Induced abortion: estimated rates and trends worldwide

Evaluation of two intervention models on contraceptive attitudes and behaviors among nulliparous women in Shanghai, China: a clustered randomized controlled trial

BACKGROUND

With increasing acceptance of premarital sex among young Chinese women, the rates of unintended pregnancies and induced abortions are becoming alarmingly high, suggesting the needs of educating women with adequate contraceptive knowledge and providing them with accessible contraceptive services. Previous studies have shown that knowledge and attitudes towards contraception could be modified through intervention strategies. This study aimed to evaluate the effects of two community intervention models on modifying contraceptive attitudes and behaviors among nulliparous women.

METHODS

In this clustered randomized controlled trial, nulliparous women aged 18-40 years from 18 communities were enrolled and randomized to either the traditional community intervention model (TC model) or the more comprehensive new community-based intervention model (NC model) with a ratio of 1:2. Contraceptive attitudes and behaviors were assessed before and after the interventions.

RESULTS

A total of 901 nulliparous women were followed. The most common contraceptive method in both groups was condom (approximately 80%) before or after interventions. The rates of using effective contraceptive methods were very low (<5%) even after the intervention. Comparing the NC with TC group, the adjusted ORs and 95% CIs regarding natural family planning, emergency contraceptive usage and short-acting OCPs were1.53 (95% CI: 1.11-2.13), 2.87 (95% CI: 2.05-4.02), and 2.71 (95% CI: 1.65-4.47), respectively; while the ORs and 95%CIs of gynecological examination and contraceptive use were 2.31 (95% CI: 1.63-3.27) and 2.89 (95% CI: 1.98-4.23), respectively. No statistical significant difference was found for the use of effective contraceptive methods at post-intervention among the two models.

CONCLUSIONS

High proportions of nulliparous women held negative attitudes and behaviors towards effective contraceptive methods. The NC model, integrating existing health resources, had more positive influence than the TC model on the favorable contraceptive attitudes and behaviors towards the use of any contraceptive methods, but had limited impact on the use of effective contraceptive methods. Our study suggested the feasibility of applying the NC model in Shanghai. Interventions on contraceptive attitudes and behaviors should base on the existing health service system, synthesize resources and selectively apply to populations with distinct characteristics.

Which outcomes do women expect to achieve after undergoing induced abortion

Introduction

Unsafe abortion is one of the most important health problems in many countries. Because of legal and moral issues, abortion is one of the most sensitive decisions. The aim of this study was to understand women’s expected gains from undergoing induced abortion.

Methods

To explain the factors leading to induced abortion, we collected the stories and experiences of a total of 21 people, including 18 women who underwent induced abortion in their most recent pregnancies, two women’s health providers, and a companion of a mother who died after an induced abortion. This qualitative study was conducted in Imam Khomeini and Razi hospital of Ahvaz and also a number of health centers, from February to September 2014. To collect the required data, we used open and semi-structured deep interviews. Content analysis method was used to analyze the data.

Results

Three major themes emerged from the analysis of the collected data, which included the following: 1) Expected favorable health-related outcomes, 2) Expected favorable economic outcomes, and 3. Expected favorable outcomes in social level and family relationships.

Conclusion

The results of this study showed that the studied women, to achieve to desirable outcomes in areas of health, economic and social, have undergone induced abortion. Hence, to develop programs for the prevention of induced abortion it is necessary to consider the motivations of women to intentionally terminate a pregnancy.

The changing pattern of contraceptive use and pregnancies in four generations of young women

INTRODUCTION

The aim of this study was to describe contraceptive use and pregnancies and their relationship to socio-economic status (SES) in four generations of young Swedish women.

MATERIAL AND METHODS

Questionnaires regarding contraceptive use and pregnancies were sent to random samples of 19-year-old women in 1981, 1991, 2001 and 2011 (n = 4732).

RESULTS

Current contraceptive use was higher in 2001 (78%) (p < 0.01) and 2011 (69%) (p < 0.05) compared with 1981 (60%) and 1991 (62%). Combined hormonal contraception (CHC) was the most common form of contraception throughout (p < 0.0001). The use of long-acting reversible contraception (LARC = implants, intrauterine contraception) and progestogen-only pills increased over time (p < 0.01). Mental side effects as a reason for CHC cessation increased over time and was the most common reason for cessation of CHC in 2011 (p < 0.001). Contraceptive use was lower in women from low SES areas (p < 0.05) in 2011. The percentage of young women who had been pregnant at ≤19 years of age was lower (p < 0.05) in the assessment from 2001 (7%) than in that in 1991 (13%) and 2011 (12%). The proportion of teenage mothers decreased from 4.4% (1981) to 1.6% (2011) (p < 0.01). More women had been pregnant at ≤19 years of age in low SES areas than in middle and high SES areas (p < 0.05).

CONCLUSIONS

The lowest pregnancy rate was in the cohort with the highest contraceptive use. Term pregnancies declined over time. A greater number of pregnancies in low SES areas and a change towards lower contraceptive use in low SES areas was recorded in 2011.

Women's and Healthcare Workers' Beliefs and Experiences Surrounding Abortion: The Case of Haiti

PURPOSE

Women in developing countries usually encounter serious inequities in terms of women's health. To date, there is limited understanding of abortion from the perspective of Haitian women. As a limited-resource country, Haiti faces complex social issues and healthcare challenges. With abortion being illegal, many adult and teenage women seek clandestine abortions. The aim of this study was to explore and gain a greater understanding of women's and healthcare workers' beliefs and experiences about abortion in Haiti.

METHODS

Descriptive qualitative design was used to elicit information for the study. Eight focus groups were conducted with Haitian women and healthcare workers in five communities in the south of Haiti: Les Cayes, Aquin, St. Louis du Sud, Cavaillon, Maniche, and Ile a Vache. Participants were purposively selected and consented to participate and to be tape recorded. Content analysis followed using the verbatim transcripts, with triangulation of four researchers; saturation was reached with this number of focus groups.

FINDINGS

The transcripts revealed six main themes regarding beliefs and experiences about abortion in Haiti: cultural aspects, consumers, perils of care, and legal concerns. Both women and healthcare workers discussed the repercussions of illegal abortion and the role of the government and hospitals. Participants identified similar perils and complications of unsafe abortions, such as postpartum hemorrhage and infection.

CONCLUSIONS

Results showed an urgent need to create a public health response that addresses different dimensions of abortion by engaging women and healthcare providers in rapid and concrete actions that promote access and safe care of women. It is imperative to conduct more research related to abortion in order to examine other associated factors to better understand the links between abortion and sexual health disparities among Haitian women. These results highlight the need for a rapid response to the need of this vulnerable group, who are experiencing high rates of mortality. This can also serve as a directive to approach this issue in other developing countries in the Caribbean region, particularly from its clinical relevance.

CLINICAL RELEVANCE

Unsafe abortions are prevalent in developing countries; yet limited research exists on the topic. It is paramount to gain an understanding of the women's and healthcare workers' beliefs and experiences surrounding abortion, in order to develop interventions that prevent abortion complications in Haitian women.

High Levels of Post-Abortion Complication in a Setting Where Abortion Service Is Not Legalized

Background

Maternal mortality due to abortion complications stands among the three leading causes of maternal death in Botswana where there is a restrictive abortion law. This study aimed at assessing the patterns and determinants of post-abortion complications.

Methods

A retrospective institution based cross-sectional study was conducted at four hospitals from January to August 2014. Data were extracted from patients’ records with regards to their socio-demographic variables, abortion complications and length of hospital stay. Descriptive statistics and bivariate analysis were employed.

Result

A total of 619 patients’ records were reviewed with a mean (SD) age of 27.12 (5.97) years. The majority of abortions (95.5%) were reported to be spontaneous and 3.9% of the abortions were induced by the patient. Two thirds of the patients were admitted as their first visit to the hospitals and one third were referrals from other health facilities. Two thirds of the patients were admitted as a result of incomplete abortion followed by inevitable abortion (16.8%). Offensive vaginal discharge (17.9%), tender uterus (11.3%), septic shock (3.9%) and pelvic peritonitis (2.4%) were among the physical findings recorded on admission. Clinically detectable anaemia evidenced by pallor was found to be the leading major complication in 193 (31.2%) of the cases followed by hypovolemic and septic shock 65 (10.5%). There were a total of 9 abortion related deaths with a case fatality rate of 1.5%. Self-induced abortion and delayed uterine evacuation of more than six hours were found to have significant association with post-abortion complications (p-values of 0.018 and 0.035 respectively).

Conclusion

Abortion related complications and deaths are high in our setting where abortion is illegal. Mechanisms need to be devised in the health facilities to evacuate the uterus in good time whenever it is indicated and to be equipped to handle the fatal complications. There is an indication for clinical audit on post-abortion care to insure implementation of standard protocol and reduce complications.

Induced Abortion: a Systematic Review and Meta-analysis

Background:

Induced abortion accounts for 1 in 8 of approximately 600000 maternal deaths that occur annually worldwide. Induced abortion rate can be considered as one of the indicators for assessing availability of the appropriate reproductive health plans for women and identifying needs for appropriate related health policies and programs.

Material and Methods:

Researchers searched Pubmed, Google Scholar, CINAHL, Embase, PsycINFO, Cochrane, Iranian Scientific Information Database (SID), Iranian biomedical journals (Iranmedex), and Iranian Research Institute of Information and Documentation (Irandoc) between January 2000 and June 2013, which reported induced abortion. Search terms from two categories including abortion and termination of pregnancy were compiled. The search terms were “induced abortion”, “illegal abortion”, “illegal abortion”, “unsafe abortion”, and “criminal abortion”. The search was also conducted with “induced termination of pregnancy”, “illegal termination of pregnancy”, “illegal termination of pregnancy”, “unsafe termination of pregnancy” and “criminal termination of pregnancy”. Meta-analysis was carried out by using OpenMeta software. Induced abortion rates were calculated based on the random effect model.

Results:

Overall induced abortion rate was obtained 58.1 per 1000 women (95%CI: 55.16-61.04). In continental level, rate of induced abortion was 14 per 1000 women (95%CI: 11-16). Nation-wide and local rates were obtained 67.27 per 1000 women (95% CI: 60.02-74.23) and 148.92 (95% CI: 140.06-157.79) respectively.

Discussion and Conclusion:

Induced abortion is a major public health problem that occurs worldwide whether under the legal restriction or freedom, and it remains as reproductive health concern globally. To eliminate the need for induced abortion is at the core of any effort for preventing this issue. Option with the highest priority is to prevent unwanted pregnancies through promoting reproductive health plans for women of reproductive age. In case the prevention strategies fail, universal provision of safe abortion services should be put in place.

Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it

BACKGROUND

Despite the increased prevalence of reversible contraception, global unintended pregnancy rates are stable. Mistakes, method failures, side effects, alcohol, stock-outs, fears, costs, delays, myths, religious interference, doctors with other priorities, traditions and lack of health professionals may all factor in. Yet these unintended pregnancies - nearly a hundred million annually - cause much individual suffering, and in the long run, can aggravate conflicts, poverty, forced emigration and climate change. Presently, non-poor women postpone childbearing because of longer educational trajectories and careers. Sterilisations are therefore less often regretted or coerced. For poor-resourced women with a completed family, an unwanted pregnancy often has serious consequences, including crossing the (extreme) poverty line in the wrong direction, choosing an unsafe abortion, or even death. Caesarean sections (CSs), which currently stand at around 23 million annually, are increasing. On an "intention-never-to-become-pregnant-again" analysis, choosing a partial, and even more so a total bilateral tubectomy to be implemented during an - anyway performed - CS is by far the most reliable and safe contraceptive choice compared to meaning to start female or male sterilisation or any other contraceptive method later, and it reduces the chance of a future ovarian carcinoma substantially. CSs make subsequent pregnancies more dangerous. Simultaneously, they provide convenient, potentially cost-free opportunities for voluntary permanent contraception (PC): particularly important if there is no guaranteed future access to reliable contraception, safe abortion and well-supervised labour.

PARTIAL SOLUTION

Millions of women are within reach of attaining freedom from the "tyranny of excessive fertility" when they have a CS. Therefore, any woman who might conceivably be of the firm opinion that her family will be (over) completed after delivery should antenatally have "what if you have a CS" counselling to assess whether she would like a tubectomy/ligation. Yet many are not provided with this option: leading to frequent regret, more often than having been giving that choice would.

CONCLUSION

Withholding antenatal counselling about the option of PC for in case the delivery might become a CS is very prevalent, yet often more medically risky, and morally questionable than when, even in labour, a doctor sometimes decides in the absence of earlier counselling, considering numerous factors, to provide the choice to undergo a concurrent sterilisation if s/he is convinced that would be in the patient's best interest.

Knowledge and Usage of Emergency Contraceptives Among University Students in Ghana

Contraceptive use is an important strategy for the prevention of unwanted pregnancy and avoidance of induced abortion. Of all the contraception methods, emergency contraceptive (EC) offers the last chance to achieve this. However, few studies have documented the use of EC among young people in Ghana. This study explored knowledge and usage of EC as well as the factors associated with it among University of Cape Coast students. Data were obtained on the knowledge and usage of ECs among University of Cape Coast students in 2013. Logistic regression analysis was used to investigate the association between students' socio-demographic characteristics and EC knowledge and use. More male students (72%) than females (59%) were sexually active. Fifty-seven percent of the respondents had ever heard of EC and 36% had ever used EC. Although males were more likely to be sexually active, females were more likely to have knowledge of EC use compared to males. The study underscores the need to increase awareness regarding EC among University students in order to offer them the opportunity that EC provides if other forms of contraceptives are missed.

An evaluation of the current state of sexual and reproductive health and rights of women in Ghana

OBJECTIVE

To provide a current account of women's sexual and reproductive health and rights (SRHR) in Ghana (West Africa), a priority area in achieving the World Health Organization's Millennium Development Goals.

METHOD

The study was observational. Three-hundred ninety Ghanaian women attending cervical cancer screening were surveyed about their SRHR. The data were analyzed with chi-squared test (p ≤ 0.05, two-sided).

RESULTS

22.1% had a life-time history of non-consensual sexual experience and 55.4% a previous history of abortion, mostly using services of a registered clinic (68.5%). Experience of sexual violence increased life-time risk of abortion (p = 0.018). The overall use of contraceptives was high (>60%); however, condom use during sexual intercourse with a new partner was low (23%), even among the highly educated women (32.7%) and women who stated to have received information on the risks and benefits of condom use (26.0%). Although condom use among the highly educated women was low, it was still 2 times higher than among the lower educated women, 15.7% (p < 0.001). There was also less condom use among the women with multiple sexual partners compared to single-partnered women (p = 0.001).

CONCLUSION

More than a decade after the inception of the Millennium Development Goals, there is still work to be done in Ghana, especially on education and sexual violence.

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.

Using Behavioral Science to Design a Peer Comparison Intervention for Postabortion Family Planning in Nepal

Despite the provision of free and subsidized family planning services and clients' demonstrated intentions to delay pregnancies, family planning uptake among women who receive abortion and postabortion services at Sunaulo Parivar Nepal (SPN), one of Nepal's largest non-governmental sexual and reproductive health (SRH) providers, remains low. Through meetings, interviews, and observations with SPN's stakeholders, service providers, and clients at its 36 SRH centers, we developed hypotheses about client- and provider-side barriers that may inhibit postabortion family planning (PAFP) uptake. On the provider side, we found that the lack of benchmarks (such as the performance of other facilities) against which providers could compare their own performance and the lack of feedback on the performance were important barriers to PAFP uptake. We designed several variants of three interventions to address these barriers. Through conversations with team members at SPN's centralized support office and service providers at SPN centers, we prioritized a peer-comparison tool that allows providers at one center to compare their performance with that of other similar centers. We used feedback from the community of providers on the tools' usability and features to select a variant of the tool that also leverages and reinforces providers' strong intrinsic motivation to provide quality PAFP services. In this paper, we detail the process of identifying barriers and creating an intervention to overcome those barriers. The intervention's effectiveness will be tested with a center-level, stepped-wedge randomized control trial in which SPN's 36 centers will be randomly assigned to receive the intervention at 1-month intervals over a 6-month period. Existing medical record data will be used to monitor family planning uptake.

Prior uterine evacuation of pregnancy as independent risk factor for preterm birth: a systematic review and metaanalysis

BACKGROUND

Preterm birth (PTB) is the number one cause of perinatal mortality. Prior surgery on the cervix is associated with an increased risk of PTB. History of uterine evacuation, by either induced termination of pregnancy (I-TOP) or spontaneous abortion (SAB), which involve mechanical and/or osmotic dilatation of the cervix, has been associated with an increased risk of PTB in some studies but not in others.

OBJECTIVE

The objective of the study was to evaluate the risk of PTB among women with a history of uterine evacuation for I-TOP or SAB.

DATA SOURCES

Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, and Sciencedirect) were searched from their inception until January 2015 with no limit for language.

STUDY ELIGIBILITY CRITERIA

We included all studies of women with prior uterine evacuation for either I-TOP or SAB, compared with a control group without a history of uterine evacuation, which reported data about the subsequent pregnancy.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcome was the incidence of PTB < 37 weeks. Secondary outcomes were incidence of low birthweight (LBW) and small for gestational age (SGA). We planned to assess the primary and the secondary outcomes in the overall population as well as in studies on I-TOP and SAB separately. The pooled results were reported as odds ratio (OR) with 95% confidence interval (CI).

RESULTS

We included 36 studies in this metaanalysis (1,047,683 women). Thirty-one studies reported data about prior uterine evacuation for I-TOP, whereas 5 studies reported data for SAB. In the overall population, women with a history of uterine evacuation for either I-TOP or SAB had a significantly higher risk of PTB (5.7% vs 5.0%; OR, 1.44, 95% CI, 1.09-1.90), LBW (7.3% vs 5.9%; OR, 1.41, 95% CI, 1.22-1.62), and SGA (10.2% vs 9.0%; OR, 1.19, 95% CI, 1.01-1.42) compared with controls. Of the 31 studies on I-TOP, 28 included 913,297 women with a history of surgical I-TOP, whereas 3 included 10,253 women with a prior medical I-TOP. Women with a prior surgical I-TOP had a significantly higher risk of PTB (5.4% vs 4.4%; OR, 1.52, 95% CI, 1.08-2.16), LBW (7.3% vs 5.9%; OR, 1.41, 95% CI, 1.22-1.62), and SGA (10.2% vs 9.0%; OR, 1.19, 95% CI, 1.01-1.42) compared with controls. Women with a prior medical I-TOP had a similar risk of PTB compared with those who did not have a history of I-TOP (28.2% vs 29.5%; OR, 1.50, 95% CI, 1.00-2.25). Five studies, including 124,133 women, reported data about a subsequent pregnancy in women with a prior SAB. In all of the included studies, the SAB was surgically managed. Women with a prior surgical SAB had a higher risk of PTB compared with those who did not have a history of SAB (9.4% vs 8.6%; OR, 1.19, 95% CI, 1.03-1.37).

CONCLUSION

Prior surgical uterine evacuation for either I-TOP or SAB is an independent risk factor for PTB. These data warrant caution in the use of surgical uterine evacuation and should encourage safer surgical techniques as well as medical methods.

Future healthcare professionals' knowledge about the Argentinean abortion law

OBJECTIVE

We assessed healthcare students' knowledge and opinions on Argentinian abortion law and identified differences between first- and final-year healthcare students.

METHODS

In this cross-sectional study, self-administered anonymous questionnaires were administered to 760 first- and 695 final-year students from different fields of study (medicine, midwifery, nursing, radiology, nutrition, speech therapy, and physiotherapy) of the School of Medicine at the University of Buenos Aires, in 2011-2013.

RESULTS

Compared to first-year students, a higher percentage of final-year students knew that abortion is legally restricted in Argentina (p < 0.001). A significantly higher percentage of final-year students could correctly identify the circumstances in which abortion is legal: woman's life risk (87.4% last vs. 79.1% first year), rape of a woman with developmental disability (66.2% first vs. 85.4% last-year; p < 0.001). More final-year students chose severe foetal malformations (37.3% first year vs. 57.3% final year) despite its being illegal.

CONCLUSIONS

Although most final-year students knew that abortion is legally restricted in Argentina, misconceptions regarding circumstances of legal abortion were observed; this may be due to the fact that abortion is inadequately covered in the medical curricula. Medical schools should ensure that sexual and reproductive health topics are an integral part of their curricula. Healthcare providers who are aware of the legality of abortion are more likely to provide the public with sound information and ensure abortions are appropriately performed.

Austerity and Abortion in the European Union

Economic hardship accompanying large recessions can lead families to terminate unplanned pregnancies. To assess whether abortions have risen during the recession, we collected crude abortion data from 2000 to 2012 from Eurostat for countries that had legal abortions and complete data. Declining trends in abortion ratios between 2000 and 2009 have been reversing. Excess abortions between 2010 and 2012 totaled 10.6 abortions per 1000 pregnancies ending in abortion or birth or 6701 additional abortions (95% CI 1190–9240) with stronger effects in younger ages. Economic shocks may increase recourse to abortion. Further research should explore causal pathways and protective factors.

Abortion experiences among Zanzibari women: a chain-referral sampling study

Background

In Zanzibar, a semi-autonomous region of Tanzania, induced abortion is illegal but common, and fewer than 12 % of married reproductive-aged women use modern contraception. As part of a multi-method study about contraception and consequences of unwanted pregnancies, the objective of this study was to understand the experiences of Zanzibari women who terminated pregnancies.

Methods

The cross-sectional study was set in Zanzibar, Tanzania. Participants were a community-based sample of women who had terminated pregnancies. We carried out semi-structured interviews with 45 women recruited via chain-referral sampling. We report the characteristics of women who have had abortions, the reasons they had abortions, and the methods used to terminate their pregnancies.

Results

Women in Zanzibar terminate pregnancies that are unwanted for a range of reasons, at various points in their reproductive lives, and using multiple methods. While clinical methods were most effective, nearly half of our participants successfully terminated a pregnancy using non-clinical methods and very few had complications requiring post abortion care (PAC).

Conclusions

Even in settings where abortion is illegal, some women experience illegal abortions without adverse health consequences, what we might call ‘safer’ unsafe abortions; these kinds of abortion experiences can be missed in studies about abortion conducted among women seeking PAC in hospitals.

Beyond the Condom: Frontiers in Male Contraception

Nearly half of all pregnancies worldwide are unplanned, despite numerous contraceptive options available. No new contraceptive method has been developed for men since the invention of condom. Nevertheless, more than 25% of contraception worldwide relies on male methods. Therefore, novel effective methods of male contraception are of interest. Herein we review the physiologic basis for both male hormonal and nonhormonal methods of contraception. We review the history of male hormonal contraception development, current hormonal agents in development, as well as the potential risks and benefits of male hormonal contraception options for men. Nonhormonal methods reviewed will include both pharmacological and mechanical approaches in development, with specific focus on methods which inhibit the testicular retinoic acid synthesis and action. Multiple hormonal and nonhormonal methods of male contraception are in the drug development pathway, with the hope that a reversible, reliable, safe method of male contraception will be available to couples in the not too distant future.

Clandestine abortion causing uterine perforation and bowel infarction in a rural area: a case report and brief review

Background

An unsafe abortion is defined as a procedure for terminating an unintended pregnancy carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards or both. Majority of these unsafe abortions are carried out in rural areas of developing countries, usually by unskilled persons who do not have proper knowledge of the anatomy of reproductive organs and in unhygienic environments thus leading to various complications.

Case presentation

We discuss the case of a 21 year old female who presented in septic shock after she underwent an unsafe abortion of an 11 weeks pregnancy with uterine wall perforation and bowel injury that required resection.

Conclusion

Unsafe abortion is an important public health problem which accounts for a significant cause of maternal mortality and morbidity in resource poor countries. A high index of suspicion of clandestine abortion with ensuing complications should prevail when faced with a woman of child bearing age with the triad of vaginal bleeding, amenorrhea and pelvic sepsis.

The effectiveness of using misoprostol with and without letrozole for successful medical abortion: A randomized placebo-controlled clinical trial

Background:

In developing countries it is important to the exploration of available and safe regimens for medical abortion. The present study was designed to assess the effect of letrozole compared to placebo pretreatment followed by sublingual misoprostol for therapeutic abortion in eligible women with gestational age less than 17 weeks.

Materials and Methods:

In this randomized control trail, 130 women eligible for legal abortions were randomly divided into two groups of case and controls. Cases received daily oral dose of 10 mg letrozole 10 mg letrozole for three days followed by sublingual misoprostol. Controls received daily oral dose of placebo followed by sublingual misoprostol. The dose of misoprostol was administrated according to ACOG guidelines based on patients’ gestational age. The rate of complete abortion, induction-of-abortion time, and side-effects were assessed as main outcomes.

Results:

Complete abortion was observed in 46 (76.7%) letrozole group and 26 (42.6%) controls (P < 0.0001). Also, in 14 subjects of letrozole group and 35 subjects in placebo group, the placenta was not delivered during follow-up and curettage was performed. The mean interval induction-to-abortion was 5.1 h in letrozole group and 8.9 h in control (P < 0.0001). The cumulative rates of the induction-of-abortion time were a significant difference between the two groups (P < 0.0001). The incidence and severity of side-effects was comparable for the two groups (P = 0.9).

Conclusion:

Letrozole could be a quite beneficial adjuvant to misoprostol for induction of complete abortion in those who are candidates for legal medical abortion.

Misoprostol versus misoprostol and foley catheter combination in 2nd trimester pregnancy terminations

OBJECTIVE

The efficacy and safety were assessed of a misoprostol regimen used alone or in combination with foley catheter for second trimester pregnancy termination.

METHODS

A retrospective examination was made of the records of patients who underwent pregnancy termination at 14-24 weeks of gestation in our university hospital between January 2011 and June 2014. Records were available for patients 378 who underwent terminations. Group 1 comprised patients with no history of cesarean section. An initial dose of 200 μg misoprostol was administered intravaginally and then until the termination was completed an additional 200 μgr dose was administered sublingually every 4 hours (Group 1: 234 patients). Group 2 comprised patients with a history of cesarean section. An initial dose of 200 μg misoprostol was administered intravaginally and 2 hours later an intracervical foley catheter was inserted (Group 2: 144 patients).

RESULTS

The total misoprostol dosage used was 1160 μg and 560 μg (p< 0.001), intervals from the administration of the first misoprostol tablet until termination were 854.8 and 704.2 minutes (p= 0.03) in Groups 1 and 2, respectively.

CONCLUSIONS

The misoprostol + foley catheter combination reduces the total dosage of misoprostol required for termination and shortens the termination interval, thereby increasing patient's comfort. Based on these results, the usage of the misoprostol + foley catheter combination can be recommended especially for patients with a history of caesarian section.

What makes a likely abortion provider? Evidence from a nationwide survey of final-year students at Ghana's public midwifery training colleges

BACKGROUND

Even in countries where the abortion law is technically liberal, the full application of the law has been delayed due to resistance on the part of providers to offer services. Ghana has a liberal law, allowing abortions for a wide range of indications. The current study sought to investigate factors associated with midwifery students' reported likelihood to provide abortion services.

METHODS

Final-year students at 15 public midwifery training colleges participated in a computer-based survey. Demographic and attitudinal variables were tested against the outcome variable, likely to provide comprehensive abortion care (CAC) services, and those variables found to have a significant association in bivariate analysis were entered into a multivariate model. Marginal effects were assessed after the final logistic regression was conducted.

RESULTS

A total of 853 out of 929 eligible students enrolled in the 15 public midwifery schools took the survey, for a response rate of 91.8%. In multivariate regression analysis, the factors significantly associated with reported likeliness to provide CAC services were having had an unplanned pregnancy, currently using contraception, feeling adequately prepared, agreeing it is a good thing women can get a legal abortion and having been exposed to multiple forms of education around surgical abortion.

DISCUSSION

Midwifery students at Ghana's public midwifery training colleges report that they are likely to provide CAC. Ensuring that midwives-in-training are well trained in abortion services, as well as encouraging empathy in these students, may increase the number of providers of safe abortion care in Ghana.

Adverse pregnancy outcomes in rural Uganda (1996-2013): trends and associated factors from serial cross sectional surveys

Objective

Community based evidence on pregnancy outcomes in rural Africa is lacking yet it is needed to guide maternal and child health interventions. We estimated and compared adverse pregnancy outcomes and associated factors in rural south-western Uganda using two survey methods.

Methods

Within a general population cohort, between 1996 and 2013, women aged 15–49 years were interviewed on their pregnancy outcome in the past 12 months (method 1). During 2012–13, women in the same cohort were interviewed on their lifetime experience of pregnancy outcomes (method 2). Adverse pregnancy outcome was defined as abortions or stillbirths. We used random effects logistic regression for method 1 and negative binomial regression with robust clustered standard errors for method 2 to explore factors associated with adverse outcome.

Results

One third of women reported an adverse pregnancy outcome; 10.8 % (abortion = 8.4 %, stillbirth = 2.4 %) by method 1 and 8.5 % (abortion = 7.2 %, stillbirth = 1.3 %) by method 2. Abortion rates were similar (10.8 vs 10.5) per 1000 women and stillbirth rates differed (26.2 vs 13.8) per 1000 births by methods 1 and 2 respectively. Abortion risk increased with age of mother, non-attendance of antenatal care and proximity to the road. Lifetime stillbirth risk increased with age. Abortion and stillbirth risk reduced with increasing parity.

Discussion

Both methods had a high level of agreement in estimating abortion rate but were markedly below national estimates. Stillbirth rate estimated by method 1 was double that estimated by method 2 but method 1 estimate was more consistent with the national estimates.

Conclusion

Strategies to improve prospective community level data collection to reduce reporting biases are needed to guide maternal health interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0708-8) contains supplementary material, which is available to authorized users.

HDSS Profile: The Kersa Health and Demographic Surveillance System

Kersa HDSS was established in 12 sub-districts of Kersa district, Eastern Hararge, Oromia Region, Ethiopia. The site is principally rural with two small towns (Kersa and Weter). The baseline census was conducted in 2007 and since then has been updated every 6 months, with registration of demographic and health events. Data are entered into the HRS-2 relational database. At baseline a total of 10 085 houses, 10 522 households and 50 830 people were registered. The sex ratio and number of persons per household were 1.0 and 5.1, respectively. At the end of 2013, the population was 60 694. Up to the end of 2013, 12 571 births and 3143 deaths were registered, respectively. Over 85% of births and deaths occurred at home. The annual net population growth ranges from 0.06 to 1.6. The majority of the population in Kersa are not working age group; hence the dependency ratio in most of the years is below 1. The total fertility rate ranges from 4.0 to 5.3. A reduction in neonatal, infant and under-five mortalities was observed. For all deaths, verbal autopsies were done. Tuberculosis is the leading cause of death among adults and malnutrition is the leading cause of death among children aged under 5 years. Kersa HDSS is ready to collaborate with interested researchers on health and demographic issues. For further details please visit: [ http://www.haramaya.edu.et/research/projects/kds-hrc/ ].

Male hormonal contraception: looking back and moving forward

Despite numerous contraceptive options available to women, approximately half of all pregnancies in the United States and worldwide are unplanned. Women and men support the development of reversible male contraception strategies, but none have been brought to market. Herein we review the physiologic basis for male hormonal contraception, the history of male hormonal contraception development, currents agents in development as well as the potential risks and benefits of male hormonal contraception for men.

Acceptability of Home-Assessment Post Medical Abortion and Medical Abortion in a Low-Resource Setting in Rajasthan, India. Secondary Outcome Analysis of a Non-Inferiority Randomized Controlled Trial

BACKGROUND

Studies evaluating acceptability of simplified follow-up after medical abortion have focused on high-resource or urban settings where telephones, road connections, and modes of transport are available and where women have formal education.

OBJECTIVE

To investigate women's acceptability of home-assessment of abortion and whether acceptability of medical abortion differs by in-clinic or home-assessment of abortion outcome in a low-resource setting in India.

DESIGN

Secondary outcome of a randomised, controlled, non-inferiority trial.

SETTING

Outpatient primary health care clinics in rural and urban Rajasthan, India.

POPULATION

Women were eligible if they sought abortion with a gestation up to 9 weeks, lived within defined study area and agreed to follow-up. Women were ineligible if they had known contraindications to medical abortion, haemoglobin < 85 mg/l and were below 18 years.

METHODS

Abortion outcome assessment through routine clinic follow-up by a doctor was compared with home-assessment using a low-sensitivity pregnancy test and a pictorial instruction sheet. A computerized random number generator generated the randomisation sequence (1:1) in blocks of six. Research assistants randomly allocated eligible women who opted for medical abortion (mifepristone and misoprostol), using opaque sealed envelopes. Blinding during outcome assessment was not possible.

MAIN OUTCOME MEASURES

Women's acceptability of home-assessment was measured as future preference of follow-up. Overall satisfaction, expectations, and comparison with previous abortion experiences were compared between study groups.

RESULTS

731 women were randomized to the clinic follow-up group (n = 353) or home-assessment group (n = 378). 623 (85%) women were successfully followed up, of those 597 (96%) were satisfied and 592 (95%) found the abortion better or as expected, with no difference between study groups. The majority, 355 (57%) women, preferred home-assessment in the event of a future abortion. Significantly more women, 284 (82%), in the home-assessment group preferred home-assessment in the future, as compared with 188 (70%) of women in the clinic follow-up group, who preferred clinic follow-up in the future (p < 0.001).

CONCLUSION

Home-assessment is highly acceptable among women in low-resource, and rural, settings. The choice to follow-up an early medical abortion according to women's preference should be offered to foster women's reproductive autonomy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01827995.

The estimated incidence of induced abortion in Kenya: a cross-sectional study

BACKGROUND

The recently promulgated 2010 constitution of Kenya permits abortion when the life or health of the woman is in danger. Yet broad uncertainty remains about the interpretation of the law. Unsafe abortion remains a leading cause of maternal morbidity and mortality in Kenya. The current study aimed to determine the incidence of induced abortion in Kenya in 2012.

METHODS

The incidence of induced abortion in Kenya in 2012 was estimated using the Abortion Incidence Complications Methodology (AICM) along with the Prospective Morbidity Survey (PMS). Data were collected through three surveys, (i) Health Facilities Survey (HFS), (ii) Prospective Morbidity Survey (PMS), and (iii) Health Professionals Survey (HPS). A total of 328 facilities participated in the HFS, 326 participated in the PMS, and 124 key informants participated in the HPS. Abortion numbers, rates, ratios and unintended pregnancy rates were calculated for Kenya as a whole and for five geographical regions.

RESULTS

In 2012, an estimated 464,000 induced abortions occurred in Kenya. This translates into an abortion rate of 48 per 1,000 women aged 15-49, and an abortion ratio of 30 per 100 live births. About 120,000 women received care for complications of induced abortion in health facilities. About half (49%) of all pregnancies in Kenya were unintended and 41% of unintended pregnancies ended in an abortion.

CONCLUSION

This study provides the first nationally-representative estimates of the incidence of induced abortion in Kenya. An urgent need exists for improving facilities' capacity to provide safe abortion care to the fullest extent of the law. All efforts should be made to address underlying factors to reduce risk of unsafe abortion.

INDUCED ABORTIONS IN PAKISTAN: EXPOSITIONS, DESTINATIONS AND REPERCUSSIONS. A QUALITATIVE DESCRIPTIVE STUDY IN RAWALPINDI DISTRICT

Over 2 million abortions occur annually in Pakistan, mostly in a clandestine and unsafe environment. This is an area of grave concern for the reproductive health of women. A dearth of credible data and incomplete information make the problem more difficult to address. This qualitative study was conducted in semi-urban settings in Pakistan to record perceptions and practices concerning care seeking, experiences and outcomes regarding induced abortions and post-abortion care services. Women who had had induced abortions and abortion service providers were interviewed. Unwanted pregnancies and poverty were found to be the main reasons for seeking an abortion. Moreover, the unwanted pregnancies occurred due to low use of contraceptives, mainly due to a fear or past experience of their side-effects, unfamiliarity with correct usage and perceived inefficacy of the methods, especially condoms. There is an obvious need for practical and innovative interventions to address unmet need for birth spacing through improved access to contraceptives. Contraceptive providers should be provided with up-to-date and detailed training in family planning counselling, and perhaps allowed unrestricted provision of contraceptives. As a long-term measure, improvement in access to education and formal schooling could increase young girls' and women's knowledge of the benefits of family planning and the risks of unsafe abortion practices. Males must be involved in all the initiatives so that both partners are in agreement on correct and consistent contraceptive use.

Causes of maternal mortality in Ethiopia: a significant decline in abortion related death

Background

Although the common direct obstetric causes of maternal mortality are known from the literature, the contribution of each cause and the change in trend over decades is unknown in Ethiopia. The objective of this review was to assess the trend of proportion of maternal mortality due to the common direct causes.

Methods

This systematic review was done on eighteen health facility based maternal mortality studies conducted between 1980 and 2012 in Ethiopia. Emphasis was given to the proportion of maternal mortality due to direct causes and their case fatality rates.

Results

The summary of the findings has shown that the top four causes of maternal mortality in the year 1980–1999 were abortion related complications (31%), obstructed labor/uterine rupture (29%), sepsis/infection (21%) and hemorrhage (12%). In the last decade, however, the top four causes of maternal mortality were obstructed labor/uterine rupture (36%), hemorrhage (22%), hypertensive disorders of pregnancy (19%) and sepsis/infection (13%).

Conclusion

Abortion and infection related maternal deaths have declined significantly in the last decade. Obstructed labor continues to be the major cause of maternal deaths; maternal deaths due to hypertensive disorders and hemorrhage showed an increasing trend. The findings in this review were somehow comparable with the WHO analysis for Africa in the same period with the exception of obstructed labor.

Contraceptive practices and induced abortions status among internal migrant women in Guangzhou, China: a cross-sectional study

BACKGROUND

China is facing the unprecedented challenges of internal migration. Migrants tend to have poorer utilization of health and family planning services as compared to the local residents. Migrant women are at greater risk of induced abortions due to their poor contraceptive knowledge and attitude. This study aims to understand the contraceptive practices and history of induced abortions, explore the potential factors influencing induced abortions, and evaluate the utilization of family planning services among migrant women in Guangzhou, China.

METHODS

An anonymous, self-administered questionnaire survey was conducted with 1003 migrant women aged 18-49 in Guangzhou, China in 2013. A multi-stage sampling method was employed. Binary logistic regression model was used for analyzing risk factors of induced abortions.

RESULTS

Among the 1003 participants, 810 (80.8 %) reported having sex in the past 6 months, including 715 (88.3 %) married and 95 (11.7 %) unmarried. The most reported contraceptive method was male condom (44.9 %), while 8.1 % never used any contraceptive methods. Only 10.4 % reported having attained free condoms from family planning service stations (FPSSs) and 39.3 % reported having acquired contraceptive knowledge from family planning workers. Of all the participants, 417 (41.6 %) had a history of induced abortion. Of married and unmarried women, 389 (49.1 %) and 28 (14.0 %) had induced abortion respectively. Of these, 152 (36.5 %) had repeated abortions. The most reported reason for having induced abortion was failure of contraception (31.9 %), followed by nonuse of any contraceptives (21.1 %). Migrants who had induced abortion tended to be older, have household registration outside Guangdong province, receive no annual health checkup, have lower education, have urban household registration, have lived longer in Guangzhou and have children (P < 0.05).

CONCLUSIONS

The prevalence rate of induced abortion, especially repeated abortions among migrant women was high in Guangzhou, China. There is an urgent need to improve the awareness of regular and appropriate use of contraceptives. The utilization of FPSSs among migrant women was reportedly low. Family planning system should be improved to provide better access for migrants and better integrated with the general health services.

[Reasons and meanings attributed by women who experienced induced abortion: an integrative review]

OBJECTIVE

Identifying the contribution of developed research on what motivates women to induce an abortion and the meaning attributed to these experiences in their lives.

METHOD

An integrative review conducted in MEDLINE/PubMed, LILACS, BDENF, CINAHL and SciELO databases, covering the periods from 2001 to 2011.

RESULTS

We selected and analyzed 11 studies with selection criteria being reasons given by women for inducing abortion and/or the meaning attributed to this experience in their lives, including social, religious, ethical and moral aspects related to this practice, as well as the suffering experienced from the experience. The illegality of abortion is identified as a risk factor for unsafe abortions, reaffirming this issue as a public health and social justice problem.

CONCLUSION

Results evidence aspects that can contribute to improving health quality and ratify the importance of research to support nursing practices.

Workforce interventions to improve access to emergency contraception pills: a systematic review of current evidence in low- and middle-income countries and recommendations for improving performance

BACKGROUND

Emergency contraceptive pills (ECP) are one of the 13 essential commodities addressed by the UN Commission on Life-Saving Commodities for Women and Children. Although ECP have been available for 20 years, a number of barriers still limit women's access ECP in low and middle-income countries (LMIC). The workforce who prescribe or dispense ECP are diverse reflecting the varied contexts where ECP are available across the health, commercial and justice sectors and in the community. No reviews currently exist that examine the roles and experiences of the workforce that provide ECP in LMIC.

METHOD

We present a narrative synthesis of research to: identify provider factors that facilitate and constraint access to ECP; assess the effectiveness of associated interventions and; explore associated health system issues in LMIC. A search of bibliographic databases, meta-indexes and websites was undertaken to retrieve peer reviewed and grey literature. Literature was screened and identified documents examined to appraise quality.

RESULTS

Thirty-seven documents were included in the review. Studies focused on formal health workers revealing knowledge gaps concerning the role of private sector and non-health providers who increasingly provide ECP. Data from the findings section in the documents were coded under 4 themes: provider knowledge; provider attitudes and beliefs; provider practice and provider training. The analysis revealed provider knowledge gaps, less than favourable attitudes and practice issues. The findings provide limited insight into products prescribed and/or dispensed, the frequency of provision, and information and advice offered to consumers. Pre and in-service training needs were noted.

CONCLUSION

As the provision of ECPs shifts from the clinic-based health sector to increasing provision by the private sector, the limited understanding of provider performance and the practice gaps revealed in this review highlight the need to further examine provider performance to inform the development of appropriate workforce interventions. A standardized approach to assessing performance using agreed outcomes measures may serve to ensure a systematic way forward that is inclusive of the diverse workforce that deliver ECP. Recommendations are outlined to enhance the performance of providers to improve access to ECP. A framework is offered to help guide this process with indicators.

Unsafe abortion requiring hospital admission in the Eastern Highlands of Papua New Guinea--a descriptive study of women's and health care workers' experiences

Background

In Papua New Guinea induced abortion is restricted under the Criminal Code Law. Unsafe abortions are known to be widely practiced and sepsis due to unsafe abortion is a leading cause of maternal mortality.

Methods

We undertook a six month, prospective, mixed methods study at the Eastern Highlands Provincial Hospital. Semi structured and in depth interviews were undertaken with women presenting following induced abortion. This paper describes the reasons why women resorted to unsafe abortion, the techniques used, decision to seek post abortion care and women’s reflections post abortion.

Results

28 women were admitted to hospital following an induced abortion. Reasons for inducing an abortion included: wanting to continue with studies, relationship problems and socio-cultural factors. Misoprostol was the most frequently used method to end the pregnancy. Physical and mechanical means, traditional herbs and spiritual beliefs were also reported. Women sought care post abortion due to excessive vaginal bleeding, and severe abdominal pain with some afraid they would die if they did not seek help.

Conclusion

In the absence of contraceptive information and services to avoid, postpone or space pregnancies, women in this setting are resorting to unsafe means to end an unwanted pregnancy, putting their lives at risk. Women need access to safe, effective means of abortion.

Women's opinions on the legalisation of abortion in Chile 2009-2013

Chile is one of only four countries in the world where there is no explicit legal exception to prohibitions on abortion, and where the criminalisation of abortion endangers women's health and may be misaligned with public opinion. In this study we explored attitudes towards the legalisation of abortion and differences in levels of support across time. Among Chilean women in 2009 and 2013, we examined: (1) an additive index indicating support for legalisation of abortion in several situations and (2) support for each situation separately. We investigated the demographic characteristics associated with support for legalisation using multivariate regression. Over 70% of women supported the legalisation of abortion in cases of risk to the woman's life, rape and foetal malformation, and support was higher in 2013 compared to 2009 (β = 0.28; 95% CI: 0.12, 0.44). Women with increasing education and those attending church services less frequently were more likely to support the legalisation of abortion (β = 0.27; 95% CI: 0.11, 0.43), while those affiliated to a religion other than Catholicism (β =  - 0.32; 95% CI:  - 0.48,  - 0.16) were less likely to do so. Our study is the first to examine public opinions on abortion in Chile and differences in levels of support across time periods. Results indicate that current policies may not reflect trends in public opinion.

Complicated illegal induced abortions at a tertiary health institution in Nigeria

Background and Objective: Globally it is estimated that 26-53 million induced abortions occur annually. An estimated 20 million of these are unsafe especially in countries with restrictive abortion laws. Approximately 48% of all abortions worldwide were unsafe and more than 97% of these are in developing countries. Our objective was to find out complications of illegal induced abortions in a tertiary care institution.

Methods: All cases of complicated induced abortion, seen over a 5 year period were reviewed. Relevant data relating to the socio-demographic profile of the patients, clinical presentation, abortion service providers and facilities and mode of termination of pregnancy were extracted.

Results: One hundred and nineteen patients, constituting 3.4% of gynaecological admissions were studied. The mean age of the patients was 23.5±6.6 years with over 80% single. The mean gestational age at abortion was 12.8± 4.1 weeks. Incomplete abortion and postabortal sepsis formed the major indication for admission. About a fifth of the cases had abdominal visceral involvement. Twenty (18%) had laparotomy and 10(9%) had renal dialysis. Over 75% of patients were discharged in stable state.

Conclusion: This study highlights the pressing need for an organised program for reproductive health education especially for the adolescents and unmarried who were most affected by abortion complications. In addition training and continuing medical education for doctors favourably disposed to abortion services is highly indicated from this study.

Health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data

BACKGROUND

Unsafe abortions are a serious public health problem and a major human rights issue. In low-income countries, where restrictive abortion laws are common, safe abortion care is not always available to women in need. Health care providers have an important role in the provision of abortion services. However, the shortage of health care providers in low-income countries is critical and exacerbated by the unwillingness of some health care providers to provide abortion services. The aim of this study was to identify, summarise and synthesise available research addressing health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia.

METHODS

A systematic literature search of three databases was conducted in November 2014, as well as a manual search of reference lists. The selection criteria included quantitative and qualitative research studies written in English, regardless of the year of publication, exploring health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The quality of all articles that met the inclusion criteria was assessed. The studies were critically appraised, and thematic analysis was used to synthesise the data.

RESULTS

Thirty-six studies, published during 1977 and 2014, including data from 15 different countries, met the inclusion criteria. Nine key themes were identified as influencing the health care providers' attitudes towards induced abortions: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence 8) quality of care and 9) stigma and victimisation.

CONCLUSIONS

Health care providers in sub-Saharan Africa and Southeast Asia have moral-, social- and gender-based reservations about induced abortion. These reservations influence attitudes towards induced abortions and subsequently affect the relationship between the health care provider and the pregnant woman who wishes to have an abortion. A values clarification exercise among abortion care providers is needed.

Applying emerging science to contraception research: implications for the clinic

Emerging science will make an important contribution towards the development of improved contraceptives. While long-acting reversible contraceptives remain the most effective method, new user-controlled, mid-acting methods will avoid the need for procedures requiring trained providers. Contraceptives combined with other agents may bring additional health benefits, such as dual protection against both pregnancy and sexually transmitted infections. Emerging research areas in proteomics allowed the discovery of new reproductive targets that may lead to non-hormonal contraceptives for both men and women. Current research objectives include the improvement of existing contraceptive methods, as well as discovery of new materials able to deliver new molecules more specifically to their target without systemic actions.

Decision making on unsafe abortions in Sri Lanka: a case-control study

BACKGROUND

Following an unintended pregnancy, not every woman would invariably choose to undergo an unsafe abortion. It suggests that in the decision making process, women face both 'push' factors that favour abortion and 'pull' factors that work against it. This study assessed the circumstances that surrounded a woman's decision to undergo an unsafe abortion, compared to a decision to continue, when faced with an unintended pregnancy in Sri Lanka.

METHODS

An unmatched case-control study was conducted among 171 women admitted to nine hospitals in eight districts following an unsafe abortion (Cases) and 600 women admitted to the same hospitals for delivery of an unintended term pregnancy (Controls). Interviewer-administered-questionnaires and in-depth interviews assessed women's characteristics, decision making process and underlying reasons for their decision. The risk of abortion related to their decision making was assessed using odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Compared to controls, the cases were significantly less-educated, employed, unmarried and primi-gravid (p < 0.05). All knew the 'illegal' status of abortion, mainly through media (65.5% cases versus 80% controls). When making a decision, the risk of undergoing an unsafe abortion was significant among those who sought assistance (44% versus 32%; OR = 1.7 (95% CI = 1.2-2.4)), with more reliance placed on non-medical sources such as spouse/partner, friend, neighbour and family/relation. Speaking to women with past experience of induced abortions (31% versus 21.5%; OR = 1.6 (1.1-2.4) and failure in making the final decision with partners also imparted a significant risk for abortion (64% versus 34%; OR = 3.4; 2.4-4.8). A decision favouring unsafe abortion was predominantly based on their economic instability (29.5%) and poor support by partners (14%), whereas a decision against it was based on ethical considerations (44% religious beliefs: 12% social stigma) over its legal implications (4%). Most abortions were performed by unqualified persons (36.1% self proclaimed abortionists; 26.2% not revealed their qualifications) for a wide range of payment in non-sterile environments (45.9% unknown place) using septic procedures (38.5% trans-vaginal insertions; 24.6% unaware of the procedure).

CONCLUSIONS

Women's risk of unsafe abortion was associated with unreliable sources of information during decision making that led to poor knowledge and positive attitudes on its safety; poor access to affordable abortion services; and their economic instability.

Missed opportunities for early access to care of HIV-infected infants in Burkina Faso

OBJECTIVE

The World Health Organization (WHO) has recommended a universal antiretroviral therapy (ART) for all HIV-infected children before the age of two since 2010, but this implies an early identification of these infants. We described the Prevention of Mother-to-Child HIV Transmission (PMTCT) cascade, the staffing and the quality of infrastructures in pediatric HIV care facilities, in Ouagadougou, Burkina Faso.

METHODS

We conducted a cross-sectional survey in 2011 in all health care facilities involved in PMTCT and pediatric HIV care in Ouagadougou. We assessed them according to their coverage in pediatric HIV care and WHO standards, through a desk review of medical registers and a semi-structured questionnaire administered to health-care workers (HCW).

RESULTS

In 2011, there was no offer of care in primary health care facilities for HIV-infected children in Ouagadougou. Six district hospitals and two university hospitals provided pediatric HIV care. Among the 67 592 pregnant women attending antenatal clinics in 2011, 85.9% were tested for HIV. The prevalence of HIV was 1.8% (95% Confidence Interval: 1.7%-1.9%). Among the 1 064 HIV-infected pregnant women attending antenatal clinics, 41.4% received a mother-to-child HIV transmission prevention intervention. Among the HIV-exposed infants, 313 (29.4%) had an early infant HIV test, and 306 (97.8%) of these infants tested received their result within a four-month period. Among the 40 children initially tested HIV-infected, 33 (82.5%) were referred to a health care facility, 3 (9.0%) were false positive, and 27 (90.0%) were initiated on ART. Although health care facilities were adequately supplied with HIV drugs, they were hindered by operational challenges such as shortage of infrastructures, laboratory reagents, and trained HCW.

CONCLUSIONS

The PMTCT cascade revealed bottle necks in PMTCT intervention and HIV early infant diagnosis. The staffing in HIV care and quality of health care infrastructures were also insufficient in 2011 in Ouagadougou.

Improving access to emergency contraception pills through strengthening service delivery and demand generation: a systematic review of current evidence in low and middle-income countries

OBJECTIVES

Emergency contraception pills (ECP) are among the 13 essential commodities in the framework for action established by the UN Commission on Life-Saving Commodities for Women and Children. Despite having been on the market for nearly 20 years, a number of barriers still limit women's access to ECP in low- and middle-income countries (LMIC) including limited consumer knowledge and poor availability. This paper reports the results of a review to synthesise the current evidence on service delivery strategies to improve access to ECP.

METHODS

A narrative synthesis methodology was used to examine peer reviewed research literature (2003 to 2013) from diverse methodological traditions to provide critical insights into strategies to improve access from a service delivery perspective. The studies were appraised using established scoring systems and the findings of included papers thematically analysed and patterns mapped across all findings using concept mapping.

FINDINGS

Ten papers were included in the review. Despite limited research of adequate quality, promising strategies to improve access were identified including: advance provision of ECP; task shifting and sharing; intersectoral collaboration for sexual assault; m-health for information provision; and scale up through national family planning programs.

CONCLUSION

There are a number of gaps in the research concerning service delivery and ECP in LMIC. These include a lack of knowledge concerning private/commercial sector contributions to improving access, the needs of vulnerable groups of women, approaches to enhancing intersectoral collaboration, evidence for social marketing models and investment cases for ECP.

"Abortion--it is my own body": women's narratives about influences on their abortion decisions in Ghana

Globally, abortion has emerged as a critical determinant of maternal morbidity and mortality. The Ghana government amended the country's abortion law in 1985 to promote safe abortion. This article discusses the findings of a qualitative study that explored the decision-making experiences of 28 female abortion seekers aged between 15 and 30 years in Ghana. Key findings from the study are that individuals claimed autonomy in their abortion decisions; underlying the abortion decisions were pragmatic concerns such as economic difficulties, child spacing, and fear of parental reaction. In conclusion, we examine the health implications of Ghanaian women's abortion decisions.

Magnitude and risk factors of abortion among regular female students in Wolaita Sodo University, Ethiopia

Background

Induced abortion is one of the greatest human rights dilemmas of our time. Yet, abortion is a very common experience in every culture and society. According to the World Health Organization, Ethiopia had the fifth largest number of maternal deaths in 2005 and unsafe abortion was estimated to account for 32% of all maternal deaths in Ethiopia. Youth are disproportionately affected by the consequences of unsafe abortion. The objective of this study was, therefore, to determine the magnitude and identify factors associated with abortion among female Wolaita Sodo University students.

Methods

A descriptive, cross-sectional study was conducted in Wolaita Sodo University between May and June 2011. Data were collected from 493 randomly selected female students using structured and pre-tested questionnaires.

Results

The rate of abortion among students was found to be 65 per 1000 women, making it three fold the national rate of abortion for Ethiopia (23/1000 women aged 15–44). Virtually all of the abortions (96.9%) were induced and only half (16) were reported to be safe. Students with history of alcohol use, who are first-year and those enrolled in faculties with no post-Grade 10 Natural Science background had higher risk of abortion than their counterparts. About 23.7% reported sexual experience. Less than half of the respondents (44%) ever heard of emergency contraception and only 35.9% of those who are sexually experienced ever used condom.

Conclusions

High rate of abortion was detected among female Wolaita Sodo University students and half of the abortions took place/initiated under unsafe circumstances. Knowledge of students on legal and safe abortion services was found to be considerably poor. It is imperative that improved sexual health education, with focus on safe and legal abortion services is rendered and wider availability of Youth Friendly family planning services are realized in Universities and other places where young men and women congregate.

The prevalence of severe maternal morbidity and near miss and associated factors in Sergipe, Northeast Brazil

BACKGROUND

The investigation of severe maternal morbidity (SAMM) and maternal near miss (NM) and associated risk factors is important for the global reduction of maternal mortality. This study investigated the prevalence of SAMM and NM cases and the associated risk factors in two reference maternity hospitals in a capital city in Northeast-Brazil.

METHODS

A cross-sectional study with a nested case-control component was conducted from June-2011 to May-2012. Case identification was prospective and data collection was performed according to WHO criteria and definitions. Odds ratio with confidence intervals and multivariate analysis were used whenever possible.

RESULTS

There were 16,243 deliveries, 1,102 SAMM cases, 77 NM cases and 17 maternal deaths. The maternal NM outcome ratio was 5.8 cases/1,000 live births (LB); the total prevalence of SAMM + NM was 72.6 cases/1,000 LB, the maternal near miss: mortality ratio was 4.5cases/1 maternal death (18% of mortality index). Management-based criteria were the most common events for NM (87.1%) and hypertensive disorders for SAMM (67.5%). Higher age, previous abortion and caesarean delivery, the non-adhesion to antenatal care, current caesarean delivery and bad perinatal results were associated with SAMM/NM. In the multivariate analysis, patient's status, previous caesarian and abortion and level of consciousness were significant when analyzed together.

CONCLUSIONS

SAMM and NM situations were prevalent in the studied population and some risk factors seem to be associated with the event, particularly previous gestational antecedents. Protocols based on SAMM/NM situations can save lives and decrease maternal mortality.

The separation of sexual activity and reproduction in human social evolution

In industrialized societies the progression of natural selection has been determined and in many cases superseded by social evolution. In the case of reproduction, there has been a decline and delay of childbearing without diminished sexual activity. While this has value for these societies, there are penalties associated with barren cycles. These include increases in endometriosis and breast and genital cancer. There also are associated issues regarding population movements that fill the "vacuums" left by underpopulation. These matters are of more than passing interest as we cope with unintended consequences of Man's dominance over the environment and other life forms.

Abortion in university and college female students of Arba Minch town, Ethiopia, 2011

INTRODUCTION

Globally, unsafe abortion is a significant cause of maternal mortality and morbidity. One of the commonest problems facing university and college students is unwanted pregnancy followed by abortion. This study has aimed to assess abortion practice of university and college female students and to identify contributing factors.

METHODOLOGY

Cross-sectional study design was used in 2011. Female students from one university and three colleges of Arba Minch town were selected by proportional probability sampling method. Quantitative data were collected using a self-administered structured questionnaire and focus group discussions were also conducted.

RESULTS AND DISCUSSION

Eight hundred and thirteen study participants with median age 20 have been involved in the study. Among participants 173 (21.3%) had had sex, 54 (6.6%) had been pregnant, and out of the students who had been pregnant 23 (43.4%) had an induced abortion, 4 (17.3%) of which were done under unsafe conditions. Students' current living residence and knowledge of abortion law are the identified contributing factors to their abortion practices.

CONCLUSION

A significant proportion of pregnancies in university and college students were terminated with induced abortion. Unsafe sex is the commonest cause of unplanned pregnancy that leads to abortion induction. Campus residents are more vulnerable to abortion induction. Knowledge of abortion law and abortion induction practices are statistically interrelated.

Triangular assessment of the etiology of induced abortion in iran: a qualitative study

BACKGROUND

About 46 million induced abortions occur in the world annually. The studies have reported 80000 cases of induced abortions in Iran annually.

OBJECTIVES

This qualitative study was conducted to identify the causes of unsafe abortion in Iran from the standpoint of three groups of experts, women with a history of abortion or unwanted pregnancy and service providers.

PATIENTS AND METHODS

A total of 72 in-depth semi structured interviews were conducted in 2012 in Tehran and Shahroud. After coordination with 8 experts, sampling from them was done using the Snowballing method in their offices. Sampling from 28 married and 10 engaged women with a history of unwanted pregnancy or unsafe abortion and 12 providers was done in health care centers and a in number of gynecologists' and midwives' offices. Sampling from women with a history of unwanted pregnancy or unsafe abortion such as single women, HIV positive women and drug users, and women who had sexual intercourse for money was started by referring to the social rehabilitation center for women and continued using the snowballing method due to difficulties in accessing them. Participants were from different ethnic groups including Fars, Gilaks, Mazandarani, Arab, Azerbaijani, and Lor. Content analysis was performed on collected data.

RESULTS

BASED ON THE RESULTS OF THE INTERVIEWS, PARTICIPANTS HAVE ABORTION FOR FOLLOWING REASONS: 1. Wanted pregnancy (sub categories: fetal abnormalities, Concern about fetal health and lack of trust to prenatal diagnostic methods, Fetal sex, Lack of independent and free decision making regarding pregnancy in women, 2. Unwanted pregnancy (sub-categories: Socio-economic factors, Beliefs and feelings, Lack of information about family planning) 3. Predisposing factors (sub-categories: Lack of information on religious aspects of abortion, Easy access to easy abortion methods). Some people, despite having unwanted pregnancy due to social, economic, cultural and family grounds, continued their pregnancy and did not have an abortion for the following reasons: Religious beliefs, Beliefs (fear of punishment in the afterlife and believing in fate) , Attachment to the unborn baby, Influence of the other people's opinions (physician, mother or spouse) Late diagnosis of pregnancy, Unsuccessful abortion attempts (Self-treatment, Unsuccessful medical abortion), Economic weakness and arbitrary treatment.

CONCLUSIONS

In the present study, women who continued their pregnancy despite being unwanted were also interviewed. Although they had the same social, economic, cultural, and family problems as women with a history of unsafe abortion and had easy access to abortion, analysis showed that the difference in religious beliefs between the two groups was the most important factor that led women to choose two different approaches. The authors believe that in-depth analysis of people's beliefs and opinions in this regard and correction of false beliefs plays a crucial role in decreasing the rate of unsafe abortion.

The horror of unsafe abortion: case report of a life threatening complication in a 29-year old woman

Background

Every year 42 million women with unintended pregnancies choose abortion, and fifty percent of these procedures, 20 million are unsafe. An unsafe abortion is defined as a procedure for terminating an unintended pregnancy carried out either by person lacking the necessary skills or in an environment that does not conform to minimal medical standards or both.

Pakistan is the one of the six countries where more than 50% of the world’s all maternal deaths occur. It is estimated that 890,000 induced abortions are performed annually in Pakistan, and estimate an annual abortion rate of 29 per 1000 women aged 15-49.

Case presentation

Here we present a case report of a 29-year old woman who underwent an unsafe abortion for unintended pregnancy resulting in uterine perforation. The unskilled provider pulled out her bowel through vagina after perforating the uterus, as a result she lost major portion of her small intestine resulting in short bowel syndrome.

Conclusion

The law of Pakistan only allows abortion during early stages of pregnancy for purpose of saving the life of a mother but does not cater for cases of rape, incest and fetal abnormalities or social reasons.

Only legalization of abortion is not sufficient, preventing unintended pregnancy should be the priority of all the nations and for this reason contraception should be widely accessible.

Practitioners need to become better trained in safer abortion methods and be to able transfer the patient to health facility when complications occur.