A comparison of termination of pregnancy procedures: Patient choice, emotional impact and satisfaction with care

Social connectedness and supported self-management of early medication abortion in the UK: experiences from the COVID-19 pandemic and learning for the future

Medication abortion has been established globally as safe and effective. This modality has increased accessibility and the opportunity to centre individual autonomy at the heart of abortion care, by facilitating self-managed abortion. Previous research has shown how self-managed abortion is beneficial in myriad settings ranging from problematic to (relatively) unproblematic contexts of access. In this paper we explore the relationship between self-management and sources of support (including health professionals, family, and friends); as well as considering issues of reproductive control and autonomy. Drawing on qualitative, experience-centred interviews, we utilise the concept of social connectedness to examine how supported self-managed abortion was experienced in the United Kingdom during the COVID-19 pandemic. Overall, self-management was welcomed, with participants speaking positively about managing their own abortion at home. However, a sense of connectedness was crucial in helping participants deal with difficult experiences; and functioned to support individual autonomy in self-care. This paper is the first to examine factors of connection, support, and isolation, as experienced by those undergoing self-managed abortion in the UK in detail. Our research suggests a continued need to advocate for high quality support for self-managed abortion, as well as for choice of abortion method, to support patient-centered care.

The illusion of treatment choice in abortion care: A qualitative study of comparative care experiences in England and Wales

Treatment choice is a key component of quality, person-centred care, but policies promoting choice often ignore how capacity to choose is unequally distributed and influenced by social structures. In abortion care, the choice of either medication or a procedure is limited in many countries, but the structuring of treatment choice from the perspective of people accessing abortion care is poorly understood. This qualitative study explored comparative experiences of abortion treatment choice in England and Wales, using in-depth interviews with 32 people who recently accessed abortion care and had one or more prior abortions. A codebook approach was used to analyse the data, informed by a multidisciplinary framework for understanding the relationship between choice and equity. Abortion treatment choice was structured by multiple intersecting mechanisms: limitations on the supply of abortion care, incomplete or unbalanced information from providers, and participants' socio-economic environments. Long waiting times or travel distances could reduce choice of both treatment options. In interactions with providers, participants described not being offered procedural abortions or receiving information that favoured medication abortion. Participants' socio-economic environments impacted the way they navigated decision-making and their ability to manage the experience of either treatment option. Individual preferences for care were shaped in part by the interplay between these structural barriers, creating an illusion of choice, as the health system bias towards medication abortion reinforced some participants' negative perceptions of procedural abortion. The erosion of choice, to the point it is rendered illusory, has unequal impacts on quality of care. People's needs for their abortion care are complex and diverse, and access to varied service models is required to meet these needs. Treatment choice could be expanded by integrating public and private non-profit sector provision, aligning time limits and workforce requirements for abortion care with international standards, addressing financial pressures on service delivery, and revising the language used to depict each treatment option.

How can patient experience of abortion care be improved? Evidence from the SACHA study

BACKGROUND

Models of abortion care have changed significantly in the last decade, most markedly during the COVID-19 pandemic, when home management of early medical abortion with telemedical support was approved in Britain.

OBJECTIVE

Our study aimed to examine women's satisfaction with abortion care and their suggestions for improvements.

DESIGN

Qualitative, in-depth, semi-structured interviews.

METHODS

A purposive sample of 48 women with recent experience of abortion was recruited between July 2021 and August 2022 from independent sector and National Health Service abortion services in Scotland, Wales and England. Interviews were conducted by phone or via video call. Women were asked about their abortion experience and for suggestions for any improvements that could be made along their patient journey - from help-seeking, the initial consultation, referral, treatment, to aftercare. Data were analyzed using the Framework Method.

RESULTS

Participants were aged 16-43 years; 39 had had a medical abortion, 8 a surgical abortion, and 1 both. The majority were satisfied with their clinical care. The supportive, kind and non-judgmental attitudes of abortion providers were highly valued, as was the convenience afforded by remotely supported home management of medical abortion. Suggestions for improvement across the patient journey centred around the need for timely care; greater correspondence between expectations and reality; the importance of choice; and the need for greater personal and emotional support.

CONCLUSION

Recent changes in models of care present both opportunities and challenges for quality of care. The perspectives of patients highlight further opportunities for improving care and support. The principles of timely care, choice, management of expectations, and emotional support should inform further service configuration.

Pregnancy termination and determinant factors among women of reproductive age in Kenya, evidence from Kenyan Demographic and Health Survey 2022: Multilevel analysis

BACKGROUND

Pregnancy termination is one of the common causes of maternal mortality, particularly in developing countries, and remains a global public health concern despite the efforts made to enhance maternal healthcare services. Maternal mortality is still the highest in sub-Saharan Africa, including Kenya, due to pregnancy termination.

OBJECTIVES

This study aimed to investigate the current burden of pregnancy termination and its determinants among reproductive-age women in Kenya.

DESIGN

A cross-sectional study design with multilevel analysis.

METHODS

The total weighted samples of 19,530 women of reproductive age were included in this study. The data were taken from the Kenyan Demographic and Health Survey 2022. A multilevel multivariable logistic regression model was used to identify the determinant factors of pregnancy termination. In the multivariable multilevel analysis, the adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to declare significant determinants of pregnancy termination among women of reproductive age.

RESULTS

The overall prevalence of pregnancy termination among women of reproductive age in Kenya was 14.19%. The determinant factors associated with pregnancy termination were the age of the women; as age increased, the risk of pregnancy termination increased, 25-29 years (AOR = 2.23; 95 CI (1.08-4.60)), 30-34 years (AOR = 2.98; 95% CI (1.43-6.18)), 35-39 years (AOR = 3.24; 95% CI (1.55-6.76)), 40-44 years (AOR = 4.57; 95% CI (2.16-9.68)), 45- 49 years (AOR = 5.16; 95% CI (2.33-9.98)); marital status: married (AOR = 5.63; 95% CI (3.08-10.29)), ever married (AOR = 5.05; 95% CI (2.74-9.33)); wealth index: richest (AOR = 1.32; 95% CI (1.05-1.63)); employment status: employed (AOR = 1.23; 95% CI (1.09-1.38)); preceding birth interval: greater than 24 months (AOR = 1.21; 95% CI (1.06-1.38)); urban residence (AOR = 1.25; 95% CI (1.06-1.46)); and Islamic followers (AOR = 1.64; 95% CI (1.31-2.06)).

CONCLUSION

Pregnancy termination among women of reproductive age in Kenya has become an important public health concern. Policymakers and other stakeholders should focus on maternal healthcare service programs to prevent the termination of pregnancy. The determinant factors are an important input to developing strategies to improve the accessibility of maternal healthcare services in the country.

Revolution in abortion care? Perspectives of key informants on the importance of abortion method choice in the era of telemedicine

Patient choice of medical or surgical abortion is a standard of quality abortion care, but the choice of surgical abortion is constrained in England and Wales, particularly since the COVID-19 pandemic and introduction of telemedicine. This qualitative study explored the perspectives of abortion service providers, managers, and funders on the need to offer a choice of methods within early gestation abortion services in England and Wales. Twenty-seven key informant interviews were conducted between August and November 2021, and framework analysis methods were used. Participants presented arguments both for and against offering method choice. Most participants felt that it was important to maintain choice, although they recognised that medical abortion suits most patients, that both methods are very safe and acceptable, and that the priority for abortion services is to maintain timely access to respectful care. Their arguments related to practicalities around patient needs, the risk of reinforcing inequalities in access to patient-centred care, potential impacts on patients and providers, comparisons to other services, costs, and moral issues. Participants argued that constraining choice has a greater impact on those who are less able to advocate for themselves and there were concerns that patients may feel stigmatised or isolated when unable to choose their preferred method. In conclusion, although medical abortion suits most patients, this study highlights arguments for maintaining the option of surgical abortion in the era of telemedicine. More nuanced discussion of the potential benefits and impacts of self-management of medical abortion is needed.

“Out of This World”: Norwegian Women’s Experiences of Medical Abortion Pain

Introduction

Medical abortion has rapidly become the dominant abortion method in western countries. Pain is a known adverse effect; however, few studies have explored women's subjective experience of medical abortion pain.

Purpose

To explore Norwegian women's experiences of pain when performing a medical abortion at home.

Material and Methods

We recruited 24 women through an advertisement on Facebook and conducted semi-structured, face-to-face interviews. The interviews were transcribed verbatim and the data were analyzed using a phenomenological hermeneutical method.

Results

Our findings consisted of two main themes: 1) Being in pain or becoming pain, and 2) Being caught off guard and struggling to cope. Participants described undergoing severe pain, comparable to giving birth, during the medical abortion. Unprepared for the type and intensity of the pain, they felt anxious and insecure. Pain is physical, but it also has important psychological, social, and existential dimensions. Our culture (in)forms our thoughts and feelings about our pain, affecting our ability to endure suffering. The participants' experiences of abortion pain prompt timely questions concerning gendered socio-cultural and existential meanings connected to pain, specifically in relation to female reproductive functions.

Conclusion

Women need realistic information about the type and intensity of abortion pain, as well as evidence-based pain medication. Psychological factors may affect the experience of abortion pain and should therefore be taken into account in abortion care.

Structural barriers or patient preference? A mixed methods appraisal of medical abortion use in England and Wales

Although patient choice of abortion method is a key component of quality care, medical abortion (MA) has become the most common method (87%) in England and Wales, as in many countries worldwide. This research aimed to critically examine factors influencing the growth in MA use in England and Wales. Mixed methods were used, combining multi-level regression analysis of national abortion statistics (2011-2020) and key informant interviews with abortion service managers, commissioners, and providers (n=27). Overall trends have been driven by growth in MA use for abortions under 10 weeks in the private non-profit sector. Variation in MA use between patient sub-groups and regions has narrowed over time. Qualitative findings highlight health system constraints that have influenced the shift towards MA, including workforce constraints, infrastructure requirements, provider policies, cost, and commissioning practices involving under-funding and competition, which have caused the private non-profit sector to limit method choice across their services to remain financially viable. While removal of legal restrictions on MA has expanded choice, similar policy progress has not been seen for surgical methods. The study concludes that abortion method choice has been constrained by structural health system factors, with potential negative consequences for service acceptability, inequalities, and patient-centredness.

Dancing during labor in the midst of COVID-19 outbreak: as an alternative non-pharmacological treatment after digital interventions

As a result of this writing, I encourage future academics to conduct further study on what sorts of music and movements are acceptable for women during birth, as this is a highly intriguing issue, especially in the midst of the COVID-19 outbreak. Music and dance can also be used as an alternative to non-pharmacological treatments, so that enough pregnant women can be assisted and their tension and anxiety during delivery can be decreased.

Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review

OBJECTIVE

To inform UK service development to support medical abortion at home, appropriate for person and context.

DESIGN

Realist review SETTING/PARTICIPANTS: Peer-reviewed literature from 1 January 2000 to 9 December 2021, describing interventions or models of home abortion care. Participants included people seeking or having had an abortion.

INTERVENTIONS

Interventions and new models of abortion care relevant to the UK.

OUTCOME MEASURES

Causal explanations, in the form of context-mechanism-outcome configurations, to test and develop our realist programme theory.

RESULTS

We identified 12 401 abstracts, selecting 944 for full text assessment. Our final review included 50 papers. Medical abortion at home is safe, effective and acceptable to most, but clinical pathways and user experience are variable and a minority would not choose this method again. Having a choice of abortion location remains essential, as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (appointment number, timing and wait-times), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and desire for awareness/involvement in the process. We found experiences could be improved by offering: an option for self-referral through a telemedicine consultation, realistic information on a range of experiences, opportunities to personalise the process, improved pain relief, and choice of when and how to discuss contraception.

CONCLUSIONS

Acknowledging the work done by patients when moving medical abortion care from clinic to home is important. Patients may benefit from support to: prepare a space, manage privacy and work/caring obligations, decide when/how to take medications, understand what is normal, assess experience and decide when and how to ask for help. The transition of this complex intervention when delivered outside healthcare environments could be supported by strategies that reduce surprise or anxiety, enabling preparation and a sense of control.

[If you were to have another abortion, would you choose the same method? A study on 1032 patients' level of satisfaction]

INTRODUCTION

In 2016, the French National College of Gynaecologists and Obstetricians revised the recommandations on abortion care. Abortions can now be medical, regardless of the term, depending on the patients' preference. The aim was to assess the influence of the term and method on patients' satisfaction, in Haute-Normandie.

METHOD

This is a prospective multicentric study. A questionnaire was completed by patients the day of the hospitalization. The main efficacy parameter was the patient's satisfaction depending on term and method.

RESULTS

A total of 1032 patients were included from November 2018 till August 2019: 733 medical abortions and 259 surgical abortions. For equivalent terms, medical abortion was associated with a lower satisfaction, OR: 1.9, CI 95 % [1.23; 2.99] P=0.004. For equivalent methods, a term higher than 9 weeks of gestation was also associated with a lower satisfaction OR: 1.56, CI 95 %: [1.09; 2.23], P=0.01. The satisfaction rate was up to 4 out of 5, regardless of the term or the method. For equivalent term and method, an imposed method due to the term was associated with a lower satisfaction OR:3.82, CI 95 % [2.15;6.90], P<0.001.

CONCLUSION

Term higher than 9 weeks of gestation, medical abortion and an imposed method are associated with a lower satisfaction.

Pre-Abortion Informed Consent Through Telemedicine vs. in Person: Differences in Patient Demographics and Visit Satisfaction

PURPOSE

Utah law requires patients to have a face-to-face "informed consent" visit at least 72 hours prior to abortion. Planned Parenthood Association of Utah (PPAU) offers this visit via telemedicine as an alternative to an in-person visit, which can require burdensome travel. This novel study identifies factors associated with using telemedicine for informed consent, patients' reasons for using it, and experiences with it, compared to in-person informed consent.

METHODS

In 2017 and 2018, patients 18 years and older seeking abortion at PPAU completed a self-administered online survey about their experiences with the informed consent visit. We used linear and logistic regression models to compare participants' demographic characteristics by informed consent visit type, and descriptive statistics to describe reasons for using each visit type and experiences with the visit. Multivariable logistic regression models examined associations between visit type and satisfaction.

RESULTS

Responses from 166 telemedicine patients and 217 in-person informed consent patients indicate that telemedicine participants would have had to travel significantly further than in-person participants traveled to attend the visit at the clinic (mean of 65 miles versus 21 miles, p < .001). In multivariable analyses, telemedicine participants had higher odds of being "very satisfied" with the visit (aOR, 2,89; 95% CI: 1.93-4.32) and "very comfortable" asking questions during the visit (aOR, 3.76; 95% CI: 2.58-5.49), compared to participants who attended in-person visits.

CONCLUSIONS

Telemedicine offers a convenient, acceptable option for mandated pre-abortion informed consent visits and reduces the burden of additional travel and associated barriers for some patients, particularly those who live further away from clinics.

Abortion method preference among people presenting for abortion care

OBJECTIVE

To explore abortion method preference, interpersonal and cultural factors associated with preference, and whether, among people with a preference for medication abortion, those presenting past 10 weeks gestation had experienced more obstacles to care.

METHODS

In 2019, we invited people aged 15 to 45 years presenting to 4 U.S. abortion clinics to complete a self-administered, anonymous iPad survey prior to seeing the health care provider. Questions focused on their pregnancy, including self-reported gestational age and experiences accessing abortion care, including abortion method preference. We used multivariate logistic regression to assess associations between worry about perceived pregnancy-related stigma or abortion-related health myths and abortion method preference.

RESULTS

The majority (784 [77%]) of those approached (1092) initiated the survey and 712 responded to the preference question. Most (597 [84%]) preferred a method: 246 (41%) preferred medication abortion and 351 (59%) an in-clinic procedure. About one-third (110 [32%]) of those preferring medication abortions exceeded 10 weeks gestation and 83% (n = 91) had experienced delay-causing obstacles to care. In multivariate analyses, we found a greater odd of preference for medication abortion over in-clinic procedure among those very worried about people's reaction to the pregnancy (adjusted OR [aOR] 1.95, 95% CI 1.16-3.28), judgment from God or religion (aOR 1.93, 95% CI 1.17-3.19) and abortion affecting mental health (aOR 2.51, 95% CI 1.45-4.34) or ability to get pregnant later (aOR 1.80, 95% CI: 1.09-2.97).

CONCLUSIONS

Many people seeking abortion have a method preference; delayed presentation to care may impede ability to obtain desired method. Pregnancy-related stigma and misinformation are associated with preference for medication abortion.

IMPLICATIONS STATEMENT

Pregnancy-related stigma and misinformation, such as health and safety myths promulgated by state-mandated abortion counseling, may motivate preference for medication abortion. Abortion access obstacles may impede individuals' ability to obtain their preferred method. Removing barriers to clinic access may enhance people's ability to obtain their preferred abortion method.

Efficacy of Nursing Support in the Pre- and Postmedical Termination of Pregnancy Phases: A Randomized Study

This study was conducted to evaluate the efficiency of a nursing support program developed in accordance with the Roy adaptation model that was applied in addition to routine nursing care during the treatment process of pregnant women for whom the medical termination decision. This study, which was conducted using a pretest-posttest design, was a prospective, single-blind, and randomized-controlled empirical study. In the experimental group, although the first and last assessment State Anxiety Inventory scores were higher than those in the control group after the medical termination nursing support program, there was no significant difference. Compared with the control group, there were positive differences in the Scale of Ways of Coping with Stress, Adaptation Assessment Form for Role Function Area, and physical complaints in the experimental group. At the follow-up assessment, the total Perinatal Grief Scale score was significantly higher than that in the control group.