Background Telemedicine is increasingly being used to access abortion services. Objective To assess the success rate, safety, and acceptability for women and providers of medical abortion using telemedicine. Search strategy We searched PubMed, EMBASE, ClinicalTrials.gov, and Web of Science up until 10 November 2017. Study criteria We selected studies where telemedicine was used for comprehensive medical abortion services, i.e. assessment/counselling, treatment, and follow up, reporting on success rate (continuing pregnancy, complete abortion, and surgical evacuation), safety (rate of blood transfusion and hospitalisation) or acceptability (satisfaction, dissatisfaction, and recommendation of the service). Data collection and analysis Quantitative outcomes were summarised as a range of median rates. Qualitative data were summarised in a narrative synthesis. Main results Rates relevant to success rate, safety, and acceptability outcomes for women ≤10+0 weeks’ gestation (GW) ranged from 0 to 1.9% for continuing pregnancy, 93.8 to 96.4% for complete abortion, 0.9 to 19.3% for surgical evacuation, 0 to 0.7% for blood transfusion, 0.07 to 2.8% for hospitalisation, 64 to 100% for satisfaction, 0.2 to 2.3% for dissatisfaction, and 90 to 98% for recommendation of the service. Rates in studies also including women >10+0 GW ranged from 1.3 to 2.3% for continuing pregnancy, 8.5 to 20.9% for surgical evacuation, and 90 to 100% for satisfaction. Qualitative studies on acceptability showed no negative impacts for women or providers. Conclusion Based on a synthesis of mainly self‐reported data, medical abortion through telemedicine seems to be highly acceptable to women and providers, success rate and safety outcomes are similar to those reported in literature for in‐person abortion care, and surgical evacuation rates are higher. Tweetable abstract A systematic review of medical abortion through telemedicine shows outcome rates similar to in‐person care.

PostprintThis is the accepted version of a paper published in The Lancet. This paper has been peer-reviewed but does not include the final publisher proof-corrections or journal pagination.Citation for the original published paper (version of record):Klingberg-Allvin, M., Cleeve, A., Atuhairwe, S., Tumwesigye, N M., Faxelid, E. et al. (2015) Comparison of treatment of incomplete abortion with misoprostol by physicians and midwives at district level in Uganda: a randomised controlled equivalence trial.

Unsafe abortion in Africa continues to be a major contributor to the global maternal mortality which affects young women in particular. In Uganda, where abortion is legally restricted and stigmatised, unsafe abortion is a major public health issue. We explored reproductive agency in relation to unsafe abortion among young women seeking post-abortion care. Through in-depth interviews we found that reproductive agency was constrained by gender norms and power imbalances and strongly influenced by stigma. Lack of resources and the need for secrecy resulted in harmful abortion practices and delayed care-seeking. Women did not claim ownership of the abortion decision, but the underlying meaning in the narratives positioned abortion as an agentive action aiming to regain control over one′s body and future. Women′s experiences shaped contraceptive intentions and discourse, creating a window of opportunity that was often missed. This study provides unique insight into how young women negotiate and enact reproductive agency in Uganda. Health systems need to strengthen their efforts to meet young women's sexual and reproductive health needs and protect their rights. Enabling young women's agency through access to safe abortion and contraception is paramount.

ObjectiveThis study aimed to assess women´s acceptability of diagnosis and treatment of incomplete abortion with misoprostol by midwives, compared with physicians.MethodsThis was an analysis of secondary outcomes from a multi-centre randomized controlled equivalence trial at district level in Uganda. Women with first trimester incomplete abortion were randomly allocated to clinical assessment and treatment with misoprostol by a physician or a midwife. The randomisation (1:1) was done in blocks of 12 and stratified for health care facility. Acceptability was measured in expectations and satisfaction at a follow up visit 14–28 days following treatment. Analysis of women’s overall acceptability was done using a generalized linear mixed-effects model with an equivalence range of -4% to 4%. The study was not masked. The trial is registered at ClinicalTrials.org, NCT 01844024.ResultsFrom April 2013 to June 2014, 1108 women were assessed for eligibility of which 1010 were randomized (506 to midwife and 504 to physician). 953 women were successfully followed up and included in the acceptability analysis. 95% (904) of the participants found the treatment satisfactory and overall acceptability was found to be equivalent between the two study groups. Treatment failure, not feeling calm and safe following treatment, experiencing severe abdominal pain or heavy bleeding following treatment, were significantly associated with non-satisfaction. No serious adverse events were recorded.ConclusionsTreatment of incomplete abortion with misoprostol by midwives and physician was highly, and equally, acceptable to women.Trial RegistrationClinicalTrials.gov NCT01844024

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As part of its core work, the WHO generates, translates and disseminates knowledge, including through guideline development. In recent years, substantial work has been undertaken to revise the Evidence to Decision framework in order to fully integrate inter alia human rights. This paper describes an innovative methodological approach taken by the authors to inform law and policy recommendations for the forthcoming third edition of the Safe Abortion: Technical and Policy Guidance for Health Systems. The methodology described here effectively integrates human rights protection and enjoyment as part of health outcomes and analysis, ensuring that subsequent recommendations are consistent with international human rights standards. This will allow guideline users to make informed decisions on interventions, including legal and policy reform, to fulfil relevant human rights including the right to health.

IntroductionThe COVID-19 pandemic has negatively impacted health systems globally and widened preexisting disparities. We conducted a scoping review on the impact of the COVID-19 pandemic on women and girls’ access to and utilisation of sexual and reproductive health (SRH) services for contraception, abortion, gender-based and intimate partner violence (GBV/IPV) and sexually transmitted infections (STIs).MethodsWe systematically searched peer reviewed literature and quantitative reports, published between December 2019 and July 2021, focused on women and girls’ (15–49 years old) access to and utilisation of selected SRH services during the COVID-19 pandemic. Included studies were grouped based on setting, SRH service area, study design, population and reported impact. Qualitative data were coded, organised thematically and grouped by major findings.ResultsWe included 83 of 3067 identified studies and found that access to contraception, in-person safe abortion services, in-person services for GBV/IPV and STI/HIV testing, prevention and treatment decreased. The geographical distribution of this body of research was uneven and significantly less representative of countries where COVID-19 restrictions were very strict. Access was limited by demand and supply side barriers including transportation disruptions, financial hardships, limited resources and legal restrictions. Few studies focused on marginalised groups with distinct SRH needs.ConclusionReports indicated negative impacts on access to and utilisation of SRH services globally, especially for marginalised populations during the pandemic. Our findings call for strengthening of health systems preparedness and resilience to safeguard global access to essential SRH services in ongoing and future emergencies.

Barriers to access abortion services globally have led to the development of alternative methods to assist and support women who seek an abortion. One such method is the use of hotlines, currently utilised globally for abortion care. This review aimed to understand (1) how abortion hotlines facilitate access to abortion; and (2) how women and stakeholders describe the impact of hotlines on abortion access. Published quantitative and qualitative studies and grey literature were systematically reviewed alongside an identification and description of abortion hotlines in the public domain. Our findings highlight that the existence of abortion hotlines is highly context-dependent. They may exist either as an independent community-based model of care, or as part of formal care pathways within the health system. Hotlines operating in contexts with legal restrictions seem to be broader in scope and will use innovative approaches to adapt to their setting and reach hard-to-reach populations. All the abortion hotlines that provided information on a data extraction form used evidence-based guidelines but women seeking medical abortion still struggle to access quality medications. There is limited data in general on abortion hotlines, especially on the user and provider experience. Abortion hotlines have the potential to facilitate access to safe abortion care through evidence-based information and to decrease maternal mortality and morbidity from unsafe abortions for women and girls globally.