. Misoprostol was self-administered at home 24–48 hours following mifepristone, and participants were instructed to take a second similar misoprostol dose at 24 hours after the initial dose if bleeding was less than a normal menstrual period. Main outcome measures Successful abortion without surgery was 94.1%, with no significant differences across the three study groups (94.7% in group I, 93.4% in group II, and 94.3% in group III; P= 0.975). Results Efficacy and adverse effects did not differ significantly across the three study groups. Pain increased significantly across the study and the gestational age groups and was associated with lower acceptability. Conclusions There appears to be a range of safe and effective options for early medical abortion with mifepristone including a choice between oral and vaginal administration of misoprostol.

Objective The primary objective of this study was to determine if buccal misoprostol was as effective as vaginal misoprostol in medical abortions. The secondary objectives were to compare side effects and acceptability. Methods This was a randomized controlled trial of 600 μg misoprostol by the buccal or vaginal routes used 3 to 6 days after 50 mg/m2 methotrexate. The participants were women presenting for abortion at 49 days or less gestation. The outcome measures were the number of women who had aborted by Day 8, side effects and acceptability. Results Day 8 completion rate was 53.5% for the buccal route and 67.5% for the vaginal route (p = 0.012). Side effects were similar in the two groups except that there was more burning with the buccal route. Overall acceptability and route acceptability were similar in the two groups. Conclusions When used after methotrexate for early abortion, the vaginal route for misoprostol is more effective and preferred to the buccal route.

To compare the effectiveness, side effects, and acceptability of medical abortions induced by methotrexate and misoprostol with abortions induced by mifepristone and misoprostol.This was a multicenter, randomized, nonblinded, controlled trial comparing 50 mg/m(2) of methotrexate followed 4-6 days later by 800 microgram of vaginal misoprostol with 600 mg of oral mifepristone followed 36-48 hours by 400 microgram of oral misoprostol.There were 518 women in the methotrexate group and 524 women in the mifepristone group. In the methotrexate group, 21 women required suction curretage, two for continuing pregnancy, eight because of physician request (usually for excessive bleeding), and 11 because of patient request. In the mifepristone group, 22 women needed surgical termination, 17 because of physician request, and five because of patient request. By day 8, only 386 (74.5%) in the methotrexate group had completed the abortion compared with 474 (90.5%) in the mifepristone group, and the mean number of days from beginning to completion was 7.1 for methotrexate and 3.3 for mifepristone (P/=.001). There were no differences in complications, and side effects were similar. Acceptance was slightly higher with mifepristone (88.0%) than with methotrexate (83.2%).Abortions induced with mifepristone completed faster than those induced with methotrexate, but the overall success rates, side effects, and complications were similar. Acceptance rates were slightly higher with mifepristone than methotrexate (P =.03).

Objective: Our aim was to find out whether intravenous fentanyl was effective in reducing the pain of first-trimester abortion. Study Design: This randomized controlled trial included 825 women attending a nonhospital abortion facility. Some women chose standard care. Women who did not choose standard care were randomly assigned to receive either 50 to 100 μg of fentanyl, a placebo, or no intervention. With SAS software and a mixed effects analysis of variance model with covariates, we compared mean pain scores of the fentanyl and placebo groups to detect a difference of at least 1 point on an 11-point pain scale. Results: The mean pain score of the fentanyl group was 1.0 point less than that of the placebo group (95% confidence interval, 3.7-4.3) and 0.9 point less than that of the observational group (95% confidence interval, 4.7-5.1). This pain reduction was statistically significant, but the women who were studied wanted a 2-point reduction from fentanyl. Conclusion: Fentanyl, when compared with the placebo, reduced abortion pain by 1.0 point on an 11-point scale. This reduction was of questionable clinical significance and was less than desired by the women included in the study. (Am J Obstet Gynecol 2001;185:103-7.)

Seven cases of uterine arteriovenous malformations associated with pregnancy were initially suspected by the history of prolonged bleeding after a medical abortion and then confirmed by color Doppler scanning. All cases were managed expectantly and resolved spontaneously. When AVMs required diagnosis by pathology or angiography, only the most severe cases would have been reported. Now that they can be recognized on ultrasound, it is possible that mild cases such as these will be found to be much more common.

This was a prospective cohort questionnaire study to compare the loss of ability to work in 62 women having medical and 69 having surgical abortions. Outcomes included the number of days lost from work outside the home and inside the home before and after the abortion appointment. The mean total loss from work inside the home was 10.1 days for the surgical group and 5.3 days for the medical group (P

Background The objectives of this study were to assess perceptions of women viewing the products of conception after abortion and to assess the feasibility of offering this choice. Study Design Women presenting for abortion at two abortion clinics were given a questionnaire asking if they wished to view the products of conception. A second questionnaire was given to women who had viewed products of conception about their perceptions. Clinic staff members were interviewed after completion of the study. Results The study revealed that 152/508 (28.7%) of women having abortions chose to view the products of conception and 98/122 (83.1%) found that viewing did not make it harder emotionally. Older women and those who had children were less likely to want to view products of conception (p=.037) and more likely to find it harder if they did (p=.05). All 11 clinic staff members interviewed were positive about offering this service. Conclusions It is feasible to offer women having abortions the choice to view the products of conception and for most, viewing does not make it emotionally harder for them.

Objective: This study was undertaken to compare oral to injected methotrexate with respect to effectiveness, side effects, and acceptability. Study Design: One hundred women in an urban primary care practice were randomly assigned in phase 1 to receive 50 mg/m 2 methotrexate by either the oral or the injected route. In phase 2 another 87 women were allowed to choose between the oral and injected routes. In both phases and in all groups the methotrexate was followed 5 to 7 days later by misoprostol administered vaginally by the patient. The main outcome was the success rate (the number whose pregnancies aborted without surgery); other outcomes included side effects and acceptability. Results: There were no differences in rates of success, side effects, or acceptability between groups receiving oral and injected methotrexate. Among the women in phase 2 the oral form was chosen by 57.5%. Conclusion: This study indicates that for medical abortions induced with methotrexate and misoprostol it is possible to offer both the oral and injected routes of methotrexate without sacrificing efficacy and that about half of the women offered a choice will choose the oral route. (Am J Obstet Gynecol 1999;181:149-52.)

The purpose of this study was to compare tamoxifen to methotrexate, with respect to effectiveness, when followed by misoprostol to induce abortion. In the first phase, 198 women presenting for medical abortion at7 weeks gestation were randomized to receive either 40 mg of tamoxifen, followed 2 to 3 days later by 800 micrograms of misoprostol self-administered vaginally or 50 mg/m2 of methotrexate, followed 5 to 7 days later by the same dose of misoprostol. In the second phase, 200 women were randomized to receive 20 mg tamoxifen twice daily for 4 days, followed by 800 micrograms misoprostol or the same regimen of methotrexate and misoprostol as in phase 1. The main outcome measure was success rate determined by the number of women who aborted without surgery. In phase 1, the success rate was higher in the methotrexate group (93.0%) compared to the tamoxifen group (85.7%) (p = 0.045). In the tamoxifen group, nine of 98 women had incomplete abortions with symptoms requiring a surgical aspiration, compared to one of 100 women in the methotrexate group. In phase 2, the success rates were 90.9% in the methotrexate group compared to 84.7% in the tamoxifen group (p = 0.20). The side effects were less in the tamoxifen group in phase 1 but not in phase 2. When tamoxifen is given as a single dose, it is less effective than methotrexate but when it is given 20 mg twice daily for 4 days, there is no significant difference. Tamoxifen does not appear to have any benefits over methotrexate.This study aims to compare the effectiveness of tamoxifen with that of methotrexate when each is used in combination with misoprostol for abortion. In the 1st phase of the study, 198 medical abortion cases at 7 weeks gestation were randomized to receive either 40 mg of tamoxifen followed by 800 mcg of misoprostol after 2-3 days or 50 mg/sq. m of methotrexate followed by the same dose of misoprostol after 5-7 days. In the 2nd phase, 20 mg tamoxifen twice daily for 4 days was administered to 200 women, followed by 800 mcg misoprostol or the same methotrexate and misoprostol regimen as in phase 1. The number of women who experienced abortion without surgery was determined to measure the success rate. The success rate in phase 1 was higher in the methotrexate group (93.0%) than in the tamoxifen group (85.7%) (p = 0.045). About 9 in 98 women in the tamoxifen group and 1 in 100 women in the methotrexate group had incomplete abortions, indicating surgical aspirations. In the 2nd phase, the success rates were 90.9% in the methotrexate group and 84.7% in the tamoxifen group (p = 0.20). There were fewer side effects in the tamoxifen group during the 1st phase but not in the 2nd phase. Tamoxifen was seen to be less effective than methotrexate if given in a single dose. There was no significant difference when tamoxifen was given in 20 mg doses twice daily for 4 days. There were no advantages observed in tamoxifen over methotrexate.

This was a dual-cohort study performed to determine if, by using methotrexate alone, abortions could be induced with fewer side effects, without sacrificing effectiveness and patient satisfaction. The subjects were 358 consecutive patients who requested elective medical termination of pregnancy at7 weeks gestation. Women were given information and allowed to choose between methotrexate alone (50 mg/m2 intramuscularly) or methotrexate followed 4 days later by 800 micrograms misoprostol vaginally. The two groups were compared with respect to the number of surgical aspirations required, the number of days until the abortion was completed, side effects, and the number of women who would choose the same method again. The surgery rate for methotrexate was 17.2%, whereas for the combination it was 10.9%. The mean numbers of days until the abortion were complete was 23 and 12, respectively. Side effects, mean pain scores, total days of bleeding, and satisfaction rates were not significantly different in the two groups. The high failure rate with methotreaxate alone suggests that it should not be offered despite the high level of satisfaction.A dual-cohort study was conducted to determine whether abortion induced by methotrexate alone produces fewer side effects than a misoprostol-methotrexate regimen without sacrificing efficacy. 358 consecutive Canadian abortion seekers with pregnancies of 7 weeks' gestation or less were given the choice of a regimen of 50 mg/sq. m of intramuscular methotrexate or methotrexate followed 4 days later by 800 mcg of vaginal misoprostol. 101 women chose the former and 257 opted for the latter regimen. Women tended to choose the methotrexate-only regimen to avoid misoprostol-related side effects; selection of the combination was motivated by a desire for a rapid pregnancy termination. 82 women (82.8%) in the methotrexate-only group and 228 (89.1%) in the combination group aborted successfully. The failure rate in both groups was significantly higher when the procedure was performed at 6 or more weeks of gestation. It took a mean of 23.1 days from injection to complete abortion in the methotrexate-only group compared with 11.7 days in the methotrexate-misoprostol group. More than half the women had medication-related side effects, primarily nausea, vomiting, and diarrhea, with no significant differences between groups. The mean number of days of bleeding was 9.0 in the methotrexate-only group and 10.1 in the combination group. The mean worst pain score (on an 11-point scale) was 6.4 in the former and 6.1 in the latter group. 91.8% of women in the methotrexate-only group and 90.7% of those in the misoprostol-methotrexate group who successfully aborted stated they would chose the same method again. Given the high failure rate, methotrexate alone should not be offered routinely to abortion seekers. Its use should be reserved for women with very early pregnancies who have relative contraindications for misoprostol.

Misinformation about the risks and sequelae of abortion is widespread. The purpose of this study was to examine whether women having an abortion who believe that there should be restrictions to abortion (i.e., that some other women should not be allowed to have an abortion) also believe this misinformation about the health risks associated with abortion.We carried out a cross-sectional survey of women presenting consecutively for an abortion at an urban abortion clinic in Vancouver, British Columbia, between February and September 2012.Of 1008 women presenting for abortion, 978 completed questionnaires (97% response rate), and 333 of these (34%) favoured abortion restrictions. More women who favoured restrictions believed that the health risk of an abortion was the same as or greater than the health risk of childbirth (84.2% vs. 65.6%, P0.001), that abortion caused mental health problems (39.1% vs. 28.3%, P0.001), and that abortion caused infertility (41.7% vs. 21.9%, P0.001). Using multivariate logistic regression analyses, believing that abortion should not be restricted was found to be a significantly correlated with correct answers about health risks, mental health problems, and infertility.Misinformed beliefs about the risks of abortion are common among women having an abortion. Women presenting for abortion who favoured restrictions to abortion have more misperceptions about abortion risks than women who favour no restrictions.

COMMENT CONCLUSION REFERENCES Abstract^ BACKGROUND: Clostridia bacteria are infrequent human pathogens. In the obstetric and gynecologic literature, Clostridium sordellii infections have been very rarely reported. This is a case of infection following medical termination of early pregnancy with mifepristone and misoprostol. CASE: A 27-year-old woman presented for termination of pregnancy at 5.5 weeks from her last menstrual period. She received mifepristone 200 mg orally followed by 800 µg vaginal misoprostol. Three days after administration of misoprostol, she complained of dizziness, pelvic pain, and bleeding. The next day, she experienced worsening of symptoms and was hospitalized. She developed pulmonary edema, ascites, and heart failure. Despite supportive measures, antibiotics, and hysterectomy, she died 3 days later. The post mortem examinations indicated that death was caused by shock secondary to C sordellii infection. CONCLUSION: The frequency of infection following medical abortion is low. The rapid and fatal course of this infection is similar to other obstetric and gynecologic cases reported in the literature. Although providers should remain vigilant to the possibility of infection following medical abortion, the overall proven safety of medical abortion remains the same.

In this double-blind study, 104 women were randomized to receive 1 mg lorazepam or placebo prior to a first-trimester abortion. In addition, 262 women were allowed to choose whether or not to take the lorazepam. The outcome measures were 11-point verbal pain scales of pain during the abortion and anxiety measured before premedication and during the abortion. The mean anxiety and pain scores did not differ significantly in the lorazepam and placebo groups of the randomized trial. In the observational group, the women who took lorazepam had their mean anxiety score drop from 5.5 to 4.7 while in those who did not take it, the score rose from 3.8 to 4.9. This study indicates that giving oral benzodiazepines preoperatively is neither helping nor hurting our patients but the placebo effect can be helpful to make our patients more comfortable.

To examine the experiences of women who are delaying motherhood by having abortions.Mixed-methods study.An abortion clinic in Vancouver, BC.Women presenting for abortion at an urban, free-standing abortion clinic. Interviews were only with women older than 35 years of age.A chart review was initially performed, followed by a survey of women presenting to the clinic, as well as in-depth interviews that were audiotaped and transcribed.Of the 1844 charts reviewed, 550 (30%) were for women 33 years of age and older and 117 (21%) of those had no children (6% of the total 1844). Plans for future pregnancies were reported in only 70 of the 117 charts; 37 (53%) of the women said they wanted children in the future and 20 (29%) said they were unsure. There were 1118 questionnaires completed (response rate of 86%). There were 334 (30%) women 33 years of age and older and 87 (26%) of those had no children (8% of the total 1113). Of these women, 47 (54%) planned to have children in the future and 24 (28%) were unsure. The most common reason these older childless women gave for having abortions was that they were "just not ready" (59%). We used logistic regression to examine predictors for delaying motherhood and the stepwise regression retained only 2 factors: high rating of "stable relationship" (P=.003) and a "partner who would be a good parent" (P=.008). The most striking themes in the interviews were women's uncertainty about childbearing and their focus on the quality of their relationships.This study contributes additional insight into the uncertainty older nulliparous women experience about childbearing, and it points to women's primary focus on relationships with partners rather than with children as a possible explanation for this trend.

Objective To describe the characteristics of women who experience sexual and mood side effects associated with use of hormonal contraception, and to compare them with women who do not. Methods We conducted a questionnaire survey of women presenting for primary care or to a reproductive health clinic. The women were asked if they had specific side effects with use of hormonal contraception in the domains of sexual desire, arousability, or irritability. The characteristics of women who reported such symptoms were compared with those who did not. Results Of the 1311 women recruited (mean age 28 years), 978 (77%) had previously used hormonal contraception. Of these women, 482 (51%) said they had at least one mood side effect and 358 (38%) said they had at least one sexual side effect. Using logistic regression, we found that women complaining of mood side effects were more likely to be unmarried ( P =0.02) and to be Caucasian or South Asian ( P =0. 002) than women without such complaints. Women complaining of sexual side effects were more likely than those without sexual side effects to be younger ( P =0.04), to have more education ( P =0.04), and to be Caucasian or South Asian ( P =0.07). Women who complained of sexual side effects were also more likely than others to complain of mood and physical side effects ( P Conclusion Understanding the characteristics of women who report mood and sexual side effects with use of hormonal contraception may be useful when counselling women about contraception. It is important for women to choose contraception that not only is effective but also does not complicate their emotional and sexual lives.

Background Many intrauterine device (IUD) users utilize intravaginal menstrual cups or tampons during menses, but no studies have investigated the impact this practice may have on IUD expulsions. Study Design Retrospective chart survey. Results Of the 930 women having IUDs placed and reporting menstrual protection, 10.3% (96) used menstrual cups, 74.2% (690) used tampons, and 43.2% (402) used pads (many women reported using more than one method). In the 743 women with adequate follow-up information, there was a full or partial expulsion (i.e., part of the IUD in the cervical canal) rate of 2.5% (27) during the first 6 weeks after insertion. There was no difference in the women using cups, tampons or pads (confidence intervals overlap). Conclusions From this study, there is no evidence that women who report using menstrual cups or tampons for menstrual protection had higher rates of early IUD expulsion.

Objective To assess physicians' knowledge, attitudes, and practice with respect to four evidence-based natural family planning (NFP) methods: Standard Days, cervical mucus, basal body temperature, and the lactational amenorrhea method. Methods We undertook a cross-sectional survey of a random sample of family physicians and all gynaecologists in British Columbia (n = 460) who have women of reproductive age in their practice, as well as all affiliated residents (n = 239). Main outcome measures were (1) physicians' attitudes towards NFP and their perceptions of its effectiveness; (2) the relationship between physicians' demographic factors, their personal experience or beliefs, and their attitudes and knowledge; and (3) how these factors affect the counselling physicians offer their patients. Results The survey response rate was 44%. Only 3% to 6% of physicians had correct knowledge of the effectiveness in perfect use of the NFP methods cited in this study. Fifty percent of physicians who responded mention NFP to their patients as an option for contraception, and 77% of physicians mention NFP as an option to couples trying to conceive. Family physicians and residents were much more likely than gynaecologists or gynaecology residents to mention NFP during counselling. Older physicians were more likely to mention NFP than younger physicians and also had more personal experience with NFP. Conclusion Most physicians in our study underestimated the effectiveness of NFP methods, and only a small proportion of physicians provide information about NFP during contraceptive counselling. Physicians need better understanding of modern methods of NFP to provide evidence-based contraceptive counselling to selected highly motivated patients who prefer NFP as a contraceptive choice.

To gain a better understanding of women's perceptions and experiences of viewing the ultrasound (US) before an abortion.This mixed-methods study included questionnaires and interviews. Women presenting for medical and surgical abortion at two urban abortion clinics completed questionnaires asking if they wished to view the US image and those women who had done so answered questions about their perceptions. A randomly selected ten women were interviewed six weeks later about their perceptions. The interviews were audio-taped, transcribed and analysed for salient themes.The 350 participants had a mean age of 27.6 years, 0.68 births, and were at a mean of 49.1 days gestation at the time of the procedure. Most women (254/350, 72.6%) chose to view the US and 179/219 (86.3%) found it a positive experience. Older women and those who had children were less likely to want to view the US image (p = 0.001). All ten interviewees recommended that this choice be offered to every woman and recommended more communication between care providers and patients at the time of the US. None of the women changed her mind about having the abortion after having seen the US.Offering the choice to view the ultrasound is both feasible and beneficial to women having abortions. Our findings support those of the only other study published on the subject.

Objective Whether Canadian physicians can refuse to refer women for abortion and whether private clinics can charge for abortions are matters of controversy. We sought to identify barriers to access for women seeking therapeutic abortion and to have them identify what they considered to be most important about access to abortion services. Methods Women presenting for abortion over a two-month period at two free-standing abortion clinics, one publicly funded and the other private, were invited to participate in the study. Phase I of the study involved administration of a questionnaire seeking information about demographics, perceived barriers to access to abortion, and what the women wanted from abortion services. Phase II involved semi-structured interviews of a convenience sample of women to record their responses to questions about access. Responses from Phase I questionnaires were compared between the two clinics, and qualitative analysis was performed on the interview responses. Results Of 423 eligible women, 402 completed questionnaires, and of 45 women approached, 39 completed interviews satisfactorily. Women received information about abortion services from their physicians (60.0%), the Internet (14.8%), a telephone directory (7.8%), friends or family (5.3%), or other sources (12.3%). Many had negative experiences in gaining access. The most important issue regarding access was the long wait time; the second most important issue was difficulty in making appointments. In the private clinic, 85% of the women said they were willing to pay for shorter wait times, compared with 43.5% in the public clinic. Conclusion Physicians who failed to refer patients for abortion or provide information about obtaining an abortion caused distress and impeded access for a significant minority of women requesting an abortion. Management of abortion services should be prioritized to reflect what women want: particularly decreased wait times for abortion and greater ease and convenience in booking appointments. Since many women are willing to pay for services in order to have an abortion within one week, this option should be considered by policy makers.

Background: The purpose of this study was to determine whether East Asian women had more side effects and a higher discontinuation rate than Caucasian women when choosing to use hormonal contraceptives. Study Design: This was an observational cohort study of usual care using questionnaires for 2 months after being given hormonal contraceptives following an abortion in Vancouver, Canada. Results: In the first month, 73 (64.4%) of the 110 East Asian and 86 (80.4%) of the 107 Caucasian women took any of the sample provided (p=.020). In the second month, 52 (47.3%) of the East Asian and 62 (57%) of the Caucasian women used the prescription to buy and take their hormonal contraception (p=.12). Total side effects were similar, but there was more nausea in the East Asian women (23.3% vs. 8.1%) (p=.03) and more acne in the Caucasian women (8.2% vs. 20.9%) (p=.05). Conclusions: There may be both physiological and cultural differences leading East Asian women to use less hormonal contraception.

⁎ Corresponding author. 1013-750 West Broadway, Vancouver, BC, Canada. Tel.: +1 604 709 5611; fax: +1 604 873 8304. E-mail address: ewiebe@interchange.ubc.ca (E. Wiebe). following methotrexate must be used. A review of studies using regimens of methotrexate followed by misoprostol or misoprostol alone found that failure rates were lower with the combined regimens [1]. The major disadvantage of methotrexate compared with mifepristone regimens is the slower speed of action. [2]. A study of misoprostol-only regimens found that the highest success rates were obtained using 800 μg misoprostol within 24 h [3]. The present study was a retrospective sequential cohort comparison trial of abortions induced in women with a pregnancy of 49 days of gestation or less, documented by endovaginal ultrasound. All women were treated similarly, with 50 mg/m2 methotrexate (Novopharm, Toronto, Canada) followed 1–5 days later by vaginal misoprostol (Apotex, Weston, Canada). Four groups of different doses of misoprostol were established: Group 1 with 800 μg once; Group 2 with 600 μg 3 times 24 h apart; Group 3 with 600 μg 3 times in 24 h (4–12 h apart); and Group 4 with 800 μg 3 times in 24 h seroprevalence. It is hoped that further expansion of TOP services in South Africa will effect a sustained reduction in maternal deaths related to septic abortion. References

A 40-year-old woman with an IUD that had been inserted in China 15 years previously presented for a pregnancy termination with a nine-week gestation. After the suction procedure was completed, an attempt was made to remove the IUD, first with an IUD hook, and then with a narrow forceps using abdominal ultrasound visualization. The IUD could be seen on ultrasound and felt with the forceps but was not easy to remove. It was eventually removed after it broke into two pieces and stretched out. The postoperative ultrasound showed an empty uterus, and the patient’s uterus felt intact to gentle exploration with the curette. The patient was apparently well at follow-up.

Context We see many Korean women in our clinics and we have found them to have negative attitudes to hormonal contraception. We need to understand their perceptions and experiences with contraception in order to improve the effectiveness of our contraceptive counseling. Methods This was a qualitative descriptive study, conducted in an urban family practice office. The participants were a convenience sample of 40 ethnic Korean women. Data were collected in semistructured interviews by one interviewer who is fluent in English and Korean. Transcribed interviews were analyzed to identify salient themes. Results There was a deep distrust of hormonal methods of contraception and belief that hormones caused permanent harm. Unlike the findings in our other studies of Asian women, these women were satisfied with their usual methods of combining condoms, rhythm and withdrawal. They described good communication with their partners (which is necessary for the effective use of their chosen approaches). Conclusion When counseling Korean women about contraception, it is important to discuss the cultural bias against hormonal contraception involving beliefs that hormones cause permanent harm. It is also important to recognize the very successful use of condoms, rhythm and withdrawal by these couples.

Objective : To examine attitudes of women presenting for elective abortions. Method : Women presenting for elective abortion induced with medication at an urban free-standing abortion clinic were given semistructured interviews about their attitudes to abortion. Results : Of the 60 women interviewed, 26 voiced antiohoice attitudes. These interviews were transcribed and analyzed for themes. The women with antichoice attitudes were similar to the women with prochoice attitudes in age, education, and religion but were less likely to be white (61.8% of prochoice women identified themselves as white, compared with 30.8% of antichoice women, P=0.02). The antichoice women felt most strongly that other women should not be allowed to have an abortion if they gave as their reason, "want no more children," "not married," or "cannot afford." The most common themes were that one needed "enough" reasons to have an abortion and that women should take better precautions to prevent conception. Conclusion : It is important for abortion clinic staff to realize that many women coming to an abortion clinic have antichoice views. These views may affect a woman's ability to recover emotionally after the procedure and will therefore have implications for the kind of supportive care women need both before and after the abortion.

Telemedicine has been used to provide abortion in severalways. The website Women onWeb [1] uses e-mail support to facilitate the provision of medical abortion to women in situations in which safe abortion is not available [2]. Some US clinics offermedical abortions in which the patients see a counselor in the clinic but see the doctor via videoconferencing [3]. Routine ultrasound is usually used to date the pregnancy and determine abortion success in North America but serial quantitative human chorionic gonadotropin (hCG) values can also be used [4]. Because mifepristone is not available in Canada, the usual regimen is methotrexate (50 mg/m intramuscularly or orally) followed by misoprostol (800 μg vaginally) repeated twice 4–12 hours later. This regimen has a similar success rate to that of mifepristone plus misoprostol [5]. We conducted a retrospective chart review of women who underwent medical abortion via telemedicine between May 1, 2012, and May 1, 2013, at Willow Women’s Clinic, Vancouver, Canada. The study was approved by the Research Ethics Board at the University of British Columbia, Vancouver, Canada. To be eligible for a telemedicine abortion at the study clinic, women must live in British Columbia (where the clinic physicians are licensed); have access to a laboratory for timely serum quantitative hCG estimations; and be able to travel to the clinic or to another community facility for surgical completion, if necessary. They see a physician and counselor via Skype (Microsoft Skype Division, Luxembourg City, Luxembourg) videoconferencing for screening, information, and consent. Thewomen go to a local laboratory for hCG tests at initial screening, on the day of the medication, and 1 week later (3 tests). If their hCG level is above 5000mIU/mL, an ultrasound is arranged. Rhesus-negative women are offered anti-D; this is arranged through a local facility. Themedications are couriered or a prescription is faxed to a local pharmacy. Women have a follow-up videoconferencing appointment to discuss their blood test results and any reactions to the medications. If their hCG level has fallen by 80% in 1 week, women are informed that the abortion is complete and that they require no further follow-up. If additional medication, surgery, or further blood tests are required, they are arranged by the clinic. Between May 2012 and May 2013, 11 women underwent medical abortion via telemedicine at the study clinic (Table 1). One woman experienced spontaneous abortionwith nomedication, 1woman required surgical completion, and 1 woman was lost to follow-up; the other women experienced uneventful medical abortion. During the study period, a further 29 women were seen in-clinic for their first visit and ultrasound, with scheduled videoconferencing for follow-up; in addition, 1858 women made regular in-clinic visits. The main innovation with regard to this program is that we see patients in their own homes using their own technology (a computer or smart phone), yet provide the same physician and counseling services as we do in the clinic. This method of providing abortion via telemedicine is feasible in the present setting and may improve access to abortion.

Objective: To examine the differences in anxiety levels and attitudes towards abortion between women having an early medical abortion and women having a surgical (manual vacuum aspiration) abortion. Methods: Women who presented for an early medical abortion or a surgical abortion at an urban, free-standing abortion clinic were invited to participate in this study. Fifty-nine women having a medical abortion and 43 women having a surgical abortion answered questionnaires before their scheduled abortion, and again 2 to 4 weeks after the abortion. Thirty women were interviewed about their answers. Results: Anxiety levels were similar in both groups before the abortion procedure. Anti-choice views about abortion were seen in 60.5% of women having a medical abortion and in 37.3% of women having a surgical abortion ( P = .027). Women who were pro-choice had a mean anxiety score of 5.0 (range, 0–10) before and 2.7 after the abortion, whereas women who were anti-choice had a mean anxiety score of 5.2 before and 4.4 after the abortion ( P = .005). Conclusion: It is important for providers of abortion care to understand that women undergoing a medical abortion may be more ambivalent about abortion than women undergoing a surgical abortion, and women who are anti-choice but having an abortion may have unresolved anxiety after the procedure.

Objective The purpose of this study is to monitor the content, timing of and response to telephone calls from medical and surgical abortion patients in order to improve the counseling and nursing care and allay patient's concerns. Methods There were 43 calls from a possible 626 surgical patients and 100 calls from a possible 671 medical patients. Calls were considered preventable in 67% of the medical patients and 46.5% of the surgical patients. Women who were having their first abortion were more likely to place preventable calls. Conclusions Calls could be reduced by explaining variations in normal bleeding and how to use analgesics and providing this information in diagrammatic form on an information sheet.

This article discusses a study that aimed to determine the rate characteristics and experience of women who reported that they had used anal sex as a method of contraception. The questionnaire survey was conducted of women presenting for an abortion at an urban abortion clinic in Canada and contained questions about womens usage and experiences of natural family planning methods including anal sex. Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

The purpose of this study was to identify barriers to the use of oral contraceptives by ethnic Chinese women presenting for abortion. Using a qualitative descriptive study design, 40 ethnic Chinese women presenting for abortion were recruited. Data were collected in semi-structured interviews by one interviewer who is fluent in English, Mandarin, and Cantonese. Transcribed interviews were systematically analyzed to identify salient themes. The attitudes toward oral contraceptives were mostly negative. The most common fears were about weight gain, permanent infertility, and being considered "bad" (promiscuous). These mostly negative attitudes toward oral contraceptives appear to be barriers to their use.

Objective: To estimate cost savings from emergency contraceptive pills in Canada. Methods: We modeled cost savings when a single emergency contraceptive treatment was provided after unprotected intercourse and when women were provided emergency contraceptive pills in advance. Results: Each dollar spent on a single treatment saved $1.19–$2.35 (in Canadian currency), depending on the regimen and on assumptions about savings from costs avoided by preventing mistimed births. The dedicated products Preven (Shire Canada, Inc., Oakville, Ontario) and Plan B (Paladin Labs, Inc., Montreal) were cost-saving even under the least favorable assumption that mistimed births prevented today occur 2 years later. Each dollar spent on advance provision of Preven saved $1.24–$12.23, depending on the regular contraception method, on how consistently emergency contraception was used when needed, and on whether mistimed births were averted forever or simply delayed. Plan B was almost always cost-saving, although less so. Conclusion: Emergency contraception was cost-saving whether provided when the emergency occurred or in advance to be used as needed. More extensive use of emergency contraception could save considerable medical costs by reducing unintended pregnancies.

Misoprostol a stable and inexpensive prostaglandin has been shown to be effective in preparing the cervix for induced abortion. However in 3 studies in which 200-400 mcg of misoprostol was inserted vaginally 30-60 minutes 6 hours and 12 hours respectively prior to induced abortion cervical dilatation was enhanced but many women experienced pain and bleeding before the procedure. The present study investigated whether vaginal insertion of 750 mcg of misoprostol 2 hours prior to induced abortion would prepare the cervix effectively with fewer side effects than were recorded in previous studies. Study participants were randomly assigned to receive either misoprostol (n = 46) or placebo (n = 47). Mean maternal age (26 years) gestational age (8 weeks) and parity (0.66 and 0.85) were the same or similar in both groups. The Pratt dilator first met resistance at 19.6 among controls and 21.4 among cases. The time taken to dilate was 63.9 seconds among controls and 54.6 seconds with misoprostol. The mean pain score on a 0-10 scale was 4.73 in the placebo group and 4.69 with misoprostol. There were no side effects in either group. These results indicate that misoprostol used vaginally 2 hours before abortion induction is not an effective way of preparing the cervix.

In an urban clinic providing abortions, it was noted that many women presenting for abortion were anemic. The U.S. National Health and Nutrition Examination Survey III established prevalence of anemia, defined as a hemoglobin lower than 120 g/ L, at 5.1% of the non-pregnant women in the population [1]. There are observational studies that associate anemia diagnosed prior to midpregnancy with increased risk of pre-term delivery, low birth weight, and fetal mortality [2,3]. A metaanalysis of trials of iron supplementation in pregnancy showed no detectable effect on any substantive functional measures of either maternal or fetal outcome [4]. The purpose of this study was to determine the prevalence of anemia in this population, identify

Seven hundred fifty-six women had abortions induced with methotrexate and misoprostol. Various protocols were compared. In Group 1, phase 1, after receiving 50 mg/m 2 methotrexate IM, 289 women were randomized to receive either 750 or 500 μg of vaginal misoprostol. In Group 1, phase 2, 84 women who had failed to abort after one dose of misoprostol were randomized to receive either vaginal or oral routes for the second dose of misoprostol given on Day 8. In Group 2, a cohort of 226 women who received 60 mg/m 2 methotrexate were compared to the 289 women who received 50 mg/m 2 in Group 1. There were no differences in rates of effectiveness in the various trial groups. Side effects were greater with 60 mg/m 2 of methotrexate. In Group 3, a cohort of 241 women received the misoprostol in three vaginal doses 8 hr apart starting on Day 5, and were compared to the 289 women in Group 1 receiving one vaginal dose. In women whose medical abortion failed, fetuses were found to have limb abnormalities. In the total group of 756 women, 88.8% aborted successfully without surgical aspiration, with only minor side effects, and the acceptance rate was high. This study indicates that medical abortions induced with methotrexate and misoprostol are safe and effective, but more research is needed to find a more effective protocol.

The objective of this study was to determine whether it is possible to reduce the concentration of lidocaine without increasing the pain experienced by women undergoing abortion under local anesthesia. According to an informal survey at the National Abortion Federation meeting in April 1995, the most common dose of local anesthetic used for abortion was 20 ml l.O”/ lidocaine. The manufacturer’s maximum recommended dose of lidocaine is 4.5 mglkg so this dose of 200 mg is close to the toxic dose, especially for small women. Therapeutic abortions are very safe but anesthetic reactions are the most common cause of abortionrelated death [1,2]. If it is possible to reduce the concentration of lidocaine without increasing the amount of pain experienced, the dose could be reduced below that known to cause toxic reactions.