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Pleasants EA, Jayaweera RT, Egwuatu I, Nmezi S, Kristianingrum IA, Zurbriggen R, Grosso B, Bercu C, Motana R, Gerdts C, Moseson H. Self-managed medication abortion trajectories: results from a prospective observational study in Argentina, Nigeria and Southeast Asia. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023:bmjsrh-2023-201979. [PMID: 37907254 DOI: 10.1136/bmjsrh-2023-201979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/11/2023] [Indexed: 11/02/2023]
Abstract
OBJECTIVES Time is a crucial factor in abortion-seeking because options for care change with pregnancy duration, and most people prefer to access abortion care early in pregnancy. We aimed to collect data on the timing of steps in accompanied self-managed abortion-seeking experiences in legally restrictive settings. METHODS In this prospective, observational, cohort study we recruited callers from three abortion accompaniment groups in Argentina, Nigeria and a country in Southeast Asia. Participants completed a baseline survey before starting a self-managed medication abortion (SMA) and two follow-up surveys (approximately 1 and 3 weeks after taking medication). Primary outcomes of interest included: (1) time from abortion decision to contacting the hotline, (2) time from contacting the hotline to obtaining pills and (3) time from obtaining pills to taking the first dose. We explored relationships between participant characteristics and each of these outcomes and evaluated differences in overall abortion time using survival analyses. RESULTS Between July 31, 2019 and October 01, 2020 we enrolled 1352 eligible callers; 1148 provided data for this analysis. After deciding to have an abortion, participants took 12.2 days on average (95% CI: 11.6, 12.9) to start medications for abortion. On average, participants at later pregnancy durations progressed through the SMA process more quickly (<4 weeks: 20.9 days, 4 weeks: 11 days, 5-6 weeks: 10.1 days, 7-9 weeks, 10.4 days, 10+ weeks: 9.1 days; p<0.001). CONCLUSIONS Overall, participants accessed accompaniment group support and started abortion regimens quickly and at relatively early pregnancy durations. SMA with accompaniment provided a time-efficient route for obtaining abortions.
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Affiliation(s)
- Elizabeth A Pleasants
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | | | - Ijeoma Egwuatu
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | - Sybil Nmezi
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | | | | | - Belén Grosso
- La Revuelta Colectiva Feminista, Neuquén, Argentina
| | - Chiara Bercu
- Ibis Reproductive Health, Oakland, California, USA
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McLean E, Blystad A, Mirkuzie AH, Miljeteig I. Health workers' experience of providing second-trimester abortion care in Ethiopia: a qualitative study. Reprod Health 2023; 20:154. [PMID: 37848942 PMCID: PMC10580537 DOI: 10.1186/s12978-023-01698-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 10/10/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Second-trimester abortions are less common than abortions in the first trimester, yet they disproportionately account for a higher burden of abortion-related mortality and morbidity worldwide. Health workers play a crucial role in granting or denying access to these services, yet little is known about their experiences. Ethiopia has been successful in reducing mortality due to unsafe abortion over the past decade, but access to second trimester abortion remains a challenge. The aim of this study is to better understand this issue by exploring the experiences of second-trimester abortion providers working in Addis Ababa, Ethiopia. METHODS A qualitative study with 13 in-depth semi-structured interviews with 16 health workers directly involved in providing second-trimester abortions, this included obstetrician and gynaecologist specialists and residents, general practitioners, nurses, and midwives. Data was collected at four public hospitals and one non-governmental clinic in Addis Ababa, Ethiopia and analysed using Malterud's text-condensation method. RESULTS The providers recognized the critical need for second-trimester abortion services and were motivated by their empathy towards women who often sought care late due to marginalisation and poverty making it difficult to access abortion before the second trimester. However, service provision was challenging according to the providers, and barriers like lack of access to essential drugs and equipment, few providers willing to conduct abortions late in pregnancy and unclear guidelines were commonly experienced. This led to highly demanding working conditions. The providers experienced ethical dilemmas pertaining to the possible viability of the fetus and women desperately requesting the service after the legal limit. CONCLUSIONS Second-trimester abortion providers faced severe barriers and ethical dilemmas pushing their moral threshold and medical risk-taking in efforts to deliver second-trimester abortions to vulnerable women in need of the service. Effort is needed to minimize health system barriers and improve guidelines and support for second-trimester abortion providers in order to increase access and quality of second-trimester abortion services in Ethiopia. The barriers forcing women into second trimester abortions also need to be addressed.
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Affiliation(s)
- Emily McLean
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, 5020, Bergen, Norway.
| | - Astrid Blystad
- Global Health Anthropology Research Group, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, 5020, Bergen, Norway
| | - Alemnesh H Mirkuzie
- John Snow Research and Training, Inc, Edna Mall Area, Addis Ababa, Ethiopia
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave, Seattle, WA, 98195, USA
| | - Ingrid Miljeteig
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, 5020, Bergen, Norway
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Dantas PBF, Trabach CB, Junqueira AA, Nunes CC, Veiga-Junior NN, Baccaro LF. The Impact of the COVID-19 Pandemic on the Care of Women Experiencing Abortion in a University Hospital in Brazil. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:113-120. [PMID: 37105194 PMCID: PMC10166645 DOI: 10.1055/s-0042-1759749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVE To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with miscarriage and legal termination of pregnancy in a university hospital in Brazil. METHODS A cross-sectional study of women admitted for abortion due to any cause at Hospital da Mulher Prof. Dr. J. A. Pinotti of Universidade Estadual de Campinas (UNICAMP), Brazil, between July 2017 and September 2021. Dependent variables were abortion-related complications and legal interruption of pregnancy. Independent variables were prepandemic period (until February 2020) and pandemic period (from March 2020). The Cochran-Armitage test, Chi-squared test, Mann-Whitney test, and multiple logistic regression were used for statistical analysis. RESULTS Five-hundred sixty-one women were included, 376 during the prepandemic period and 185 in the pandemic period. Most patients during pandemic were single, without comorbidities, had unplanned pregnancy, and chose to initiate contraceptive method after hospital discharge. There was no significant tendency toward changes in the number of legal interruptions or complications. Complications were associated to failure of the contraceptive method (odds ratio [OR] 2.44; 95% confidence interval [CI] 1.23-4.84), gestational age (OR 1.126; 95% CI 1.039-1.219), and preparation of the uterine cervix with misoprostol (OR 1.99; 95% CI 1.01-3.96). CONCLUSION There were no significant differences in duration of symptoms, transportation to the hospital, or tendency of reducing the number of legal abortions and increasing complications. The patients' profile probably reflects the impact of the pandemic on family planning.
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Affiliation(s)
| | - Carolina Braga Trabach
- Departamento de Tocoginecologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | - Carina Cordeiro Nunes
- Departamento de Tocoginecologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | | | - Luiz Francisco Baccaro
- Departamento de Tocoginecologia, Universidade Estadual de Campinas, Campinas, SP, Brazil
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Constant D, Lopes S, Grossman D. Could routine pregnancy self-testing facilitate earlier recognition of unintended pregnancy? A feasibility study among South African women. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:e60-e66. [PMID: 33972398 DOI: 10.1136/bmjsrh-2020-201017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION We explored whether routine pregnancy self-testing is feasible and acceptable to women at risk of late recognition of pregnancy as a strategy to facilitate early entry into either antenatal or abortion care. METHODS A feasibility study among South African sexually active women not desiring pregnancy within 1 year, and not using long-acting or injectable contraceptives. At recruitment, we provided five free urine pregnancy tests for self-testing on the first day of each of the next 3 months. We sent monthly text reminders to use the tests with requests for no-cost text replies. Our main outcome was the proportion of participants self-testing within 5 days of the text reminder over three consecutive months. Other outcomes were ease of use of tests, preference for self-testing versus clinic testing, acceptability of routine self-testing (all binary responses followed by open response options) and response to text messages (four-point Likert scale). RESULTS We followed up 71/76 (93%) participants. Two confirmed new pregnancies at the first scheduled test and completed exit interviews, and 64/69 (93%) self-reported completing all three monthly tests. Self-testing was easy to do (66/71, 93%); advantages were convenience (21/71, 30%) and privacy (18/71, 25%), while the main disadvantage was no nurse present to advise (17/71, 24%). Most would recommend monthly testing (70/71, 99%). Text reminders were generally not bothersome (57/71, 80%); 35/69 (51%) participants replied with test results over all three months. CONCLUSION Providing free pregnancy tests to women at risk of late recognition of pregnancy is feasible to strengthen early confirmation of pregnancy status.
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Affiliation(s)
- Deborah Constant
- Women's Health Research Unit, School of Public Health & Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sofia Lopes
- Women's Health Research Unit, School of Public Health & Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, California, USA
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Somefun OD, Harries J, Constant D. Reproductive awareness and recognition of unintended pregnancy: young women, key informants and health care providers perspectives in South Africa. Reprod Health 2021; 18:211. [PMID: 34702283 PMCID: PMC8549136 DOI: 10.1186/s12978-021-01262-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND South Africa has a liberal abortion law, yet denial of care is not uncommon, usually due to a woman being beyond the legal gestational age limit for abortion care at that facility. For women successfully obtaining care, time from last menstrual period to confirmation of pregnancy is significantly longer among those having an abortion later in the second trimester compared to earlier gestations. This study explores women's experiences with recognition and confirmation of unintended pregnancy, their understanding of fertile periods within the menstrual cycle as well as healthcare providers' and policy makers' ideas for public sector strategies to facilitate prompt confirmation of pregnancy. METHODS We recruited participants from July through September 2017, at an urban non-governmental organization (NGO) sexual and reproductive health (SRH) facility and two public sector hospitals, all providing abortion care into the second trimester. We conducted in-depth interviews and group discussions with 40 women to elicit information regarding pregnancy recognition and confirmation as well as fertility awareness. In addition, 5 providers at these same facilities and 2 provincial policy makers were interviewed. Data were analysed using thematic analysis. RESULTS Uncertainties regarding pregnancy signs and symptoms greatly impacted on recognition of pregnancy status. Women often mentioned that others, including family, friends, partners or colleagues noticed pregnancy signs and prompted them to take action. Several women were unaware of the fertility window and earliest timing for accurate pregnancy testing. Health care providers and policy makers called for strategies to raise awareness regarding risk and signs of pregnancy and for pregnancy tests to be made more readily accessible. CONCLUSION Early recognition of unintended pregnancy in this setting is frustrated by poor understanding and awareness of fertility and pregnancy signs and symptoms, compounded by a distrust of commercially available pregnancy tests. Improving community awareness around risk and early signs of pregnancy and having free tests readily available may help women confirm their pregnancy status promptly.
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Affiliation(s)
- Oluwaseyi Dolapo Somefun
- Women's Health Research Unit, University of Cape Town, Anzio Road, 7925 Observatory, Cape Town, South Africa
| | - Jane Harries
- Women's Health Research Unit, University of Cape Town, Anzio Road, 7925 Observatory, Cape Town, South Africa
| | - Deborah Constant
- Women's Health Research Unit, University of Cape Town, Anzio Road, 7925 Observatory, Cape Town, South Africa.
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Kapp N, Edelman A, Gomperts R, Srinivasan K, Dabash R. Addressing the urgent global need for later abortion care during COVID-19 and beyond. BMJ SEXUAL & REPRODUCTIVE HEALTH 2021; 47:e15. [PMID: 33504511 PMCID: PMC8515098 DOI: 10.1136/bmjsrh-2020-200945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 01/05/2021] [Accepted: 01/13/2021] [Indexed: 06/12/2023]
Affiliation(s)
| | - Alison Edelman
- Oregon Health & Science University, Portland, Oregon, USA
| | - Rebecca Gomperts
- Women on Web International Foundation, Amsterdam, The Netherlands
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Cavalari CAA, Veiga-Junior NN, Kajiura BD, Eugeni C, Tavares BVG, Baccaro LF. Factors Associated with Abortion Complications after the Implementation of a Surveillance Network (MUSA Network) in a University Hospital. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:507-512. [PMID: 34461660 PMCID: PMC10303421 DOI: 10.1055/s-0041-1735129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE To evaluate the factors associated with abortion complications following the implementation of the good-practice surveillance network Mujeres en Situación de Aborto (Women Undergoing Abortion, MUSA, in Spanish). METHODS A cross-sectional study with women who underwent abortion due to any cause and in any age group at UNICAMP Women's Hospital (part of MUSA network), Campinas, Brazil, between July 2017 and Agust 2019. The dependent variable was the presence of any abortion-related complications during hospitalization. The independent variables were clinical and sociodemographic data. The Chi-square test, the Mann-Whitney test, and multiple logistic regression were used for the statistical analysis. RESULTS Overall, 305 women were enrolled (mean ± standard deviation [SD] for age: 29.79 ± 7.54 years). The mean gestational age was 11.17 (±3.63) weeks. Accidental pregnancy occurred in 196 (64.5%) cases, 91 (29.8%) due to contraception failure. At least 1 complication was observed in 23 (7.54%) women, and 8 (34.8%) of them had more than 1. The most frequent complications were excessive bleeding and infection. The factors independently associated with a higher prevalence of complications were higher gestational ages (odds ratio [OR]: 1.22; 95% confidence interval [95%CI]: 1.09 to 1.37) and contraceptive failure (OR: 3.4; 95%CI: 1.32 to 8.71). CONCLUSION Higher gestational age and contraceptive failure were associated with a higher prevalence of complications. This information obtained through the surveillance network can be used to improve care, particularly in women more susceptible to unfavorable outcomes.
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Affiliation(s)
- Camila Ayume Amano Cavalari
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
| | - Nelio Neves Veiga-Junior
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
| | - Beatriz Deguti Kajiura
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
| | - Caroline Eugeni
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
| | | | - Luiz Francisco Baccaro
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, State University of Campinas - UNICAMP - Brazil
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Kapp N, Andersen K, Griffin R, Handayani AP, Schellekens M, Gomperts R. Medical abortion at 13 or more weeks gestation provided through telemedicine: A retrospective review of services. Contracept X 2021; 3:100057. [PMID: 33615210 PMCID: PMC7881210 DOI: 10.1016/j.conx.2021.100057] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives To evaluate medical abortion effectiveness and safety in women at 13 or more weeks gestation provided care through Women on Web's telemedicine service. Study Design We conducted a retrospective case study of abortions at 13 or more weeks gestation provided by Women on Web between 2016 and 2019. Women received mifepristone and misoprostol or misoprostol alone for abortion. We extracted demographic characteristics and outcome data for cases with pregnancy continuation outcomes. Results We identified 144 women who used medical abortion at 13 or more weeks; 131 (91%) provided abortion outcome data. Almost all, 118 (90%) received mifepristone and misoprostol. The population had an average age of 26 ± 5.8 years, 102 (78%) reported a gestational age of 13 to 15 weeks, 114 (87%) had experienced prior pregnancy, and represented all world regions. Overall, 13 (10%) women reported a continuing pregnancy, with 5 (5%) among women 13 to 15 weeks and 8 (28%) among those ≥16 weeks (p = 0.001); 38 (29%) reported adverse events (heavy bleeding, fever), 53 (43%) sought additional care from a health provider, and 18% of all cases received treatment with D&C/aspiration. Conclusions Efficacy of self-administered medical abortion decreases as gestational age increases, risking continuation of pregnancy. Provision through telemedicine at 13 to 15 weeks appears safe and effective. Implications Limited data suggest that medical abortion through telemedicine services may be a safe option through 15 weeks gestation in settings where there is ready access to the formal health system. More research with adequate sample sizes and high rates of follow-up is needed to inform on the safety of telemedicine for pregnancies 13 weeks and greater.
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Kapp N, Griffin R, Bhattarai N, Dangol DS. Does prior ultrasonography affect the safety of induced abortion at or after 13 weeks' gestation? A retrospective study. Acta Obstet Gynecol Scand 2020; 100:736-742. [PMID: 33185906 PMCID: PMC8246849 DOI: 10.1111/aogs.14040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/24/2020] [Accepted: 11/04/2020] [Indexed: 11/30/2022]
Abstract
Introduction We aimed to assess whether ultrasonography prior to dilation and evacuation or medical abortion ≥13 weeks was correlated with safety. Material and methods We conducted a retrospective chart review of patients undergoing abortion ≥13 weeks at eight sites in Nepal from 2015 to 2019. Results We included 2294 women undergoing abortion ≥13 weeks (no upper gestational age limit); 593 underwent dilation and evacuation and 1701 had a medical abortion. Demographics differed by procedure for parity (19% vs 33% nulliparous, dilation and evacuation, and medical abortion) and gestational age (90% vs 52% were 13‐15 weeks, dilation and evacuation, and medical abortion). Ultrasonography was performed in 81% of cases overall. Complications were rare (<1% of dilations and evacuations, 1.4% of medical abortions). The most common adverse events with dilation and evacuation were hemorrhage and cervical laceration; three women required re‐aspiration. Following medical abortion, 13.5% had retained products, 12.9% with prior ultrasound and 16.3% who had not had an ultrasound. Hemorrhage and severe side‐effects occurred at similarly low rates regardless of whether ultrasonography was performed. In a logistic regression model where patient characteristics and case clustering within facilities were controlled for, we found a correlation between ultrasonography and complications when retained placenta was included in the model, but there was no correlation between ultrasonography and complications when retained placenta was excluded. Conclusions This study confirms low complication rates among women having an abortion ≥13 weeks’ gestation in healthcare facilities. Settings without universal availability of ultrasound may still maintain low, comparable complication rates.
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Baum SE, Ramirez AM, Larrea S, Filippa S, Egwuatu I, Wydrzynska J, Piasecka M, Nmezi S, Jelinska K. "It's not a seven-headed beast": abortion experience among women that received support from helplines for medication abortion in restrictive settings. Health Care Women Int 2020; 41:1128-1146. [PMID: 33156737 DOI: 10.1080/07399332.2020.1823981] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
There are a growing number of abortion helplines where counselors provide person-centered medication abortion services in legally restrictive settings. Few researchers have explored the perceptions and experiences of the people who obtain support from these helplines. Between April and August 2017, we conducted 30 interviews with women who had a medication abortion with support from helpline counselors in Poland, Brazil, or Nigeria. Before seeking care with the helpline, women often heard negative stories about abortion and faced enacted stigma from the formal healthcare sector, or chose not to seek services from their doctors due to fear of stigmatizing treatment. Conversely, during their care with the helpline counselors, women received clear information in a timely manner, and were treated with kindness, compassion, respect, and without judgment. Many women gained knowledge and understanding of medication abortion, and some gained a sense of community among those who experienced abortion. Helpline models can provide high-quality, person-centered abortion care to people seeking abortions in legally restrictive contexts. Evidence from these service-delivery models could help improve service within the formal healthcare systems and expand access to high-quality, safe abortion by redefining what it means to provide care.
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Affiliation(s)
- Sarah E Baum
- Ibis Reproductive Health, Oakland, California, USA
| | | | - Sara Larrea
- Women Help Women, Amsterdam, the Netherlands
| | | | - Ijeoma Egwuatu
- Generation Initiative for Youth and Women Network, Lagos, Nigeria
| | | | | | - Sybil Nmezi
- Generation Initiative for Youth and Women Network, Lagos, Nigeria
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