The association between intimate partner violence and self-managed abortion: a cross-sectional study among women in urban Bangladesh.

In Bangladesh, abortion is illegal, except to save a woman's life. However, menstrual regulation (MR) to induce menstruation up to 12 weeks from the last menstrual period is permitted. Although safe and legal MR services are available, many women choose to self-manage their abortions. The prevalence of intimate partner violence (IPV) in Bangladesh is high. Whether IPV is associated with self-managed abortion is unknown. Between January and December 2019 we administered cross-sectional surveys to women presenting for MR or post-abortion care (PAC) services at facilities in six cities in Bangladesh assessing if women had ever experienced IPV and if they attempted to self-manage their abortion. We used multivariable logistic regression to assess the association between IPV and self-managed abortion and multinomial logistic regression to the association between IPV by type: (none, any physical, any sexual, or both) and self-managed abortion. Among 2679 women who presented for MR or PAC care and participated in the survey, 473 (17.7%) had previously attempted to self-manage abortion. Women who had ever experienced any IPV were more likely to attempt self-managed abortion prior to presenting for MR or PAC (adjusted odds ratio (aOR) = 1.52, 95% CI 1.24, 1.87). Women who ever experienced physical IPV were more likely to attempt self-managed abortion (adjusted relative risk ratio (aRRR) = 1.62, 95% CI 1.30, 2.03). Women who have ever experienced physical IPV may be more likely to attempt a self-managed abortion because they seek more covert ways of ending a pregnancy out of fear for their safety, or because of limited mobility or lack of resources. Interventions to support women to safely self-manage abortion should focus on populations with higher rates of IPV.

Effect of Paracervical Block Volume on Pain Control for Dilation and Aspiration: A Randomized Controlled Trial.

OBJECTIVE: To compare pain scores during office dilation and aspiration between low-volume and high-volume paracervical block of the same dose. METHODS: We conducted a multi-site, randomized, single-blind, placebo-controlled trial from October 2018 to December 2020. We randomized participants presenting for office dilation and aspiration under minimal sedation stratified by procedural indication (induced abortion vs early pregnancy loss) to a 20-mL buffered 1% lidocaine paracervical block or a 40-mL buffered 0.5% lidocaine paracervical block, both with two units of vasopressin in a standardized technique. To detect a 15-mm or greater difference in pain at the time of cervical dilation with 80% power and a two-sided alpha of 0.05, a total of 104 participants was required. The study was also powered to detect a 20-mm or greater difference in pain at the time of cervical dilation within each stratum (induced abortion and early pregnancy loss). The primary outcome was pain with cervical dilation on a 100-mm visual analog scale in the overall cohort. Secondary outcomes included pain with cervical dilation within each stratum. We used a Wilcoxon rank-sum test to compare median pain scores between groups. RESULTS: We enrolled 114 participants. There was no difference in median pain scores between low-volume and high-volume groups during dilation (62 mm vs 59 mm, P=.94), aspiration (69.5 mm vs 70 mm, P=.47), postprocedure (25 mm vs 25 mm, P=.76), or overall (60 mm vs 60 mm, P=.23). Stratified by indication, there were no significant differences in scores at any time point between the low-volume and high-volume paracervical block groups. There was decreased overall pain in patients with induced abortion who received the higher volume paracervical block, though this did not reach statistical significance (67.5 mm vs 60.5 mm, P=.08). Pain during paracervical block administration was similar between groups (55 mm vs 45 mm, P=.24) and there was no difference in occurrence of side effects (P=.63). CONCLUSION: We found no difference in pain with cervical dilation among participants who received the low-volume compared with high-volume paracervical block when studied alone. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03636451.

An Examination of Misconceptions and Their Impact on Cervical Cancer Prevention Practices among Sub-Saharan African and Middle Eastern Refugees.

Objective: The purpose of the study was to understand cervical cancer screening and prevention practices of refugee women in San Diego, California and identify desired components of a cervical cancer screening toolkit. Methods: We conducted a qualitative study utilizing semi-structured focus groups and identified common themes via grounded theory analysis. Results: There were 53 female refugee participants from Sub-Saharan Africa and the Middle East. Over half of all women surveyed expressed a fear of pelvic exams and loss of modesty as barriers to seeking gynecologic care, with nearly 34% avoiding routine pap tests. Of the 18 participants who were asked if they were aware of the Human Papilloma Virus (HPV) vaccination, only one had heard of the vaccine and none had received it for themselves or their children. Over 60% of participants were interested in educational materials surrounding HPV and pap tests. Conclusion: There is a significant lack of knowledge regarding cervical cancer screening and HPV vaccination among refugee women in San Diego, California. Refugee women in this study were interested in multi-modal educational materials as part of a cervical cancer screening toolkit.

Out-of-clinic and self-managed abortion in Bangladesh: menstrual regulation provider perspectives.

BACKGROUND: In Bangladesh, abortion is illegal except to save a woman's life, though menstrual regulation (MR) is permitted. MR involves the use of manual uterine aspiration or Misoprostol (with or without Mifepristone) to induce menstruation up to 10-12 weeks from the last menstrual period. Despite the availability of safe and legal MR services, abortions still occur in informal setttings and are associated with high complication rates, causing women to then seek post abortion care (PAC). The objective of this study is to contextualize MR in Bangladesh and understand systemic barriers to seeking care in formal settings and faciltators to seeking care in informal settings via the perspective of MR providers in an effort to inform interventions to improve MR safety. METHODS: Qualitative individual semi-structured interviews were conducted with 25 trained MR providers (doctors and nurses) from urban tertiary care facilities in six different cities in Bangladesh from April to July, 2018. Interviews explored providers' knowledge of MR and abortion in Bangladesh, knowledge/experience with informal MR providers, knowledge/experience with patients attempting self-managed abortion, personal attitudes and moral perspectives of MR/abortion in general, and barriers to formal MR. Team based coding and a directed content analysis approach was performed by three researchers. RESULTS: There were three predominant yet overlapping themes: (i) logistics of obtaining MR/PAC/abortion, (ii) provider attitudes, and (iii) overcoming barriers to safe MR. With regards to logistics, lack of consensus among providers revealed challenges with defining MR/abortion gestational age cutoffs. Increasing PAC services may be due to patients purchasing Mifepristone/Misoprostol from pharmacists who do not provide adequate instruction about use, but are logistically easier to access. Patients may be directed to untrained providers by brokers, who intercept patients entering the hospitals/clinics and receive a commission from informal clinics for bringing patients. Provider attitudes and biases about MR can impact who receives care, creating barriers to formal MR for certain patients. Attitudes to MR in informal settings was overwhelmingly negative, which may contribute to delays in care-seeking and complications which endanger patients. Perceived barriers to accessing formal MR include distance, family influence, brokers, and lack of knowledge. CONCLUSIONS: Lack of standardization among providers of MR gestational age cutoffs may affect patient care and MR access, causing some patients to be inappropriately turned away. Providers in urban tertiary care facilities in Bangladesh see primarily the complicated MR/PAC cases, which may impact their negative attitude, and the safety of out-of-clinic/self-managed abortion is unknown. MR safety may be improved by eliminating brokers. A harm reduction approach to improve counseling about MR/abortion care in pharmacies may improve safety and access. Policy makers should consider increasing training of frontline health workers, such as Family Welfare Visitors to provide evidence-based information about Mifepristone/Misoprostol.

Motherhood increases support for family planning among Kenyan adolescents.

OBJECTIVE: Adolescent fertility rates are high in Kenya, and increase the risks of unintended repeat pregnancies and maternal and infant morbidity and mortality. Our objective was to examine knowledge, practices, and influences surrounding contraceptive access and use among Kenyan postpartum adolescents. STUDY DESIGN: We conducted a mixed methods study (surveys and focus group discussions) with postpartum adolescents and family planning (FP) providers at two maternal and child health clinics in Kenya. MAIN OUTCOME MEASURES: Four focus group discussions (FGDs) were conducted with postpartum adolescents (stratified by age and site), and two FGDs were conducted with FP providers (stratified by site). Transcripts were analyzed for prevalent themes. The participants also completed individual surveys that were analyzed for contraceptive knowledge. RESULTS: Adolescent contraceptive decision-making and use were shaped by social norms of adolescent sexual behaviour. Lack of FP knowledge, community misinformation, and insufficient counselling and time with providers all contributed to adolescent concerns about FP. However, as adolescents transitioned to motherhood, they felt more encouraged to use FP and had increased awareness of FP benefits. CONCLUSION: Both postpartum adolescents and providers felt delivery of FP services could be improved if providers had better training and counselling tools.

Bits and Pieces: A Crowd-Sourced Series of 54 Cases of Fractured Hormonal Implants.

STUDY OBJECTIVE: The fracture of hormonal implants, including Implanon, Nexplanon (both from Merck & Co, Inc), and histrelin acetate is rare. Our aim was to describe patient demographic characteristics, mechanisms, and consequences of fractured implants by surveying physicians' experience via listservs and social media. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We developed a Research Electronic Data Capture survey for physicians regarding their experience with implant fracture, including patient characteristics, mechanism of fracture, changes in menstrual bleeding patterns, time from insertion to fracture, and time from fracture to seeking care. We distributed the survey to providers in listservs for the North American Society for Pediatric and Adolescent Gynecology, the Family Planning Fellowship, the Ryan Program, and the Facebook Physician Moms Group and Facebook OB-GYN Mom Group. We performed descriptive analyses. RESULTS: We received 42 survey responses, representing 54 discrete implant fractures of which 70% (n=14) were Nexplanon, 26% (n=38) were Implanon, and 4% (n=2) were histrelin acetate. Mechanisms of implant fracture included patient manipulation (23%, n=12), unintentional trauma (11%, n=6), interpersonal violence (8%, n=4), lifting/carrying (6%, n=3), fracture with removal (6%, n=3), and unknown (47%, n=25). Bleeding pattern was not altered in 78% (n=42) of cases. Time interval between placement and fracture was less than 2 years for 63% (n=34) of cases. Thirty-nine percent (n=21) of patients presented for care more than 1 month from the time of fracture. CONCLUSION: Patients should be counseled about potential for hormonal implant fracture, advised against excessive manipulation of implants, and counseled to present for care immediately upon noticing an implant fracture. Surveying physicians through listervs and social media is an effective strategy to increase the reporting of rare complications and events.