OBJECTIVES:To examine longitudinal trends in the provision of medication abortion (MA) in Australian general practice. STUDY DESIGN:Retrospective study of Australian females aged 14-49 years attending Australian general practices between 2014 and 2021. Data were sourced from the national general practice dataset, MedicineInsight. We calculated rates of MA provision and reported characteristics of those receiving and providing MA services. RESULTS:We identified 4306 instances of MA provision to 3980 unique individuals. The rate of MA provision increased from 0.11 per 1000 females in 2014/15 to 2.10 per 1000 females in 2020/21. A greater absolute increase in the rate of MA was evident among those aged 25-29 years, those residing in regional areas or those in areas of lower socioeconomic status. The proportion of general practices providing MA increased from 4.4% in 2014 to 22.7% in 2021. The proportion of general practices providing MA was higher among those located outside of major cities and in higher socioeconomic status areas. CONCLUSIONS:Despite modest increases in the rates of MA provision in general practice over time, less than one third of general practices provide MA. Significant geographical variation in MA provision is also evident according to remoteness, socioeconomic status and state/territory. The findings emphasise the need for additional initiatives to ensure equitable access to abortion care within the general practice setting, and future research should examine the underlying reasons for differences in MA uptake by patient characteristics and geographical location, informing targeted interventions and service planning.

BACKGROUND:There is a lack of evidence regarding the impact of body weight on the safety of surgical abortion. STUDY DESIGN:We performed a systematic review and meta-analysis of observational studies reporting the effects of obesity on perioperative anaesthetic and surgical outcomes during surgical abortion. Analytical observational studies examining individuals undergoing surgical abortion up to 28 weeks gestation were eligible for inclusion if they reported perioperative anaesthetic or surgical outcomes in participants with body mass index (BMI) in two groups: BMI < 30 kg/m2 and BMI ≥ 30 kg/m2. Sub-analyses were performed comparing outcomes in those with BMI < 30 kg/m2 and ≥ 40 kg/m2. RESULTS:Eight retrospective cohort studies were included, comprising 9912 obese and 31 672 non-obese participants. 1770 participants had BMI ≥ 40 kg/m2 and only 71 had BMI ≥ 50 kg/m2. BMI ≥ 30 kg/m2 was not associated with an increase in major surgical adverse outcomes (RR [95% CIs] 1.16 [0.83-1.62]) compared to BMI < 30 kg/m2. BMI ≥ 40 kg/m2 was associated with increased risk of major complications (RR [95% CIs] 2.60 [1.28-5.28]) based on low-quality evidence from two studies on second-trimester surgical abortion. Anaesthetic adverse outcomes were rare and not increased by BMI ≥ 30 kg/m2 (RR [95% CIs] 1.02 [0.50-2.06]) or BMI ≥ 40 kg/m2 (RR [95% CIs] 2.0 [0.55-7.24]). CONCLUSIONS:Anaesthetic and surgical risks are not increased by BMI ≥ 30 kg/m2. Individuals with BMI ≥ 40 kg/m2 may have increased risk of major surgical complications. The lack of sufficient data on those in the BMI ≥ 40 kg/m2 and BMI ≥ 50 kg/m2 categories underscores the need for further research to ensure high-quality abortion care for this population.

BACKGROUND:It is unclear whether previous caesarean section (CS) increases the risk of complications during surgical abortion. AIMS:To compare surgical abortion complication rates in women with a history of previous CS to those without previous CS. MATERIALS AND METHODS:Four databases were systematically searched in July 2024. Primary studies in English reporting on surgical abortion complications in women with and without a history of previous CS were included. Overall complications and major complications were compared between women with and without previous CS using a random effects meta-analysis. Sub-analyses were performed in women with > 1 previous CS, and incidence of emergency hysterectomy. Certainty of evidence was assessed using GRADE. RESULTS:Ten retrospective cohort studies with 3123 women with and 14,514 without a previous CS were included in the meta-analysis. The overall incidence of major complications from surgical abortion was 0.9 %. Previous CS was associated with an increase in overall complications (OR = 2.00, CI 1.32-3.04, p = 0.001) and major complications (OR = 2.82, CI 1.83-4.36, p < 0.00001). Major complications included haemorrhage requiring transfusion, uterine perforation and unplanned laparoscopy/laparotomy, while minor complications included cervical laceration and the need for repeat evacuation. There were no cases of uterine rupture during pre-procedural cervical ripening. Hysterectomy was an exceptionally rare occurrence (0.05 %); low-quality evidence from seven studies showed an association between history of CS and need for emergency hysterectomy (OR = 8.73, CI = 1.83-41.61, p = 0.007). The quality of the evidence was judged to be very low to medium mainly due to risk of bias of the included studies. CONCLUSION:While major surgical complications of surgical abortion are rare, women with a prior history of CS were more than twice as likely to experience a complication.

OBJECTIVES:To investigate the association between previous cesarean section (CS) and major complications during first- and second-trimester surgical abortion. STUDY DESIGN:We conducted a national retrospective case-control study using prospectively collected data from all MSI Australia surgical abortion facilities between 2016 and 2024. Individuals undergoing surgical abortion between 5 + 0 and 23 + 6 weeks' gestation were eligible. Cases were procedures complicated by hemorrhage ≥ 500 mL, transfusion, uterine perforation, hospital transfer, laparotomy, laparoscopy, or hysterectomy. Each case was matched to four gestation-matched controls (±3 weeks) through a blinded process. A composite severe outcome included hysterectomy, laparotomy, intensive care admission, disseminated intravascular coagulation, or massive hemorrhage (≥2000 mL). Logistic regression estimated adjusted odds ratios (aORs) with 95% confidence intervals (CIs). RESULTS:Among 159 major-complication cases and 636 gestation-matched controls, a history of previous CS was more common among cases than controls. After adjustment for age, gestational age, parity and body mass index, previous CS remained associated with increased likelihood of being a case (aOR 2.6, 95% CI 1.7-4.0). Odds of being a case increased with increasing numbers of previous CS (aOR 2.0 per cesarean, 95% CI 1.5-2.6). Previous CS was more common among composite severe adverse outcome cases than controls (OR 9.56, 95% CI 4.34-21.04). CONCLUSION:A history of previous CS was more common among cases than controls, with the odds of being a case increasing according to the number of prior CS. These findings may assist counseling, pre-procedure assessment and perioperative planning for patients with a history of cesarean birth. IMPLICATIONS:Previous cesarean section was more common among cases than controls, including cases with severe adverse outcomes. Increasing numbers of prior cesarean sections were associated with higher odds of being a case. These findings may inform counseling and perioperative planning.

Long-acting reversible contraceptive methods, including the contraceptive implant and intrauterine devices, are highly effective and cost-effective options for women who have no specific contraindications. Long-acting reversible contraceptives are more effective at reducing unintended pregnancy than short-acting contraceptives. Short-acting contraceptive methods consist of combined hormonal contraception (e.g. the combined oral contraceptive pill, vaginal ring), progestogen-only pills, and the progestogen-containing contraceptive injection. Choice of contraception is based on factors such as medical eligibility (i.e. precautions, contraindications), patient preference and reproductive life stage. Counselling patients on the benefits and risks of all contraceptive methods is important for informed decision-making. Regular contraceptive review can allow for patient education and monitoring of adverse effects.

Unsafe abortion is a preventable contributor to maternal morbidity and mortality, particularly for young unmarried women in low resource settings. In Papua New Guinea, abortion is legally restricted and highly stigmatised, limiting access to safe abortion and post-abortion care, resulting in unsafe abortion. This paper explores young people's lived experiences and agency in relation to unsafe abortion. We undertook qualitative research between 2019 and 2021 in rural, peri-urban and urban settings in Papua New Guinea and found that agency was enacted or constrained at different points along their abortion trajectories. Findings demonstrate the ways in which abortion was negotiated within (and outside of) young people's intimate relationships, while highlighting the social, temporal and emotional dimensions of this agency. By considering what agency means, and the different forms it takes, it is possible to identify critical support mechanisms and socio-structural changes that could support young people at different stages of their abortion trajectories, from accessing modern contraceptives to prevent unintended pregnancy, to seeking support for safe abortion. Moving forward, we call for greater attentiveness to young people's everyday lived experiences of sexual and reproductive health as a basis for understanding how to support them to safely prevent and manage unintended pregnancy.

Numerous community and professional myths and misconceptions around hormonal contraception exist, many promulgated through social media. As a result of these and other factors, people are moving away from hormonal methods and potentially exposing themselves to increased risk of unintended pregnancy. A number of key myths and misconceptions have been identified in a range of papers and here we summarise the evidence around the basis for these misunderstandings. The themes we explore are the physical side effects, the mental health effects, the impact on sexuality, the concerns about infertility, the concept of “unnaturalness”, concerns about menstruation, concerns about safety and destigmatisation of side effects. For many of these themes, there is some evidence justifying the concern, but overall for most people, we argue that the benefits of hormonal contraception outweigh the disadvantages.

BACKGROUND:Unsafe abortions are a leading cause of maternal mortality. This study aimed to conduct a legislative analysis and scoping review to i) describe the abortion laws in Papua New Guinea (PNG), Fiji, Vanuatu, Solomon Islands, and Samoa, ii) identify what safe and unsafe abortion practices and services are available in these countries, and iii) understand women's experiences of accessing these services. METHODS:Abortion law data for these five countries were extracted and examined from the Global Abortion Policies Database. A scoping review identified relevant peer-reviewed and grey literature. Studies from all years and all languages were eligible. A systematic search was conducted on 1 December 2024 using Medline (Ovid), Embase (Ovid), and CINAHL (EBSCO) databases. Additionally, we hand-searched Google Scholar and the websites and databases of organisations focused on sexual and reproductive health (SRH) in the selected Pacific Island countries. Two independent reviewers screened studies for eligibility using Covidence software. An expert advisory group of Pacific Islander clinicians guided this review. RESULTS:The legislative analysis revealed that abortion laws are generally unclear and restrictive in all five countries. Fiji has the most legal grounds for abortion (five), while Vanuatu has the fewest (one). In all five countries, abortion law specifies penalties (imprisonment) for women, providers, and anyone assisting with abortion. The scoping review included 17 articles: 10 from PNG, three from Vanuatu, one from the Solomon Islands, one from Fiji, and two from the Pacific Islands. Studies discussed various abortion strategies and experiences of post-abortion care, but none discussed safe abortion care. Misoprostol use was widely documented to induce abortion. Unsafe abortion methods included using various physical means and consuming traditional herbs. Women lacked control over abortion decision-making and described their experiences seeking post-abortion care for complications. CONCLUSION:We found limited evidence surrounding safe abortion services in these five countries. Future research should examine what optimal safe abortion care may look like within these countries' health systems. Concerted advocacy is necessary to drive legislative reform, dismantle barriers, and create an enabling environment for safe abortion services, thereby facilitating the achievement of SRH and rights.

PROBLEM:Many women lack access to contraception information and services during pregnancy and postnatally and are at risk of unintentionally falling pregnant again soon after birth. BACKGROUND:Contraception enables women to attain their desired number and spacing of births. Better access to postpartum contraception is critical for informed decision-making, higher uptake and improved health outcomes. Home-based provision of the contraceptive implant may contribute to increasing access. AIM:To explore the views of midwives on the implementability of midwives providing contraceptive implants during postnatal home visits METHODS: We conducted an exploratory qualitative interview study with 21 midwives. Reflexive thematic analysis was used to construct themes. FINDINGS:Home implant insertions were seen as generally acceptable and potentially feasible. Midwives' primary concerns related to workload and scheduling, although most felt this could be manageable, particularly in continuity models. Two factors to promote implementability included i) enhanced 'contraception conversations' in maternity settings, and ii) strong leadership and support, including a policy and training framework, opportunities for practice, and consideration of workload. DISCUSSION:Midwives felt home insertions would be well-suited to continuity care models. Although this may be a beneficial starting point, it means key groups of women who would also benefit from contraception may be missed. CONCLUSION:Midwives viewed provision of home implant insertions as generally acceptable and potentially feasible, in the context of early and ongoing contraception conversations and proper planning and support. Further research trialling implant insertions during midwife postnatal home visits is warranted to determine feasibility and acceptability in real settings.

PROBLEM:Limited awareness about the importance of preconception health is a recognised barrier to preparing for pregnancy. BACKGROUND:Opportunities exist to improve the health of future parents through preconception care. One of the recognised barriers to pregnancy preparation is a lack of knowledge and a lack of presentation for information and care. AIM:To explore the understanding of "preconception health" amongst people of reproductive age in Australia to inform the delivery of preconception care. METHODS:A qualitative descriptive study using online interviews with people of reproductive age in Australia. Recruitment was via social media (Facebook). Interview transcripts were analysed thematically. FINDINGS:Of the 20 women and five men we interviewed, all acknowledged the importance of preparing for pregnancy. Despite broadly understanding the concept, most participants had limited understanding of the details of preconception health. To increase their knowledge, participants' preferred sources of information included education in schools, reputable online sources, primary and maternity healthcare providers, and community members with lived experience. DISCUSSION:People in Australia are keen to learn about preparing for pregnancy and appreciate this as important. Suggested avenues to improve awareness and understanding about optimal preconception health included through school education, primary and reproductive healthcare providers, and online resources. This can improve understanding and behaviours before first and subsequent pregnancies. CONCLUSION:Preconception care requires a life-course approach, beginning with universal education through schools, enhanced by readily accessible reputable online resources, and access to trusted primary and maternity care providers. Maternity care providers can be key drivers in this process.

Violence against women remains a severe human rights violation and public health challenge across Asia and Oceania, with significant variations in prevalence and response capacity among countries. Despite global frameworks such as the Convention on the Elimination of All Forms of Discrimination Against Women and regional initiatives like the ASEAN Declaration on the Elimination of Violence Against Women and Violence Against Children, implementation gaps hinder effective protection. The Asia‐Oceania Federation of Obstetrics and Gynaecology (AOFOG) Declaration on Violence Against Women: A Commitment to Action and Change reinforces key commitments across 10 action areas, including recognizing violence against women as a critical issue, advancing international agreements, strengthening regional cooperation, mobilizing stakeholders, empowering healthcare professionals, enhancing comprehensive services, promoting public education, improving healthcare training, supporting research and data collection, and preparing for crisis responses such as pandemics. Emphasizing evidence‐based policymaking and regional collaboration, the Declaration establishes a roadmap for accountability through robust monitoring and evaluation. By uniting stakeholders across sectors, AOFOG aims to eliminate VAW and foster environments where women's rights, safety, and dignity are universally upheld. This Declaration was officially presented at the 28th AOFOG Congress held in Busan, Korea, on May 18, 2024.

BACKGROUND:Prevention and self-management of lifestyle risks can reduce non-communicable disease risks and improve the health of mothers and their children. We explored Australian women's preferences for lifestyle risk reduction engagement during the interconception period. METHODS:We conducted a qualitative descriptive interview study between February and May 2022. Women and people who have been pregnant and intended to have more children were recruited. We asked participants about their preferences for lifestyle risk reduction between pregnancies. Following reflexive thematic analysis, we conceptualised findings using the COM-B system. RESULTS:Among 17 participants, most had given birth to one child and intended to have another child in 1 to 2 years. Our analysis found that most described lifestyle risk reduction engagement through nutrition and exercise, informed by personal experiences and their health goals for a future pregnancy/child. Key attributes affecting engagement in lifestyle risk reduction activities included their feasibility and practicality, habits and routines, motivation, pregnancy planning, and the source and quality of information. Participants' capacity and capability to engage in lifestyles supportive of interconception health were varied and influenced by juggling the routines of work, finances, health and evolving caring responsibilities. Community-based influences, including the availability of recreational infrastructure, the level of support provided by partners/family/peers and culture, also influenced participants' engagement in lifestyle risk reduction activities. CONCLUSIONS:For lifestyles that encourage interconception health, maximising participants' capability and opportunities required motivation and access to infrastructure supportive of healthy meal options and exercise, health services and community networks.

BACKGROUND:Previous caesarean section (CS) is increasingly common among women undergoing induced abortion. AIMS:To map and analyse existing literature on abortion safety, outcomes and management in those with previous CS. MATERIALS AND METHODS:Four databases were systematically searched from inception to July 2024. Primary human studies in English reporting on outcomes, safety or management of first- or second-trimester medical (MToP) or surgical (SToP) abortion in women with previous CS were included. Uterine rupture incidence was analysed cumulatively in the first and secondtrimesters by the number of CS and the type of prostaglandin used. Data on the efficacy and safety of MToP and SToP, including studies reporting on the management of abortion in the setting of abnormal placentation, were collected and analysed by theme. RESULTS:In total, 164 articles met inclusion criteria. Incidence of uterine rupture in first-trimester MToP was 0 of 2194 cases, in second-trimester misoprostol MToP in those with 1 previous CS was 0.5% (10/1910) and 2.2% (18/835) in women with ≥ 2 CS (p < 0.001). Mifepristone priming did not increase the rupture rate in second-trimester MToP (p = 0.77). Previous CS was a modest risk factor for retained products after MToP across both trimesters (OR 1.48, CI 1.29-1.70). CONCLUSION:Medical and surgical abortion in the first and second trimester appears safe in women with prior CS; however, risks include uterine rupture, need for surgical intervention and haemorrhage from undiagnosed placenta accreta. Further research and guidance are needed on managing abortion after previous classical CS, ≥ 3 previous CS and those with abnormally invasive placenta.

Background Documenting medical and lifestyle preconception health risk factors in electronic medical records (EMRs) could assist general practitioners (GPs) to identify those reproductive-aged women who could most benefit from preconception care (PCC). However, it is unclear to what extent PCC risk factors are identifiable in general practice records. This study aimed to determine the extent to which medical and lifestyle preconception health risk factors are documented in general practice EMRs.Methods We conducted an audit of the documentation of medical and lifestyle preconception risk factors in 10 general practice EMRs in Melbourne, Australia. We retrospectively analysed the EMRs of 100 consecutive women aged 18-44 years who visited each practice between January and September 2022. Using a template informed by PCC guidelines, we extracted data from structured fields in the EMR and conducted a descriptive analysis.Results Among the data extracted, the more commonly documented medical and lifestyle preconception health risk factors in the EMRs included smoking (79%), blood pressure (74%), alcohol consumption (63%) and body mass index (57%). Among the women audited, 14% were smokers, 24% were obese, 7% had high blood pressure, 5% had diabetes, 28% had a mental health condition, 13% had asthma, 6% had thyroid disease and 17% had been prescribed and could be using a potentially teratogenic medication.Conclusions Better documentation of medical and lifestyle preconception health risk factors in structured fields in EMRs may potentially assist primary care providers including GPs in identifying and providing PCC to women who could most benefit from it.

As part of a global liberalising trend, the last two decades have seen abortion decriminalised in each of Australia’s States and Territories. In this article, we focus on New South Wales (NSW) – the country’s most populous jurisdiction – and locate the State’s abortion law reform in its global context. Abortion was decriminalised in NSW in 2019. As part of this, the State introduced a new legal framework that continues the long history of exceptionalising abortion in the legal regulation of heath care. Furthermore, while decriminalisation is a necessary modernising reform, it is not a guarantee of improved access to services. This has been the experience in a number of decriminalised jurisdictions, including NSW. In this, we argue that services remain simultaneously over- and under-regulated. Responding to this, and centring public responsibility for abortion care, we propose a model designed to advance universal access to abortion services. In this regard, there remains a central role for law and policy in improving health equity. In addressing the role of law in post-decriminalisation jurisdictions, we advance understandings of law as a determinant of health.

Introduction: Rural populations in Australia rely upon local primary health care for medication abortion access. Yet little is known about how individual primary healthcare providers themselves negotiate the unique complexities of the rural health system to provide local abortion services. Methods: To address this gap, we conducted qualitative, semi-structured interviews with primary healthcare providers in rural New South Wales (NSW). Recruitment strategies included sending invitations to all GP clinics in Western NSW, distribution of flyers via professional networks and social media posts as well as snowballing. The Framework Method was used to conduct an inductive thematic analysis. Results: We interviewed 16 rural GPs, nurses, midwives and women's health clinic operational staff. Four themes were identified: (1) scarce abortion services place overreliance on availability and goodwill of local prescribers; (2) lack of back-up support, financial incentives and training deters providers; (3) there is interprofessional stigma, secrecy and obstruction; and (4) local abortion access requires workarounds through informal rural networks. Participants described abortion exceptionalism within Australia's health system and chronic rural workforce shortages in rural settings as unique and compounding challenges to local provision. Conversely, strong rural community networks were identified as important enablers of informal pathways to abortion within or around systemic barriers. Conclusion: Improving rural abortion access in Australia requires attention to the numerous intersecting barriers that local primary care providers themselves face when providing services at the periphery of an unaccommodating health system.

Purpose of reviewWomen are particularly vulnerable to unintended pregnancy in the 12 months following a birth. Improving access to postpartum contraception within maternity settings can prevent unintended and closely spaced births, improving the health of mother and child. This review will summarize the recent research in postpartum contraception (PPC), building on existing knowledge and developments in this field.Recent findingsCurrent models of postpartum contraceptive provision may not adequately meet women's needs. The COVID-19 pandemic led to changes in postpartum contraceptive provision, with an increasing emphasis placed on maternity services. Antenatal contraceptive discussion is associated with increased postpartum contraceptive planning and uptake of methods after birth. Digital health interventions may be a useful tool to support information about contraception. The most effective long-acting reversible contraceptive (LARC) methods, such as the intrauterine device (IUD) and implant, can be challenging to provide in the maternity setting because of availability of trained providers. Postpartum IUD insertion remains relatively under-utilized, despite evidence supporting its safety, efficacy and cost-effectiveness.SummaryAntenatal information needs to be partnered with access to the full range of methods immediately after birth to reduce barriers to PPC uptake. Training and education of maternity providers is central to successful implementation of PPC services.

In 2021, the Preconception Health Network Australia co-developed preconception health core indicators identified as critical to ensuring optimal maternal and child outcomes following conception. We conducted an audit of perinatal databases across each state and territory to identify whether preconception core indicator data were available. Seven health domains co-developed by the Preconception Health Network were mapped against the data collected in the perinatal databases. Indicator data were lacking across all seven health domains, with data missing for social determinants of health indicators. Better data linkage and developing a national evidence-based framework would allow ongoing monitoring of women's preconception health nationally.