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AimThe 2019 National Institute for Health and Care Excellence (NICE) guidance on abortion care emphasised the importance of teaching the topic at undergraduate and postgraduate level. This study aimed to investigate the current provision of undergraduate abortion education in UK medical schools.MethodsRelevant medical ethics and clinical leads from the 33 established UK medical schools were invited to complete surveys on the ethico-legal or clinical aspects, respectively, of their institution’s abortion teaching. The surveys explored how abortion is currently taught, assessed the respondent’s opinion on current barriers to comprehensive teaching, and their desire for further guidance on undergraduate abortion teaching.ResultsSome 76% (25/33) of medical schools responded to one or both surveys. The number of hours spent on ethico-legal teaching ranged from under 1 hour to over 8 hours, with most clinical teaching lasting under 2 hours. Barriers to teaching were reported by 68% (21/31) of respondents, the most common being difficulty accessing clinical placements, lack of curriculum time, and the perception of abortion as a sensitive topic. Some 74% (23/31) of respondents would welcome additional guidance on teaching abortion to medical undergraduates.ConclusionsEducation on abortion, particularly clinical education, varies widely among UK medical schools. Most educators experience barriers to providing comprehensive abortion teaching and would welcome up-to-date guidance on teaching both the clinical and ethico-legal aspects of abortion to medical students. It is essential that medical schools address the barriers to teaching, to ensure all medical students have the knowledge, skills and attitudes to provide competent and respectful abortion-related care once qualified.

IntroductionThe National Institute for Health and Care Excellence, the Royal College of Obstetricians and Gynaecologists and the World Health Organization recommend that services provide a choice between medical and surgical methods of abortion. We analysed qualitative study data to examine patient perspectives on abortion method choice and barriers to meeting them.MethodsIn-depth interviews with 24 clients who had an abortion at British Pregnancy Advisory Service clinics were carried out between December 2018 and July 2019 to examine perspectives of quality of abortion care. In this article we focus on client perspectives on choice of abortion method. We performed thematic analysis of data relating to choice of abortion method, refined the analysis, interpreted the findings, and organised the data into themes.ResultsParticipants’ preferences for abortion method were shaped by prior experience of abortion, accessibility and privacy, perceptions of risk and experiences of abortion method, and information gathering and counselling. Participants’ ability to obtain their preferred method was impacted by intersecting constraints such as appointment availability, service location and gestational age.ConclusionsOur findings show that many factors shape participants’ preferences for abortion method. In response to the COVID-19 pandemic, some abortion services have constrained abortion method choices, with an emphasis on medical abortion and ‘no-touch’ care. Providers in the UK and beyond should aim to restore and expand more treatment options when the situation allows.

Objective Evaluate satisfaction and experience with telemedicine consultation and home use of mifepristone and misoprostol for abortion to 10 weeks’ gestation. Study Design Cross-sectional evaluation of British Pregnancy Advisory Service (BPAS) clients who used mifepristone and misoprostol at home from 11 May to 10 July 2020. We sent a text message with a link to a web-survey 2 to 3 weeks postabortion. Questions assessed satisfaction and experiences with a service model including telephone consultation and provision of medicines by mail or collection from the clinic. We used bivariate and multivariate regression to explore associations between client characteristics and outcomes. Our primary outcomes were overall satisfaction (5-point Likert scale) and reported contact with a health care provider. Results A total of 1,333 clients participated. Respondents described home use of medications as “straightforward” (75.8%) and most were “very satisfied” (78.3%) or “satisfied” (18.6%) overall. Being “very satisfied” was associated with parity (aOR 1.53, 95% CI 1.09−2.14) and pain control satisfaction (aOR 2.22, 95% CI 1.44−3.44). Health care provider contact was reported by 14.7%; mainly to BPAS’ telephone aftercare service (76.8%). Dissatisfaction with pain control (aOR 3.62, 95% CI 1.79−7.29) and waiting >1 week to use mifepristone (aOR3.71, 95% CI 1.48−9.28) were associated with health care provider contact. If needed in the future, most would prefer consultation by phone (74.3%) and home use of mifepristone and misoprostol (77.8%). Conclusions Satisfaction with telemedicine and home use of mifepristone and misoprostol is high. Most clients do not need health care provider support when administering medicines at home or post abortion.

OBJECTIVE: To compare outcomes before and after implementation of medical abortion (termination of pregnancy) without ultrasound via telemedicine. DESIGN: Cohort analysis. SETTING: The three main abortion providers. POPULATION OR SAMPLE: Medical abortions at home at ≤69 days' gestation in two cohorts: traditional model (in-person with ultrasound, n = 22 158) from January to March 2020 versus telemedicine-hybrid model (either in person or via telemedicine without ultrasound, n = 29 984, of whom 18 435 had no-test telemedicine) between April and June 2020. Sample (n = 52 142) comprises 85% of all medical abortions provided nationally. METHODS: Data from electronic records and incident databases were used to compare outcomes between cohorts, adjusted for baseline differences. MAIN OUTCOME MEASURES: Treatment success, serious adverse events, waiting times, gestation at treatment, acceptability. RESULTS: Mean waiting time from referral to treatment was 4.2 days shorter in the telemedicine-hybrid model and more abortions were provided at ≤6 weeks' gestation (40% versus 25%, P 0.999), serious adverse events (0.02% versus 0.04%, P = 0.557) and incidence of ectopic pregnancy (0.2% versus 0.2%, P = 0.796) were not different between models. In the telemedicine-hybrid model, 0.04% were estimated to be over 10 weeks' gestation at the time of the abortion; all were completed safely at home. Within the telemedicine-hybrid model, effectiveness was higher with telemedicine than in-person care (99.2% versus 98.1%, P

INTRODUCTION The safety and acceptability of medical abortion using mifepristone and misoprostol at home at ≤9+0 weeks' gestation is well established. However, the upper gestational limit at which the procedure remains safe and acceptable at home is not known. To inform a national guideline on abortion care we conducted a systematic review to determine what gestational limit for expulsion at home offers the best balance of benefits and harms for women who are having medical abortion. MATERIAL AND METHODS We searched Embase, MEDLINE, Cochrane Library, Cinahl Plus and Web-of-Science on 2 January 2020 for prospective and retrospective cohort studies with ≥50 women per gestational age group, published in English from 1995 onwards, that included women undergoing medical abortion and compared home expulsion of pregnancies of ≤9+0 weeks' gestational age with pregnancies of 9+1 -10+0 weeks or >10+1 weeks' gestational age, or compared the latter two gestational age groups. We assessed risk-of-bias using the Newcastle-Ottowa scale. All outcomes were meta-analyzed as risk ratios (RR) using the Mantel-Haenszel method. The certainty of the evidence was assessed using GRADE. RESULTS Six studies (n = 3381) were included. The "need for emergency care/admission to hospital" (RR = 0.79, 95% confidence interval [CI] 0.45-1.4), "hemorrhage requiring transfusion/≥500 mL blood loss" (RR = 0.62, 95% CI 0.11-3.55), patient satisfaction (RR = 0.99, 95% CI 0.95-1.03), pain (RR = 0.91, 95% CI 0.82-1.02), and "complete abortion without the need for surgical intervention" (RR = 1.03, 95% CI 1-1.05) did not differ statistically significantly between the ≤9+0 and >9+0 weeks' gestation groups. The rates of vomiting (RR = 0.8, 95% CI 0.69-0.93) and diarrhea (RR = 0.85, 95% CI 0.73-0.99) were statistically significantly lower in the ≤9+0 weeks group but these differences were not considered clinically important. We found no studies comparing pregnancies of 9+1 -10+0 weeks' gestation with pregnancies of >10+0 weeks' gestation. The certainty of this evidence was predominantly low and mainly compromised by low event rates and loss to follow up. CONCLUSIONS Women who are having a medical abortion and will be taking mifepristone up to and including 10+0 weeks' gestation should be offered the option of expulsion at home after they have taken the misoprostol. Further research needs to determine whether the gestational limit for home expulsion can be extended beyond 10+0 weeks.

BackgroundDuring the COVID-19 pandemic, the British governments issued temporary approvals enabling the use of both pills for medical abortion at home. This permitted the introduction of a fully telemedical model of abortion care with consultations taking place via phone or video call and medications delivered to women’s homes. The approvals in England and Wales will expire at the end of March 2022, while that in Scotland remains under consultation.MethodsWe interviewed 30 women who had undergone an abortion in England, Scotland or Wales between August and December 2021. We explored their views on the changes in abortion service configuration during the pandemic and whether abortion via telemedicine and use of abortion medications at home should continue.ResultsSupport for continuation of the permission to use mifepristone and misoprostol at home was overwhelmingly positive. Reasons cited included convenience, comfort, reduced stigma, privacy, and respect for autonomy. A telemedical model was also highly regarded for similar reasons but for some its necessity was linked to safety measures during the pandemic and an option to have an in-person interaction with a health professional at some point in the care pathway was endorsed.ConclusionsThe approval to use abortion pills at home via telemedicine are supported by women having abortions in Great Britain. The respective governments in England, Scotland, and Wales, should be responsive to the patient voice and move to make permanent these important advances in abortion care.What is already known on this topicDuring the COVID-pandemic, specific permission to use both pills for medical abortion at home was granted in England, Scotland and Wales leading to the widespread implementation of a telemedical model with direct-to-patient delivery of medications. The safety, effectiveness, and acceptability of this model of care had been well-documented prior to and during the pandemic.What this study addsThis study adds the voices of women undergoing abortion during the pandemic regarding the specific changes that led to the transformation of medical abortion care in Britain. Amongst 30 women interviewed, there was endorsement for the continuation of permissions to use medical abortion pills at home via telemedicine.How this study might affect research, practice, or policyThe UK government’s vision of health provision puts patients and the public first, where “no decision about me, without me” is the norm. Our findings support law and policy makers in applying this principle to recent developments in abortion care by making the permissions permanent.

BACKGROUND Long-acting reversible contraceptives (LARCs) are safe, effective and convenient post-abortal methods. However, there is concern that some LARCs may reduce the effectiveness of abortifacient drugs or result in other adverse outcomes. OBJECTIVE AND RATIONALE We undertook two systematic reviews to examine the early administration of LARCs in women undergoing medical abortion with mifepristone and misoprostol. (i) For women who are having a medical abortion and who plan to use a progestogen-only contraceptive implant or injectable, does administration of the contraception at the same time as mifepristone influence the efficacy of the abortion? (Implant/injectable review). (ii) For women who have had a medical abortion, how soon after expulsion of the products of conception is it safe to insert an intrauterine contraceptive device/system? (LNG-IUS/Cu-IUD review). SEARCH METHODS On 19 November 2018, we searched Embase Classic, Embase; Ovid MEDLINE(R) including Daily and Epub Ahead-of-Print, In-Process and Other Non-Indexed Citations; the Cochrane Library; Cinahl Plus; and Web of Science Core Collection. Eligible studies were randomised controlled trials (RCTs), in English from 1985 (Implant/injectable review) or 2007 (LNG-IUS/Cu-IUD review) onwards, conducted in women undergoing medical abortion with mifepristone and misoprostol and studying either (i) simultaneous administration of mifepristone and a progestogen-only contraceptive implant or injectable compared to administration >24 h after mifepristone, or (ii) immediate insertion of intrauterine contraception after expulsion of the products of conception compared to early insertion (≤7 days) or to delayed insertion (>7 days) or early compared to delayed insertion. One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for RCTs. All the outcomes were analysed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel–Haenszel statistical method and a fixed-effect model. The overall quality of the evidence was assessed using GRADE. OUTCOMES Two RCTs (n = 1027) showed lower ‘subsequent unintended pregnancy’ rates and higher ‘patient satisfaction’ rates, and no other differences, after simultaneous administration of mifepristone and the implant compared to delayed administration. One RCT (n = 461) showed higher ‘patient satisfaction’ rates after simultaneous administration than after delayed administration of mifepristone and the injectable, but no other differences between these interventions. Three RCTs (n = 536) found no differences other than higher copper IUC uptake after early compared to delayed insertion at ≤9 weeks of gestation and higher rates of IUC expulsion, continuation and uptake after immediate compared to delayed insertion at 9+1–12+0 weeks of gestation and higher IUC continuation rates after immediate compared to delayed insertion at 12+1–20+0 weeks of gestation. The quality of this evidence ranged from very low to high and was mainly compromised by low event rates, high attrition and no blinding. WIDER IMPLICATIONS The contraceptive implant or injectable should be offered on the day of taking mifepristone. Intrauterine methods of contraception should be offered as soon as possible after expulsion of the pregnancy.

Abortion care is a fundamental part of women's reproductive health care. Surgical and medical abortion methods are safe and effective throughout the gestational age range wherein abortions are performed. Although risks increase with the gestational age of the pregnancy being terminated, rates of complications remain low and comparable between surgical and medical techniques. A high-quality abortion service should offer women a choice between abortion methods and provide the one they prefer.

Most hospitals in Great Britain only offer a medical termination of pregnancy for a fetal anomaly (TOPFA) in the second trimester. We describe the safety and acceptability of a surgical TOPFA service delivered by an independent-sector abortion provider. Non-identifiable data for women undergoing TOPFA at British Pregnancy Advisory Service from 1 January 2015 to 31 March 2016 was extracted from existing databases. Anonymous feedback was obtained using a questionnaire. Women (

We assessed whether a low-sensitivity pregnancy test is effective at identifying ongoing pregnancy after medication abortion at 64 to 70 days of gestation.From October 2018 to March 2020, we performed a prospective observational study of participants in England and Wales undergoing medication abortion. Participants were scheduled to return to the clinic 14 ± 3 days after mifepristone administration to perform a low-sensitivity pregnancy test (human chorionic gonadotropin threshold of 1000 mIU/mL) and symptom checklist, and state whether they thought the abortion was complete. Clinicians also assessed the low-sensitivity pregnancy test and performed an ultrasound to determine abortion status. We calculated the sensitivity, specificity, negative and positive predictive value of the low-sensitivity pregnancy test (with and without a symptom checklist) for detecting ongoing pregnancy.We enrolled 757 participants. Thirty-one did not progress to abortion and 558 (76.9%) completed follow-up. Most (79.6%) attended per-protocol; 22 (3.9%) attended earlier than 11 days and 92 (16.5%) later than 17 days. Thirteen participants (2.3%) had an ongoing pregnancy. The low-sensitivity pregnancy test correctly identified all the ongoing pregnancies (sensitivity = 100%; specificity = 84.8%; negative predictive value = 100%; positive predictive value = 13.5%). The symptom checklist alone had a sensitivity of 76.9% and a negative predictive value of 99.4% for identifying ongoing pregnancies. Participants and clinicians agreed on the interpretation of the low-sensitivity pregnancy test 94.6% of the time.Patient self-assessment of a low-sensitivity pregnancy test after medication abortion between 64- and 70 days' gestation has high sensitivity and negative predictive value for identification of ongoing pregnancy.Patients can be offered a low-sensitivity pregnancy test to assess for ongoing pregnancy after medication abortion up to 70 days of gestation thereby reducing the need for in-person visits. Services should be prepared to provide in-person assessments after positive or inconclusive results to ensure early identification of abortion complications.

Background Quality of care (QOC) is increasingly identified as an important contributor to healthcare outcomes, however little agreement exists on what constitutes quality in abortion care or the recommended indicators from the service-user perspective. Our study aimed to explore perceptions and experiences of abortion QOC in England and Wales. Methods We performed in-depth interviews (via phone or in-person) with participants who had an abortion at a nationwide independent sector provider in the previous 6 months. We explored their experiences of the abortion service at each point in the care pathway, their perspectives on what contributed to and detracted from the experience meeting their definitions of quality, and their reflections on different aspects of QOC. We used content analysis to generate themes. Results From December 2018 to July 2019, we conducted 24 interviews. Ten participants had a surgical and 14 had a medical abortion. Seventeen (71%) were treated in the first 12 weeks of pregnancy and 7 (29%) beyond that, with an average gestational age of 10 weeks + 5 days (range 5–23 + 6). We identified 4 major themes that contributed to participant’s perception of high quality care: (1) interpersonal interactions with staff or other patients, (2) being informed and prepared, (3) participation and choices in care and (4) accessibility. Nearly all participants identified interpersonal interactions with staff as an important contributor to quality with positive interactions often cited as the best part of their abortion experience and negative interactions as the worst. For information and preparation, participant described not only the importance of being well prepared, but how incongruencies between information and the actual experience detracted from quality. Participants said that making choices about their care, for example, method of abortion, was a positive contributor. Finally, participants identified access to care, specifically in relation to waiting times and travel, as an important aspect of QOC. Conclusions Participants situated quality in abortion care in 4 domains: interpersonal aspects of care, information and preparation, choices, and accessibility. Indicators identified can be used to develop standard metrics to ensure care meets service-user needs., Plain English summary Quality of care is an important aspect of delivering healthcare in a patient-centred manner. There is a lack of agreement about what consititutes quality care for an abortion service. In our study, we interviewed 24 participants who had an abortion in the last 6 months to assess their perceptions of quality of care. Based on our analysis, we identified 4 themes that were important contributors to quality: (1) interactions with clinic staff or other patients, (2) information and preparation for the abortion, (3) making choices about care, and (4) access to abortion care. Almost all of our study participants said that positive interactions with clinic staff contributed to a quality experience. Participants wanted to be well-prepared for their abortion. They reported a negative experience when the information they were given did not match their experience. Participants felt that active participation in choices around their abortion experience improved quality. Finally, ease of access to abortion care made for a more positive experience. Abortion providers and researchers should consider using the results of our study to ensure their services meet patients’ needs.

Background One in three women in the United Kingdom (UK) will have an abortion before age 45, making abortion provision an essential aspect of reproductive healthcare. Despite this, abortion remains ethically contested and stigmatised, with variable teaching in UK medical schools and concerns about falling numbers of doctors willing to participate in abortion care. University College London Medical School (UCLMS) has designed practical, inclusive, teaching that aims to give students an understanding of the importance of abortion care and prepare them to be competent practitioners in this area. This study aimed to determine students’ opinions of this teaching and their wider attitudes towards abortion. Methods We invited all 357 final-year UCL medical students to complete an online survey consisting of closed-ended questions, exploring their opinions on their abortion teaching, their personal beliefs about abortion and their future willingness to be involved in abortion care. We analysed responses using non-parametric tests. Results One hundred and forty-six questionnaires (41% response rate) showed 83% of students identified as pro-choice (agree with the right to choose an abortion). Fifty-seven percent felt they received the right amount of abortion teaching, 39% would have liked more and 4% stated they received too much. There was no correlation between students’ attitudes to abortion and the rating of teaching; both pro-choice and pro-life (opposed to the right to choose an abortion) students generally rated the teaching as important and valued the range of methods used. Students requested more simulated practice speaking to patients requesting an abortion. Students with pro-life beliefs expressed lower willingness to discuss, refer, certify and provide future abortions. Students interested in careers in specialties where they may encounter abortion were more likely to be pro-choice than pro-life. Conclusions The majority of participating UCL medical students were pro-choice and willing to be involved in future abortion care. Efforts to make teaching on abortion practical, engaging, sensitive and inclusive were appreciated. As well as preparing students to be competent and caring practitioners, the teaching appears to contribute towards them viewing abortion as an essential aspect of women’s healthcare, and may contribute to destigmatising abortion.

OBJECTIVE This study aimed to determine the optimal cervical priming regimen before surgical abortion between 14+0 and 24+0 weeks' gestation. DATA SOURCES Embase, MEDLINE, and the Cochrane Library were searched for publications up to February 2020. Experts were consulted for any ongoing or missed trials. STUDY ELIGIBILITY CRITERIA Randomized controlled trials, published in English after 1985, that compared (1) mifepristone, misoprostol, and osmotic dilators against each other, alone or in combination; (2) different doses of mifepristone and misoprostol; (3) different intervals between priming and abortion; or (4) different routes of administration of misoprostol were included. METHODS Risk of bias was assessed using the Cochrane Collaboration checklist for randomized controlled trials, and data were meta-analyzed in Review Manager 5.3. Dichotomous outcomes were analyzed as risk ratios using the Mantel-Haenszel method, and continuous outcomes were analyzed as mean differences using the inverse variance method. Fixed effects models were used when there was no significant heterogeneity (I2

No area of healthcare is immune to the impact of COVID-19. The pandemic will affect sexual and reproductive health (SRH) worldwide in positive and negative ways. Home isolation and fears of contracting the virus appear to have led to decreased uptake of SRH services, increased reports of intimate partner violence, and in some settings reduced access to contraception and safe abortion care.1 2 Vulnerable populations are disproportionately affected, including young people, Indigenous peoples, as well as refugees and asylum-seekers whose safety and care is deprioritised.3 Predictions have been made about higher rates of unintended pregnancy, unsafe abortion, short interpregnancy intervals, and untreated sexually transmitted infections.1 The pandemic has also led to rapid implementation of innovations and legal and regulatory changes that have transformed and improved care for some people. New policies, practices and even enactment of laws have removed barriers to care which could otherwise take years of bureaucracy to overturn.4–6 This editorial draws on the expertise of a range of international clinicians and researchers to examine these changes to policy and practice, many of which may have lasting community benefits. Many countries have recognised continuity of contraception provision, particularly long-acting reversible contraception (LARC), as essential. Where infrastructure permits, there has been a significant shift to telemedicine, for instance in the United States (US), Canada, UK, France, Australia, Scandinavia, China, South Africa and Nepal.4 6 ,7 Some countries have been able to maintain LARC access through brief procedural visits with appropriate personal protective equipment (PPE) following a virtual …

Objective To evaluate outcomes with mifepristone 200 mg orally followed 24–48 h later by misoprostol 800 mcg vaginally for medical abortion at 64–70 days of gestation. Study design We reviewed electronic databases and medical records for medical abortion cases at 64–70 days' gestation at British Pregnancy Advisory Service clinics in England and Wales from May 2015 through October 2016. Women selected in-office follow-up or self-evaluation of abortion outcome using a checklist along with low-sensitivity urine pregnancy testing. We excluded cases in which we could not locate records and when women did not proceed with medical abortion, did not use misoprostol following mifepristone if abortion had not occurred and did not attend a scheduled follow-up assessment. We analyzed demographic characteristics, treatment outcomes and significant adverse events. We defined treatment success as complete abortion without surgical evacuation and without continuing pregnancy. Results Of 2743 cases identified, we could not locate 40 charts and excluded 30 cases, leaving a final sample of 2673. Overall, 2538 (94.9%, 95% CI 94.1–95.8) women had a successful medical abortion. Reasons for failure included continuing pregnancy (n=90, 3.4%, 95% CI 2.7–4.1), retained nonviable pregnancy (n=2, 0.1%, 95% CI 0–0.2) and incomplete abortion (n=43, 1.6%, 95% CI 1.1–2.1). Of those with continuing pregnancies, 81 underwent a uterine aspiration and 9 opted to continue the pregnancy. Thirty-five (1.3%, 95% CI 0.9–1.7) women had significant adverse events; 16 (0.6%, 95% CI 0.3–0.9) underwent an in-hospital aspiration. Pelvic infection (n=4, 0.2%) and transfusion (n=1, 0.03%) occurred rarely. Conclusion Medical abortion from 64 to 70 days with mifepristone and vaginal misoprostol is effective with a low rate of serious adverse events. Implications Medical abortion between 64 and 70 days of gestation may be offered on an outpatient basis using mifepristone and vaginal misoprostol. Service provision without an in-person follow-up is feasible. Not all women with a continuing pregnancy after medical abortion treatment opt to have an aspiration procedure.

Objective To compare the effectiveness, safety, and acceptability of in-clinic and remote/self-assessment, as well as different remote/self-assessments, for confirming the success of medical abortion at ≤10+0 weeks’ gestation. Data Sources Ovid Embase Classic and Embase; Ovid MEDLINE(R) and Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations and Daily; and the Cochrane Library. We also consulted experts in this field for any ongoing or missed trials. Study Eligibility Criteria Randomized controlled trials published in English from 2000 onward, comparing in-clinic assessment with ultrasound to remote or self-assessment or comparing different remote or self-assessment strategies to confirm the success of medical abortion of pregnancies up to and including 10+0 weeks gestation, reporting any of the following outcomes: “missed ongoing pregnancy,” “correct implementation of the follow-up strategy,” patient satisfaction/preference, “adherence to follow-up strategy,” “unscheduled visits/telephone calls to the abortion service,” and surgical intervention. Study Appraisal and Synthesis Methods One author assessed the risk of bias in the studies using the Cochrane Collaboration checklist for randomized controlled trials. All outcomes were analyzed as risk ratios and meta-analysed in Review Manager 5.3 using the Mantel–Haenszel statistical method and a fixed effect model. The overall quality of the evidence was assessed using GRADE. Results Four randomized controlled trials (n = 5761) compared in-clinic to remote self-assessment and found no clinically significant differences apart from higher preference rates for remote follow-up, especially in the remote follow-up groups. The quality of this evidence was compromised by attrition, no blinding, inconsistency, indirectness, and low event rates. Two randomized controlled trials (n = 1125) compared different remote assessment strategies (using urine pregnancy tests) and also found no clinically significant differences apart from a clinically significantly lower rate of unscheduled visits to the abortion service in the remote follow-up group using a multilevel urine pregnancy test compared to remote follow-up using a high-sensitivity urine pregnancy test. The quality of this evidence was compromised by small event rates, lack of blinding, indirectness and high attrition rates. Conclusion The published data support offering women who have had a medical abortion up to and including 10+0 weeks’ gestation the choice of self-assessment, remote assessment, or clinic follow-up.

Background Despite Britain, Colombia, and some Mexican states sharing a health exception within their abortion laws, access to abortion under the health exception varies widely. This study examines factors that result in heterogeneous application of similar health exception laws and consequences for access to legal abortion. Our research adds to previous literature by comparing implementation of similar abortion laws across countries to identify strategies for full implementation of the health exception. Methods We conducted a cross-country comparative descriptive study synthesizing data from document and literature review, official abortion statistics, and interviews with key informants. We gathered information on the use and interpretation of the health exception in the three countries from peer-reviewed literature, court documents, and grey literature. We next extracted public and private abortion statistics to understand the application of the law in each setting. We used a matrix to synthesize information and identify key factors in the use of the law. We conducted in-depth interviews with doctors and experts familiar with the health exception laws in each country and analyzed the qualitative data based on the previously identified factors. Results The health exception is used broadly in Britain, somewhat in Colombia, and very rarely in Mexican states. We identified five factors as particularly salient to application of the health exception in each setting: 1) comprehensiveness of the law including explicit mention of mental health, 2) a strong public health sector that funds abortion, 3) knowledge of and attitudes toward the health exception law, including guidelines for physicians in providing abortion, 4) dissemination of information about the health exception law, and 5) a history of court cases that protect women and clarify the health exception law. Conclusions The health exception is a valuable tool for expanding access to legal abortion. Differences in the use of the health exception as an indication for legal abortion result in wide access for women in Britain to nearly no access in Mexican states. Our findings highlight the difference between theoretical and real access to legal abortion. The interpretation and application of the health exception law are pivotal to expanding real access to abortion.

To evaluate outcomes with simultaneous administration of mifepristone and misoprostol for medical abortion at 63 days of gestation or less in the year after its implementation in a British clinic system.We conducted a retrospective cohort study using deidentified data from the electronic booking and complications databases and medical records of women who underwent medical abortion at British Pregnancy Advisory Service. Our primary outcome was treatment success with simultaneous dosing compared with a regimen with a 24- to 48-hour interval between medications. We defined success as complete abortion without surgical evacuation and without continuing pregnancy. To assess relative regimen effectiveness while accounting for self-assignment to simultaneous or interval dosing, we modeled the probability of treatment success using logistic regression with propensity score adjustment for demographic and clinical characteristics. Secondary outcomes were reasons for abortion failure and clinically significant adverse events (hospital admission, blood transfusion, intravenous antibiotic administration).Of 28,901 women treated between May 2015 and April 2016, 85% chose simultaneous dosing. Overall success rates were high with both regimens but lower with simultaneous than with interval dosing (94.5% vs 97.1%, respectively, adjusted relative risk 0.973, 95% CI 0.967-0.979). For both regimens, success rates were lower at higher gestational ages, but the relative effectiveness of simultaneous dosing did not vary significantly with gestational age (P=.268). Surgical intervention rates for continuing pregnancy were lowest at 49 days of gestation or less (1.4% simultaneous vs 0.2% interval, P.001) and highest at 57-63 days of gestation (5.0% and 2.2%, P.001). The rate of clinically significant adverse events was 0.2% and did not differ by regimen (P=.972).Simultaneous administration of mifepristone and misoprostol is 97% as effective as a 24- to 48-hour interval at all gestational ages 63 days or less with no increase in the risk of clinically significant adverse events. Pragmatic use of simultaneous dosing is reasonable given the small difference in effectiveness.

Women having a termination of pregnancy (TOP) have higher rates of Chlamydia trachomatis (CT) than the general population. In this study, we explored CT treatment and prevention in Dutch TOP clinics in comparison to that provided in Great Britain (GB).A qualitative study including 14 semi-structured interviews with health care professionals (HCPs) in TOP clinics (the Netherlands: 9, GB: 5). Interviews were recorded, transcribed, and analysed by thematic content analysis.Prophylactic treatment with azithromycin is routinely prescribed after surgical TOP, but not after medical TOP ('abortion pill'). Sexually transmitted infections (STI) tests are offered to clients who are considered at high risk of having STI. Uptake varies according to health insurance coverage of STI testing. Some Dutch clinics are able to provide free testing for women under 25 years of age. Sexual health counselling is often limited to discussing birth control. The major difference between the Netherlands and GB is that GB TOP clinics more often offer free STI testing and prophylaxis to their clients.HCPs in Dutch TOP clinics consider STI testing an important part of their service, but financial barriers prevent testing on location. Dutch TOP clinics should offer STI tests to all women, and collaboration with public health services could improve STI testing and counselling for young people. Furthermore, clinics should treat all TOP clients with prophylactic azithromycin. This could prevent CT and other upper genital tract post-abortion infections.

Five intrauterine devices (IUDs) are available in the United States: four levonorgestrel-releasing intrauterine systems (two containing 52 mg, one containing 19.5 mg and one containing 13.5 mg) and one copper-bearing device (Copper T 380A). All IUDs have very low typical-use failure rates and high acceptability ratings, yet they are used by a minority of women, with nulliparous women less likely to do so than parous women. The objective of this clinical review is to give evidence-based recommendations for the use of IUDs in nulliparous women. Intrauterine devices are safe and effective for the majority of women including those who are nulliparous, and should be routinely included in the contraception options offered to them.

Background Cervical preparation has been shown to reduce complications with dilatation and evacuation (D&E), but the optimal regimen is unknown. While most published reports are from North America and describe overnight cervical preparation, recent research suggests the safety of same-day cervical preparation up to a gestational age of 18 weeks. We investigated the safety and efficacy of a same-day preparation protocol using a combination of Dilapan-S and misoprostol for gestations of 18–22 weeks. Study Design This retrospective chart review evaluated 281 consecutive women who had a D&E from 18+0 to 21+6 weeks’ gestation at the British Pregnancy Advisory Service clinic in Richmond, London, between January and December 2010. Misoprostol and Dilapan-S osmotic dilators were used in combination for approximately 3 h prior to evacuation. Women who had induced fetal demise were excluded. We evaluated procedure success, duration and the frequency of adverse events. Results A total of 274 cases were included in this analysis. In 97% of cases, 400 mcg vaginal misoprostol was used, and in 85% of cases, three Dilapan dilators were inserted. Mean cervical preparation time was 3 h and 40 min (SD 41.2 min), and mean procedure time was 10 min (SD 4.2). There were two immediate complications: one cervical laceration [0.36%, 95% confidence interval (CI) 0.01–2.01] and one extramural delivery in the clinic after cervical preparation agents were placed (0.36%, 95% CI 0.01–2.01). There were no cases of uterine perforation, hemorrhage or inability to complete the procedure. Conclusion This study suggests that same-day cervical preparation with Dilapan-S and misoprostol is safe and feasible for second-trimester surgical abortion up to 22 weeks’ gestation.

Objective To examine contraceptive choices among women seeking termination of pregnancy (TOP) and the provision of the chosen methods. Design Population-based study. Setting British Pregnancy Advisory Service (BPAS) clinics in England and Wales. Population Between 1 January 2011 and 31 December 2014, 211 215 women had a TOP at BPAS, were offered contraceptive counselling, and were eligible to obtain contraception at no cost. Methods We examined electronic records from BPAS and assessed the proportions of women who accepted contraceptive counselling and chose a contraceptive method, as well as the distributions of methods chosen, analysed by provider and by TOP type. We calculated the proportions receiving their chosen method and the methods chosen by women using no method at conception. We used logistic regression to examine the factors associated with choice of an intrauterine contraceptive (IUC) or implant. Main outcome measures Post-TOP contraceptive method choice. Receipt of chosen method post-TOP. Results Eighty-five per cent of women accepted contraceptive counselling and 51% chose to obtain a method from BPAS rather than from a GP or contraception and sexual health clinic post-TOP. [correction added on 25 November 2016 after first online publication: 51% has been inserted in the preceding sentence.] Among those who wanted to receive contraception from BPAS, 51% chose an IUC or implant and 19% chose oral contraceptives. Ninety-one per cent of women who obtained contraception from BPAS received their chosen method. Women were more likely to choose an IUC or implant if they obtained contraception from BPAS, had a surgical TOP, were parous, young, white, or had one or more previous TOPs. Conclusions The standards set for patient-centred TOP care should emphasise the need for a full range of contraceptive options to be offered and provided post-TOP. Tweetable abstract Uptake targets for long-acting reversible methods do not reflect women's post-TOP contraceptive preferences.

Restrictive policies that limit access to abortion often lead women to seek services abroad. We present results from an exploratory study aimed at documenting the socio-demographic characteristics, travel and abortion-seeking experiences of non-resident women seeking abortions in the UK.Between August 2014 and March 2015, we surveyed a convenience sample of 58 non-UK residents seeking abortions at three British Pregnancy Advisory Service (BPAS) abortion clinics in England in order to better understand the experiences of non-resident women who travel to the UK seeking abortion services.Participants travelled to England from 14 countries in Europe and the Middle East. Twenty-six percent of participants reported gestational ages between 14 and 20 weeks, and 14% (n = 8) were beyond 20 weeks since their last menstrual period (LMP). More women from Western Europe sought abortions beyond 13 weeks gestation than from any other region. Women reported seeking abortion outside of their country of residence for a variety of reasons, most commonly, that abortion was not legal (51%), followed by having passed the gestational limit for a legal abortion (31%). Women paid an average of £631 for travel expenses, and an average of £210 for accommodation. More than half of women in our study found it difficult to cover travel costs.Understanding how and why women seek abortion care far from their countries of residence is an important topic for future research and could help to inform abortion-related policy decisions in the UK and in Europe.

Two intrauterine devices (IUDs) are available in the United States, the levonorgestrel-bearing intrauterine system (Mirena) and the copper-bearing T380A (Paragard). These devices have very low typical-use failure rates but are used by only a minority of women. In particular, there is concern about their use in nulliparous women. We review the available data to address common concerns about using IUDs in this population and show that nulliparous women desiring effective contraception should be considered candidates for IUDs.

Background We sought to establish the accuracy of abdominal ultrasonography in determining gestational age and identifying the presence of a gestational sac and embryonic pole before and after medical abortion. Methods We included all 120 women enrolled in a study of simultaneous oral mifepristone and buccal misoprostol for abortion through 63 days' gestation. Vaginal and abdominal ultrasound examinations were performed before and 24 h after medication administration. Visualization of a gestational sac and embryonic pole and presence or absence of cardiac activity were recorded. Sensitivity and specificity were calculated with the results from vaginal ultrasonography as the gold standard. The effect of body mass index (BMI) on ultrasound findings was also assessed. Results Before treatment, the sensitivities of abdominal ultrasonography were 100% (95% CI 97–100) and 68% (95% CI 58–77) for presence of a gestational sac and an embryonic pole, respectively. Overall, abdominal imaging underestimated mean gestational age by 1.6 days (95% CI 1.0–2.2). After treatment, abdominal ultrasonography missed three of 34 retained gestational sacs (sensitivity 91%, 95% CI 76–98%). Fourteen women had gestational cardiac activity by vaginal ultrasound at follow-up. Abdominal imaging identified the gestational sac in all cases, but cardiac motion was only visible in 10 (71%, 95% CI 42–92%). For every 10-point increase in BMI, the odds ratio for missing an embryonic pole at baseline was 2.8 (95% CI 1.5–5.0). Conclusions Abdominal ultrasonography is sensitive for diagnosing the presence or absence of a gestational sac, but less sensitive at detecting an embryonic pole. This may lead to a small underestimation of gestational age and missing a continuing pregnancy at follow-up when one exists.

Background and methodology This survey was undertaken to obtain the opinions of women in the UK about their home management of early medical abortion (EMA) with mifepristone and misoprostol. All eligible women undergoing EMA at any BPAS clinic during a 2-week period were invited to participate. Women were contacted by telephone 1 week after the EMA and a five-item structured questionnaire was administered. One open-ended question gave women the opportunity to freely comment. Demographics and responses were tabulated using descriptive statistics. Mulitivariable logistic regression was used to assess the influence of demographic characteristics on responses. Results Of 249 enrolled participants, 162 were successfully surveyed (a 65% response rate). Most respondents (86%) would rather go home to complete an EMA than remain in a clinical setting. The majority (96%) found home management very or somewhat acceptable and 96% felt they could have obtained medical help easily if necessary. Most respondents (62%) would prefer home use of misoprostol as opposed to returning to the clinic to obtain and use the medication. Women were less likely to prefer home management if they were Asian (OR 0.21, 95% CI 0.05–0.87) or had a gestational age >49 days (OR 0.26, 95% CI 0.10–0.71). Discussion and conclusions Home management of EMA is acceptable to most women in the UK who have experienced it and is, for many, preferable to a clinical setting. Consideration should be given to updating the interpretation of the UK9s 1967 Abortion Act to allow home administration of misoprostol.

Objectives To evaluate the ability of endometrial thickness after medical abortion to predict the need for subsequent dilatation and curettage (D&C). Methods We pooled data from two multicenter medical abortion trials involving 2208 women who received mifepristone orally followed by misoprostol vaginally. Women returned for transvaginal ultrasonography approximately 7 days later. The endometrial thickness was measured if no gestational sac was present. Final status was confirmed by a phone interview at 5 weeks. The area under the receiver–operating characteristics (ROC) curve was calculated to assess the overall ability of endometrial thickness to predict the need for subsequent D&C. Endometrial thickness was dichotomized using threshold values at 5-mm increments from 10 to 30 mm. The sensitivity, specificity, negative predictive value and positive predictive value were calculated to evaluate the ability of each endometrial thickness threshold value to predict subsequent D&C. Multivariable regression analysis was performed to adjust endometrial thickness values for study, treatment group, and study site. Results At 7 days after misoprostol treatment, 1870 women (84.7%) had endometrial thickness assessed. Thirty of these women (1.6%) subsequently underwent D&C. The mean endometrial thickness was 14.5 mm for women who underwent D&C and 10.9 mm for those who did not (difference 3.5 mm (95% CI, 1.8–5.3 mm)). Endometrial thickness was poorly predictive of the need for D&C, with an area under the ROC curve of 0.65. All endometrial thickness thresholds had positive predictive values of 25% or less. The results were unchanged by adjustment of endometrial thickness values by multivariable modeling. Conclusions Although endometrial thickness following successful expulsion of the gestational sac is thicker in women who will eventually require surgical intervention after medical abortion, endometrial thickness is not a clinically useful predictor of the subsequent need for D&C. Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd.

We sought to compare endometrial thickness after misoprostol or dilation and curettage (DC) for early pregnancy failure and to assess the predictive value of endometrial thickness for subsequent DC after misoprostol treatment.In a randomized trial of early pregnancy failure management, 491 women were treated with misoprostol vaginally, and 161 were treated with DC. Transvaginal ultrasonography was planned for 2 and 14 days after misoprostol treatment, and 14 days after DC.The mean endometrial thickness 14 days after treatment was 9.0 mm for the misoprostol group and 6.9 mm for the DC group, (difference 2.1 mm, 95% confidence interval [CI] 1.0-3.2). After the ultrasonograms 2 and 14 days after misoprostol, 13 (3.8%) and 12 (3.2%) women, respectively, subsequently underwent DC. Women requiring DC after successful expulsion had significantly greater endometrial thickness than those who did not at 2 days (mean difference 5.2 mm, 95% CI 1.6-8.8) and 14 days (mean difference 5.5 mm, 95% CI 2.3-8.8) after misoprostol. However, endometrial thickness was a poor predictor of subsequent DC. The areas under the receiver operating characteristic curves for endometrial thickness at 2 and 14 days were 0.71 and 0.73, respectively. Regardless of cutoff values used for predicting subsequent DC, endometrial thickness had a positive predictive value of 40% or less.The difference in endometrial thickness between misoprostol treatment and DC for early pregnancy failure is not clinically significant. Endometrial thickness is not a useful predictor of subsequent surgical intervention after successful expulsion of the gestational sac after misoprostol for early pregnancy failure.ClinicalTrials.gov,www.clinicaltrials.gov, NCT00177333I.

Background Simultaneous oral mifepristone and vaginal misoprostol has a 24-h expulsion rate of approximately 90% when used for abortion through 63 days' gestation. This pilot study sought to determine if a simultaneous regimen using buccal misoprostol would be similarly effective and merit further investigation. Study design One hundred twenty women were enrolled into three equal groups by gestational age: ≤49 days (Group 1), 50–56 days (Group 2) and 57–63 days (Group 3). After swallowing 200 mg of mifepristone, subjects received 800 mcg buccal misoprostol. Participants returned in 24±1 h for evaluation of expulsion by ultrasonography. Women with a persistent gestational sac received 800 mcg vaginal misoprostol. Further follow-up occurred at 1, 2 and 5 weeks by telephone or in person, as appropriate. Sample sizes for each group were estimated with the aim of establishing a 24-h expulsion rate of 90% (95% CI=76–95). Results The 24-h expulsion rates for Groups 1, 2 and 3 were 73% (95% CI=56–85), 69% (95% CI=52–83) and 73% (95% CI=56–85), respectively. Common side effects were nausea (62%), vomiting (33%) and diarrhea (48%), which did not differ by gestational age. Forty-three percent of subjects found the taste of buccal misoprostol objectionable; 30% found buccal retention uncomfortable or inconvenient, and 10% reported oral irritation, sensitivity, numbness or oral ulcers. Conclusions Simultaneous oral mifepristone and buccal misoprostol had a lower-than-hypothesized expulsion rate at 24 h. Although overall success rates at 7 or 15 days could have been higher than those observed at 24 h, we believe that this regimen does not warrant further study.

Background Ambivalence towards pregnancy is rarely acknowledged in policy discussions. Methods We surveyed 441 nonpregnant women who consecutively presented to two urgent care clinics in California about their current intentions to conceive using a five-point scale. We examined the association between ambivalence towards pregnancy, sociodemographic characteristics and use of contraception. Results Almost one third of women (29.0%; 95% CI=25–33%) expressed ambivalence about their intentions to become pregnant. In multivariable modeling, being older than 30, being nonwhite and having a personal or religious objection to abortion were significantly associated with ambivalence towards pregnancy. Compared with women who stated they were trying to avoid pregnancy, women who expressed ambivalence were significantly less likely to have used a barrier or hormonal form of contraception at last intercourse (OR=0.36, 95% CI=0.23–0.57) and more likely to use the natural family planning (NFP) method (OR=3.31, 95% CI=1.39–7.90) or withdrawal (OR=1.61, 95% CI=0.98–2.65). Conclusion Ambivalence towards pregnancy is common and is associated with use of less effective contraceptive methods.

This ethnobotanical literature survey is part of an on-going study in New York City investigating Dominican and Chinese healing systems and the herbal treatments used for the following women's conditions: uterine fibroids (benign tumors of uterine smooth muscle); menorrhagia (excessive uterine bleeding); endometriosis (growth of endometrial tissue outside of the uterus); and hot flashes (sudden brief sensations of heat commonly experienced during menopause). The objectives of this survey were: (1) to search literature on medicinal plants used in the Dominican Republic and identify those used for the above listed conditions and their symptoms; (2) to compare the use between herbal treatments reported in the literature with those prescribed by Dominican healers in New York City; and (3) to evaluate the extent to which healers may have changed their use of plants in order to adapt to availability in the New York City environment. A total of 87 plant species were reported in the Dominican literature for these conditions and symptoms. Nineteen species overlapped from the literature survey and the fieldwork with Dominican healers in New York City, representing 29% (n=65) of the plants prescribed by healers in New York City. This study offers a model to investigate changes in plant use as people migrate to urban centers where they are surrounded by diverse cultures, healing systems, and new environments.

UK regulations on managing fetal tissue after pregnancy loss, including abortion, are underscored by the concept of 'sensitive disposal'. This involves offering women burial or cremation and, when disposal is by the health care provider, separating fetal tissue from other clinical waste before incineration. We interviewed 23 women who had undergone one or more abortions about their understanding, attitudes and experiences of fetal tissue disposal and 'sensitive disposal'. Transcripts were analysed for representative themes.Prior to the abortion, most participants did not give consideration to disposal methods because their focus was on ending the pregnancy. Appropriate disposal by health professionals was assumed but some women undergoing early medical abortion reported anxiety about how to manage disposal at home. The term 'sensitive disposal' was unfamiliar to most respondents. Participants generally favoured separation of fetal tissue from other clinical waste and approved of incineration as a means of destruction. Ceremonial disposal was approved of following the loss of a wanted pregnancy but not following elective abortion. Most wanted the opportunity to access information about disposal but did not favour being asked or required to make decisions about disposal.Knowledge about the management of fetal tissue after abortion or the concept of 'sensitive disposal' was limited among the women we interviewed. Current guidelines appear discordant with the views of women terminating an unwanted pregnancy. Further research is needed to better inform policy on this issue.

Choice of a medical or surgical method of termination for fetal anomaly (TFA) is advocated in national guidelines based on a similar risk profile. We investigated whether women are offered a choice of method, by surveying members of a UK parent support organisation. An online questionnaire was designed to examine respondents' experience of TFA. A total of 351 responses were included in the final analysis. TFAs after 24 weeks' gestation and selective reductions were excluded. Mean gestational age at TFA was 17 weeks; 14% (n = 50) were offered a choice of method, falling to 8% (n = 19) after 14 weeks' gestation. Overall, 78% (n = 275) underwent medical TFA with 88% stating they chose it because it was the only method offered; 60% (n = 30) of those offered a choice had a surgical TFA. Our survey suggests that women having TFA are not offered a choice of method. Service delivery should be improved to meet national guidance and women's needs.

BACKGROUND: Preparing the cervix prior to surgical abortion is intended to make the procedure both easier and safer. Options for cervical preparation include osmotic dilators and pharmacologic agents. Many formulations and regimens are available, and recommendations from professional organizations vary for the use of preparatory techniques in women of different ages, parity or gestational age of the pregnancy. OBJECTIVES: To determine whether cervical preparation is necessary in the first trimester, and if so, which preparatory agent is preferred. SEARCH STRATEGY: We searched Cochrane, Popline, Embase, Medline and Lilacs databases for randomised controlled trials investigating the use of cervical preparatory techniques prior to first trimester surgical abortion. In addition, we hand-searched key references and contacted authors to locate unpublished studies or studies not identified in the database searches. SELECTION CRITERIA: Randomised controlled trials investigating any pharmacologic or mechanical method of cervical preparation, with the exception of nitric oxide donors (the subject of another Cochrane review), administered prior to first trimester surgical abortion were included. Outcome measures must have included the amount of cervical dilation achieved, the procedure duration or difficulty, side-effects, patient satisfaction or adverse events to be included in this review. DATA COLLECTION AND ANALYSIS: Trials under consideration were evaluated by considering whether inclusion criteria were met as well as methodologic quality. Fifty-one studies were included, resulting in 24 different cervical preparation comparisons. Results are reported as odds ratios (OR) for dichotomous outcomes and weighted mean differences for continuous data. MAIN RESULTS: When compared to placebo, misoprostol (400-600 microg given vaginally or sublingually), gemeprost, mifepristone (200 or 600 mg), prostaglandin E and F(2alpha) (2.5 mg administered intracervically) demonstrated larger cervical preparation effects. When misoprostol was compared to gemeprost, misoprostol was more effective in preparing the cervix and was associated with fewer gastrointestinal side-effects. For vaginal administration, administration 2 hours prior was less effective than administration 3 hours prior to the abortion. Compared to oral misoprostol administration, the vaginal route was associated with significantly greater initial cervical dilation and lower rates of side-effects; however, sublingual administration 2-3 hours prior to the procedure demonstrated cervical effects superior to vaginal administration.When misoprostol (600 microg oral or 800 microg vaginal) was compared to mifepristone (200 mg administered 24 hours prior to procedure), misoprostol had inferior cervical preparatory effects. Compared to day-prior laminaria tents, 200 or 400 microg vaginal misoprostol showed no differences in the need for further mechanical dilation or length of the procedure; similarly, the osmotic dilators Lamicel and Dilapan showed no differences in cervical ripening when compared to gemeprost, although gemeprost had cervical effects which were superior to laminaria tents. Older prostaglandin regimens (sulprostone, prostaglandin E(2) andF(2alpha)) were associated with high rates of gastrointestinal side-effects and unplanned pregnancy expulsions. Few studies reported women's satisfaction with cervical preparatory techniques. AUTHORS' CONCLUSIONS: Modern methods of cervical ripening are generally safe, although efficacy and side-effects between methods vary. Reports of adverse events such as cervical laceration or uterine perforation are uncommon overall in this body of evidence and no published study has investigated whether cervical preparation impacts these rare outcomes. Cervical preparation decreases the length of the abortion procedure; this may become increasingly important with increasing gestational age, as mechanical dilation at later gestational ages takes longer and becomes more difficult. These data do not suggest a gestational age where the benefits of cervical dilation outweigh the side-effects, including pain, that women experience with cervical ripening procedures or the prolongation of the time interval before procedure completion. Mifepristone 200 mg, osmotic dilators and misoprostol, 400microg administered either vaginally or sublingually, are the most effective methods of cervical preparation.

Internists care for women of reproductive age, but little is known about internists' training in contraceptive counseling or provision of contraceptive methods.We surveyed 152 residents in nine internal medicine programs in Los Angeles County during the 2004-2005 academic year. The self-administered, 29-item survey included demographic, contraceptive practice pattern, and training variables. Descriptive statistics and multivariable logistic regression were used to illustrate counseling and prescribing practices and to identify predictors of counseling and provision of contraceptives.Most (95%) future internists surveyed reported clinical responsibility for women of reproductive age. However, few (17%) routinely provided contraceptive counseling, and 39% rarely or never provided contraceptive counseling. Residents had prescribed contraception on a median of 2 (range 0-30) occasions in the past year. Some formal education in contraceptive methods was reported by 51% of respondents; however, 75% of residents reported a desire for more training about contraception.Internal medicine residents commonly care for women of reproductive age but infrequently assess or address contraceptive needs. Further training on how to provide contraception is desired by many internal medicine residents.

The development of dilatation and evacuation (D&E) as a method of second trimester surgical abortion occurred soon after abortion law reform took place in the 1960s and 1970s in Europe and the United States. Today, D&E is the predominant method of second trimester abortion in many parts of the world. Debate still exists as to whether surgical or medical methods are optimal for second trimester pregnancy termination. A continuing challenge to provision of D&E is the availability of a large enough pool of skilled providers. This article reviews the current surgical methods used in second trimester abortion, as well as their safety, advantages and disadvantages, acceptability and associated complications. Methods used to ensure safe and efficient surgical termination of second trimester pregnancies such as cervical preparation and ultrasound guidance are also reviewed.

Background: Determining the optimal method of performing second-trimester abortions is important, since they account for a disproportionate amount of abortion-related morbidity and mortality. Objectives: To compare surgical and medical methods of inducing abortion in the second trimester of pregnancy with regard to efficacy, side effects, adverse events, and acceptability. Search strategy: We identified trials using Pub Med, EMBASE, POPLINE, and the Cochrane Central Register of Controlled Trials (CENTRAL). We also searched the reference lists of identified studies, relevant review articles, book chapters, and conference proceedings for additional, previously unidentified studies. We contacted experts in the field for information on other published or unpublished research. Selection criteria: Randomised trials comparing any surgical to any medical method of inducing abortion at >/= 13 weeks' gestation were included. Data collection and analysis: We assessed the validity of each study using the methods suggested in the Cochrane Handbook. Investigators were contacted as needed to provide additional information regarding trial conduct or outcomes. Two reviewers abstracted the data. Odds ratios and 95% confidence intervals were calculated for dichotomous variables using RevMan 4.2. The trials did not have uniform interventions, therefore, we were unable to combine them into a meta-analysis. Main results: Two studies met criteria for this review. One compared dilation and evacuation (D&E) to intra-amniotic instillation of prostaglandin F(2) (alpha). The second study compared D&E to induction with mifepristone and misoprostol. Compared with prostaglandin instillation, the combined incidence of minor complications was lower with D&E (OR 0.17, 95% CI 0.04-0.65) as was the total number of minor and major complications (OR 0.12, 95% CI 0.03-0.46). The number of women experiencing adverse events was also lower with D&E than with mifepristone and misoprostol (OR 0.06, 95% CI 0.01-0.76). Although women treated with mifepristone and misoprostol reported significantly more pain than those undergoing D&E, efficacy and acceptability were the same in both groups. In both trials, fewer subjects randomised to D&E required overnight hospitalisation. Authors' conclusions: Dilation and evacuation is superior to instillation of prostaglandin F(2) (alpha). The current evidence also appears to favour D&E over mifepristone and misoprostol, however larger randomised trials are needed.

The government has done much to tackle female genital mutilation (FGM),1 2 3 but the planned rollout of FGM Enhanced Data Collection across the NHS in October 2015 is ill considered. All healthcare professionals will be legally obliged to submit highly sensitive, patient identifiable information on every woman with FGM attending the NHS for whatever reason. A woeful consultation preceded the ministerial direction, which also says patient consent is not …

Objective We sought to examine outcomes of mifepristone and misoprostol for early pregnancy failure (EPF) treatment in a nonresearch setting. Study Design A protocol was developed for physicians to use mifepristone 200 mg orally and misoprostol 800 μg vaginally for EPF. Success rates were analyzed and an adjusted multivariable regression was used to identify factors predictive of success. Results Treatment success occurred in 99 (80%; 95% confidence interval, 72–87%) of 123 patients after mifepristone and a single dose of misoprostol and 102 (83%; 95% confidence interval, 75–89%) patients overall. The odds of successful medical treatment were increased in women with a diagnosis of intrauterine embryonic/fetal demise (odds ratio, 3.80) and decreased in women who made additional emergency department visits (odds ratio, 0.12). Conclusion Patients and clinicians may be more likely to intervene surgically with an EPF when a strict study protocol is not being followed.