Abortion education in Canadian family medicine residency programs

BACKGROUND

Abortion has been decriminalized in Canada since 1988 and is considered an essential medical service. There is concern that decreasing numbers of abortion providers may impair access to abortion. This study examined the quantity of exposure and education that Canadian family medicine residents receive on abortion during training and their preparation to provide abortions. In addition, the study assessed residents' attitudes, intention and expressed competency to provide abortion in future practice and the association between medical training and changes in these factors.

METHODS

The authors developed a 21-item survey in consultation with experts in medical education. The survey was distributed online in 2016. A total of 1517 family medicine residents in their first, second and third year of training attending 8 English language schools across Canada were invited to participate. Associations between attitudes, education, exposure and intention were assessed using relative risks based on bivariate analysis of self-reported measures and odds ratios from ordered logistic regression.

RESULTS

The response rate was 28.7% (436/1517). The majority of residents, 79%, reported never observing or assisting with an abortion during training. Similarly, 80% of residents reported receiving less than 1 hour of formal education on abortion. Residents strongly supported receiving abortion education. Self reported exposure to a single abortion during training was associated with an increase in residents' intention (RR = 1.95, 95% CI 1.54-2.47) and self-rated competency to provide a medical abortion (RR = 2.16, 95% CI 1.60-2.93). Twenty five percent of residents were unaware of ethical and legal requirements towards abortion provision and referral.

CONCLUSIONS

Canadian family medicine residents receive little education or exposure to abortion during training most do not feel competent to provide abortion services. Residents expressed strong support for receiving abortion training. The Canadian College of Family Physicians curriculum does not currently include abortion as a training objective. The authors argue there is a need for family medicine training programs to increase education and exposure to abortion during residency, while respecting residents' rights to opt out of such training. Failure to do so may impair future access to abortion provision.

Medical society engagement in contentious policy reform: the Ethiopian Society for Obstetricians and Gynecologists (ESOG) and Ethiopia's 2005 reform of its Penal Code on abortion

Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have reformed their laws to permit safer, legal abortion, and professional medical associations have not tended to spearhead this type of reform. Support from a professional association typically carries more weight than does that from an individual medical professional. However, theory predicts and the empirical record largely reveals that medical associations shy from engagement in conflictual policymaking such as on abortion, except when professional autonomy or income is at stake. Using interviews with 10 obstetrician-gynaecologists and 44 other leaders familiar with Ethiopia's reproductive health policy context, as well as other primary and secondary sources, this research examines why, counter to theoretical expectations from the sociology of medical professions literature and experience elsewhere, the Ethiopian Society of Obstetricians & Gynecologists (ESOG) actively supported reform of national law on abortion. ESOG leadership participation was motivated by both individual and ESOG's organizational commitments to reducing maternal mortality and also by professional training and work experience. Further, typical constraints on medical society involvement in policymaking were relaxed or removed, including those related to ESOG's organizational structure and history, and to political environment. Findings do not contradict theory positing medical society avoidance of socially conflictual health policymaking, but rather identify how the expected restrictions were less present in Ethiopia, facilitating medical society participation. Results can inform efforts to encourage medical society participation in policy reform to improve women's health elsewhere in sub-Saharan Africa.

Differences in Abortion Service Delivery in Hostile, Middle-ground, and Supportive States in 2014

OBJECTIVES

In 2013, the majority of women lived in states considered hostile to abortion rights, or states with numerous abortion restrictions. By comparison, 31% lived in supportive states. This study examined differences in abortion service delivery according to the policy climate in which clinics must operate.

METHODS

Data come from the 2014 Abortion Provider Census, which contains information about all known abortion-providing facilities in the United States. In addition to number and type of facility, we examine several aspects of abortion care: provision of only early medication abortion (EMA-only), whether an advanced practice clinician provided abortions, gestational parameters, and average charge for procedure. All indicators were examined nationally and according to whether the clinic was in a state that was hostile, middle ground, or supportive of abortion rights.

RESULTS

In 2014, hostile and supportive states accounted for the same proportion of all U.S. abortions-44% (each)-although 57% of women age 15 to 44 lived in hostile states. Hostile states had one-half as many abortion-providing facilities as supportive ones. EMA-only facilities accounted for 37% of clinics in supportive states compared with 8% in hostile states. Sixty-five percent of clinics in supportive states reported that advanced practice clinicians provided abortion care, compared with 3% in hostile states. After cost of living adjustments, a first-trimester surgical abortion was most expensive in middle-ground states ($470) and least expensive in supportive states ($402).

CONCLUSIONS

The distribution of abortion services, the type of facility in which they are provided, and the amount a facility charges all vary according to the abortion policy climate.

A critical review of conscientious objection and decriminalisation of abortion in Chile

From 1989 through September 2017, Chile's highly restrictive abortion laws exposed women to victimisation and needlessly threatened their health, freedom and even lives. However, after decades of unsuccessful attempts to decriminalise abortion, legislation regulating pregnancy termination on three grounds was recently enacted. In the aftermath, an aggressive conservative drive designed to turn conscientious objection into a pivotal new obstacle, mounted during the congressional debate, has led to extensive, complex arguments about the validity and legitimacy of conscientious objection. This article offers a critical review of the emergence of conscientious objection and its likely policy and ethical implications. It posits the need to regulate conscientious objection through checks and balances designed to keep it from being turned into an ideological barrier meant to hinder women's access to critical healthcare.

Abortion of Fetus with Down's Syndrome: India Joins the Worldwide Controversy Surrounding Abortion Laws

Abortion continues to be a moral and ethical dilemma in medicine. While abortions in general have always faced social stigmas, the abortion of fetuses with Down's syndrome in particular remains the subject of debate across the globe. In India, under the Medical Termination of Pregnancy Act, abortion is legal under prescribed circumstances only till 20 weeks of gestation. Laws for abortion after 20 week of gestation are ill defined. In a recent ruling of the Supreme Court in India, a woman was denied the right to abortion of her 26 week old fetus. With this ruling, India has joined the rest of the world in the debate surrounding abortion laws and the ethics of abortion.

Abortion Bans, Doctors, and the Criminalization of Patients

January 2018, the American College of Obstetrics and Gynecology issued a position statement opposing the punishment of women for self-induced abortion. To those unfamiliar with emerging trends in abortion in the United States and worldwide, the need for the declaration might not be apparent. Several studies suggest that self-induced abortion is on the rise in the United States. Simultaneously, prosecutions of pregnant women for behavior thought to harm the fetus are increasing. The ACOG statement responds to both trends by urging doctors to honor the integrity and confidentiality inherent in the doctor-patient relationship. Seen in the context of the larger battle over legal abortion, the statement has far broader implications. By acknowledging the role doctors play in enforcing pregnancy-related crimes, the ACOG position statement wisely anticipates the ways in which doctors will be implicated should access to legal abortion be further restricted. To understand the need for the ACOG directive, you must first understand that the story of what will happen if abortion becomes a crime in the United States is not to be found in history books; it is staring at us across our southern border.

ESHRE Capri Workshop Group. Induced abortion

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Perspectives on induced abortion among Palestinian women: religion, culture and access in the occupied Palestinian territories

Induced abortion is an important public health issue in the occupied Palestinian territories (OPT), where it is illegal in most cases. This study was designed to elicit the views of Palestinian women on induced abortion given the unique religious, ethical and social challenges in the OPT. Sixty Palestinian women were interviewed on their perceptions of the religious implications, social consequences and accessibility of induced abortions in the OPT at Al-Makassed Islamic Charitable Hospital in East Jerusalem. Themes arising from the interviews included: the centrality of religion in affecting women's choices and views on abortion; the importance of community norms in regulating perspectives on elective abortion; and the impact of the unique medico-legal situation of the OPT on access to abortion under occupation. Limitations to safe abortion access included: legal restrictions; significant social consequences from the discovery of an abortion by one's community or family; and different levels of access to abortion depending on whether a woman lived in East Jerusalem, the West Bank, or Gaza. This knowledge should be incorporated to work towards a legal and medical framework in Palestine that would allow for safe abortions for women in need.

Freedom of conscience in Europe? An analysis of three cases of midwives with conscientious objection to abortion

While abortion has been legal in most developed countries for many years, the topic remains controversial. A major area of controversy concerns women's rights vis-a-vis the rights of health professionals to opt out of providing the service on conscience grounds. Although scholars from various disciplines have addressed this issue in the literature, there is a lack of empirical research on the topic. This paper provides a documentary analysis of three examples of conscientious objection on religious grounds to performing abortion-related care by midwives in different Member States of the European Union, two of which have resulted in legal action. These examples show that as well as the laws of the respective countries and the European Union, professional and church law each played a part in the decisions made. However, support from both professional and religious sources was inconsistent both within and between the examples. The authors conclude that there is a need for clear guidelines at both local and pan-European level for health professionals and recommend a European-wide forum to develop and test them.

Trends in Abortion Incidence and Availability in North Carolina, 1980-2013

OBJECTIVES

Abortion incidence has declined nationally during the last decade. In recent years, many states, including North Carolina, have passed legislation related to the provision of abortion services. Despite the changing political environment, there is no comprehensive analysis on past and current trends related to unintended pregnancy and abortion in North Carolina.

METHODS

This study is a secondary analysis of vital registration data made publicly available by the North Carolina State Center for Health Statistics. Birth and induced abortion records were obtained for the years 1980 to 2013. We describe abortion incidence and demographic characteristics of women obtaining abortions over time.

RESULTS

The number of North Carolina abortions declined 36% between 1980 and 2013. The abortion ratio declined from 26/100 pregnancies (live births and abortions) in 1980 to just 14/100 in 2013. These ratios, however, vary across demographic subgroups. In 2013, the abortion ratio was more than 2 times greater for non-Hispanic black women than non-Hispanic white women (22 and 9, respectively). Among non-Hispanic black and Hispanic women, the abortion ratio is greater among women with a previous pregnancy as compared with women in their first pregnancy. For non-Hispanic white women, the abortion ratios are similar for first and higher-order pregnancies.

CONCLUSIONS

Trends in North Carolina are similar to national trends; however, detailed analyses by race/ethnicity, age, and parity demonstrate important distinctions among abortion patients over time in the state. We discuss these trends in relation to policy changes and increased access to effective contraceptives.

Islamic medical jurisprudence syllabus: A Review in Saudi Arabia

INTRODUCTION

The ever-increasing technological advances of Western medicine have created new ethical issues awaiting answers and response. The use of genetic therapy, organ transplant, milk-banking, end-of-life care and euthanasia are of paramount importance to the medical students and need to be addressed.

METHODS

A series of searches were conducted of Medline databases published in English between January 2000 and January 2017 with the following keywords: medical ethics, syllabus, Islam, jurisprudence.

RESULTS

Islamic medical jurisprudence is gaining more attention in some medical schools. However, there is still lack of an organised syllabus in many medical colleges.

CONCLUSION

The outlines of a syllabus in Islamic medical jurisprudence including Islamic values and moral principles related to both the practice and research of medicine are explored.

If Abortion, then Infanticide

Our contention is that all of the major arguments for abortion are also arguments for permitting infanticide. One cannot distinguish the fetus from the infant in terms of a morally significant intrinsic property, nor are they morally discernible in terms of standing in different relationships to others. The logic of our position is that if such arguments justify abortion, then they also justify infanticide. If we are right that infanticide is not justified, then such arguments will fail to justify abortion. We respond to those philosophers who accept infanticide by putting forth a novel account of how the mindless can be wronged which serves to distinguish morally significant potential from morally irrelevant potential. This allows our account to avoid the standard objection that many entities possess a potential for personhood which we are intuitively under no obligation to further or protect.

Regulating cinematic stories about reproduction: pregnancy, childbirth, abortion and movie censorship in the US, 1930-1958

In the mid-twentieth century film studios sent their screenplays to Hollywood's official censorship body, the Production Code Administration (PCA), and to the Catholic Church's Legion of Decency for approval and recommendations for revision. This article examines the negotiations between filmmakers and censorship groups in order to show the stories that censors did, and did not, want told about pregnancy, childbirth and abortion, as well as how studios fought to tell their own stories about human reproduction. I find that censors considered pregnancy to be a state of grace and a holy obligation that was restricted to married women. For censors, human reproduction was not only a private matter, it was also an unpleasant biological process whose entertainment value was questionable. They worried that realistic portrayals of pregnancy and childbirth would scare young women away from pursuing motherhood. In addition, I demonstrate how filmmakers overcame censors' strict prohibitions against abortion by utilizing ambiguity in their storytelling. Ultimately, I argue that censors believed that pregnancy and childbirth should be celebrated but not seen. But if pregnancy and childbirth were required then censors preferred mythic versions of motherhood instead of what they believed to be the sacred but horrific biological reality of human reproduction.

Zika, public health, and the distraction of abortion

This paper suggests that the focus on abortion legalization in the aftermath of the Zika outbreak is distracting for policy and lawmakers from what needs to be done to address the outbreak effectively. Meeting basic health needs (i.e. preventive measures), together with research and development conducive to a vaccine or treatment for the Zika virus should be priorities.

Accompaniment of second-trimester abortions: the model of the feminist Socorrista network of Argentina

OBJECTIVE

Legal restrictions on abortion access impact the safety and timing of abortion. Women affected by these laws face barriers to safe care that often result in abortion being delayed. Second-trimester abortion affects vulnerable groups of women disproportionately and is often more difficult to access. In Argentina, where abortion is legally restricted except in cases of rape or threat to the health of the woman, the Socorristas en Red, a feminist network, offers a model of accompaniment wherein they provide information and support to women seeking second-trimester abortions. This qualitative analysis aimed to understand Socorristas' experiences supporting women who have second-trimester medication abortion outside the formal health care system.

STUDY DESIGN

We conducted 2 focus groups with 16 Socorristas in total to understand experiences accompanying women having second-trimester medication abortion who were at 14-24 weeks' gestational age. We performed a thematic analysis of the data and present key themes in this article.

RESULTS

The Socorristas strived to ensure that women had the power of choice in every step of their abortion. These cases required more attention and logistical, legal and medical risks than first-trimester care. The Socorristas learned how to help women manage the possibility of these risks and were comfortable providing this support. They understood their work as activism through which they aim to destigmatize abortion and advocate against patriarchal systems denying the right to abortion.

CONCLUSION

Socorrista groups have shown that they can provide supportive, women-centered accompaniment during second-trimester medication abortions outside the formal health care system in a setting where abortion access is legally restricted.

IMPLICATIONS

Second-trimester self-use of medication abortion outside of the formal health system supported by feminist activist groups could provide an alternative model for second-trimester care worldwide. More research is needed to document the safety and effectiveness of this accompaniment service-provision model.

Evaluating the impact of a mandatory pre-abortion ultrasound viewing law: A mixed methods study

BACKGROUND

Since mid-2013, Wisconsin abortion providers have been legally required to display and describe pre-abortion ultrasound images. We aimed to understand the impact of this law.

METHODS

We used a mixed-methods study design at an abortion facility in Wisconsin. We abstracted data from medical charts one year before the law to one year after and used multivariable models, mediation/moderation analysis, and interrupted time series to assess the impact of the law, viewing, and decision certainty on likelihood of continuing the pregnancy. We conducted in-depth interviews with women in the post-law period about their ultrasound experience and analyzed them using elaborative and modified grounded theory.

RESULTS

A total of 5342 charts were abstracted; 8.7% continued their pregnancies pre-law and 11.2% post-law (p = 0.002). A multivariable model confirmed the law was associated with higher odds of continuing pregnancy (aOR = 1.23, 95% CI: 1.01-1.50). Decision certainty (aOR = 6.39, 95% CI: 4.72-8.64) and having to pay fully out of pocket (aOR = 4.98, 95% CI: 3.86-6.41) were most strongly associated with continuing pregnancy. Ultrasound viewing fully mediated the relationship between the law and continuing pregnancy. Interrupted time series analyses found no significant effect of the law but may have been underpowered to detect such a small effect. Nineteen of twenty-three women interviewed viewed their ultrasound image. Most reported no impact on their abortion decision; five reported a temporary emotional impact or increased certainty about choosing abortion. Two women reported that viewing helped them decide to continue the pregnancy; both also described preexisting decision uncertainty.

CONCLUSIONS

This law caused an increase in viewing rates and a statistically significant but small increase in continuing pregnancy rates. However, the majority of women were certain of their abortion decision and the law did not change their decision. Other factors were more significant in women's decision-making, suggesting evaluations of restrictive laws should take account of the broader social environment.

Abortion rights judgment: a ray of hope!

While granting a prisoner the right to abort her foetus, a recent Bombay High Court judgment recognised a woman's absolute right to abortion. This article discusses the judgment in detail and the bioethical debates over abortion rights. It deals with the restrictions imposed by the law not only on when the foetus can be aborted, but also who can get the abortion done and in what circumstances.

Reproductive Justice: A Policy Window for Social Work Advocacy

Reproductive rights are at risk in many parts of the United States. To inspire social workers to act, this article begins by defining and describing the concepts of reproductive rights and reproductive justice. Next, it summarizes threats to reproductive rights in five areas: preventing pregnancy, terminating pregnancy, pregnancy loss, personhood measures, and drug use during pregnancy. Applying John Kingdon's policy streams framework, the article urges more social workers to embrace the current policy window and advocate for pregnant women and others whose reproductive rights are in jeopardy. The article also provides suggestions for ways that social work practitioners, educators, and researchers can act to promote reproductive justice for all.

Abortion in Islamic Ethics, and How it is Perceived in Turkey: A Secular, Muslim Country

Abortion is among the most widely discussed concepts of medical ethics. Since the well-known ethical theories have emerged from Western world, the position of Islamic ethics regarding main issues of medical ethics has been overlooked. Muslims constitute a considerable amount of world population. Turkish Republic is the only Muslim country ruled with secular democracy and one of the three Muslim countries where abortion is legalized. The first aim of this paper is to present discussions on abortion in Islamic ethics in the context of major ethical concepts; the legal status of the fetus, respect for life and the right not to be born. The second aim is to put forth Turkey's present legislation about abortion in the context of Islamic ethical and religious aspects.

Incidence of induced abortion in Malawi, 2015

Background

In Malawi, abortion is legal only if performed to save a woman’s life; other attempts to procure an abortion are punishable by 7–14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi’s high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained. An estimated 67,300 induced abortions occurred in Malawi in 2009 (equivalent to 23 abortions per 1,000 women aged 15–44), but changes since 2009, including dramatic increases in contraceptive prevalence, may have impacted abortion rates.

Methods

We conducted a nationally representative survey of health facilities to estimate the number of cases of post-abortion care, as well as a survey of knowledgeable informants to estimate the probability of needing and obtaining post-abortion care following induced abortion. These data were combined with national population and fertility data to determine current estimates of induced abortion and unintended pregnancy in Malawi using the Abortion Incidence Complications Methodology.

Results

We estimate that approximately 141,044 (95% CI: 121,161–160,928) induced abortions occurred in Malawi in 2015, translating to a national rate of 38 abortions per 1,000 women aged 15–49 (95% CI: 32 to 43); which varied by geographical zone (range: 28–61). We estimate that 53% of pregnancies in Malawi are unintended, and that 30% of unintended pregnancies end in abortion. Given the challenges of estimating induced abortion, and the assumptions required for calculation, results should be viewed as approximate estimates, rather than exact measures.

Conclusions

The estimated abortion rate in 2015 is higher than in 2009 (potentially due to methodological differences), but similar to recent estimates from nearby countries including Tanzania (36), Uganda (39), and regional estimates in Eastern and Southern Africa (34–35). Over half of pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.

Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia

BACKGROUND

Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation.

METHODS

An intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country's abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships.

RESULTS

After 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides.

CONCLUSIONS

These findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa.

The Social Life of Abortion Law: on Personal and Political Pedagogy

The current contribution seeks to start a conversation around our pedagogical practice in respect of abortion law. Centralising the traditional portrayal of abortion law within the medical law curriculum, this essay highlights the privileging of a very particular storyline about abortion. Exploring the terrain in evaluating medical law methodologies, this essay highlights the illusion of 'balance', 'objectivity', and 'neutrality' that emerges from current pedagogy in light of how abortion law is framed and in particular what is excluded: women's own voices. Focusing on a number of 'exclusions' and 'silences' and noting how closely these mirror dominant discourse in the public sphere, this essay highlights the irony of a curriculum that reflects, rather than challenges, these discursive gaps. Arguing that the setting of a curriculum is inevitably political, ambitions for delivering a programme around abortion that is 'neutral', 'objective', or 'balanced' are dismissed. Instead, highlighting the problems of what is currently excluded, how materials are ordered, and the tacit hierarchies that lend legitimacy and authority to a particular way of 'knowing' abortion, this essay argues for a new curriculum and a new storyline-one which is supported by prior learning in feminist legal scholarship and a medical law curriculum in which the social, historical, geographical, and above all, personal is ever-present and central.

The Adolescent's Right to Confidential Care When Considering Abortion

In this statement, the American Academy of Pediatrics reaffirms its position that the rights of adolescents to confidential care when considering abortion should be protected. Adolescents should be encouraged to involve their parents and other trusted adults in decisions regarding pregnancy termination, and most do so voluntarily. The majority of states require that minors have parental consent for an abortion. However, legislation mandating parental involvement does not achieve the intended benefit of promoting family communication, and it increases the risk of harm to the adolescent by delaying access to appropriate medical care. This statement presents a summary of pertinent current information related to the benefits and risks of legislation requiring mandatory parental involvement in an adolescent's decision to obtain an abortion.

Physicians' and non-physicians' views about provision of medical abortion by nurses and AYUSH physicians in Maharashtra and Bihar, India

There is only limited evidence on whether certified and uncertified health care providers in India support reforming the Medical Termination of Pregnancy (MTP) Act to expand the abortion provider base to allow trained nurses and AYUSH physicians (who are trained in Indian systems of medicine) to provide medical abortion. To explore their views, we conducted a survey of 1,200 physicians and other health care providers in Maharashtra and Bihar states and in-depth interviews with 34 of them who had used medical abortion in their practices. Findings indicate that obstetrician-gynaecologists and other allopathic physicians were less supportive than non-physicians of nurses and AYUSH physicians providing early medical abortion. The physicians did not think that these providers would be able to assess women's eligibility for medical abortion correctly. In contrast, the majority of non-physicians found task shifting of medical abortion provision to trained nurses and AYUSH physicians acceptable, and they were confident that these providers would be able to provide medical abortion as safely and effectively as trained physicians. Assuming the reforms are passed, efforts will need to be made by government and medical professional bodies to train these new providers to undertake this role, prepare the health infrastructure to include them, and create an environment, including among physicians, that is conducive to enabling non-physicians to provide medical abortion.

Utah's 72-Hour Waiting Period for Abortion: Experiences Among a Clinic-Based Sample of Women

CONTEXT

In 2012, Utah became the first state to enact a 72-hour waiting period for abortion. Despite debate about the law's potential effects, research has not examined women's experiences with it.

METHODS

A cohort of 500 women recruited at four family planning facilities in Utah in 2013-2014 completed baseline surveys at the time of an abortion information visit and follow-up telephone interviews three weeks later. Logistic regression and coding of open-ended responses were used to examine which women had abortions and, for those who did not, their reasons.

RESULTS

Among the 309 women completing follow-up, 86% had had an abortion, 8% were no longer seeking abortion, 3% had miscarried or discovered they had not been pregnant, and 2% were still seeking abortion; one woman was still deciding, and the waiting period had pushed one woman beyond her facility's gestational limit for abortion. At the information visit, women reported little conflict about the abortion decision (mean score on a scale of 0-100 was 13.9 for those who eventually had an abortion and 28.5 for others). Low decisional conflict, but not socioeconomic status, was associated with having an abortion (odds ratio, 1.1). On average, eight days elapsed between the information visit and the abortion.

CONCLUSION

As most women in this cohort were not conflicted about their decision when they sought care, the 72-hour waiting requirement seems to have been unnecessary. Individualized patient counseling for the small minority who were conflicted when they presented for care may have been more appropriate.

Women's Knowledge of and Support for Abortion Restrictions in Texas: Findings from a Statewide Representative Survey

CONTEXT

States have passed numerous laws restricting abortion, and Texas passed some of the most restrictive legislation between 2011 and 2013. Information about women's awareness of and support for the laws' provisions could inform future debates regarding abortion legislation.

METHODS

Between December 2014 and January 2015, some 779 women aged 18-49 participated in an online, statewide representative survey about recent abortion laws in Texas. Poisson regression analysis was used to assess correlates of support for a law that would make obtaining an abortion more difficult. Women's knowledge of specific abortion restrictions in Texas and reasons for supporting these laws were also assessed.

RESULTS

Overall, 31% of respondents would support a law making it more difficult to obtain an abortion. Foreign-born Latinas were more likely than whites to support such a law (prevalence ratio, 1.5), and conservative Republicans were more likely than moderates and Independents to do so (2.3). Thirty-six percent of respondents were not very aware of recent Texas laws, and 19% had never heard of them. Among women with any awareness of the laws, 19% supported the requirements; 42% of these individuals said this was because such laws would make abortion safer.

CONCLUSIONS

Many Texas women of reproductive age are unaware of statewide abortion restrictions, and some support these requirements because of misperceptions about the safety of abortion. Advocates and policymakers should address these knowledge gaps in efforts to protect access to legal abortion.

On prenatal diagnosis and the decision to continue or terminate a pregnancy in France: a clinical ethics study of unknown moral territories

This article presents a part of the results of an empirical study conducted at a Parisian hospital between 2011 and 2014. It aimed at understanding the women and couples' motivations to terminate or not a pregnancy once a prenatal diagnosis has revealed a genetically related disease in the embryo or fetus. The article first presents the social and legal context of the study, the methodology used and the pathologies that were encountered. Then, it examines the results of the interviews conducted with 5 women alone and 23 couples explaining their reasons for deciding to terminate or not the pregnancy. Finally, it explores the patients' views about the doctor's involvement in the decision-making process. The findings reveal the reasons they formulate when they ponder whether to terminate or not the pregnancy. It highlights the process of their deliberation, their hierarchisation of arguments and concerns. They also show how patients, though often consumed in sorrow, claim to be the legitimate decision-makers, especially women, in a social and legal context in which the rejection of eugenics is viewed as an undisputable principle.

Comparison of Outcomes before and after Ohio's Law Mandating Use of the FDA-Approved Protocol for Medication Abortion: A Retrospective Cohort Study

BACKGROUND

In February 2011, an Ohio law took effect mandating use of the United States Food and Drug Administration (FDA)-approved protocol for mifepristone, which is used with misoprostol for medication abortion. Other state legislatures have passed or enacted similar laws requiring use of the FDA-approved protocol for medication abortion. The objective of this study is to examine the association of this legal change with medication abortion outcomes and utilization.

METHODS AND FINDINGS

We used a retrospective cohort design, comparing outcomes of medication abortion patients in the prelaw period to those in the postlaw period. Sociodemographic and clinical chart data were abstracted from all medication abortion patients from 1 y prior to the law's implementation (January 2010-January 2011) to 3 y post implementation (February 2011-October 2014) at four abortion-providing health care facilities in Ohio. Outcome data were analyzed for all women undergoing abortion at ≤49 d gestation during the study period. The main outcomes were as follows: need for additional intervention following medication abortion (such as aspiration, repeat misoprostol, and blood transfusion), frequency of continuing pregnancy, reports of side effects, and the proportion of abortions that were medication abortions (versus other abortion procedures). Among the 2,783 medication abortions ≤49 d gestation, 4.9% (95% CI: 3.7%-6.2%) in the prelaw and 14.3% (95% CI: 12.6%-16.0%) in the postlaw period required one or more additional interventions. Women obtaining a medication abortion in the postlaw period had three times the odds of requiring an additional intervention as women in the prelaw period (adjusted odds ratio [AOR] = 3.11, 95% CI: 2.27-4.27). In a mixed effects multivariable model that uses facility-months as the unit of analysis to account for lack of independence by site, we found that the law change was associated with a 9.4% (95% CI: 4.0%-18.4%) absolute increase in the rate of requiring an additional intervention. The most common subsequent intervention in both periods was an additional misoprostol dose and was most commonly administered to treat incomplete abortion. The percentage of women requiring two or more follow-up visits increased from 4.2% (95% CI: 3.0%-5.3%) in the prelaw period to 6.2% (95% CI: 5.5%-8.0%) in the postlaw period (p = 0.003). Continuing pregnancy was rare (0.3%). Overall, 12.6% of women reported at least one side effect during their medication abortion: 8.4% (95% CI: 6.8%-10.0%) in the prelaw period and 15.6% (95% CI: 13.8%-17.3%) in the postlaw period (p < 0.001). Medication abortions fell from 22% (95% CI: 20.8%-22.3%) of all abortions the year before the law went into effect (2010) to 5% (95% CI: 4.8%-5.6%) 3 y after (2014) (p < 0.001). The average patient charge increased from US$426 in 2010 to US$551 in 2014, representing a 16% increase after adjusting for inflation in medical prices. The primary limitation to the study is that it was a pre/post-observational study with no control group that was not exposed to the law.

CONCLUSIONS

Ohio law required use of a medication abortion protocol that is associated with a greater need for additional intervention, more visits, more side effects, and higher costs for women relative to the evidence-based protocol. There is no evidence that the change in law led to improved abortion outcomes. Indeed, our findings suggest the opposite. In March 2016, the FDA-protocol was updated, so Ohio providers may now legally provide current evidence-based protocols. However, this law is still in place and bans physicians from using mifepristone based on any new developments in clinical research as best practices continue to be updated.

Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends

BACKGROUND

Information about the incidence of induced abortion is needed to motivate and inform efforts to help women avoid unintended pregnancies and to monitor progress toward that end. We estimate subregional, regional, and global levels and trends in abortion incidence for 1990 to 2014, and abortion rates in subgroups of women. We use the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion.

METHODS

We requested abortion data from government agencies and compiled data from international sources and nationally representative studies. With data for 1069 country-years, we estimated incidence using a Bayesian hierarchical time series model whereby the overall abortion rate is a function of the modelled rates in subgroups of women of reproductive age defined by their marital status and contraceptive need and use, and the sizes of these subgroups.

FINDINGS

We estimated that 35 abortions (90% uncertainty interval [UI] 33 to 44) occurred annually per 1000 women aged 15-44 years worldwide in 2010-14, which was 5 points less than 40 (39-48) in 1990-94 (90% UI for decline -11 to 0). Because of population growth, the annual number of abortions worldwide increased by 5.9 million (90% UI -1.3 to 15.4), from 50.4 million in 1990-94 (48.6 to 59.9) to 56.3 million (52.4 to 70.0) in 2010-14. In the developed world, the abortion rate declined 19 points (-26 to -14), from 46 (41 to 59) to 27 (24 to 37). In the developing world, we found a non-significant 2 point decline (90% UI -9 to 4) in the rate from 39 (37 to 47) to 37 (34 to 46). Some 25% (90% UI 23 to 29) of pregnancies ended in abortion in 2010-14. Globally, 73% (90% UI 59 to 82) of abortions were obtained by married women in 2010-14 compared with 27% (18 to 41) obtained by unmarried women. We did not observe an association between the abortion rates for 2010-14 and the grounds under which abortion is legally allowed.

INTERPRETATION

Abortion rates have declined significantly since 1990 in the developed world but not in the developing world. Ensuring access to sexual and reproductive health care could help millions of women avoid unintended pregnancies and ensure access to safe abortion.

FUNDING

UK Government, Dutch Ministry of Foreign Affairs, Norwegian Agency for Development Cooperation, The David and Lucile Packard Foundation, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Abortion law in Muslim-majority countries: an overview of the Islamic discourse with policy implications

Religion plays a significant role in a patient’s bioethical decision to have an abortion as well as in a country’s abortion policy. Nevertheless, a holistic understanding of the Islamic position remains under-researched. This study first conducted a detailed and systematic analysis of Islam’s position towards abortion through examining the most authoritative biblical texts (i.e. the Quran and Sunnah) as well as other informative factors (i.e. contemporary fatwas, Islamic mysticism and broader Islamic principles, interest groups, and transnational Islamic organizations). Although Islamic jurisprudence does not encourage abortion, there is no direct biblical prohibition. Positions on abortion are notably variable, and many religious scholars permit abortion in particular circumstances during specific stages of gestational development. It is generally agreed that the least blameworthy abortion is when the life of the pregnant woman is threatened and when 120 days have not lapsed; however, there is remarkable heterogeneity in regards to other circumstances (e.g. preserving physical or mental health, foetal impairment, rape, or social or economic reasons), and later gestational development of the foetus. This study secondly conducted a cross-country examination of abortion rights in Muslim-majority countries. A predominantly conservative approach was found whereby 18 of 47 countries do not allow abortion under any circumstances besides saving the life of the pregnant woman. Nevertheless, there was substantial diversity between countries, and 10 countries allowed abortion ‘on request’. Discursive elements that may enable policy development in Muslim-majority countries as well as future research that may enhance the study of abortion rights are discussed. Particularly, more lenient abortion laws may be achieved through disabusing individuals that the most authoritative texts unambiguously oppose abortion, highlighting more lenient interpretations that exist in certain Islamic legal schools, emphasizing significant actors that support abortion, and being mindful of policy frames that will not be well-received in Muslim-majority countries.