Angel M. Foster

First impressions: what are preclinical medical students in the US and Canada learning about sexual and reproductive health?

BACKGROUND This study evaluates the inclusion of sexual and reproductive health (SRH) topics in preclinical US and Canadian medical education. STUDY DESIGN Between 2002 and 2005, we sent surveys to the student coordinators of active Medical Students for Choice chapters at 122 US and Canadian medical schools. Students reported on the preclinical curricular inclusion of 50 specific SRH topics in the broad categories of pregnancy, contraception, infertility, elective abortion, ethical and social issues, and other topics. RESULTS We received 77 completed surveys, for an overall response rate of 63%. Coverage of pregnancy physiology and STIs/HIV was uniformly high. In contrast, inclusion of contraceptive methods and elective abortion procedures greatly varied by subtopic and geographic region. Thirty-three percent of respondents reported no coverage of elective abortion-related topics. CONCLUSIONS Inclusion of contraception and elective abortion in preclinical medical school courses varies widely. As critical components of womens lives and health, we recommend that medical schools work to integrate comprehensive family planning content into their standard curricula.

Would you say you had unprotected sex if...? Sexual health language in emails to a reproductive health website

The words and metaphors that people use to describe sexuality and reproductive health reflect experiences with peers, sexual partners, health service providers and public health campaigns. In this paper we analyse 1134 emails sent to an emergency contraception website in the USA over the course of one year. Through an examination of the terminology used by authors to describe contraceptive methods, sexual intercourse and other sexual acts, we analyse what those terms signify within their textual context. We find that the kinds of risk concerns used in assessing sexual activity – whether evaluating pregnancy risk, disease transmission risk or moral risk – influence the definitions people give to terms that are multiply defined or whose definitions are culturally contested. This finding emerged clearly in the meanings given to terms for ‘sex’ and ‘unprotected sex’, which varied widely. We conclude with a discussion of the implications of this finding for research, clinical care and health education activities.

“In rape cases we can use this pill”: A multimethods assessment of emergency contraception knowledge, access, and needs on the Thailand − Burma border

To evaluate availability, service delivery, and barriers to access to emergency contraceptive pills (ECPs) along the Thailand–Burma border.

Ob/Gyn training in abortion care: results from a national survey

BACKGROUND Abortion is one of the most common health services utilized by women in the USA. Training new providers is an important factor in ensuring an adequate supply of clinicians to provide comprehensive reproductive health services. STUDY DESIGN Data came from a mailed survey of obstetrician/gynecologists who completed residency in 2007. RESULTS Participation in first-trimester procedures training was lower than that in second-trimester procedures training. Notably, residents reported less exposure to medication abortion than nearly all other abortion procedures; only 41% of survey participants reported having received training in mifepristone/misoprostol. Significantly more respondents who trained in programs with routine training participated in first-trimester procedures, specifically medication abortion, manual vacuum aspiration and electric vacuum aspiration, compared to those who attended programs with elective training. DISCUSSION As the vast majority of abortions in the USA occur during the first trimester, exposure to the full array of common first-trimester abortion procedures, including both medication abortion and aspiration abortion procedures, warrants attention. These findings suggest that residency education guidelines may need to be revised to ensure adequate training in medication abortion.

Satisfaction guaranteed? How individual, partner, and relationship factors impact sexual satisfaction within partnerships

Within committed relationships, a wide range of factors may challenge or facilitate sexual satisfaction. The aim of this study was to clarify which individual, partner-, and partnership-related aspects of a sexual relationship are crucial for the prediction of sexual satisfaction. The study included data of a representative sample of 964 couples from the general population. The actor-partner interdependence model was used to estimate actor and partner effects. Overall, predictors explained 57% of outcome variance. Actor effects were found for sexual function, sexual distress, frequency of sexual activity, desire discrepancy, sexual initiative, sexual communication, sociosexual orientation, masturbation, and life satisfaction. Gender-specific partner effects were found for sexual function and sexual distress. Neither age, nor relationship duration were significant predictors. To deepen our understanding of sexual satisfaction, it is necessary to take quantitative and qualitative aspects of sexual relationships into account and to consider actor-, partner-, and relationship-related predictors.

From qualified physician to licensed health care professional: the time has come to change mifepristone's label.

From qualified physician to licensed health care professional: the time has come to change mifepristones label Angel M. Foster⁎, Courtney B. Jackson, Kathryn J. LaRoche, Katherine Simmonds, Diana Taylor Faculty of Health Sciences, University of Ottawa New View Data Solutions Massachusetts General Hospital, Institute of Health Professions Advancing New Standards in Reproductive Health, University of California, San Francisco

Sounding board: Sixteen years of overregulation: Time to unburden mifeprex: Mifeprex REMS study group

On March 29, 2016, the Food and Drug Administration (FDA) approved an updated label for Mifeprex (mifepristone 200-mg tablets, Danco Laboratories), the product that is commonly used in the United States in combination with misoprostol to induce a medical abortion. The changes made to the label were sweeping: they included a more effective dosing regimen containing less mifepristone and more misoprostol, expansion of the gestational limit for treatment from 49 to 70 days, omission of the recommendation for inperson follow-up, removal of language indicating that the prescriber must be a physician, and elimination of the requirement to report nonfatal adverse events. These revisions were supported by extensive data about mifepristone that have been accumulated since the FDA first approved the drug in 2000.1-7 Professional guidelines for medical abortion had already incorporated many of the new procedures,8-10 and thus the FDA’s action brought the drug label into line with current standard practice. The new label will undoubtedly have substantial benefits. Because the label now conforms with scientific evidence, it will reduce confusion among women, providers, and policymakers about the appropriate use of the drug. Moreover, it is expected to make abortion less expensive, more convenient, and more widely available in the handful of states where legislatures have enacted laws requiring adherence to the FDA-approved Mifeprex label.11 We suggest, however, that in merely updating the label, the FDA did not go far enough: the distribution of Mifeprex remains substantially and unnecessarily encumbered by a Risk Evaluation and Mitigation Strategy (REMS), which was left fundamentally unchanged. A REMS is a set of restrictions beyond the label that the FDA may impose under the authority of the federal Food, Drug, and Cosmetic Act (FDCA) when necessary to ensure that the benefits of a drug outweigh its risks.12,13 REMS programs are intended for drugs that are known or suspected to cause serious adverse effects that cannot be mitigated simply by the label instructions. The FDCA includes six factors that the FDA should consider when deciding whether to require a REMS, including the benefits and risks of the drug, the duration of treatment, the number of expected users, and the background risk of adverse events in the population (see Box). Each REMS is customized to address the specific risks of a given drug. The REMS for clozapine, which is indicated for the treatment of schizophrenia, is illustrative: because the drug can cause severe neutropenia, its REMS requires, among other measures, that pharmacists verify that each patient has had a recent neutrophil count before dispensing the drug.14 At this time, 7412 of the approximately 1750 prescription drug and therapeutic biologic active ingredients that have been approved by FDA and marketed in the United States15 have REMS programs. The core of the Mifeprex REMS is three provisions designated as “elements to assure safe use.”16 First, the drug may be dispensed to patients only in clinics, medical offices, and hospitals by or under the supervision of a certified prescriber; it may not be sold in retail pharmacies. Second, to prescribe the drug, a health care provider must become “certified” by completing and sending a form to the drug distributor attesting that he or she can assess pregnancy duration, diagnose ectopic pregnancy, and provide surgical intervention if needed, either personally or by referral. Third, each woman taking Mifeprex must be given an FDA-approved medication guide and sign an FDAapproved patient agreement that summarizes the use instructions specified in the label and the potential risks of the drug. Whereas drug labels are generally not binding for individual clinicians17 — misoprostol, for example, is approved for the prevention of gastric ulcers but is legally and widely used off-label for gynecologic purposes,

Migrant women's experiences, meanings and ways of dealing with postnatal depression : a meta-ethnographic study

Aim To conduct a meta-ethnographic study of the experiences, meanings and ways of ‘dealing with’ symptoms or a diagnosis of postnatal depression amongst migrant women living in high income countries. Background Prevalence of postnatal depression is highest amongst women who are migrants. Yet many women do not seek help for their symptoms and health services do not always respond appropriately to migrant women’s needs. Studies have reported migrant women’s experiences of postnatal depression and it is timely to synthesise findings from these studies to understand how services can be improved. Design A meta-ethnographic synthesis of 12 studies reported in 15 papers Data sources Five databases were searched for papers published between January 1999 and February 2016 Review methods The quality of included studies was assessed using the Critical Appraisal Skills Program tool. The synthesis process was guided by the seven steps of meta-ethnography outlined by Noblit and Hare. Findings Four key metaphors were identified: “I am alone, worried and angry—this is not me!”; ‘Making sense of my feelings’ ‘Dealing with my feelings’ and ‘What I need to change the way I feel!’. Primarily women related their feelings to their position as a migrant and as women, often living in poor socio-economic circumstances and they were exhausted keeping up with expected commitments. Many women were resourceful, drawing on their personal strengths and family / community resources. All the studies reported that women experienced difficulties in accessing appropriate services. Conclusion The meta-ethnographic study demonstrates the impact of migration on perinatal mental health, particularly for women lacking family support, who have no employment, a precarious migration status and/or relationship conflict. Migrant women are resourceful and this requires support through appropriate services. Further research is needed to evaluate effective support strategies for migrant women in the perinatal period.

Exploring Canadian women's knowledge of and interest in mifepristone: results from a national qualitative study with abortion patients

INTRODUCTION Although Canada decriminalized abortion in 1988, significant disparities in access to services and an uneven geographic distribution of providers persists. Health Canada registered mifepristone, the gold standard of medication abortion, in July 2015. Our study explored Canadian womens knowledge of, interest in, and perspectives on mifepristone prior to registration. METHODS From November 2012 through July 2015 we conducted in-depth interviews with 174 Anglophone and Francophone women from Alberta, Manitoba, New Brunswick, Ontario, and Quebec about their abortion experiences and their opinions about medication abortion. We purposively recruited participants from different age cohorts and different regions within each study province to explore a range of perspectives. We analyzed these interviews for content and themes related to mifepristone using both deductive and inductive analytic techniques. RESULTS The overwhelming majority of participants had no knowledge of mifepristone at the time of the interview. However, after providing a brief description of an evidence-based mifepristone/misoprostol regimen, more than half of the participants reported that they would have considered this method had it been available at the time of their abortion and most would have been comfortable receiving medication abortion care from a family physician or nurse practitioner. Most women supported the approval of mifepristone and felt Canadian women would benefit from having more options for early pregnancy termination. CONCLUSION Although knowledge of mifepristone among recent abortion patients was low, considerable interest in medication abortion exists. Expanding awareness-raising efforts and supporting the approval of evidence-based regimens and provision of mifepristone appears warranted. IMPLICATIONS The approval and introduction of mifepristone for early abortion in Canada promises to increase options and access. Creating tailored and culturally and contextually resonant messages about mifepristone is of high priority. Promoting evidence-based protocols and the inclusion of a full range of qualified professionals in service provision is also warranted.

They made me go through like weeks of appointments and everything: Documenting women's experiences seeking abortion care in Yukon territory, Canada.

BACKGROUND Abortion has been legal without restriction in Canada since 1988 and is recognized as a medically necessary service. However, research indicates that women still face numerous barriers to accessing care, challenges that are amplified for women living in rural, remote and northern regions in Canada. OBJECTIVES This qualitative study aimed to document womens experiences seeking and obtaining abortion services while residing in Yukon Territory, identify financial and personal costs and explore avenues through which services could be improved. METHODS We conducted 16 in-depth semi-structured phone interviews with women who accessed abortion services on/after January 1, 2005, while residing in the Yukon. We employed an iterative multiphase analytic approach centering on content and themes, using both inductive and deductive techniques. RESULTS With the Yukons sole facility offering first trimester abortions twice a month, women experienced difficulty navigating a fragmented process and long wait times. Women found the process of attending multiple pre-procedure appointments at multiple locations with multiple health care providers, all while enduring pregnancy symptoms and handling other life commitments, physically, financially and emotionally taxing. CONCLUSION Efforts to streamline the process of obtaining an abortion and providing women with more information at the first point of contact would improve service access and quality. Mifepristone has the potential to improve access for rural and remote populations, reduce wait times and alleviate privacy concerns, but only if the medication abortion regimen is affordable and available at a range of service delivery points and provision requirements are aligned with the global evidence. IMPLICATIONS By documenting womens experiences, the identified barriers and outlined suggestions for improvement offer realistic avenues through which current abortion services in Yukon Territory can be modified in order to increase access. This study highlights future reproductive health care initiatives that warrant prioritization in Canadas North.