Evidence supporting broader access to safe legal abortion

A scoping review considering the processes involved in changing abortion laws in low- and middle-income countries

Providing legal and safe abortion is promoted as one of the key global strategies for reducing maternal mortality. Following the landmark 1994 International Conference on Population and Development, low- and middle-income countries (LMICs) are shifting towards more liberal abortion legislation. Whilst the existing literature has predominantly focused on agenda setting and individual country contexts, there is a need to understand the universal policy process of changing abortion laws. Drawing on the heuristic policy stages model and policy analysis triangle, this paper explores the processes involved in changing abortion laws in LMICs and discusses the influencing factors. We conducted a search for peer-reviewed literature in ProQuest, Scopus, Global Health (Ovid), PubMed and CINAHL. Initially, the search was conducted in February 2021 and was then re-run in May 2023. A total of 25 studies were included in the analysis. Following a descriptive, thematic and interpretive analysis of the extracted data, we have drawn out the key stages involved in changing abortion laws in LMICs: (1) establishing the need for changing abortion laws in a local context; (2) generating local evidence to support changes in abortion laws; (3) drafting of new and/or amendments of existing abortion laws; (4) adoption and enactment of changes in abortion laws; (5) translating the legal provisions into services and (6) assessing the impact of changes in abortion laws on maternal health. Our analysis explores the influence of actors and contextual factors, and we also discuss the policy solutions and decisions made by governments. The findings demonstrate that while the timing of change in abortion law was found to be dependent on the context of individual settings, the process and factors that influenced the change were remarkably consistent across geographies. Further research is required to evaluate the link between changes in abortion laws and maternal health outcomes.

Pharmacy dispensing of abortion pills in Ghana: experiences of pharmacy workers and users

BACKGROUND

Self-managed medical abortions are generally safe; however, pharmacy provision of abortion pills is against the Ghanaian abortion law. Nevertheless, evidence shows increasing numbers of women use it. An understanding of the influence of the law on pharmacies dispensing abortifacients and women who needed hospital care after using these pills is lacking. This study aimed to address this gap.

METHODS

We conducted 26 interviews with eight pharmacy workers and 18 women who sought hospital care after using abortion pills. Study participants were recruited from private pharmacies and hospitals within the Ashanti Region of Ghana between June 2017 and March 2018. We employed phenomenology in analysing the data.

RESULTS

Results show that criminalising medical abortion care from pharmacies does not stop abortions but rather drives it to be provided without oversight. It also denied pharmacy workers formal training in medical abortion care, resulting in situations where they failed to provide correct dosage information, used their discretion in determining the price of abortifacients and to whom they would dispense the pills. For women, it contributed to limited interaction with providers and an inability to insist on their rights even in instances where the pills were sold at exorbitant prices.

CONCLUSIONS

Due to the increasing numbers of Ghanaian women using medical abortion pills from pharmacies, although it is illegal, the ideal would be for medical abortion pills to be made legally available through pharmacies. Given that this may not occur in the short term, an immediate solution would be to upskill pharmacy workers.

Knowledge, attitude, and intended practice of abortion among pharmacy students in Thailand after the amendment of the Thai Abortion Law

BACKGROUND

The recently amended Thai abortion law allows pregnant women to undergo abortions up to the gestational age of 12 weeks. Medical abortion is significant because it has revolutionized access to safe abortion care-abortion medicine can now be safely and effectively administered outside of a healthcare facility to women in early pregnancy. This contribution supports the pharmacists' role in interprofessional safe abortion teamwork. Adequate knowledge of the current laws regarding safe abortion services will increase pharmacists' competence in providing services. However, safe abortions as a subject have not been formally incorporated into the curriculum for Thai pharmacy students. Therefore, this study aimed to evaluate the knowledge, attitude, and intended practice of fifth-year pharmacy students at Chulalongkorn University.

METHODS

A cross-sectional study was conducted using an electronic self-administered questionnaire adapted from previously published studies to evaluate participants' knowledge of the recently amended Thai abortion law, attitude toward abortion, and intended practices. The invitations were sent to all fifth-year pharmacy students at Chulalongkorn University.

RESULTS

Among all invitations sent, 104/150 (69.3%) participants responded to the survey. Only a third of the participants (31.7%) had good knowledge scores. Based on five questions regarding the gestational age limit for legal abortion, most participants (52.7%) answered questions incorrectly. Although more than half of the participants (52.5%) disagreed with two pro-choice statements, an overwhelming majority (87.5%) agreed that abortion was a woman's right. Safe abortion services were mostly agreed upon with serious fetal defects (91.9%), non-HIV maternal health conditions (82.2%), and sexual assaults (77.4%). A positive attitude toward abortion affects the intention to perform an abortion under socioeconomic conditions.

CONCLUSION

Most participants lacked knowledge on the amended abortion law, especially on the gestational limits of abortion. Participants with favorable attitudes toward abortion tended to be more liberal regarding safe abortion services.

Main barriers to services linked to voluntary pregnancy termination on three grounds in Chile

Introduction

After decades of absolute criminalization, on September 14, 2017, Chile decriminalized voluntary termination of pregnancy (VTP) when there is a life risk to the pregnant woman, lethal incompatibility of the embryo or fetus of genetic or chromosomal nature, and pregnancy due to rape. The implementation of the law reveals multiple barriers hindering access to the services provided by the law.

Objectives

To identify and analyze, using the Tanahashi Model, the main barriers to the implementation of law 21,030 in public health institutions. This article contributes to the follow-up of this public policy, making visible the obstacles that violate women's rights of women to have dignified access to abortion and that affect the quality of health care in Chile.

Material and method

Qualitative design, following the postpositivist paradigm. The sample consisted of relevant actors directly related to pregnancy termination. Snowball sampling and semi-structured interviews were used. Grounded theory was used through inductive coding, originating categories regrouped into meta-categories following Tanahashi's model. The rigor criteria of transferability, dependability, credibility, authenticity, and epistemological theoretical adequacy were used. The identity of the participants and the confidentiality of the information were protected.

Results

From January 2021 to October 2022, 62 interviews were conducted with 20 members of the psychosocial support team; 18 managers; 17 members of the biomedical health team; 4 participants from of civil society, and three women users. The main obstacles correspond to availability barriers, accessibility barriers, acceptability barriers, contact barriers, and effectiveness barriers.

Conclusions

Barriers to access abortion under three grounds violate the exercise of women's sexual and reproductive rights. It is urgent to carry out actions of control and follow-up of this public policy to the corresponding entities.

A global review of penalties for abortion-related offences in 182 countries

Public health research and human rights bodies have demonstrated the risks involved with criminalising abortion services and noted a need for full decriminalisation. Despite this, abortions are criminalised in some circumstances in almost all countries in the world today. This paper uses data from the Global Abortion Policies Database (GAPD) to analyse what criminal penalties exist for those who are seeking, providing and assisting in abortions in 182 countries.This paper uses data on abortion-related penalties available on the GAPD as of October 2022. It includes which actors are penalised, whether specific penalties exist for negligence, non-consensual abortions, whether any secondary additional considerations/judicial discretion exist in sentencing and the legal sources for these penalties.134 countries penalise abortion-seekers, 181 countries penalise abortion-providers and 159 countries penalise persons assisting in abortions. The maximum penalty is between 0 and 5 years of imprisonment in a majority of countries; however, it can be much higher in other countries. Some countries further prescribe fines, and professional sanctions for providers and those who assist. 34 countries restrict the dissemination of information about abortion.The range of possible penalties across countries and associated aggravating and mitigating factors for imposing these penalties support arguments for the decriminalisation of abortion on the grounds of arbitrariness. Abortions are also predominantly regulated through the criminal law, which may compound the stigma associated with seeking, assisting with and/or providing abortions when it is criminalised.There has been no comprehensive study of penalties for abortion at a global level. This article describes what specific penalties abortion seekers and providers face, what factors may increase or decrease these penalties, and the legal sources for these penalties. The findings provide additional evidence of the arbitrariness and potential for stigma associated with the criminalisation of abortion and strengthen the case for decriminalisation.

Conscientious objection as structural violence in the voluntary termination of pregnancy in Chile

Introduction

After three decades of the absolute prohibition of abortion, Chile enacted Law 21,030, which decriminalizes voluntary pregnancy termination when the person is at vital risk, when the embryo or fetus suffers from a congenital or genetic lethal pathology, and in pregnancy due to rape. The law incorporates conscientious objection as a broad right at the individual and institutional levels.

Objectives

The aim of the study was to explore the exercise of conscientious objection in public health institutions, describing and analyzing its consequences and proposals to prevent it from operating as structural violence.

Materials and methods

This study uses a qualitative, post-positivist design. At the national level, according to the chain technique, people who were identified as key actors due to their direct participation in implementing the law were included. Grounded theory was used to analyze the information obtained through a semi-structured interview. The methodological rigor criteria of transferability or applicability, dependability, credibility, auditability, and theoretical-methodological adequacy were met.

Results

Data from 17 physicians, 5 midwives, 6 psychologists, 8 social workers, 2 nursing technicians, and 1 lawyer are included. From an inductive process through open coding, conscientious objection as structural violence and strategies to minimize the impact of objection emerge as meta-categories. The first meta-category emerges from the barriers linked to the implementation of the law, the infringement of the rights of the pregnant person, and pseudo conscientious objection, affecting timely and effective access to pregnancy termination. The second meta-category emerges as a response from the participants, proposing strategies to prevent conscientious objection from operating as structural violence.

Conclusion

Conscientious objection acts as structural violence by infringing the exercise of sexual and reproductive rights. The State must fulfill its role as guarantor in implementing public policies, preventing conscientious objection from becoming hegemonic and institutionalized violence.

Understanding the relationship between social determinants of health and maternal mortality: Scientific Impact Paper No. 67

Within this document we use the terms pregnant woman and women's health. However, it is important to acknowledge that it is not only people who identify as women for whom it is necessary to access care. Obstetric and gynaecology services and delivery of care must therefore be appropriate, inclusive and sensitive to the needs of those individuals whose gender identity does not align with the sex they were assigned at birth.

[13 Years Later: Dialogues on Voluntary Termination of Pregnancy in Portugal]

Law 16/2007 represented a milestone in the quest for sexual and reproductive rights of Portuguese citizens, instituting the possibility of excluding all illegality for voluntary termination of pregnancy, performed until the 10th week, at the request of the women involved. Using a descriptive-analytical research, the objective was to establish the opinion of citizens and researchers (active in the cause), in the course of this process and the transformations that resulted from it, with emphasis on the current context. Between March and September, 12 interviews were conducted, divided into two stages. When the Discourse Analysis techniques were analyzed, there were some weak points, such as the uncertainty about access, the presence of judgments and the limitations interposed by the conscientious objectors, which reflect the need to expand the allowed gestational period for termination. There was recognition of security in procedures, women's freedom in their choices, greater openness to dialogue, a fact that contributed jointly with the strengthening of family planning. In addition to these constructions, new demands were configured.

Contemplating abortion: a qualitative study of men and women’s reactions to unplanned pregnancy in Sierra Leone

Globally, millions of unintended pregnancies result in unsafe abortions each year. In Sierra Leone, abortion-related complications are a major driver of maternal mortality. Despite these costs, women continue to seek unsafe abortions, yet how individuals understand the risks and benefits of pregnancy termination remains under-researched. This study seeks to understand perceptions of abortion by women and men experiencing unplanned pregnancy and to highlight factors that inform their abortion trajectories. Findings indicate that abortion was contemplated in response to anxieties regarding caring for a child, interruptions to schooling, and stigma associated with extra-marital pregnancy. While many women and men preferred not to abort-due to cultural values tied to parenthood-others faced obstacles stemming from lack of knowledge of and access to services. Findings can be used to inform interventions to support women and men in realising their fertility preferences in the face of unplanned pregnancy.

Access to Reproductive Healthcare for Persons Who Have Experienced Sexual Violence

Pregnancy resulting from abuse is a public health concern that millions of persons will experience in their lifetimes. Access to professional and safe reproductive healthcare, including sex education, contraception, and abortion, is essential to protecting the rights of persons to control their reproductive health. Currently, access to safe and timely reproductive healthcare is at particular peril. Affirming a patient's right to choose or, advocating autonomy in healthcare decisions is a key component of trauma-informed care. It is the position of the International Association of Forensic Nurses that access to, and autonomy in decision making about reproductive healthcare, including safe and legal contraception and abortion, is a basic human right.

Experiences of women seeking care for abortion complications in health facilities: Secondary analysis of the WHO Multi-Country Survey on Abortion in 11 African countries

OBJECTIVE

Despite evidence of acute and long-term consequences of suboptimal experiences of care, standardized measurements across countries remain limited, particularly for postabortion care. We aimed to determine the proportion of women reporting negative experiences of care for abortion complications, identify risk factors, and assess the potential association with complication severity.

METHODS

Data were sourced from the WHO Multi-Country Survey on Abortion for women who received facility-based care for abortion complications in 11 African countries. We measured women's experiences of care with eight questions from an audio computer-assisted self-interview related to respect, communication, and support. Multivariable generalized estimating equations were used for analysis.

RESULTS

There were 2918 women in the study sample and 1821 (62%) reported at least one negative experience of postabortion care. Participants who were aged under 30 years, single, of low socioeconomic status, and economically dependent had higher odds of negative experiences. Living in West or Central Africa, rather than East Africa, was also associated with reportedly worse care. The influence of complication severity on experience of care appeared significant, such that women with moderate and severe complications had 12% and 40% higher odds of reporting negative experiences, respectively.

CONCLUSION

There were widespread reports of negative experiences of care among women receiving treatment for abortion complications in health facilities. Our findings contribute to the scant understanding of the risk factors for negative experiences of postabortion care and highlight the need to address harmful provider biases and behaviors, alleviate health system constraints, and empower women in demanding better care.

Contraception needs and pregnancy termination in sub-Saharan Africa: a multilevel analysis of demographic and health survey data

BACKGROUND

Women in sub-Saharan Africa (SSA) have a higher risk of unintended pregnancies that are more likely to be terminated, most of which are unsafe with associated complications. Unmet need for contraception is highest in SSA and exceeds the global average. This study investigates the association between unmet/met need for contraception and pregnancy termination SSA.

METHODS

We used pooled data from Demographic and Health Surveys conducted from January 2010 to December 2018 in 32 countries in SSA. Our study involved 265,505 women with diverse contraception needs and with complete data on all variables of interest. Multilevel logistic regression at 95% CI was used to investigate the association between individual and community level factors and pregnancy termination.

RESULTS

We found an overall pregnancy termination rate of 16.27% ranging from 9.13% in Namibia to 38.68% in Gabon. Intriguingly, women with a met need for contraception were more likely to terminate a pregnancy [aOR = 1.11; 95% CI 1.07-1.96] than women with unmet needs. Women with secondary education were more likely to terminate a pregnancy as compared to those without education [aOR = 1.23; 95% CI 1.19-1.27]. With regards to age, we observed that every additional age increases the likelihood of terminating a pregnancy. At the contextual level, the women with female household heads were less likely to terminate a pregnancy [aOR = 0.95; 95% CI 0.92-0.97]. The least socio-economically disadvantaged women were less likely to terminate a pregnancy compared to the moderately and most socio-economically disadvantaged women.

CONCLUSIONS

Our study contributes towards the discussion on unmet/met need for contraception and pregnancy termination across SSA. Women with met need for contraception have higher odds of terminating a pregnancy. The underlying cause of this we argued could be poor adherence to the protocols of contraceptives or the reluctance of women to utilise contraceptives after experiencing a failure. Governments of SSA and non-governmental organisations need to take pragmatic steps to increase met needs for contraception and also utilise mass media to encourage women to adhere to the prescription of contraceptives in order to reduce the incidence of unplanned pregnancies and unsafe abortions.

Impact of abortion law reforms on health services and health outcomes in low- and middle-income countries: a systematic review

While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, expanding the grounds on which abortion can be performed legally. However, the implications of these reforms on women's access to and use of health services, as well as their health outcomes, are uncertain. This systematic review aimed to evaluate and synthesize empirical research evidence concerning the effects of abortion law reforms on women's health services and health outcomes in LMICs. We searched Medline, Embase, CINAHL and Web of Science databases, as well as grey literature and reference lists of included studies. We included pre-post and quasi-experimental studies that aimed to estimate the causal effect of a change in abortion law on at least one of four outcomes: (1) use of and access to abortion services, (2) fertility rates, (3) maternal and/or neonatal morbidity and mortality and (4) contraceptive use. We assessed the quality of studies using the quasi-experimental study design series checklist and synthesized evidence through a narrative description. Of the 2796 records identified by our search, we included 13 studies in the review, which covered reforms occurring in Uruguay, Ethiopia, Mexico, Nepal, Chile, Romania, India and Ghana. Studies employed pre-post, interrupted time series, difference-in-differences and synthetic control designs. Legislative reforms from highly restrictive to relatively liberal were associated with reductions in fertility, particularly among women from 20 to 34 years of age, as well as lower maternal mortality. Evidence regarding the impact of abortion reforms on other outcomes, as well as whether effects vary by socioeconomic status, is limited. Further research is required to strengthen the evidence base for informing abortion legislation in LMICs. This review explicitly points to the need for rigorous quasi-experimental studies with sensitivity analyses to assess underlying assumptions. The systematic review was registered in PROSPERO database CRD42019126927.

Optimizing task-sharing in abortion care in Ghana: Stakeholder perspectives

Ghana has made progress in expanding providers in abortion care but access to the service is still a challenge. We explored stakeholder perspectives on task‐sharing in abortion care and the opportunities that exist to optimize this strategy in Ghana. We purposively sampled 12 representatives of agencies that played a key role in expanding abortion care to include midwives for key informant interviews. All interviews were audio recorded, transcribed verbatim, and then coded for thematic analysis. Stakeholders indicated that Ghana was motivated to practice task‐sharing in abortion care because unsafe abortion was contributing significantly to maternal mortality. They noted that the Ghana Health Service utilized the high maternal mortality in the country at the time, advancements in medicine, and the lack of clarity in the definition of the term “health practitioner” to work with partner nongovernmental organizations to successfully task‐share abortion care to include midwives. Access, however, is still poor and provider stigma continues to contribute significantly to conscientious objection. This calls for further task‐sharing in abortion care to include medical or physician assistants, community health officers, and pharmacists to ensure that more women have access to abortion care.

Midwives are providing abortion care in Ghana through task‐sharing; access is still limited, therefore further expansion to include physician assistants and community health nurses is needed.

Risk factors for spontaneous preterm delivery

BACKGROUND

There is a substantial variation in rates of preterm delivery between different parts of the world. The understanding of these variations, as well as the biological mechanisms behind spontaneous preterm delivery, is limited. Although the benefit of antenatal interventions has been shown to be limited, using well-known risk factors for spontaneous preterm delivery to select the correct pregnant women for targeted interventions is important from both a medical and caregiving perspective.

OBJECTIVE

To provide an introduction to a substantial research area dealing with risk factors of spontaneous preterm delivery.

METHODS

Risk factors in this review were classified as demographical, obstetrical, and gynecological and those related to the current pregnancy according to high-quality evidence of recent literature.

RESULTS AND CONCLUSION

An introduction to a substantial research area in maternal and fetal medicine was provided that might help clinicians to better understand the risk factors related to preterm delivery and select the correct pregnant women for targeted interventions.

Induced abortion: a cross-sectional study on knowledge of and attitudes toward the new abortion law in Maputo and Quelimane cities, Mozambique

BACKGROUND

Maternal mortality, of which 6.7% is attributable to abortion complications, remains high in Mozambique. The objective of this paper is to assess the level of induced abortion at the community, as well as to assess awareness of and attitudes towards the new abortion law among women of reproductive age in suburban areas of Maputo and Quelimane cities.

METHODS

A cross-sectional household survey among women aged 15-49 years in Maputo and Quelimane cities was conducted using a multi-stage clustered sampling design. Data on sociodemographic characteristics, maternal outcomes, contraceptive use, knowledge and attitudes towards the new abortion law were collected. Bivariate and multiple logistic regression analysis using the complex samples procedure in SPSS were applied.

RESULTS

A total of 1657 women (827 Maputo and 830 Quelimane) were interviewed between August 2016 and February 2017. The mean age was 27 years; 45.7% were married and 75.5% had ever been pregnant. 9.2% of the women reported having had an induced abortion, of which 20.0% (17) had unsafe abortion. Of the respondents, 28.8% knew the new legal status of abortion. 17% thought that the legalization of abortion was beneficial to women's health. Having ever been pregnant, being unmarried, student, Muslim, as well as residing in Maputo were associated with higher odds of having knowledge of the new abortion law.

CONCLUSION

Reports of abortion appear to be low compared to other studies from Sub-Saharan African countries. Furthermore, respondents demonstrated limited knowledge of the abortion law. Social factors such as education status, religion, residence in a large city as well as pregnancy history were associated with having knowledge of the abortion law. Only a small percentage of women perceived abortion as beneficial to women's health. There is a need for widespread sensitization about the new law and its benefits.

What post-abortion care indicators don't measure: Global abortion politics and obstetric practice in Senegal

Since the early 1990s, post-abortion care (PAC) has been advocated as a harm reduction approach to maternal mortality and morbidity in countries with restrictive abortion laws. PAC indicators demonstrate that the intervention integrates safer uterine aspiration technology such as the Manual Vacuum Aspiration (MVA) syringe into obstetric practice and facilitates task-shifting from physicians to midwives. In other words, PAC not only saves women's lives, but more generally enhances the organization, quality, and cost-effectiveness of obstetric care. This article draws on my ethnography of Senegal's PAC program, conducted between 2010 and 2011, to illustrate how PAC indicators obscure the professional and technological complexities of treating abortion complications in contexts where abortion is illegal. Data collection methods include observation of PAC services and records at three hospitals; 66 in-depth interviews with health workers, government health officials, and NGO personnel; and a review of national and global PAC data. I show how anxieties about the capacity of the MVA syringe to induce abortion have engendered practices and policies that compromise the quality and availability of care throughout the health system. I explore the multivalent power of MVA statistics in strategically conveying commitments to national and global maternal mortality reduction agendas while eliding profound gaps in access to and quality of care for low-income and rural women. I argue that PAC strategies, technologies, and indicators must be situated within a global framework of reproductive governance, in which safe abortion has been omitted from maternal and reproductive health care associated with reproductive rights. Ethnographic attention to daily obstetric practices challenges globally circulating narratives about PAC as an apolitical intervention, revealing not only how anxieties about abortion ironically suppress the very rates of MVA utilization that purportedly convey PAC quality, but also how they simultaneously give rise to and obscure obstetric violence against women.

Mandatory pre-abortion counseling is a barrier to accessing safe abortion services

Empirical research showcases that pre-abortion counseling scarcely reverses the woman’s decision either to terminate a pregnancy or not. Growing evidence regarding the high levels of decisional certainty among women seeking abortions renders a careful rethink of the place of mandatory pre-abortion counseling packages. Mandatory counseling packages, when inscribed in the laws, at times contain false information that can deter women from going in for safe abortions. Mandatory waiting times indirectly label opting for an abortion as not being the right thing to do. In areas where abortion stigma from health care providers and communities remains highly prevalent, women are forced to incur extra expenses by travelling to other countries. I argue that pre-abortion counseling on opting-in grounds is ethically sound (enhances the woman’s reproductive autonomy), since most clients in need of abortions are certain on their decisions before the abortion care provider and do not regret these decisions after the process. Regrets are prone to be more prevalent in areas with high unsafe abortion practices, generally due to complications from excessive bleeding, pain, and post abortion infections. Allowing systematic mandatory pre-abortion counseling practice as the rule in a competent adult is unjustified ethically and empirically, is time consuming and presents the legality of abortions in most settings an oxymoron.

Assessment of early damage of endometrium after artificial abortion by shear wave elastography

OBJECTIVES

This study aimed to investigate the application of shear wave elastography (SWE) in the early damage detection through assessing the endometrial elasticity after artificial abortion.

METHODS

A total of nulliparous women (20-30 years) who received ultrasonography in our hospital were recruited between January 2017 and December 2017. These women were divided into normal control group (NC; n = 65), after once artificial abortion group (AOAA; n = 68), after twice artificial abortion group (ATAA; n = 61), and after three times or more (range, 3-6) artificial abortion group (ATTMAA; n = 60). SWE was performed to evaluate the endometrium; Young's modulus of the endometrium was determined and then the endometrial thickness was measured.

RESULTS

Young's modulus of the endometrium increased in the order of NC group, AOAA group, ATAA group, and ATTMAA group, and Young's modulus increased with the increase in the number of artificial abortions (p < 0.05). The endometrial thickness in the ATTMAA group was significantly lower than in the NC group, AOAA group, and ATAA group (p < 0.05), but there was no marked difference among the NC group, AOAA group, and ATAA group (p > 0.05).

CONCLUSIONS

SWE increases with increasing number of abortions, which may indicate the damage that is done to the endometrium earlier than measurement of the endometrial thickness do.

Understanding of changes in abortion rate following liberalization of abortion law among Brazilian residents in obstetrics and gynecology

OBJECTIVE

To evaluate residents' knowledge about the evolution of abortion rates in countries where abortion has been legalized, and to assess whether such knowledge correlates with residents' sociodemographic characteristics and experience in abortion care.

METHODS

A multicenter, cross-sectional study was conducted in 21 Brazilian hospitals with 404 medical residents in obstetrics and gynecology. Data collection occurred during February 2015 through January 2016. Data were collected through a self-administered, anonymous questionnaire. The χ² test, Fisher exact test, and multiple logistic regression analysis were performed.

RESULTS

Of residents, 60% believed that the abortion rate would increase after legalization; 82% had been involved in the care of women with incomplete abortion and 71% in the care of women admitted for legal abortion. Associations were found between knowledge of the evolution of the abortion rate after legalization and region of birth, region of medical school, and importance attached to religion. Multiple regression confirmed that studying medicine in the south/southeast of Brazil and attaching little importance to religion were associated with knowing that legalization does not lead to an increase in abortion rate.

CONCLUSION

Information relating to abortion in medical schools and during residency is very limited and should be improved.

Conhecimento de médicos residentes em Ginecologia e Obstetrícia sobre o aborto medicamentoso

O aborto medicamentoso ou farmacológico tem demonstrado ser um meio eficaz para a interrupção da gravidez. Entretanto, o treinamento de provedores no uso do misoprostol tem sido limitado. O presente artigo tem como objetivo identificar o grau de conhecimento dos médicos residentes em Ginecologia e Obstetrícia sobre aborto medicamentoso. Realizou-se um estudo transversal multicêntrico com residentes regularmente inscritos no programa de residência em Ginecologia e Obstetrícia de vinte e um hospitais de ensino. Foi utilizado um questionário de autorresposta. As respostas corretas a cada uma das alternativas foram identificadas e uma variável de resposta binária (≥ P70, < P70) foi definida pelo percentil 70 do número de perguntas sobre o misoprostol. Quatrocentos e sete médicos residentes devolveram o questionário, sendo que 404 estavam preenchidos e três em branco. A maioria (56,3%) dos residentes tinha até 27 anos de idade, era do sexo feminino (81,1%) e não vivia junto com um(a) companheiro(a) (70%). A maior proporção (68,2%) estava cursando o primeiro ou segundo ano da residência. Apenas 40,8% dos participantes acertaram 70% ou mais das afirmativas. Na análise múltipla, cursar o terceiro ano de residência ou superior (OR = 2,18; IC95%: 1,350-3,535) e ter participado do atendimento a uma mulher com abortamento induzido ou provavelmente induzido (OR = 4,12; IC95%: 1,761-9,621) mostraram-se associados a um maior conhecimento sobre o tema. Entre os médicos brasileiros residentes em Ginecologia e Obstetrícia, o conhecimento sobre o aborto medicamentoso é muito reduzido e constitui um obstáculo para o bom atendimento dos casos de interrupção legal da gestação.

Factors associated with unsafe abortion practices in Nepal: Pooled analysis of the 2011 and 2016 Nepal Demographic and Health Surveys

BACKGROUND

Unsafe abortion contributes to maternal morbidities, mortalities as well as social and financial costs to women, families, and the health system. This study aimed to examine the factors associated with unsafe abortion practices in Nepal.

METHODS

Data were derived from the 2011 and 2016 Nepal Demographic and Health Surveys (NDHS). A total of 911 women aged 15-49 years who aborted five years prior to surveys were included in the analysis. The multivariate logistic regression analysis was employed to determine factors associated with unsafe abortion.

RESULTS

Unsafe abortion rate was seven per 1000 women aged 15-49 years. This research found that women living in the Mountains (adjusted Odds Ratio (aOR) 2.36; 95% CI 1.21, 4.60), or those who were urban residents (aOR 2.11; 95% CI 1.37, 3.24) were more likely to have unsafe abortion. The odds of unsafe abortion were higher amongst women of poor households (aOR 2.16; 95% CI 1.18, 3.94); Dalit women (aOR 1.89; 95% CI 1.02, 3.52), husband with no education background (aOR 2.12; 95%CI 1.06, 4.22), or women who reported agriculture occupation (aOR 1.82; 95% CI 1.16, 2.86) compared to their reference's group. Regardless of knowledge on legal conditions of abortion, the probability of having unsafe abortion was significantly higher (aOR 5.13; 95% CI 2.64, 9.98) amongst women who did not know the location of safe abortion sites. Finally, women who wanted to delay or space childbirth (aOR 2.71; 95% CI 1.39, 5.28) or those who reported unwanted birth (aOR = 2.33; 95% CI 1.19, 4.56) were at higher risk of unsafe abortion.

CONCLUSION

Going forward, increasing the availability of safe abortion facilities and strengthening family planning services can help reduce unsafe abortion in Nepal. These programmatic efforts should be targeted to women of poor households, disadvantaged ethnicities, and those who reside in mountainous region.

Characterisation of induced abortion and consequences to women's health at Hospital Central do Huambo - Angola

To characterise patients with abortion in Huambo, Angola, we have undertaken a descriptive, longitudinal, prospective survey. A structured questionnaire was applied to 715 patients. The study variables were grouped in socio-demographic and clinical-epidemiological variables. There were 29.8% women were aged 20-24, 45.6% had primary education, 41.1% were single and 26.9% worked as a non-formal salesperson. Menarche occurred at 16-18 years (55.5%), first sexual intercourse at 13-15 years (40.3%) and 74.8% did not use contraceptive methods. Abortion was of indeterminate type in 84.3% and 79.3% had had a previous abortion. Serious complications occurred in 8.0% with six maternal deaths (0.8%). Age of menarche and age at onset of sexual activity are interdependent variables (p ≤ .001), the earlier menarche appears, the earlier sexual activity begins. When there was a history of abortion, new abortions occurred earlier (p ≤ .001) and were of indeterminate type (89%). Indeterminate induced abortion is influenced by socioeconomic, educational and political conditions and continues to be a frequent cause of morbidity and mortality.Impact statementWhat is already known on this subject? Unsafe abortion contributes greatly to maternal morbidity and mortality, principally in countries with restrictive abortion laws. The relationship between socio-educational level and unwanted pregnancies is consensual.What the results of this study add? Early initiation of sexual activity combined with non-contraception contributes to unwanted pregnancy and consequent unsafe abortion. Most of the women had previously had an abortion.What the implications are of these findings for clinical practice and/or further research? It is necessary to develop access to adequate information and family planning to combat unwanted pregnancies. It is also important to evaluate long-term consequences of unsafe abortion.

Safe abortion: The public health rationale

It is now more than 50 years since the World Health Assembly recognized abortion as a serious public health problem. The challenge still stands. Addressing the problem of unsafe abortion is a national and global public health imperative, dictated by the magnitude of the problem and its impact on individuals and society, inequity of the burden of disease, and an international consensus of the global health community. Almost every abortion death and disability could be prevented through cost-effective public health interventions including sexuality education, use of effective contraception, provision of safe, legal induced abortion, and quality humane postabortion care. Safe abortion continues to be a challenge to public health because of diverse national restrictive legal regulations, prevailing stigma, and lack of political commitment. Health professionals have a social responsibility to educate policymakers, legislators, and the public at large about adverse impacts of restrictive abortion regulations, laws, and policies on women's health.

Perceptions of attending medical staff by women accessing pregnancy termination in Poland: a qualitative study

OBJECTIVES

Polish society is strongly influenced by the Catholic Church and Poland has one of the most restrictive abortion laws in Europe. We attempted to gather information by questionnaire from women considering termination of pregnancy (TOP). Women were asked about their perceptions of the attending medical staff and whether they felt they had been fully informed of their rights, as well as about conduct of the procedure itself in light of physicians' use of the 'conscience clause'.

METHODS

Between June 2014 and May 2016 all women deemed eligible for TOP for medical reasons were asked to complete an anonymous questionnaire (n = 240). A total of 150 questionnaires (62.5%) were returned and analysed.

RESULTS

Most respondents (95%) lived in a town or city, and a significant number (40%) lived outside the area where the study centre was located. The main reason for such a large group of out-of-region respondents (53%) was the lack of centres offering TOP in the area where the women lived. Only one attending obstetrician did not support a decision to abort the pregnancy. Although 65% of treating physicians supported the woman's decision, only 8% were willing to perform the procedure themselves.

CONCLUSION

Most regional centres offer no access to TOP, despite the legal right of women to abort their pregnancy in the event of a severe fetal defect. Some physicians refuse to perform abortions, citing conscientious objection. Double standards among treating physicians have been detected, as many support the decision of their patient but refuse to perform the procedure themselves.

Abortion laws reform may reduce maternal mortality: an ecological study in 162 countries

BACKGROUND

Unsafe abortion is one of the commonest causes of maternal mortality. Abortion-related maternal deaths are higher in countries with the most restrictive abortion laws. We assess whether maternal mortality varies within and between countries over time according to the flexibility of abortion laws (the number of reasons a woman can have an abortion).

METHOD

We conducted an ecological study to assess the association between abortion laws and maternal mortality in 162 countries between 1985 and 2013. Aggregate-level data on abortion laws and maternal mortality were extracted from United Nations (UN), and World Health Organization's (WHO) database respectively. A flexibility score of abortion laws (Score 0-7) was calculated by summing the number of reasons for which abortion was legally allowed in each country. The outcome was maternal mortality ratio (MMR), which represented maternal deaths per 100,000 live births. MMR was modelled as a continuous variable and flexibility score as an ordinal ranked variable (categories 0-7 with 0 as the reference, and < 3 vs > = 3). We used fixed effects linear regression models to estimate the association between flexibility score and MMR, adjusting for gross domestic product per capita (GDP per capita), and time in five-year intervals.

RESULTS

Compared to when a country's flexibility score was < 3, maternal deaths were reduced by 45 per 100,000 live births (95% CI: -64, - 26) when the flexibility score increased ≥3, after adjusting for the GDP per capita and five-year time intervals. With the exception of a flexibility score 6, MMR was lower when higher than zero. This may indicate the role of other country- specific effects.

CONCLUSION

This study provides evidence that abortion law reform in countries with restricted abortion laws may reduce maternal mortality.

Investigation of the prevalence and causes and of legal abortion of teenage married mothers in Iran

Background The therapeutic abortion law, in accordance with the fatwa issued by our Muslim jurisprudent approved by the parliament in 2005, has made major developments in dealing with cases of therapeutic abortions. Objective This study aimed at identifying the prevalence and causes of therapeutic abortion requests to the Legal Medicine Organization of Fars province, Shiraz, by pregnant teenager mothers. Methods This study was a retrospective, cross-sectional, descriptive survey. In this study, all documents related to therapeutic abortion requests from the Legal Medicine Organization of Fars province (southern Iran) from 2006 to 2013 were investigated. The total sample size included 1664, out of which 142 were teenagers. Sampling was carried out using Convenience method. Data were analyzed using SPSS statistical software, version 16, descriptive statistics and χ2. Results In this study, 142 mothers were under 20 years of age (8.5%). The prevalence of fetal abortion license requests was 110 (78.6%) and for maternal causes was 30 (21.4%). There was no significant statistical correlation between fetal causes in different years (p = 0.083). The most common causes of fetal abortion request were for thalassemia treatment in 78 cases (79.9%) followed by fetal malformations (20.9%); also, the most common maternal cause was thalassemia in 14 cases (51.9%) and depression in three cases (1.11%), respectively. Conclusion Our results showed that after approval of therapeutic abortion law, requests for therapeutic abortion due to fetal causes are extensively increasing. There is still a need for coordination of judicial, medical and legal authorities for prompt notification.

Abortion as agentive action: reproductive agency among young women seeking post-abortion care in Uganda

Unsafe abortion in Africa continues to be a major contributor to the global maternal mortality which affects young women in particular. In Uganda, where abortion is legally restricted and stigmatised, unsafe abortion is a major public health issue. We explored reproductive agency in relation to unsafe abortion among young women seeking post-abortion care. Through in-depth interviews we found that reproductive agency was constrained by gender norms and power imbalances and strongly influenced by stigma. Lack of resources and the need for secrecy resulted in harmful abortion practices and delayed care-seeking. Women did not claim ownership of the abortion decision, but the underlying meaning in the narratives positioned abortion as an agentive action aiming to regain control over one's body and future. Women's experiences shaped contraceptive intentions and discourse, creating a window of opportunity that was often missed. This study provides unique insight into how young women negotiate and enact reproductive agency in Uganda. Health systems need to strengthen their efforts to meet young women's sexual and reproductive health needs and protect their rights. Enabling young women's agency through access to safe abortion and contraception is paramount.