Pregnancy Options Counseling and Abortion Referrals Among US Primary Care Physicians: Results From a National Survey

BACKGROUND AND OBJECTIVES

Primary care physicians (PCPs) can play a critical role in addressing unintended pregnancy through high-quality options counseling and referrals.

METHODS

We surveyed a nationally representative sample of 3,000 PCPs in general, family, and internal medicine on practices and opinions related to options counseling for unintended pregnancy. We assessed predictors of physician practices using multivariable logistic regression weighted for sampling design and differential non-response.

RESULTS

Response rate was 29%. Seventy-one percent believed residency training in options counseling should be required, and 69% believed PCPs have an obligation to provide abortion referrals even in the presence of a personal objection to abortion. However, only 26% reported routine options counseling when caring for women with unintended pregnancy compared to 60% who routinely discuss prenatal care. Among physicians who see women seeking abortion, 62% routinely provide referrals, while 14% routinely attempt to dissuade women. Family physicians were more likely to provide routine options counseling when seeing patients with unintended pregnancy than internal medicine physicians (32% vs 21%, P=0.002). In multivariable analyses, factors associated with higher odds of routine abortion referrals were more years in practice (OR=1.03 for each additional year, 95% CI: 1.00-1.05), identifying as a woman vs a man (OR=2.11, 95% CI: 1.31-3.40), practicing in a hospital vs private primary care/multispecialty setting (OR=3.17, 95% CI: 1.10-9.15), and no religious affiliation of practice vs religious affiliation (OR for Catholic affiliation=0.27, 95% CI: 0.11-0.66; OR for other religious affiliation=0.36, 95% CI: 0.15-0.83). Personal Christian religious affiliation among physicians who regularly attend religious services vs no religious affiliation was associated with lower odds of counseling (OR=0.48, 95% CI: 0.26-0.90) and referrals (OR=0.31, 95% CI: 0.15-0.62), and higher odds of abortion dissuasion (OR=4.03, 95% CI: 1.46-11.14).

CONCLUSIONS

Findings reveal the need to support fuller integration of options counseling and abortion referrals in primary care, particularly through institutional and professional society guidelines and training opportunities to impart skills and highlight the professional obligation to provide non-directive information and support to women with unintended pregnancy.

The Effects of Abortion Training on Family Medicine Residents' Clinical Experience

BACKGROUND AND OBJECTIVES

RHEDI, Reproductive Health Education in Family Medicine, offers technical assistance and funding to family medicine residency programs to support integrated opt-out abortion and reproductive health training for residents. This study assessed the impact of this enhanced training on residents' reproductive health experience.

METHODS

Investigator-developed pre- and post-surveys were administered online to 214 residents at 12 family medicine residency programs before and after their RHEDI training experience. Surveys addressed experience in contraception and abortion, attitudes around abortion provision, and post-residency intentions. Descriptive statistics were generated, and statistical tests were performed to assess changes after training.

RESULTS

Surveys had a 90% response rate. After the RHEDI enhanced reproductive health rotation, residents reported increased experience in contraception provision, early pregnancy ultrasound, aspiration and medication abortion, and miscarriage management. After training, residents with experience in IUD insertion increased from 85% to 99%, and contraceptive implant insertion experience rose from 60% to 85%. Residents who had performed any abortions increased from 15% to 79%, and self-rated competency in abortion increased. Finally, almost all residents agreed that early abortion was within the scope of family medicine, and training confirmed residents' intentions to provide reproductive health services after residency.

CONCLUSIONS

Integrated training in reproductive health, with an emphasis on abortion, increases residents' experience and underscores their understanding of the role of these services in family medicine. Increasing the number of family medicine residency programs that offer this training could help prepare family physicians to meet their patients' needs for reproductive health services.

Systems Change Enhances Access to Family Planning Training and Care Delivery

BACKGROUND AND OBJECTIVES

Long-acting reversible contraceptives (LARCs) are very effective methods of pregnancy prevention. To ensure autonomy over childbearing, women need access to contraception and abortion services. Family physicians can improve access by increasing numbers and locations of trained providers. In 2014, the University of Maryland (UMD) Reproductive Health EDucation In family medicine (RHEDI) program sought to enhance LARC and abortion training by increasing: (1) resident participation in LARC services, (2) resident participation/interest in abortion care, (3) patient access to LARCs and medication abortions (MABs).

DESIGN

We used a pre-post framework comparing years 2013 and 2014 with respect to number of resident-provided LARC services, number of residents participating in abortion, and total number of LARCs and MABs provided practice-wide.

SETTING

The setting is an urban residency practice.

INTERVENTION

(1) increased dedicated appointments for LARC and MABs, (2) dedicated appointment scheduler, (3) comprehensive family planning didactics and clinical workshops, (4) faculty-supported Residents for Choice group.

RESULTS

2014: Residents provided substantially more LARC services compared to 2013. Placement increased from 50 to 90, and removals tripled (25 to 73). 2014 site-wide LARC placement also increased (160 versus 98), removals increased (44 in 2013, 106 in 2014). Twelve residents per year are eligible to participate in abortion care. In 2013, two participated: in 2014, 10 participated. MABs provided in 2014 (18) did not change from 2013 (17).

CONCLUSIONS

The UMD RHEDI program demonstrated that attention to care-provision systems and education enhances resident training and increases patient access to family planning services. Programs with similar goals may find our methods helpful.

Assessing abortion coverage in nurse practitioner programs in Canada: a national survey of program directors

OBJECTIVES

Although nurse practitioners (NPs) play a critical role in the delivery of reproductive health services in Canada, there is a paucity of published information regarding the reproductive health education provided in their training programs. Our study aimed to understand better the didactic and curricular coverage of abortion in Canadian NP programs.

STUDY DESIGN

In 2014, we conducted a 3-contact, bilingual (English-French) mailed survey to assess the coverage of, time dedicated to and barriers to inclusion of 17 different areas of reproductive health, including abortion. We also asked respondents to speculate on whether or not mifepristone would be incorporated into the curriculum if approved by Health Canada for early abortion. We analyzed our results with descriptive statistics and used inductive techniques to analyze the open-ended questions for content and themes.

RESULTS

Sixteen of 23 (70%) program directors or their designees returned our survey. In general, abortion-related topics received less coverage than contraception, ectopic pregnancy management and miscarriage management. Fifty-six percent of respondents reported that their program did not offer information about first-trimester abortion procedures and/or post-abortion care in the didactic curriculum. Respondents expressed interest in incorporating mifepristone/misoprostol into NP education and training.

CONCLUSION

Reproductive health issues receive uneven and often inadequate curricular coverage in Canadian NP programs. Identifying avenues to expand education and training on abortion appears warranted. Embarking on curricular reform efforts is especially important given the upcoming introduction of mifepristone into the Canadian health system for early abortion.

IMPLICATIONS

Our findings draw attention to the need to integrate abortion-related content into NP education and training programs. The approval of Mifegymiso® may provide a window of opportunity to engage in curriculum reform efforts across the health professions in Canada.

Medical students are afraid to include abortion in their future practices: in-depth interviews in Maharastra, India

BACKGROUND

Unsafe abortions are estimated to cause eight per-cent of maternal mortality in India. Lack of providers, especially in rural areas, is one reason unsafe abortions take place despite decades of legal abortion. Education and training in reproductive health services has been shown to influence attitudes and increase chances that medical students will provide abortion care services in their future practice. To further explore previous findings about poor attitudes toward abortion among medical students in Maharastra, India, we conducted in-depth interviews with medical students in their final year of education.

METHOD

We used a qualitative design conducting in-depth interviews with twenty-three medical students in Maharastra applying a topic guide. Data was organized using thematic analysis with an inductive approach.

RESULTS

The participants described a fear to provide abortion in their future practice. They lacked understanding of the law and confused the legal regulation of abortion with the law governing gender biased sex selection, and concluded that abortion is illegal in Maharastra. The interviewed medical students' attitudes were supported by their experiences and perceptions from the clinical setting as well as traditions and norms in society. Medical abortion using mifepristone and misoprostol was believed to be unsafe and prohibited in Maharastra. The students perceived that nurse-midwives were knowledgeable in Sexual and Reproductive Health and many found that they could be trained to perform abortions in the future.

CONCLUSIONS

To increase chances that medical students in Maharastra will perform abortion care services in their future practice, it is important to strengthen their confidence and knowledge through improved medical education including value clarification and clinical training.

Student perceptions of reproductive health education in US medical schools: a qualitative analysis of students taking family planning electives

BACKGROUND

Abortion services will be sought by an estimated one in three US women before they reach age 45. Despite the importance of family planning (FP) care, many medical schools do not currently offer formal education in this area, and students are unable to meet associated competency standards prior to graduation.

PURPOSE

The purpose of this study was to explore students' motivations in pursuing FP electives throughout the United States, their experiences during these courses, and any impact of these rotations on their plans for future practice.

METHOD

We conducted a qualitative study consisting of semi-structured interviews with medical students upon completing fourth-year FP electives at US medical schools. Thirty-seven LCME-accredited US medical schools offered fourth-year FP electives. Course directors at 21 of these institutions recruited study participants between June 2012 and June 2013. Interviews were transcribed, coded, and analyzed with ATLAS/ti software to identify salient themes.

RESULTS

We interviewed 29 students representing 14 institutions from all regions of the United States (East Coast, Midwest, South, and West Coast). Five central themes emerged. Medical students are using FP electives to fill gaps in the standard curriculum. Elective participation did not change students' pre-elective stance on abortion. Many students intend to provide abortion in the future but identified possible limiting factors. Proficiency in contraception and options counseling were top competencies desired and gained. Students reported excellent satisfaction with FP electives and would recommend it to their peers, regardless of their personal beliefs.

CONCLUSIONS

Interview data revealed that students are using FP electives to fill gaps within preclinical and clinical medical school curriculum. Future physicians will be unable to provide comprehensive care for their female patients if they are not provided with this education. Research should be directed at development and analysis of comprehensive FP curricula, which will allow students to obtain the knowledge necessary to best care for their patients.

Recruitment and retention strategies for expert nurses in abortion care provision

OBJECTIVE(S)

The purpose of this thematic analysis is to describe recruitment, retention and career development strategies for expert nurses in abortion care provision.

STUDY DESIGN

Thematic analysis influenced by grounded theory methods were used to analyze interviews, which examined cognitive, emotional, and behavioral processes associated with how nurses make decisions about participation in abortion care provision. The purposive sample consisted of 16 nurses, who were interviewed between November 2012 and August 2013, who work (or have worked) with women seeking abortions in abortion clinics, emergency departments, labor and delivery units and post anesthesia care units.

RESULTS

Several themes emerged from the broad categories that contribute to successful nurse recruitment, retention, and career development in abortion care provision. All areas were significantly influenced by engagement in leadership activities and professional society membership. The most notable theme specific to recruitment was exposure to abortion through education as a student, or through an employer. Retention is most influenced by flexibility in practice, including: advocating for patients, translating one's skill set, believing that nursing is shared work, and juggling multiple roles. Lastly, providing on the job training opportunities for knowledge and skill advancement best enables career development.

CONCLUSION(S)

Clear mechanisms exist to develop expert nurses in abortion care provision.

IMPLICATIONS

The findings from our study should encourage employers to provide exposure opportunities, develop activities to recruit and retain nurses, and to support career development in abortion care provision. Additionally, future workforce development efforts should include and engage nursing education institutions and employers to design structured support for this trajectory.

Association of reproductive health training on intention to provide services after residency: the family physician resident survey

BACKGROUND AND OBJECTIVES

High rates of unintended pregnancy and need for reproductive health services (RHS), including abortion, require continued efforts to train medical professionals and increase availability of these services. With US approval 12 years ago of Mifepristone, a medication abortion pill, abortion services are additionally amenable to primary care. Family physicians are a logical group to focus on given that they provide the bulk of primary care.

METHODS

We analyzed data from an annual survey (2007--2010) of third-year family medicine residents (n=284, response rate=48%--64%) in programs offering abortion training to examine the association between such training and self-reported competence and intentions to provide RHS (with a particular focus on abortion) upon graduation from residency.

RESULTS

The majority of residents (75% in most cases) were trained in each of the RHS we asked about; relatively fewer trained in implant insertion (39%), electric vacuum aspiration (EVA) (58%), and manual vacuum aspiration (MVA) (69%). Perceived competence on the part of the graduating residents ranged from high levels in pregnancy options counseling (89%) and IUD insertion (85%) to lows in ultrasound and EVA (both 34%). Bivariate analysis revealed significant associations between number of procedures performed and future intentions to provide them. The association between competence and intentions persisted for all procedures in multivariate analysis, adjusting for number of procedures. Further, the total number of abortions performed during residency increased the odds of intending to provide MVA and medication abortion by 3% and 2%, respectively.

CONCLUSIONS

Findings support augmenting training in RHS for family medicine residents, given that almost half (45%) of those trained intended to provide abortions. The volume of training should be increased so more residents feel competent, particularly in light of the fact that combined exposure to different abortion procedures has a cumulative impact on intention to provide MVA and medication abortion.

A long-term evaluation of a required reproductive health training rotation with opt-out provisions for family medicine residents

BACKGROUND

Family physicians are critical to reproductive health care provision. Previous studies have evaluated the immediate impact of training family physicians in abortion and reproductive health care but have not conducted long-term follow-up of those trained.

METHODS

In a cross-sectional survey performed in 2009, all 2003--2008 graduates from four family medicine residency programs with a required abortion training rotation with opt-out provisions were asked to participate in a confidential online follow-up survey that was linked to rotation evaluations. The follow-up surveys addressed current reproductive health practice, desire to integrate services in ideal practice, perceived barriers, and desired support for provision of services.

RESULTS

Of 183 eligible graduates, 173 had contact information, and 116 completed the survey. The majority of respondents had provided a range of reproductive health services since residency. Of full training participants, many had performed IUD insertion (72%), endometrial biopsies (55%), miscarriage management (52%), and abortion (27%), compared to 39%, 22%, 17%, and 0% of opt-out training participants, respectively. Of those residents intending future abortion provision, 40% went on to do so. In multivariate analysis among full participants, procedural volume was positively correlated with future abortion provision after controlling for intention to provide abortions, gender, and residency program (adjusted OR=1.42 [95% CI=1.03--1.94]). While most respondents considered comprehensive reproductive health services including miscarriage management and abortion as important to include in their ideal practice, many faced barriers to providing all the services they desired.

CONCLUSIONS

Family medicine residency graduates fully participating in abortion training reported increased provision of most reproductive health services compared to opt-out graduates. Many intending to provide abortions reported a variety of barriers to provision. Training programs that provide assistance for overcoming obstacles to practice initiation may improve comprehensive reproductive health provision among graduates.

"How can I gain skills if I don't practice?" The dynamics of prohibitive silence against pre-marital pregnancy and sex in Zimbabwe

Young people face sexual and reproductive health (SRH) problems including Human immunodeficiency virus (HIV) and Acquired immunodeficiency syndrome (AIDS). It is critical to continue documenting their situation including the contexts they live in. As part of a larger study that explored perspectives of men to SRH and more specifically abortion and contraceptive use, 546 pupils (51% female; age range 9-25 years) from a rural area in Zimbabwe were invited to write anonymously questions about growing up or other questions they could not ask adults for fear or shame. The pupils were included following descriptions by adults of the violence that is unleashed on unmarried young people who engaged in sex, used contraceptives, or simply suggested doing so. The questions by the young people pointed to living in a context of prohibitive silence; their sexuality was silenced and denied. As a consequence they had poor knowledge and their fears and internal conflicts around sexuality and pregnancy were not addressed. Current action suggests concerted effort at the policy level to deal with young people's SRH in Zimbabwe. It nevertheless remains necessary, as a way to provide support to these efforts, to continue examining what lessons can be drawn from the past, and how the past continues to reflect in and shape present dynamics and relations. There is also need to look more critically at life skill education, which has previously been described as having failed to address adequately the practical needs of young people. Life skill education in Zimbabwe has rarely been systematically evaluated. A fuller understanding is also needed of the different factors co-existing in contemporary African societies and how they have been and continue to be constituted within history, and the implications to the promotion of adolescent SRH.

Medical students' attitudes toward abortion education: Malaysian perspective

BACKGROUND

Abortion is a serious public health issue, and it poses high risks to the health and life of women. Yet safe abortion services are not readily available because few doctors are trained to provide such services. Many doctors are unaware of laws pertaining to abortion. This article reports survey findings on Malaysian medical students' attitudes toward abortion education and presents a case for including abortion education in medical schools.

METHODS AND RESULTS

A survey on knowledge of and attitudes toward abortion among medical students was conducted in two public universities and a private university in Malaysia in 2011. A total of 1,060 students returned the completed questionnaires. The survey covered about 90% of medical students in Years 1, 3, and 5 in the three universities. About 90% of the students wanted more training on the general knowledge and legal aspects of abortion, and pre-and post-abortion counseling. Overall, 75.9% and 81.0% of the students were in favor of including in medical education the training on surgical abortion techniques and medical abortion, respectively. Only 2.4% and 1.7% were opposed to the inclusion of training of these two methods in the curriculum. The remaining respondents were neutral in their stand. Desire for more abortion education was associated with students' pro-choice index, their intention to provide abortion services in future practice, and year of study. However, students' attitudes toward abortion were not significantly associated with gender, type of university, or ethnicity.

CONCLUSIONS

Most students wanted more training on abortion. Some students also expressed their intention to provide abortion counseling and services in their future practice. Their desire for more training on abortion should be taken into account in the new curriculum. Abortion education is an important step towards making available safe abortion services to enable women to exercise their reproductive rights.

Evaluation of nurse providers of comprehensive abortion care using MVA in Nepal

BACKGROUND

Although Nepal's maternal mortality ratio has fallen over the past decade, unsafe abortion remains a leading cause of maternal morbidity and mortality. A key strategy for improving access to safe abortion services is to train mid-level providers such as nurses in comprehensive abortion care (CAC). The Family Health Division of the Nepal Ministry of Health trained an initial cohort of 96 nurses to provide first trimester CAC services using manual vacuum aspiration (MVA) between September 2006 and July 2009. This study evaluates the acceptability and quality of CAC services provided by trained nurses in Nepal.

METHODS

Five assessments were used to evaluate post-training service provision on CAC: facility logbooks registry, nurse provider interviews, facility assessments, facility manager interviews and procedure observation checklists. Ninety-two nurses from 50 facilities participated in the evaluation. Descriptive statistics are reported.

RESULTS

Overall, 5,600 women received CAC services from 42 facilities where nurses were providing services between June 2009 and April 2010. Complications were experienced by 68 surgical abortion clients (1.6%) and 12 medical abortion clients (1.2%). All nurses reported that clients were happy to receive care from them, and 67% of facility managers reported that clients preferred nurse providers over physicians or had no preference. Facility managers and nurses reported a need for additional support, including further training and improved drug and equipment supply.

CONCLUSIONS

Trained nurses provide high quality CAC services in Nepal. Additional support in the form of facilitative supervision and training should be considered to strengthen CAC service provision.

The effect of child support enforcement on abortion in the United States

OBJECTIVES

This project aims to answer a critically important question of public policy: Does effective child support enforcement lead to a change in the incidence of abortion across the United States?

METHODS

Using state-level data collected from 1978–2003 from a variety of sources, we employ fixed effects regression analysis to examine whether financial security as measured by five types of child support enforcement effectiveness impacts abortion outcomes.

RESULTS

We find that child support enforcement effectiveness decreases the incidence of abortion as measured by the abortion rate, but not the abortion ratio.

CONCLUSIONS

Income transfer policies such as child support enforcement can affect certain fertility outcomes such as abortion rates across the states.

Failure to achieve the association of professors in gynecology and obstetrics objectives for abortion in third-year medical student curriculum

OBJECTIVE

To determine if third-year medical students achieve the Association of Professors in Gynecology and Obstetrics (APGO) objectives regarding abortion.

STUDY DESIGN

Medical students at the University of Colorado were surveyed at the end of the third year (May 2009) regarding their knowledge and experience in abortion training. Results were analyzed using chi2 and Fisher's exact test.

RESULTS

One hundred twenty-seven of 131 surveys were completed. Students scored 47% correct on knowledge-based questions. No formal didactics were reported by 57%, and only 24% rotated through a clinic that provided abortions. Didactics and clinical exposure were not associated with higher scores. Students with "any reading focused on abortion" had higher scores (52% vs. 42%, p=0.02), as did those intending to pursue obstetrics and gynecology residencies (63% vs. 46%, p=0.05). Students were receptive to abortion training: 80% wanted didactics and 45% reported unsatisfactory clinical opportunities.

CONCLUSION

The current curriculum does not meet the APGO objectives or the needs of medical students. Given that many students will eventually care for reproductive-age women, focus on meeting these objectives is warranted.

Abortion provision among practicing obstetrician-gynecologists

OBJECTIVE

To estimate prevalence and correlates of abortion provision among practicing obstetrician-gynecologists (ob-gyns) in the United States.

METHODS

We conducted a national probability sample mail survey of 1,800 practicing ob-gyns. Key variables included whether respondents ever encountered patients seeking abortions in their practice and whether they provided abortion services. Correlates of providing abortion included physician demographic characteristics, religious affiliation, religiosity, and the religious affiliation of the facility in which a physician primarily practices.

RESULTS

Among practicing ob-gyns, 97% encountered patients seeking abortions, whereas 14% performed them. Female physicians were more likely to provide abortions than were male (18.6% compared with 10.6%, adjusted odds ratio 2.54, 95% confidence interval 1.57-4.08), as were those in the youngest age group, those in the Northeast or West, those in highly urban postal codes, and those who identify as being Jewish. Catholics, Evangelical Protestants, non-Evangelical Protestants, and physicians with high religious motivation were less likely to provide abortions.

CONCLUSION

The proportion of U.S. ob-gyns who provide abortions may be lower than estimated in previous research. Access to abortion remains limited by the willingness of physicians to provide abortion services, particularly in rural communities and in the South and Midwest.

LEVEL OF EVIDENCE

II.

Treatment of early pregnancy failure: does induced abortion training affect later practices?

OBJECTIVE

The objective of the study was to examine the relationship between induced abortion training and views toward, and use of, office uterine evacuation and misoprostol in early pregnancy failure (EPF) care.

STUDY DESIGN

We surveyed 308 obstetrician-gynecologists on their knowledge and attitudes toward treatment options for EPF and previous training in office-based uterine evacuation.

RESULTS

Sixty-seven percent of respondents reported training in office uterine evacuation, and 20.3% reported induced abortion training. Induced abortion training was associated with strongly positive views toward both office-based uterine evacuation and misoprostol as treatment for EPF compared with those with office uterine evacuation training in other settings (odds ratio [OR], 2.64; P < .004 and OR, 3.22; P < .003, respectively). Furthermore, induced abortion training was associated with the use of office uterine evacuation for EPF treatment compared with those with office evacuation training in other settings (OR, 2.90; P = .004).

CONCLUSION

Training experiences, especially induced abortion training, are associated with the use of office uterine evacuation for EPF.

The International Confederation of Midwives essential competencies for basic midwifery practice. an update study: 2009-2010

OBJECTIVE

a 2-year study was conducted to update the core competencies for basic midwifery practice, first delineated by the International Confederation of Midwives in 2002. A competency domain related to abortion-related care services was newly developed.

DESIGN

a modified Delphi survey process was conducted in two phases: a pilot item affirmation study, and a global field survey.

SETTING

a global survey conducted in 90 countries.

PARTICIPANTS

midwifery educators or clinicians associated with midwifery education schools and programmes located in any of the ICM member association countries. Additional participants represented the fields of nursing, medicine, and midwifery regulatory authorities. A total of 232 individuals from 63 member association and five non-member countries responded to one or both of the surveys. The achieved sample represented 42% of member association countries, which was less than the 51% target. However, the sample was proportionally representative of ICM's nine global regions.

MEASUREMENTS

survey respondents expressed an opinion whether to retain or to delete any of 255 statements of midwifery knowledge, skill, or professional behaviour. They also indicated whether the item should be a basic (core) item of midwifery knowledge or skill that would be included as mandatory content in a programme of midwifery pre-service education, or whether the item could be added to the fund of knowledge or acquired as an additional skill by those who would need or wish to include the item within the scope of their clinical practice.

FINDINGS

a majority consensus of .85 was required to accept the item without further deliberation. An expert panel made final decisions in all instances where consensus was not achieved. The panel also amended the wording of selected items, or added new items based on feedback received from survey respondents. The final document contains 268 items organised within seven competency domains.

Abortion law reforms in Colombia and Nicaragua: issue networks and opportunity contexts

This article analyses two instances of abortion law reform in Latin America. In 2006, after a decades-long impasse, the highly controversial issue of abortion came to dominate the political agenda when Colombia liberalized its abortion law and Nicaragua adopted a total ban on abortion. The article analyses the central actors in the reform processes, their strategies and the opportunity contexts. Drawing on Htun's (2003) framework, it examines why these processes concluded with opposing legislative outcomes. The authors argue for the need to understand the state as a non-unitary site of politics and policy, and for judicial processes to be seen as a key variable in facilitating gender policy reforms in Latin America. In addition, they argue that ‘windows of opportunity’ such as the timing of elections can be critically important in legislative change processes.

Religion and attitudes toward abortion and abortion policy in Brazil

This study examines the association between religion and attitudes toward the practice of abortion and abortion policy in Brazil. Drawing upon data from the 2002 Brazilian Social Research Survey (BSRS), we test a number of hypotheses with regard to the role of religion on opposition to the practice of abortion and its legalization. Findings indicate that frequently attending Pentecostals demonstrate the strongest opposition to the practice of abortion and both frequently attending Pentecostals and Catholics demonstrate the strongest opposition to its legalization. Additional religious factors, such as a commitment to biblical literalism, were also found to be significantly associated with opposition to both abortion issues. Ultimately, the findings have implications for the future of public policy on abortion and other contentious social issues in Brazil.

South Africa's abortion values clarification workshops — an opportunity to deepen democratic communication missed

A rich literature exists on local democracy and participation in South Africa. While the importance of participation is routinely built into the rhetoric of government, debate has increasingly focused on the dysfunctionality of participatory mechanisms and institutions in post-apartheid South Africa. Processes aimed ostensibly at empowering citizens, act in practice as instruments of social control, disempowerment and cooptation. The present article contributes to these debates by way of a critique of the approach used by the South African state, in partnership with the non-governmental sector, in what are called abortion "values clarification" (VC) workshops. This article examines the workshop materials, methodology and pedagogical tools employed in South African abortion VC workshops which emanate from the organization Ipas — a global body working to enhance women's sexual and reproductive rights and to reduce abortion-related deaths and injuries. VC workshops represent an instance of a more general trend in which participation is seen as a tool for generating legitimacy and "buy-in" for central state directives rather than as a means for genuinely deepening democratic communication. The manipulation of participation by elites may serve as a means to achieve socially desirable goals in the short term but the long-term outlook for a vibrant democracy invigorated by a knowledgeable, active and engaged citizenry that is accustomed to being required to exercise careful reflection and to its views being respected, is undermined. Alternative models of democratic communication, because they are based on the important democratic principles of inclusivity and equality, have the potential both to be more legitimate and more effective in overcoming difficult social challenges in ways that promote justice.

"Abortion will deprive you of happiness!": Soviet reproductive politics in the post-Stalin era

This article examines Soviet reproductive politics after the Communist regime legalized abortion in 1955. The regime's new abortion policy did not result in an end to the condemnation of abortion in official discourse. The government instead launched an extensive campaign against abortion. Why did authorities bother legalizing the procedure if they still disapproved of it so strongly? Using archival sources, public health materials, and medical as well as popular journals to investigate the antiabortion campaign, this article argues that the Soviet government sought to regulate gender and sexuality through medical intervention and health "education" rather than prohibition and force in the post-Stalin era. It also explores how the antiabortion public health campaign produced "knowledge" not only about the procedure and its effects, but also about gender and sexuality, subjecting both women and men to new pressures and regulatory norms.

Attitudes to abortion in the era of reform: evidence from the Abortion Law Reform Association correspondence

This article examines letters sent by members of the general public to the Abortion Law Reform Association (ALRA) in the decade immediately before the 1967 Abortion Act. It shows how a voluntary organisation, in their aim of supporting a specific cause of unclear legality, called forth correspondence from those in need. In detailing the personal predicaments of those facing an unwanted pregnancy, this body of correspondence was readily deployed by ALRA in their efforts to mobilise support for abortion law reform, thus exercising a political function. A close examination of the content of the letters and the epistolary strategies adopted by their writers reveals that as much as they were a lobbying tool for changes in abortion law, these letters were discursively shaped by debates surrounding that very reform.

TRAP abortion laws and partisan political party control of state government

Targeted Regulation of Abortion Providers (or TRAP) laws impose medically unnecessary and burdensome regulations solely on abortion providers in order to make abortion services more expensive and difficult to obtain. Using event history analysis, this article examines the determinants of the enactment of a TRAP law by states over the period 1974–2008. The empirical results find that Republican institutional control of a state's legislative/executive branches is positively associated with a state enacting a TRAP law, while Democratic institutional control is negatively associated with a state enacting a TRAP law. The percentage of a state's population that is Catholic, public anti-abortion attitudes, state political ideology, and the abortion rate in a state are statistically insignificant predictors of a state enacting a TRAP law. The empirical results are consistent with the hypothesis that abortion is a redistributive issue and not a morality issue.