Induced abortion: estimated rates and trends worldwide

Outcomes and complications of second-trimester induction of labor using laminaria and gemeprost: A single-center experience in Japan

AIM

To document the outcomes of second-trimester induction of labor with laminaria cervical dilation followed by gemeprost vaginal tablets, with a particular emphasis on its complications.

METHODS

This was a single-center retrospective cohort study of women who experienced medical abortions between 12 and 21 weeks of gestation from January 2016 to July 2021. Procedures were performed with three laminaria cervical dilation for 2 days followed by the administration of gemeprost (1 mg, vaginal tablet) every 3 h with a maximum of five tablets per day. Epidural anesthesia was provided upon request. The primary outcome was successful labor induction, which was defined as fetal expulsion without assisted surgical procedures. Other maternal outcomes, complications and related interventions during and after the procedure were assessed.

RESULTS

Among 319 women, 313 (98.1%) experienced successful labor induction with a median of one gemeprost tablet. The median blood loss during the abortion was 145 mL, and three women (0.9%) required blood transfusion. Fever was observed in 19 women (6.0%) during hospitalization, although most cases were drug fever. Thirteen women (4.1%) had abnormal uterine bleeding ~24 days after the abortion. Eleven cases (3.4%) were associated with retained products of conception, of which three cases required uterine artery embolization and three needed surgical curettage.

CONCLUSIONS

Second-trimester induction of labor with laminaria cervical dilation and subsequent gemeprost vaginal tablets is a reliable method for completing medical abortions. Abnormal uterine bleeding several weeks after abortion is suspected to be a retained product of conception that could require invasive treatment.

Case report: Peritonitis secondary to traumatic bowel perforation during second-trimester surgical abortion

INTRODUCTION AND IMPORTANCE

Uterine perforation and bowel injury are rare but potentially life-threatening complications of surgical abortion. Early diagnosis results in easier management and better prognosis. We report here a case of a 39-year-old presented with peritonitis secondary to traumatic bowel perforation after second-trimester surgical abortion.

CASE PRESENTATION

A 39-year-old Gravida 3 Para 2 presented with acute abdominal pain two days after second trimester induced abortion. On physical examination, the patient was febrile and hypotensive with diffuse abdominal tenderness. Emergency abdomino-pelvic-CT showed generalized peritonitis with pneumoperitoneum. The patient underwent an emergency laparotomy. Per operative exploration revealed a perforation of the fundus of the uterus and the sigmoid portion of the large intestine, resulting in stercoral peritonitis. We proceeded with thorough cleansing of the abdominal cavity with physiological serum, followed by partial colectomy including the perforated sigmoid and a Hartmann's procedure. The patient was admitted to the post-operative intensive care unit for 18 days and discharged on day 27 after the surgery. Intestinal continuity restoration was performed six months after the surgery.

CLINICAL DISCUSSION

Given the severity of second trimester pregnancy termination complications, efforts should be made to promote contraception and medical first-trimester pregnancy termination. Any unusual symptom after surgical induced abortion should lead to suspect uterine perforation.

CONCLUSION

Uterine perforation during induced abortion is usually asymptomatic and can generally be managed conservatively. However, bowel injury may result in peritonitis, requiring immediate laparotomy and resection of perforated bowel. CT-scans can help diagnose this rare complication.

Knowledge, Attitudes and Practices on Reproductive Health Among Abortion Adolescents in Vietnam

Background

Adolescent pregnancy is a global issue. The majority of these adolescents experience unintended pregnancy ending in abortion. Knowledge gaps and misconceptions about reproductive health are the main reasons for unintended pregnancy among adolescents.

Objective

This study aims to identify knowledge, attitudes, practices, and related factors of reproductive health among adolescent post-abortion or those seeking abortion at Hanoi Obstetrics and Gynecology Hospital (HOGH), a tertiary hospital in Vietnam.

Methods

Ours was a descriptive cross-sectional study of 103 adolescents who sought induced abortions between January 1, 2022 and June 30, 2023. Participants were interviewed directly via questionnaires to collect information.

Results

The mean age of participants was 16.3 years. 64.1% of the population did not have general knowledge regarding reproductive health, 42.7% of subjects displayed incorrect attitudes regarding reproductive health. As a result, lack of knowledge and incorrect attitudes led to unsafe sex. The percentage of adolescents practicing unsafe sex is incredibly high (90.3%) thus causing unintended pregnancies. Education levels and family economic status were the main factors linked to knowledge, attitudes, and practices (KAP) regarding reproductive health.

Conclusion

Most adolescents seeking abortion had poor KAP regarding reproductive health. Their KAP of reproductive health were linked to levels of education and family economic status. The findings emphasize the need to provide reproductive health care information and services for adolescents, and the need for appropriate attention from both family and society to the target group. We believe this will result in the improvement of their health and the avoidance of unfortunate consequences.

History of induced abortion and the risk of preterm birth: a retrospective cohort study

OBJECTIVES

To explore the relationship between a history of induced abortion and follow-up preterm birth.

METHODS

We performed a retrospective cohort study of 27,176 women aged 19 to 48 years old in the city of Dongguan. Participants were divided into two groups according to the history of induced abortion. We used log-binomial regression to estimate adjusted risk ratios of preterm birth (gestation at less than 37 weeks) and early preterm birth (gestation at less than 34 weeks) for women with a history of induced abortion. Four models adjusted for different baseline data were used to verify the stability of the results. We also performed a subgroup analysis and mediation effect analysis to control for the influence of confounding factors and analyzed the relationship between the number of abortions and subsequent preterm birth.

RESULTS

Our study included 2,985 women who had undergone a prior induced abortion. Women who reported having a prior induced abortion were more likely to have preterm births before 37 weeks and 34 weeks, with risk ratios of 1.18 (95% CI 1.02-1.36) and 1.65 (95% CI 1.23-2.21), respectively. The above associations were stable in all models. We also found that a history of induced abortion was independently associated with a higher risk of preterm birth and early preterm birth in the subgroups. After controlling for the indirect effect of demographic data, the direct effect of abortion history on follow-up preterm delivery was still significantly different. The higher the number of abortions, the greater the risk of subsequent preterm birth.

CONCLUSIONS

This study suggests that induced abortion increases the risk of subsequent preterm birth.

An analysis of misoprostol effectiveness in second trimester pregnancy terminations

Background/Aim: Misoprostol is frequently used as a single agent in pregnancy terminations. However, it increases the risk of uterine rupture in patients who have had previous uterine surgery and terminations due to stillbirths. Therefore, it is used with concern by clinicians. The aim of this study was to evaluate the clinical features of the groups that responded and did not respond to termination treatment with misoprostol in a tertiary center and to investigate its efficacy and safety. Methods: The study design was comprised of a retrospective cohort study. A total of 114 second trimester pregnancies (between 13-24 weeks gestational age) were included in the study. These pregnancies were indicated for termination based on the prenatal diagnosis unit for fetal or maternal causes. According to the International Federation of Gynecology and Obstetrics (FIGO) directions, misoprostol was applied in the following dosages: for 13-17 weeks gestational ages, one tablet per 6 hours; for 18-26 gestational ages, ½ tablet per 6 hours; and for other indications 2 tablets per 3 hours were administered. If the patient had had a previous cesarean operation, all doses were halved. After the first 24 hours, the percentage and demographics results, such as age, body mass index (BMI), gravida, number of cesareans, number of curettages, cervical lengths, BISHOP scores, gestational age, amniotic fluid index, and fetal cardiac beat of the patients with miscarriage, were recorded. Results: The number of cases resulting in miscarriage within 24 hours were 84 (73.7%) and within 48 hours were 14 (12.2%). The total of misoprostol doses used were 8 tablets of 200 mg, mean time until the complete abortion was 17 hours. Sixteen patients required additional treatment, of whom four required Foley catheterization, five required D&E, seven required resting, and no one required a hysterectomy. Uterine rupture occurred in two patients who needed laparotomic surgery. The maternal age (P=0.340), BMI (P=0.790), gravida (P=0.270), previous cesarean history (P=0.390), previous curettage number (P=0.520), cervical length (P=0.380), Bishop score (P=0.190), gestational age (P=0.072), amniotic fluid index (P=0.470) and presence of fetal cardiac beat (P=0.350) were similar between groups Conclusion: Our results indicated that misoprostol is a safe, useful, and effective treatment option for second trimester medical terminations. Caution should be exercised in its use in patients with a history of uterine surgery.

Legal Limits Relaxed: Time to Look at Other Barriers Faced by Women Seeking Termination of Pregnancy for Fetal Anomalies

Introduction Advancements in prenatal diagnostic techniques have led to an increase in demand for termination of pregnancy for fetal anomalies (TOPFA). While relaxation in the legal gestational age limits across various countries relieves an important barrier, there is a need to identify the reasons that lead to delays in seeking abortion for fetal anomalies, because abortion-related complications increase with gestational age. Methods In this hospital-based qualitative study, antenatal women referred to a tertiary care institute in North India because of major fetal anomalies were explained about the study. Those women who fulfilled the inclusion criteria were recruited after taking consent. Details of antenatal care and prenatal tests were recorded. An in-depth inquiry was made into the reasons for the delay in prenatal tests, the delay in the decision for abortion, and specific problems that they faced in seeking TOPFA. Results Out of 80 women who met the inclusion criteria and consented to participate, more than 75% had received antenatal care in public healthcare facilities. Less than 50% of women received folic acid in the first trimester while 26% had first contact with healthcare facilities in the second trimester. Only 21 women underwent screening for common aneuploidies. Second-trimester anomaly scan was delayed in 35 women due to women-centered reasons (n = 17) or provider-centered (n = 19) reasons. Only 37.5% of women were counseled about fetal anomalies by their primary care provider. Owing to delay at multiple levels, 40 women (50%) could receive counseling about fetal abnormality for the first time after 20 weeks. These women could not be offered abortion because this study was carried out before the amendments in the Medical Termination of Pregnancy Act in India. The older act allowed abortion up to 20 weeks of gestation. Seventeen women could obtain permission for an abortion from a court of law. Arrangements for travel and stay and dependence on family members were the main problems faced by women seeking TOPFA. Conclusions Delay in diagnosis of a fetal anomaly due to delay in seeking antenatal care, irregular follow-up, and lack of pre-test counseling are the major reasons for the delay in the decision for abortion. This is further compounded by inadequate post-test counseling. Lack of awareness, failure or delay in counseling, need to travel to another facility for abortion, dependence on family members, and financial issues are the major barriers.

Recent trend and correlates of induced abortion in China: evidence from the 2017 China Fertility Survey

BACKGROUND

Although there are more than 10 million induced abortions per year in China, there are few comprehensive, systematic, and characteristic-based data on induced abortions among Chinese women. This study aims to examine the overall trend in induced abortions in China and to analyze the correlation between induced abortions and some socio-economic factors.

METHODS

Drawing from the 2017 China Fertility Survey, this study analyzed induced abortions using multiple indicators from period and cohort perspectives on a sample of 240,957 women. The indicators include the abortion rate and proportion, average age at the time of induced abortion, age-specific cumulative proportions, and the number of induced abortions by cohort. The analysis also differentiated based on residency, ethnicity, education level, and marital status. A binomial logistic regression model was used to examine the association between induced abortions and socio-economic factors.

RESULTS

Between 2006 and 2016, among women aged 15-49, there was an increase in the induced abortion rate and the average age of women who had induced abortions, but a decline in the proportion of abortions. The proportion of induced abortion was higher among premarital than post-marital pregnancies, among unintended than planned pregnancies. Women with induced abortion experiences accounted for less than 30% of all cohorts, and the cumulative number of induced abortions per woman in each cohort was less than 0.45. These indicators varied with birth cohort, residence, ethnicity, education level, and marital status. The results of binomial logistic regression confirmed the association between induced abortion and these socio-economic variables. Sex-selective abortions of female fetuses still exist, despite the government's considerable efforts to eliminate them.

CONCLUSION

The practice of induced abortions differs by cohort and socio-economic characteristics. The profile of women who resort to abortions in China has shifted from well-educated urban women to rural, less-educated women. More effective measures should be taken by the government to reduce the number of induced abortions among women with higher abortion risks.

Effects of a Novel Erectogenic Condom on Men and Women's Sexual Pleasure: Randomized Controlled Trial

We tested whether CSD500 (Futura Medical; Guildford, UK), a novel condom containing erectogenic gel designed to increase penile firmness, penile size, and erection duration, results in greater sexual pleasure. In 2017-2020, we randomized heterosexual couples in Thanh Hoa, Vietnam to use CSD500 (N = 248) or standard condoms (N = 252) and followed them up for six months. Women completed the Quality of Sexual Experience (QSE) scale; men completed the QSE, Sexual Experience Questionnaire (SEX-Q), and 11 condom acceptability items. Female participants' mean age was 32.1 years (SD = 0.24; range 21-46). QSE scores were higher among women (B, 0.12; 95% CI, 0.03-0.21) and men (B, 0.21; 95% CI, 0.08-0.35) in the CSD500 relative to the control arm. SEX-Q scores were higher among men in the CSD500 compared to the control arm (B, 3.22; 95% CI, 1.53-4.91). Higher proportions of men in the CSD500 relative to the control arm reported the condom felt "natural" during sex (68.6% vs. 32.3%; p < .01) and that sex with the condom felt "a lot better" than condomless sex (15.5% vs. 5.3%; p < .01). Compared with standard condoms, CSD500 use was associated with higher reports of sexual pleasure and condom acceptability.

Prevalence of induced abortion among Chinese women aged 18-49 years: Findings from three cross-sectional studies

There are few latest researches about induced abortion in China. We aimed to evaluate the prevalence of induced abortion and the related factors, thereby helping make targeted policies and measures to promote women's health. Three comparable cross-sectional surveys among Chinese women aged 18-49 years were performed in 2016, 2017, and 2021. A total of 14,573 eligible respondents were included in the study. 16.70% (95%CI 16.10%-17.31%) of respondents self-reported having experienced induced abortion, while 6.88% (95%CI 6.46%-7.29%) self-reported repeat induced abortion. Age range of 25-49 years (aOR 2.27-6.31, all P<0.05), living in western (aOR 1.72, 95%CI 1.50-1.98) and central (aOR 1.36, 95%CI 1.21-1.52) regions, having children (aOR 2.85, 95%CI 2.35-3.46) were associated with higher prevalence of induced abortion. Moreover, age range of 25-49 years, living in western and central regions, having children were also related to higher prevalence of repeat induced abortion (aOR 1.67-11.52, all P<0.05). Conversely, educational level of college or higher, household annual income over 80,000 Chinese yuan were associated with lower prevalence of induced abortion and repeat induced abortion (aOR 0.52-0.80, all P<0.05). Induced abortion remains noticeable in China. Sustained efforts are required to reduce unintentional pregnancy, improve reproductive health and post-abortion care services, and promote women's health.

Cervical Dilators Used Concurrently With Misoprostol to Shorten Labor in Second-Trimester Termination of Pregnancy: A Randomized Controlled Trial

OBJECTIVE

To evaluate the use of cervical dilators concurrently with misoprostol to shorten labor in second-trimester medical termination of pregnancy.

METHODS

This multicenter randomized controlled trial compared the efficacy of cervical dilators inserted concurrently with misoprostol with that of misoprostol, alone, to shorten labor for women undergoing termination of pregnancy between 15 0/7 and 27 6/7 weeks of gestation. The primary outcome was the proportion of women with a duration of labor exceeding 12 hours. Secondary outcomes included median duration of labor, time to amniotomy, side effects, complications, NPRS (Numeric Pain Rating Scale) score, and women's distress as measured by the IES-R (Impact of Event Scale-Revised). These outcomes also were studied separately in the nulliparous subgroup. To demonstrate a reduction of 50% of the proportion of women with a duration of labor exceeding 12 hours in the dilator group, with a power of 80% and a 2-sided 0.05 significance level, a sample of 268 women (134 in each group) was required.

RESULTS

Between December 2017 and September 2019, this study enrolled and analyzed 347 women: 174 in the dilator group and 173 in the control group, including 87 and 93 nulliparous patients, respectively. Sociodemographic and obstetric characteristics were similar between groups. The proportion of women with labor exceeding 12 hours was not different between groups (49/174 [28.2%] in the dilator group vs 53/173 [30.6%] in the control group [ P =.61] for the whole population, and 37/87 [42.5%] vs 42/93 [45.2%] [ P =.72], respectively, among nulliparous patients). Median duration of labor was 8.5 hours in the dilator group compared with 9.2 hours in the control group ( P =.65) for the whole population, and 10.5 hours compared with 11.8 hours, respectively, among nulliparous patients ( P =.33). Median time to amniotomy was 3.6 hours in the dilator group compared with 5.0 hours in the control group ( P =.08) for the whole population, and 3.5 hours compared with 6.7 hours, respectively, among nulliparous patients ( P =.003). Side effects, complications, NPRS score, and IES-R score were similar between groups.

CONCLUSION

Cervical dilators inserted concurrently with misoprostol did not reduce the proportion of women whose labor exceeded 12 hours compared with misoprostol alone.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov , NCT03194230.

Second-Trimester Medical Abortion with Misoprostol Preceded by Two Sequential Doses of Mifepristone: An Observational Study

Introduction

Based upon the pharmacokinetics of mifepristone, we postulated that repeating a dose after its half-life period may potentiate its abortifacient effect.

Methods

We administered mifepristone (200 mg) on days one and two, and misoprostol on day three (200 or 400 μg, vaginally, six-hourly, upto three doses in 12 h) in 100 women (intervention group). We compared their outcome with that of another 100 women who received the one-dose mifepristone regimen (mifepristone on day one and misoprostol on day three) during the months immediately preceding the study period (historical controls).

Results

The mean age, parity and gestation (18 weeks) were similar in the two groups. On day three (before initiating misoprostol), cervix admitted one finger in significantly more women in the intervention group (36 versus 8% in historical controls; p = 0.001). All women aborted successfully in the two groups. The IAI of the intervention group was significantly shorter than the IAI of historical controls (10.45 vs 13.75 h; p = 0.013), and the misoprostol requirement was also significantly lower (mean 434 vs 500 μg among historical controls, p = 0.04).

Conclusions

Second-trimester medical abortion using two sequential doses of mifepristone followed by misoprostol reduced the IAI and misoprostol requirement without adding any extra days to the existing regimen. Further randomized studies can assess if the 'two-dose' mifepristone regimen is more efficient than the 'one-dose' regimen.

Country-specific estimates of unintended pregnancy and abortion incidence: a global comparative analysis of levels in 2015-2019

Introduction

Internationally comparable estimates of unintended pregnancy and abortion incidence can illuminate disparities in sexual and reproductive health and autonomy. Country-specific estimates are essential to enable international comparison, and to inform country-level policy and programming.

Methods

We developed a Bayesian model which jointly estimated unintended pregnancy and abortion rates using information on contraceptive needs and use, contraceptive method mix, birth rates, the proportions of births from unintended pregnancies and abortion incidence data. Main outcomes were the estimated rates of unintended pregnancy and abortion for 150 countries and territories, reported for the 5-year period 2015–2019, as annual averages per 1000 women aged 15–49 years.

Results

Estimated unintended pregnancy rates ranged from 11 (80% uncertainty interval: 9 to 13) in Montenegro to 145 (131 to 159) in Uganda per 1000 women aged 15–49 years. Between-country heterogeneity was substantial in all Sustainable Development Goal (SDG) regions, but was greatest in sub-Saharan Africa. Estimated abortion rates ranged from 5 (5 to 6) in Singapore to 80 (55 to 113) in Georgia. Variation between country estimates was similar in all SDG regions except for Europe and Northern America, where estimated abortion rates were generally lower.

Conclusion

The estimates reflect variation in the degree to unintended pregnancy and abortion that are experienced in countries throughout the world. This evidence highlights the importance of investing in access to contraception and comprehensive abortion care, including in regions which may have lower rates of unintended pregnancy or abortion, respectively, as countries may differ substantially from regional averages.

Acute pancreatitis in pregnancy and its impact on the maternal and foetal outcomes: A systematic review

BACKGROUND

The prevalence of AP in pregnancy (APIP) is uncertain with varying reports of its impact on maternal and foetal outcomes.

OBJECTIVES

This study was aimed to find the prevalence of APIP and its effect on the maternal and foetal outcomes.

SEARCH STRATEGY

Electronic databases were searched upto 31.05.2020 for the appropriate studies.

SELECTION CRITERIA

Prospective, retrospective observational studies or case series evaluating APIP in terms of maternal and foetal outcomes were included.

DATA COLLECTION AND ANALYSIS

Data on the prevalence of APIP, etiology, maternal mortality rates and foetal outcomes were collated. Due to high heterogeneity among the studies, the data has been represented as a systematic review.

RESULTS

A total of 16 studies with 8466 pregnant patients were included in the systematic review. The overall prevalence of APIP ranged from 0.225/1000 pregnancies to 2.237/1000 pregnancies. Gallstone disease was the most common cause ranging from 14.29 to 96.3%, with eastern studies reporting more cases of hypertriglyceridemia as etiology. Mild pancreatitis was noted in 33.33-100% of cases with milder disease among western studies. APIP incidence was higher during 3rd trimester (27.27%-95.24%). Maternal mortality ranged from 0 to 12.12/100 pregnancies. Foetal loss ranged from 0 to 23.08%, with adverse foetal outcomes ranging from 0 to 57.41%. Neonatal mortality ranged from 0 to 75.5/1000 neonatal live birth.

CONCLUSION

APIP is usually mild, but its incidence increases with gestational age. Maternal outcome is usually good but adverse foetal outcome is high in APIP (PROSPERO No.: CRD42020194313).

Unintended Pregnancy and Associated Factors among Women Who Live in Ilu Gelan District, Western Ethiopia, 2021

Background

The World Health Organization Report noted that unintended pregnancy is the most common cause of maternal mortality in developing countries. Most unintended pregnancies occur where access to maternal care is limited, and because of this, many mothers lose their life. Therefore, this study was an attempt to assess the proportion of unintended pregnancy and associated factors among women who live in Ilu Gelan District, Western Ethiopia, 2021.

Method

A community-based cross-sectional study was conducted in the rural and urban kebeles of Ilu Gelan Woreda West Shoa Zone, Ethiopia, from March 1 to 30, 2021. The study population consists of 540 pregnant women who were living in Ilu Gelan Woreda for at least the last six months during the data collection period. Simple random sampling by lottery method was used to recruit the study subject. Data were checked, coded, entered to EpiData version 3, and then exported to SPSS version 25 for analysis. Both descriptive and analytical statistical procedures were utilized. Both bivariable and multivariable logistic regressions was implemented.

Result

In this study, the proportion of unintended pregnancy was found to be 55%, at 95% CI: 50.7-59.3. Multivariable logistic regression results showed that married women (AOR = 0.117, CI: 0.04-0.38), monthly income less than 1000 Ethiopian Birr (AOR = 4.93, CI: 1.72-14.09), gravidity greater than or equal to five (AOR = 6.07, CI: 2.4-15.28), birth interval less than 2 years (AOR = 3.35 (1.44-7.8)), lack of awareness about contraceptive (AOR = 2.06 (1.03-4.15)), and husband decision-making on health care (AOR = 11.1 (2.07-59.51)) were significantly associated with unintended pregnancy. Conclusion and Recommendation. This study indicated that more than half of pregnant women reported that their current pregnancy was found to be unintended pregnancy. Married women, family monthly income less than 1000 Ethiopian Birr, gravidity greater than or equal to five, birth space less than two years, lack of contraceptive awareness, and health care decisions by husband only showed a significant association with unintended pregnancy. To decrease the current level of unintended pregnancy, all concerned stakeholders should emphatically consider those identified factors for intervention; specifically, Ilu Gelan District Health Bureau and health providers should empower women with health education about family planning and decision-making related to their health issues in the study area.

The potential of Zishen Yutai pills to facilitate endometrial recovery and restore fertility after induced abortion in rats

CONTEXT

Abortions damage the endometrium in women. Currently, therapeutic options for endometrial recovery are limited. Zishen Yutai Pill (ZYP) was found to promote endometrial blood supply as a traditional Chinese medicine. However, whether ZYP promotes endometrial recovery post-abortion has not yet been explored.

OBJECTIVE

This study evaluated the role of ZYP in rat endometrial recovery after induced abortion and explored its mechanism of action.

MATERIALS AND METHODS

Sprague-Dawley rats were divided into three groups: no-operation group, control group, and ZYP group. The rats in the control and ZYP group were induced abortion, and then treated with normal saline or ZYPs, respectively, for 1-3 oestrous cycles. Morphological changes in the endometrium were examined. Expression levels of the factors related to endometrial recovery were analyzed. The duration of this study was almost seven months.

RESULTS

The endometrial thickness (7.3 ± 0.17 mm) and number of glands (5.5 ± 0.20) increased significantly in the ZYP group compared with those in the control group (5.5 ± 0.15 mm and 3.5 ± 0.18; p < 0.05). Fibrosis of the endometrium was ameliorated by ZYP administration (45 ± 6% vs. 58 ± 7%; p < 0.05). ZYPs treatment increased the expression of VEGF, ER, MMP-9, LIF, and HB-EGF, but decreased TGF-β expression. Moreover, the average number of pups in the ZYP group (9.0 ± 1.5) was greater than that in the control (4 ± 1.3).

DISCUSSION AND CONCLUSION

ZYPs accelerate endometrial recovery and restored fertility in rats, suggesting its potential to promote human endometrial repair.

Abortion and its correlates among female fisherfolk along Lake Victoria in Uganda

INTRODUCTION

In Uganda, people living in fishing communities tend to engage in high-risk sexual activity which leads to unintended pregnancies that may end in abortions. Abortion has negative social, psychological, and medical impacts. We determined the frequency of abortion and its correlates among female fisher-folk along Lake Victoria in Uganda.

METHODS

A cross-sectional survey was conducted among women aged 15- 49 years from Kigungu and Nsazi fishing communities. Data were collected on socio-demographic characteristics, abortion, and family planning use. Associations between abortion and participant characteristics were assessed using logistic regression models.

RESULTS

Of the 713 women interviewed, 36, 5% were pregnant and 247, 34.6 % were using contraception. Majority (600, 84.2%) of those interviewed reported ever being pregnant. Approximately 45% of the pregnancies were un-intended while a third of those who had ever been pregnant (195, 32.5%) reported having aborted before. Slightly over a third (247, 34.6%) reported currently using or ever using family planning. Women aged 30+ years were more likely to abort compared to those aged 15-29 years (aOR: 2.7; 95% CI: 1.23-5.91). Women who had living children were less likely to abort compared to those who didn't have any living child (aOR: 0.06; 95% CI: 0.01 - 0.17).

CONCLUSION

The rate of abortion among female fisher-folk in Uganda is substantial. Family planning use is still low and unintended pregnancies are common. Abortion risk increased with the age of the mother. Continuous behavioral change communication and optimization of family planning use are recommended to reduce abortions.

How Not to Defend the Unborn

It is sometimes proposed that killing or harming abortion providers is the only logically consistent position available to opponents of abortion. Since lethal violence against morally responsible attackers is normally viewed as justified in order to defend innocent parties, pro-lifers should also think so in the case of the abortion doctor and so they should act to defend the unborn. In our paper, we defend the mainstream pro-life view against killing abortion doctors. We argue that the pro-life view can, in various ways, reject the assumption that defensive violence to save innocent individuals is always permissible. Now even if that assumption is accepted, we contend that defensive violence against abortion doctors still is not justified. Drawing on Frances Kamm's work, we contend that there are structural similarities between abortion and letting someone die who needs your help to stay alive; and we argue that it is impermissible to kill those who kill in order to avoid giving life-saving aid.

A research on abortion: ethics, legislation and socio-medical outcomes. Case study: Romania

This article presents a research study on abortion from a theoretical and empirical point of view. The theoretical part is based on the method of social documents analysis, and presents a complex perspective on abortion, highlighting items of medical, ethical, moral, religious, social, economic and legal elements. The empirical part presents the results of a sociological survey, based on the opinion survey method through the application of the enquiry technique, conducted in Romania, on a sample of 1260 women. The purpose of the survey is to identify Romanians perception on the decision to voluntary interrupt pregnancy, and to determine the core reasons in carrying out an abortion.

Knowledge, Practice and Associated Factors Towards Medication Abortion Among Reproductive-Age Women in Sexual and Reproductive Health Clinics of Addis Ababa, Ethiopia, 2018: Cross-Sectional Study

Background

Abortion rates following unintended pregnancies are increasing in developing countries, and unsafe abortion is a commonly neglected reproductive health-care problem. In Ethiopia, the number of women receiving treatment for complications from unsafe abortion is increasing. Improving the level of knowledge of reproductive-age women on medication abortion contributes to the prevention of unsafe abortion. Therefore, the purpose of this study was to assess knowledge, and practice of medication abortion and associated factors among women in SRH clinics of Addis Ababa, Ethiopia, 2018.

Methods

A cross-sectional quantitative study design was conducted to collect data from 30th February to March 30, 2018. Study participants were selected by using a convenient sampling technique. The data were coded and entered into EpiData version 4.2, and SPSS version 23 was used for analysis. Bivariate and multivariate analysis with 95% CI were employed. The strength of association was declared at a P value <0.05.

Results

The overall knowledge and practice of medication abortion were 72.1%, and 33%, respectively. Participants level of education (AOR=3.54, 95% CI (1.02, 12.26)), father education (AOR=2.80, 95% CI (1.42, 5.52)), participants way of living (AOR=6.08, 95% CI (2.41, 15.33)), income (AOR=2.19, 95% CI (1.02, 4.75)), and history of unwanted pregnancy (AOR=11.7, 95% CI (1.11, 12.46)) were some of the factors associated with knowledge and practice of medication abortion.

Conclusion

This study provided that women were relatively knowledgeable but their practice on medication abortion was low. The low practice of medication abortion call health-care providers to give due attention to awareness creation and strengthened action to provide quality maternal care for childbearing mothers towards medication abortion and unsafe abortion in particular.

Restrictions On US Global Health Assistance Reduce Key Health Services In Supported Countries

The 2017 expanded Mexico City Policy prohibits non-US-based nongovernmental organizations from receiving US global health assistance if they either perform or refer for abortion services. We study the effects of the expanded policy on implementing partners of US-funded HIV programming by the President's Emergency Plan for AIDS Relief (PEPFAR) via a primary survey in all recipient countries and key-informant interviews in South Africa and the Kingdom of Eswatini (May-November 2018). Survey results showed that 28 percent (56 of 198) of organizations reported stopping or reducing at least one service in response to the policy. Reported service reductions included reducing the delivery of information about sexual and reproductive health, pregnancy counseling, contraception provision, and HIV testing and counseling. Interview data highlighted how these reductions were often a result of decreased patient flows or implementation of the expanded policy beyond what is required. Reductions disproportionately harmed pregnant women, youth, and key populations such as sex workers and men who have sex with men. Reduced delivery of sexual and reproductive health services has the potential to negatively affect many intended beneficiaries of PEPFAR funding, especially in areas with high HIV prevalence. Policy makers must respond to disruptions in service delivery and end any implementation that undermines US investment in high-quality HIV and sexual and reproductive health services.

Pregnancy associated coagulopathies in selected community hospitals in Southwest Nigeria

Background and Aim:

Pregnancy is characterized by multiple changes in the coagulation system which occurs at different stages of the condition, representing one of the major triggers of maternal and foetal morbidity/mortality in the world during complicated incidences. This study determined the prevalence of coagulation disorders among pregnant women in Southwest Nigeria to buttress the need for prompt and accurate routine diagnosis of these disorders.

Methods:

Four hundred and five participants (405) attending some selected tertiary health facilities in Southwestern Nigeria were randomly recruited for the study, comprising two hundred and seventy (270) pregnant subjects and one hundred and thirty-five (135) apparently healthy age- and socio-economic status-matched non-pregnant women as controls. The platelet count was assessed; prothrombin time and activated partial thromboplastin time were assessed. Immunoturbidimetric and chromogenic techniques were also used to assess the level of D-dimer and activated protein C resistance.

Results:

Platelet count, PT and INR in all three trimesters were significantly (p < 0.05) reduced when compared to the non-pregnant control subjects. However, the level of circulating D-dimer was significantly (p < 0.05) increased in all three trimesters when compared with the control group, with observable steady increase in the second and third trimesters. Also, 13% of respondents had thrombotic predisposition and 14.8% with tendencies for consumption coagulopathy while 1.1% are APCr positive individuals.

Conclusion:

The study affirms the hypercoagulable state of pregnancy coupled with mild gestational thrombocytopenia which could be pointers to onset of coagulation disorders in some participants, subjects with coagulation profiles indicative of thrombotic tendencies and possible onset of consumption coagulopathy and the presence of activated protein C resistant in the region. A review of the coagulation monitoring strategies for pregnant women from primary care to include more definite assays and its proper implementation will immensely contribute to early diagnosis along with intervention for pregnancy associated coagulopathies in resource-limited settings.

Comparison of surgical versus medical termination of pregnancy between 13-20 weeks of gestation in Ethiopia: A quasi-experimental study

Background

Dilation and evacuation is a method of second trimester pregnancy termination introduced recently in Ethiopia. However, little is known about the safety and effectiveness of this method in an Ethiopian setting. Therefore, the study is intended to determine the safety and effectiveness of dilation and evacuation for surgical abortion as compared to medical abortion between 13–20 weeks’ gestational age.

Methods

This is a quasi-experimental study of women receiving second trimester termination of pregnancy between 13–20 weeks. Patients were allocated to either medical or surgical abortion based on their preference. A structured questionnaire was used to collect demographic information and clinical data upon admission. Procedure related information was collected after the procedure was completed and before the patient was discharged. Additionally, women were contacted 2 weeks after the procedure to evaluate for post-procedural complications. The primary outcome of the study was a composite complication rate. Data were collected using Open Data Kit and then analyzed using Stata version 14.2. Univariate analyses were performed using means (standard deviation), or medians (interquartile range) when the distribution was not normal. Multiple logistic regression was also performed to control for confounders.

Results

Two hundred nineteen women chose medical abortion and 60 chose surgical abortion. The composite complication rate is not significantly different among medical and surgical abortion patients (15% versus 10%; p = 0.52). Nine patients (4.1%) in the medical arm required additional intervention to complete the abortion, while none of the surgical abortion patients required additional intervention. Median (IQR) hospital stay was significantly longer in the medical group at 24 (12–24) hours versus 6(4–6) hours in the surgical group p<0.001.

Conclusion

From the current study findings, we concluded that there is no difference in safety between surgical and medical methods of abortion. This study demonstrates that surgical abortion can be used as a safe and effective alternative to medical abortion and should be offered equivalently with medical abortion, per the patient’s preference.

Repeat induced abortion in 30 Chinese provinces: A cross-sectional study

OBJECTIVE

To report the proportion and determinants of repeat induced abortions in China.

METHODS

Cross-sectional data were collected of 79 954 women who received an induced abortion from 297 hospitals across 30 Chinese provinces in 2013, using a stratified cluster sampling design. Logistic and Poisson regression models were fitted to identify characteristics associated with repeat abortion. Putative factors included age, household registration (hukou) status, marital status, education, occupation, reproductive history, and current contraceptive practices.

RESULTS

Of all abortions, 65.2% were repeat induced abortions. The proportion of repeat abortions varied substantially across provinces, from 36.9% in Qinghai to 85% in Hubei. The strongest factors associated with repeat induced abortion were being older than 40 years (adjusted odds ratio [OR_adj ] 7.0, 95% confidence interval [CI] 6.2-7.9), divorced or widowed (OR_adj 2.1, 95% CI 1.6-2.7), and using oral contraceptives (OR_adj 2.1, 95% CI 1.9-2.3).

CONCLUSION

A high proportion of repeat induced abortion was observed across many Chinese provinces, highlighting the need to reduce the incidence of unwanted pregnancy. Several sociodemographic and clinical factors were found to be significantly associated with repeat abortions and should be considered in post-abortion family planning services.

Complications of illegal abortion in the suburbs of Tehran: A 9-year cross-sectional study

Background:

Illegal abortion is a common way to terminate unintended pregnancy. It may be associated with severe complications and may raise maternal mortality and morbidity rate. Illegal abortion is one of the important concerns in health system. In our study, we consider illegal abortion claims in Medical Council court in the suburbs of Tehran.

Materials and Methods:

A retrospective study was conducted. Data were extracted from registered judicial complainant cases of illegal abortion in Shahriyar medical court, Iran, during 2009–2017.

Results:

There were 751 registered claims during 2009–2017. Among them, a total of 95 gynecological claims were included in the study. Four (4.2%) registered claims were illegal abortion with severe complications such as peritonitis, rupture of uterine, small intestine, rectum, and mesentery perforation. Three cases had consumed misoprostol (prostaglandin E2) and one case had used prostaglandin E1 before curettage. Misoprostol was also used significantly more frequently than other methods for abortion before curettage (P < 0.05). Minor and short-term complications did not registered.

Conclusion:

The feature of claims showed that only severe morbidity and complications were registered in medical court. The definition of illegal abortion as a criminal act can be one of the factors of decreasing of abortion's complication claims.

Intimate partner violence against women in Ethiopia and its association with unintended pregnancy: a national cross-sectional survey

OBJECTIVES

To investigate the association between intimate partner violence (IPV) and unintended pregnancy among women in Ethiopia.

METHODS

A retrospective analysis of nationally representative data was conducted among 2969 married women of reproductive age (15-49 years). Logistic regression models were used to estimate the association of IPV with the outcome variable.

RESULTS

Unintended pregnancy was reported by 26.5% of women. About 36% of participants reported having ever experienced IPV (a composite measure of physical, sexual, and emotional abuse) and 56% had experienced at least one act of partner controlling behaviour. After controlling for potential confounders, a significant association was observed between IPV and unintended pregnancy (AOR 1.39, 95% CI 1.05, 1.85) and between multiple acts of partner controlling behaviours and unintended pregnancy (AOR 1.57, 95% CI 1.16, 2.14).

CONCLUSIONS

In Ethiopia, which has a high fertility rate (4.6 children per woman) and low use of contraception (36%), IPV including partner controlling behaviour further contributes to the problem of unintended pregnancy. Reproductive health programs should be sensitive to the relational aspects of fertility control and incorporate IPV interventions into reproductive health services.

Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990-2019

BACKGROUND

Unintended pregnancy and abortion estimates document trends in sexual and reproductive health and autonomy. These estimates inform and motivate investment in global health programmes and policies. Variability in the availability and reliability of data poses challenges for measuring and monitoring trends in unintended pregnancy and abortion. We developed a new statistical model that jointly estimated unintended pregnancy and abortion that aimed to better inform efforts towards global equity in sexual and reproductive health and rights.

METHODS

We developed a model that simultaneously estimated incidence of unintended pregnancy and abortion within a Bayesian framework. Data on pregnancy intentions and abortion were compiled from country-based surveys, official statistics, and published studies found through a literature search, and we obtained data on livebirths from the World Population Prospects. We analysed results by World Bank income groups, Sustainable Development Goal regional groupings, and the legal status of abortion.

FINDINGS

In 2015-19, there were 121·0 million unintended pregnancies annually (80% uncertainty interval [UI] 112·8-131·5), corresponding to a global rate of 64 unintended pregnancies (UI 60-70) per 1000 women aged 15-49 years. 61% (58-63) of unintended pregnancies ended in abortion (totalling 73·3 million abortions annually [66·7-82·0]), corresponding to a global abortion rate of 39 abortions (36-44) per 1000 women aged 15-49 years. Using World Bank income groups, we found an inverse relationship between unintended pregnancy and income, whereas abortion rates varied non-monotonically across groups. In countries where abortion was restricted, the proportion of unintended pregnancies ending in abortion had increased compared with the proportion for 1990-94, and the unintended pregnancy rates were higher than in countries where abortion was broadly legal.

INTERPRETATION

Between 1990-94 and 2015-19, the global unintended pregnancy rate has declined, whereas the proportion of unintended pregnancies ending in abortion has increased. As a result, the global average abortion rate in 2015-19 was roughly equal to the estimates for 1990-94. Our findings suggest that people in high-income countries have better access to sexual and reproductive health care than those in low-income countries. Our findings indicate that individuals seek abortion even in settings where it is restricted. These findings emphasise the importance of ensuring access to the full spectrum of sexual and reproductive health services, including contraception and abortion care, and for additional investment towards equity in health-care services.

FUNDING

UK Aid from the UK Government, Dutch Ministry of Foreign Affairs, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and The Bill & Melinda Gates Foundation.

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.

The efficacy of letrozole supplementation for medical abortion: a meta-analysis of randomized controlled trials

INTRODUCTION

The efficacy of letrozole supplementation for medical abortion remains controversial. We conduct a systematic review and meta-analysis to explore the influence of letrozole supplementation for medical abortion.

METHODS

We searched PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases through October 2018 for randomized controlled trials (RCTs) assessing the effect of letrozole supplementation for medical abortion. This meta-analysis is performed using the random-effect model.

RESULTS

Six RCTs involving 555 patients are included in the meta-analysis. Overall, compared with control group for pregnant women, letrozole supplementation shows significantly increased complete abortion (RR = 1.38; 95% CI = 1.07-1.78; p = .01), and decreased estradiol (std. MD = -2.86; 95% CI = -4.45 to -1.27; p = .0004), but has no remarkable effect on induction-abortion time (std. MD = -1.03; 95% CI = -2.99-0.93; p = .30), progesterone (std. MD = 0.02; 95% CI = -0.30-0.34; p = .89), vaginal hemorrhage (std. MD = 1.84; 95% CI = 0.05-70.90; p = .74), nausea and vomiting (std. MD = 073; 95% CI = 0.44-1.21; p = .22).

CONCLUSIONS

Letrozole supplementation provides benefits to medical abortion in pregnant women.

USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy

BACKGROUND

The Mexico City Policy, first announced by US President Ronald Reagan and since lifted and reinstated by presidents along partisan lines, prohibits US foreign assistance to any organisation that performs or provides counselling on abortion. Many organisations affected by this policy are also providers of modern contraception. If the policy reduces these organisations' ability to supply modern contraceptives, it could have the unintended consequence of increasing abortion rates.

METHODS

We empirically examined patterns of modern contraception use, pregnancies, and abortion among women in 26 countries in sub-Saharan Africa in response to the reinstatement and subsequent repeal of the Mexico City Policy across three presidential administrations (William Clinton, George W Bush, and Barack Obama). We combine individual-level data on pregnancies and abortions from 743 691 women, country-year data on modern contraception use, and annual data on development assistance for family planning and reproductive health in a difference-in-difference framework to examine relative changes in use of modern contraception, pregnancy, and abortion in response to the policy.

FINDINGS

We found that when the Mexico City Policy was in effect (2001-08), abortion rates rose among women in countries highly exposed to the policy by 4·8 abortions per 10 000 woman-years (95% CI 1·5 to 8·1, p=0·0041) relative to women in low-exposure countries and relative to periods when the policy was rescinded in 1995-2000 and 2009-14, a rise of approximately 40%. We found a symmetric reduction in use of modern contraception by 3·15 percentage points (relative decrease of 13·5%; 95% CI -4·9 to -1·4; p=0·0006) and increase in pregnancies by 3·2 percentage points (relative increase of 12%; 95% CI 1·6 to 4·8; p<0·0001) while the policy was enacted.

INTERPRETATION

Our findings suggest that curbing US assistance to family planning organisations, especially those that consider abortion as a method of family planning, increases abortion prevalence in sub-Saharan African countries most affected by the policy.

FUNDING

The William and Flora Hewlett Foundation, the Doris Duke Charitable Foundation, the David and Lucile Packard Foundation, and the Stanford Earth Dean's Fellowship.

Causes and contributory factors of maternal mortality: evidence from maternal and perinatal death surveillance and response in Ogun state, Southwest Nigeria

BACKGROUND

Nigeria still ranks second globally in the number of maternal deaths. Most maternal death reviews in Nigeria are isolated research based reports from a single health facility. This study determined causes and contributory factors of maternal mortality in Ogun statefollowing a periodic State-widematernal and perinatal deaths surveillance and response (MPDSR) review.

METHODS

We carried out a retrospective analysis of cases of maternal deaths notified (n = 77) and reviewed (n = 45) in health facilities in Ogun State from 2015 to 2016selected using total sampling method. Using the national MPDSR structured and validated data collection tools or questionnaire, collected data was extracted from existing MPDSR data base, andanalyzed using the Statistical Package for Social Sciences (SPSS) software 20.0. We obtained approval from the State Ministry of Health for this study.

RESULTS

Average age at maternal death was 30.8 ± 5.7 years. Haemorrhageand pre-eclampsia or eclampsia account for 43.4 and 36.9% of causes respectively. Leading contributory factors ofmaternal deaths include inadequate human resource for health, delay in seeking care, inadequate equipment, lack of ambulance transportation, and delay in referrals services. 51.1%of the women had antenatal care while a significant proportion of the women were referred from Traditional Births Attendants (TBAs) and mission houses.

CONCLUSION

We concluded that many of the contributory factors of maternal mortality could be avoided if preventive measures were taken and adequate care available. MPDSR provides a platform for critical evidence of where the main problems lie, and can provide valuable information on strategies which maternal mortality prevention programs should focus on. The implementation and institutionalization of MPDSR programme is on course in Ogun State. MPDSR is feasible and should be institutionalized in all states of Nigeria. A commitment to act upon the findings of MPDSR is a key prerequisite for success.

Reproductive autonomy and contraceptive use among women in Hanoi, Vietnam

Objective

Reproductive autonomy (i.e., power to control and decide about contraceptive use, pregnancy and childbearing) could determine a woman’s capacity to use contraception. Although the Reproductive Autonomy Scale was developed to quantitatively assess women’s reproductive autonomy, it has not been validated in any population outside the United States.

Study design

We conducted a cross-sectional study of reproductive-age, sexually active women in Hanoi, Vietnam, who did not desire pregnancy. We administered a questionnaire containing the Reproductive Autonomy Scale and calculated composite scores of the measure’s three subscales: (1) decision-making power, (2) freedom from coercion and (3) communication ability. To assess internal consistency, we calculated Cronbach’s alpha score for each subscale. We used logistic regression to evaluate differences in subscale scores between women who did and did not engage in unprotected sex in the past month.

Results

Analysis is based on 500 participants; of these women, 17% (n = 85) engaged in unprotected sex in the past month. Subscales had moderate to high internal consistency (Cronbach’s alpha: 0.65–0.87). Mean subscale scores did not vary between women who did and did not engage in recent unprotected sex. Unprotected sex in the past month was not associated with decision-making power (adjusted odds ratio [aOR], 0.77; 95% confidence interval [CI], 0.49–1.20), freedom from coercion (aOR, 0.94; 95% CI, 0.52–1.67) or communication ability (aOR, 1.69; 95% CI, 0.92–3.09).

Conclusion

Findings highlight the need to develop and validate a new measure for reproductive autonomy for populations outside the United States or to adapt the existing measure for these contexts.

Deaths of women hospitalized for childbirth and abortion, and of their concept, in maternity wards of Brazilian public hospitals

The aim of this cross-sectional hospital-based study of 7,845 pregnancies was to analyze deaths of women hospitalized for childbirth and abortion, and fetal and neonatal deaths, in public hospitals in the cities of São Paulo, Rio de Janeiro and Niteroi (RJ), Brazil, in 2011. Outcomes of the pregnancies were: one maternal death, 498 abortions, 65 fetal deaths, 44 neonatal deaths and 7,291 infant survivors. Data were collected through interviews, medical records and the women's pregnancy records, and from the Mortality Information System (SIM). The study population was described and kappa coefficients of causes of death (from the SIM, and certified by research) and mortality health indicators were estimated. The maternal mortality ratio was 13.6 per 100,000 live births (LB), the fetal death rate was 8.8‰ births and the neonatal mortality rate was 6.0‰ LB. The drug most used to induce abortion was Misoprostol. The main causes of fetal and neonatal deaths were respiratory disorders and maternal factors. Congenital syphilis, diabetes and fetal death of unspecified cause were under-reported in the SIM. Kappa coefficients by chapter were 0.70 (neonatal deaths) and 0.54 (stillbirths). Good quality care in reproductive planning, prenatal care, during labor and at birth will result in prevention of deaths.

Low Socioeconomic Status Leading to Unsafe Abortion-related Complications: A Third-world Country Dilemma

Introduction An unsafe abortion is a persistent, preventable dilemma. It is a procedure where an unintended pregnancy is terminated either by untrained individuals, or in an environment not meeting medical standards, or both, as defined by the World Health Organization (WHO). It endangers women in developing countries, where abortion is restricted either by law and culture or legally permitted but not easily accessible. Induced abortions are usually performed by unqualified and untrained individuals or are self-induced. Such incidents take place in unhygienic conditions and involve inappropriate methods or administration of medications. Even if carried out by medical experts, a clandestine abortion carries an additional risk, medical coverage is not immediately available in an emergency and the woman may not receive appropriate post-abortion attention. Induced abortion-related complications happen and the woman may hesitate to seek medical care. Unsafe abortion-induced complications contribute a major burden, such as increased hospital stay, drug costs, and an unusual delay of other operations on gynecological services in developing countries. The purpose of this study was to seek an association between low socioeconomic status and complications related to unsafe abortion. Materials and methods A total of 296 female patients of child-bearing age presented between 2012 and 2015 in the emergency department (ED), Nishtar Hospital, Multan, after an unsafe abortion, were included. Spontaneous miscarriages and abortions cases carried out on legal or medical grounds were excluded. Patient or their attendants (who usually present the real picture of incidents leading towards unsafe abortion) were interviewed for determinants leading to unsafe abortion. A detailed clinical assessment of the patient was done and complications like hemorrhage, uterine perforation, and bowel perforation were recorded along with basic demographic information such as age, gestational age, parity, and weight. Results There were 296 female patients in the study with a mean age 28.391 ± 4.57 (Range: 13-40 years). In a majority of patients, gravida and parity were 5-6. The mean weight was 60.283 ± 9.31 kilograms and the mean gestational age was 7.733 ± 2.45 weeks. The determinant in the shape of poor economic status was 71.6%. Hemorrhage was seen in 30.1% of the patients followed by uterine perforation (49.3%) and bowel perforation (45.6%). Conclusion Our results indicate that unsafe abortion is a major cause of maternal morbidity, mostly because the service is being sought from untrained healthcare providers in unhygienic conditions secondary to poor socioeconomic status. Since maternal morbidity due to unsafe abortion is a violation of a woman's basic human right: the right to life, there is a dire need to prevent these unwanted complications by improving the quality of the family planning program and providing safe abortion services.

Ethical challenges in research on post-abortion care with adolescents: experiences of researchers in Zambia

Post-abortion care (PAC) research is increasingly being conducted in low- and middle-income countries (LMICs) to help reduce the high burden of unsafe abortion. This study aims to help address the evidence gap about ethical challenges that researchers in LMICs face when carrying out PAC research with adolescents. Employing an explorative qualitative approach, the study identified several ethics challenges encountered by PAC researchers in Zambia, including those associated with seeking ethics and regulatory approvals at institutional and national levels. Persistent stigma around abortion and community perceptions that PAC studies encourage adolescents to seek abortion affected adolescents' right to exercise their autonomy and to make decisions as well as exposed adolescents to social stigmatization risks. Challenges with recruitment was reported to result in abandoning of studies, thereby undermining development of PAC services that are more responsive to adolescent needs. Training needs identified included knowledge of best practices for conducting and disseminating PAC research. Strategies for addressing the ethical challenges included trust building and using less value-laden terminology when seeking permission and consent. It is essential to the future of PAC research in Zambia and globally that these important challenges be addressed through the development of comprehensive ethics guidance.

Methods for the assessment of selection bias in drug safety during pregnancy studies using electronic medical data

Electronic health data are routinely used for population drug studies. Due to the ethical dilemma in carrying out experimental drug studies on pregnant women, the effects of medication usage during pregnancy on fetal and maternal outcomes are largely evaluated using this data collection medium. One major limitation in this type of study is the delayed inclusion of pregnancies in the cohort. For example, in the province of Quebec, Canada, a major pregnancy cohort only captured pregnancies after 20 weeks gestation. The purpose of this study was to demonstrate three methods that can be used to assess the extent of selection bias due to the delayed inclusion of pregnancies. We use causal directed acyclic graphs to explain the source of this selection bias. In an example involving a cohort of pregnant asthmatic women reconstructed from the linkage of administrative health databases from the province of Quebec, we use numerical derivations, a simulation study and a sensitivity analysis to investigate the potential for bias and loss of power due to the delayed inclusion. We find that this selection bias can be partially mitigated by controlling for variables related to (spontaneous or therapeutic) abortion and the outcome of interest. The three proposed methods allow for the pre and post hoc ascertainment of the bias. While delayed pregnancy inclusion selection bias (which includes "live birth bias") can produce substantial bias in pregnancy drug studies, all three methods are effective at producing estimates of the size of the bias.

"It's something that marks you": Abortion stigma after decriminalization in Uruguay

BACKGROUND

Abortion stigma is experienced by women seeking abortion services and by abortion providers in a range of legal contexts, including Uruguay, where abortion was decriminalized up to 12 weeks gestation in 2012. This paper analyzes opinions and attitudes of both abortion clients and health professionals approximately two years following decriminalization and assesses how abortion stigma manifests among these individuals and in institutions that provide care.

METHODS

In 2014, we conducted twenty in-depth, semi-structured interviews with abortion clients (n = 10) and health care professionals (n = 10) in public and private facilities across Uruguay's health system. Interviews were recorded, transcribed, and then coded for thematic analysis.

RESULTS

We find that both clients and health professionals express widespread satisfaction with the implementation of the new law. However, there exist critical points in the service where stigmatizing ideas and attitudes continue to be reproduced, such as the required five-day waiting period and in interactions with hospital staff who do not support access to the service. We also document the prevalence of stigmatizing ideas around abortion that continue to circulate outside the clinical setting.

CONCLUSION

Despite the benefits of decriminalization, abortion clients and health professionals still experience abortion stigma.

Efficiency of the Foley catheter versus the double balloon catheter during the induction of second trimester pregnancy terminations: a randomized controlled trial

PURPOSE

To compare induction-to-delivery intervals of Foley catheters and double balloon catheters in second trimester pregnancy terminations.

METHODS

This randomized parallel study was conducted on women who underwent second trimester terminations between December 2016 and December 2017. Pregnant women in the second trimester with a Bishop score < 6 were included in the study. Participants were randomized into two groups, the first being the Foley catheter group and the second being the double balloon catheter group. The time frames from insertion of catheters to the delivery were recorded in each group. A multiple regression analysis was carried out to examine the contribution of factors to the induction-to-delivery interval. A survival analysis was conducted to compare the Foley method and the double balloon method.

RESULTS

A total of 91 pregnant women were included in the final analysis. The induction-to-delivery interval was shorter in the Foley catheter group than in the double balloon catheter group (38 h 54 min ± 21 h 6 min versus 58 h 17 min ± 25 h 56 min). We also found that women with intrauterine fetal death (IUFD) had a shorter time to delivery compared to women with live fetuses (39 h 12 min ± 18 h 46 min vs 51 h 30 min ± 26 h 42 min, p = 0.04). Women with a history of vaginal delivery also had a shorter induction-to-delivery time compared to women who never delivered vaginally before (38 h 12 min ± 17 h 42 min vs 53 h 54 min ± 27 h 18 min, p = 0.004). In the multiple regression analysis, the most significant contributor to the induction-to-delivery time was the method used for induction of labor and followed by other factors including the viability of the fetus (live/IUFD), history of vaginal delivery and PPROM. The survival analysis showed that the induction-to-delivery interval was significantly shorter in the Foley catheter group than in the double balloon catheter group (HR 2.51, 95% CI 1.57-4.00, p = 0.001).

CONCLUSION

During the termination of second trimester pregnancies time from induction of labor to delivery is shorter with the Foley catheter compared to double balloon catheter.

Practices and knowledge of female gynecologists regarding contraceptive use: a real-world Chinese survey

Background

There is no evidence of the practices of obstetricians and gynecologists (OB/GYNs) regarding contraceptive use and determinants influencing contraceptive choices, including emergency methods such as combined oral contraceptives (COCs) and levonorgestrel intrauterine system (LNGIUS). This survey determines the practices and knowledge among Chinese female OB/GYNs regarding modern contraceptive methods.

Methods

A multicenter questionnaire was completed by 2000 female OB/GYNs participating in training courses organized by the gynecological endocrinology training committee of the Chinese Medical Doctor Association from February to May 2013.

Results

This survey achieved a response rate of 51.4%. The rate of induced abortion among this group was 56.3%; this may be attributable to unreliable contraceptive methods (55.5%) and failure of reliable contraceptive methods (18.9%). Intrauterine devices (IUDs) were more commonly used by parous women than nulliparous women (42.6% vs 1.7%; p < 0.0001), followed by condom and rhythm method (24.2% vs 20.8%). However, nulliparous women commonly used rhythm method (48.3% vs 3.3%; p < 0.0001) and condoms (19.2% vs 10.5%; p = 0.008). OB/GYNs demonstrated misconceptions of OB/GYNs about COCs, such as the risk of breast cancer, amenorrhea and premature ovarian failure, and decreased fertility as reported by 37.10, 10.6, and 7.5% of the respondents, respectively.

Conclusions

IUDs were commonly used by parous Chinese OB/GYNs. Unreliable contraceptive methods and misconceptions about the side effects of COCs may result in the high rate of unintended pregnancies. Hence, awareness of safe and effective contraceptive methods should be strengthened among OB/GYNs in China.

Development of an intervention delivered by mobile phone aimed at decreasing unintended pregnancy among young people in three lower middle income countries

BACKGROUND

Unintended pregnancies can result in poorer health outcomes for women, children and families. Young people in low and middle income countries are at particular risk of unintended pregnancies and could benefit from innovative contraceptive interventions. There is growing evidence that interventions delivered by mobile phone can be effective in improving a range of health behaviours. This paper describes the development of a contraceptive behavioural intervention delivered by mobile phone for young people in Tajikistan, Bolivia and Palestine, where unmet need for contraception is high among this group.

METHODS

Guided by Intervention Mapping, the following steps contributed to the development of the interventions: (1) needs assessment; (2) specifying behavioural change to result from the intervention; (3) selecting behaviour change methods to include in the intervention; (4) producing and refining the intervention content.

RESULTS

The results of the needs assessment produced similar interventions across the countries. The interventions consist of short daily messages delivered over 4 months (delivered by text messaging in Palestine and mobile phone application instant messages in Bolivia and Tajikistan). The messages provide information about contraception, target attitudes that are barriers to contraceptive uptake and support young people in feeling that they can influence their reproductive health. The interventions each contain the same ten behaviour change methods, adapted for delivery by mobile phone.

CONCLUSIONS

The development resulted in a well-specified, theory-based intervention, tailored to each country. It is feasible to develop an intervention delivered by mobile phone for young people in resource-limited settings.

Complicated unsafe abortion in a Nigerian teaching hospital: pattern of morbidity and mortality

Addressing unsafe abortion in developing countries may propel a rapid decline in overall maternal death. A retrospective review of patients with complicated unsafe abortion was conducted in a Nigerian Tertiary Hospital. In order to provide evidence that may inform policy changes, we describe patients' clinical profiles, abortion providers, and morbidity and mortality patterns. Of 3122 gynaecological admissions, 231 (7.4%) had unsafe abortion-related complications. The majority (53.2%) of admissions were between 16 and 25 years. Single women constituted 51% while 57% were nulliparous. Common presentations were abdominal pain (62%), fever (54%) and vaginal bleeding (53%). The most frequent complications were anaemia (55%) and retained products of conception (47%). Doctors reportedly performed 42% of abortions. There were 392 maternal mortalities; 39 (9.9%) from unsafe abortions and sepsis was responsible in 31 (80%) patients. Abortion remains a major public health issue. Youths are mostly involved. Doctors were reportedly the highest abortion providers. Mortality is high, occurring mostly from sepsis. Impact Statement What is already known on this subject? Doctors are reported as being involved in a high proportion of unsafe abortions in low and middle income countries where abortion remains a significant contributor to maternal mortality and morbidity. What the results of this study add? Our study agrees with existing literature that doctors reportedly performed most of the unsafe abortions. It also found that doctors were reported as abortion providers in the majority (35.9%) of those unsafe abortions that ended in mortality. What the implications are of these findings for clinical practice and/or further research? There is a need to conduct studies that will verify the status of abortion providers rather than rely on clients' report; and also inspect facilities to confirm adherence to minimum medical standards. Such research findings will be needed prior to local and possibly national healthcare interventions and policy changes.

Management of post abortion complications in Botswana -The need for a standardized approach

BACKGROUND

Post abortion complications are the third leading cause of maternal death after hemorrhage and hypertension in Botswana where abortion is not legalized. This study aimed at assessing the management of post abortion complications in Botswana.

METHODS

A retrospective study was conducted at four hospitals in Botswana in 2014. Socio-demographic, patient management and outcomes data were extracted from patients' medical records. Descriptive statistics and chi-square test were used to analyze and present the data.

RESULT

A total of 619 patients' medical records were reviewed. The duration of hospital stay prior to uterine evacuation ranged from less than an hour to 480 hours. All the patients received either prophylactic or therapeutic antibiotics. Use of parenteral antibiotics was significantly associated with severity of abortion, second trimester abortion, use of blood products and the interval between management's decision and uterine evacuation. Uterine evacuation for retained products of conception was achieved by metallic curettage among 516 (83.4%) patients and by vacuum aspiration in 18 (2.9%). At all the study sites, Misoprostol or Oxytocin were used concurrently with surgical evacuation of the uterus. None use of analgesics or anesthetics in the four hospitals ranged between 12.4% to 28.8%.

CONCLUSION

There is evidence of delayed patient care and prolonged hospital stay. Metallic curette was the primary method used for uterine evacuation across all the facilities. Pain management and antibiotics use was not standardized. A protocol has to be developed with the aim of standardizing post abortion care.

An Intervention Delivered by App Instant Messaging to Increase Acceptability and Use of Effective Contraception Among Young Women in Bolivia: Protocol of a Randomized Controlled Trial

Background

Unintended pregnancy is associated with numerous poorer health outcomes for both women and their children. Fulfilling unmet need for contraception is essential in avoiding unintended pregnancies, yet millions of women in low- and middle-income countries continue to face obstacles in realizing their fertility desires. In Bolivia, family planning progress has improved in recent decades but lags behind other countries in the region. Unmet need for contraception among women aged 15 to 19 years is estimated to be 38%, with the adolescent fertility rate at 70 per 1000 women. Mobile phones are an established and popular mode in which to deliver health behavior support. The London School of Hygiene & Tropical Medicine and the Centro de Investigación, Educación y Servicios in Bolivia have partnered to develop and evaluate a contraceptive behavioral intervention for Bolivian young women delivered by mobile phone. The intervention was developed guided by behavioral science and consists of short instant messages sent through an app over 4 months.

Objective

The objective of this study is to evaluate the effect of the intervention on young women’s use of and attitudes toward the most effective contraceptive methods.

Methods

We will allocate 1310 women aged 16 to 24 years with an unmet need for contraception in a 1:1 ratio to receive the intervention messages or the control messages about trial participation. The messages are sent through the Tú decides app, which contains standard family planning information. Coprimary outcomes are use and acceptability of at least one effective contraceptive method, both measured at 4 months.

Results

Recruitment commenced on March 1, 2017 and was completed on July 29, 2017. We estimate that the follow-up period will end in January 2018.

Conclusions

This trial will evaluate the effect of the intervention on young women’s use of and attitudes toward the (nonpermanent) effective contraception methods available in Bolivia.

Trial Registration

ClinicalTrials.gov NCT02905526; https://clinicaltrials.gov/ct2/show/NCT02905526 (Archived by WebCite at http://www.webcitation.org/6vT0yIFfN)

Restricted reproductive rights and risky sexual behaviour: How political disenfranchisement relates to women's sense of control, well-being and sexual health

Few studies have investigated the role of disenfranchisement and denial of agency in women's sexual health. To address this, a cross-sectional study of disenfranchisement, control (general and reproductive control) and health was conducted in Ireland, where abortion is severely restricted. Multiple mediation models ( N = 513 women) indicated that general but not reproductive control mediates the association between disenfranchisement and psychological well-being. Additionally, serial mediation shows disenfranchisement is associated with lower sense of control, which is linked to poorer well-being and risky sexual behaviour. Disenfranchisement arising from socio-political contexts may have important implications for women's sexual health.

An intervention delivered by text message to increase the acceptability of effective contraception among young women in Palestine: study protocol for a randomised controlled trial

BACKGROUND

Unintended pregnancy can negatively impact women's lives and is associated with poorer health outcomes for women and children. Many women, particularly in low- and middle-income countries, continue to face obstacles in avoiding unintended pregnancy. In the State of Palestine, a survey conducted in 2006 estimated that 38% of pregnancies are unintended. In 2014, unmet need for contraception was highest among young women aged 20-24 years, at 15%. Mobile phones are increasingly being used to deliver health support. Once developed, interventions delivered by mobile phone are often cheaper to deliver than face-to-face support. The London School of Hygiene and Tropical Medicine and the Palestinian Family Planning and Protection Association have partnered to develop and evaluate a contraceptive behavioural intervention for young women in Palestine delivered by mobile phone. The intervention was developed guided by behavioural science and consists of short, mobile phone text messages that contain information about contraception and behaviour change methods delivered over 4 months.

METHODS

We will evaluate the intervention by conducting a randomised controlled trial. Five hundred and seventy women aged 18-24 years, who do not report using an effective method of contraception, will be allocated with a 1:1 ratio to receive the intervention text messages or control text messages about trial participation. The primary outcome is self-reported acceptability of at least one method of effective contraception at 4 months. Secondary outcomes include the use of effective contraception, acceptability of individual methods, discontinuation, service uptake, unintended pregnancy and abortion. Process outcomes include knowledge, perceived norms, personal agency and intervention dose received. Outcomes at 4 months will be compared between arms using logistic regression.

DISCUSSION

This trial will determine the effect of the intervention on young women's attitudes towards the most effective methods of contraception. If the intervention is found to be effective, the intervention will be implemented widely across Palestine. The results could also be used to design a larger trial to establish its effect on unintended pregnancy.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02905461 . Registered on 14 September 2016.

Nonpaternity and Half-Siblingships as Objective Measures of Extramarital Sex: Mathematical Modeling and Simulations

Background

Understanding the epidemiology of HIV and other sexually transmitted infections (STIs) requires knowledge of sexual behavior, but self-reported behavior has limitations. We explored the reliability and validity of nonpaternity and half-siblings ratios as biomarkers of current and past extramarital sex.

Methods

An individual-based Monte Carlo simulation model was constructed to describe partnering and conception in human populations with a focus on Sub-Saharan Africa (SSA). The model was parameterized with representative biological, behavioral, and demographic data.

Results

Nonpaternity and half-siblings ratios were strongly correlated with extramarital sex, with Pearson correlation coefficients (PCC) of 0.79 (95% CI: 0.71–0.86) and 0.77 (0.68–0.84), respectively. Age-specific nonpaternity ratios correlated with past extramarital sex at time of conception for different scenarios: for example, PCC, after smoothing by moving averages, was 0.75 (0.52–0.89) in a scenario of steadily decreasing nonmarital sex and 0.39 (0.01–0.73) in a scenario of transient drops in nonmarital sex. Simulations assuming self-reported levels of extramarital sex from Kenya yielded nonpaternity levels lower than global nonpaternity data, suggesting sizable underreporting of extramarital sex.

Conclusions

Nonpaternity and half-siblings ratios are useful objective measures of extramarital sex that avoid limitations in self-reported sexual behavior.

Abortion, an increasing public health concern in Ecuador, a 10-year population-based analysis

OBJECTIVES

To describe the epidemiology of abortion in Ecuador from 2004 to 2014 and compare the prevalence between the public and the private health care systems.

METHODS

This is a cross-sectional analysis of the overall mortality and morbidity rate due to abortion in Ecuador, based on public health records and other government databases.

RESULTS

From 2004 to 2014, a total of 431,614 spontaneous abortions, miscarriage and other types of abortions were registered in Ecuador. The average annual rate of abortion was 115 per 1,000 live births. The maternal mortality rate was found to be 43 per 100,000 live births.

CONCLUSIONS

Abortion is a significant and wide-ranging problem in Ecuador. The study supports the perception that in spite of legal restrictions to abortion in Ecuador, women are still terminating pregnancies when they feel they need to do so. The public health system reported >84% of the national overall prevalence.