Search

Background: We describe clients in Mexico City's public abortion programme, Interrupción Legal de Embarazo (ILE), during the COVID-19 pandemic and test whether the pandemic exacerbated inequities in access., Methods: We conducted a cohort study of all abortions in the ILE programme from 1 January 2019 to 30 June 2022. We compared patients from within and outside the Mexico City Metropolitan area (ZMVM) by pandemic stage (pre-, acute-, mid- and late-COVID periods) and assessed changes in client characteristics (adolescent age, education, weeks' gestation) by place of residence (ZMVM vs outside the ZMVM) using linear probability models clustered on state., Results: We included 45 031 abortions. The proportion of abortions to women who travelled from outside the ZMVM decreased from 6.5% pre-COVID to 4.4%-4.8% in in the acute, mid- and late-COVID periods. The adjusted probability of being an adolescent who travelled from outside the ZMVM dropped between pre-COVID (14.4%, 95% CI 12.7% to 16.1%) and mid-COVID (9.3%, 95% CI 7.9% to 10.7%). The proportion of abortions to women with a high school education stayed fairly flat among those travelling, while it rose among those residing in the ZMVM. The adjusted probability of presenting at 11 gestational weeks or greater was higher among women residing in the ZMVM in the pre-pandemic period; this flipped during all pandemic stages, with a higher probability of presenting at 11 weeks or greater among those who travelled from outside the ZMVM., Conclusions: The COVID-19 pandemic exacerbated existing disparities in who can access ILE services. To reduce inequities in access to essential health services, public sector abortion services should be made available in all Mexican states., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We used the newly developed Abortion Care Quality Tool (ACQTool) to compare client-reported quality of medication abortion care by source (facility-managed vs pharmacy-sourced self-managed abortion (SMA)) in Bangladesh., Methods: We leveraged exit and 30-day follow-up surveys collected to develop and validate the ACQTool collected at nongovernmental organisation (NGO)-supported or -operated facilities in the public and private sector and pharmacies from three districts in Bangladesh. We used bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by source (facility vs pharmacy). We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client sociodemographic characteristics., Results: Of 550 abortion clients, 146 (26.5%) received a facility-managed medication abortion and 404 (73.5%) had a pharmacy-sourced SMA. Clients reported higher quality in facilities for five indicators, and higher in pharmacies for two indicators; the remaining 11 indicators were not different by source. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (adjusted odds ratio (aOR) 3.55; 95% CI 2.27 to 5.58) but lower odds of reporting high information provision (aOR 0.14; 95% CI 0.09 to 0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse event occurred (aOR 0.45; 95% CI 0.23 to 0.82)., Conclusions: In Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable., Competing Interests: Competing interests: BGD’s institution receives research funding from Organon and the Office of Population Affairs (OPA) on which she is Principal Investigator, and she is a member of the Board of Directors of the Society of Family Planning (SFP) and a Deputy Editor on Contraception. She has received an honorarium from the American College of Obstetrics and Gynecology (ACOG) for committee work., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To identify whether covid-19 vaccines are associated with menstrual changes in order to address concerns about menstrual cycle disruptions after covid-19 vaccination., Design: Global, retrospective cohort study of prospectively collected data., Setting: International users of the menstrual cycle tracking application, Natural Cycles., Participants: 19 622 individuals aged 18-45 years with cycle lengths of 24-38 days and consecutive data for at least three cycles before and one cycle after covid (vaccinated group; n=14 936), and those with at least four consecutive cycles over a similar time period (unvaccinated group; n=4686)., Main Outcome Measures: The mean change within individuals was assessed by vaccination group for cycle and menses length (mean of three cycles before vaccination to the cycles after first and second dose of vaccine and the subsequent cycle). Mixed effects models were used to estimate the adjusted difference in change in cycle and menses length between the vaccinated and unvaccinated., Results: Most people (n=15 713; 80.08%) were younger than 35 years, from the UK (n=6222; 31.71%), US and Canada (28.59%), or Europe (33.55%). Two thirds (9929 (66.48%) of 14 936) of the vaccinated cohort received the Pfizer-BioNTech (BNT162b2) covid-19 vaccine, 17.46% (n=2608) received Moderna (mRNA-1273), 9.06% (n=1353) received Oxford-AstraZeneca (ChAdOx1 nCoV-19), and 1.89% (n=283) received Johnson & Johnson (Ad26.COV2.S). Individuals who were vaccinated had a less than one day adjusted increase in the length of their first and second vaccine cycles, compared with individuals who were not vaccinated (0.71 day increase (99.3% confidence interval 0.47 to 0.96) for first dose; 0.56 day increase (0.28 to 0.84) for second dose). The adjusted difference was larger in people who received two doses in a cycle (3.70 days increase (2.98 to 4.42)). One cycle after vaccination, cycle length was similar to before the vaccine in individuals who received one dose per cycle (0.02 day change (99.3% confidence interval -0.10 to 0.14), but not yet for individuals who received two doses per cycle (0.85 day change (99.3% confidence interval 0.24 to 1.46)) compared with unvaccinated individuals. Changes in cycle length did not differ by the vaccine's mechanism of action (mRNA, adenovirus vector, or inactivated virus). Menses length was unaffected by vaccination., Conclusions: Covid-19 vaccination is associated with a small and likely to be temporary change in menstrual cycle length but no change in menses length., Competing Interests: Competing interests AE reports honoraria and travel reimbursement from the American College of Obstetricians and Gynecologists, World Health Organization, and Gynuity for committee activities and honorariums for peer review from the Karolinska Institute. AE receives royalties from UptoDate. Oregon Health and Science University (OHSU) receives research funding from OHSU Foundation, Merck, HRA Pharma, and the National Institutes of Health for which Alison Edelman is the principal investigator. BGD reports honorariums and travel reimbursement from the American College of Obstetricians and Society of Family Planning for board, committee, and mentorship activities. OHSU receives research funding from Merck/Organon and Office of Population Affairs/Department of Health and Human Services for which BGD is the principal investigator. OHSU receives research funding from OHSU foundation, the Bill & Melinda Gates Foundation, American Board of Obstetrics and Gynecology, American Society for Reproductive Medicine, and the National Institutes of Health for which Leo Han is the principal investigator. EB, AVL, and JTP are employees of Natural Cycles. Natural Cycles received cost reimbursement from grant funds for data processing and secure transfer. KAM reports honorariums and travel reimbursement from the American Board of Obstetrics and Gynecology and travel reimbursement from American College of Obstetricians and Gynecologists. Women and Infants Hospital received funding from Myovant for consulting work done by KAM on outcomes measures for heavy menstrual bleeding. VM reports research funding from Borne, payment for acting as an external examiner for the Universities of Cambridge, Leeds and Swansea, and royalties received for contribution to Immunology 9th edition (Elsevier). STC is the editor-in-chief of BMJ Sexual and Reproductive Health and reports an honorarium from Gedeon Richter Nordics for a lecture on contraception. ERB declares no competing interests.

Objective: To describe the community context of women who travel to access Mexico City's public sector abortion programme and identify factors associated with travelling from highly marginalised settings., Methods: We used data from the Interrupción Legal de Embarazo (ILE) programme (2016-2019) and identified all abortion clients who travelled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to describe ILE clients' individual characteristics and municipalities on several measures of vulnerability. We also compared municipalities that ILE clients travelled from with those where no one travelled from. We used logistic regression to identify factors associated with travelling to access ILE services from highly marginalised versus less marginalised municipalities., Results: Our sample included 21 629 ILE clients who travelled to Mexico City from 491 municipalities within all 31 states outside Mexico City. The majority of clients travelled from the least marginalised (81.9%) and most populated (over 100 000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom three quintiles. Clients with a primary or secondary education (vs high school or more) and those from a municipality with a high adolescent fertility rate (top two quintiles) had higher odds of travelling from a highly marginalised (vs less) municipality (adjusted odds ratio (aOR) 1.46, 95% CI 1.35 to 1.58 and aOR 1.89, 95% CI 1.68 to 2.12, respectively)., Conclusion: ILE clients travel from geographically and socioeconomically diverse communities. There is an unmet need for legal abortion across Mexico., Competing Interests: Competing interests: BGD receives research support from Merck., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: We examined parity and age among women seeking an abortion in Mexico City's public first-trimester abortion programme, Interrupcion Legal de Embarazo (ILE). We hypothesised that younger women, especially students, used abortion to prevent first births while older women used abortion to limit births., Methods: We used clinical data from a sample of 47 462 women who had an abortion between 2007 and 2016 and classified them as nulliparous or parous according to previous births prior to the abortion. We used logistic regression to identify sociodemographic and clinical factors associated with using abortion to prevent a first birth (nulliparous) versus limiting births (parous) and calculated absolute multivariable predicted probabilities., Results: Overall, 41% of abortions were in nulliparous women seeking to prevent a first birth, and 59% were in women who already had one or more children. The adjusted probability of using abortion to prevent a first birth was 80.4% (95% CI 78.3 to 82.4) for women aged 12-17 years and 54.3% (95% CI 51.6 to 57.0) for women aged 18-24 years. Adolescents (aged 12-17 years) who were employed or students had nearly 90% adjusted probability of using abortion to prevent a first birth (employed 87.8%, 95% CI 82.9 to 92.8; students 88.5%, 95% CI 82.9 to 94.1). At all ages, employed women and students had higher probabilities of using abortion to prevent a first birth compared with unemployed women and women who work in the home., Conclusion: Legal first-trimester abortion services in Mexico can help prevent first births in adolescents, especially students., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: First-trimester abortion is widely available in Mexico City since legalisation in 2007, but few data exist surrounding pharmacy staff knowledge and sales practices. We describe misoprostol availability, whether a prescription is required, and knowledge of the legal status of abortion and uses for misoprostol among pharmacy staff in Mexico City., Methods: Data were collected from 174 pharmacies in Mexico City. One employee at each pharmacy was asked about availability, need for prescription, indications for misoprostol, and sociodemographic information. Our primary outcome was availability of misoprostol. We used descriptive and bivariate statistics to compare knowledge and practices by type of pharmacy and staff gender., Patients and Public Involvement: No patients were involved in this study., Results: Of the 174 pharmacies, 65 were chain and 109 small independent. Misoprostol was available at 61% of sites. Only 49% of independent pharmacies sold misoprostol, compared with 81.5% of chain pharmacies (p<0.05). Knowledge of indications for misoprostol use was similar. The majority (80%) of respondents knew that abortion was legal in Mexico City, and 44% reported requiring a prescription for sale of misoprostol, with no significant difference between male and female staff or by pharmacy type., Conclusions: Availability, requirement of a prescription, and knowledge of indications for use of misoprostol varies among pharmacies, resulting in differential access to medical abortion. Pharmacies may be a good place to target education for pharmacy staff and women about safe and effective use of misoprostol for abortion., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Data on utilisation of in-facility second-trimester abortion services are sparse. We describe temporal and geographical trends in utilisation of in-facility second-trimester abortion services across Mexico., Methods: We used 2007-2015 data from Mexico's Automated Hospital Discharge System (SAEH) to identify second-trimester abortive events (ICD O02-O08) in public hospitals across Mexico's 32 states. We described utilisation, calculated rates using population data, and used logistic regression to identify woman- and state-level factors (municipality-level marginalisation, state-level abortion law) associated with utilisation of second-trimester versus first-trimester services., Results: We identified 145 956 second-trimester abortions, or 13.4% of total documented hospitalizations for abortion between 2007 to 2015. The annual utilisation rate of second-trimester abortion remained constant, between 0.5 to 0.6 per 1000 women aged 15-44 years. Women living in highly marginalised municipalities had 1.43 higher odds of utilising abortions services in their second versus their first trimester, when compared with women in municipalities with low marginalisation (95% CI 1.18 to 1.73). Living in a state with a health or fetal anomaly exception to abortion restrictions was not associated with higher utilisation of second-trimester abortion services., Conclusions: Our results suggest there is a need for all types of second-trimester abortion services in Mexico. To improve health outcomes for Mexican women, especially the most vulnerable, access to safe second-trimester abortion services must be ensured through the implementation of current legal exceptions and renewed attention to the training of healthcare providers., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.