Clinical practice. A request for abortion

Abortion services and providers in Canada in 2019: results of a national survey

BACKGROUND

Since 2016, abortion care has undergone several important changes, particularly related to the provision of medical abortion using mifepristone. We aimed to document characteristics of the abortion care workforce in Canada after the update of clinical practice guidelines of mifepristone use for medical abortion.

METHODS

We conducted a national, web-based, anonymized, bilingual (English/French) survey. We collected demographics and clinical care characteristics of physicians and nurse practitioners who provided abortion care in 2019. Between July and December 2020, we distributed the survey through professional organizations, including The College of Family Physicians of Canada and The Society of Obstetricians and Gynaecologists of Canada. We present descriptive statistics.

RESULTS

Overall, 465 respondents representing all 10 provinces and 3 territories in Canada completed the survey. Of these, 388 (83.4%), including 30 nurse practitioners, provided first-trimester medical abortion, of which 350 (99.4%) used mifepristone. Two hundred and nineteen (47.1%) respondents provided first-trimester surgical abortion, 109 (23.4%) provided second-trimester surgical abortion and 115 (24.7%) provided second- or third-trimester medical abortion. Half of respondents reported fewer than 5 years of experience with any abortion care. Respondents reported providing a total of 48 509 abortions in 2019, including 32 345 (66.7%) first-trimester surgical abortions and 13 429 (27.7%) first-trimester medical abortions. In Quebec, only 1918 (12.5%) of reported abortions were first-trimester medical abortions. Primary care providers provided 34 540 (71.2%) of the total abortions. First-trimester medical abortions represented 44.4% (n = 2334) of all abortions in rural areas, as opposed to 25.6% (n = 11 067) in urban areas.

INTERPRETATION

The increased availability of medical abortion facilitates abortion access, especially in primary care and rural settings, and where surgical abortion is not available. Rejuvenation of the workforce is a critical contributor to equitable access to abortion services.

Association of Intrauterine Microbes with Endometrial Factors in Intrauterine Adhesion Formation and after Medicine Treatment

Intrauterine adhesions (IUAs) have caused serious harm to women’s reproductive health. Although emerging evidence has linked intrauterine microbiome to gynecological diseases, the association of intrauterine microbiome with IUA, remains unknown. We performed metagenome-wide association, metabolomics, and transcriptomics studies on IUA and non-IUA uteri of adult rats to identify IUA-associated microbial species, which affected uterine metabolites and endometrial transcriptions. A rat model was used with one side of the duplex uterus undergoing IUA and the other remaining as a non-IUA control. Both 16S rRNA sequencing and metagenome-wide association analysis revealed that instead of Mycoplasmopsis specie in genital tract, murine lung pathogen Mycoplasmopsispulmonis markedly increased in IUA samples and displayed a distinct positive interaction with the host immune system. Moreover, most of the IUA-enriched 58 metabolites positively correlate with M.pulmonis, which inversely correlates with a mitotic progression inhibitor named 3-hydroxycapric acid. A comparison of metabolic profiles of intrauterine flushing fluids from human patients with IUA, endometritis, and fallopian tube obstruction suggested that rat IUA shared much similarity to human IUA. The endometrial gene Tenascin-N, which is responsible for extracellular matrix of wounds, was highly up-regulated, while the key genes encoding parvalbumin, trophectoderm Dkkl1 and telomerase involved in leydig cells, trophectoderm cells, activated T cells and monocytes were dramatically down-regulated in rat IUA endometria. Treatment for rat IUA with estrogen (E2), oxytetracycline (OTC), and a traditional Chinese patent medicine GongXueNing (GXN) did not reduce the incidence of IUA, though inflammatory factor IL-6 was dramatically down-regulated (96–86%) with all three. Instead, in both the E2 and OTC treated groups, IUA became worse with a highly up-regulated B cell receptor signaling pathway, which may be associated with the significantly increased proportions of Ulvibacter or Staphylococcus. Our results suggest an association between intrauterine microbiota alterations, certain uterine metabolites, characteristic changes in endometrial transcription, and IUA and the possibility to intervene in IUA formation by targeting the causal factors, microbial infection, and Tenascin-like proteins.

The potential of Zishen Yutai pills to facilitate endometrial recovery and restore fertility after induced abortion in rats

CONTEXT

Abortions damage the endometrium in women. Currently, therapeutic options for endometrial recovery are limited. Zishen Yutai Pill (ZYP) was found to promote endometrial blood supply as a traditional Chinese medicine. However, whether ZYP promotes endometrial recovery post-abortion has not yet been explored.

OBJECTIVE

This study evaluated the role of ZYP in rat endometrial recovery after induced abortion and explored its mechanism of action.

MATERIALS AND METHODS

Sprague-Dawley rats were divided into three groups: no-operation group, control group, and ZYP group. The rats in the control and ZYP group were induced abortion, and then treated with normal saline or ZYPs, respectively, for 1-3 oestrous cycles. Morphological changes in the endometrium were examined. Expression levels of the factors related to endometrial recovery were analyzed. The duration of this study was almost seven months.

RESULTS

The endometrial thickness (7.3 ± 0.17 mm) and number of glands (5.5 ± 0.20) increased significantly in the ZYP group compared with those in the control group (5.5 ± 0.15 mm and 3.5 ± 0.18; p < 0.05). Fibrosis of the endometrium was ameliorated by ZYP administration (45 ± 6% vs. 58 ± 7%; p < 0.05). ZYPs treatment increased the expression of VEGF, ER, MMP-9, LIF, and HB-EGF, but decreased TGF-β expression. Moreover, the average number of pups in the ZYP group (9.0 ± 1.5) was greater than that in the control (4 ± 1.3).

DISCUSSION AND CONCLUSION

ZYPs accelerate endometrial recovery and restored fertility in rats, suggesting its potential to promote human endometrial repair.

Perspectives Among Canadian Physicians on Factors Influencing Implementation of Mifepristone Medical Abortion: A National Qualitative Study

PURPOSE

Access to family planning health services in Canada has been historically inadequate and inequitable. A potential solution appeared when Health Canada approved mifepristone, the gold standard for medical abortion, in July 2015. We sought to investigate the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals and how these factors relate to abortion policies, systems, and service access throughout Canada.

METHODS

We conducted 1-on-1 semistructured interviews with a national sample of abortion-providing and nonproviding physicians and health system stakeholders in Canadian health care settings. Our data collection, thematic analysis, and interpretation were guided by Diffusion of Innovation theory.

RESULTS

We conducted interviews with 90 participants including rural practitioners and those with no previous abortion experience. In the course of our study, Health Canada removed mifepristone restrictions. Our results suggest that Health Canada's initial restrictions discouraged physicians from providing mifepristone and were inconsistent with provincial licensing standards, thereby limiting patient access. Once deregulated, remaining factors were primarily related to local and regional implementation processes. Participants held strong perceptions that mifepristone was the new standard of care for medical abortion in Canada and within the scope of primary care practice.

CONCLUSION

Health Canada's removal of mifepristone restrictions facilitated the implementation of abortion care in the primary care setting. Our results are unique because Canada is the first country to facilitate provision of medical abortion in primary care via evidence-based deregulation of mifepristone.

Hormonal and reproductive factors and reduction in the risk of colorectal cancer

Females differ from males in incidence and clinical characteristics of colorectal cancer. Understanding the differences can lead to development of preventive approaches. To identify reproductive factors currently associated with the risk of colorectal cancer. Consecutively diagnosed female colorectal cancer cases and randomly chosen colorectal cancer-free controls matched on age/ethnicity/primary care clinic within the molecular epidemiology of colorectal cancer study, a population-based case-control study in Northern Israel, were included. A total of 2867 female cases and 2333 controls participated in this analysis. Participants were interviewed on reproductive history: ages at menarche, menopause, first birth, terminations of pregnancies, miscarriages, births, use of oral contraceptives. Among 5200 women, spontaneous miscarriages (odds ratio = 0.71, 0.61-0.83 for ever/never in Jews; odds ratio = 0.76, 0.53-1.08 in Arabs) and number of miscarriages, but not termination of pregnancies, as well as use, and duration of use, of oral contraceptives (Jews: odds ratio = 0.49, 0.39-0.62 for ever/never; Arabs: odds ratio = 0.14, 0.04-0.47) were strongly inversely associated with colorectal cancer risk. Up to 5 pregnancies were associated with increased risk while ages at menarche, at menopause and at first birth were not associated with colorectal cancer risk. Miscarriages but not terminations of pregnancy or full-term pregnancies, and use of oral contraceptives, were strongly associated with reduced odds of developing colorectal cancer suggesting unique hormonal influences on colorectal cancer.

Implementation of mifepristone medical abortion in Canada: pilot and feasibility testing of a survey to assess facilitators and barriers

BACKGROUND

Direct primary care provision of first-trimester medical abortion could potentially address inequitable abortion access in Canada. However, when Health Canada approved the combination medication Mifegymiso® (mifepristone 200 mg/misoprostol 800 mcg) for medical abortion in July 2015, we hypothesized that the restrictions to distribution, prescribing, and dispensing would impede the uptake of this evidence-based innovation in primary care. We developed and pilot-tested a survey related to policy and practice facilitators and barriers to assess successful initiation and ongoing clinical provision of medical abortion service by physicians undertaking mifepristone training. Additionally, we explored expert, stakeholder, and physician perceptions of the impact of facilitators and barriers on abortion services throughout Canada.

METHODS

In phase 1, we developed a survey using 2 theoretical frameworks: Greenhalgh's conceptual model for the Diffusion of Innovations in health service organizations (which we operationalized) and Godin's framework to assess the impact of professional development on the uptake of new practices operationalized in Légaré's validated questionnaire. We finalized questions in phase 2 using the modified Delphi methodology. The survey was then tested by an expert panel of 25 nationally representative physician participants and 4 clinical content experts. Qualitative analysis of transcripts enriched and validated the content by identifying these potential barriers: physicians dispensing the medication, mandatory training to become a prescriber, burdens for patients, lack of remuneration for mifepristone provision, and services available in my community. To assess the usability and reliability of the online survey, in phase 3, we pilot-tested the survey for feasibility.

RESULTS

We developed and tested a 61-item Mifepristone Implementation Survey suitable to study the facilitators and barriers to implementation of mifepristone first-trimester medical abortion practice by physicians in Canada.

CONCLUSIONS

Our team operationalized Greenhalgh's theoretical framework for Diffusion of Innovations in health systems to explore factors influencing the implementation of first-trimester medical abortion provision. This process may be useful for those evaluating other health system innovations. Identification of facilitators and barriers to implementation of mifepristone practice in Canada and knowledge translation has the potential to inform regulatory and health system changes to support and scale up facilitators and mitigate barriers to equitable medical abortion provision.

Could implementation of mifepristone address Canada's urban-rural abortion access disparity: a mixed-methods implementation study protocol

INTRODUCTION

In January 2017, mifepristone-induced medical abortion was made available in Canada. In this study, we will seek to (1) understand facilitators and barriers to the implementation of mifepristone across Canada, (2) assess the impact of a 'community of practice' clinical and health service support platform and (3) engage in and assess the impact of integrated knowledge translation (iKT) activities aimed to improve health policy, systems and service delivery issues to enhance patient access to mifepristone.

METHODS AND ANALYSIS

This prospective mixed-methods implementation study will involve a national sample of physicians and pharmacists recruited via an online training programme, professional networks and a purpose-built community of practice website. Surveys that explore constructs related to diffusion of innovation and Godin's behaviour change frameworks will be conducted at baseline and at 6 months, and qualitative data will be collected from electronic interactions on the website. Survey participants and a purposeful sample of decision-makers will be invited to participate in in-depth interviews. Descriptive analyses will be conducted for quantitative data. Thematic analysis guided by the theoretical frameworks will guide interpretation of qualitative data. We will conduct and assess iKT activities involving Canada's leading health system and health professional leaders, including evidence briefs, Geographical Information System (GIS)maps, face-to-face meetings and regular electronic exchanges. Findings will contribute to understanding the mechanisms of iKT relationships and activities that have a meaningful effect on uptake of evidence into policy and practice.

ETHICS AND DISSEMINATION

Ethical approval was received from the University of British Columbia Children's and Women's Hospital Ethics Review Board (H16-01006). Full publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to research participants through newsletters and media interviews, and to policy-makers through invited evidence briefs and face-to-face presentations.

Induced abortion

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Prevalence of intrauterine adhesions after termination of pregnancy: a systematic review

OBJECTIVES

Termination of pregnancy (TOP) is one of the most performed interventions in women worldwide: approximately one in three women will have at least one TOP in their reproductive life. Intrauterine adhesions (IUAs) have been reported as a possible complication after TOP, but their prevalence has not been established, as women are not routinely evaluated. IUAs are associated with menstrual disturbances, infertility and obstetric complications.

METHODS

We searched Ovid MEDLINE, Ovid EMBASE and CENTRAL from inception until November 2015 for studies evaluating women following TOP. We selected studies in which women were evaluated consecutively, independently of symptoms, by hysteroscopy or hysterosalpingography (HSG), for the presence of IUAs.

RESULTS

After an extensive review of the literature, no studies were found that evaluated women after medical TOP and no randomised trials following surgical TOP. Only two prospective cohort studies were identified. In the first, IUAs were detected in 21.2% of women evaluated by hysteroscopy following first trimester surgical TOP; adhesions were moderate to severe in 48%. In the second, IUAs were detected in 16.2% of women evaluated by HSG after second trimester TOP by intra-amniotic prostaglandin induction followed by D&C; a pathologically wide internal cervical os was observed in 12%.

CONCLUSIONS

This systematic review suggests a link between TOP and adhesion formation, but, according to the scientific literature and despite new diagnostic facilities, the relationship between the methods of TOP and IUA formation remains unclear. Nevertheless, the reported frequency is in accordance with that found in women following D&C for miscarriage. Further research is required.

Contraception and Unintended Pregnancy among Unmarried Female University Students: A Cross-sectional Study from China

This study aims to understand the level of contraceptive knowledge and attitudes towards contraception, and then to explore the association between the contraceptive behavior and unintended pregnancy in unmarried female university students in China. A cross-sectional study was conducted of university students in 49 universities across 7 cities in China from September 2007 to January 2008. We distributed 74,800 questionnaires, of which 69,842 were returned. In this paper, the data from 35,383 unmarried female university students were analyzed. The prevalence of sexual intercourse in unmarried female university students was 10.2%. The prevalence of unintended pregnancy in those sexually active female university students, was 31.8%. Among students with pregnancy, 53.5% experienced two or more pregnancies. 28.3% of the students with sexual intercourse reported that they always adopted contraceptive methods, and of those 82.9% chose to use male condoms. The majority (83.9%) of students with unintended pregnancy chose to terminate the latest pregnancy by surgical abortion or medical abortion. The contraceptive knowledge level of students who experienced unintended pregnancy was lower than those who did not. In China, about one third of unmarried female students with sexual intercourse experience unintended pregnancy. A variety of contraceptive methods are adopted, but the frequency of contraceptive use is low. Most of unmarried female students who experienced unintended pregnancy would choose to terminate the pregnancy with surgical or medical abortion. University students, especially the ones who have experienced unintended pregnancy, lack contraceptive and reproductive health knowledge.

Early surgical abortion: safe and effective

OBJECTIVES

To evaluate patients' characteristics and complications of surgical abortion performed at an early gestation, compared to later gestations.

METHODS

A total of 4310 women with unintended pregnancies attending the family planning unit of a government maternity hospital in Konya, Turkey, were included retrospectively. Abortions were carried out from 6 weeks' up to 10 weeks gestation.

RESULTS

The gestational age in 62% of the cases was between 6 weeks and 6 weeks + 6 days. Only 8.5% of the 4310 women had used a modern contraceptive method, and 16% had had a surgical abortion for an unplanned pregnancy previously. These women were younger, had more siblings, and a shorter time had elapsed since their last pregnancy when compared to women who never had an abortion. There were four failures (0.09%). The rate of retained products of conception (RPCs) was 1.9% in women aborted between six and six (+ 6) weeks' gestation, and 6.2% (p < 0.001) in those aborted later. Women who had had a surgical abortion previously more often had RPCs than those who never had (16% vs. 1%, respectively, p < 0.001). Of the 151 women with RPCs, 65 (43%) had been using an intrauterine device prior to surgical abortion.

CONCLUSION

Early surgical abortion (at six-six(+ 6) weeks' gestation) generates few complications. Delaying surgical abortion until a somewhat later gestation causes complication rates (particularly RPCs) to increase.

Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later

During the 40 years since the US Supreme Court decision in Doe versus Wade and Doe versus Bolton, restrictions on termination of pregnancy (TOP) were overturned nationwide. The use of TOP was much wider than predicted and a substantial fraction of reproductive age women in the U.S. have had one or more TOPs and that widespread uptake makes the downstream impact of any possible harms have broad public health implications. While short-term harms do not appear to be excessive, from a public perspective longer term harm is conceiving, and clearly more study of particular relevance concerns the associations of TOP with subsequent preterm birth and mental health problems. Clearly more research is needed to quantify the magnitude of risk and accurately inform women with the crisis of unintended pregnancy considering TOP. The current US data-gathering mechanisms are inadequate for this important task.

On abortion: exploring psychological meaning and attitudes in a sample of Mexican gynecologists

Elective abortion has become an issue of ethical and political debate in many countries including Mexico. As gynecologists are directly involved in the practice of abortion, it is important to know the psychological meaning that the term 'elective abortion' has for them. This study explores the psychological meaning and attitudes toward elective abortion of one hundred and twenty-three Mexican gynecologists. We used the semantic networks technique, which analyzed the words the participants associated with the term 'elective abortion'. The defining words most frequently used by participants implied a negative sanction. There were important differences by gender and religiosity: male gynecologists, as well as those with strong religious beliefs (mainly Catholics), revealed a more negative psychological meaning and more negative attitudes than females or physicians with weak religious beliefs. A contribution of the present study is that it highlights the importance of psychology to enhancing understanding of the issue of elective abortion.