BMJ Sexual & Reproductive Health

Abstract Many women experience menopausal symptoms after stopping hormone replacement therapy (HRT). An evidence gap remains regarding how women and healthcare professionals (HCPs) make decisions about discontinuing and restarting HRT. Aim To explore experiences of HCPs that support women when they discontinue and restart HRT. Design and setting Qualitative study with HCPs working in NHS primary care. Method Semi-structured interviews with HCPs (n = 15) conducted between October 2025 and March 2026. A preliminary coding template was created using the discussion guide as a framework. Each interview was then coded inductively against the template which developed iteratively. Team based discussion helped refine codes into themes and sub-themes, and a subsequent conceptual model was created. Results The model describes HCPs experiences of supporting women to discontinue HRT as an iterative process characterised by uncertainty. Discussions about discontinuation were commonly prompted by changes in clinical risk or annual HRT review, but decisions about whether and when to stop also depended on womens symptoms, side effects, life stage and readiness. HCPs described agreeing an individualised discontinuation strategy, providing support during the process, and reviewing women after discontinuation to consider alternative treatments or, where appropriate, restarting HRT. Conclusion HCPs recognise the importance of readiness to discontinue and that decision making should be woman led, with HCP support, clear practice guidance and opportunities to revisit treatment. Further research is needed to support women weigh up their personalised risk and benefit of continuing/discontinuing and identify discontinuation strategies that limit resurgent symptoms.

Objective: to describe the provision of preconception care across publicly funded or contracted health and social care settings in the UK. Design and setting: online cross-sectional survey conducted October-December 2025. Population: healthcare professionals delivering preconception care, recruited via professional organisations and networks. Methods: quantitative data were analysed using descriptive statistics and qualitative free-text responses using inductive content analysis. Outcome measures: preconception care content, target population, frequency of provision, funding and commissioning models, and approaches for reporting and monitoring. Results: Eighty-seven healthcare professionals completed the survey. Most were women (89.3%), aged 41-60 (63.1%) and based in England (84.5%). Participants represented diverse roles, mainly obstetric/maternal-fetal specialists (23.0%), specialist nurses (16.0%), GPs and midwives (13.8% each). Preconception care primarily targeted women [≥]20 years (98.9%), with fewer targeting men and adolescents. Care was usually embedded within relevant consultations (69.4%), particularly contraception, medication and health condition reviews, and often a one-off interaction (75.3%). Content focused on condition-related management/medication (68.6%), folic acid (66.3%), risky behaviours (smoking, alcohol, illicit drugs) (40.7%), diet (37.2%) and weight (36.0%). Services were mostly not formally commissioned (62.4%), lacked financial incentives (84.7%) and had no audit/service evaluation requirements (81.2%). Conclusions: Preconception care in the UK is delivered by a wide range of healthcare professionals. Their engagement has improved considerably when compared with studies conducted over a decade ago, but preconception care remains fragmented, opportunistic and poorly supported by commissioning and system infrastructure. Strengthening integrated care pathways, funding mechanisms and use of standardised resources is essential to achieve consistent and equitable preconception care.

Background: Female sterilisation is the most widely used contraceptive method in India. But nationally representative evidence on the frequency, outcome and correlates of sterilisation failure remains scarce. The objectives of this study were to estimate the prevalence of contraceptive failure, describe the outcomes of pregnancies resulting from failure, determine the time interval between sterilisation and failure, and compute the Pearl Index. Methods: This secondary data analysis used the Individual Recode dataset of the National Family Health Survey 5 (NFHS 5). Sterilisation failure was derived from reproductive and contraceptive history variables. Weighted prevalence, socio-demographic and procedural correlates, and a Pearl Index were estimated using survey-adjusted statistical methods. Results: Among 189,021 women who had adopted sterilisation, 623 (weighted prevalence 0.34%) experienced a failure. The most common outcome of sterilisation failure was abortion (96.0%). The Pearl Index was 2.87 failures per 100 woman-years (95% CI: 2.58, 3.20). Failure was significantly associated with years since sterilisation, decade and age at sterilisation, marital duration, parity, place and type of sterilisation (all p<0.05), but not with education, religion, caste, or wealth index. Failures occurred at any point from one month to over a decade after the procedure, with a disproportionately higher share among women sterilised at mobile clinics/camps. Conclusion: Female sterilisation failure in India, while uncommon, is not negligible and persists well beyond the immediate postoperative period. Procedural quality of care, particularly at camp-based settings, appears to be a key modifiable driver. The postoperative counselling needs to include a clear message that a missed period any time after (months to year) sterilisation can be a pregnancy resulting from failure of sterilization.

Background There has been a proliferation of new person-centered and human rights-based contraception measures in recent years, though their application in research remains limited. Improved measures offer an opportunity to examine how contraceptive decision-making agency relates to individuals ability to act in line with their contraceptive preferences. We sought to assess the association between contraceptive agency and subsequent Preference-aligned Fertility Management (PFM) over 12 months in a cohort of women in rural Uganda. Methods We analyzed data from a prospective cohort study conducted in five largely rural Ugandan districts from 2022 to 2024. Data were collected at baseline, 6 and 12 months from a convenience sample of women who were new users of contraception or not using contraception. We used mixed-effects logistic regression models to examine the association between baseline Agency in Contraceptive Decisions Scale overall and subscale scores and future PFM Index scores at 6 and 12 months, assessing whether associations varied over time using interaction terms for follow-up time point. We used interactions between agency scores and follow-up visit to assess whether associations differed between the 6- and 12-month visits. We assessed effect modification by age group and baseline contraceptive method category using three-way interaction terms and predicted probabilities. Results The analytic sample comprised 2,227 women. The percentage of women practicing PFM increased from 85.7% at baseline to 93.3% at 12 months. A one-unit increase in Agency in Contraceptive Decisions Scale score was associated with higher odds of subsequent PFM (aOR: 1.68, 95% CI: 1.10-2.54). Subscales 3 (knowledge aligned with preferences) and 4 (control over use or non-use) of the Agency in Contraceptive Decisions Scale were significantly associated with future PFM (aOR: 1.31, 95% CI: 1.04-1.66 and aOR: 1.27, 95% CI: 1.06-1.51, respectively). The association between overall contraceptive agency and PFM did not differ between the 6- and 12-month visits. Three-way interaction tests suggested that the associations between the overall Agency in Contraceptive Decisions Scale score and the PFM outcomes varied jointly by age group and baseline contraceptive method category: overall PFM Index (p<0.001), PFM1 (p=0.011), and PFM2 (p<0.001). Conclusion Our findings suggest that higher levels of contraceptive agency may help women act in line with their contraceptive preferences. Increasing womens knowledge and control over contraceptive use may be particularly essential for preferred contraceptive use. The findings also suggest that the association between contraceptive agency and PFM may vary by womens age group and the method of choice, though further exploration is necessary to examine this influence.

Background: Pregnancy is a uniquely complex ethical and clinical context in which precision medicine approaches, including genomics-driven risk prediction tools, biomarker-based stratification, and data-intensive analytics, are rapidly evolving. There is a need for community consultation on the ethical, social, and practical implications of precision medicine in pregnancy research and healthcare. Aim: The primary aim of this study was to engage healthcare consumers to build consensus on the acceptability of precision medicine approaches in pregnancy research and healthcare. We also sought to identify consumer priorities for future research. Methods: A two-round modified Delphi study was conducted to determine consumer opinions on the use of precision medicine approaches in pregnancy research and healthcare. Seven in-person workshops (round one) were held, with purposeful recruitment to ensure a representative group of healthcare consumers who engage with the healthcare system during pregnancy. These included first-time parents, culturally and linguistically diverse women, Aboriginal and Torres Strait Islander women, and women and their partners who had experienced previous pregnancy complications. Recruitment was conducted through established advocacy networks, and each workshop was facilitated by representatives from each organization. A second-round online survey, based on workshop content, was completed to assess the acceptability of precision medicine and to determine consumer priorities for future precision medicine research on pregnancy health. Results: Precision medicine research and the implementation of new technologies in clinical care were acceptable to participants; however, the need for transparency and trust between participants and researchers regarding the use and storage of genetic material was highlighted, particularly among Aboriginal and culturally and linguistically diverse participants. Outcomes related to survival and perinatal complications (stillbirth, preterm birth, and labor complications) were the highest-rated consumer research priorities, along with maternal mental health and breastfeeding. When asked whether participants would like to see PM available as part of routine pregnancy care for conditions with available treatments, complete consensus (100%) was reached. Conclusion: Healthcare consumers strongly support the use of precision medicine in pregnancy research and its translation into routine clinical care, particularly when effective interventions are available. However, implementation must be underpinned by transparency, trust, culturally appropriate governance, and clear communication about the collection, storage, and use of genetic material. These findings provide a consumer-informed framework for prioritizing future precision medicine research and guiding its responsible translation into pregnancy care.

Background Chemsex, drug use before/during sex to facilitate and enhance the experience, is undertaken by a minority of gay, bisexual and other men who have sex with men (GBMSM), but evidence of chemsex prevalence in England is limited. This study describes trends in chemsex prevalence between 2022-2025 and identifies factors associated with chemsex amongst GBMSM in England. Methods Data from the RiiSH study (2022-2025), an annual online cross-sectional survey of GBMSM recruited through social networking/dating apps and community partners, were analysed. Trends in chemsex prevalence and adjusted prevalence were estimated using log-binomial regression models. The following seven variables were candidate factors associated with chemsex and were assessed through logistic regression: age, sexual orientation, education, employment, HIV status, HIV PrEP use, and sexual health service (SHS) use. Results 5728 GBMSM were included in this study. Adjusted chemsex prevalence varied from 6.1% in 2022 to 4.2% in 2023, 5.1% in 2024 and 6.8% in 2025. Chemsex was more likely in GBMSM who were: gay (aOR=1.57 versus other sexual orientations; 95%CI 1.11-2.29, p=0.01), unemployed (aOR=3.08 versus employed full-time; 95%CI 2.19-4.26, p<0.001); aged 35-59 versus 16-34 years (p<0.001), with recent HIV PrEP use (aOR=3.79 versus no recent use; 95%CI 2.63-5.56, p<0.001), SHS use (aOR=2.23 versus no recent use; 95%CI 1.76-2.83, p<0.001), and living with HIV (aOR=3.16 versus negative/unknown HIV status; 95%CI 2.43-4.09, p<0.001). Conclusions Chemsex prevalence was low and stable between 2022-2025. PrEP and SHS use were associated with chemsex, supporting integration of specialist support services within SHS.

Background: Artificial intelligence (AI) is increasingly used in healthcare, but data on its real-world use and perceptions among obstetricians and gynecologists remain limited. Objectives: To assess familiarity, use, perceptions, and expectations regarding AI among physicians practicing obstetrics and gynecology in France. Study Design: We conducted a cross-sectional survey between June 2 and July 30, 2025, mainly distributed through professional organizations or associations and social media. Participation was voluntary and self-selected. AI use was defined as any use of an AI tool in routine clinical practice, regardless of type or frequency. Comparisons were made between AI users and non-users and between junior and senior physicians. Results: Among 469 respondents, representing approximately 5% of the target population, 199 of 466 (42.7%) reported AI use in practice; three respondents were excluded from this analysis because of discordant questionnaire responses. AI use was associated with male gender and professional status, with residents more represented among users. Junior physicians reported greater AI use than senior physicians and expressed greater concern regarding medical confidentiality. Current applications primarily involved administrative tasks, medical writing, literature retrieval, and translation; anticipated future uses centered on clinical decision support and medical data interpretation. Perceptions of several AI applications differed between groups. Conclusions: AI was reported to be used by a substantial proportion of respondents, primarily for supportive and informational tasks. These findings support further evaluation of training, validation, governance, and safe implementation of AI in obstetrics and gynecology.

Population Services International (PSI) set out to demonstrate the engagement of the private sector in increasing access to modern contraceptives through innovative financing strategies, with a focus on marginalised populations, by implementing the SARAL or Universal Access to Quality Contraception (UAQ) project in the city of Agra, Uttar Pradesh. The objective of the UAQ program was to provide a full basket of choices of family planning methods to newly-married women, incentivising them to delay pregnancy for a specified period. A cross-sectional baseline survey was conducted in Agra during the month of June 2022, covering 1240 currently married women. Using baseline survey data, this paper examined the determinants of women's preference for an additional child, and whether supply-side family planning interventions alone are sufficient to drive adoption of family planning methods. Regression analysis was done to find the determinants of wanting more children and the determinants of the willingness to join the program. The results show that the two most significant variables in determining a womans preference for another child are the total number of children she already has, and not having any male children resulting in a strong son preference. The most significant variable in determining a womans preference for enrolling herself in the SARAL program is whether she has faced financial constraints in accessing family planning methods, with other determinants being inconvenience of using contraceptive methods, exposure to the governments outreach about family planning, and preference for a male child. The findings indicate that womens preferences for an additional child are mostly based on their own desires, and are generally determined by the number and gender of their existing children. However, when it comes to the use of family planning methods, the husbands views are a critical factor in making family planning decisions - this would imply that family planning programs need to reach out not just to women, but to their husbands as well. Raising awareness of, and increasing exposure to family planning services is much needed, and programs should incorporate a strong Information, Education and Communication (IEC) component.

Background Worldwide use of systemic menopausal hormone therapy (MHT) declined sharply after 2002 following reports of increased breast cancer and cardiovascular risks. Evidence that the benefit-risk balance depends on initiation timing and treatment patterns has renewed clinical interest in MHT recently. A comprehensive characterisation of utilisation patterns is thus needed to assess alignment with guidelines. We describe systemic MHT use among women aged [&ge;]45 years in France between 2011 and 2024. Methods In this descriptive nationwide study using the French National Health Data System (SNDS), we included 21,983,503 women aged [&ge;]45 years affiliated with the main health insurance scheme between 2011 and 2024. Systemic MHT was identified from reimbursements for drugs containing systemic oestrogen. Users had at least two reimbursements for systemic oestrogen (unopposed or with a progestogen) within 12 months, and initiators had no reimbursements in the preceding five years. Annual prevalence, initiation and discontinuation proportions were estimated overall and by age group. Results We identified 1,250,037 systemic MHT users and 578,668 initiators between 2011 and 2024. Annual prevalence decreased from 4.3% in 2011 to 2.0% in 2022, then stabilised, with a slight increase after 2022 among women aged 45-59 years. Prevalence was consistently highest among women aged 55-59 years. Initiation declined from 0.5% of women in 2011 to 0.2% in 2022, before increasing to 0.3% in 2024, and was highest among women aged 50-54 years. Discontinuation was highest among women aged 45-49 years, peaking in 2019, and remained stable in older age groups. Median age at initiation was 52 (Interquartile Range [IQR] 50-55) years, and median treatment duration was 2.1 (IQR 0.6-6.1) years. Most initiators (79.3%) started combined oestrogen-progestogen therapy. Oestradiol was used almost exclusively (98.5%), mainly transdermally (74.2%). Micronised progesterone was the predominant progestogen, used exclusively by 62.9% of combined therapy initiators, followed by dydrogesterone (9.2%). Conclusion After prolonged declining use, systemic MHT initiation increased modestly after 2022. Prescribing appeared broadly aligned with current recommendations favouring transdermal oestradiol combined with micronised progesterone, for relatively short durations. These findings provide a benchmark for public health authorities to monitor alignment between prescribing patterns and guidelines and inform future decisions.

Background Preventing sexually transmitted re-infections brings health benefits and can be significantly less costly than treating their sequelae. Safetxt is a potential novel digital intervention developed to promote safer sexual behaviours. However, a recent randomised controlled trial of safetxt found no effect on reinfection at 1 year (OR 1.13, 95%CI: 0.98-1.31). We investigated if safetxt's effect was mediated through sexually risky behaviours. Methods We used data from 6248 young people with STIs from 92 UK sexual health clinics. The direct and indirect effects of safetxt on reinfection were estimated using the counterfactual approach. Condom use at last sexual encounter, number of sexual partners and STI testing were assessed as mediators. These were analysed singly and together, using regression models and a formal weighting approach. The assumptions of each approach were considered and tested. Analyses were repeated in the subgroup showing the most promising effect of safetxt: men who have sex with men or with men and women (MSM/MSMW). Results No evidence was found for the total, indirect or direct effects differing from the null. Despite not being significant, for MSM/MSMW, some of safetxt's effect on reducing reinfection was identified as being offset through its effect on number of sexual partners. Conclusions There was no evidence that safetxt's effect on reinfection was mediated through changes in sexually risky behaviours. Adaptations to specifically target these behaviours are unlikely to improve safetxt's overall effect. However, improving safetxt's effect on the number of sexual partners a participant has may improve its effect for MSM/MSMW.

Background: Gender-affirming medical care (GAMC) for children and adolescents in Australia has become increasingly politicized, despite care being provided in accordance with latest evidence-based international guidelines. Critics of GAMC claim that current assessment and deliberation processes are insufficient, and that too many young people are accessing medical interventions, no longer identifying as trans, and expressing treatment regret. These claims have led to widespread bans on the provision of paediatric GAMC, despite growing evidence regarding harms caused by such bans. Aim: This study sought to describe the care journeys of the young people attending Australia's largest paediatric gender service, with a focus on reporting the rates at which young people commenced medical interventions, re-identified with their birth-assigned sex, and expressed regret about their treatment. Methods: The Royal Children's Hospital Gender Service (RCHGS) is a statewide service that provides individualised multidisciplinary care to trans and gender diverse young people in Victoria, Australia. An initial extended triage appointment explores the needs and goals of the young person and their family. Some proceed to receive individualised multidisciplinary care (MDC) at RCHGS which can include psychosocial assessment and management, family support, and medical interventions including pubertal suppression (PS) and gender-affirming hormonal therapy (GAHT). We undertook a retrospective file audit of all patients who had attended at least one RCHGS appointment and been discharged between 1/1/2017-31/12/2024. For each person, key data were extracted from their electronic medical record and recorded in REDCap. Results: 1,391 patients were discharged over the 8-year study period and many different care trajectories were observed. 814 (58.5%) did not access ongoing MDC. Of the remaining 577, 353 (25.4% of total cohort) started a medical intervention ((PS: n=64/1391 (4.6%); estradiol: n=97/1391 (7.0%); testosterone: n=244/1391 (17.5%)). For those who started these medical interventions, the median duration and number of sessions from first appointment until commencement of medications was 530 (IQR: 371-693) days and 9 (IQR: 7-13) sessions. 346 of these patients (98.0%) had data on gender identity at discharge and subsequent care pathways. 7 (2.0%) re-identified with their birth-registered sex and stopped treatment: 4 did so after commencing PS (4/61=6.6% of those starting PS), 2 did so after commencing testosterone, and 1 did so after commencing estradiol (3/341=0.9% of those starting GAHT). Just one of these patients, who had been on estradiol for 1 month, expressed treatment regret given concerns about initial breast budding and future fertility. Conclusion: This study highlights varied trajectories of those referred to paediatric gender services, directly challenges claims used to justify restrictions on paediatric GAMC and underscores the importance of a person-centred approach to care.

Abstract Background: We developed and evaluated a behaviour change intervention to improve health outcomes for pregnant women and neonates in rural Pakistan. Methods: We used a parallel, three-arm, unblinded, cluster randomised controlled trial design. Eligible clusters were upgraded health facilities plus all associated community health workers (CHWs) and catchment populations. Randomisation was by computer program (1:1:1 ratio). All pregnant women were eligible. Control CHWs provided usual care to pregnant women. Arm 1 CHWs provided structured birth planning, including birth preparedness and complication readiness planning, and a voucher allowing free travel to access emergency obstetric/neonatal care. Arm 2 CHWs provided structured planning alone. Co-primary outcomes were skilled (doctors and midwifery-trained cadres) birth attendance and neonatal mortality (NNM) at 28 days. Findings: Between November 2011 to May 2012, respectively in arms 1, 2 and the control 21,317, 19,267 and 18,867 women were recruited, and 21,214, 19,125 and 18,812 were followed-up and analysed. Vouchers were almost never used to reclaim travel costs. Skilled attendance was 64% (12,045/18,812) in the control arm, 72.3% (15,335/21,214) (adjusted odds ratio [aOR] 1.56 [95% CI: 0.93, 2.62; p = 0.21]) in arm 1 and 78.1% (14,944/19,125) (aOR 2.16 [95% CI: 1.29, 3.62; p = 0.007]) in arm 2. NNM was 13.4 (per 1,000 live births) in the control arm, 45 (aOR 2.32 [95% CI: 1.48, 3.63; p < 0.001]) in arm 1 and 16.2 (aOR 1.36 [95% CI: 0.84, 2.21; p = 0.21]) in arm 2. Conclusions: Birth planning had inconsistent effects on skilled attendance and NNM, including apparently negative effects on NNM, with concerns about the quality of midwifery care. However, the control arm and arm 2 NNM was improbably low for this setting, and bias in the outcome may explain the observed differences. The travel voucher was little used.

BACKGROUND: Sexual pleasure is integral to sexual health, offering important physical and mental benefits. Yet, sex education programs often neglect pleasure, focusing instead on preventing sexual risk behaviors (SRBs), which young adults are particularly vulnerable to. AIM: This study investigates the association between SRBs and sexual pleasure in young adults and whether sex assigned at birth moderates this relationship. METHODS: Embedded within the Generation R cohort, 1010 young adults completed an online questionnaire assessing sexual pleasure using the six subscales of the Amsterdam Sexual Pleasure Inventory (ASPI 1.0), Arousal Enjoyment, Enjoyment-Related Self-Efficacy, Enjoyment-Related Self-Worth, Interaction Enjoyment, Bonding Enjoyment, and Sexual Experience Enjoyment, and various SRBs including sexual debut <15 years, six or more lifetime partners, frequent unprotected sex, and substance use during sex. Multiple linear regression analyses were performed for each SRB and sexual pleasure subscale, adjusting for demographics, self-esteem, relationship status, socioeconomic status, and psychopathology, with additional stratification by sex assigned at birth. OUTCOMES: The primary outcome measure is sexual pleasure, measured across six domains, examined in relation to SRBs. RESULTS: Fully adjusted regression analyses showed that engaging in SRB was positively associated with several dimensions of sexual pleasure. All SRBs were associated with higher Enjoyment-Related Self-Efficacy (ERSE) scores (p<0.002). Early sexual debut was additionally linked to higher Interaction Enjoyment scores, while having six or more lifetime partners was associated with increased Enjoyment-Related Self-Worth and Sexual Experience Enjoyment scores (p<0.002). Some associations, particularly involving ERSE, were only significant among males. Individuals without partnered sexual experience reported lower sexual pleasure scores. CLINICAL IMPLICATIONS: Incorporating sexual pleasure into sex education could promote a more balanced, realistic understanding of sexuality among young adults, emphasizing both enjoyment and responsible sexual decision-making. STRENGHTS & LIMITATIONS: Key strengths of this study are the use of the multidimensional Amsterdam Sexual Pleasure Inventory (ASPI 1.0) and the large population-based cohort study design, enabling a nuanced and generalizable analysis. This study is limited by potential selection and reporting bias, the cross-sectional design, residual confounding, and the absence of universally agreed-upon thresholds for defining SRBs. CONCLUSION: These findings suggest there is a positive association between engagement in SRB and sexual pleasure, possibly reflecting greater overall sexual experience. The stronger associations observed among males might reflect gendered differences in the role of self-esteem and societal expectations.

Background: Post-abortion care (PAC) encompasses emergency treatment, counselling, contraceptive services, and referral linkages. Emergency post-abortion care (EPAC), the life-saving component of PAC, addresses acute abortion-related complications, including haemorrhage, sepsis, retained products of conception, and severe pain. In Uganda, where abortion is legally restricted and socially stigmatised, womens care experiences are shaped by clinical urgency, fear, moral vulnerability, provider interactions, and structural health system constraints. Despite EPACs centrality to maternal survival, qualitative evidence on how women interpret and evaluate their care experiences in referral hospital settings in Uganda remains limited. This study explored womens experiences of EPAC at Kawempe National Referral Hospital (KNRH) and identified the factors that shaped those experiences. Methods: A qualitative phenomenological design was employed. Sixteen in-depth interview transcripts from women who received EPAC at KNRH in March-April 2026 were analysed using inductive thematic analysis. The Socio-Ecological Model (SEM) was applied as an interpretive framework. Results: Six themes were identified: (1) survival and physical relief as the immediate measure of good care; (2) pain, fear, and emotional distress during treatment; (3) reassurance and support as buffers against vulnerability; (4) dignity under pressure: communication and privacy in EPAC; (5) structural barriers across the pathway of care; and (6) experiences beyond discharge: incomplete recovery and uncertainty. Care was frequently evaluated through the lens of survival, yet these accounts co-existed with intense procedural pain, compromised privacy, delays, financial burden, and inadequate post-discharge support. EPAC at KNRH was experienced as a complex encounter shaped by bodily vulnerability, interpersonal dynamics, and system-level constraints. Conclusions: Strengthening EPAC requires patient-centred approaches that integrate clinical effectiveness with respectful communication, pain management, improved triage, and structured post-discharge support.

Background: The Greater Manchester Care Record (GMCR) integrates health and social care data for 2.8 million individuals. While it contains maternity information, identifying individual pregnancies, including timing and outcomes, is complex due to variations in healthcare interactions and recording practices. This study develops open-source code to create a pregnancy register within the GMCR using diagnosis- and procedure-based algorithm established in other databases. Methods: 1,448 maternity SNOMED clinical codes identified pregnancy-related primary care records among women aged 14-49 years between March 2012 and August 2023. Codes were grouped by pregnancy outcome, with a hierarchical ruling approach where multiple outcomes appeared within one episode. Pregnancy start dates were derived from hierarchical coded events or imputed using biologically plausible duration based on outcome type. Internal validation compared GMCR register episodes against Hospital Episode Statistics (HES) hospital maternity admissions; external validation compared outcome rates against published UK estimates. Results: The algorithm was developed across 379,832 women, identifying 880,926 pregnancies. Internal validation showed nearly half of register deliveries had a corresponding HES record, with a positive predictive value (PPV) of 48.1%and a median date difference of 17 days (IQR 1-30). External comparison revealed live birth (927.8 vs. 995.6 per 1,000 deliveries) and stillbirth (2.12 vs. 3.9 per 1,000 births) rates close to national estimates but a notable discrepancy for miscarriage (8.00 vs. 15.3 per 100 pregnancies) and termination of pregnancy (5.36 vs. 25.1 per 1,000 women). Demographic alignment was strong for maternal age (31 vs. 29.8 years) and deprivation (IMD10 median: 3 vs. 2.6), though ethnic minority representation was expectedly higher in the GMCR (37.0% vs. 28.7%). Conclusions: This pregnancy register enriches the GMCR for maternal health research, enabling more comprehensive and regionally tailored studies to inform healthcare delivery and policy. This work represents an important first step in developing a scalable, open-source algorithmic tool to support pregnancy research across diverse populations. By making the code openly available, it can be adapted for use in federated data environments, enhancing reproducibility and collaboration.

Contraception is important for preventing unintended pregnancies and reducing maternal and infant mortality. Among women living with HIV (WLHIV), it is also central to preventing vertical HIV transmission. Yet unmet need for contraception remains high among WLHIV in sub-Saharan Africa. Mental health symptoms may contribute to unmet need, but evidence among WLHIV remains limited. We examined the relationship between depression and anxiety and unmet need for contraception. We used baseline survey data from Kenyan WLHIV receiving routine HIV care participating in a cluster randomized clinical trial evaluating a reproductive health counselling intervention at 10 HIV clinics. Women who were fecund, did not desire a pregnancy within two years, and not using a modern method of contraception were considered to have unmet need for contraception and were eligible for this analysis. Surveys captured data on depression, anxiety, fertility intentions and contraceptive use. We constructed separate generalized linear models to assess the relationship between depression and/or anxiety and unmet need for contraception.

Background Cancer stigma contributes to low cervical cancer screening rates among Nepali women. However, no stigma reduction interventions have been implemented thus far in Nepal. This study assessed the effectiveness of a muticomponent cervical cancer stigma reduction intervention on cancer stigma scores and cervical cancer screening uptake rates among urban Nepali women. Methods A two-arm, parallel cluster-randomized trial was conducted in Budhanilkantha Municipality, Kathmandu District, Nepal. Twelve administrative wards were randomized in a 1:1 ratio to the intervention or control group, with wards serving as the unit of randomization and individual women as the unit of analysis. A total of 310 women aged 30-60 years who had not undergone cervical cancer screening during the previous five years were enrolled. The three-hour intervention included cervical cancer education, a video featuring cervical cancer survivors, participatory group discussions, and myth-versus-fact activities addressing cancer stigma. Cancer stigma was assessed two months after the intervention using the Nepali version of the Cancer Stigma Scale. Cervical cancer screening uptake was assessed six months after the intervention. Data were analyzed using intent-to-treat and as treated approaches with a generalized estimation equation with logistic regression. Results From June 2022 to February 2023, 310 women were enrolled. At 2 months, stigma data were available for 248 participants (120 intervention, 128 control). In the intention-to-treat analysis, the odds of cancer stigma were lower in the intervention group than in the control group (OR 0.25, 95% CI 0.08 to 0.8; p=0.022). Odds were also lower for the severity domain (OR 0.31, 95% CI 0.10 to 0.90; p=0.048) and awkwardness domain (OR 0.21, 95% CI 0.08 to 0.56; p=0.001) with no differences in other subdomains. At 6 months, the odds of cervical cancer screening was 3.9 times greater in the intervention group than in the control group (95% CI: 1.1-13.20, p=0.028). As treated analysis reinforced these findings, with lower odds of stigma (AOR:0.09, 95% CI: 0.01-0.53, p=0.007), severity (AOR:0.16, 95% CI: 0.06-0.42, p<0.001), and awkwardness (AOR:0.1, 95% CI: 0.02-0.44, p=0.02). Cervical cancer screening odds was 4.02 times higher in the intervention group (95% CI:1.1-13.7, p=0.026). Conclusions Compared with the control condition, participants allocated to a community-based multicomponent intervention designed to reduce cancer stigma had lower odds of elevated cancer stigma two months after the intervention and higher odds of cervical cancer screening by six months. Larger cluster-randomized trials with more clusters and longer follow-up are needed to assess the reproducibility, durability, and generalizability of these findings.

Stigmatizing language in medical documentation may reflect and perpetuate bias, but its prevalence in obstetrics has not been systematically quantified. We applied a keyword-guided BERT classifier to 640,345 obstetric notes from 26,178 pregnancies at an academic medical center. Stigmatizing language was detected in 47% of 26,178 pregnancies. Black pregnancies had significantly higher odds of stigmatizing language compared with Asian (aOR=1.5, p=3x10-8) or White (aOR=1.4, p=6x10-6). Indicated and spontaneous preterm births were also significantly associated with stigmatizing language compared to term (aORs=1.5, 1.2; p=7x10-12, 0.01). Pregnant individuals with only 12th-grade maternal education were more likely to experience stigma than those with college (aOR=1.5; p=4x10-14). These findings provide evidence of differences in clinical documentation across race, education levels, and clinical conditions. They also demonstrate how automated natural language processing can enable systematic monitoring of bias in healthcare language at scale.

Abstract Background: The qualitative study was conducted to understand the socio-cultural factors (challenges and enabling factors) those influence the decisions and ability of the pregnant women and their families to make better use of the available safe birthing and EmONC services in two districts (Khanewal and Jhang) of Punjab, Pakistan. Objectives: To explore the key social, personal and professional considerations (factors) that influence the women (and family) decision and ability to utilise various birthing and EMONC services and to understand care providers interest and ability to offer these safe birthing services in the districts of Jhang and Khanewal in Pakistan. Study Design: The qualitative study was conducted, during the year 2013/14, on three rural health centers and two district headquarter hospitals in Kanewal and Jhang districts in Punjab. Through purposive sampling, 42 registered clients were interviewed to explain the different birthing experience along with 15 service providers, 2 district level programme managers and 2 transport vendors. The collected qualitative data from interviews were transcribed, and key emerging concepts/ themes were identified. A range and continuum of coded responses/ comments were compiled and discussed under each theme. Results: Main themes were structured birth planning; antenatal at health centres; skilled birth attendance; emergency obstetric and neonatal care (EmONC); and EmONC travel. The study found that pregnant women consult their husbands and mother in laws for taking birthing decisions; consult the skilled birth attendant for management of complication; private clinics are preferred for various social and logistic reasons; many private clinics doing caesarean are not adequately equipped; male reluctance (for cultural reasons) to make in-advance transport arrangement for possible EmONC; travel voucher utilisation remained low because of limited coverage and less-friendly procedures. Conclusion: Safe birthing decisions could be complex; and influenced by multiple social, cultural, economic, service access and quality considerations. Safe birthing practices can be improved if interventions remain sensitive to these preferences and realities. Keywords: Skilled birth attendance, social determinants, lady health workers, birth planning

BACKGROUND Extensive research has documented medication abortion safety. Large-scale insurance claims data offer an important complement to clinical studies by assessing real-world outcomes in routine practice. In claims data, researchers must infer mifepristone use, clinical outcomes, and event severity from diagnosis, treatment, and utilization codes. Understanding how these analytic choices influence safety and effectiveness estimates is important for interpreting evidence used to inform care delivery and medication policy. METHODS We conducted a retrospective cohort study of mifepristone use with national multipayer claims data, both medical and pharmacy, from 2017 through 2023. We identified both a broad cohort and a more specific medication-abortion cohort after excluding evidence of other indications. We classified potential safety events, effectiveness outcomes, and health care utilization within 45 days of mifepristone use. Serious adverse events required claims-observable consequences consistent with FDA seriousness criteria. RESULTS The broad cohort included 869,409 mifepristone uses among 698,780 unique patients for medication abortion or other indications. After restriction to uses with additional evidence of medication abortion, 775,931 uses among 626,443 unique patients remained. In the medication-abortion cohort, 3,306 uses were followed by at least one serious adverse event, resulting in an absolute 45-day risk of 0.43%. Serious bleeding or hemorrhage occurred after 0.24% of uses, serious infection or sepsis after 0.05%, serious hypersensitivity or anaphylaxis after 0.01%, and serious ectopic-pregnancy outcomes after 0.05%. CONCLUSIONS Serious adverse events after mifepristone use were rare in this national study. Applying established, clinically grounded criteria markedly reduced the number of events classified as serious.