CONTEXT State legislation restricting access to abortion in the clinic setting raises the possibility that an increasing number of individuals in the United States will self-manage their abortion at home. Medications sourced online represent a potential pathway to abortion self-management. Yet, very little is known about the reasons U.S. residents may seek abortion online or their experiences finding medications and information. METHODS In January-June 2017, anonymous in-depth interviews were conducted with 32 people from 20 states who sought abortion medications online (30 women and two men seeking medications for their partners). Participants were asked about their (or their partners') motivations for considering self-managed abortion, the sources of medications they identified and any other methods they considered. Transcripts were coded and analyzed according to the principles of grounded theory. RESULTS The analysis revealed four key themes: Seeking abortion medications online can be a response to clinic access barriers both in states with and in ones without restrictive abortion laws; self-managed abortion can be a preference over clinical care; online options offer either information or medications, but not both; and the lack of trusted online options can delay care and lead to consideration of ineffective or unsafe alternatives. CONCLUSION Current online options for abortion medications leave many important needs unmet, particularly for women who encounter barriers to obtaining clinic-based abortion services. There is a public health justification to reduce clinic access barriers and to make medication abortion that is sourced online and managed at home as safe and supported as possible.

Motivations and Experiences of People Seeking Medication Abortion Online in the United States.

To evaluate the feasibility of conducting a prospective study to measure self-managed medication abortion outcomes, and to collect preliminary data on safety and effectiveness of self-managed medication abortion, we recruited callers to accompaniment groups (volunteer networks that provide counselling through the out-of-clinic medication abortion process by trained counselors over the phone or in-person). In 2019, we enrolled callers to three abortion accompaniment groups in three countries into a prospective study on the safety and effectiveness of self-managed medication abortion with accompaniment support. Participants completed up to five interview-administered questionnaires from baseline through 6-weeks after taking the pills. Primary outcomes included: (1) the number of participants enrolled in a 30-day period, (2) the proportion that had a complete abortion; and (3) the proportion who experienced any warning signs of potential or actual complications. Over the 30-day recruitment period, we enrolled 227 participants (95% of those invited), and retained 204 participants (90%) for at least one study follow-up visit. At the 1-week follow-up, two participants (1%) reported a miscarriage prior to taking the pills, and 202 participants (89% of those enrolled and 99% of those who participated in the 1-week survey) had obtained and taken the medications. Three weeks after taking the medications, 192 (95%) participants reported feeling that their abortion was complete. Three (1.5%) received a surgical intervention, two (1%) received antibiotics, and five (3%) received other medications. Participants did not report any major adverse events. These results establish the feasibility of conducting prospective studies of self-managed medication abortion in legally restrictive settings. Further, the high effectiveness of self-managed medication abortion with accompaniment support reported here is consistent with high levels of effectiveness reported in prior studies. Trial registration ISRCTN95769543.

/pdf/self-managed-medication-abortion-outcomes-results-from-a-4z6hgmvep6.pdf

Self-managed medication abortion outcomes: results from a prospective pilot study

Background: In order to prevent spread and improve control of infectious diseases, public health experts need to closely monitor human and animal populations. Infectious disease surveillance is an established, routine data collection process essential for early warning, rapid response, and disease control. The quantity of data potentially useful for early warning and surveillance has increased exponentially due to social media and other big data streams. Digital epidemiology is a novel discipline that includes harvesting, analysing, and interpreting data that were not initially collected for healthcare needs to enhance traditional surveillance. During the current COVID-19 pandemic, the importance of digital epidemiology complementing traditional public health approaches has been highlighted. Objective: The aim of this paper is to provide a comprehensive overview for the application of data and digital solutions to support surveillance strategies and draw implications for surveillance in the context of the COVID-19 pandemic and beyond. Methods: A search was conducted in PubMed databases. Articles published between January 2005 and May 2020 on the use of digital solutions to support surveillance strategies in pandemic settings and health emergencies were evaluated. Results: In this paper, we provide a comprehensive overview of digital epidemiology, available data sources, and components of 21st-century digital surveillance, early warning and response, outbreak management and control, and digital interventions. Conclusions: Our main purpose was to highlight the plausible use of new surveillance strategies, with implications for the COVID-19 pandemic strategies and then to identify opportunities and challenges for the successful development and implementation of digital solutions during non-emergency times of routine surveillance, with readiness for early-warning and response for future pandemics. The enhancement of traditional surveillance systems with novel digital surveillance methods opens a direction for the most effective framework for preparedness and response to future pandemics.

/pdf/data-and-digital-solutions-to-support-surveillance-40ekgi0qf1.pdf

Data and Digital Solutions to Support Surveillance Strategies in the Context of the COVID-19 Pandemic.

Introduction Strategies of harm reduction (HR) include policies and community-based measures aimed to reduce the risk of self-harm while continuing potentially hazardous behaviors, such as illegal drug, alcohol, and tobacco use. Objectives To assess whether and to which extent strategies of HR could have beneficial, or harmful, effects on sexual and reproductive health, for general and at-risk populations. Methods A literature research was performed between July 2020 and January 2021, investigating the association between harm reduction strategies and sexual and reproductive health. Results HR strategies are mostly aimed at providing support to at-risk population, such as injection drug users or sex workers. Alcohol and drug use, smoking and high-risk sexual behaviors are among the main targets for HR strategies. Barriers to access, such as stigma, marginalization or lacking awareness, are often present as negative risk factors and require attention from professionals. Preventing sexually transmitted infections (STIs), early/unwanted pregnancies and violence are the most important results HR programs could provide for sexual and reproductive health. However, evidence is limited and often qualitative, rather than quantitative. Conclusion HR strategies are important measures to improve sexual and reproductive health in at-risk populations. Increasing personal and social awareness is a key factor for the success of HR programs. A Sansone, E. Limoncin, E Colonnello, et al. Harm Reduction in Sexual Medicine. Sex Med Rev 2021;XX:XXX–XXX.

Harm Reduction in Sexual Medicine.

### Summary box

With unsafe abortion a significant cause of maternal mortality and morbidity, especially in poor and crisis settings, Medecins Sans Frontieres (MSF) calls for the urgent expansion of contraception and safe abortion care (SAC) during the COVID-19 pandemic. The development of self-managed models of care through engagement with women and their communities is needed to prevent a spike in these avertable deaths.

While the COVID-19 pandemic is unprecedented in many ways, experience from previous humanitarian emergencies shows that when routine healthcare services are disrupted, the consequences can be catastrophic, especially for women and children who are disproportionately affected by crisis.1 For example, reports from the 2014–2015 Ebola epidemic suggest that the shutdown of routine services resulted in more maternal and child mortality and morbidity than the outbreak itself.2 3 Here we argue that despite this compelling evidence on the indirect but devastating impact of epidemics, the global health community is dangerously close to repeating similar mistakes with regard to an often-neglected aspect of sexual and reproductive health (SRH): access to safe abortion and contraceptive services that reduce numbers of potentially fatal or debilitating pregnancy-related complications.

The current crisis has intensified the need for SRH …

https://gh.bmj.com/content/bmjgh/5/7/e003175.full.pdf

Now is the time: a call for increased access to contraception and safe abortion care during the COVID-19 pandemic.

Background In Peru, abortion is legal only to preserve the life and health of the woman. A non-profit clinic system in Peru implemented a harm-reduction model for women with unwanted pregnancy that included pre-abortion care with instructions about misoprostol use and post-abortion care; they started offering telephone follow-up for clients in 2011. This study aimed to evaluate the effectiveness and safety of the harm-reduction model, and to compare outcomes by type of follow-up obtained. Methods Between January 2012 and March 2013, 500 adult women seeking harm-reduction services were recruited into the study. Telephone surveys were conducted approximately four weeks after their initial harm-reduction counseling session with 262 women (response rate 52%); 9 participants were excluded. The survey focused on whether women pursued an abortion, and if so, what their experience was. Demographic and clinical data were also extracted from clinic records. Results Eighty-six percent of participants took misoprostol; among those taking misoprostol, 89% reported a complete abortion at the time of the survey. Twenty-two percent obtained an aspiration after taking misoprostol and 8% self-reported adverse events including hemorrhage without transfusion, infection, or severe pain. Among women who took misoprostol, 46% reported receiving in-person follow-up (in some cases both telephone and in-person), 34% received telephone only, and 20% did not report receiving any form of follow-up. Those who had in-person follow-up with the counselor were most likely to report a complete abortion (<0.001). Satisfaction with both types of follow-up was very high, with 81%-89% reporting being very satisfied. Conclusions Liberalization of restrictive abortion laws is associated with improvements in health outcomes, but the process of legal reform is often lengthy. In the interim, giving women information about evidence-based regimens of misoprostol, as well as offering a range of follow-up options to ensure high quality post-abortion care, may reduce the risks associated with unsafe abortion.

/pdf/a-harm-reduction-model-of-abortion-counseling-about-5np2mo5roh.pdf

A harm-reduction model of abortion counseling about misoprostol use in Peru with telephone and in-person follow-up: A cohort study

The emergence of the Zika virus (ZIKV) in Latin America and the Caribbean during the 2015-2016 outbreak has required local health systems to adapt, suddenly and continuously. This field action report explores the outbreak's sexual and reproductive health (SRH) complexities and the experience of the International Planned Parenthood Federation (IPPF) and 4 of its member associations as part of the United States Agency for International Development's rapid response in the region. It outlines approaches and actions that IPPF and its member associations undertook over 3 broad programmatic phases-developing ZIKV protocols and training personnel; delivering ZIKV-integrated services and information; and providing screening, care, and support for children and families affected by congenital Zika syndrome (CZS)-as the project worked to integrate ZIKV prevention, screening, and response within SRH service delivery models. It also describes the challenges and lessons learned in implementing a ZIKV response program in the region and recommendations from a service delivery perspective that can be useful in informing the responses to future rapid onset epidemics with SRH relevance. Challenges identified include adapting to a rapidly evolving evidence base during the early stages of the epidemic; traditional and restrictive regional social norms around gender, sex, and sexuality; the lack of focus on sexual transmission in national ZIKV public health messaging; and a lack of services, government support, and referral pathways for supporting children and families affected by CZS. Some of the key recommendations include finding ways to share rapidly evolving clinical updates conveniently and frequently, such as through digital technologies and platforms; partnering with multidisciplinary organizations, such as disability rights and services organizations, that can fill gaps in needed services; and leveraging the need for urgent action as a catalyst of change around more inclusive and gender-transformative social norms and services.

/pdf/rapid-integration-of-zika-virus-prevention-within-sexual-and-xka90ufmt0.pdf

Rapid Integration of Zika Virus Prevention Within Sexual and Reproductive Health Services and Beyond: Programmatic Lessons From Latin America and the Caribbean

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A harm-reduction model of abortion counseling about misoprostol use in Peru with telephone and in-person follow-up: A cohort study

Rapid Integration of Zika Virus Prevention Within Sexual and Reproductive Health Services and Beyond: Programmatic Lessons From Latin America and the Caribbean