Highlights from this issue BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2018-200292 on 8 January 2019. Downloaded from In this issue

The impact of Northern Ireland’s women’s healthcare services are being findings could shape future interventions laws on women seeking abortion programmed. See page 10 aimed at removing barriers to abortion Despite Northern Ireland being part of services. See page 23 the United Kingdom, abortion remains Innovative approaches to safer illegal there except in very limited circum- An evaluation of the quality of sex: messages from imprisoned stances. Aiken and colleagues interviewed online information for women American women 30 women who had sought abortion by For incarcerated women, transition into seeking abortion travelling to clinics in Great Britain or by the community is known to be accom- In developed countries, women with using online telemedicine to self-manage panied by an increased frequency of unwanted pregnancies will usually turn a medication abortion at home. The key behaviour that may increase the risk to the internet when seeking help in themes that emerged from the in-depth of acquisition of sexually transmitted accessing abortion services. Sadly the interviews were that there are multiple infections (STIs). Few efficacious inter- information that they retrieve may be barriers to travelling for abortion services ventions have addressed STI prevention inaccurate, or unrelated to the jurisdic- even when abortion is provided without among such women. ‘Sexual health tion in which they reside. Duffy and charge, that self-management is often prevention for incarcerated women: colleagues performed a formative eval- preferred over travel, that Customs can eroticizing safe sex during community uation of 619 abortion-related websites, obstruct import of abortion medications, re-entry’ was an exploratory qualita- of which 83 dealt with accessing services. and that there is mistrust of the health- tive study with 21 women in detention The searches (in 2016) were performed care system because of fears regarding in the USA, exploring perceptions of from the perspective of users in England, the legal obligations of healthcare STI prevention methods and strategies Northern Ireland and the Irish Republic. professionals. Northern Ireland’s abor- to overcome the challenges in imple- The sites were evaluated using an Abor- tion laws affect the quality and safety of menting these. The authors suggest that tion Service Information Assessment women’s healthcare and can have serious the period prior to release and the rein- Tool (ASIAT), developed by the authors. implications for women’s physical and tegration period offer ideal opportunities Fewer than one third provided informa- emotional health. This study’s findings tion that was rated as ‘good’ or ‘excel- for intervention. They explored narra- copyright. offer new perspectives for the debate tives of sexual negotiation and challenges lent’. They conclude that the needs of over Northern Ireland’s abortion laws in the uptake of prevention strategies users must be central to the design of and suggest a public health rationale for such as the use of condoms. The women websites; their tool can assist organisa- decriminalising abortion. See page 3 themselves were colourfully outspoken tions to identify areas for improvement in identifying approaches to increasing in their own information. This report of Intimate partner violence protective behaviours and the authors a very robust study will repay detailed and pregnancy decision by hope that this could inform the design of reading by all abortion providers. See underprivileged women in India future STI prevention interventions. See page 32 Numerous factors are implicated in page 17 the high rate of unintended pregnancy http://jfprhc.bmj.com/ in India, including lack of education, Menstrual restriction and intimate poverty, social factors such as son pref- A case management programme partner violence in Nepal erence, and intimate partner violence for women seeking later second In certain areas of Nepal, ‘menstrual (IPV). Dasgupta and colleagues analysed trimester abortion in the USA restriction’ is widespread. During data from a large study of mothers of Abortion access has become increas- menstruation, women and girls must infants in slum communities in Mumbai, ingly restricted in the USA, and women leave their home, sleep wherever they focussing on the relationship between requiring later second trimester abor- can find a place, and girls must miss IPV, ‘external’ decision-making by tions, particularly those in low income schooling. In August 2017, Nepal passed on September 28, 2021 by guest. Protected husbands and in-laws, and unintended groups, face barriers in finding units a law criminalising the most restrictive pregnancy. Women who reported exter- that can accommodate their needs. forms of this practice. Nepal has also nally-decided pregnancies and pre-preg- Ho and colleagues reviewed data from been seeking to reduce the incidence of nancy IPV were significantly more likely the Massachusetts Access Programme, emotional, economic or physical and to have had mistimed pregnancies than which was established to facilitate access sexual intimate partner violence (IPV). intended pregnancies, reflecting the to appropriate providers. The study Cardoso and colleagues analysed data low engagement of married women in describes core programme services as from a large randomised trial of IPV family planning decisions. Although well as a patient navigator role that was reduction to record the prevalence of mistimed, the recent pregnancies were identified by providers as key in sorting menstrual restriction among married not generally reported as ‘unwanted’, through the evolving abortion landscape. women and to examine potential asso- and the authors discuss possible reasons They conclude that the Massachusetts ciations with IPV. While the prevalence for this finding. This study highlights the Access Programme is a highly accept- of both was high, after controlling for need for women’s involvement in repro- able, potentially replicable interven- demographic variables no form of IPV ductive decision-making an in formu- tion that has shown ‘some success’ in was found to be associated with a high lating messages on IPV reduction when improving abortion access and that their menstrual restriction rate. The authors

BMJ Sex Reprod Health 2019;45:1–2. doi:10.1136/bmjsrh-2018-200292 1 Highlights from this issue BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2018-200292 on 8 January 2019. Downloaded from conclude that the well-being of women anaemia is complex. Very few studies women because it appears to give and girls might best be served by water have investigated whether different them more personal control over and sanitation programmes, which would contraceptive methods modify women’s their fertility than some pharma- do much to reduce menstrual stigma. See anaemia risk. Using data from Africa-wide ceutical methods. Hough submitted page 38 Demographic and Health Surveys, a complaint to the UK Advertising Gebremedhin and Asefa reviewed the Standards Authority (ASA) and on 29 Removal of intrauterine haemoglobin status of women of over August 2018 the ASA concluded that contraception with non-visible 105 000 women using various fertility the company’s claims of ‘highly accu- threads regulation methods in 24 sub-Saharan rate contraceptive app’ and ‘clinically A small proportion of women using countries. The association between tested alternative to birth control intrauterine contraception (IUC) present contraception method and anaemia was methods’ were indeed misleading. with threads that are not visible at the assessed using a logistic regression model, In their Personal View, Hough and cervical os. Elizabeth Stephens reviewed adjusted for potential confounders. They Bryce report on the background a series of such women who presented showed that the use of injectables, oral to the ASA’s judgement, the most at a specialist clinic for device removal. contraceptives and implants is associated important feature of which was that Over 90% of those who required inter- with reduced risk of anaemia and also the effectiveness of Natural Cycles vention had successful IUC removal in that anaemia prevalence declines with had been exaggerated by the use of the clinic with the aid of ultrasound and longer use of injectables and oral contra- ‘perfect use’ rather than ‘typical use’ simple instrumentation. But the most ceptives. The results of this study could Pearl Index rates. Advertising content interesting finding of this study was that do much to inform both health policies like this can now be restricted in when uterine cavity length was measured, and family planning policies in many the UK, but on a world-wide basis, comparison with the combined length countries where anaemia continues to be internet-based misinformation will of the devices and threads suggested a major problem. See page 54 undoubtedly continue - as it does in that 91% of the devices had not been so many other spheres. This debate placed fundally at insertion. Non-fundal An initiative to improve postpartum emphasises how good contraception placement of IUC is therefore likely to contraception provision in a UK is about accurate information aswell be a highly significant cause of non-vis- hospital as biological safety. Natural Cycles ible threads. The author suggests that Discussion and provision of contracep- have been offered a right of reply. See performing an ultrasound scan imme- tion should be part of maternity care, both page 71 diately after IUC insertion would allow in the antenatal and postpartum periods, copyright. non-fundal devices to be removed and to enable new mothers to commence a The effects of UK immigration replaced, reducing the incidence and secure, preferably long-acting, method policies on migrants’ access to inconvenience of ‘lost’ threads. See page of contraception as soon as possible. sexual and reproductive healthcare 44 But implementing such arrangements In her insightful essay, which won can be difficult. In their article in this the FSRH’s 2018 Margaret Jackson A feasibility trial of a suction journal’s Better Way of Working series, Prize for medical students, Isabelle cervical retractor for IUD insertion Brammeier and colleagues describe the Whelan reviews the ways in which A new suction cervical retractor, the development and commencement of a the UK government’s ‘hostile envi- Bioceptive SCR, is a device designed to ‘postpartum family planning initiative’ at ronment’ policy threatens migrants’ replace the standard single-tooth tenac- the University Hospital of Wales, Cardiff, ability to access treatment, endan- http://jfprhc.bmj.com/ ulum to apply atraumatic traction to UK. The initiative has three aims - to gering their own health and having the cervix. A three-stage feasibility trial train midwives in antenatal and postnatal potential wider consequences for was conducted on this device for intra- contraceptive advice and care, to develop public health. Examples include the uterine device (IUD) placement. The information for pregnant women on need for ‘overseas visitors’ to pay in study included a small randomised trial their post-natal contraceptive options advance for non-urgent NHS care in assessing pain scores with the SCR and and to offer contraception supplies to England and the agreement between a conventional tenaculum. The study every maternity patient before their NHS Digital and the Home Office on September 28, 2021 by guest. Protected showed that use of the SCR device for discharge after delivery. The information to share confidential patient infor- IUD insertion appears to be safe and on the problems that were faced, and the mation. Whelan discusses the impli- clinically acceptable both for patients ways in which they were overcome, will cations for sexual healthcare access, and providers. While there was a trend be of benefit to any maternity unit plan- particularly relating to HIV, the needs towards lower pain scores with the SCR, ning similar developments. See page 68 of sex workers, reproductive health- the study was not powered to detect care including contraception and statistical significance and the authors Advertising Standards Authority abortion, and late presentation for therefore suggest that further studies of upholds complaint about antenatal care. Her powerful conclu- the device are warranted. See page 47 contraception app's marketing sion is that current policies pose campaign barriers to access to care for some Hormonal contraception reduces In our last issue, Hough and of the most marginalised people in anaemia risk in African countries colleagues reported critically on the our society and that SRH staff must In countries where anaemia is prevalent, advertising methods and claims of not be complacent in thinking that the relationship between contraception the Natural Cycles fertility awareness those policies will not affect their use or non-use, pregnancy, lactation and app – a method popular with some services. See page 74

2 BMJ Sex Reprod Health 2019;45:1–2. doi:10.1136/bmjsrh-2018-200292