Improving effective contraception uptake through provision of bridging contraception within community pharmacies: findings from the Bridge-it Study process evaluation.

OBJECTIVE: To present process evaluation results from the Bridge-it Study, a pragmatic cluster randomised cross-over trial to improve effective contraception uptake through provision of the progestogen only pill (POP) plus sexual and reproductive health (SRH) clinic rapid-access to women presenting to community pharmacies for emergency contraception (EC). RESEARCH DESIGN AND METHODS: A multimethod process evaluation was conducted to assess intervention implementation, mechanisms of change and contextual factors. Data were gathered from screening logs (n=599), observations of pharmacist training, analysis of data from 4-month follow-up questionnaires (n=406), monitoring of contemporaneous events and qualitative interviews with 22 pharmacists, 5 SRH clinical staff and 36 study participants in three participating UK sites in Lothian, Tayside and London. RESULTS: The intervention was largely delivered as intended and was acceptable. Pharmacists', SRH clinical staff and participants' accounts highlighted that providing a supply of POP with EC from the pharmacy as routine practice may have positive impacts on contraceptive practices in the short term, and potentially longer term. Key mechanisms of change included ease of access, increased awareness of contraception and services, and greater motivation and perceptions of self-efficacy. Few participants took up the offer to attend an SRH service (rapid-access component), and existing barriers within the SRH context were apparent (eg, lack of staff). Participant accounts highlight persistent barriers to accessing and using routine effective contraception remain. CONCLUSIONS: Implementation appeared to be acceptable and feasible, highlighting the potential for provision of POP within EC consultations as routine practice in community pharmacies. However, lack of engagement with the rapid access component of the intervention and existing barriers within the SRH context suggest that signposting to SRH services may be sufficient. Wider implementation should consider ways to address key implementation challenges to increase effectiveness and sustainability, and to overcome persistent barriers to accessing and using effective contraception. TRIAL REGISTRATION NUMBER: ISRCTN70616901.

Adherence to treatment and prevalence of side effects when medical abortion is delivered via telemedicine: a prospective observational cohort study during COVID-19.

BACKGROUND: The Scottish government introduced legislation during the COVID-19 outbreak to permit medical abortion at home with telemedicine. All women received an initial telephone consultation. For those choosing medical abortion, we provided self-administered medications to eligible women with pregnancies under 12 weeks' gestation. AIMS: To assess adherence to the recommended abortion drug regimen, with particular focus on the number of misoprostol doses used and the interval between mifepristone and misoprostol administration and the induction-expulsion interval. Additionally, to evaluate use of analgesia, antiemetics and antibiotics, and the side effects, pain and bleeding profile of medical abortion at home. METHODS: We conducted a prospective cohort study of 663 women choosing medical abortion at home via telemedicine at an NHS abortion service in Edinburgh, Scotland between 1 April and 9 July 2020. Interviewer-administered questionnaires were completed at telephone follow-up 4 and 14 days following treatment. Outcome measures were self-reported and included use of mifepristone and misoprostol, induction-expulsion interval (time from misoprostol administration until expulsion of pregnancy), antiemetics, antibiotics, analgesia use, pain scores, rates of side effects, bleeding and preparedness for treatment. RESULTS: Among the respondents, 652/663 women (98%) answered at least one questionnaire, and 594/663 (89.6%) used both abortion medications as directed (24-72 hours between medications). The mean (SD) induction-expulsion interval was 4.3 (4.3) hours. Antiemetics were used by 611/663 (92%), 383/599 (64%) completed the course of prophylactic antibiotics, and 616/663 (93%) used analgesia, with mean (SD) worst-pain scores of 6.7 (2.2) out of 10. Regarding side effects, 510/663 (77%) experienced either nausea, vomiting, diarrhoea or headache, 101/663 (15%) experienced headache and 510/663 (77%) experienced bleeding that was heavier than a period; 554/663, (84%) felt prepared for their treatment by teleconsultation. CONCLUSION: Patients are able to correctly self-administer abortion medications following a telemedicine consultation. Further research is required to optimise pain management and gastrointestinal side effects during medical abortion.

Provision of the progestogen-only pill by community pharmacies as bridging contraception for women receiving emergency contraception: the Bridge-it RCT.

INTRODUCTION: Unless women start effective contraception after using emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies that are unable to provide ongoing contraception (apart from barrier methods which have high failure rates). This means that women need an appointment with a general practitioner or at a sexual and reproductive health clinic. We conducted a pragmatic cluster randomised cohort crossover trial to determine whether or not pharmacist provision of a bridging supply of a progestogen-only pill plus the invitation to attend a sexual and reproductive health clinic resulted in increased subsequent use of effective contraception (hormonal or intrauterine). METHODS: Twenty-nine pharmacies in three UK cities recruited women receiving emergency contraception (levonorgestrel). In the intervention, women received a 3-month supply of the progestogen-only pill (75 µg of desogestrel) plus a card that provided rapid access to a local sexual and reproductive health clinic. In the control arm, pharmacists advised women to attend their usual contraceptive provider. The primary outcome was reported use of an effective contraception (hormonal and intrauterine methods) at 4 months. Process evaluation was also conducted to inform any future implementation. RESULTS: The study took place December 2017 and June 2019 and recruited 636 women to the intervention (n = 316) and control groups (n = 320). There were no statistically significant differences in demographic characteristics between the groups. Four-month follow-up data were available for 406 participants: 63% (198/315) of the control group and 65% (208/318) of the intervention group. The proportion of participants reporting use of effective contraception was 20.1% greater (95% confidence interval 5.2% to 35.0%) in the intervention group (58.4%, 95% confidence interval 48.6% to 68.2%) than in the control group (40.5%, 95% confidence interval 29.7% to 51.3%) (adjusted for recruitment period, treatment arm and centre; p = 0.011). The proportion of women using effective contraception remained statistically significantly larger, when adjusted for age, current sexual relationship and history of past use of effective contraception, and was robust to the missing data. There were no serious adverse events. CONCLUSION: Provision of a bridging supply of the progestogen-only pill with emergency contraception from a pharmacist and the invitation to a sexual and reproductive health clinic resulted in a significant increase in self-reported subsequent use of effective contraception. This simple intervention has the potential to prevent more unintended pregnancies for women after emergency contraception. TRIAL REGISTRATION: Current Controlled Trials ISRCTN70616901. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 27. See the NIHR Journals Library website for further project information.

The emergency contraceptive pill can prevent pregnancy following unprotected sex or a burst condom; however, unless women start a regular method of contraception they remain at risk of pregnancy. Most women obtain emergency contraception from a community pharmacy (chemist), but then require an appointment with a general practitioner or at a sexual and reproductive health clinic for ongoing contraception. Getting an appointment can take time and unintended pregnancies can occur during this time. If a pharmacist could give women a small supply of a progestogen-only pill or 'mini-pill' with their emergency contraception, together with help to get an appointment at a clinic, then this might help more women to start effective contraception. We undertook a study in 29 pharmacies in Lothian, Tayside and London among women receiving emergency contraception. Pharmacists provided either their standard advice about contraception (control group) or the intervention. The intervention was a 3-month supply of the progestogen-only pill plus a rapid-access card, which, if presented at a sexual and reproductive health clinic, would help women get an appointment for contraception. The order in which the pharmacy provided either control or intervention was randomised. We conducted telephone interviews with the women 4 months later to find out what contraception they were using. A total of 636 women took part in the study, 316 in the intervention group and 320 in the control group. The proportion who said that they were using an effective method of contraception was around 20% larger in the intervention group. In addition, fewer women in this group said that they had used emergency contraception again. This study shows that community pharmacy provision of a small supply of progestogen-only pills and the invitation to attend a sexual and reproductive health clinic results in a large increase in the use of effective contraception after emergency contraception. If this became routine practice then it could help prevent unintended pregnancies.

Telemedicine medical abortion at home under 12 weeks' gestation: a prospective observational cohort study during the COVID-19 pandemic.

BACKGROUND: In response to the COVID-19 pandemic, legislation and guidance were introduced in Scotland permitting medical abortion at home by telemedicine for pregnancies at less than 12 weeks' gestation. Women had a telephone consultation with a clinician. Routine ultrasound was not performed. Medications and a low-sensitivity pregnancy test to confirm success of treatment were collected by or delivered to the woman, with telephone support provided as needed. METHODS: A prospective cohort study of 663 women choosing medical abortion at home via the NHS Lothian telemedicine abortion service between 1 April and 9 July 2020. Interviewer-administered questionnaires were completed 4 and 14 days following treatment. Regional hospital databases were reviewed to verify abortion outcomes and complications within 6 weeks. Outcome measures included efficacy, complications and acceptability. RESULTS: Almost all (642/663, 98.2%) the women were under 10 weeks' gestation. For 522/663 (78.7%) women, gestation was determined using last menstrual period alone. Some 650/663 (98%) women had a complete abortion, 5 (0.8%) an ongoing pregnancy and 4 (0.6%) an incomplete abortion. No one was treated inadvertently beyond 12 weeks' gestation, but one woman was never pregnant. One woman who had a pre-abortion ultrasound was later managed as a caesarean scar ectopic. There were two cases of haemorrhage and no severe infections. Some 123 (18.5%) women sought advice by telephone for a concern related to the abortion and 56 (8.4%) then attended a clinic for review. Most (628, 95%) women rated their care as very or somewhat acceptable. CONCLUSIONS: This model of telemedicine abortion without routine ultrasound is safe, and has high efficacy and high acceptability among women.

Use of effective contraception following provision of the progestogen-only pill for women presenting to community pharmacies for emergency contraception (Bridge-It): a pragmatic cluster-randomised crossover trial.

BACKGROUND: Unless women start effective contraception after oral emergency contraception, they remain at risk of unintended pregnancy. Most women in the UK obtain emergency contraception from community pharmacies. We hypothesised that pharmacist provision of the progestogen-only pill as a bridging interim method of contraception with emergency contraception plus an invitation to a sexual and reproductive health clinic, in which all methods of contraception are available, would result in increased subsequent use of effective contraception. METHODS: We did a pragmatic cluster-randomised crossover trial in 29 UK pharmacies among women receiving levonorgestrel emergency contraception. Women aged 16 years or older, not already using hormonal contraception, not on medication that could interfere with the progestogen-only pill, and willing to give contact details for follow-up were invited to participate. In the intervention group, women received a 3-month supply of the progestogen-only pill (75 µg desogestrel) plus a rapid access card to a participating sexual and reproductive health clinic. In the control group, pharmacists advised women to attend their usual contraceptive provider. The order in which each pharmacy provided the intervention or control was randomly assigned using a computer software algorithm. The primary outcome was the use of effective contraception (hormonal or intrauterine) at 4 months. This study is registered, ISRCTN70616901 (complete). FINDINGS: Between Dec 19, 2017, and June 26, 2019, 636 women were recruited to the intervention group (316 [49·6%], mean age 22·7 years [SD 5·7]) or the control group (320 [50·3%], 22·6 years [5·1]). Three women (one in the intervention group and two in the control group) were excluded after randomisation. 4-month follow-up data were available for 406 (64%) participants, 25 were lost to follow-up, and two participants no longer wanted to participate in the study. The proportion of women using effective contraception was 20·1% greater (95% CI 5·2-35·0) in the intervention group (mean 58·4%, 48·6-68·2), than in the control group (mean 40·5%, 29·7-51·3 [adjusted for recruitment period, treatment group, and centre]; p=0·011).The difference remained significant after adjusting for age, current sexual relationship, and history of effective contraception use, and was robust to the effect of missing data (assuming missingness at random). No serious adverse events occurred. INTERPRETATION: Provision of a supply of the progestogen-only pill with emergency contraception from a community pharmacist, along with an invitation to a sexual and reproductive health clinic, results in a clinically meaningful increase in subsequent use of effective contraception. Widely implemented, this practice could prevent unintended pregnancies after use of emergency contraception. FUNDING: National Institute for Health Research (Health Technology Assessment Programme project 15/113/01).

Pragmatic cluster randomised cohort cross-over trial to determine the effectiveness of bridging from emergency to regular contraception: the Bridge-It study protocol.

INTRODUCTION: Oral emergency contraception (EC) can prevent unintended pregnancy but it is important to start a regular method of contraception. Women in the UK usually access EC from a pharmacy but then need a subsequent appointment with a general practitioner or a sexual and reproductive health (SRH) service to access regular contraception. Unintended pregnancies can occur during this time. METHODS AND ANALYSIS: Bridge-It is a pragmatic cluster randomised cohort cross-over trial designed to determine whether pharmacist provision of a bridging supply of a progestogen-only pill (POP) plus rapid access to a local SRH clinic, results in increased uptake of effective contraception and prevents more unintended pregnancies than provision of EC alone. Bridge-It involves 31 pharmacies in three UK regions (London, Lothian and Tayside) aiming to recruit 626-737 women. Pharmacies will give EC (levonorgestrel) according to normal practice and recruit women to both intervention and the control phases of the study. In the intervention phase, pharmacists will provide the POP (desogestrel) and offer rapid access to an SRH clinic. In the control phase, pharmacists will advise women to attend a contraceptive provider for contraception (standard care).Women will be asked 4 months later about contraceptive use. Data linkage to abortion registries will provide abortion rates over 12 months. The sample size is calculated on the primary outcome of effective contraception use at 4 months (yes/no) with 90% power and a 5% level of significance. Abortion rates will be an exploratory secondary analysis. Process evaluation includes interviews with pharmacists, SRH clinicians and women. Cost-effectiveness analysis will use a healthcare system perspective and be expressed as incremental cost-effectiveness ratio. ETHICS AND DISSEMINATION: Ethical approval was received from South East Scotland REC June 2017. Results will be published in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER: ISRCTN70616901.

Impact of self-administration of misoprostol for early medical abortion: a prospective observational cohort study.

INTRODUCTION: In October 2017, Scotland legalised the home use of misoprostol for the purpose of early medical abortion (EMA). Women up to 9+6 weeks' gestation can now self-administer the drug at home, 24-48 hours after receiving mifepristone in the clinic. OBJECTIVE: To evaluate the impact of this change on the uptake and success rate of EMA, and on the provision of effective contraception on discharge. METHODS: A prospective observational study was conducted to compare the outcomes of two cohorts of women in the 6 months before and 6 months after the introduction of home administration of misoprostol. The main outcome measures were uptake of EMA, success of EMA and provision of long-acting reversible contraception (LARC) to women undergoing EMA. RESULTS: There was a statistically significant increase in the uptake of EMA from 698/1075 (64.9%) women in the first study period to 823/1146 (71.8%) in the second study period. There was no statistically significant difference in the success rate of EMA: 99.3% and 98.9% in clinic and home misoprostol cohorts, respectively. There was also no statistically significant difference in the proportion of women provided with LARC: 37.7% and 33.7% in clinic and home misoprostol cohorts, respectively. CONCLUSIONS: Self-administration of misoprostol at home increased uptake of EMA, with no effect on the high success rate that was previously seen with clinic administration of misoprostol. In addition, the reduced number of visits associated with home use of misoprostol has not affected the provision of effective contraception to women.

Initiating intramuscular depot medroxyprogesterone acetate 24-48 hours after mifepristone administration does not affect success of early medical abortion.

OBJECTIVES: The primary objective of this study was to determine whether intramuscular depot medroxyprogesterone acetate (IM DMPA) given at the time of misoprostol administration, 24-48 hours after mifepristone, affects the rate of continuing pregnancy. In addition, the study explored factors predictive of continuing pregnancy. DESIGN: Case-control study based on database review of women who underwent early medical abortion (EMA) over a 4-year period. SETTING: Single abortion service in Scotland. PARTICIPANTS: 5122 women who underwent an EMA within the timeframe of this study. MAIN OUTCOME MEASURES: Continuing pregnancies among women receiving IM DMPA were compared with those choosing other hormonal methods of contraception, non-hormonal contraception or no contraception at the time of misoprostol administration. Logistic regression was performed to assess the effects of demographic characteristics, gestation at presentation and method of contraception provided, on outcome of pregnancy. RESULTS: A total of 4838 women with complete data were included, of which there were 20 continuing pregnancies (0.4%); 284 women were excluded due to missing data. There was no increased risk of a continuing pregnancy among women who initiated IM DMPA at the time of misoprostol administration (24-48 hours after mifepristone) compared with women who initiated no hormonal contraception at this time (RR 0.48; 95% CI 0.06 to 3.81). Gestation ≥8 weeks and previous terminations were factors associated with increased likelihood of continuing pregnancy. CONCLUSIONS: Women choosing IM DMPA after EMA can be reassured that IM DMPA can be safely initiated at the time of misoprostol administration 24-48 hours after mifepristone without an increase in the risk of a continuing pregnancy. Both increasing gestation and previous termination were factors associated with an increased likelihood of continuing pregnancy following an EMA.

'Abortion' or 'termination of pregnancy'? Views from abortion care providers in Scotland, UK.

BACKGROUND: The phrase 'termination of pregnancy' has recently been adopted by a number of British medical institutions as a preferred descriptor of induced abortion. How it is used by abortion care providers is unclear, although the ongoing stigmatisation of abortion may play a role. METHODS: A mixed methods study of the views of abortion care providers in Scotland, UK. Self-administered anonymous questionnaires were distributed to abortion care providers at a national conference (Scottish Abortion Care Providers). The main outcomes measured were the proportion of respondents reporting that they found the terms 'abortion' and 'termination of pregnancy' to be distressing, and their preferred terminology for use in consultations with women. In-depth interviews were conducted with 19 providers from a single clinic in Scotland to contextualise use of the terminology. RESULTS: The questionnaire was completed by 90/118 delegates (76%). More respondents indicated they found the term 'abortion' distressing (28%), compared with those who found 'termination of pregnancy' distressing (6%; P<0.0001). Interview participants reported that 'termination of pregnancy' was the default phrase used in consultations. Some respondents stated that they occasionally purposely used 'abortion' in consultations to emphasise the seriousness of the procedure (morally, physically and/or emotionally). CONCLUSIONS: 'Termination of pregnancy' is the most commonly used term to describe induced abortion in patient consultations in Scotland. This and the term 'abortion' appear to play different roles, with the former being used euphemistically, and the latter as a more emphatic term. Further research is warranted to investigate how this interacts with patient care, service provision, and abortion stigma.

Routine provision of intrauterine contraception at elective cesarean section in a national public health service: a service evaluation.

INTRODUCTION: We conducted a prospective health service evaluation to assess the feasibility and acceptability of routinely offering insertion of intrauterine contraception at cesarean section in a maternity setting in the UK. MATERIAL AND METHODS: One month before scheduled cesarean section, women were sent information about postpartum contraception including the option of insertion of an intrauterine contraception at cesarean. Women choosing intrauterine contraception (copper intrauterine device or levonorgestrel intrauterine system) were followed up in person at six weeks, and telephone contact was made at three, six and 12 months postpartum. Our main outcome measures were uptake of intrauterine contraception and complications by six weeks. Secondary outcomes were continuation and satisfaction with intrauterine contraception at 12 months. RESULTS: 120/877 women opted to have intrauterine contraception (13.7%), of which 114 were fitted. By six weeks, there were seven expulsions (6.1%). The expulsion rate by one year was 8.8%. There were no cases of uterine perforations and one case of infection (0.8%). Follow-up rates were 82.5% at 12 months, and continuation rates with intrauterine contraception at 12 months were 84.8% of those contacted. At 12 months, 92.7% of respondents asked were either 'very' or 'fairly' happy with their intrauterine contraception. CONCLUSIONS: Routine provision of intrauterine contraception at elective cesarean for women in a public maternity service is feasible and acceptable to women. It is associated with good uptake and good continuation rates for the first year. This could be an important strategy to increase use of intrauterine contraception and prevent short inter-pregnancy intervals and unintended pregnancies.

Comparison of uptake of long-acting reversible contraception after abortion from a hospital or a community sexual and reproductive healthcare setting: an observational study.

BACKGROUND: Uptake of the most effective long-acting reversible methods of contraception (LARC) immediately after abortion has been shown to reduce a woman's risk of further abortion. We aimed to compare the uptake of LARC at abortion services from a hospital department of obstetrics and gynaecology and a specialist contraceptive setting of a community sexual and reproductive health (SRH) service within the same city. METHODS: Retrospective database review of women (n=2473) requesting abortion who were assessed at either a community SRH service or a hospital department of obstetrics and gynaecology, in the same UK city over a period of 1 year. The main outcome measures were immediate post-abortal uptake of LARC from each site. RESULTS: A higher proportion of women assessed at the SRH service received LARC after abortion [50.2%; 95% confidence interval (CI) 0.47-0.53%] compared to those attending the hospital site (39.2%; 95% CI 0.36-0.42%; p<0.0001). Amongst women having an outpatient early medical abortion, LARC uptake at the SRH was twice that of the hospital setting (48.4% vs 23.3%; p<0.0001). CONCLUSIONS: Higher uptake of immediate post-abortal LARC was observed amongst women who were assessed at the specialist contraceptive service in the community SRH setting compared to the hospital setting. Further research is required to determine the reasons for these observations since all abortion services should provide the same high-quality contraceptive service to women undergoing abortion.

Shifting abortion care from a hospital to a community sexual and reproductive health care setting.

BACKGROUND: Community sexual and reproductive health (SRH) services are well placed to deliver abortion assessment services and early medical abortion (EMA), but comparative data on safety and acceptability from both settings are important for future service planning. METHODS: Retrospective review of computerised records of 1342 women undergoing outpatient EMA (≤9 weeks) in a community SRH or hospital department of gynaecology in the same city, and a self-completed, anonymous survey of 303 women requesting abortion at both sites. Primary outcome was safety in terms of re-attendance rates for a complication related to EMA. Secondary outcomes were telephone contact with each site for an EMA-related concern and satisfaction with information about abortion (defined as score out of 10) received at each site. RESULTS: There was no difference in re-attendance rates to either service for a complication following outpatient EMA (2.7%). A higher proportion of women undergoing EMA at the SRH site made telephone contact compared to women at the hospital site (18.8% vs 10.8%; p=0.033). Women rated both settings highly in terms of information received before abortion (9.2 and 9.6 out of 10) at the hospital and SRH sites, respectively. CONCLUSIONS: This study suggests that provision of outpatient EMA in a community SRH setting is as safe as that delivered from a hospital setting, and that women are similarly satisfied with the information they receive about abortion from each setting. More abortion assessment and outpatient EMA services in Great Britain could shift from hospital to community SRH settings.

Giving information about the contraceptive implant using a DVD: is it acceptable and informative? A pilot randomised study.

BACKGROUND: To provide standardised information about the contraceptive implant (Nexplanon(®)), a digital video disc (DVD) was developed for use within a sexual and reproductive health (SRH) service in Edinburgh. The aim was to determine if the accuracy of information recalled after watching a DVD was comparable to that following a face-to-face consultation, and if patients found the use of a DVD acceptable. METHODS: Fifty women attending an SRH service abortion clinic considering using Nexplanon for the first time agreed to be randomised to receive information about the implant either by (a) a DVD (n=35) developed using information taken from Faculty of Sexual & Reproductive Healthcare guidance or (b) a face-to-face consultation (n=15). A structured interview was conducted immediately following the DVD/face-to-face consultation and by telephone 3 months later. A small number of participants from each group attended for in-depth interview. RESULTS: Knowledge recall (e.g. expected side effects) immediately following each intervention was similar in both groups. Most of the women who watched the DVD felt it was helpful (89%), easy to understand (94%) and acceptable (69%). Subsequently 76% of participants were contacted successfully at 3 months. The majority of those who had watched the DVD agreed that it had been informative (93%) and would be happy to receive contraceptive information via a DVD in future (93%). CONCLUSIONS: The use of a DVD to provide patient information on Nexplanon is acceptable and informative, and may enhance patient consultations. A large randomised controlled trial may determine if provision of quality standardised information via DVD can improve uptake or continuation rates of long-acting reversible methods of contraception.

Do women seeking termination of pregnancy need pre-abortion counselling?

BACKGROUND: Pre-termination counselling is currently voluntary in the UK; however, there has been political debate regarding the introduction of mandatory pre-termination counselling as well as who should be providing the abortion counselling services. OBJECTIVE: To quantify the proportion of women who use pre-termination counselling services and to evaluate their experience. METHOD: An anonymous self-administered questionnaire of women requesting an abortion at Chalmers Sexual Health Centre and the Royal Infirmary of Edinburgh NHS Lothian from 6 October to 2 December 2014. RESULTS: Only 18 (9%) of the 201 women surveyed reported using pre-termination counselling. The majority of women did not feel counselling was necessary because they were already certain of their decision. Nearly a quarter (22%) of women claimed to not know counselling was available. Women who did use counselling were satisfied with the services they received. The majority of counselling services were provided by the National Health Service and only one woman used a 'pro-life' charity. Women stated that they would prefer face-to-face counselling rather than telephone or Internet-based counselling. CONCLUSIONS: Most women do not seem to want or need pre-termination counselling therefore policies aimed at mandatory counselling, would be contrary to women's wishes. Counselling should be targeted at women with risk factors for psychological complications post-termination.

Does a full bladder assist insertion of intrauterine contraception? A randomised trial.

BACKGROUND: Bladder distension is thought to cause the uterine axis to become more aligned with the cervical canal. Among women undergoing assisted conception it has been demonstrated that having a full bladder facilitates the passage of an intrauterine catheter for embryo transfer. OBJECTIVE: To determine if insertion of intrauterine contraceptive devices is easier in women who have a full bladder at the time of insertion. METHODS: 200 women requesting intrauterine contraception with a pre-filled bladder were randomised to delayed emptying (after insertion; n=100) or immediate emptying (before insertion; n=100). Comparisons were made between doctors' reported ease of insertion and women's pain scores. RESULTS: There was no significant difference with reported ease of insertion between the groups. Doctors reported that insertions were either 'very easy' or 'quite easy' in 82% and 83% of women in the immediate and delayed emptying groups, respectively (95% CIs for difference -10% to +11%). There was no significant difference in reported pain scores, with mean pain scores (out of 10) of 3.8 and 4.4 in the delayed and immediate emptying groups, respectively. CONCLUSIONS: Bladder filling does not have a significant effect on ease of insertion of an intrauterine method of contraception. Insertion is mostly associated with low levels of discomfort, even in the presence of a full bladder.

Assessment of a 'fast-track' referral service for intrauterine contraception following early medical abortion.

BACKGROUND: A 'fast-track' referral system for intrauterine contraception was established in 2007 between the medical abortion service at the Royal Infirmary of Edinburgh and the principal family planning clinic (FPC) in Edinburgh. METHODS: Case note review of women fast-tracked for intrauterine contraception after medical abortion between January 2007 and June 2009. Main outcome measures were numbers of women referred, attendance rates, interval to insertion, devices chosen and known complication rates. RESULTS: Of the 237 women referred, 126 (53%) attended for intrauterine contraception insertion. Attenders were slightly but significantly older than non-attenders (mean ages of 30 and 27 years, respectively; p=0.003), less likely to live in an area of deprivation (p=0.045) and were significantly more likely to have attended the FPC in the past (p<0.0001). Most attenders (90%; n=113) proceeded to have an intrauterine method inserted; 57% (n=64) chose the levonorgestrel intrauterine system and 43% (n=49) chose a copper intrauterine device. The median interval to insertion was 21 (range 0-54) days. Of those women (n=55) who attended for routine follow-up 6 weeks later (49%), there were four (7.2%) cases of expulsion, two (3.6%) requests for removal and four (7.2%) cases of suspected infection. CONCLUSIONS: Only half the women fast-tracked for intrauterine contraception actually attended and these tended to be women who were pre-existing clients of the FPC. Consideration should therefore be given to provision of immediate insertion where possible.

Telephone follow-up and self-performed urine pregnancy testing after early medical abortion: a service evaluation.

INTRODUCTION: Telephone follow-up with a self-performed low-sensitivity urine pregnancy (LSUP) test was introduced at the Royal Infirmary of Edinburgh, Scotland, as an alternative to routine ultrasonography for confirming successful abortion at 2 weeks following early medical abortion (<9 weeks' gestation). Women who screened 'positive' at telephone follow-up on the basis of ongoing pregnancy symptoms, scant bleeding or LSUP test result subsequently attended the clinic for a confirmatory ultrasound. METHODS: A service evaluation was conducted of the first 8 months of telephone follow-up consisting of a review of the numbers choosing this method of follow-up, the proportion successfully contacted and the efficacy for detecting ongoing pregnancies. In the last 3 months of the study, women were surveyed about their satisfaction with this method of follow-up. RESULTS: Opting for telephone follow-up were 476 out of 619 women (77%). Four women (1%) attended the clinic before telephone follow-up because of pain or bleeding. A total of 410 (87%) of the remaining 472 women were successfully contacted by telephone. Sixty women (15%) screened 'positive', three of whom had ongoing pregnancies, and one woman falsely screened 'negative'. The sensitivity of the telephone follow-up was 75% [95% confidence interval (CI) 30.1-95.4], and specificity was 86% (95% CI 82.2-89). The negative predictive value was 99.7% (95% CI 98.4-99.9), and positive predictive value was 5% (95% CI 1.7-13.7). All women surveyed (n=75) would recommend telephone follow-up to a friend. CONCLUSION: A telephone follow-up and an LSUP test at 2 weeks are effective for detecting ongoing pregnancy, have good follow-up rates and are popular choices for women.

Comparison of unscheduled re-attendance and contraception at discharge, among women having the final stage of early medical abortion at home and those remaining in hospital.

INTRODUCTION: Throughout Great Britain, increasing numbers of women having an early medical abortion are choosing to go home soon after administration of misoprostol, to expel the pregnancy at home (early medical discharge, EMD), rather than remain upon the hospital premises (day case). However, data are lacking on how this impacts upon an abortion service in terms of unscheduled re-attendance rates and contraception provision at discharge. METHODS: A retrospective audit was carried out of women undergoing medical abortion (up to 64 days' gestation) over 9 months at a National Health Service hospital in Scotland, to determine (1) unscheduled re-attendance rates within 6 weeks of the procedure for an abortion-related complication and (2) method of contraception provided at discharge. RESULTS: Over the audit period 1128 women had an early medical abortion of whom 590 (52%) chose EMD. There was no significant difference in unscheduled re-attendance rates between EMD (n=23, 4%) and day case groups (n=20, 4%). There was no significant difference in the proportion of women in each group who left hospital with an effective method of contraception (n=362, 61% and n=355, 60% for EMD and day case groups, respectively). CONCLUSIONS: Women undergoing early medical abortion who choose to expel the pregnancy at home are no more likely to re-attend hospital with a post-abortal complication and are just as likely to receive effective contraception than those who remain on hospital premises.

Pilot study of home self-administration of subcutaneous depo-medroxyprogesterone acetate for contraception.

BACKGROUND: Subcutaneous depo-medroxyprogesterone acetate (DMPA-SC) offers the possibility of self-administration. STUDY DESIGN: This is a pilot study of self-administration of DMPA-SC. Existing users of the intramuscular preparation (DMPA-IM) who wished to self-inject (n=64) were taught self-administration using DMPA-SC. The main outcome was the continuation rate of the method at 12 months compared to a control group of existing users of DMPA-IM (n=64) who continued to attend a clinic to receive the method. Women's satisfaction with the method and the proportion of self-injections given at correct time were also determined. RESULTS: The 12-month discontinuation rate of the DMPA-SC group (12%) did not differ significantly from that of the DMPA-IM group (22%) (95% confidence intervals of 13%-33% and 6%-23% for DMPA-SC and DMPA-IM, respectively; p=.23). All self-injections were given within the appropriate interval. There was no significant difference in the proportion of women in either group who were satisfied with the method. CONCLUSION: Self-administration of DMPA-SC for contraception is feasible and is associated with similar continuation rates and satisfaction to clinician-administered DMPA-IM.