Maternal mortality, abortion access, and optimizing care in an increasingly restrictive United States: A review of the current climate

The United States is facing a national crisis related to increasing rates of maternal morbidity and mortality. Over the past few years, significant focus has been turned to initiatives that aim to address maternal morbidity and mortality rates. In parallel, the United States has seen a significant increase in restrictive abortion access state laws. The link between abortion restrictions and worsening maternal outcomes has been proposed. This review article outlines the national crisis of maternal morbidity and mortality, the potential role of limiting abortion access in this crisis, and the significant racial, socioeconomic, and geographical disparities that exist.

Abortion exile: navigating Mexico's fractured abortion landscape

This paper develops the concept of 'abortion exile' to understand the situation of women who are forced to travel for abortion services because the procedure is outlawed, stigmatized, unaffordable or otherwise inaccessible in their place of residence. A number of legislative, economic, and moral mechanisms conspire to deny women abortion rights at home such that they must journey within and across national borders in pursuit of needed abortion care. While anthropologists have examined the movement of women and men in search of fertility care that is unavailable at home, attention to the situation of women forced to relocate to terminate an untenable pregnancy is surprisingly scarce. Taking Mexico's fractured abortion landscape as an ethnographic starting place, this paper examines the experiences of women made to venture to the capital for legal abortion services because the procedure is criminalised and difficult to access elsewhere in the country. The concept of 'abortion exile' can helpfully explain the forced movement, political status and subjective experiences of women in different world regions where abortion rights are limited, absent, or under threat, and for whom reproductive citizenship remains elusive.

Accommodating conscientious objection in the midwifery workforce: a ratio-data analysis of midwives, birth and late abortions in 18 European countries in 2016

BACKGROUND

In recent years, the role of a midwife has expanded to include the provision of abortion-related care. The laws on abortion in many European countries allow for those who hold a conscientious objection to participating to refrain from such participation. However, some writers have expressed concerns that this may have a detrimental effect on the workforce and limit women's access to the service.

METHOD

The aim of this study was to provide a picture of the potential exposure midwives in Europe have to late abortions, an important factor in the integration of accommodation of conscientious objection to abortion by midwives into workload planning. We collected data from Ministries of Health or government statistical departments in 32 European countries on numbers of births, abortions, late abortions and midwives in 2016. We conducted a ratio-data analysis in those countries that met the inclusion criteria.

RESULTS

Eighteen of the 32 countries provided full data; thus, our calculations are based on a total of 4 036 633 live births, 49 834 late abortions and a total of 132 071 midwives. The calculated ratios of live births to midwife, abortions to midwife and late abortions to midwife illustrate the wide variations between countries in relation to ratios of midwives to live births (15.22-53.99) and late abortions (0.17-1.47) CONCLUSIONS: This study provides the first comprehensive insight to ratios relating to birth and abortion, especially late abortion services, with regard to the midwifery workforce. It is essential to improve the reporting of abortion data and access to it within Europe to support evidence-informed decisions on optimising the contribution of the midwifery workforce especially within highly contentious fields such as abortion services. The study's findings suggest that there should be neither be any difficulty for those who are responsible for workload allocation nor compromises to a women's right to abortion services.

Artificial Womb Technology and the Choice to Gestate Ex Utero: Is Partial Ectogenesis the Business of the Criminal Law?

It is frequently claimed that artificial wombs (AWs) could alleviate the burdens placed exclusively on women in reproduction. In this article, I demonstrate how AWs used for the partial gestation of preterm neonates could introduce new choices for women by changing perceptions of tolerable risks in gestation. In light of advancing medical technology, it is necessary to consider whether the current legal framework in England and Wales would support increased choice for women about alternative forms of gestation. I examine the ill-defined offence of 'unlawfully procuring miscarriage' in the Offences Against the Person Act 1861 and demonstrate that different conclusions about the legal significance of ending a pregnancy are evident, depending on the analytical lens adopted in interpreting ambiguities. Furthermore, I demonstrate that the defences available to pregnancy termination under the Abortion Act 1967 are too narrow to support choices about alternative forms of gestation, even if they become physically and medically possible. Therefore, we should decriminalise termination of pregnancy, or, if it is assumed that gestation is the business of the criminal law, specific reforms to the legal framework are necessary. The offence of unlawfully procuring miscarriage is too uncertain and broad, and the defences available are too restrictive.

The "Abortion Pill" Misoprostol in Brazil: Women's Empowerment in a Conservative and Repressive Political Environment

In the aftermath of the introduction of severe restrictions on abortion in several US states, some activists have argued that providing widespread access to an abortive drug, misoprostol, will transform an induced abortion into a fully private act and therefore will empower women. In Brazil, where abortion is criminalized, the majority of women who wish to terminate an unwanted pregnancy already use the illegal, but easily accessible, misoprostol. We examine the history of misoprostol as an abortifacient in Brazil from the late 1980s until today and the professional debates on the teratogenicity of this drug. The effects of a given pharmaceutical compound, we argue, are always articulated, elicited, and informed within dense networks of sociocultural, economic, legal, and political settings. In a conservative and repressive environment, the use of misoprostol for self-induced abortions, even when supported by formal or informal solidarity networks, is far from being a satisfactory solution to the curbing of women's reproductive rights.

Reproductive Injustice at the US Border

The detention of immigrants inside US borders is not a new phenomenon. However, a dramatic shift has occurred in both the number and treatment of immigrants in detention.We examine recent changes in immigration policies that have systematized the mistreatment of children and pregnant immigrants, including a ban on abortion for unaccompanied minors in immigration detention, the neglect and mistreatment of pregnant immigrants in detention, and the separation and prolonged detention of parents and children in unsafe facilities.We employ the reproductive justice framework to demonstrate how these policies violate all 3 primary values of reproductive justice: the right to have children, the right not to have children, and the right to parent children in safe and secure environments. We argue that, when analyzed through the lens of reproductive justice, these policies can be seen as manifestations of a single targeted strategy to control the reproductive autonomy of migrants as a tool of immigration enforcement. We conclude with a call to action to the public health community.

Adolescents Obtaining Abortion Without Parental Consent: Their Reasons and Experiences of Social Support

CONTEXT

Most states require adolescents younger than 18 to involve a parent prior to obtaining an abortion, yet little is known about adolescents' reasons for choosing abortion or the social support received by those who seek judicial bypass of parental consent for abortion.

METHODS

In-depth interviews were conducted with 20 individuals aged 16-19 who sought judicial bypass in Texas between 2015 and 2016 to explore why they chose to get an abortion, who they involved in their decision and what their experiences of social support were. Data were analyzed thematically using stigma and social support theories.

RESULTS

Participants researched their pregnancy options and involved others in their decisions. They chose abortion because parenting would limit their futures, and they believed they could not provide a child with all of her or his needs. Anticipated stigma motivated participants to keep their decision private, although they desired emotional and material support. Not all male partners agreed with adolescents' decisions to seek an abortion, and agreement by some males did not guarantee emotional or material support; some young women described their partners' giving them the "freedom" to make the decision as avoiding responsibility. After a disclosure of their abortion decision, some participants experienced enacted stigma, including shame and emotional abuse.

CONCLUSIONS

Abortion stigma influences adolescents' disclosure of their abortion decisions and limits their social support. Fears of disclosing their pregnancies and abortion decisions are justified, and policymakers should consider how laws requiring parental notification may harm adolescents. Further research is needed on adolescents' experiences with abortion stigma.

Factors associated with the timing of abortions

The timing of an abortion (often measured as gestational age) can have important effects on the woman's physical health and on the cost of the procedure. To the authors' knowledge, there has been only one national analysis of the factors associated with the gestational age at abortion, but it employed data from over 20 years ago. The state-specific studies that have explored abortion timing have typically examined the effects of a specific change in abortion regulations. In this study, we employ annual, state-level data covering the 1991-2014 period that measure the frequency of abortions by gestational age. We regress these measures of abortion utilization on policy, economic, demographic, and health care infrastructure characteristics. The estimates indicate that the introduction of state restrictions on Medicaid funding of abortions is associated with a 13% increase in the rate of abortions after the first trimester. We do not find a statistically significant association between parental involvement laws and the rate or percentage of post-first-trimester abortions.

Leadership for success in transforming medical abortion policy in Canada

Objectives

Mifepristone was approved for use in medical abortion by Health Canada in 2015. Approval was accompanied by regulations that prohibited pharmacist dispensing of the medication. Reproductive health advocates in Canada recognized this regulation would limit access to medical abortion and successfully worked to have this regulation removed in 2017. The purpose of this study was to assess the leadership involved in changing these regulations so that the success may be replicated by other groups advocating for health policy change.

Methods

This study involved a mixed methods instrumental design in the context of British Columbia, Canada. Our data collection included: a) interviews with seven key individuals, representing the organizations that worked in concert for change to Canadian mifepristone regulations, and b) document analysis of press articles, correspondence, briefing notes, and meeting minutes. We conducted a thematic analysis of transcripts of audio-recorded interviews. We identified strengths and weaknesses of the team dynamic using the Develop Coalitions, Achieve Results and Systems Transformation domains of the LEADS Framework.

Results

Our analysis of participant interviews indicates that autonomy, shared values, and clarity in communication were integral to the success of the group’s work. Analysis using the LEADS Framework showed that individuals possessed many of the capabilities identified as being necessary for successful health policy leadership. A lack of post-project assessment was identified as a possible limitation and could be incorporated in future work to strengthen dynamics especially when a desired outcome is not achieved. Document analysis provided a clear time-line of the work completed and suggested that strong communication between team members was another key to success.

Conclusions

The results of our analysis of the interviews and documents provide valuable insight into the workings of a successful group committed to a common goal. The existing collegial and trusting relationships between key stakeholders allowed for interdisciplinary collaboration, rapid mobilization, and identification of issues that facilitated successful Canadian global-first deregulation of mifepristone dispensing.

International Law and the Legalization of Abortion in Northern Ireland

On July 24, 2019, the Parliament of the United Kingdom passed an act that included an amendment requiring Northern Ireland to implement recommendations from the Committee on the Elimination on Discrimination Against Women. The amendment required Northern Ireland to repeal the 1861 abortion act and requires the decriminalization of abortion. The law went into effect on October 22, 2019, since the Northern Ireland power-sharing government (Stormont) did not reconvene before October 21, 2019. Since the law did go into effect, it gave women the right to obtain abortions under the CEDAW recommendations; however, when the Northern Irish government (Stormont) reconvenes, it can recriminalize abortion. They made this attempt when Stormont under DUP leadership reconvened briefly on January 11, 2020 before the official Brexit the next day. This Note argues that abortion should be legal in Northern Ireland regardless of whether the new legislation from British Parliament ever went into effect or gets overturned by the Stormont legislature because of several treaties and domestic decisions from the Supreme Court in Belfast and the new regulations made in accordance with the amendment need to meet the standards of the CEDAW recommendations.

Women's abortion seeking behavior under restrictive abortion laws in Mexico

Abortion is regulated in Mexico at the state level, and it is permitted under certain criteria in all 32 states, except in Mexico City where first-trimester abortion is decriminalized. Yet, more than a million abortions occur in Mexico each year. But most terminations occurring outside of Mexico City are clandestine and unsafe due to profound stigma against the procedure, lack of trained providers, lack of knowledge of where to find a safe abortion and poor knowledge of the laws. While this situation is moderated by the increasing use of misoprostol, a relatively safe method of abortion, the safety of the procedure cannot be assured in restrictive legal contexts. The purpose of this study is to explore women’s experiences with induced abortion in three federal entities with different legal contexts, and whether abortion seeking behavior and experiences differ across these settings. The study was carried out in three states, representing three different degrees of restrictiveness of abortion legislation. Queretaro with the “most restrictive” law, Tabasco with a “moderately restrictive” law, and Mexico state with the “least restrictive” law. We hypothesize that women living in more restrictive states will resort to the use of more unsafe and risky methods and providers for their abortion than their counterparts in less restrictive states. Women who recently obtained abortions were selected through snowball sampling and qualitative data were collected from them using semi-structured indepth interviews. Data collection took place between mid-2014 and mid-2015, with a final sample size N = 60 (20 from each state). Various themes involved in the process of abortion seeking behavior were developed from the IDIs and examined here: women’s knowledge of the abortion law in their state, reasons for having an abortion; the methods and providers used and women’s positive and negative experiences with abortion methods and providers used. Our results indicate that abortion safety is not associated with the restrictiveness of abortion legislation. Findings show that there is a new pattern of abortion service provision in Mexico, with misoprostol, a relatively safe and easy to use method, playing an important role. Nevertheless, while access to misoprostol tends to increase the safety of abortion, the improvement is moderated by women and their informants (relatives, friends and partners) not having accurate information on how to safely self-induce an abortion with misoprostol. On the other hand, some women manage to have safe abortion in illegal setting by going to Mexico City or with the support of NGOs knowlegeable on abortion. Findings demonstrate the importance of decriminalization of abortion, but meanwhile, harm reduction strategies, including promotion of accurate information about self-use of misoprostol where abortion is legally restricted will result in safe abortion.

Advocating safe abortion: outcomes of a multi-country needs assessment on the potential role of national societies of obstetrics and gynecology

In 2019 the International Federation of Gynecology and Obstetrics (FIGO) embarked on an initiative that aims to strengthen the capacity of 10 national societies of obstetrics and gynecology (ObGyn) in advocacy for safe abortion. In 2018 needs assessments that entailed a desk study, interviews, and stakeholder workshops were conducted in Benin, Cameroon, Côte d'Ivoire, Kenya, Mali, Mozambique, Panama, Peru, Uganda, and Zambia. The general aim of the needs assessments was to gain a deeper understanding of the contextual situation and identify the needs of ObGyn societies in relation to safe abortion advocacy. This paper provides a cross‐country analysis of the outcomes of the needs assessments and reflects on the capabilities, barriers, and opportunities to strengthen this role of ObGyn societies. Common barriers, such as unavailability of services, lack of technical guidance, unawareness and ambiguity about the legal framework, provider attitudes, and abortion stigma, pose challenges for ObGyn societies to work constructively on safe abortion advocacy. However, ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers’ advocacy role. Five strategies were developed to strengthen the capacity of ObGyn societies in safe abortion advocacy.

ObGyn societies have the potential to advance women's health and rights to safe abortion care by strengthening their advocacy role through a multi‐strategy approach.

Abortion Decriminalisation in New South Wales: An Analysis of the Abortion Law Reform Act 2019 (NSW)

Abortion was decriminalised in New South Wales in October 2019. While New South Wales is the seventh jurisdiction in Australia to decriminalise abortion and regulate it under health legislation, the recent passage of the Abortion Law Reform Act 2019 (NSW) (the Act) saw the adoption of a number of principle-based amendments that distinguish it from abortion legislation in other Australian jurisdictions. This article critiques key sections of the Act regarding sex selection abortion, a doctor's duties in relation to offering a woman counselling, the distinct crime of abortion coercion, and the protection of conscience for health professionals. It also identifies where future research may assist us in understanding both the application of these new legal requirements, and the community's experiences with abortion.

Men's support for abortion in Upper East and Upper West Ghana

The second leading cause of maternal mortality in Ghana is unsafe abortion. Research in Ghana shows that men's support influences women's use of safe abortion services. The aim of this study was to understand what men know about abortion, why they support their partners to seek an abortion, and to identify effective ways to reach men with abortion information. We conducted eleven focus groups and ten in-depth interviews with men of reproductive age in rural Ghana. Inclusion criteria were written consent, age and marital status. Focus groups and interviews were conducted in local languages using a semi-structured guide. Focus groups and interviews were audiotaped, transcribed, translated, computerised and coded for analysis. Most men knew the difference between unsafe and safe abortion and would support their partner to have an abortion. Messages that reinforce safe abortion as acceptable and that address fears of death or barrenness should be developed to educate men about safe abortion. Multiple channels to communicate these messages should be used and include pictures, video or audio for those men who cannot read. Through an intensive intervention inclusive of men, women's access to safe abortion services can be improved in Ghana.

The access paradox: abortion law, policy and practice in Ethiopia, Tanzania and Zambia

INTRODUCTION

Unsafe abortion is a major contributor to the continued high global maternal mortality and morbidity rates. Legal abortion frameworks and access to sexuality education and contraception have been pointed out as vital to reduce unsafe abortion rates. This paper explores the relationship between abortion law, policy and women's access to safe abortion services within the different legal and political contexts of Ethiopia, Tanzania and Zambia. The research is inspired by recent calls for contextualized policy research.

METHODS

The research was based in Addis Ababa (Ethiopa), Dar es Salaam (Tanzania) and Lusaka (Zambia) and had a qualitative exploratory research design. The project involved studying the three countries' abortion laws and policies. It moreover targeted formal organizations as implementers of policy as well as stakeholders in support of, or in opposition to the existing abortion laws. Semi-structured interviews were carried out with study participants (79) differently situated vis-à-vis abortion, exploring their views on abortion-related legal- and policy frames and their perceived implications for access.

RESULTS

The abortion laws have been classified as 'liberal' in Zambia, 'semi-liberal' in Ethiopia and 'restrictive' in Tanzania, but what we encountered in the three study contexts was a seeming paradoxical relationship between national abortion laws, abortion policy and women's actual access to safe abortion services. The study findings moreover reveal that the texts that make up the three national abortion laws are highly ambiguous. The on-paper liberal Zambian and semi-liberal Ethiopian laws in no way ensure access, while the strict Tanzanian law is hardly sufficient to prevent young women from seeking and obtaining abortion. In line with Walt and Gilson's call to move beyond a narrow focus on the content of policy, our study demonstrates that the connection between law, health policy and access to health services is complex and critically dependent on the socio-economic and political context of implementation.

CONCLUSIONS

Legal frameworks are vital instruments for securing the right to health, but broad contextualized studies rather than classifications of law along a liberal-restrictive continuum are demanded in order to enhance existing knowledge on access to safe abortion services in a given context.

Health, life and rights: a discourse analysis of a hybrid abortion regime in Tanzania

BACKGROUND

Unsafe abortion continues to be a major hazard for maternal health in Sub-Saharan Africa, where abortion remains highly controversial and access to safe abortion services is unequally distributed. Although national abortion laws are central in indicating women's potential for accessing safe abortion services, the character of an abortion law may alone say little about national discursive abortion landscapes and access scenarios. The article calls for the study and problematization of the relationship between legal abortion frameworks on the one hand, and discourses surrounding abortion on the other, in an attempt to move closer to an understanding of the complexity of factors that influence knowledge about and access to safer abortion services. With the restrictive abortion law in Tanzania as a starting point, the paper explores the ways in which the major global abortion discourses manifest themselves in the country and indicate potential implications of a hybrid abortion regime.

METHODS

The study combined a review of major legal and policy documents on abortion, a review of publications on abortion in Tanzanian newspapers between 2000 and 2015 (300 articles), and 23 semi-structured qualitative interviews with representatives from central institutions and organizations engaged in policy- or practical work related to reproductive health.

RESULTS

Tanzania's abortion law is highly restrictive, but the discursive abortion landscape is diverse and is made manifest through legal- and policy documents and legal- and policy related disputes. The discourses were characterized by diverse frames of reference based in religion, public health and in human rights-based values, and as such reflect the major global discourses. Fairclough's concepts interdiscursivity and recontextualization were drawn upon to develop an understanding of how the concepts health, rights and life emerge across the discourses, but are employed in contrasting lines of argumentation in struggles for hegemony and legitimacy.

DISCUSSION AND CONCLUSIONS

The paper demonstrates that a hybrid discursive regime relating to abortion characterizes the legally restrictive abortion context of Tanzania. We argue that such a complex discursive landscape, which cuts across the restrictive - liberal divide, generates an environment that seems to open avenues for enhanced access to abortion related knowledge and services.