Time from first clinical contact to abortion in Texas and California.

OBJECTIVE: To assess whether having an abortion in Texas, a U.S. state with many restrictive abortion laws, is associated with increased time between contacting an abortion provider and receiving an abortion, compared to having an abortion in California, a less restrictive U.S. state. STUDY DESIGN: This is a multisite, cross-sectional survey of 434 patients in 12 abortion facilities (ambulatory surgical centers and clinics) in Texas (n = 291) and three abortion clinics in California (n = 143) from 2018 to 2019. At 11 facilities in Texas the response rate was 76%. The response rate was not collected at other sites. We compare the clinical-contact-to-abortion time interval between the facilities in these two states using mixed-effects multivariable logistic regression, adjusting for age, race, education, household income, parity, marital status, and insurance status. We also compare barriers to scheduling and traveling to abortion appointments. RESULTS: Median clinical-contact-to-abortion time is similar among respondents in Texas and California [(9 vs 8 days, p = 0.86). The odds of having a clinical-contact-to-abortion time ≥7 days is similar among respondents in Texas compared to California (adjusted odds ratio 1.0 (95% confidence interval, 0.4-2.6, p = 0.98). Respondents in Texas travel farther for their abortion (mean 22.1 vs 13.5 miles, p < 0.01), are more likely to sell something of value or delay paying another expense to pay for their abortion (49.7% vs 11.4%, p < 0.01), and to miss work to attend their abortion (73.9% vs 61.3%, p = 0.03). CONCLUSIONS: In this study, we found no difference in clinical-contact-to-abortion time between respondents in Texas and those in California. Respondents in Texas, however, face other significant barriers in obtaining abortion care, which result in life disruptions and financial hardship. IMPLICATIONS: Patients face greater financial barriers when seeking abortion in Texas compared to California. Though we found no significant difference in clinical-contact-to-abortion time in this sample between the two states, clinical-contact-to-abortion time may be a useful measure of facility congestion and the obstacles patients face obtaining abortion care.

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.

How student nurses can influence care quality.

With support from NHS England, NHS Improving Quality and universities, student nurses have run conferences across the country on pressure ulcer prevention. The success of the events suggests that, as emerging nurse leaders, students recognise they have a key role in educating, motivating and galvanising their peers around a shared purpose.

Wnt genes in the mouse uterus: potential regulation of implantation.

Wnt genes are involved in critical developmental and growth processes. The present study comprehensively analyzed temporal and spatial alterations in Wnt and Fzd gene expression in the mouse uterus during peri-implantation of pregnancy. Expression of Wnt4, Wnt5a, Wnt7a, Wnt7b, Wnt11, Wnt16, Fzd2, Fzd4, and Fzd6 was detected in the uterus during implantation. Wnt4 mRNA was most abundant in the decidua, whereas Wnt5a mRNA was restricted to the mesometrial decidua during decidualization. Wnt7a, Wnt7b, and Wnt11 mRNAs were abundantly detected in the endometrial epithelia. The expression of Wnt7b was robust in the luminal epithelium (LE) at the implantation site on Gestational Day 5, whereas Wnt11 mRNA disappeared in the LE adjacent to the embryo in the antimesometrial implantation chamber but remained abundant in the LE. Wnt16 mRNA was localized to the stroma surrounding the LE on Day 4 and remained in the stroma adjacent to the LE but not in areas undergoing the decidual reaction. Fzd2 mRNA was detected in the decidua, Fzd4 mRNA was in the vessels and stroma surrounding the embryo, and Fzd6 mRNA was observed in the endometrial epithelia, stroma, and some blood vessels during implantation. Ovarian steroid hormone treatment was found to regulate Wnt genes and Fzd receptors in ovariectomized mice. Especially, single injections of progesterone stimulated Wnt11 mRNA, and estrogen stimulated Wnt4 and Wnt7b. The temporal and spatial alterations in Wnt genes likely play a critical role during implantation and decidualization in mice.