BMJ Sexual & Reproductive Health

Over 300,000 children were born in the United Kingdom (UK) through assisted reproductive technology (ART). ART is associated with prematurity and congenital anomalies, while long-term health risks are currently considered low. Large-scale qualitative research exploring womens perspectives on these issues remains limited. Therefore, this study investigates womens concerns about health and educational outcomes following ART, and their views on information provision and national database studies. Women who underwent ART, were considering ART or conceived naturally were invited to participate voluntarily. An anonymous online survey was distributed via social media channels of a UK-based fertility charity and accepted responses for 8 months. Free-text responses underwent thematic analysis, and descriptive statistics were produced for categorical responses. Of the 562 participants, most were aged 25-40 (74.5%), White (93.2%) and held a degree or higher qualification (87.9%). The majority underwent ART through the private sector (42.3%) in the 2020s (69.1%) and had successful childbirth (52.4%). While up to 82.5% of respondents reported no health and educational concerns, others were concerned about reproductive, endocrine and hormone treatment-related cancer risks in themselves, in addition to potential reproductive, neurological and developmental issues in their offspring. Most participants (up to 91.9%) stated they received no information about ART-related health and educational outcomes in themselves and their child; those who did cited healthcare professionals or videos as sources. More than half (68.3%) supported using national databases to study childrens outcomes, and they expressed that such findings should be disseminated sensitively through healthcare professionals before treatment. Although most women reported no concerns or information about long-term health and educational outcomes for themselves or their children, many expressed concerns. The lack of information and support for database studies can inform patient-centred communication that addresses womens concerns. Future ART studies may consider incorporating patient and public involvement surveys to shape research priorities.

PurposeTo explore mens assisted reproductive technology (ART) experiences, awareness and concerns about fertility-associated health outcomes, and perceptions of using administrative health records in the United Kingdom (UK) without consent to investigate these outcomes. MethodsOver a two-year period, all adult men were eligible to complete an anonymous online survey distributed via a UK-based fertility charitys social media. Free-text responses underwent thematic analysis, and categorical responses were analysed with descriptive statistics and Fishers exact test. ResultsAmong 80 participants, most were aged [≥]40 (66.7%), completed university (70.2%), White (77.2%) and UK residents (83.0%). Older (p=0.004) and White (p=0.001) men more likely underwent ART. Most ART users received treatment privately (60%) within the past three years (71.4%). Only one-fifth of the 15 men with identified fertility problems received discussion on fertility-associated health outcomes in clinic. Regarding perceptions, most were unaware of but concerned about these outcomes across biopsychosocial aspects, with participant quotes reflecting uncertainty and vulnerability. Recency of ART was associated with awareness (p=0.015) and concerns (p=0.001). Overall, 90.3% supported using administrative health records to investigate long-term health of fertility-challenged men, and 84.2% had no concerns about doing so without individual consent under established legal frameworks. Others raised concerns about the reliability of data anonymisation. Quotes suggested participants desire to understand the wider health implications of male fertility amidst a perceived gender imbalance in fertility research. ConclusionsGaps in participant knowledge, clinician communication and research in male fertility-associated outcomes support the need for universal education and further investigations in these outcomes. Capsule SummaryMost men showed limited awareness of but notable concern about fertility-related long-term health outcomes, and most supported using administrative health records without individual consent for investigating these outcomes.

Objective: Since 2020, medication abortion provision in the U.S. has been reshaped by changing abortion policies and expanded telehealth access, yet little is known about how medication abortion service delivery has evolved. We examined national trends in service delivery from 2020 to 2025, including changes in abortion facility types, telehealth provision, and gestational limits. Study Design: Using ANSIRHs Abortion Facility Database, a national census of publicly advertising abortion facilities (2020 to 2025), we analyzed trends in medication abortion service delivery. Systematic web searches and mystery shopper calls gathered data on facility types, telehealth provision, and gestational limits. Data analysis included frequencies and comparisons across regions and states. Results: Medication abortion-only facilities increased nationally, from 35% of facilities in 2020 to 65% in 2025, with substantial growth in abortion-restrictive regions such as the Midwest and South. By 2025, 99% of facilities provided medication abortion. Telehealth provision expanded from 7 facilities in 2020 to 606 facilities by 2025, driven by growth in both brick-and-mortar facilities offering telehealth care and new virtual clinics. Overall, 46% of all facilities offered medication abortion by telehealth in 2025. Gestational limits for medication abortion increased nationally, from <1% of facilities offering medication abortion after 11 weeks in 2020 to 38% in 2025. Conclusions: Medication abortion service delivery has adapted to legal and logistical challenges by increasing telehealth options and expanding gestational limits. These changes improve access for abortion seekers, especially those living in restrictive environments. Sustaining abortion access will require ongoing provider adaptation and supportive policy environments.

ObjectivesTo assess the impact of the December 2018 approval of home administration of misoprostol in England on access to medical abortion. DesignTime series analysis SettingBritish Pregnancy Advisory Service (BPAS), independent-sector abortion provider in England Participants145,529 abortions carried out by BPAS across England between 2018 and 2019. InterventionApproval of home administration of misoprostol in early medical abortions (EMA) in December 2018 Main outcome measureGestational age at abortion and EMAs as a proportion of all abortions. The analysis was stratified by key sociodemographic characteristics to assess differential impacts of the approval Results99,008 abortions took place in the period before the approval or during its implementation phase (January 2018 - June 2019) and 46,521 took place after (July 2019 - Dec 2019). Compared to if former trends had continued, the actual proportion of EMAs was 4.2% higher in December 2019 and the mean gestational age 3.4 days lower. ConclusionFollowing the approval of home use of misoprostol, we saw an acceleration in the trends towards increasing proportion of all abortions that were EMAs and decreasing gestational age at abortion, especially in more deprived areas of England. Some inequities remain across race/ethnicity groups that require further investigation. Policymakers should take the positive results of this study into consideration when reviewing rules for home management of medical abortions, including with home use of mifepristone. What is already known on this topicIn 2018 in England, a womans "home" was designated as a class of place where misoprostol could be used to induce abortion up to 10 weeks gestation following administration of mifepristone in a medical facility. This model of abortion care has been shown in numerous international studies to be highly effective, safe, and preferred by women over in-clinic use. Existing data anticipated positive clinical and acceptability outcomes with implementation of home use, but whether or how the change would impact access particularly in relation to barriers such as area-level deprivation, race/ethnicity, and disability was uncertain. What this study addsThe approval of home use of misoprostol as part of a medical abortion regimen in England was associated with material and equitable improvements in abortion access as evidenced by a higher proportion of medical abortions provided, lower gestational age at treatment, and higher odds of having a medical abortion across all racial/ethnic groups and socioeconomic groups. Pre-approval trends toward greater uptake of medical abortion and declining gestational age were accelerated post-approval and were greatest in the most deprived quintiles but not across all racial/ethnic groups. Patient and Public Involvement StatementThis study was a quantitative data analysis of existing clinical data and patients were not directly involved in the research. Authors note on terminologyThe authors would like to note that abortions are experienced not only by cis-women, but also by trans, non-binary and intersex people, who should be recognised and treated as equal recipients of abortion care. The term women will be used in this project for simplicity and in acknowledgment of the fact that the majority of the patients identify as women.

BackgroundFertility tracking apps have gained widespread popularity as a convenient method for women to monitor their menstrual cycles and improve chances of conception. Despite their prevalence, there is limited research synthesizing womens lived experiences and perceptions regarding the use of these apps. Understanding womens perspectives is crucial to address concerns about accuracy, privacy, and emotional well-being impacts, and to ensure that fertility apps are meeting the needs of their users. ObjectivesThis systematic review aims to synthesize qualitative research on womens perceptions and experiences of using fertility tracking apps. The review will explore womens attitudes, motivations, perceived benefits, and challenges related to the use of these apps. Specifically, it will identify key themes related to how these apps influence womens emotional well-being, relationships, and decision-making processes, while identifying gaps in current literature to guide future research. Methods and AnalysisThis review will consider qualitative studies that include women of reproductive age who have used or are currently using fertility tracking apps. The systematic review will be conducted in accordance with JBI methodology for systematic reviews of qualitative evidence using a meta-aggregative approach. A comprehensive search strategy will be employed across multiple databases, including PubMed, Web of Science, Embase, CINAHL, MEDLINE, The Cochrane Library, PsycINFO, and Scopus, from each databases inception to January 2025. Two independent reviewers will screen titles and abstracts using Covidence, assess full texts against inclusion criteria, and extract qualitative data using standardized tools. Study quality will be critically appraised using the JBI Critical Appraisal Checklist for Qualitative Research. Data will be analyzed using thematic synthesis following a three-step meta-aggregative approach: extracting findings verbatim, grouping similar findings into categories, and synthesizing categories into overarching findings. The certainty of findings will be assessed using the ConQual approach. DiscussionThis systematic review will provide the first comprehensive synthesis of womens experiences with fertility tracking apps, generating actionable insights for app developers, healthcare providers, and researchers. The synthesized findings can inform the development and refinement of fertility tracking apps to better meet user needs and preferences. Healthcare providers may benefit from these insights to guide patient discussions about fertility tracking and provide more tailored support. The identification of literature gaps will help direct future research efforts toward more diverse and inclusive studies on fertility tracking apps, ultimately contributing to improved womens reproductive health and well-being. PROSPERO registration numberCRD42025645316

BackgroundPostpartum contraception start and use are important to avoid unwanted pregnancy and to optimize birth spacing. There is limited knowledge concerning the factors influencing the type and timing of contraceptive initiation and adherence after delivery. MethodsThis was a prospective register-based study. We identified 26 650 women that delivered between 1st of January 2019 and 31st of December 2019, using the Finnish Medical Birth Register. Postpartum follow-up time for each woman was one year. The primary outcome of the study was postpartum purchase of HC from a pharmacy, identified from the Prescription Centre. Additionally, we analyzed if mode of delivery, epidural analgesia, induction of labor, hypertensive complications, fear of childbirth or gestational diabetes affected HC purchase. ResultsAltogether 33% (n=8902) of the women purchased a HC method postpartum. The most purchased method was desogestrel-only pill (56%, n=4978), and other progestin-only preparations, which covered almost 90% of all methods started. Additionally, 4% (n=1141) received an intrauterine device (IUD) in primary health care. Instrumental delivery (OR 1.15, CI 1.06-1.25), cesarean section (OR 1.26, CI 1.13-1.41 for planned C-section and OR 1.25, CI 1.15-1.36 for emergency C-section), epidural analgesia (OR 1.12, CI 1.05-1.18) and induction of labor with balloon (OR 1.14, CI 1.01-1.28) were associated with a significantly higher rate of HC purchase. ConclusionsOverall, 37% of women purchased a HC method or received an IUD during the first postpartum year. Common delivery complications were associated with higher rate of postpartum HC purchase.

BackgroundMost surveys examining health professionals knowledge, attitudes and practices around abortion have used convenience samples and have targeted doctors. Our goal in the SACHA Study, drawing on evidence-based strategies to maximise response rates, was to achieve a representative sample of a wider range of health professionals, working in general practice, maternity services, pharmacies, sexual and reproductive health (SRH) clinics and specialist abortion services in Britain, to explore the knowledge, attitudes and experience of abortion care and views on future models of delivery. MethodsA cross-sectional questionnaire-based survey of midwives, doctors, nurses and pharmacists in England, Scotland and Wales was undertaken between November, 2021 and July, 2022. We used a stratified cluster sampling approach to select a random sample of sites and all eligible staff within those services were asked to respond to the survey. Evidence-based strategies to maximise completion rates were adopted, including postal delivery of the one-page questionnaire with personal letter of invitation and a stamped address envelope for return, inclusion of an unconditional voucher and follow-up. ResultsOverall, 147 of the 314 (46.8%) health service sites randomly selected took part in the survey. Reasons for non-participation included local Research and Development (R&D) Department non-response, lack of resources or insufficient time to support or approve the study, lack of interest in or perceived relevance of the topic and insufficient capacity to take part, exacerbated by work demands during the COVID epidemic. Of the 1370 questionnaires sent to eligible identified participants within these services, 771 were completed and returned (56.3%). At the service level the highest proportion of returns was from SRH clinics (81.0%) and the lowest from general practice (32.4%). In relation to profession, returns were highest amongst midwives (69.6%) and lowest amongst pharmacists (36.5%). ConclusionsObtaining information about health professional knowledge, attitudes and practices is key to guide service development and policy and to identify gaps in training and service provision in abortion. Despite our attempts to gain a representative sample of health professionals, the challenges we experienced limited the representativeness of the sample, despite the use of an evidence-based strategy.

In 2015, mifepristone, the international gold standard for medical abortion, was approved for use in Canada. Our content analysis of Canadian newspaper coverage describes arguments in favor or against medical abortion and the evolving regulatory framework for mifepristone from six months before approval until the last province included the medication as a publicly insured health benefit (2015-2019). Our study found an exceptionally high level of support for the approval, introduction and removal of regulatory barriers to mifepristone for medical abortion. Of 402 articles, 67% were pro-medical abortion, 25% presented balanced or neutral coverage and only 8% presented solely anti-medical abortion viewpoints. Of the 761 stakeholders cited, more than 90% made positive or neutral statements about medical abortion. Most articles discussed medical abortion as a health issue and contained arguments about how liberalization of the regulatory framework and public payment for mifepristone would improve abortion availability (68%), accessibility (87%), acceptability (34%) and quality (19%). Mifepristones introduction in Canada was presented in newspapers as a way to increase womens health, specifically in rural areas where disparities in abortion access exist. Rather than formal balance, which presents contrasting arguments as equally valid even when the scientific evidence for one vastly outweighs the other, our study identified evidentiary balance where coverage aligned with the majority of evidence and expert opinion. Our results differ from analyses in other high-income countries (United Kingdom, United States) that have found that media frame abortion as a stigmatized and controversial issue or mention abortion predominantly with respect to electoral politics rather than as a health issue. The Canadian print media presented overwhelmingly favorable arguments towards the expansion of mifepristone medical abortion and served to destigmatize abortion by framing the introduction and universal coverage of medical abortion as fulfilling core components of the right to health.

Background Recent research has documented poor reproductive health among women and people assigned female in England. Access to reproductive health services is hindered by an opaque and fragmented system. Methods We conducted the 2023 Reproductive Health Survey for England, a non-probability online survey, in September and October 2023 (N = 59,332). In this analysis, we examined access to reproductive health services across three domains: heavy menstrual bleeding and severe pain, gynaecological symptoms and conditions and menopause-related symptoms. Weighting the sample to match the 2021 Census age distribution, we assessed differences by ethnic group, subjective financial situation, educational attainment and region across the domains using logistic regression analysis and controlling for age. Results Respondents reported low access to reproductive health services overall, including 34.8% (8,644/24,952) of those with heavy bleeding or severe period pain, 44.7% (6,709/15,569) with menopausal symptoms and 55.3% (21,010/37,411) with gynaecological symptoms or conditions. When controlling for age, there were decreased odds of service access for menopause-related symptoms and increased odds of service access for gynaecological symptoms or conditions among Black ethnic groups. Respondents with a higher education degree had greater access to services for heavy bleeding or severe pain and gynaecological symptoms and conditions. Compared to London, all other regions had lower access to services for heavy bleeding or severe pain. Satisfaction ranged from 16.5% (741/4,666) for polycystic ovary syndrome services to 80.2% (166/207) for reproductive cancer services. Conclusions Access to reproductive health services is poor in England and requires urgent action to address barriers to access.

There are several barriers to uptake of intrauterine devices (IUDs), with the fear of pain during insertion an emerging concern. Using data from an online survey, we sought to understand the experience of women who had undergone IUD insertion, with a particular focus on their expectation compared with their reported experience of pain. We found that, while most participants expected a moderate level of pain at insertion, many reported a high level of pain. Pain relief offered was variable, and, aside from that administered by an anaesthetist, no single method appeared to significantly reduce reported pain.

In June 2022, the U.S. Supreme Court overturned Roe v Wade. Half of states now face proposed or in-effect abortion bans, which affect the ability of obstetrics and gynecology (ObGyn) residency programs to provide abortion training. Prior to the Supreme Court decision, we surveyed ObGyn residents at all four programs in Wisconsin and Minnesota to assess residents attitudes toward abortion, desire to learn about abortion, and intentions about providing abortion care in their future practice. We found that participants overwhelmingly support abortion, find the issue to be important, and plan to incorporate abortion into future practice. The reversal of Roe v Wade and its impact on access to abortion training may have implications for ObGyn residency recruitment and training, related career decision-making, and future workforce.

Background/ImportanceBalancing work and family life is a particular challenge for physicians, yet finding a good balance is crucial given that childcare responsibilities and institutional support strongly influence career trajectories. This study examined female fertility and gender differences in family founding, working hours and childcare responsibilities among physicians in Switzerland. ObjectiveCharacterize fertility and family-founding among women physicians, compare womens and mens family-founding attitudes, and examine how work patterns, caregiving responsibilities and perceived institutional support relate to reproductive outcomes. Design, Setting, and ParticipantsSecondary analysis of an existing, anonymous, cross-sectional, web-based survey of the Swiss internal medicine workforce (fielded from December 2021 to April 2022). Main Outcomes and MeasuresDesire to have children, past or current intent to delay childbearing, self-reported female infertility, number of children, maternal age at first birth, perceived adequacy of external childcare, and employer respect of pregnancy-related working-hour limits. Group comparisons used Welchs t-tests and chi-square tests, and associations with workload used linear regression models. ResultsThis analysis included 682 physicians, 278 (41%) men and 404 (59%) women. Mens age was 39{+/-}12 years (mean {+/-} standard deviation [SD]), and womens age was 36{+/-}10 years. The prevalence of self-reported infertility among female physicians was 27.7%, which exceeds Swiss general population estimates of 10-15% (p<0.001). The mean age at first birth among physician-mothers was 31.3 years, which did not differ from the Swiss average (p=0.388). Women physicians had fewer children than men physicians (p=0.006). Among physicians without children, more women (69.8%) than men (51.6%) currently postponed having children (p<0.001). Also, among parents more women (42.2%) than men (21.8%) had delayed having children (p<0.001). Overall, satisfaction with childcare was limited, with 37% of men and 30% of women rating their childcare situation as inadequate. Among women who had ever been pregnant during employment (n = 123), 57% reported that legally prescribed pregnancy-related working-hour limits were not respected. Conclusions and RelevanceIn this national physician sample, women reported having fewer children and more frequently postponing having children than men, and experienced a higher prevalence of self-reported infertility than the Swiss population. Perceived childcare adequacy was suboptimal for both genders, and many reported insufficient adherences to pregnancy-related working-hour protections. Improving scheduling, enforcing maternity protections, increasing access to reliable childcare, and promoting equitable caregiving norms could enhance reproductive and professional outcomes for women in medicine in Switzerland.

BackgroundRemote consultations (via telephone or video) were critical during COVID-19 restrictions for Sexual and Reproductive Health Services (SRHS) in England and Wales and continue to be implemented widely. However, there remains limited evidence on their impact on outcomes and health inequalities. This study, guided by the Framework for Digital Health Equity, explores the equity implications of remote sexual health consultations in England and Wales, examining their acceptability and appropriateness. MethodsWe conducted semi-structured interviews with 54 service users and potential service users and 35 professional stakeholders across three diverse case study areas. Participants were purposively sampled to ensure diversity in socio-demographic profile and service experience. All participants provided informed consent, and ethical approval for the study was granted by NHS Research Ethics Committee (REC: 23/NS/0128). Data were thematically analysed into narrative themes, with findings interpreted collaboratively with public and patient involvement groups. ResultsThe study found that remote consultations have reshaped care delivery, improving efficiency but also generating additional clinical workload and, for some clinicians, reduced job satisfaction. While generally acceptable, remote models were perceived to affect rapport, extend care pathways for some service users, and impact privacy and safeguarding. We found the benefits of remote consultation are unevenly distributed, with those experiencing digital exclusion, who lack access to suitable private spaces, or who experience language barriers, being less able to take advantage of their convenience. ConclusionsRemote consultations transform SRHS delivery, improving efficiency for some but introducing challenges by impacting interaction, equity, and confidentiality. Benefits and burdens are unevenly distributed, reflecting structural, social, and individual factors influencing access. SRHS must ensure equitable access to appropriate care for all populations when implementing remote consultations. The findings show that a one-size-fits-all approach is not appropriate, and that giving service users choice in how they consult, including in-person, is important.

ImportanceHormonal contraceptives (HCs) support reproductive goals and alleviate symptoms of gynaecological conditions for millions of women. Despite widespread use, individual long-term HC use trends, medication switching, and impact of genetics on HC side effects remain uncharacterised. ObjectiveTo study HC use trends among Estonian Biobank (EstBB) participants, compare with national statistics, and evaluate suitability of EstBB for studying genetic risk for HC side effects. DesignLongitudinal descriptive analysis of HC refill data collected from 2004-2022 and user profiles, integrating demographic, genetic, and electronic health records data. SettingVolunteer-based longitudinal cohort representing 20% of Estonian adult population, where participants signed broad informed consent. ParticipantsWomen aged 15-55 in 2004-2022 with complete health and medication history available through linked electronic health records. ExposureHC use defined as prescription and purchase of drugs of the Anatomical Therapeutic Chemical (ATC) coding system level 3 G02B and G03A, and ATC level 5 G03HB01 during follow-up. Main Outcomes and MeasuresPrimary measures included age-stratified annual HC users prevalence rates, inferred HC usage period duration, switching frequencies, and user profiles. Secondary measures included HC use during COVID-19 period, and genetic and health-relatedthromboembolism risk factors. ResultsOver 19-year study period, twenty HC formulations with five administration routes (intrauterine device, ring, pill, patch and implant) were used by 73,071 women (mean age at joining EstBB (sd) = 35.6 (10.6)). Comparable to the Estonian population, combined HCs dominated, while progestin-only HC use increased with age and time. Next, 64.3% of users switched formulations at least once, with 17.7% being rapid switchers. Rapid switchers showed side effect-related diagnoses before switching, indicating the datasets potential for studying genetic risk of side effects. Medical abortion overlapped with inferred usage periods in 3.2% of users, suggesting contraceptive failure. Finally, 5.3% of HC users carried at least one VTE-associated genetic variant, and 1.5% of carriers developed thromboembolism during inferred HC use. Conclusions and RelevanceThese HC use trajectories, consistent with population statistics, provide insights into real-world use patterns, offering additional context and support for understanding prescription trends, womens preferences, as well as HC effectiveness and safety. Moreover, EstBB dataset has potential for genetic analyses of HC use and associated side effects. Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=131 SRC="FIGDIR/small/25333767v1_ufig1.gif" ALT="Figure 1"> View larger version (43K): org.highwire.dtl.DTLVardef@83874eorg.highwire.dtl.DTLVardef@12833fforg.highwire.dtl.DTLVardef@6dcfdeorg.highwire.dtl.DTLVardef@16a3075_HPS_FORMAT_FIGEXP M_FIG C_FIG

Remote consultations, including telephone, video, text or web-based consultations, are now common in sexual and reproductive health services (SRHS) in England and Wales, offering convenience and efficiency but raising concerns about safeguarding service users compared to in-person care. Ensuring protection and support for individuals remain central to SRHS. While guidance exists, evidence on how safeguarding is enacted remotely is limited. This study explores how safeguarding is managed in remote SRHS, examining associated challenges, benefits, and perceptions of acceptability. This qualitative study, part of the CONNECT study (NIHR153151), explored safeguarding in remote delivery of SRHS across three diverse case study areas in England and Wales. Semi-structured interviews were conducted with service users and providers (March 2024-January 2025). Data were thematically analysed using inductive and deductive approaches. Eighty-nine interviews were conducted with 54 service users/potential service users and 35 professional stakeholders across three study sites. Four key themes were identified: (1) challenges of delivering remote safeguarding in practice, (2) importance of a safe space for the patient, (3) one size approach does not fit all, and (4) strategies to support remote safeguarding. Participants described difficulties identifying risks without visual cues, variable comfort with disclosure, and privacy concerns. Providers used adaptive, collaborative approaches to build trust, ensure safety, and tailor safeguarding to individual circumstances. Both service users and providers recognised the effectiveness of remote safeguarding largely depended on clinician judgement, structured questioning, and sensitive communication. While remote consultations offered flexibility, remote safeguarding relied on service users having access to safe, private space. People with language barriers or those less able to create a safe space at home, such as those experiencing housing instability or coercive control may also have greater safeguarding needs. Ensuring access to in-person options, clear safeguarding protocols, and appropriate clinician training is essential to mitigate these challenges. Author summaryDuring the COVID-19 pandemic, sexual and reproductive health services used more remote appointments, such as phone, video, or online consultations. These appointments can make it easier for some people to get care. But there are concerns about whether staff can spot safeguarding issues, such as people who may be at risk of harm, without seeing them in person. In this study, we spoke with people who use sexual and reproductive health services, people who had never used these services before, and staff who work in these settings. People described challenges with remote appointments, including not being able to see body language, feeling unsure about talking about sensitive issues, and worries about privacy at home. Staff described changing how they worked by asking careful questions, building trust, and making safeguarding fit each persons situation. Both service users and staff felt that keeping people safe during remote appointments depends on clear communication and professional judgement. It is harder when people do not have a private space, face language difficulties, or live in unsafe housing or controlling relationships. Our findings show the importance of keeping in-person appointments available and making sure staff have the right training and guidance.

BackgroundIn Scotland, the effects of the COVID-19 pandemic on womens access to contraception are unknown. Globally, COVID-19 restrictions have led to a shift to telehealth service delivery alongside a reduction in contraceptive provision. Research into whether the effects of COVID-19 on contraception have abated after restrictions have been lifted is lacking. MethodsThis is a retrospective longitudinal study of prescribing data from the Scottish Health and Social Care Open Data repository (https://www.opendata.nhs.scot) between January 2016 and January 2023. Contraceptives were extracted and categorised using truncated British National Formulary codes and analysed using R. Contraceptive provision was compared across four periods: pre-COVID-19 (01/01/2016-23/03/2020), lockdown (24/03/2020-29/05/2020 & 05/01/2021-26/04/2021), restrictions (30/05/2020-04/01/2021 & 27/04/2021-30/04/2022), and post-COVID-19 (01/05/2022-01/01/2023). ResultsDuring lockdowns, contraceptive prescribing in Scotland decreased by 82.90% of pre-COVID-19 levels. This trend was more severe for long-acting reversible contraception which fell to 11.80% of pre-COVID-19 prescriptions. After COVID-19, the level of contraceptive prescribing has risen to 108.23% of its pre-pandemic level. Large increases in subcutaneous medroxyprogesterone acetate (499.05%), progestogen-only pills (125.07%), the patch (165.09%), levonorgestrel-IUS (112.54%), and ulipristal acetate emergency contraception prescribing (357.97%). Conversely, combined oral contraceptive pills (75.04%), Cu-IUD (83.63%), the implant (81.10%), and levonorgestrel emergency contraception (67.42%) prescribing has decreased. ConclusionsCOVID-19 vastly decreased contraceptive prescribing during lockdowns in Scotland. Post-COVID-19, changes in contraceptive prescribing within Scottish general practices are reported, with implications for health policy and service delivery planning. Availability of Data & CodeAll code and data used are fully available from Zenodo (doi:10.5281/zenodo.8310085) The raw dataset used is also publicly available from the Scottish Health and Social Care Open Data repository (opendata.nhs.scot).

BackgroundWomen with limited or no English proficiency experience persistent barriers to accessing maternity care in the UK, contributing to well-documented inequalities in maternal and perinatal outcomes. NHS parent education classes are predominantly delivered in English, and provision of multilingual classes within individual maternity units is often limited and duplicative. Evidence to inform collaborative, cross-trust service models remains scarce. ObjectiveTo assess womens access to, preferences for, and perceived relevance of NHS parent education classes, with particular focus on willingness to travel across London to attend classes delivered in a preferred language, in order to inform equitable and efficient service design. MethodsA cross-sectional, multilingual survey was conducted as a quality improvement initiative across multiple London maternity networks. The survey was translated into 18 languages and captured sociodemographic characteristics, access to parent education, preferences for delivery format, timing, location, and language, and perceived relevance of content. Quantitative data were analysed descriptively and thematically. ResultsA total of 97 women participated in the survey (n=97), the majority of whom reported speaking at least one non-English language at home (79.4%, n=77). Regarding mode of delivery, 51.6% of women preferred in-person parent education classes (n=50), 15.5% preferred online delivery (n=15), and 32.9% reported no preference (n=32). Most participants reported access to a suitable device and reliable internet (85.6%, n=83) and confidence using online platforms (77.3%, n=75). In relation to timing and format, weekends were the most commonly preferred time for classes (40.2%, n=39), followed by weekdays during school hours (35.1%, n=34) and weekday evenings (24.7%, n=24). Nearly half of women preferred delivery across two 2-hour sessions (48.5%, n=47), while 30.9% reported no preference regarding session length or number (n=30); fewer preferred two 3-hour sessions (11.3%, n=11) or a single 4-hour session (8.3%, n=8). Regarding willingness to travel, 67.0% of participants reported they would attend parent education classes delivered outside their booking maternity unit (n=65). Overall, 68.0% were willing to travel up to 45 minutes for in-person classes (n=66), while 29.9% preferred not to travel (n=29). With respect to language of delivery, 40.2% of women preferred classes delivered in their native language (n=39), and a further 40.2% reported English with an interpreter as acceptable (n=39); fewer were comfortable relying on a partner or friend to translate (19.6%, n=19). Most participants perceived that delivery by a native-speaking health professional would improve trust and learning (75.3%, n=73), and an equal proportion expressed a preference for a female interpreter (75.3%, n=73). ConclusionsWomen with limited English proficiency demonstrate clear willingness to travel across maternity networks to access antenatal education in their preferred language. These findings support the development of collaborative, cross-trust models that standardise core antenatal content while centralising multilingual provision, reducing duplication and improving equity of access across London maternity services.

IntroductionThe global rise in medical interventions during childbirth, such as caesarean sections, has raised concerns regarding their necessity and impact on maternal and neonatal outcomes. Midwifery-led units (MLUs) have demonstrated lower intervention rates and higher maternal satisfaction.This study evaluates the implementation and effects of the first MLU in the Spanish National Health System. MethodsA retrospective cross-sectional trend study and a cohort study were conducted to compare childbirth interventions and outcomes at XX with other hospitals of varying complexities. ResultsThe introduction of the MLU at XX resulted in a significant reduction in caesarean sections, decreasing from 23.5% to 13.5%, and an increase in spontaneous vaginal births, rising from 64.2% to 78.7%. These trends reversed following the MLUs closure in 2022, with caesarean sections increasing to 22.9% and spontaneous births dropping to 69.0%. The MLU served 1286 women, with the majority classified as low-risk pregnancies. Obstetric emergencies in the MLU were low and comparable to those in countries with established MLUs. DiscussionThis study highlights the potential benefits of integrating MLUs into traditionally medicalized healthcare systems to promote physiological childbirth and reduce unnecessary interventions. The positive outcomes achieved at HM are comparable to those in countries with more established MLU practices, reflecting the units commitment to evidence-based care. The increasing interest among women in midwifery-led care indicates a broader demand for supportive, less medicalized childbirth environments. ConclusionsMLU can lead to lower caesarean section rates and higher spontaneous vaginal birth rates, contributing to more positive maternal and neonatal outcomes. However, sustained support and investment in these units are crucial to maintain these benefits. Policymakers and healthcare providers should consider expanding the integration of MLUs within the Spanish National Health System to enhance maternal care quality and align with best practices.

Background Fertility rates in Australia have been declining over recent decades, reaching a record low total fertility rate of 1.48 births per woman in 2024. Concurrently, vasectomy remains widely accessible and increasingly normalised as a permanent contraceptive option. Despite extensive commentary on falling birth rates, no contemporary Australian study has examined vasectomy rates relative to birth rates over time. We aimed to compare population level vasectomy and birth rates across Australian jurisdictions and age groups. Study design Nationwide retrospective time-series study. Retrospective population-based study using Medicare Benefits Schedule item 37623 to identify vasectomy procedures performed between July 2015 and December 2024. Rates were calculated per 100,000 male population using quarterly Australian Bureau of Statistics (ABS) population estimates and summarised as rolling 12-month averages. Birth rates were derived using matched ABS data for women across equivalent age strata (18-24, 25-34, 35-44 years). Results: Vasectomy rates increased nationally from 32 per 100,000 in 2016 to 55 per 100,000 in 2023 before declining modestly in 2024. Birth rates declined from 5,200 to 3,800 per 100,000 over the same period. Trends were consistent across states and age groups, with the greatest vasectomy uptake in men aged 35-44 years. Conclusion: Australia is undergoing a demographic shift characterised by rising vasectomy uptake and declining fertility. While vasectomy rates remain lower than birth rates, their convergence signals changing reproductive intentions and contraceptive behaviours. Ongoing monitoring of permanent and long-acting contraception is essential to understand evolving population dynamics and inform reproductive health policy.

To date, the discourse on bodily autonomy has been narrowly focused on contraception and abortion and needs to be expanded to include experiences of agency during pregnancy and birth. Disrespect and mistreatment are widely reported in low resource countries but very little is known about experiences of perinatal care in high resource countries and how to improve care for minoritized populations. MethodsWe examine experiences of autonomy in decision-making during pregnancy among people who were pregnant in Canada between 2009 and 2022, using a large national dataset of patient-reported experiences and outcomes that were collected via a cross-sectional online survey. We measured autonomy with a globally validated patient-reported experience measure, the My Autonomy in Decision-Making (MADM) scale. To assess variations in autonomy by identity or life circumstances, we conducted multivariable regression analyses, controlling for pregnancy year, repeat observations, and place of residence and stratifying by model of care (physician or midwife-led). In a separate analysis, we tested contextual factors such as onset of prenatal care, length of appointments, and model of care (physician-led or midwife-led) that might reduce disparities in autonomy among minoritized childbearing people. FindingsDiverse participants (n=5389) reported on 7049 interactions with healthcare providers. In the adjusted models, autonomy scores were significantly lower among those with high school education or less (physician-led care: IRR=0.86, 95 % CI: 0.82-0.92; midwife-led care: IRR=0.93, 95% CI: 0.88-0.98) and newcomers to Canada (physician-led care: IRR=0.97, 95 % CI: 0.93-0.99). Scores were higher among pregnant people with majorized identities and circumstances, i.e. those who reported low discrimination (physician-led care: IRR=1.21, 95 % CI: 1.15-1.26; midwife-led care: IRR=1.06, 95% CI: 1.02-1.11), no disability (physician-led care: IRR=1.07, 95 % CI: 1.02-1.13; midwife-led care: IRR=1.04, 95% CI: 1.00-1.09), no need for social services (physician-led care: IRR=1.11, 95 % CI: 1.04-1.19; midwife-led care: IRR=1.13, 95% CI: 1.06-1.21), identified as heterosexual (physician-led care: IRR=1.10, 95 % CI: 1.06-1.15; midwife-led care: IRR=1.03, 95% CI: 1.01-1.06), Cis gender (midwife-led care: IRR=1.08, 95% CI: 1.01-1.16), and had sufficient income to meet financial obligations (physician-led care: IRR=1.18, 95 % CI: 1.11-1.24), compared to the reference groups. Several modifiable factors were linked to higher autonomy, including early entry into prenatal care, sufficient time during prenatal appointments, and midwife-led care. Midwife led care was the only contextual factor that was associated with significant increases in autonomy scores for minoritized people. ConclusionsSelf-determination, including the ability to lead decisions during pregnancy, birth and the postpartum period, is a reproductive right, yet minoritized communities reported significant loss of autonomy. Differences persisted across models of care, pointing to structural inequities in patient-led decision-making during pregnancy.