BACKGROUND: Access to post-abortion contraception (PAC) is critical for reducing unintended pregnancies and supporting reproductive decision-making. Patients often face challenges in identifying, accessing and initiating their preferred contraceptive methods post-abortion. This may be particularly so with telemedicine models of care with absence of in-person appointments, and reduced opportunities to provide some contraceptive methods. This qualitative service evaluation explored patients\' perspectives on PAC consultations and decision-making to inform future PAC service models in the era of telemedicine.
METHODS: Qualitative interviews with 15 patients who had telemedicine medical abortion at home up to 12 weeks\' gestation. Data were analysed using reflexive thematic analysis.
RESULTS: Contraceptive discussions during pre-abortion consultations were valued for supporting informed choices about future contraceptive use. Decision-making was influenced by previous contraception experiences, emotional state at the time of abortion and concerns about contraceptive \'failure\'. Some preferred non-hormonal methods due to past negative experiences with hormonal contraceptives. However, limited information about \'natural\' contraceptive methods and concerns about discussing these with healthcare professionals were described. Barriers to accessing preferred methods, particularly long-acting reversible contraception (LARC), included reduced availability of appointments and caring responsibilities. Fast-tracked appointments for LARC fitting post-abortion were valued. The need for flexible PAC consultations and access after abortion, for example, remote consultations complemented by personalised interactions with sexual and reproductive health experts, was emphasised.
CONCLUSIONS: The findings highlight the need for flexible and more accessible PAC service models in the era of telemedicine care to ensure timely access to preferred contraceptive methods.

BACKGROUND: Medical abortion after 12 gestational weeks often requires a stay in hospital. We hypothesised that administering the first misoprostol dose at home could increase day-care procedures as compared with overnight care procedures, shorten inpatient stays, and improve patient satisfaction.
METHODS: This multicentre, open-label, randomised controlled trial was done at six hospitals in Sweden. Participants were pregnant people aged 18 years and older who were undergoing medical abortion at 85-153 days of pregnancy. Randomisation was done in blocks 1:1 to mifepristone administered in-clinic followed by home administration or hospital administration of the first dose of misoprostol. Allocation was done by opening of opaque allocation envelopes. Due to the nature of the intervention, masking was not feasible. Between 24-48 h after mifepristone 200 mg, the participants administered 800 μg of misoprostol either at home 2 h before admission to hospital or in hospital. The primary outcome was the proportion of day-care procedures (defined as abortion completed in <9 h). The intention-to-treat analysis included all participants randomly assigned to receive the study drug and who had known results for the primary outcome. Individuals who received any treatment were included in the safety analyses. This trial is registered at ClinicalTrials.gov, NTC03600857, and EudraCT, 2018-000964-27.
RESULTS: Between Jan 8, 2019, and Dec 21, 2022, 457 participants were randomly assigned to treatment groups. In the intention-to-treat-population, 220 participants were assigned to the home group and 215 to the hospital group. In the home group, 156 (71%) of 220 participants completed the abortion as day-care patients, compared with 99 (46%) of 215 in the hospital group (difference 24·9%, 95% CI 15·4-34·3; p<0·0001). In total, 97 (22%) of 444 participants in the safety analysis had an adverse event. Seven (2%) of 444 participants aborted after mifepristone only. Two (1%) of 220 in the home group aborted after the first dose of misoprostol, before hospital admission.
CONCLUSIONS: Home administration of misoprostol significantly increases the proportion of day-care procedures in medical abortion after 12 gestational weeks, offering a safe and effective alternative to in-clinic protocols.
BACKGROUND: Region Västra Götaland, Hjalmar Svensson\'s Fund, the Gothenburg Society of Medicine, Karolinska Institutet-Region Stockholm, and The Swedish Research Council.

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BACKGROUND: Abortion-related complications remain a main cause of maternal mortality. There is little evidence on the availability and quality of post-abortion care (PAC) in humanitarian settings. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic, CAR).
METHODS: We mapped indicators corresponding to the eleven domains of the WHO Maternal and Newborn Health quality-of-care framework to assess inputs, processes (provision and experience of care), and outcomes of PAC. We measured these indicators in four components of a cross-sectional multi-methods study: 1) an assessment of the hospitals\' PAC signal functions, 2) a survey of the knowledge, attitudes, practices, and behavior of 140 Nigerian and 84 CAR clinicians providing PAC, 3) a prospective review of the medical records of 520 and 548 women presenting for abortion complications and, 4) a survey of 360 and 362 of these women who were hospitalized in the Nigerian and CAR hospitals, respectively.
RESULTS: Among the total 27 PAC signal functions assessed, 25 were available in the Nigerian hospital and 26 in the CAR hospital. In both hospitals, less than 2.5% were treated with dilatation and sharp curettage. Over 80% of women received blood transfusion or curative antibiotics when indicated. However, antibiotics were given to about 30% of patients with no documented indication. Among discharged women in CAR, 99% received contraceptive counseling but only 39% did in Nigeria. Over 80% of women in Nigeria reported positive experiences of respect and preservation of dignity. Conversely, in CAR, 37% reported that their privacy was always respected during examination and 62% reported short or very short waiting time before seeing a health provider. In terms of communication, only 15% felt able to ask questions during treatment in both hospitals. The risk of abortion-near-miss happening ≥ 24h after presentation was 0.2% in Nigeria and 1.1% in CAR. Only 65% of women in the Nigerian hospital and 34% in the CAR hospital reported that the staff provided them best care all the time.
CONCLUSIONS: Our comprehensive assessment identified that these two hospitals in humanitarian settings provided lifesaving PAC. However, hospitals need to strengthen the patient-centered approach engaging patients in their own care and ensuring privacy, short waiting times and quality provider-patient communication. Health professionals would benefit from instituting antibiotic stewardships to prevent antibiotic-resistance.
In humanitarian contexts, abortion complications are a leading cause of maternal mortality. Providing quality post-abortion care (PAC) is therefore an important part of needed services. We assessed the quality of PAC in two hospitals supported by an international organization in Jigawa State (Nigeria) and Bangui (Central African Republic). We measured quality indicators in four components: 1) an assessment of the equipment and human resources available in hospitals, 2) a survey of the knowledge, attitudes, practices, and behavior of clinicians providing PAC, 3) an assessment of the medical care provided by clinicians to women presenting with abortion complications and, 4) a survey of a subgroup of these women who were hospitalized. Both hospitals had almost all the equipment and human resources necessary to provide post-abortion care. Less than 2.5% of women received a non-recommended method to evacuate their uterus in both hospitals. More than 80% of women received a blood transfusion or antibiotics when they needed them. However, 30% of women received antibiotics without written justification and only 15% of women reported being able to ask questions about their treatment. Overall, only 65% of Nigerian women and 34% of Central African women said that the staff provided them with the best care all the time. The fact that less than 2% of women experienced a very severe complication 24 hours or more after their arrival at the two hospitals suggests that the care provided was lifesaving. But they urgently need to adopt a better patient-centered approach as well as to improve the rational management of antibiotics.

BACKGROUND: Remimazolam, a recently developed anesthetic characterized by its rapid and ultra-short-acting properties, exhibits pharmacological attributes that make it potentially suitable for painless surgical abortion procedures. The objective of this study was to determine the effective dose of remimazolam when administered in combination with sufentanil, with the intention of inhibiting body movement during surgical abortion. Additionally, a secondary objective was to assess the recovery profile from general anesthesia.
METHODS: The study enrolled a total of 25 healthy women aged 20 to 40, with a body mass index between 18 and 28 kg/m2, in their first trimester of pregnancy (up to 12 weeks), and American Society of Anesthesiologists status I and II. Anesthesia induction was initiated by administering sufentanil at a dose of 0.1 μg/kg. The modified Dixon up-and-down method was employed to determine the induction dose of remimazolam for each patient.
RESULTS: The 50% and 95% effective dose of remimazolam for inhibitory effects of body movement was estimated using centered isotonic regression to be 0.145 mg/kg (95% CI: 0.115, 0.207), and 0.242 mg/kg (95% CI: 0.232, 0.620), respectively. Five out of 25 (20%) experienced hiccups, with 1 patient having persistent hiccups until the end of the surgery. The mean time to first eye-opening was 51.4 ± 20.5 seconds, and the time to obey verbal command was 54.5 ± 20.6 seconds. Upon arrival at the postanesthesia care unit, 95.7% of the patients achieved a Modified Aldrete score ≥ 9.
CONCLUSIONS: The 50% and 95% effective dose of remimazolam for inhibiting body movement during surgical abortion when used in combination with 0.1 μg/kg of sufentanil were 0.145 mg/kg and 0.242 mg/kg, respectively.

BACKGROUND: Evidence indicates that postpartum and post-abortion women accept family planning at a higher rate when offered timely at appropriate sites. Therefore, this study explored barriers and enablers of postpartum and post-abortion family planning utilization in primary health care units of Wolaita Zone, Southern Ethiopia, from June 20 to July 25, 2022.
METHODS: We used a case study strategy of qualitative research using both the Consolidated Framework for Implementation Research (CFIR) and Gender, Youth, and Social Inclusion (GYSI) frameworks was conducted from June to July 2022. We conducted 41 in-depth and key informant interviews and six focus group discussions. We also used Open Code software version 4.02 for coding and further analysis and applied a framework analysis.
RESULTS: The analysis of this study identified barriers and enablers of postpartum and post-abortion family planning service uptake in five CFIR domains and four GYSI components. The barriers included misconceptions and sole decision-making by husbands, cultural and religious barriers, and healthcare providers paying less attention to adolescents and husbands, which prevented them from using immediate postpartum and postabortion family planning services. The health facilities were not adequately staffed; there was a shortage and delay of supplies and infrastructure, trained staff turnover, and poor accountability among service providers. The existence of community structure, equal access and legal rights to the service, and having waivered services were enablers for postpartum and post-abortion family planning service uptake.
CONCLUSIONS: The current study identified various barriers and enablers to the uptake of postpartum and post-abortion family planning. Therefore, there is a need for high-impact interventions such as targeting male partners and girls, ensuring infrastructure, supplies, and equipment, building staff capacity, and making decisions jointly.

BACKGROUND: Female sex workers (FSW) are particularly vulnerable to unintended pregnancy. Research examining the experience of unintended pregnancy due to commercial sex among Chinese FSW, however, is limited. This study aimed to examine the prevalence and correlates of unintended pregnancy due to commercial sex among FSW in China.
METHODS: In 2021, a cross-sectional study was conducted among 1257 FSW in five cities from Guangdong provinces in South China. Data were collected on social-demographic characteristics, sexual behaviors, experience of unintended pregnancy due to commercial sex and its pregnancy outcome, as well as experience of abortion in lifetime. Multivariable logistic regression analysis was employed to identify factors associated with unintended pregnancy.
RESULTS: Among the 1257 FSW, 19.3% reported having at least one unintended pregnancy due to commercial sex. Of those, 96.7% chose to terminate the pregnancy through induced abortion, and 40.5% reported undergoing multiple induced abortions in their lifetime. Multivariable logistic regression indicated that FSW working in current location over one year (adjusted Odds Ratio (aOR): 2.82, 95% CI 1.71-4.64) and having more than seven clients in the past week (aOR: 4.53, 95% CI 2.74-7.51) were more likely to have had unintended pregnancy due to commercial sex. Working in high tier (aOR: 0.21, 95% CI 0.14-0.30) and consistent condom use with clients in the past month (aOR: 0.16, 95% CI 0.10-0.23) were associated with a lower proportion of FSW having ever had unintended pregnancy.
CONCLUSIONS: Unintended pregnancy are prevalent among FSW in South China. Interventions aimed at reducing the prevalence of unintended pregnancy and enhancing post-abortion care could be necessary among Chinese FSW.
Female sex workers (FSW) are particularly vulnerable to unintended pregnancies. Research on the experience of unintended pregnancy resulting from commercial sex among Chinese FSW is, however, limited.To address this knowledge gap, we investigated the prevalence and correlates of unintended pregnancies due to commercial sex among FSW in China. We conducted a cross-sectional study among 1257 FSW in five cities across Guangdong Province in South China in 2021. Multivariable logistic regression analysis was used to identify factors associated with unintended pregnancy.Among 1257 FSW, 19.3% reported having experienced at least one unintended pregnancy due to commercial sex. The factors significantly associated with unintended pregnancy in the multivariate analysis included participants working in high tier, working in current location over one year, using condom with clients inconsistently in the past month, and having more clients in the past week.The findings from this study could provide valuable insights for the development of policies aimed at reducing unintended pregnancies, improving abortion care, and enhancing family planning programs targeted at FSW.

BACKGROUND: Despite attempts to increase Universal Health Coverage, availability, accessibility, acceptability, and quality-related challenges remain barriers to receiving essential services by women who need them. We aimed to explore the experiences and perceptions of women receiving post-abortal care services in Zambia, within a human-rights framework.
METHODS: A qualitative case study was conducted between August and September 2021 in Lusaka and Copperbelt provinces of Zambia. Fifteen (15) women seeking post-abortion care services were` interviewed using audio recorders; transcribed data was analyzed using thematic analysis. We report women\'s experiences and perceptions of the healthcare system, their experiences of abortion, and healthcare-seeking behaviour. We used the availability, accessibility, acceptability, and quality (AAAQ) framework to understand how women claimed their right to healthcare as they sought and utilized post-abortion care services.
RESULTS: Women who experienced spontaneous abortions delayed seeking health care by viewing symptoms as \'normal pregnancy symptoms\' and not dangerous. Women also delayed seeking care because they feared the negative attitudes from their communities and the health care providers towards abortion in general, despite it being legal in Zambia. Some services were considered costly, impeding their right to access quality care.
CONCLUSIONS: Women delayed seeking care compounded by fear of negative attitudes from the community and healthcare providers. To ensure the provision and utilization of quality all abortion-related healthcare services, there is a need to increase awareness of the availability and legality of safe abortion services, the importance of seeking healthcare early for any abortion-related discomfort, and the provision and availability of free services at all levels of care should be emphasized.
Unsafe abortions continue to be an avoidable public health concern both globally and locally. In Zambia, a fifth of maternal deaths are related to unsafe abortions. Unsafe abortions have been defined as any induced termination of pregnancy outside the health facility, performed by untrained health personnel. Several strides have been made including the provision of comprehensive abortion care in all facilities, and the training of health personnel to provide these services at different levels of healthcare. Despite the increased availability of comprehensive abortion care through liberalized abortion laws and regulations and the training of health personnel to provide these services at different levels of healthcare, the need for quality post-abortion care specifically persists. As such, we carried out in-depth interviews to explore the experiences of women who present at healthcare facilities in Lusaka and the Copperbelt provinces in Zambia seeking post-abortion services. It was found that delay in seeking care at a health facility was due to fear that the service is illegal; alongside judgment from health care providers and society for seeking such a service that is generally perceived as evil. The assumption that the cost of receiving such services is high and a general lack of awareness about the service being provided free was also expressed. The study highlighted the need for community awareness of the legal framework on abortions to ensure women access services at any time necessary without fear of being judged, which will consequently reduce the number of abortion-related disabilities and deaths.

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