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The COVID-19 pandemic abruptly disrupted the provision of sexual and reproductive health care in the United States.We conducted interviews with family planning clinic staff at 55 health care facilities in Arizona, Iowa, and Wisconsin in late 2020 and early 2021. We asked respondents about the challenges they faced and ways they adapted their service provision as a result of the pandemic. We conducted content and thematic analyses of the interview transcripts using an inductively developed qualitative coding scheme.Family planning clinics and providers made a variety of changes to their clinic operations and service delivery. The three major areas of change for these facilities were implementation of COVID-19 safety procedures, shifting service delivery and staffing to meet patient needs, and the rapid uptake and expansion of telehealth.While providers faced many challenges, they also described opportunities to innovate and rethink standard of care protocols that may continue to shape sexual and reproductive health care even after the pandemic abates.

Background Young Ghanaian women experience high rates of unmet need for contraception and unintended pregnancy, and face unique barriers to accessing sexual and reproductive health services. This study provides a comprehensive national analysis of young women’s contraceptive and abortion practices and needs. Methods In 2018, we conducted a nationally representative survey of women aged 15–49, including 1039 women aged 15–24. We used descriptive statistics, multivariable logistic and multinomial regression to compare young versus older (25–49 year-old) women’s preferred contraceptive attributes, reasons for discontinuing contraception, quality of counseling, use of Primolut N-tablet, method choice correlates, and friends’ and partners’ influence. We also examined youth’s self-reported abortion incidence, abortion methods, post-abortion care, and barriers to safe abortion. Results Among Ghanaian 15–24 year-olds who had ever had sex, one-third (32%) were using contraception. Compared to older women, they had higher desires to avoid pregnancy, lower ever use of contraception, more intermittent sexual activity, and were more likely to report pregnancies as unintended and to have recently ended a pregnancy. Young contraceptors most commonly used condoms (22%), injectables (21%), withdrawal (20%) or implants (20%); and were more likely than older women to use condoms, withdrawal, emergency contraception, and N-tablet. They valued methods for effectiveness (70%), no risk of harming health (31%) nor future fertility (26%), ease of use (20%), and no effect on menstruation (19%). Infrequent sex accounted for over half of youth contraceptive discontinuation. Relative to older women, young women’s social networks were more influential on contraceptive use. The annual self-reported abortion rate among young women was 30 per thousand. Over half of young women used abortion methods obtained from non-formal providers. Among the third of young women who experienced abortion complications, 40% did not access treatment. Conclusions Young people’s intermittent sexual activity, desire for methods that do not harm their health, access barriers and provider bias, likely contribute to their greater use of coital-dependent methods. Providers should be equipped to provide confidential, non-discriminatory counseling addressing concerns about infertility, side effects and alternative methods. Use of social networks can be leveraged to educate around issues like safe abortion and correct use of N-tablet., Plain English summary Young Ghanaian women can experience difficulties accessing sexual and reproductive health services, and many are not using contraception despite wanting to avoid pregnancy. To better understand their needs, we describe their preferences and behaviors around contraception and abortion. We surveyed a nationally representative sample of women aged 15–49, and compared young (15–24) versus older (25–49) women’s contraceptive preferences, reasons for stopping contraception, quality of counseling, friends’ and partners’ influence on contraceptive use, and use of abortion. One-third of 15–24 year-olds who ever had sex were using contraception. Compared to older women, young women’s pregnancies were more likely to be unintended and to end in abortion. Young women most commonly used condoms, injectables, withdrawal or implants; and were more likely than older women to use condoms, withdrawal, emergency contraception, and Primolut N-tablet. They preferred methods that were effective, did not harm their health or future fertility, were easy to use, and did not disrupt their menstrual cycle. Over half of young women who stopped contraception did so because they were not having sex regularly. Friends had more influence on contraceptive use among young women than older women. Each year on average, there were 30 abortions per 1000 young women. Over half of young women who had abortions used methods from non-formal providers, and 40% of those who had complications did not get treated. Providers should be equipped to provide confidential, non-discriminatory counseling about contraceptive side effects and options. Social networks can be used to educate women about safe abortion.

Objective To understand the barriers and facilitators of hormonal contraceptive use among Ghanaian women, in order to help improve contraceptive counseling and reduce the high rates of unintended pregnancy. Study design We conducted a nationally representative community-based survey of 4143 women aged 15-49 in 2018, and used descriptive statistics and logistic regression to examine correlates of current hormonal method use, preferred method attributes and their association with method choice, and the role of side effects in hormonal method discontinuation. Results Hormonal method use (vs. contraceptive non-use) was associated with younger age, higher parity and education, but not with union status, wealth or residence. Preferences for key method attributes were associated with choosing particular methods. Most valued attributes were effectiveness at preventing pregnancy, and low risks of harming health and future fertility. These last 2 concerns are echoed in the second most common reason for discontinuation (health concerns). While menstrual changes were a common concern, leading some respondents to discontinue hormonal contraceptives, many were willing to endure these effects. In contrast, having experienced long-term health issues as a perceived result of hormonal method use more than halved the odds of current use. Contraceptive counseling on menstrual changes, other side effects, and impacts on future fertility had not been universally provided. Conclusions Ghanaian women value hormonal methods for their effectiveness against pregnancy. However, concerns about side effects (particularly bleeding changes), future fertility impairment, and long-term health issues led some women to discontinue hormonal methods. Counseling on these issues was reportedly inadequate. Implications Identifying barriers to, and facilitators of, hormonal contraceptive use, as well as method attributes important to Ghanaian women, can help to better tailor contraceptive counseling to individual needs, in order to ensure that all women can access the method that suits them best, and decide whether and how to manage side effects, switch methods or discontinue.

IntroductionInduced abortion is legally permitted in Ghana under specific conditions, but access to services that meet guidelines approved by government is limited. As part of a larger project comparing five methodologies to estimate abortion incidence, we implemented an indirect estimation approach: the Abortion Incidence Complications Methodology (AICM), to understand the incidence of abortion in Ghana in 2017.MethodsWe drew a nationally representative, two-stage, stratified sample of health facilities. We used information from 539 responding facilities to estimate treated complications stemming from illegal induced abortions, and to estimate the number of legal abortions provided. We used information from 146 knowledgeable informants to generate zonal multipliers representing the inverse of the proportion of illegal induced abortions treated for complications in facilities in Ghana’s three ecological zones. We applied multipliers to estimates of treated complications from illegal abortions, and added legal abortions to obtain an annual estimate of all induced abortions.ResultsThe AICM approach suggests that approximately 200 000 abortions occurred in Ghana in 2017, corresponding to a national abortion rate of 26.8 (95% CI 21.7 to 31.9) per 1000 women 15–49. Abortion rates were lowest in the Northern zone (18.6) and highest in the Middle zone (30.4). Of all abortions, 71% were illegal.ConclusionDespite Ghana’s relatively liberal abortion law and efforts to expand access to safe abortion services, illegal induced abortion appears common. A concurrently published paper compares the AICM-derived estimates presented in this paper to those from other methodological approaches.

Objective To compare the effectiveness of outpatient medical abortion with mifepristone 200 mg and two misoprostol 800 mcg doses at 64–70 and 71–77 days of gestation. Study design We conducted a retrospective chart review of medical abortion outcomes among clients with 64–77 day gestations at a Mexico City public clinic between February 2014 and November 2016 who took mifepristone 200 mg followed 24–48 h later by two doses of misoprostol 800 mcg four hours apart (first dose buccally, second dose sublingually). The primary outcome was successful medical abortion, defined as pregnancy expulsion without surgical intervention. We also assessed additional management and visits to other facilities. We compared outcomes by gestational age (64–70 vs 71–77 days). Results Of 602 charts reviewed, we analyzed 232 and 218 in the respective groups for effectiveness; nearly 25% of clients were lost to follow up. Treatment success occurred in 231 (99.6%, 95% CI 97.6–100%) clients at 64–70 days and 213 (97.7%, 95% CI 94.7–99.3%) clients at 71–77 days (p = 0.11). Ongoing pregnancy occurred in 1 (0.4%, 95% CI 0–2.4%) and 3 (1.4%, 95% CI 0.3–4.0%) clients, respectively (p = 0.36). Two charts from the 71–77 days group documented visits to other facilities: one bleeding concern prior to scheduled follow up and a hemorrhage during an aspiration intervention. Conclusions Regimen effectiveness was high at 64–70 and 71–77 days among clients who attended follow up. However, with 25% attrition, it is difficult to draw definitive conclusions about effectiveness and associated safety. Implications Mifepristone 200 mg followed by two doses of misoprostol 800 mcg four hours apart is a promising medical abortion regimen to improve efficacy in pregnancies from 64–77 days of gestation as compared to regimens with an initial single misoprostol dose. Prospective research is recommended to achieve more robust efficacy estimates.

Objectives To evaluate the safety, feasibility, and acceptability of a direct-to-patient telemedicine service that enabled people to obtain medical abortion without visiting an abortion provider in person. Study design We offered the service in five states. Each participant had a videoconference with a study clinician and had pre-treatment laboratory tests and ultrasound at facilities of her choice. If the participant was eligible for medical abortion, the clinician sent a package containing mifepristone, misoprostol, and instructions to her by mail. After taking the medications, the participant obtained follow-up tests and had a follow-up consultation with the clinician by telephone or videoconference to evaluate abortion completeness. The analysis was descriptive. Results Over 32 months, we conducted 433 study screenings and shipped 248 packages. The median interval between screening and mailing was 7 days (91st percentile 17 days), and no participant took the mifepristone at ≫71 days of gestation. We ascertained abortion outcomes of 190/248 package recipients (77%): 177/190 (93%) had complete abortion without a procedure. Of the 217/248 package recipients who provided meaningful follow-up data (88%), one was hospitalized for postoperative seizure and another for excessive bleeding, and 27 had other unscheduled clinical encounters, 12 of which resulted in no treatment. A total of 159/248 participants who received packages (64%) completed satisfaction questionnaires at study exit; all were satisfied with the service. Conclusions This direct-to-patient telemedicine abortion service was safe, effective, efficient, and satisfactory. The model has the potential to increase abortion access by enhancing the reach of providers and by offering people a new option for obtaining care conveniently and privately. Implications Provision of medical abortion by direct-to-patient telemedicine and mail has the potential to increase abortion access by increasing the reach of providers and by offering people the option of obtaining abortion care without an in-person visit to an abortion provider.