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Gbagbo FY, Morhe RAS, Morhe EKS. Availability of Safe Second-Trimester Abortion Services in Health Facilities in Accra, Ghana. Matern Child Health J 2023; 27:850-860. [PMID: 36807234 DOI: 10.1007/s10995-023-03617-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND We examined providers, methods employed, cost, and other determinants of availability of second-trimester abortion services in health facilities in Accra, Ghana in 2019 to inform policy and program decisions. METHODS A two-stage mixed quantitative and qualitative study designs were employed in the conduct of the study. The first stage was a short interaction of the mystery client with a clinical care provider to identify health facilities that provide second trimester induced abortion, the cost, and referral practices, where the facility did not have the service. The second stage was in-depth interviews of second-trimester abortion care providers and non-providers in various health facilities. For internal validity, it also explored the procedure cost, referral, and other practices at the health facilities included in the study, independent of what was captured in the mystery client survey. RESULTS Second-trimester abortion services in Accra, Ghana are widely unavailable even in most facilities that provided abortion services. Referral policies and practices indicated by the service providers at various facility levels were inadequate. Criminalization of the procedure, social stigma, and fear of complications are the main factors that adversely influence the availability of second-trimester abortion in health facilities in Accra. CONCLUSION Albeit increasing demand for second-trimester abortion in health facilities in Accra, services are not readily available due to the ambiguity of the law, its interpretation, and limited flow of accurate information on providers. Policies and programs that limit access to Second-trimester abortions in Ghana are amendable to ensure safe services.
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Affiliation(s)
- Fred Yao Gbagbo
- Faculty of Science Education, Department of Health Administration and Education, University of Education, Winneba, Ghana.
| | - Renee Aku Sitsofe Morhe
- Department of Private Law, Faculty of Law, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Lattof SR, Coast E, Rodgers YVDM, Moore B, Poss C. The mesoeconomics of abortion: A scoping review and analysis of the economic effects of abortion on health systems. PLoS One 2020; 15:e0237227. [PMID: 33147223 PMCID: PMC7641432 DOI: 10.1371/journal.pone.0237227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/08/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the high incidence of abortion around the globe, we lack synthesis of the known economic consequences of abortion care and abortion policies at the mesoeconomic level (i.e. health systems and communities). This scoping review examines the mesoeconomic costs, benefits, impacts, and values of abortion care and policies. METHODS AND FINDINGS Searches were conducted in eight electronic databases. We conducted the searches and application of inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined at least one of the following outcomes: costs, benefits, impacts, and value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 150 included mesoeconomic studies, costs to health systems are the most frequently reported mesoeconomic outcome (n = 116), followed by impacts (n = 40), benefits (n = 17), and values (n = 11). Within health facilities and health systems, the costs of providing abortion services vary greatly, particularly given the range with which researchers identify and cost services. Financial savings can be realized while maintaining or even improving quality of abortion services. Adapting to changing laws and policies is costly for health facilities. American policies on abortion economically impact health systems and facilities both domestically and abroad. Providing post-abortion care requires a disproportionate amount of health facility resources. CONCLUSIONS The evidence base has consolidated around abortion costs to health systems and health facilities in high-income countries more than in low- or middle-income countries. Little is known about the economic impacts of abortion on communities or the mesoeconomics of abortion in the Middle East and North Africa. Methodologically, review papers are the most frequent study type, indicating that researchers rely on evidence from a core set of costing papers. Studies generating new primary data on mesoeconomic outcomes are needed to strengthen the evidence base.
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Affiliation(s)
- Samantha R. Lattof
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Ernestina Coast
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Yana van der Meulen Rodgers
- Department of Labor Studies and Employment Relations, Rutgers University, Piscataway, New Jersey, United States of America
- Department of Women’s and Gender Studies, Rutgers University, Piscataway, New Jersey, United States of America
| | - Brittany Moore
- Ipas, Chapel Hill, North Carolina, United States of America
| | - Cheri Poss
- Ipas, Chapel Hill, North Carolina, United States of America
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Mori AT, Binyaruka P, Hangoma P, Robberstad B, Sandoy I. Patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa: a systematic review. HEALTH ECONOMICS REVIEW 2020; 10:26. [PMID: 32803373 PMCID: PMC7429732 DOI: 10.1186/s13561-020-00283-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 08/05/2020] [Indexed: 06/01/2023]
Abstract
BACKGROUND Morbidity and mortality due to pregnancy and childbearing are high in developing countries. This study aims to estimate patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. METHODS A systematic review of the literature was conducted to identify costing studies published and unpublished, from January 2000 to May 2019. The search was done in Pubmed, EMBASE, Cinahl, and Web of Science databases and grey literature. The study was registered in PROSPERO with registration No. CRD42019119316. All costs were converted to 2018 US dollars using relevant Consumer Price Indices. RESULTS Out of 1652 studies identified, 48 fulfilled the inclusion criteria. The included studies were of moderate to high quality. Spontaneous vaginal delivery cost patients and health systems between USD 6-52 and USD 8-73, but cesarean section costs between USD 56-377 and USD 80-562, respectively. Patient and health system costs of abortion range between USD 11-66 and USD 40-298, while post-abortion care costs between USD 21-158 and USD 46-151, respectively. The patient and health system costs for managing a case of eclampsia range between USD 52-231 and USD 123-186, while for maternal hemorrhage they range between USD 65-196 and USD 30-127, respectively. Patient cost for caring low-birth weight babies ranges between USD 38-489 while the health system cost was estimated to be USD 514. CONCLUSION This is the first systematic review to compile comprehensive up-to-date patient and health system costs of managing pregnancy and birth-related complications in sub-Saharan Africa. It indicates that these costs are relatively high in this region and that patient costs were largely catastrophic relative to a 10 % of average national per capita income.
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Affiliation(s)
- Amani Thomas Mori
- Centre for International Health, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway.
- Department of Global Public Health and Primary Care, Section for Ethics and Health Economics, University of Bergen, Bergen, Norway.
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway.
| | - Peter Binyaruka
- Department of Health System, Impact Evaluation and Policy, Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Peter Hangoma
- Department of Health Policy and Management, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Bjarne Robberstad
- Centre for International Health, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
- Department of Global Public Health and Primary Care, Section for Ethics and Health Economics, University of Bergen, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
| | - Ingvild Sandoy
- Centre for International Health, University of Bergen, P.O. Box 7804, 5020, Bergen, Norway
- Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
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4
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Lince-Deroche N, Berry KM, Hendrickson C, Sineke T, Kgowedi S, Mulongo M. Women's costs for accessing comprehensive sexual and reproductive health services: findings from an observational study in Johannesburg, South Africa. Reprod Health 2019; 16:179. [PMID: 31842904 PMCID: PMC6916226 DOI: 10.1186/s12978-019-0842-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 12/03/2019] [Indexed: 11/10/2022] Open
Abstract
Background Evaluating progress towards the Sustainable Development Goal of universal access to sexual and reproductive (SRH) services requires an understanding of the health needs of individuals and what constitutes access to services. We explored women’s costs of accessing SRH services in Johannesburg, South Africa and contextualized costs based on estimates of household income. Methods We conducted an observational study of women aged 18–49 at a public HIV treatment site and two public primary health care facilities from June 2015 to August 2016. Interviews assessed women’s SRH needs (for contraception, fertility problems, menstrual problems, menopause symptoms, sexually transmitted infections (STI), experiences of intimate-partner violence (IPV), and cervical and breast cancer screening) and associated costs. We calculated average and total costs (including out-of-pocket spending, lost income, and estimated value of time spent) for women who incurred costs. We also estimated the total and average costs of meeting all SRH needs in a hypothetical “full needs met” year. Finally, we contextualize SRH spending against a measure of catastrophic expenditure (> 10% of household income). Results Among the 385 women who participated, 94.8% had at least one SRH need in the prior 12 months; 79.7% incurred costs for accessing care. On average, women spent $28.34 on SRH needs during the prior year. Excluding one HIV-negative woman who spent 112% of her annual income on infertility treatment, HIV-positive women spent more on average annually for SRH care than HIV-negative women. Sixty percent of women reported at least one unmet SRH need. If all participants sought care for all reported needs, their average annual cost would rise to $52.65 per woman. Only two women reported catastrophic expenditure – for managing infertility. Conclusions SRH needs are constants throughout women’s lives. Small annual costs can become large costs when considered cumulatively over time. As South Africa and other countries grapple with increasing access to SRH services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to SRH services. Plain English summary Literature on women’s financial and economic costs for accessing comprehensive sexual and reproductive health care in low- and middle-income countries is extremely limited, and existing literature often overlooks out-of-pocket costs associated with travel, child care, and time spent accessing services. Using data from a survey of 385 women from a public HIV treatment site and two public primary health care facilities in Johannesburg, we found nearly all women reported at least on sexual and reproductive health need and more than 75% of women incurred costs related to those needs. Furthermore, more than half of women surveyed reported not accessing services for their sexual and reproductive health needs, suggesting a total annual cost of more than $50 USD, on average, to access services for all reported needs. While few women spent more than 10% of their total household income on sexual and reproductive health services in the prior year, needs are constant and costs incur throughout a woman’s life suggesting accessing services to meet these needs might still result in financial burden. As South Africa grapples with increasing access to sexual and reproductive health services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to services.
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Affiliation(s)
- Naomi Lince-Deroche
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 39 Empire Road, Parktown, Johannesburg, South Africa.
| | - Kaitlyn M Berry
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Ave. 3rd Floor, Boston, MA, 02118, USA
| | - Cheryl Hendrickson
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 39 Empire Road, Parktown, Johannesburg, South Africa
| | - Tembeka Sineke
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 39 Empire Road, Parktown, Johannesburg, South Africa
| | - Sharon Kgowedi
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, 39 Empire Road, Parktown, Johannesburg, South Africa
| | - Masangu Mulongo
- Right to Care, Helen Joseph Hospital, Perth Road, Westdene, Johannesburg, South Africa
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Harries J, Constant D. Providing safe abortion services: Experiences and perspectives of providers in South Africa. Best Pract Res Clin Obstet Gynaecol 2019; 62:79-89. [PMID: 31279763 DOI: 10.1016/j.bpobgyn.2019.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/05/2019] [Accepted: 05/14/2019] [Indexed: 10/26/2022]
Abstract
Despite abortion being legally available on request up to and including the gestational age of 12 weeks in South Africa, barriers to access remain. Barriers include provider opposition to abortion and a shortage of trained and willing providers, which has implications for access to safe abortion services. Exploring the factors that determine providers' levels of involvement in abortion services can facilitate improvements in service provision. Providers' conceptualizations of abortion are influenced by numerous factors, including moral and religious views, in which abortion is perceived by some as a sin, whereas others view access to safe abortions as an important component of a woman's right to reproductive autonomy and choice. Barriers to service provision include limited abortion and values clarification training and misinterpretation of conscientious objection. Providers have difficulties with the emotional and visual impact of second trimester abortions. There is an urgent need to address provider shortage, and abortion education and training need to be included in medical and nursing curricula to ensure sustaining abortion services.
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Affiliation(s)
- Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa.
| | - Deborah Constant
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, South Africa.
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Favier M, Greenberg JMS, Stevens M. Safe abortion in South Africa: "We have wonderful laws but we don't have people to implement those laws". Int J Gynaecol Obstet 2018; 143 Suppl 4:38-44. [PMID: 30374986 DOI: 10.1002/ijgo.12676] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In South Africa, abortion was legalized in 1996, during the nation's transition from apartheid to independence and democracy, under the Choice on Termination of Pregnancy Act (CTOPA). The law drew from both a public health and rights-based framework. A coalition of advocates played a key role in passage. In the years after the CTOPA was passed, abortion services were expanded-in part through a 2008 amendment that allowed trained registered nurses to provide abortions-and deaths from unsafe abortions decreased. However, there have been hurdles to implementation, including competing health priorities such as HIV/AIDS, and a high number of conscientious objectors. There is a geographic disparity in accessibility of abortion services between provinces as well as between urban and rural areas. Women seeking legal abortions face a lack of accessible information on where to obtain an abortion, often experience stigma at facilities, and many obtain illegal procedures.
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Affiliation(s)
- Mary Favier
- Parklands Surgery, Cork, Ireland.,Doctors for Choice Ireland, Dublin, Ireland
| | - Jamie M S Greenberg
- Mailman School of Public Health, Columbia University Medical Center, New York, NY, USA
| | - Marion Stevens
- Sexual and Reproductive Justice Coalition, Cape Town, South Africa
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The costs and cost effectiveness of providing second-trimester medical and surgical safe abortion services in Western Cape Province, South Africa. PLoS One 2018; 13:e0197485. [PMID: 29953434 PMCID: PMC6023192 DOI: 10.1371/journal.pone.0197485] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 05/03/2018] [Indexed: 11/19/2022] Open
Abstract
Background In South Africa, access to second-trimester abortion services, which are generally performed using medical induction with misoprostol alone, is challenging for many women. We aimed to estimate the costs and cost effectiveness of providing three safe second-trimester abortion services (dilation and evacuation (D&E)), medical induction with mifepristone and misoprostol (MI-combined), or medical induction with misoprostol alone (MI-misoprostol)) in Western Cape Province, South Africa to aid policymakers with planning for service provision in South Africa and similar settings. Methods We derived clinical outcomes data for this economic evaluation from two previously conducted clinical studies. In 2013–2014, we collected cost data from three public hospitals where the studies took place. We collected cost data from the health service perspective through micro-costing activities, including discussions with site staff. We used decision tree analysis to estimate average costs per patient interaction (e.g. first visit, procedure visit, etc.), the total average cost per procedure, and cost-effectiveness in terms of the cost per complete abortion. We discounted equipment costs at 3%, and present the results in 2015 US dollars. Results D&E services were the least costly and the most cost-effective at $91.17 per complete abortion. MI-combined was also less costly and more cost-effective (at $298.03 per complete abortion) than MI-misoprostol (at $375.31 per complete abortion), in part due to a shortened inpatient stay. However, an overlap in the plausible cost ranges for the two medical procedures suggests that the two may have equivalent costs in some circumstances. Conclusion D&E was most cost-effective in this analysis. However, due to resistance from health care providers and other barriers, these services are not widely available and scale-up is challenging. Given South Africa’s reliance on medical induction, switching to the combined regimen could result in greater access to second-trimester services due to shorter inpatient stays without increasing costs.
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Ely GE, Hales TW, Jackson DL, Kotting J, Agbemenu K. Access to choice: Examining differences between adolescent and adult abortion fund service recipients. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:695-704. [PMID: 29687508 DOI: 10.1111/hsc.12582] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/28/2018] [Indexed: 06/08/2023]
Abstract
The results of a study examining differences between U.S. adolescent and adult abortion fund service recipients are presented in this paper. Using existing case data from 2010 to 2015 from the National Network of Abortion Funds (N = 3,288), a secondary data analysis was conducted to determine whether or not the experiences of adolescent (n = 481) and adult abortion patients (n = 2,807) who received financial assistance to help pay for an abortion differed. Fisher's exact tests examined differences in dichotomous variables, and regression examined differences in procedural costs, patient resources and expected travel distances to obtain an abortion. Results show that a greater proportion of adolescents in this data set identified as African American, and that adolescents were more likely to report seeking an abortion due to lack of contraception, and rape, while adult patients were more likely to be seeking an abortion due to contraceptive failure and partner violence. Results are discussed using a trauma-informed framework.
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Affiliation(s)
- Gretchen E Ely
- School of Social Work, University at Buffalo, The State University of New York, Buffalo, NY
| | - Travis W Hales
- School of Social Work, University at Buffalo, The State University of New York, Buffalo, NY
| | - D Lynn Jackson
- Department of Social Work, Texas Christian University, Ft. Worth, TX
| | | | - Kafuli Agbemenu
- School of Nursing, University at Buffalo, The State University of New York, New York, NY
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Sullivan ME, Harrison A, Harries J, Sicwebu N, Rosen RK, Galárraga O. Women's reproductive decision making and abortion experiences in Cape Town, South Africa: A qualitative study. Health Care Women Int 2017; 39:1163-1176. [PMID: 29111909 DOI: 10.1080/07399332.2017.1400034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Unintended pregnancy is a significant public health issue in South Africa. Despite free services including contraception, women face structural and institutional barriers to accessing care. This qualitative study comprised interviews with 16 women aged 18 to 40 years and receiving post-abortion services at a public clinic in Cape Town. Data analysis revealed three main themes: personal journeys in seeking abortion, contraceptive experiences, and contrasting feelings of empowerment (in reproductive decision making) and disempowerment (in the health care system). Women perceived themselves as solely responsible for their reproductive health, but found it difficult to obtain adequate information or services.
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Affiliation(s)
- Marie E Sullivan
- a Department of Health Services, Policy and Practice , Brown University School of Public Health , Providence , Rhode Island , USA
| | - Abigail Harrison
- a Department of Health Services, Policy and Practice , Brown University School of Public Health , Providence , Rhode Island , USA
| | - Jane Harries
- b Women's Health Research Unit School of Public Health & Family Medicine, University of Cape Town , Cape Town , South Africa
| | - Namhla Sicwebu
- b Women's Health Research Unit School of Public Health & Family Medicine, University of Cape Town , Cape Town , South Africa
| | - Rochelle K Rosen
- a Department of Health Services, Policy and Practice , Brown University School of Public Health , Providence , Rhode Island , USA.,c Centers for Behavioral and Preventive Medicine, The Miriam Hospital , Providence , Rhode Island , USA
| | - Omar Galárraga
- a Department of Health Services, Policy and Practice , Brown University School of Public Health , Providence , Rhode Island , USA
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Lince-Deroche N, Fetters T, Sinanovic E, Blanchard K. Accessing medical and surgical first-trimester abortion services: women's experiences and costs from an operations research study in KwaZulu-Natal Province, South Africa. Contraception 2017; 96:72-80. [DOI: 10.1016/j.contraception.2017.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 03/21/2017] [Accepted: 03/25/2017] [Indexed: 10/19/2022]
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11
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Purcell C, Brown A, Melville C, McDaid LM. Women's embodied experiences of second trimester medical abortion. FEMINISM & PSYCHOLOGY 2017; 27:163-185. [PMID: 28546655 PMCID: PMC5431358 DOI: 10.1177/0959353517692606] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abortions in general, and second trimester abortions in particular, are experiences which in many contexts have limited sociocultural visibility. Research on second trimester abortion worldwide has focused on a range of associated factors including risks and acceptability of abortion methods, and characteristics and decision-making of women seeking the procedure. Scholarship to date has not adequately addressed the embodied physicality of second trimester abortion, from the perspective of women's lived experiences, nor how these experiences might inform future framings of abortion. To progress understandings of women's embodied experiences of second trimester abortion, we draw on the accounts of 18 women who had recently sought second trimester abortion in Scotland. We address four aspects of their experiences: later recognition of pregnancy; experiences of a second trimester pregnancy which ended in abortion; the "labour" of second trimester abortion; and the subsequent bodily transition. The paper has two key aims: Firstly, to make visible these experiences, and to consider how they relate to dominant sociocultural narratives of pregnancy; and secondly, to explore the concept of "liminality" as one means for interpreting them. Our findings contribute to informing future research, policy and practice around second trimester abortion. They highlight the need to maintain efforts to reduce silences around abortion and improve equity of access.
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Affiliation(s)
- Carrie Purcell
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, UK
| | | | | | - Lisa M McDaid
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, UK
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