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Footman K. The illusion of treatment choice in abortion care: A qualitative study of comparative care experiences in England and Wales. Soc Sci Med 2024; 348:116873. [PMID: 38615614 DOI: 10.1016/j.socscimed.2024.116873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 03/12/2024] [Accepted: 04/04/2024] [Indexed: 04/16/2024]
Abstract
Treatment choice is a key component of quality, person-centred care, but policies promoting choice often ignore how capacity to choose is unequally distributed and influenced by social structures. In abortion care, the choice of either medication or a procedure is limited in many countries, but the structuring of treatment choice from the perspective of people accessing abortion care is poorly understood. This qualitative study explored comparative experiences of abortion treatment choice in England and Wales, using in-depth interviews with 32 people who recently accessed abortion care and had one or more prior abortions. A codebook approach was used to analyse the data, informed by a multidisciplinary framework for understanding the relationship between choice and equity. Abortion treatment choice was structured by multiple intersecting mechanisms: limitations on the supply of abortion care, incomplete or unbalanced information from providers, and participants' socio-economic environments. Long waiting times or travel distances could reduce choice of both treatment options. In interactions with providers, participants described not being offered procedural abortions or receiving information that favoured medication abortion. Participants' socio-economic environments impacted the way they navigated decision-making and their ability to manage the experience of either treatment option. Individual preferences for care were shaped in part by the interplay between these structural barriers, creating an illusion of choice, as the health system bias towards medication abortion reinforced some participants' negative perceptions of procedural abortion. The erosion of choice, to the point it is rendered illusory, has unequal impacts on quality of care. People's needs for their abortion care are complex and diverse, and access to varied service models is required to meet these needs. Treatment choice could be expanded by integrating public and private non-profit sector provision, aligning time limits and workforce requirements for abortion care with international standards, addressing financial pressures on service delivery, and revising the language used to depict each treatment option.
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Affiliation(s)
- Katy Footman
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, WC2A 2AE, UK.
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Lewandowska M, Carter DJ, Gasparrini A, Lohr PA, Wellings K. Impact of approval of home use of misoprostol in England on access to medical abortion: An interrupted time series analysis. Int J Gynaecol Obstet 2024; 164:286-297. [PMID: 37621171 DOI: 10.1002/ijgo.15044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/18/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023]
Abstract
OBJECTIVE In 2018, the Department of Health and Social Care in England approved the use of misoprostol at home for early medical abortions, following administration of mifepristone at clinic. The objective of the present study was to assess the impact of the approval of home administration of misoprostol in England on access to medical abortion, assessed through proxy measures of the proportion of all abortions that were medical and gestational age. METHODS This study uses the clinical data from the British Pregnancy Advisory Service on abortions in England in years 2018-2019, containing demographic and procedure characteristics of patients. We conducted an interrupted time series analysis to establish the differences before and after the approval in access to medical abortion, measured by the proportion of all abortions that were medical, and gestational age. The analysis also examined whether these changes were equitable, with focus on area-level deprivation. RESULTS The analysis of the data (145 529 abortions) suggested that there was an increase in the proportion of medical abortions and decrease in gestational age of abortions after the approval. Compared with the situation if former trends had continued, the actual proportion of early medical abortions was 4.2% higher in December 2019, and the mean gestational age 3.4 days lower. We found that the acceleration of existing trends in increase in proportion of medical abortions and decrease in gestational age were larger in the most deprived quintiles and in those reporting a disability, but not equal across ethnic groups, with Black and Black British women experiencing little change in trajectories post-approval. CONCLUSION The approval of home use of misoprostol as part of an early medical abortion regimen in England was associated with material and equitable improvements in abortion access. Pre-approval trends toward greater uptake of medical abortion and declining gestational age were accelerated post-approval and were greatest in the most deprived areas of England, but not across all racial/ethnic groups. The present findings strongly support the continuation or introduction of home management of medical abortions.
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Affiliation(s)
- Maria Lewandowska
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Daniel J Carter
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Antonio Gasparrini
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Patricia A Lohr
- Centre for Reproductive Research and Communication, British Pregnancy Advisory Service, London, UK
| | - Kaye Wellings
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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3
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Shimels T, Getnet M, Shafie M, Belay L. Comparison of mifepristone plus misoprostol with misoprostol alone for first trimester medical abortion: A systematic review and meta-analysis. Front Glob Womens Health 2023; 4:1112392. [PMID: 36970118 PMCID: PMC10038101 DOI: 10.3389/fgwh.2023.1112392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/07/2023] [Indexed: 03/08/2023] Open
Abstract
ObjectiveTo compare mifepristone plus a misoprostol-combined regimen with misoprostol alone in the medical abortion of first trimester pregnancy.MethodsAn internet-based search of available literature was performed using text words contained in titles and abstracts. PubMed/Medline, Cochrane CENTRAL, EMBASE, and Google scholar were used to locate English-based articles published until December 2021. Studies fulfilling the inclusion criteria were selected, appraised, and assessed for methodological quality. The included studies were pooled for meta-analysis, and the results were presented in risk ratio at a 95% confidence interval.FindingsNine studies comprising 2,052 participants (1,035 intervention and 1,017 controls) were considered. Primary endpoints were complete expulsion, incomplete expulsion, missed abortion, and ongoing pregnancy. The intervention was found to more likely induce complete expulsion irrespective of gestational age (RR: 1.19; 95% CI: 1.14–1.25). The administration of misoprostol 800 mcg after 24 h of mifepristone pre-treatment in the intervention group more likely induced complete expulsion (RR: 1.23; 95% CI: 1.17–1.30) than after 48 h. The intervention group was also more likely to experience complete expulsion when misoprostol was used either vaginally (RR: 1.16; 95% CI: 1.09–1.17) or buccally (RR: 1.23; 95% CI: 1.16–1.30). The intervention was more effective in the subgroup with a negative foetal heartbeat at reducing incomplete abortion (RR: 0.45; 95% CI: 0.26–0.78) compared with the control group. The intervention more likely reduced both missed abortion (RR: 0.21; 95% CI: 0.08–0.91) and ongoing pregnancy (RR: 0.12; 95% CI: 0.05–0.26). Fever was less likely to be reported (RR: 0.78; 95% CI: 0.12–0.89), whereas the subjective experience of bleeding was more likely to be encountered (RR: 1.31; 95% CI: 1.13–1.53) by the intervention group.ConclusionThe review strengthened the theory that a combined mifepristone and misoprostol regimen can be an effective medical management for inducing abortions during first trimester pregnancy in all contexts. Specifically, there is a high-level certainty of evidence on complete expulsion during the early stage and its ability to reduce both missed and ongoing pregnancies.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42019134213, identifier CRD42019134213.
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Affiliation(s)
- Tariku Shimels
- Research Directorate,St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Correspondence: Tariku Shimels
| | - Melsew Getnet
- Research Directorate,St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Mensur Shafie
- Department of Pharmacology, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Lemi Belay
- Department of Obstetrics and Gynaecology, St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Baraitser P, Free C, Norman WV, Lewandowska M, Meiksin R, Palmer MJ, Scott R, French R, Wellings K, Ivory A, Wong G. Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review. BMJ Open 2022; 12:e066650. [PMID: 36385017 PMCID: PMC9670095 DOI: 10.1136/bmjopen-2022-066650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To inform UK service development to support medical abortion at home, appropriate for person and context. DESIGN Realist review SETTING/PARTICIPANTS: Peer-reviewed literature from 1 January 2000 to 9 December 2021, describing interventions or models of home abortion care. Participants included people seeking or having had an abortion. INTERVENTIONS Interventions and new models of abortion care relevant to the UK. OUTCOME MEASURES Causal explanations, in the form of context-mechanism-outcome configurations, to test and develop our realist programme theory. RESULTS We identified 12 401 abstracts, selecting 944 for full text assessment. Our final review included 50 papers. Medical abortion at home is safe, effective and acceptable to most, but clinical pathways and user experience are variable and a minority would not choose this method again. Having a choice of abortion location remains essential, as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (appointment number, timing and wait-times), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and desire for awareness/involvement in the process. We found experiences could be improved by offering: an option for self-referral through a telemedicine consultation, realistic information on a range of experiences, opportunities to personalise the process, improved pain relief, and choice of when and how to discuss contraception. CONCLUSIONS Acknowledging the work done by patients when moving medical abortion care from clinic to home is important. Patients may benefit from support to: prepare a space, manage privacy and work/caring obligations, decide when/how to take medications, understand what is normal, assess experience and decide when and how to ask for help. The transition of this complex intervention when delivered outside healthcare environments could be supported by strategies that reduce surprise or anxiety, enabling preparation and a sense of control.
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Affiliation(s)
| | - Caroline Free
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Wendy V Norman
- Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Maria Lewandowska
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rebecca Meiksin
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa J Palmer
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rachel Scott
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Rebecca French
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Kaye Wellings
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Alice Ivory
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
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Veldhuis S, Sánchez-Ramírez G, Darney BG. Locating Autonomous Abortion Accompanied by Feminist Activists in the Spectrum of Self-Managed Medication Abortion. Stud Fam Plann 2022; 53:377-387. [PMID: 35347718 DOI: 10.1111/sifp.12194] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Diverse models of self-managed medication abortion exist-ranging from some interaction with medical personnel to completely autonomous abortion. In this commentary, we propose a new classification of self-managed medication abortion and describe the different modalities. We highlight autonomous abortion accompanied by feminist activists, called "acompañantes," as a community- and rights-based strategy that can be a safe alternative to clinical abortion services in clandestine as well as legal settings. To improve access, abortion needs to be decriminalized and governments must acknowledge and facilitate the diversity of safe abortion options so women may choose where, when, how, and with whom to abort.
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Affiliation(s)
- Suzanne Veldhuis
- Department of Health, El Colegio de la Frontera Sur (ECOSUR), San Cristóbal de las Casas, Chiapas 29290, México
| | - Georgina Sánchez-Ramírez
- Department of Health, El Colegio de la Frontera Sur (ECOSUR), San Cristóbal de las Casas, Chiapas 29290, México
| | - Blair G Darney
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR 97239, USA.,Centro de Investigación en Salud Poblacional (CISP), Instituto Nacional de Salud Publica (INSP), 62100 Cuernavaca, Morelos, México
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Rydelius J, Edalat M, Nyman V, Jar-Allah T, Milsom I, Hognert H. Influence of the COVID-19 pandemic on abortions and births in Sweden: a mixed-methods study. BMJ Open 2022; 12:e054076. [PMID: 35197343 PMCID: PMC8882666 DOI: 10.1136/bmjopen-2021-054076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Although considered an essential service by the WHO, there are indications that access to induced abortion care has been restricted during the COVID-19 pandemic. OBJECTIVES To investigate if the number of induced abortions and ongoing pregnancies changed during the first pandemic wave of COVID-19 in 2020 compared with recent years prior to the pandemic and explore possible reasons for the findings. DESIGN Convergent parallel mixed-methods design. Collection of quantitative data from the Swedish National Board of Health and Welfare and the Swedish Pregnancy Register, and qualitative data from interviews. SETTING AND TIME PERIOD National data on abortions (January 2018-June 2020) and births (January 2018-March 2021). Interviews performed at the main abortion clinic, Gothenburg, Sweden, in June 2020. PARTICIPANTS All women aged 15-44 years living in Sweden 2018-2020, approximately 1.9 million. 15 women who sought abortion were interviewed. PRIMARY AND SECONDARY OUTCOME MEASURES Number of abortions and births/1000 women aged 15-44 years. Themes and subthemes identified from interviews. RESULTS The number of abortions and ongoing pregnancies did not change significantly during the study period compared with before the pandemic started. Interview themes identified were the following: meeting with abortion care during the COVID-19 pandemic (availability, and fear of being infected and infecting others); and the impact of the COVID-19 pandemic on the abortion decision (to catch COVID-19 during pregnancy, feelings of loneliness and isolation, and social aspects). CONCLUSIONS This study shows that the number of abortions and ongoing pregnancies remained unchanged during the first wave of the COVID-19 pandemic in 2020 in Sweden compared with before the start of the pandemic. Abortion-seeking women did not hesitate to proceed with the abortion. The women expressed a number of fears concerning both availability of care and their health, which could have been properly addressed by the authorities.
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Affiliation(s)
- Johanna Rydelius
- Institute of Clinical Sciences, Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Mina Edalat
- Reproductive and Perinatal Health, Institute of Health and Care Science, Sahlgrenska Academy, Gothenburg, Sweden
| | - Viola Nyman
- Reproductive and Perinatal Health, Institute of Health and Care Science, Sahlgrenska Academy, Gothenburg, Sweden
| | - Tagrid Jar-Allah
- Institute of Clinical Sciences, Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Ian Milsom
- Institute of Clinical Sciences, Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg, Sweden
| | - Helena Hognert
- Institute of Clinical Sciences, Department of Obstetrics and Gynecology, Sahlgrenska Academy, Gothenburg, Sweden
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Whitehouse KC, Blaylock R, Makleff S, Lohr PA. It's a small bit of advice, but actually on the day, made such a difference…: perceptions of quality in abortion care in England and Wales. Reprod Health 2021; 18:221. [PMID: 34743705 PMCID: PMC8574046 DOI: 10.1186/s12978-021-01270-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 10/25/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Quality of care (QOC) is increasingly identified as an important contributor to healthcare outcomes, however little agreement exists on what constitutes quality in abortion care or the recommended indicators from the service-user perspective. Our study aimed to explore perceptions and experiences of abortion QOC in England and Wales. METHODS We performed in-depth interviews (via phone or in-person) with participants who had an abortion at a nationwide independent sector provider in the previous 6 months. We explored their experiences of the abortion service at each point in the care pathway, their perspectives on what contributed to and detracted from the experience meeting their definitions of quality, and their reflections on different aspects of QOC. We used content analysis to generate themes. RESULTS From December 2018 to July 2019, we conducted 24 interviews. Ten participants had a surgical and 14 had a medical abortion. Seventeen (71%) were treated in the first 12 weeks of pregnancy and 7 (29%) beyond that, with an average gestational age of 10 weeks + 5 days (range 5-23 + 6). We identified 4 major themes that contributed to participant's perception of high quality care: (1) interpersonal interactions with staff or other patients, (2) being informed and prepared, (3) participation and choices in care and (4) accessibility. Nearly all participants identified interpersonal interactions with staff as an important contributor to quality with positive interactions often cited as the best part of their abortion experience and negative interactions as the worst. For information and preparation, participant described not only the importance of being well prepared, but how incongruencies between information and the actual experience detracted from quality. Participants said that making choices about their care, for example, method of abortion, was a positive contributor. Finally, participants identified access to care, specifically in relation to waiting times and travel, as an important aspect of QOC. CONCLUSIONS Participants situated quality in abortion care in 4 domains: interpersonal aspects of care, information and preparation, choices, and accessibility. Indicators identified can be used to develop standard metrics to ensure care meets service-user needs.
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Affiliation(s)
- Katherine C Whitehouse
- Centre for Reproductive Research & Communication, BPAS, 30-31 Furnival Street, London, EC4A 1JQ, UK.
| | - Rebecca Blaylock
- Centre for Reproductive Research & Communication, BPAS, 30-31 Furnival Street, London, EC4A 1JQ, UK
| | - Shelly Makleff
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Patricia A Lohr
- Centre for Reproductive Research & Communication, BPAS, 30-31 Furnival Street, London, EC4A 1JQ, UK
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Boydell N, Reynolds-Wright JJ, Cameron ST, Harden J. Women's experiences of a telemedicine abortion service (up to 12 weeks) implemented during the coronavirus (COVID-19) pandemic: a qualitative evaluation. BJOG 2021; 128:1752-1761. [PMID: 34138505 PMCID: PMC8441904 DOI: 10.1111/1471-0528.16813] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 11/28/2022]
Abstract
Objective To explore the experiences of women in Scotland who accessed medical abortion at home up to 12 weeks’ gestation, delivered via a telemedicine abortion service implemented in response to the coronavirus (COVID‐19) pandemic, to identify areas for improvement and inform service provision. Design Qualitative interview study. Setting Abortion service in one National Health Service health board in Scotland. Population or sample Twenty women who accessed telemedicine abortion services and self‐administered mifepristone and misoprostol at home up to 12 weeks’ gestation. Methods Thematic analysis of semi‐structured qualitative interviews, informed by the Framework analytic approach. Main outcome measures Women’s experiences of accessing telemedicine for medical abortion at home, specifically: acceptability of the telephone consultation and remote support; views on no pre‐abortion ultrasound scan; and self‐administration of abortion medications at home. Results Novel study findings were three‐fold: (1) participants valued the option of accessing abortion care via telemedicine and emphasised the benefits of providing a choice of telephone and in‐person consultation to suit those with different life circumstances; (2) the quality of abortion care was enhanced by the telemedicine service in relation to access, comfort and flexibility, and ongoing telephone support; (3) participants described being comfortable with, and in some cases a preference for, not having an ultrasound scan. Conclusions This research demonstrates support for the continuation of telemedicine abortion services beyond the temporary arrangements in place during COVID‐19, and lends weight to the argument that offering the option of telemedicine abortion care can enable women to access this essential health service. Tweetable abstract #Telemedicine provision of medical #abortion at home up to 12 weeks’ gestation is acceptable and highly valued by #women #Research #SRHR @nbw80 @doctorjjrw @jeniharden @cameronsharon @mrc_crh @edinuniusher. #Telemedicine provision of medical #abortion at home up to 12 weeks’ gestation is acceptable and highly valued by #women #Research #SRHR @nbw80 @doctorjjrw @jeniharden @cameronsharon @mrc_crh @edinuniusher. This article includes Author Insights, a video abstract available at: https://vimeo.com/bjog/authorinsights16813
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Affiliation(s)
- N Boydell
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - J J Reynolds-Wright
- NHS Lothian, Edinburgh, UK.,MRC Centre for Reproductive Healthcare, University of Edinburgh, Edinburgh, UK
| | - S T Cameron
- NHS Lothian, Edinburgh, UK.,MRC Centre for Reproductive Healthcare, University of Edinburgh, Edinburgh, UK
| | - J Harden
- Usher Institute, University of Edinburgh, Edinburgh, UK
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9
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López Cabello A, Gaitán AC. Safe Abortion in Women's Hands: Autonomy and a Human Rights Approach to COVID-19 and Beyond. Health Hum Rights 2021; 23:191-197. [PMID: 34194212 PMCID: PMC8233031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Andrés López Cabello
- Lawyer at the Center for Legal and Social Studies, Buenos Aires, Argentina.,Please address correspondence to Andrés López Cabello. .
| | - Ana Cecilia Gaitán
- Assistant Researcher at the National University of San Martín, Buenos Aires, Argentina
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10
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Harden J, Ancian J, Cameron S, Boydell N. Women's experiences of self-administration of misoprostol at home as part of early medical abortion: a qualitative evaluation. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:144-149. [PMID: 32718985 DOI: 10.1136/bmjsrh-2020-200661] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/04/2020] [Accepted: 06/21/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Between 2017 and 2019, legislation was introduced in the UK that approved the home as a place for self-administration of misoprostol for early medical abortion. While research has shown that early medical abortion at home is as safe as in a clinical setting, women's experiences in the UK in the light of this change have not yet been investigated. This qualitative research explored the experiences of women in one region of Scotland, UK who accessed early medical abortion with home self-administration of misoprostol. METHODS Qualitative interviews were conducted with 20 women who had recently undergone early medical abortion (≤69 days' gestation) with home self-administration of misoprostol. The data were analysed thematically using an approach informed by the Framework analytic approach. RESULTS Women appreciated the flexibility that home administration of misoprostol offered, including the opportunity to control the timing of the abortion. This was particularly important for women who sought not to disclose the abortion to others. Most women valued being in the comfort and privacy of the home when preparing for self-administration, although a small number highlighted some concerns about being at home. Most women reported that self-administration of misoprostol was straightforward; however, some expressed concerns around assessing whether their experiences were 'normal'. CONCLUSIONS Women welcomed the opportunity for home self-administration of misoprostol. To further improve women's early medical abortion experience we suggest that the legislation be amended so that women can self-administer in an appropriate non-clinical setting, not just their home.
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Affiliation(s)
- Jeni Harden
- Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - Sharon Cameron
- Chalmers Sexual and Reproductive Health Centre, NHS Lothian, Edinburgh, UK
- University of Edinburgh Division of Health Sciences, Edinburgh, UK
| | - Nicola Boydell
- University of Edinburgh Centre for Population Health Sciences, Edinburgh, UK
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11
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Cashman C, Downing SG, Russell D. Women's experiences of accessing a medical termination of pregnancy through a Queensland regional sexual health service: a qualitative study. Sex Health 2021; 18:232-238. [PMID: 33985645 DOI: 10.1071/sh20220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/12/2021] [Indexed: 11/23/2022]
Abstract
Background An estimated 25% of Australian women will undergo induced abortion. Few studies have explored Australian women's experiences of accessing medical termination of pregnancy (MToP). This study explored the experiences of women accessing MToP through a regional sexual health service in North Queensland. It aimed to determine the aspects of the process from seeking information about abortion to completion that worked well and to identify areas for improvement. METHODS Semi-structured telephone interviews with 11 women who accessed MTOP at Cairns Sexual Health Service (CSHS) were conducted. Interviews were recorded and transcribed verbatim. A deductive analysis approach was used to analyse the data. RESULTS Most women had little prior knowledge of MToP or access options and used the Internet to source information. Accessing MToP through a sexual health service was considered positive, non-judgemental, discrete and low-cost despite challenges of fitting in with appointment times and obtaining off-site ultrasound. GPs did not always provide referral; some women described experiences of stigma, discrimination and judgemental care during consultation and when obtaining ultrasounds. Concern for women living in more rural/remote areas was raised. Potential solutions including increased provision through rural general practitioners (GPs) and telehealth. CONCLUSION Our study highlights the need for greater awareness of abortion options and access points among the community and healthcare providers. Access through sexual health clinics in regional settings is accepted; however, other options such as increased provision through rural GPs, primary health clinics, telehealth and nurse-led models of care could help overcome some of the barriers faced by rural and remote women.
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Affiliation(s)
- Colette Cashman
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Cairns, Qld, Australia; and Corresponding author.
| | - Sandra G Downing
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Cairns, Qld, Australia
| | - Darren Russell
- Cairns Sexual Health Service, Cairns, Qld 4870, Australia
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12
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Purcell C, Maxwell K, Bloomer F, Rowlands S, Hoggart L. Toward normalising abortion: findings from a qualitative secondary analysis study. CULTURE, HEALTH & SEXUALITY 2020; 22:1349-1364. [PMID: 31933421 PMCID: PMC7611965 DOI: 10.1080/13691058.2019.1679395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 10/08/2019] [Indexed: 06/02/2023]
Abstract
In most settings worldwide, abortion continues to be highly stigmatised. Whilst a considerable body of literature has addressed abortion stigma, what is less commonly examined are the ways in which those with experience of abortion describe it in non-negative terms which may resist or reject stigma. Drawing on qualitative secondary analysis of five UK datasets using a narrative inquiry approach, we explore: the use of non-negative language around abortion, potential components of a normalising narrative, and constraints on non-negativity. As such, we present the first empirical UK study to critically examine how a dominant negative abortion narrative might be disrupted.
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Affiliation(s)
- Carrie Purcell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Karen Maxwell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Fiona Bloomer
- School of Applied Social and Policy Sciences, Ulster University, Newtownabbey, UK
| | - Sam Rowlands
- Centre of Postgraduate Medical Research and Education, Bournemouth University, Bournemouth, UK
| | - Lesley Hoggart
- School of Health, Wellbeing and Social Care, The Open University, Milton Keynes, UK
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Danet Danet A. [Women's emotional accounts of induced abortion]. GACETA SANITARIA 2020; 35:361-373. [PMID: 32451189 DOI: 10.1016/j.gaceta.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To explore women's emotional accounts of induced abortion, analyzing qualitative scientific publications. METHOD Qualitative systematic review of 19 studies published in PubMed, Science Direct and Scopus from 2010 onwards. The articles based on qualitative research design were revised using inductive content analysis. RESULTS The analysis identified three main themes regarding women's emotional experiences: access to abortion, emotional impact during medical assistance, and individual, relational and sociocultural determinants. The studies showed the variability in women's emotional accounts, mainly determined by the following factors: Access and waiting times, health system, type of intervention, degree of awareness and participation regarding the use of technical and medical technologies, interaction with health professionals, and specificity of individual, relational and sociocultural context. The main emotional difficulties were related to the ethical conflict, the decision-making, the relation with the social and health system and stigma. As main facilitating aspects, women highlighted autonomy in decision-making and emotional support, while barriers referred to social rejection and negative messages perceived from the political, social and health system. CONCLUSIONS The emotional accounts around induced abortion depend on individual and relational factors, as well as on health assistance, all mediated by gender inequalities and bias. Improvements in health assistance refer to an integral and individualized attention, adapted to women's needs.
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Affiliation(s)
- Alina Danet Danet
- Departamento de Organización de Empresas, Marketing y Sociología, Área de Sociología, Universidad de Jaén, Jaén, España.
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14
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Maxwell KJ, Hoggart L, Bloomer F, Rowlands S, Purcell C. Normalising abortion: what role can health professionals play? BMJ SEXUAL & REPRODUCTIVE HEALTH 2020; 47:bmjsrh-2019-200480. [PMID: 32241826 PMCID: PMC7611714 DOI: 10.1136/bmjsrh-2019-200480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 05/31/2023]
Abstract
BACKGROUND Despite being a common gynaecological procedure, abortion continues to be widely stigmatised. The research and medical communities are increasingly considering ways of reducing stigma, and health professionals have a role to play in normalising abortion as part of routine sexual and reproductive healthcare (SRH). We sought to investigate how health professionals may normalise abortion and challenge prevailing negative sociocultural narratives. METHODS As part of the Sexuality and Abortion Stigma Study (SASS), qualitative secondary analysis was conducted on two datasets containing health professionals' accounts of providing abortion in Scotland and England. A subsample of 20 interviews were subjected to in-depth, thematic analysis. RESULTS Four key themes were identified in heath professionals' accounts: (1) encountering resistance to abortion from others working in SRH; (2) contending with prevailing negative sociocultural narratives of abortion; (3) enacting overt positivity towards abortion provision; and (4) presenting abortion as part of normal, routine healthcare. CONCLUSIONS It is clear that negative attitudes toward abortion persist both inside and outside of healthcare systems, and need to be challenged in order to destigmatise those accessing and providing services. Health professionals can play a key role in normalising abortion, through the ways in which they frame their work and present abortion to women they treat, and others more widely. Our analysis suggests a key way to achieve this is by presenting abortion as part of normal, routine SRH, but that appropriate support and structural change are essential for normalisation to become embedded.
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Affiliation(s)
- Karen J Maxwell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - Lesley Hoggart
- Faculty of Health and Social Care, The Open University, Milton Keynes, UK
| | - Fiona Bloomer
- Institute for Research in Social Sciences, Ulster University-Jordanstown Campus, Newtownabbey, UK
| | - Sam Rowlands
- Faculty of Health and Social Science, Bournemouth University, Bournemouth, UK
| | - Carrie Purcell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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Finch RE, McGeechan K, Johnstone A, Cameron S. Impact of self-administration of misoprostol for early medical abortion: a prospective observational cohort study. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:bmjsrh-2018-200278. [PMID: 31422346 DOI: 10.1136/bmjsrh-2018-200278] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 05/16/2019] [Accepted: 07/21/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
| | - Kevin McGeechan
- School of Public Health, Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Sharon Cameron
- Department of Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
- University of Edinburgh Division of Health Sciences, Edinburgh, UK
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Smith JL, Cameron S. Current barriers, facilitators and future improvements to advance quality of abortion care: views of women. BMJ SEXUAL & REPRODUCTIVE HEALTH 2019; 45:bmjsrh-2018-200264. [PMID: 31028169 DOI: 10.1136/bmjsrh-2018-200264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 05/05/2023]
Abstract
BACKGROUND Barriers to accessing abortion care continue to exist even in settings where abortion is legal. We aimed to determine current barriers faced by women seeking abortion, factors that facilitate access to care, and what future improvements women would like made to abortion care in Scotland. METHODS A self-administered anonymous questionnaire of women requesting abortion care at a community abortion service in Edinburgh. Women selected the top three options from predefined lists of barriers to seeking abortion, facilitators of care, and future service improvements. RESULTS 154/165 (93%) questionnaires were completed by women presenting for abortion. The most commonly ranked number one barrier to seeking an abortion (n = 49; 32%) was 'being scared about what the abortion process involved'. The highest ranked facilitator of care was information provided to women via the abortion clinic website. The most commonly chosen number one response for potential improvement to abortion services was the option to get an early medical abortion from a general practitioner, which was chosen by 70 (45%) women. CONCLUSIONS This study suggests that lack of knowledge and information surrounding the abortion process and the ease with which women can receive abortion care are areas of concern. Efforts are needed to reduce waiting times, to ensure that high-quality, standardised information is widely and publicly available regarding what women can expect during the abortion process, and to expand provision of early medical abortion within the community, in order to improve abortion care.
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Affiliation(s)
- Jodie Louise Smith
- Centre for Reproductive Health, University of Edinburgh, College of Medicine and Veterinary Medicine Erskine Medical Library, Edinburgh, UK
| | - Sharon Cameron
- Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
- Division of Health Sciences, University of Edinburgh, Edinburgh, UK
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17
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Larsson A, Ronnberg AM. Expanding a woman's options to include home use of misoprostol for medical abortion up until 76 days: an observational study of efficacy and safety. Acta Obstet Gynecol Scand 2019; 98:747-752. [DOI: 10.1111/aogs.13537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 01/10/2019] [Accepted: 01/11/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Amanda Larsson
- Department of Obstetrics and Gynecology University Hospital Örebro Örebro Sweden
| | - Ann‐Kristin M. Ronnberg
- Department of Obstetrics and Gynecology University Hospital Örebro Örebro Sweden
- School of Medical Sciences Faculty of Medicine and Health Örebro University Örebro Sweden
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18
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Lord J, Regan L, Kasliwal A, Massey L, Cameron S. Early medical abortion: best practice now lawful in Scotland and Wales but not available to women in England. BMJ SEXUAL & REPRODUCTIVE HEALTH 2018; 44:bmjsrh-2018-200134. [PMID: 29986873 DOI: 10.1136/bmjsrh-2018-200134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 06/05/2018] [Accepted: 06/06/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Jonathan Lord
- Department of Gynaecology, Royal Cornwall Hospitals NHS Trust, Truro, UK
- British Society of Abortion Care Providers (BSACP), London, UK
| | - Lesley Regan
- Royal College of Obstetricians and Gynaecologists, London, UK
- Department of Obstetrics and Gynaecology, Imperial College London, London, UK
| | - Asha Kasliwal
- Faculty of Sexual and Reproductive Healthcare, London, UK
- Community Gynaecology and Reproductive Health, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Louise Massey
- British Society of Abortion Care Providers (BSACP), London, UK
- Sexual and Reproductive Health, Aneurin Bevan University Health Board, Wales, UK
| | - Sharon Cameron
- British Society of Abortion Care Providers (BSACP), London, UK
- Sexual and Reproductive Health, NHS Lothian, Edinburgh, UK
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19
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Aiken ARA, Guthrie KA, Schellekens M, Trussell J, Gomperts R. Barriers to accessing abortion services and perspectives on using mifepristone and misoprostol at home in Great Britain. Contraception 2017; 97:177-183. [PMID: 28941978 DOI: 10.1016/j.contraception.2017.09.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 09/04/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine reasons for seeking abortion services outside the formal healthcare system in Great Britain, where abortion is legally available. STUDY DESIGN We conducted a mixed-methods study among women resident in England, Scotland, and Wales who requested at-home medication abortion through online telemedicine initiative Women on Web (WoW) between November 22, 2016, and March 22, 2017. We examined the demographics and circumstances of all women requesting early medication abortion and conducted a content analysis of a sample of their anonymized emails to the service to explore their reasons for seeking help. RESULTS Over a 4-month period, 519 women contacted WoW seeking medication abortion. These women were diverse with respect to age, parity, and circumstance. One hundred eighty women reported 209 reasons for seeking abortion outside the formal healthcare setting. Among all reasons, 49% were access barriers, including long waiting times, distance to clinic, work or childcare commitments, lack of eligibility for free NHS services, and prior negative experiences of abortion care; 30% were privacy concerns, including lack of confidentiality of services, perceived or experienced stigma, and preferring the privacy and comfort of using pills at home; and 18% were controlling circumstances, including partner violence and partner/family control. CONCLUSION Despite the presence of abortion services in Great Britain, a diverse group of women still experiences logistical and personal barriers to accessing care through the formal healthcare system, or prefer the privacy of conducting their abortions in their own homes. Health services commissioning bodies could address existing barriers if supported by policy frameworks. IMPLICATIONS The presence of multiple barriers to accessing abortion care in Great Britain highlights the need for future guidelines to recommend a more woman-centered approach to service provision. Reducing the number of clinic visits and designing services to meet the needs of those living in controlling circumstances are particularly important goals.
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Affiliation(s)
- Abigail R A Aiken
- LBJ School of Public Affairs, University of Texas at Austin, Austin, TX, 78712, USA; Population Research Center, University of Texas at Austin, Austin, TX, 78712, USA.
| | | | | | - James Trussell
- Office of Population Research, Princeton University, Princeton, NJ, 08544, USA; Chalmers Centre, University of Edinburgh, Edinburgh, EH3 9ES, UK
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Purcell C, Cameron S, Lawton J, Glasier A, Harden J. Self-management of first trimester medical termination of pregnancy: a qualitative study of women's experiences. BJOG 2017; 124:2001-2008. [PMID: 28421651 PMCID: PMC5724679 DOI: 10.1111/1471-0528.14690] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To explore the experiences of women in Scotland who return home to complete medical termination of pregnancy (TOP) ≤63 days of gestation, after being administered with mifepristone and misoprostol at an NHS TOP clinic. DESIGN Qualitative interview study. SETTING One National Health Service health board (administrative) area in Scotland. POPULATION OR SAMPLE Women in Scotland who had undergone medical TOP ≤63 days, and self-managed passing the pregnancy at home; recruited from three clinics in one NHS health board area between January and July 2014. METHODS In-depth, semi-structured interviews with 44 women in Scotland who had recently undergone TOP ≤63 days of gestation, and who returned home to pass the pregnancy. Data were analysed thematically using an approach informed by the Framework method. MAIN OUTCOME MEASURES Women's experiences of self-management of TOP ≤63 days of gestation. RESULTS Key themes emerging from the analysis related to self-administration of misoprostol in clinic; reasons for choosing home self-management; facilitation of self-management and expectation-setting; experiences of getting home; self-managing and monitoring treatment progress; support for self-management (in person and remotely); and pregnancy self-testing to confirm completion. CONCLUSIONS Participants primarily found self-administration of misoprostol and home self-management to be acceptable and/or preferable, particularly where this was experienced as a decision made jointly with health professionals. The way in which home self-management is presented to women at clinic requires ongoing attention. Women could benefit from the option of home administration of misoprostol. TWEETABLE ABSTRACT Women undergoing medical TOP 63 days found home self-management to be acceptable and/or preferable.
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Affiliation(s)
- C Purcell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
| | - S Cameron
- Chalmers Centre for Sexual and Reproductive Health (NHS Lothian), Edinburgh, UK
| | - J Lawton
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - A Glasier
- Obstetrics and Gynaecology, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - J Harden
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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