Health services utilization after induced abortions in Ontario: a comparison between community clinics and hospitals

Cross-sectional study to assess the impact of the COVID-19 pandemic on healthcare services and clinical admissions using statistical analysis and discovering hotspots in three regions of the Greater Toronto Area

OBJECTIVES

The COVID-19 pandemic disrupted healthcare services, leading to the cancellation of non-urgent tests, screenings and procedures, a shift towards remote consultations, stalled childhood immunisations and clinic closures which had detrimental effects across the healthcare system. This study investigates the impact of the COVID-19 pandemic on clinical admissions and healthcare quality in the Peel, York and Toronto regions within the Greater Toronto Area (GTA).

DESIGN

In a cross-sectional study, the negative impact of the pandemic on various healthcare sectors, including preventive and primary care (PPC), the emergency department (ED), alternative level of care (ALC) and imaging, procedures and surgeries is investigated. Study questions include assessing impairments caused by the COVID-19 pandemic and discovering hotspots and critical subregions that require special attention to recover. The measuring technique involves comparing the number of cases during the COVID-19 pandemic with before that, and determining the difference in percentage. Statistical analyses (Mann-Whitney U test, analysis of variance, Dunn's test) is used to evaluate sector-specific changes and inter-relationships.

SETTING

This work uses primary data which were collected by the Black Creek Community Health Centre. The study population was from three regions of GTA, namely, the city of Toronto, York and Peel. For all health sectors, the sample size was large enough to have a statistical power of 0.95 to capture 1% variation in the number of cases during the COVID-19 pandemic compared with before that.

RESULTS

All sectors experienced a significant decline in patient volume during the pandemic. ALC admissions surged in some areas, while IPS patients faced delays. Surgery waitlists increased by an average of 9.75%, and completed IPS procedures decreased in several subregions.

CONCLUSIONS

The COVID-19 pandemic had a universally negative impact on healthcare sectors across various subregions. Identification of the hardest-hit subregions in each sector can assist health officials in crafting recovery policies.

The abortion and mental health controversy: A comprehensive literature review of common ground agreements, disagreements, actionable recommendations, and research opportunities

The abortion and mental health controversy is driven by two different perspectives regarding how best to interpret accepted facts. When interpreting the data, abortion and mental health proponents are inclined to emphasize risks associated with abortion, whereas abortion and mental health minimalists emphasize pre-existing risk factors as the primary explanation for the correlations with more negative outcomes. Still, both sides agree that (a) abortion is consistently associated with elevated rates of mental illness compared to women without a history of abortion; (b) the abortion experience directly contributes to mental health problems for at least some women; (c) there are risk factors, such as pre-existing mental illness, that identify women at greatest risk of mental health problems after an abortion; and (d) it is impossible to conduct research in this field in a manner that can definitively identify the extent to which any mental illnesses following abortion can be reliably attributed to abortion in and of itself. The areas of disagreement, which are more nuanced, are addressed at length. Obstacles in the way of research and further consensus include (a) multiple pathways for abortion and mental health risks, (b) concurrent positive and negative reactions, (c) indeterminate time frames and degrees of reactions, (d) poorly defined terms, (e) multiple factors of causation, and (f) inherent preconceptions based on ideology and disproportionate exposure to different types of women. Recommendations for collaboration include (a) mixed research teams, (b) co-design of national longitudinal prospective studies accessible to any researcher, (c) better adherence to data sharing and re-analysis standards, and (d) attention to a broader list of research questions.

Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis

OBJECTIVES

Measures of pregnancy associated deaths provide important guidance for public health initiatives. Record linkage studies have significantly improved identification of deaths associated with childbirth but relatively few have also examined deaths associated with pregnancy loss even though higher rates of maternal death have been associated with the latter. Following PRISMA guidelines we undertook a systematic review of record linkage studies examining the relative mortality risks associated with pregnancy loss to develop a narrative synthesis, a meta-analysis, and to identify research opportunities.

METHODS

MEDLINE and SCOPUS were searched in July 2015 using combinations of: mortality, maternal death, record linkage, linked records, pregnancy associated mortality, and pregnancy associated death to identify papers using linkage of death certificates to independent records identifying pregnancy outcomes. Additional studies were identified by examining all citations for relevant studies.

RESULTS

Of 989 studies, 11 studies from three countries reported mortality rates associated with termination of pregnancy, miscarriage or failed pregnancy. Within a year of their pregnancy outcomes, women experiencing a pregnancy loss are over twice as likely to die compared to women giving birth. The heightened risk is apparent within 180 days and remains elevated for many years. There is a dose effect, with exposure to each pregnancy loss associated with increasing risk of death. Higher rates of death from suicide, accidents, homicide and some natural causes, such as circulatory diseases, may be from elevated stress and risk taking behaviors.

CONCLUSIONS

Both miscarriage and termination of pregnancy are markers for reduced life expectancy. This association should inform research and new public health initiatives including screening and interventions for patients exhibiting known risk factors.

Barriers to rural induced abortion services in Canada: findings of the British Columbia Abortion Providers Survey (BCAPS)

BACKGROUND

Rural induced abortion service has declined in Canada. Factors influencing abortion provision by rural physicians are unknown. This study assessed distribution, practice, and experiences among rural compared to urban abortion providers in the Canadian province of British Columbia (BC).

METHODS

We used mixed methods to assess physicians on the BC registry of abortion providers. In 2011 we distributed a previously-published questionnaire and conducted semi-structured interviews.

RESULTS

Surveys were returned by 39/46 (85%) of BC abortion providers. Half were family physicians, within both rural and urban cohorts. One-quarter (17/67) of rural hospitals offer abortion service. Medical abortions comprised 14.7% of total reported abortions. The three largest urban areas reported 90% of all abortions, although only 57% of reproductive age women reside in the associated health authority regions. Each rural physician provided on average 76 (SD 52) abortions annually, including 35 (SD 30) medical abortions. Rural physicians provided surgical abortions in operating rooms, often using general anaesthesia, while urban physicians provided the same services primarily in ambulatory settings using local anaesthesia. Rural providers reported health system barriers, particularly relating to operating room logistics. Urban providers reported occasional anonymous harassment and violence.

CONCLUSIONS

Medical abortions represented 15% of all BC abortions, a larger proportion than previously reported (under 4%) for Canada. Rural physicians describe addressable barriers to service provision that may explain the declining accessibility of rural abortion services. Moving rural surgical abortions out of operating rooms and into local ambulatory care settings has the potential to improve care and costs, while reducing logistical challenges facing rural physicians.

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.