Archive for the ‘Latest Research’ Category

An Interview with Dr. Abigail Aiken – Part 3

Tuesday, January 16th, 2018

Abigail Aiken trained in clinical medicine at the University of Cambridge, before completing an MPH at Harvard School of Public Health, a PhD in public policy at the University of Texas at Austin, and a post-doc at the Office of Population Research at Princeton. She is now assistant professor at the LBJ School of Public Affairs at the University of Texas at Austin. Aiken is a new associate editor of BMJ SRH.

 

Kate Womersley, BMJ SRH’s social media editor, caught up with Aiken to hear about the current political challenges to the field, Aiken’s upbringing in Northern Ireland and her vision for research in sexual and reproductive health that speaks to the public.

**Read part 1 of the interview here**

**Read part 2 of the interview here**

I was struck by one of your recent papers that questions the difference between an ‘unintended’ pregnancy and an ‘undesired’ pregnancy. I was hoping you could talk more about that. 

That paper was motivated by a qualitative study we did here in Texas examining a persistent difficulty that you see in the quantitative data on pregnancy intentions. Even though a woman might classify a pregnancy as ‘unintended’, she still might say that she is very happy about it. This sounds likes an incongruent or discordant situation – why would you be happy about a pregnancy you didn’t intend? But what we found by talking to women in a series of in-depth interviews is that for many people, pregnancy intentions are not a dichotomy between ‘intended’ and ‘unintended’. They are not first and foremost a timing-based concept. People don’t often think “Now is exactly the right time for me so I’m going to plan out conception.” Some would say there is never a good time for them. Really what women identified as most important, and what they based their feelings on was much more about the life impacts: am I in a place right now where I can feel good about this? Does the idea of a child make me feel happy? So even though someone might not have specifically planned or intended a pregnancy, and in that sense they would classify it as “unintended”, it might still be greeted with happiness, and therefore still be “desired”.

One major reason why that distinction between “unintended” and “undesired” is important is that people have been trying for a long time to look at the relationship between unintended pregnancy and negative health outcomes. That evidence has been very mixed – either inconclusive or weak. Our hypothesis is that part of that the lack of a strong association may be because there is conflation between those pregnancies that weren’t planned and weren’t quite intended or expected but actually turned out to be a really positive, life-affirming experience, with those that were truly a seriously negative life event for somebody.

If deep interviews give us better insight into the distinction between planning pregnancy and a woman’s feelings about pregnancy, how do you think such research could shape policy to better serve women?

A lot of public health policy is focused on reducing unintended pregnancy – both in the U.S. and the U.K. This is despite the fact that there isn’t actually strong evidence that unintended pregnancy (as it is currently measured) leads to adverse health outcomes. That approach puts a strong focus on pregnancy planning and the idea that everyone needs to plan exactly when to get pregnant and be in the ‘right life circumstances’ for a child.

In real life, though, we know that for many women, planning a pregnancy is not an idea that resonates or simply isn’t realistic in the context of their lives. As we develop these new measures and try to focus less on translating timing-based intentions to strict plans, and more on trying to help women prevent those pregnancies that they really don’t want, this would allow a reproductive-rights and reproductive justice orientated approach.

We want people to be able to have the families and lives they desire, and really, it’s for them to decide what’s best in terms of their reproductive goals. We can facilitate fulfillment of those goals through policies that recognize the plurality of individual desires and circumstances.

Do researchers choose questions that are easy to ask rather than perhaps asking the right question to start with?

I think so. What we really need to find, which we have been unsuccessful with so far but hope to be successful with in the future – is a measure that picks up the spectrum of feelings and attitudes people have with respect to a potential pregnancy, yet is simple enough to be asked in the context of a large survey or a 15-minute consultation. The biggest challenge is how to take the complex, interesting information from in-depth interviews, and operationalize it into a question that can be asked easily and quickly.

What have you learned from running this research – about designing and leading such projects?

The first important thing is to think carefully about why you are doing qualitative work. There are generally two reasons: One is that you find a really interesting pattern or quirk in your quantitative data, and you want to be able to say why this is so. For example, we know from large data sets that some people are happy about pregnancies they didn’t intend, but the number we have in front of us – the proportion of people who said that – can’t tell us why they said it.

The second reason is that you might be looking at an area that’s completely new. We want to know how women in the US are accessing abortion online, but we don’t yet know anything about that. We have no large-scale quantitative data to tell us about it. So we may start with a qualitative project to try and figure out what the landscape looks like, what’s even going on before we start trying to design a survey or another method for getting at the question on a large scale.

In terms of how you do it, I think it’s really important to have a research team that’s well educated in the issue you’re studying and the contexts of peoples’ lives. If researchers can meet participants in person, that’s even better as you can see where people live and what life is like for them. To have really good interviewers who are comfortable exploring very personal issues – who can put people at ease, and empathize even if they have never been through the experience themselves – is one of the most important elements of qualitative research.

Did you get a sense from these interviews that women didn’t have opportunities to talk about these feelings with healthcare professionals?

That’s sometimes the case. Women at the end interviews would say, “Gosh, it was so nice just to be able to talk about that, or to know that someone cared what I thought or had to say about that.” But I have an hour or more to sit and listen in an interview, whereas doctors and other professionals don’t have that luxury. If you’re talking to someone about contraceptive options, you want to talk about their pregnancy intentions and attitudes to pregnancy all in a couple of minutes. One of the things I’ve been working on with some clinicians is to develop key questions to use in these conversation to overcome the limitations of a clinical encounter.

Could you share some of the ways you might ask those questions?

A lot of the conversations about contraception start of with, “Do you plan to have children at any time in the future and, if so, how many and when? And what method of contraception are you going to use to make sure you don’t get pregnant before you plan to?” It’s introduced as a strict planning paradigm. The assumption is, every pregnancy must be planned.

The reality, however, is that a lot of women don’t plan. It’s just not meaningful for them. In their lives, they’ve never known any woman who’s planned a pregnancy, and it’s not something they may feel empowered to do. Beginning a conversation with, “Right, when do you want to get pregnant, and what are you going to do in the meantime to ensure you don’t?” isn’t really resonating with them.

Instead, we’ve thought about beginning a conversation with, “Do you think you would like to have (more) children some day?” Just something open like that, to avoid putting pressure on them to get their ducks in a row. It sounds very obvious but I think as clinicians we are trained to optimize a patient’s health, and even if we go about it in a rigid way, we’re always looking for a good outcome. It’s important to realize that so much of what you get from the encounter with the patient happens when you allow them to see you’re interested in hearing what they have to say, that you’re open to their view of the world. “What do you think about having children in the future?” is a lot easier to answer than “When are you having children and what are you doing in the meantime to prevent it?”

Some people feel stigmatized and embarrassed to say, “I’m not in a ‘good’ place where it’s perfect for me to have a kid right now, but I might want one anyway.” Just because someone doesn’t tell you that, doesn’t mean they’re not going to think it. It’s really important to take an open-minded approach.

We’ve been talking about women who do actually get to see a health professional. Your work on contraception and access in Texas shows that with budget cuts for reproductive care (you were looking at women postpartum) the numbers of women receiving LARC is decreasing. Does it look like the situation in Texas at last might be changing for the better?

We have two competing goals in Texas. On the one hand the national ‘Healthy People 2020’ goal is to reduce unintended pregnancy, the prevalence of which is even higher in Texas than the national average. On the other hand, the goal of some legislators is to restrict women’s access to contraception as much as possible. The two things clearly conflict.

The main problem people have in accessing LARC methods is the very high upfront costs. When the family planning budget was cut by two thirds in Texas in 2011, many clinics that wanted to be able to serve the same number of women had to cut LARC methods or severely reduce what they could offer. LARCs are the most expensive method of contraception for providers in clinics to buy, as well as for women to access up front. Since then, there has definitely been a public conversations and a groundswell of advocacy. Clinicians became involved too, saying that we have to be able to offer people the most effective contraceptive methods. Not everyone is going to want them, but we have to realize it’s not acceptable for these options not to be available due to cost. As a result, some public funding for family planning that was cut was reinstated in the 2013 legislative budget. However, the damage had already been done. The reinstated money did not necessarily go back to the clinics serving the population that needs them most.

Texas is still lagging behind many other states when it comes to contraceptive access. The way the legislature goes about providing family planning services is flawed because any provider who offers abortions is still excluded from receiving state funds. The legislature are still trying to make sure that people are diverted away from Planned Parenthood, even if the person wouldn’t be going there for anything other than contraception, a Pap smear or an STI test.

Even though there is lots of support for access to IUDs and implants, women have to be able to get to providers nearby, which are accessible and acceptable to them. Many women have been going to Planned Parenthood for years as their trusted provider in their local area. There is a real disconnect when legislators say “Yes, we do want these women to have access to LARC methods, but we don’t want to them have access via their regular provider.” We still have a lot of work to do try to figure out how to get around that problem.

What role do you think clinicians have in advocating for their patients?

A huge role. Clinicians have a key part to play in ensuring their patients have access to the full range of contraceptive options. Evidence from Texas indicates that some clinicians still have their own opinions about what kind of methods women should use, or they’re a bit behind on the evidence. For example, some clinicians are late getting on board with the recommendations from ACOG that it’s absolutely fine to give IUDs to nulliparous women. It used to be thought you could only give an IUD to women who have had children, because the cervix of a nulliparous women would make placement too painful and difficult. The best evidence shows this isn’t the case. By being up-to-date and listening to patients’ needs and preferences, providers in Texas and the whole of the USA really can do a lot for the patients they serve by helping to remove barriers to contraceptive access.

What is on the horizon for your research in 2018?

The most exciting thing coming up is a project we’ve been working on to extend work on the safety and effectiveness of medical abortion in Ireland and Northern Ireland through Women on Web regarding how successful these abortions are and what the complication rates looks like. What the first study wasn’t able to speak to, though, is what exactly the experience of this process is like for women.

We are coming to the end of a comparative study that looks at Irish and Northern Irish women who have travelled, and women who have used pills online. We really wanted to get to the heart of how a woman makes that decision – is it all about the resources she has? Or might there be other reasons people prefer one method rather than the other? Also, what are the unmet needs people have as they go through either process?

This research is coming at an opportune time, because as we look forward to 2018 and the referendum that the Irish people have been promised on the Eighth Amendment––which guarantees fetuses equal rights to pregnant women in Ireland––we really need peer-reviewed scientific evidence that illuminates what the decision-making process and experience is like for women. We are trying to finish in time to inform the conversation before the referendum.

We are hoping the research will do two things. Firstly, that those in the Irish parliament making these decisions will take it into consideration when they lay out the terms of the referendum. And second, we hope it will inform the public conversation.

It’s clear you work hard to make your research relevant to the scientific community, as well as distilling information to the media and suggesting tweetable messages. Do you have advice to other researchers about how to do this well?

It is so important to do that. The discipline of public policy has impressed that upon me. The incentives in academia can be quite perverse. We are expected to publish – “publish or perish” is what they say, and sometimes it’s tempting to get stuck in that race to get publications out. But if you’re working on issues that are relevant to current policy conversations, you might be faced with a decision about whether your results could inform a public conversation that’s happening right now. Are you going to wait for the publishing process in an academic journal, or will you go ahead and release those results because you know they could have an impact on the real world? I think that’s one thing academic publishing could really help with: understanding that the work academics do is useful in the policy world and public conversation. It would be great to have ways through journals to expedite research which has power to inform policy-making to make sure it gets out there in time.

My advice for others would be that when you have evidence and expertise in an area, sharing that knowledge beyond your scholarly colleagues and to look beyond the ivory tower of the academic field is so important. If you’re able to communicate your research, to testify to a legislature or write an op-ed, don’t be afraid to. It really is one of the most rewarding things you can do as a scholar.

***

An Interview with Dr. Abigail Aiken – Part 2

Monday, January 15th, 2018

Abigail Aiken trained in clinical medicine at the University of Cambridge, before completing an MPH at Harvard School of Public Health, a PhD in public policy at the University of Texas at Austin, and a post-doc at the Office of Population Research at Princeton. She is now assistant professor at the LBJ School of Public Affairs at the University of Texas at Austin. Aiken is a new associate editor of BMJ SRH.

 

 

Kate Womersley, BMJ SRH’s social media editor, caught up with Aiken to hear about the current political challenges to the field, Aiken’s upbringing in Northern Ireland and her vision for research in sexual and reproductive health that speaks to the public.

**Read part 1 of the interview here**

 

How do you see the field of sexual and reproductive health today in 2018?

Since I’ve been in the field, ten years now, it’s been really exciting to see changes. We have many more disciplines engaged. Many clinicians have been interested in these issues for a long time, and have been able to address them in clinical practice as well as through research. But now we have people in sociology, public affairs, and public health – all working together. I really like to see interdisciplinary collaboration. We also have the reproductive justice element which has been around for a long time, but only made it’s way into mainstream clinical and sociological conversations of late. Reproductive justice is particularly important because it enables us to understand who really loses out and suffers when laws restricting access to contraception and abortion are allowed to go unchecked.

We have become a lot richer and more visible as a field, and will continue to do so with the arrival of new journals like BMJ SRH, to make sure that the research really gets out there to people and is expressed in a way that allows the public to understand the messages. There is usually a barrier: “Oh that’s academic research, , it’s going to be for the doctors.” But the field has realized how important it is to connect to people’s personal experiences in the research, as well as numbers. You need to be able to make generalizations, which only robust quantitative studies can provide, but you also need studies that people can really connect with so they can see an issue in terms of real-life experiences.

One of the most important developments in our field is partnerships that have developed between research and practice. You see many researchers working closely with healthcare professionals, public health organizations, and policy think tanks to answer the most pressing questions that affect real-life access to and quality of reproductive healthcare.

Do you feel that the questions and challenges are particularly urgent right now in our political present?

If you look at the historical trajectory – the U.S. and Ireland are the contexts I know best – there is definitely an urgency right now. In the US, we have seen challenges to abortion access ever since 1973 when Roe v. Wade was handed down. But challenges have become much more intense. Also the public conversation has really shifted. Back when the Hyde amendment stopped Medicaid funding for abortion, which came in 1976 three years after Roe v. Wade, it really compromised access for women of low-income at the time. It’s not as though this all started happening yesterday. But if you look at the rate of new pieces of restrictive legislation being enacted, that has increased dramatically recently. I think part of the reasons it’s so important we talk about this and produce research to engage with this question right now, is that we have an opening in the public attention cycle. That’s something people in public policy talk about––it means that there is a window to really impact the current trajectory of policy.

The case for urgency is also there in Ireland as we see a possible referendum approaching on the Eighth Amendment. Also in Northern Ireland, where we see MPs like Stella Creasy’s campaign for funding of abortion on the NHS for women who travel to England, you have a window when people pay attention and a difference can be made in public policy. This window is something as academics we often don’t think about. But if you’re engaged in public affairs you know that you have an opportunity to make a difference by bringing new evidence to the debate, and you have to try and respond to that.

How did your upbringing in Northern Ireland shape your research interests?

I was living in Northern Ireland at a time when there was, for example, no Women on Web. There was no way to access abortion care. There was very little taught in schools about sex education, about what sex was, or about contraception. I had no idea how I would get contraception if I needed it. My mum was very much a person who was supportive of reproductive rights, and was very progressive for her time (1940s) and for where she was living. But I remember her saying to me as a teenager, “You’ll do many things, but please, whatever you do, don’t get pregnant. That’s one thing I can’t help you with. We would have to travel, we wouldn’t have the resources, we wouldn’t be able to do that without telling people.”

I grew up in an environment where I was very aware of the fact that being female and being able to get pregnant put you in a situation that was different from men. I have always been very influenced by that unfairness. I felt from the start that this was an issue I was interested in tackling, trying to understand why things are this way, and what we can do about it.

For those who aren’t well versed in changes since the 1980s, and the NHS’ recent decision to offer terminations to Northern Irish women, could you give a potted history of what’s happened, and what hasn’t?

When the Abortion Act came in 1967 to the rest of the UK, Northern Ireland did have a chance to enact it, but they decided not to. They said, “We’re not going to touch that.” It was with the dawn of organizations like Women on Web sailing a boat to Ireland, and working with the activist groups on the ground in both the South and the North, that suddenly an online option was available to people. Others started saying, “We’re going to talk about this.” That’s been almost unbelievable change.

When I was living there in the 1980s, 1990s and early 2000’s, nobody would ever have talked about abortion. It wasn’t something you saw in the newspapers. It was maybe talked about only in the most closed groups, and only then in a very negative and sad way.

The biggest change we have seen has not really been a policy or political change; it’s been the groundswell of activism and a movement of women in Northern Ireland who are now speaking out about the fact that abortion is happening and can’t be ignored anymore. We don’t have the same rights as women in the rest of the U.K., even though we’re a part of it. That has led to the only actual policy change in years in Northern Ireland: that women who travel will hopefully be able to get their procedure covered by the NHS, similar to a woman who lives in England who is NHS-eligible.

But how that is actually going to play out is not yet clear. Although the policy is there in theory – it’s not been stated how those abortions are going to be commissioned and paid for. You still have the issue that travel needs to be paid for, which has not changed under the new rules.

How has your expertise in the Northern Ireland situation prepared you for your research in America? Are there interesting continuities and differences?

There really are. It’s very interesting to me because when I first came to the U.S. in 2009, the situation regarding abortion or any other reproductive healthcare was not as bad as it is now. Over the past few years it has become obvious to me that if you look at a woman in Northern Ireland and a woman in Texas (where I’m sitting at the moment), their options for accessing an abortion if they haven’t got many resources, money and social support, are really not that different.

Although you’ve got two very different legal situations – in the United States abortion is a legally-protected right, whereas in Northern Ireland it is not. But still women experiencing an unwanted pregnancy have strikingly similar options: you can either continue with that unwanted pregnancy, or you can travel a long way at high cost because with the closure of so many clinics and requirements for multiple appointments under new laws, you need to have the money and resources to actually get there and pay for the care. In Northern Ireland, you’re looking at a plane or ferry ride. In Texas, it’s at a very long drive – possibly hundreds of miles – or even a plane if you’re going out of state.

More recently, you’ve also got the options online. The biggest different is that in Northern Ireland there is Women on Web which is able to provide a genuine, safe, supported service to women. In the U.S. if your only option is to look online, it’s very unclear what you’re going to get. Online pharmacies may not be well-regulated – they are a bit of an unknown quantity.

In principle, you’ve got two very different legal situations, but the actual practical realities for women who don’t have many resources are very similar.

It’s surprising that in Northern Ireland, with the safety built into Women on Web, women may be in a better position to access a safe termination compared to women in the US.

I’ve often thought that myself. It was part of what motivated my paper that was recently published about the safety and effectiveness of online abortion using telemedicine, using Women on Web data. We know many women are doing their own abortions using pills online, and we want to know if it’s safe and effective. I was sitting in America thinking, “Gosh, women here do not have that option, and I would love to be able to understand what’s not available to them by virtue of not having that service.” If that service were available, could we say it would potentially be safe and effective? Could we say it is a public health imperative to be able to provide them with a service like that?

For people who aren’t familiar with Women on Web, how do they ensure that safety and efficacy we’ve been talking about. 

There are a number of ways in which they do that. Of course the service is still completely remote and online – you don’t someone face-to-face. You have a consultation with a doctor online, and medicine is prescribed to you by that doctor. What’s different about it is that you have to fill in your own online consultation form, which is entirely reliant on self-report. They trust women to say, “Here is my medical history and my gestational age, and this is an accurate report.”

One of the biggest worries people have about the service is that women might be at a more advanced gestational age than they say they are, and this could lead to problems. It was one of the things we were able to look at in the paper. We found that the service does have very high levels of efficacy, comparable to what you would see with the same medications in the clinic setting, as well as very low rates of complications. The first reason this might be so is that the instructions are very clear about how to take the medicine, what to look out for, and what the red flags are for serious complications. There is also advice about where do you go, what to do if complications do happen to you. Women on web also offer almost real-time support – you’re emailing back and forth with them before, during and after the abortion so that you’re able to get your questions answered.

Women are reassured the medications really are mifepristone and misoprostol in the correct doses, packaged in a way that’s stable, so they won’t degrade and becoming ineffective in transit.

These three things: clear instructions, genuine medications and a really good source of support with access to quick information when you need it, makes Women on Web different to just an online pharmacy.

Might online services be a preferable way to deliver terminations, even in a country like England where the NHS provides terminations in hospital?

This is something I hope to be able to describe in upcoming research in which we’ve been asking women about whether they would actually prefer this kind of model. It’s a very individual thing and a big challenge in abortion care in the future: how we can individualize care to suit the needs and requirements of every woman?

There are some women who are always going to want to go to a hospital – they just feel better about being in a medical setting and they get reassurance from that. There will also be people who are over a gestational limit and may need to go in for a surgical abortion. But for many women in Britain as well as Northern Ireland, there are many barriers to accessing clinical care that aren’t necessarily thought about. It may not be a financial issue if the procedure is covered by the NHS, but there are still issues of transport, distance, finding childcare or getting time off work. There are other women who want the independence of doing an abortion at home where they feel comfortable and in control. I often think about home birth in relation to this. There are some women who are low risk, and are just more comfortable out of a medicalized environment.

I think that telemedicine is the future of abortion care under a certain gestational age. The legal barriers in many places are still really high. It would take both a political change and a medical culture change to really allow that to take off as a model and realize its full potential.

**Part 3 of the interview will be posted later this week.**

An Interview with Dr. Abigail Aiken – Part 1

Friday, January 12th, 2018

Abigail Aiken trained in clinical medicine at the University of Cambridge, before completing an MPH at Harvard School of Public Health, a PhD in public policy at the University of Texas at Austin, and a post-doc at the Office of Population Research at Princeton. She is now assistant professor at the LBJ School of Public Affairs at the University of Texas at Austin. Aiken is a new associate editor of BMJ SRH.

 

 

Aiken’s current research focuses on three key areas:

1) Abortion outside the formal healthcare setting
2)
Unintended pregnancy
3)
Contraceptive desires and access

Kate Womersley, BMJ SRH’s social media editor, caught up with Aiken to hear about the current political challenges to the field, Aiken’s upbringing in Northern Ireland and her vision for research in sexual and reproductive health that speaks to the public.

 

How would you describe what you do?

Given my background in clinical medicine and now as an academic at a policy school, I’m very motivated to evaluate what current policy in sexual and reproductive health looks like, and to inform that policy with the best available evidence. No matter whether you’re in the U.S. (in Texas where I am now), in the UK, Northern Ireland or the Republic of Ireland, reproductive health policies have serious impacts on people’s lives.

Part of the problem we’ve had historically is that since sexual and reproductive health is a relatively new discipline in terms of research – there is often not a lot of good evidence underlying policy at the legislative level or sometimes even the clinical level. As someone who has made the transition from talking with individuals as a clinician to now looking at reproductive health at the population level, I’ve never forgotten those links.

For example, current clinical guidance in the UK (excluding Northern Ireland, of course) requires women accessing medical abortion to take the first tablet, mifepristone, in the presence of a medical professional and then return to the clinic 24-48 hours later to take the second tablets, misoprostol. Not only is this protocol out-of-date in terms of best scientific evidence (which indicates that women can safely and successfully take misoprostol and also mifepristone at home), if you actually listen to what women say about their experience, you quickly find that they don’t like having to travel from the clinic or hospital. They worry that they’re going to start bleeding or must manage cramping and nausea in the car or on public transport on the way home.

I’m interested in how we can bring not only the best statistical data but also the voice of the individual in a scientifically sound way to influence public policy on sexual and reproductive health.

Do you think that people with a background like yours – an MD with a public health degree – are well placed to answer pressing questions in the field?

I really do. I feel the longer I’m in this field, the more I learn. Reproductive health is such an interdisciplinary subject. You’ve got the clinical part, the biological science part, and then the sociological part. And then you also have to understand institutions, political systems and policies. As we move into a brand of academics where people are encouraged to collaborate across disciplines, I think it’s helping a lot. Some of the most exciting work produced today has a clinical question driving it, but you may have a data scientist, a sociologist and someone in public affairs all collaborating together – that’s when you really get those exciting insights. An example of this that’s close to home is the work my sister, Dr. Catherine Aiken, who is maternal fetal medicine specialist at the University of Cambridge, and my husband, Dr. James Scott, who is a statistician at the University of Texas at Austin, have done together predicting successful instrumental delivery in prolonged second stage of labor. The research originated from my sister’s desire to develop evidence-based policy to inform the decision of whether to attempt an instrumental delivery in an obstructed labor situation versus proceeding directly to emergency Cesarean section. The study was used to inform the ACOG Guidelines on Operative Vaginal Delivery, Practice Bulletin 154.

Are there are assumptions informing reproductive health policy that may not be rooted in either evidence or women’s experience?

Yes, absolutely. If you look at a country like Ireland or Northern Ireland, the kind of laws you have governing very basic aspects of reproductive health (such as abortion) date from the 1860s. Science, our cultural and social norms have moved on a lot since then. Part of the reason things haven’t changed is definitely due to political will – a public conversation needs to be had, with all the facts available, rather than simply accepting law based on the opinions of a handful of people in power. Part of that conversation rests on being able to provide good evidence about why a law should be different, which itself relies on the experience of individuals who are actually impacted by the law, as well as the best biological and clinical knowledge we have.

Whereas in the United States the law is very different––abortion is a legally protected right––but people are seeking to put barriers and restrictions in the way of women seeking abortion services. Many recently enacted laws have required doctors to give women medically inaccurate and biased information about abortion, including unsupported claims that abortion increases the risk of breast cancer. It’s really important to be able to say, “Let’s question why we are putting these laws in place. Is there actually any evidence that these laws will benefit someone’s health, or someone’s bodily autonomy, or someone’s ability to exercise their own reproductive rights?”

What do you see to be the primary barriers preventing good evidence from informing policy?

Firstly, the evidence must be generated. It’s very exciting to see an emerging group of scholars who are committed to saying “Ok, we do need to be interested in what’s going on in the public sphere. We have to be not just scientists, but scientists who are willing and able to bring our expertise into the public dialogue, into those conversations politicians are having in legislatures, and try to influence that process.” These individuals–– Dr. Angel Foster, Dr. Rebecca Gomperts, and Dr. Dan Grossman spring to mind – work hard to influence the public conversation, to interact with the media and say, “We really want our findings to not only go into the scientific literature and stay there, but we also want the knowledge to be reachable by people outside academia.”

It’s clear these are not just scientific issues, they are also for many people – for better or worse – moral issues. Even though many of us have particular ideas and particular beliefs we hold dear, we have to be cognizant that evidence can get lost in a conversation when people have very strong emotional reactions. We have to think carefully about how to best use our evidence to inform those conversations, and to acknowledge but not necessarily agree with others’ beliefs, even when that can be difficult.

**Parts 2 and 3 of the interview will be posted next week.**

User Controlled Implantable Contraception: Baby, You Can Turn Me On

Tuesday, January 26th, 2016

Over the course of this month, there has been quite a bit of press attention given to the Bimek SLV, a device purporting to be the first attempt to achieve user-reversible, surgical, male contraception.

Men have, for a considerable amount of time, been left behind in the field of contraception. Women have both hormonal and non-hormonal methods of which both short and long acting are available. Men, on the other hand, have the dichotomy of condoms or vasectomy, with no halfway option between instantly reversible and surgical permanence. Unsurprisingly, those who wish permanent contraception sometimes wish to have the procedure reversed, which is not guaranteed to be successful.

On the face of it, the Bimek SLV seems to be a good idea. Implanted into the vas deferens, the device contains an occluding valve, which can be changed from an open to a closed position by the user pressing a switch attached to it. However, there were some worrying gaps in the press reports about the device: what were its success rates so far, for example? It transpires that the device is beginning Phase I trials soon, and that the only person in which the device has been implanted is the inventor himself.

Further review of the product information reveals that so far, no animal testing has been performed for the device at all, and this is revealed as a selling point, so that the device can be used by vegan men. Yet despite the lack of objective evidence, the product literature, and website, contain references to the apparent safety of the device, and that the procedure is “low risk”. It’s easier to find information on investing in the project that it is to find information on trial participation.

Bimek himself is not a medical professional, and has brought the device to preliminary trials under his own steam. He is seeking further funding in order to proceed, hence the attempt to drum up media support. In the age of crowd-funding and peer-to-peer lending, traditional methods of research and development are being bypassed. Perhaps this is of value, and perhaps the drive to implantable technology without animal testing will revolutionise healthcare research as we known it, but given that earlier this week a Phase I trial in France resulted in the death of a participant and the hospitalisation of several others, perhaps Bimek would do well to tone down their claims of safety, in the face of scant supporting evidence.

Ultimately, for the time being, what the Bimek SLV has done well to showcase, is that sensationalist reporting without a full grasp of the facts, remains depressingly popular as a way of communicating new science developments to the masses. Here’s hoping that time, and further research, means that it can prove its claims.

Constructing Information Requests: Making The New Normal

Friday, January 1st, 2016

When we collect information from our patients, we ask, often unthinkingly, for quite a lot of it. Some of it has obvious value to our consultations: how long has it been there, and where does it itch? Some of it has additional use in research, and in auditing our practice. Today, we’re going to take a look at how we ask for some of these basic demographics and what it says about our perception of society, and of our patients’ lives, when we do.

In the UK, we classify infants at birth by many characteristics, and sex is one of those. This is obvious to anyone who has tried to pick a gift, or a card, to congratulate new parents: we, as a society as a whole, treat sex as a dichotomy of male or female. This is referred to as the gender binary. If this were a fundamental truth, it makes collecting information regarding sex to be as simple as checking a box for either, and in turn, stored in a binary form digitally; however, the truth is more complex. Many countries allow for the legal recognition of a third gender, and this is a state welcomed by people who do not identify with either, or with aspects of both. This may due to an intersex condition diagnosed at birth, or a subjective lack of affiliation with either sex despite sexual organs and characteristics of one sex. One can argue that the reasons are academic, as it is the end state of requiring an option outside of the gender binary that matters.

For many people, the definition of the word “gender” is roughly interchangeable with “sex”, and both terms are taken to mean the reproductive organs existing within a person and associated secondary sexual characteristics; however, some people and organisations define gender as being the abstract social roles based on sex, and diverging the definition of “sex” to be the definition stated above, pertaining to sexual organs and characteristics. In this post, we’ll be using the latter.

One organisation which collects vast amounts of personal data: Facebook, has come into focus as it demonstrates how to handle information outside of the gender binary in an attempt to sensitively reflect the real life experiences of users; however, as a recent paper reviewing Facebook’s handling of this information shows, the way that Facebook deals with the information regarding sex is not new, but over time has been changed by user pressure. When Facebook began to collect user data on sex, it allowed options for male, female or other and subsequently used this information to provide gender based pronouns describing user activity. Over time, the use of “they” as a gender neutral pronoun created some translation difficulties and was derided as grammatically incorrect, so an attempt was made to force users to choose a pronoun on the basis of sex, and this overrode the original sex identity e.g. if you chose a female pronoun, your choice of “other” was changed to female.

Users self-organised to protest this, driving change by producing guides on amending the source code of the pages to allow reversion to the original “other” state, raising the question why this needed changed in the first place if the choice was not removed from the database itself. Over time, Facebook amended its policy and in 2014, allowed limited use of gender neutral pronouns and a greater range of non-binary identities; although the choice of a gender specific pronoun reverts the stored identity to a binary one.

The multiple options presented when signing up for Facebook with relation to sex is potentially confusing and, whilst presenting many options, remains restrictive if your choice is not offered, raising the question if there is a better way of working when requesting information. Web designer Sarah Dopp, who wrote an open letter to web designers and developers regarding this in 2010, and reminding us that the dangers of the gender binary, and the promotion of it as normal at the expense of all else, marginalises those who already feel marginalised, something that we, as healthcare professionals, should be striving to avoid.

So, the next time we sit down to ask a patient, or client, for their gender, we should take the time to reflect that whilst this may be a single question in a page of several, and perhaps just a tick in a box to us, that for them it may be a huge part of their identity that we are refusing to acknowledge through ignorance, and souring our relationship with them before we start.

For those of us who are doctors, we have benefited from the privilege of a free gender-neutral pronoun as a by-product of completion of a degree. If it’s important to us to use this title as an expression of professional identity, we could at least extend the courtesy to our patients to express, fundamentally, who they are.

Nominations open for the UK Sexual Health Awards 2014

Monday, September 30th, 2013

The UK Sexual Health Awards recognise outstanding work in and around sexual health. If you know of any incredible people, projects, services, campaigns, storyline or article – we want to hear about them.

Whether you’re nominating yourself, the organisation you work for, someone you work with, or something that has been done by someone else; if you think it deserves to be recognised and celebrated – make a nomination now!

There are seven categories open for nomination:

  • Sexual health professional of the year
  • Young person of the year
  • Adult sexual health service/project of the year
  • Young people’s sexual health service/project of the year
  • The Pamela Sheridan sex and relationships education award – recognising good practice in education in schools
  • Sexual health media campaign/storyline of the year
  • Rosemary Goodchild Award for excellence in sexual health journalism.

All shortlisted finalists get a free ticket to the glittering awards dinner and ceremony on Friday 14 March 2014 at 8 Northumberland Avenue – a stunning venue in the centre of London, Trafalgar Square.

Visit the Awards website to find out more or contact awards@brook.org.uk

ESC – 13thCongress and call for applications for project funding

Monday, September 16th, 2013

Mark your calendar:

28 till 31 May 2014
Lisbon, Portugal

First announcement

Check out the first announcement including:

  • programme overview: 8 workshops, 21 congress sessions, 2 debates…
  • abstract submission instructions (deadline 1 December 2013)
  • registration form

Register now

Please find here an overview of the registration fees.
You can now register through the online registration form

General information / Programme overviewCall for abstracts (deadline = 1st December 2013)/ Registration

ESC newsletter

Call for project or course applications

The ESC provides funding to support a project within Europe

The available budget for applications received between 1 August and 31 December 2013 is 30,000 euro. Applications should meet the following minimal conditions:

  • The applicant must be a paid-up ESC member
  • The grant may be used to support an individual, group, institute or organisation with a project related to the aims of the ESC.
  • Examples of projects include: research, audit, review, needs assessment

Deadline for the application period:  31 December 2013

Application Form

 

 

July Journal published as Impact Factor soars to 2.1!

Thursday, June 20th, 2013

The July edition of the Journal is now available online and includes:

Venous thromboembolism and COCs: an ongoing saga

This ongoing controversy recently resulted in the decision of the French authorities to withdraw the combined oral contraceptive (COC) containing ethinylestradiol (EE) and cyproterone acetate (i.e. Diane 35®) from the market. This consensus statement from 26 international experts in contraception concludes that “Both epidemiological data and clinical trials must be taken into account when best practice is defined. Regulatory restrictions of previously registered methods should only be made after careful assessment of all the available evidence”. See page 156

Serum CA125 for ovarian cancer screening

This timely commentary raises questions about the widespread use of screening women with non-specific symptoms by measuring serum CA125 levels, following the publication of the NICE guideline on ovarian cancer in 2012. The authors acknowledge that there are barriers that prevent women with symptoms associated with ovarian cancer from presenting to their general practitioner. However, the authors also point out that this will lead to increased use of CA125 in general practice and raise concerns about how women with raised CA125 in the absence of evidence of any disease should be managed. See page 160

Ovarian cancer symptom awareness and help-seeking behaviour

Ovarian cancer symptom awareness is low in the UK, and varies widely between symptoms. In this study, Low et al. identify variables that may be implicated in a longer time to help-seeking for possible ovarian cancer symptoms, and highlights the need for more in-depth research into the factors related to time to help-seeking in real-world situations. See page 163

Fertility preservation decisions faced by women with breast cancer

This article presents a contemporary summary of fertility preservation techniques available to women of reproductive age with breast cancer. It offers unique insights into the difficult treatment decisions coupled with the difficult fertility preservation treatment decisions that these women face. The article highlights a number of themes that influence the decision-making process for these women. Egg and embryo banking appear to be the fertility preservation treatment of choice. Finally, this work may assist health care commissioners when deciding funding priorities within a health economy such as the NHS in the UK. See page 172

Correlates of unprotected sex in drug-injecting women

This study demonstrates that despite the high risk for HIV acquisition or transmission and unintended pregnancy, condom use among women who inject illicit drugs or who have sexual partners who inject drugs in St Petersburg in Russia is low. Programmes to investigate and improve contraceptive use, including condoms, among this vulnerable group of women are needed and might benefit from addressing alcohol misuse. See page 179

Contraception in a university environment

This is a very simple real-life observational study of a cohort of young, nulliparous women in a university-based general practice choosing and continuing with long-acting reversible contraceptive methods (LARCs) as their first line method of contraception. This article urges the health professional reader to consider offering this ‘fit and forget’ method of contraceptive to our younger population as a matter of routine. See page 186

Impact of UKMEC on CHC prescribing

Briggs et al. have assessed the effect of the UKMEC on prescribing of combined hormonal contraceptives (CHCs). Sadly, although there has been a small decrease in the proportion of higher-risk women being prescribed CHCs, their results suggest that in 2010 7.3% of CHC users had UKMEC Category 3 or 4 risk factors, particularly BMI ≥35 kg/m2. The authors point out that it is likely many of these women were being placed at an unnecessarily high risk of cardiovascular events, given the availability of lower-risk alternatives. See page 190

Financial cost to patients of a suspected ectopic pregnancy

In this article, Unger and colleagues in Edinburgh report on their assessment of an area of patient experience that is not often considered when assessing medical interventions. The financial impact on patients’ lives of the need to seek medical attention can be considerable and may become more significant as economic hardship increases. This article describes a well-conducted questionnaire study on the costs that patients themselves incurred in attending their general practitioners and a hospital clinic with a suspected ectopic pregnancy. The authors argue that such costs need to be factored into decisions regarding the cost-effectiveness of medical procedures. See page 197

Emergency contraception algorithm based on risk assessment

Introduction of a standardised protocol for the provision of emergency contraception (EC) has significantly increased the proportion of women offered an intrauterine device (IUD) as postcoital contraception, particularly in women at high risk of conception. Introduction of ulipristal acetate as an alternative method of EC has resulted in a reduction in the uptake of the emergency IUD. McKay and Gilbert state that this is cause for concern, and further investigation into the reasons behind this decrease in IUD uptake is needed. See page 201

No need for water torture

Cameron and colleagues set out to answer a simple question, namely does a full bladder assist insertion of intrauterine contraception? In the world of assisted conception a full bladder had been shown to aid intrauterine catheter insertion for embryo transfer, but could this knowledge be transferred usefully to the world of contraception? This simple question was answered in a simple and elegant way with a properly constructed and conducted randomised trial, which showed that we needn’t ask our clients requesting IUD/IUS insertion to arrive bursting – a fact for which both they and clinic staff will be duly grateful. See page 207

New monophasic natural estradiol COC

Lee Shulman reviews a new monophasic natural estradiol COC, Zoely®. This COC benefits from the progestogen nomegestrol acetate (NOMAC), which appears to result in good cycle control, with a 24/4 regimen. Since it is monophasic, it also has potential for extended cycle use. The great hope is that natural estradiol COCs will have a lower risk of venous thromboembolism (VTE) than EE-containing pills, but it should be stressed that there is currently no actual evidence for this. Studies are ongoing, but at present these COCs should be treated just like any other from the point of view of VTE. See page 211

Brook/FPA UK Sexual Health Awards 2013

The Journal’s Consumer Correspondent writes about the recently awarded Brook/FPA UK Sexual Health Awards, and opines that awards of this type are a good thing for the SRH profession generally and so rightly should be regarded as a highlight of the sexual health year. See page 219

Plus

An obituary for Dr Alison Bigrigg by Dr Audrey Brown; an organisational factfile on Tommys; a conference report from the FSRH Annual Scientific Meeting at University of Warwick;

And last, but by no means least, the Journal Impact Factor has risen, once again, to 2.1. Many congratulations to Anne Szarewski and her team.

 

New injectable – Sayana Press and Dianette VTE update

Monday, June 17th, 2013

Sayana Press®

is a progestogen-only injectable contraceptive licensed for subcutaneous use. It contains 104mg of medroxyprogesterone acetate (MPA) in 0.65ml suspension and is bioequivalent to IM depot medroxyprogesterone acetate. It is administered at intervals of 13 weeks +/- 7 days via a new delivery system (Unijet) – a single dose pre-filled injector.

Sayana

Although ideal for self-administration it is not currently licensed for use in this way.  The April issue of the Journal included a commentary on SC MPA by Sharon Cameron from Edinburgh.

Further information for professionals including a step-by-step administration guide will be available via MedIsis website.

Dianette® and cyproterone acetate products: strengthening of warnings, new contraindications, and updated indication

In agreement with the MHRA and European Medicines Agency (EMA) Bayer has written to health professionals about Dianette®, co-cyprindiol and cyproterone acetate products. This follows the outcome of a review of the known risk of thromboembolic events by the EMA’s Pharmacovigilance Risk Assessment Committee (PRAC). There are no new data, but there has been a “scare” in France which led to this and other so-called third generation products being removed from the market leaving very limited options for women.

The PRAC recommendations include:

  • Dianette® and other medicines containing cyproterone acetate 2mg/ethinylestradiol 35 mcg are indicated for the treatment of moderate to severe acne related to androgen-sensitivity (with or without seborrhea) and/or hirsutism, in women of reproductive age.
  • For the treatment of acne, Dianette® and other cyproterone acetate 2mg/ethinylestradiol 35 mcg products should only be used after topical therapy or systemic antibiotic treatment have failed.
  • Since Dianette® and all other cyproterone acetate 2mg/ethinylestradiol 35 mcg products are also a hormonal contraceptive, they should not be used in combination with other hormonal contraceptives.
  • To increase awareness of the risk and risk factors of thromboembolism in relation to the use of Dianette® and other cyproterone acetate 2mg/ethinylestradiol 35 mcg products (e.g. increasing age, smoking, immobility), the warnings and precautions regarding this risk have been strengthened.

 

 

Copenhagen Impressions

Monday, June 3rd, 2013

European Society of Contraception and Reproductive Health
First Global Conference

Global

Highlights of the Congress included:

Crown Princess Mary opening the Congress followed by the amazing Copenhagen drummers                          drummers

 

 

 

Green contraception – estrogen in water an issue, rating methods for their ‘greenness’: hormones, packaging etc.

Lidegaard / Shulman / Dinger – continuing debate on VTE, interpreting research, epidemiology and practical applications.

Emergency Contraception – confirmation that pills have no impact globally on unintended pregnancy rates only IUDs do.

Meeting friends, old and new, from wider across the globe than usual, especially from the Baltic states, Africa and the Far East.

In addition the Board voted to set up a working group to investigate and promote multidisciplinary working across Europe.

bella sky

The startling Bella Sky hotel & conference centre

– especially the, trompe l’oeil, walkway between the 2 towers on the 23rd floor. It goes uphill from Tower 1 to 2 but from a distance appears to go the other way.

 

 

oresund  The Oresund Bridge

– the 5 mile rail and road link between Copenhagen and Malmo

 

 

 

bikesBicycles, bicycles and more bicycles

and particularly proper, separate, dedicated cycle lanes – at times quite scary and felt like being in the middle of the Tour de France peloton without the lycra and wrap-around shades!,

Great open sandwiches (smorrebrod) but hardly any danish pastries.

Herrrings, steak & frites. Not brilliant for veggies.

Good beer but not wine – used by next years hosts in Lisbon as an enticement to go there.

Lisbon