Women's Perspectives on Medical Abortion in Mexico, Colombia, Ecuador and Peru: A Qualitative Study

Menstrual regulation: examining the incidence, methods, and sources of care of this understudied health practice in three settings using cross-sectional population-based surveys

BACKGROUND

Menstrual regulation is a practice that may exist within the ambiguity surrounding one's pregnancy status and has been the subject of limited research. The aim of this study is to measure the annual rate of menstrual regulation in Nigeria, Cote d'Ivoire, and Rajasthan, India, overall and by background characteristics and to describe the methods and sources women use to bring back their period.

METHODS

Data come from population-based surveys of women aged 15-49 in each setting. In addition to questions on women's background characteristics, reproductive history, and contraceptive experiences, interviewers asked women whether they had ever done something to bring back their period at a time when they were worried they were pregnant, and if so, when it occurred and what methods and source they used. A total of 11,106 reproductive-aged women completed the survey in Nigeria, 2,738 in Cote d'Ivoire, and 5,832 in Rajasthan. We calculated one-year incidence of menstrual regulation overall and by women's background characteristics separately for each context using adjusted Wald tests to assess significant. We then examined the distribution of menstrual regulation methods and sources using univariate analyses. Method categories included surgery, medication abortion pills, other pills (including unknown pills), and traditional or "other" methods. Source categories included public facilities or public mobile outreach, private or non-governmental facilities or doctors, pharmacy or chemist shops, and traditional or "other" sources.

RESULTS

Results indicate substantial levels of menstrual regulation in West Africa with a one-year incidence rate of 22.6 per 1,000 women age 15-49 in Nigeria and 20.6 per 1,000 in Cote d'Ivoire; women in Rajasthan reported only 3.3 per 1,000. Menstrual regulations primarily involved traditional or "other" methods in Nigeria (47.8%), Cote d'Ivoire (70.0%), and Rajasthan (37.6%) and traditional or "other" sources (49.4%, 77.2%, and 40.1%, respectively).

CONCLUSION

These findings suggest menstrual regulation is not uncommon in these settings and may put women's health at risk given the reported methods and sources used. Results have implications for abortion research and our understanding of how women manage their fertility.

How, when and where? A systematic review on abortion decision making in legally restricted settings in sub-Saharan Africa, Latin America, and the Caribbean

Background

With increasing global availability of medication abortion drugs, a safer option exists for many women to terminate a pregnancy even in legally restrictive settings. However, more than 22,000 women die each year from unsafe abortion, most often in developing countries where abortion is highly legally restricted. We conducted a systematic review to compile existing evidence regarding factors that influence women’s abortion-related decision making in countries where abortion is highly legally restricted.

Methods

We searched ten databases in two languages (English and Spanish) for relevant literature published between 2000 and 2019 that address women’s decision-making regarding when, where and how to terminate a pregnancy in sub-Saharan African, Latin American and the Caribbean countries where abortion is highly legally restricted.

Results

We identified 46 articles that met the review’s inclusion criteria. We found four primary factors that influenced women’s abortion-related decision-making processes: (1) the role of knowledge, including of laws, methods and sources; (2) the role of safety, including medical, legal and social safety; (3) the role of social networks and the internet, and; (4) cost affordability and convenience.

Conclusions

The choices women make after deciding to terminate a pregnancy are shaped by myriad factors, particularly in contexts where abortion is highly legally restricted. Our review catalogued the predominant influences on these decisions of when, where and how to abort. More research is needed to better understand how these factors work in concert to best meet women’s abortion needs to the full limit of the law and within a harm reduction framework for abortions outside of legal indications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-022-01962-0.

A mixed-methods study exploring women's perceptions of terminology surrounding fertility and menstrual regulation in Côte d'Ivoire and Nigeria

Background

Women use various terms when discussing the management of their fertility and menstrual irregularities and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology used to refer to abortion-like experiences (specifically menstrual regulation and pregnancy removal), and the specific scenarios that these practices encompass among women who reported doing something to bring back a late period or ending a pregnancy in Nigeria and Côte d’Ivoire.

Methods

Our analysis draws upon surveys with women in Nigeria (n = 1114) and Cote d’Ivoire (n = 352). We also draw upon qualitative in-depth interviews with a subset of survey respondents in Anambra and Kaduna States in Nigeria, and Abidjan, Cote d’Ivoire (n = 30 in both countries). We examine survey and interview questions that explored women’s knowledge of terminology pertaining to ending a pregnancy or bringing back a late period. Survey data were analyzed descriptively and weighted, and interview data were analyzed using inductive thematic analysis.

Results

We find that the majority (71% in Nigeria and 70% in Côte d’Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy.

Conclusions

Overall, menstrual regulation and pregnancy removal are seen as distinct experiences in both settings. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women’s reproductive health needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01306-5.

Women use various words and phrases to describe their experiences managing their fertility and menstrual irregularities, and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology women use to refer to abortion-like experiences (specifically menstrual regulation, which refers to actions taken to regulate a menstrual cycle, and pregnancy removal), and the specific scenarios that these practices encompass among women who reported having had an abortion in Côte d’Ivoire and Nigeria. Our analysis draws upon data from surveys and qualitative interviews conducted in both countries. We find that the majority (71% in Nigeria and 70% in Côte d’Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women’s reproductive health needs.

Women's experiences using drugs to induce abortion acquired in the informal sector in Colombia: qualitative interviews with users in Bogotá and the Coffee Axis

In 2006, abortion in Colombia was decriminalised under certain circumstances. Yet some women continue to avail themselves of ways to terminate pregnancies outside of the formal health system. In-depth interviews (IDIs) with women who acquired drugs outside of health facilities to terminate their pregnancies (n = 47) were conducted in Bogotá and the Coffee Axis in 2018. Respondents were recruited when they sought postabortion care at a health facility. This analysis examines women's experiences with medication acquired outside of the health system for a termination: how they obtained the medication, what they received, how they were instructed to use the pills, the symptoms they were told to expect, and their abortion experiences. Respondents purchased the drugs in drug stores, online, from street vendors, or through contacts in their social networks. Women who used online vendors more commonly received the minimum dose of misoprostol according to WHO guidelines to complete the abortion (800 mcg) and received more detailed instructions and information about what to expect than women who bought the drug elsewhere. Common instructions were to take the pills orally and vaginally; most women received incomplete information about what to expect. Most women seeking care did not have a complete abortion before coming to the health facility (they never started bleeding or had an incomplete abortion). Women still face multiple barriers to safe abortion in Colombia; policymakers should promote better awareness about legal abortion availability, access to quality medication and complete information about misoprostol use for women to terminate unwanted pregnancies safely.

Medical abortion ratios and gender equality in Europe: an ecological correlation study

Medical abortion (MA) is recommended by the WHO as a safe and effective pregnancy termination method in the first trimester. From a feminist perspective, it is a non-medicalised, self-managed, emancipating procedure allowing persons seeking abortion to be more in control of their abortion, as opposed to surgical procedures. In European countries where MA is legal, the proportion of MA (relative to surgical abortions) varies greatly. We hypothesised that this ratio may be partly explained by country-level dimensions of gender equality. We assessed the association between MA ratios and gender equality in Europe in correlation and regression analyses, using several country-level gender equality indices. The relevance of other factors, i.e. date of introduction of MA and pregnancy week until which MA is permitted, was also investigated. MA ratios ranged from 24.4% (Italy) to 97.7% (Finland). MA was more frequent relative to surgical abortion in countries with higher levels of gender equality. All gender equality indices were associated with MA ratios (e.g. Global Gender Gap Index corr. coeff: 0.761, p < 0.0001). Specifically, markers of economic and political gender equality seemed to drive the correlations. The pregnancy week until which MA is permitted was associated with both gender equality and MA ratios. Our study suggests that women’s participation in the economic and political sphere may have repercussions on the methods offered and used through abortion services. It highlights the link between feminist perspectives, reproductive health policies and practices, and gender equality, especially in terms of access to economic resources and political representation.

The microeconomics of abortion: A scoping review and analysis of the economic consequences for abortion care-seekers

Background

The economic consequences of abortion care and abortion policies for individuals occur directly and indirectly. We lack synthesis of the economic costs, impacts, benefit or value of abortion care at the micro-level (i.e., individuals and households). This scoping review examines the microeconomic costs, benefits and consequences of abortion care and policies.

Methods and findings

Searches were conducted in eight electronic databases and applied inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined at least one of the following outcomes: costs, impacts, benefits, and value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 230 included microeconomic studies, costs are the most frequently reported microeconomic outcome (n = 180), followed by impacts (n = 84), benefits (n = 39), and values (n = 26). Individual-level costs of abortion-related care have implications for the timing and type of care sought, globally. In contexts requiring multiple referrals or follow-up visits, these costs are multiplied. The ways in which people pay for abortion-related costs are diverse. The intersection between micro-level costs and delay(s) to abortion-related care is substantial. Individuals forego other costs and expenditures, or are pushed further into debt and/or poverty, in order to fund abortion-related care. The evidence base on the economic impacts of policy or law change is from high-income countries, dominated by studies from the United States.

Conclusions

Delays underpinned by economic factors can thwart care-seeking, affect the type of care sought, and impact the gestational age at which care is sought or reached. The evidence base includes little evidence on the micro-level costs for adolescents. Specific sub-groups of abortion care-seekers (transgendered and/or disabled people) are absent from the evidence and it is likely that they may experience higher direct and indirect costs because they may experience greater barriers to abortion care.

Factors influencing abortion decisions, delays, and experiences with abortion accompaniment in Mexico among women living outside Mexico City: results from a cross-sectional study

Access to abortion throughout much of Mexico has been restricted. Fondo Maria is an abortion accompaniment fund that provides informational, logistical, financial, and emotional support to people seeking abortion care in Mexico. This cross-sectional study examines the factors that influenced decision-making and contributed to delays in accessing care and explores experiences with Fondo Maria’s support among women living outside Mexico City (CDMX). We describe and compare the experiences of women across the sample (n = 103) who were either supported by Fondo Maria to travel to CDMX to obtain an abortion (n = 60), or self-managed a medical abortion in their home state (n = 43). Data were collected between January 2017 and July 2018. Seventy-seven percent of participants reported that it was difficult to access abortion care in their home state and 34% of participants indicated they were delayed in accessing care, primarily due to a lack of financial support. The majority of participants (58%) who travelled to CDMX for their abortion did so because it seemed safer. The money/cost of the trip was the most commonly cited reason (33%) why participants who self-managed stayed in their home state. Eighty-seven percent of participants said Fondo Maria’s services met or exceeded their expectations. Our data suggest that people seeking abortion and living outside CDMX face multiple and overlapping barriers that can delay care-seeking and influence decision-making. Abortion accompaniment networks, such as Fondo Maria, offer a well-received model of support for people seeking abortion in restrictive states across Mexico.

Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries

OBJECTIVE

Abortion-related complications remain one of the leading causes of maternal morbidity and mortality worldwide. Nearly half of all abortions are unsafe, and the vast majority of these occur in low- and middle-income countries. The use of mifepristone with misoprostol for medical abortion has been proposed and implemented to improve abortion safety.

DATA SOURCES

A systematic review of the literature was conducted in PubMed, Embase, Cochrane, and CINAHL.

STUDY SELECTION

Criteria for study inclusion were first-trimester abortion, use of mifepristone with misoprostol, and low- or middle-income country status as designated by the World Health Organization.

DATA EXTRACTION

Results for effectiveness, safety, acceptability, and qualitative information were assessed.

DATA SYNTHESIS

The literature search resulted in 181 eligible articles, 52 of which met our criteria for inclusion. A total of 34 publications reported effectiveness data on 25 385 medical abortions. The average effectiveness rate with mifepristone 200 mg and misoprostol 800 µg was 95% up to 63 days gestation. A sensitivity analysis was performed to assume that all women lost to follow-up failed treatment, and the recalculated effectiveness rate remained high at 93%. The average continuing pregnancy rate was 0.6%. A total of 22 publications reported safety and acceptability data on 17 381 medical abortions. Only 0.8% abortions required presentation to hospital, and 87% of patients found the side effects of treatment acceptable. Overall, 95% of women were satisfied with their medical abortion, 94% would choose the method again, and 94% would recommend this method to a friend. A total of 16 publications reported qualitative results and the majority supported positive patient experiences with medical abortion.

CONCLUSIONS

Mifepristone and misoprostol is highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.

Women's voices and medical abortions: A review of the literature

Globally, a growing proportion of induced abortions are medical abortions. The procedure has been hailed as a revolutionary technology, which, according to experts, has the potential to transform women's experiences of abortion and the way abortion services are accessed. Noticeably absent in the discourse, however, are women's voices. More specifically, there is a lack of understanding about what shapes women's preferences for medical abortion and the challenges they experience in accessing the drugs for the procedure. We conducted a systematic review of the literature to draw attention to these important issues which exist, but are often embedded within research highlighting other dominating aspects of medical abortions. A comprehensive search of four databases - supplemented by searching reference sections of selected articles, tracking their citations, and hand searching special editions on medical abortion - was conducted. A total of 45 peer-reviewed studies met our inclusion criteria. The studies were assessed for quality and analyzed using a critical interpretive synthesis approach. The findings revealed significant variations in women's preferences for surgical versus medical abortions. Country-specific abortion laws, implementing protocols, side-effects, rates of failures, and the need to verify the abortion shaped women's preference for abortion methods. Overall, women who preferred medical abortions did so because they perceived it as a 'natural' and safe procedure that can be self-conducted at home, thereby reducing their dependency on the health system. However, women face significant barriers to medical abortion care. These include legal requirements around type of provider, site of service, need for follow-up, providers' limited knowledge of the procedure, and preferences for surgical abortions. Borderless internet-based services have enabled some women to circumvent these barriers. Our review suggests that medical abortions are used by women either in countries where the health system is fully supportive or where the health system is completely disengaged, usually due to restricted abortion laws. In those countries where abortions are legal but often difficult to access due to health system barriers, women tend to prefer surgical abortions.

Estimating abortion prevalence and understanding perspectives of community leaders and providers: Results from a mixed-method study in Istanbul, Turkey

OBJECTIVES

Abortions are difficult to measure; yet, accurate estimates are critical in developing health programs. We implemented and tested the validity of a list experiment of lifetime abortion prevalence in Istanbul, Turkey. We complemented our findings by understanding community perspectives using in-depth interviews with key informants.

METHODS

We conducted a household survey between March and June 2018. In a random sample of 4040 married women aged 16-44 years, we implemented a double list experiment. We averaged difference in mean values calculations between the average counts for each list to provide an estimated lifetime abortion prevalence. We conducted in-depth interviews with 16 key informants to provide insights into possible explanations for the quantitative results.

RESULTS

The abortion prevalence estimate from the list experiment was close to that of the direct question (3.25% vs 2.97%). Key informant narratives suggest that differing definitions of abortion, inaccessibility, provider bias, lack of knowledge of abortion laws and safety, and religious norms could contribute to under-reporting. Results from the qualitative study suggest that abortion is largely inaccessible and highly stigmatized.

CONCLUSION

Measuring experiences of abortion is critical to understanding women's needs and informing harm-reduction strategies; however, in highly stigmatized settings, researchers may face unique challenges in obtaining accurate reports.

The changing landscape of abortion care: Embodied experiences of structural stigma in the Republic of Ireland and Northern Ireland

The private use of abortion medication outside of the formal healthcare setting is an international phenomenon. Despite new and expanding pathways to abortion access, we know little about how women's perceptions and experiences of abortion may also be changing. This study examines the embodied experience of 68 women who sought abortion services in Northern Ireland and the Republic of Ireland. Social stigma and restrictive abortion laws were major barriers to care at the time of study, providing the opportunity to explore the ways biological, social, and structural factors shape embodiment. Those who obtained an abortion either traveled abroad for clinical care or self-managed a medication abortion at home. Participant's perceptions of pain, the fetus, the method (medication vs. surgical), and environment in which they sought abortion care (at home vs. in a clinic) were shaped by structural stigma. Women gained greater experiential knowledge through medication self-management, allowing them to relate abortion to other natural bodily processes and redefine their beliefs about pregnancy and the fetus. Preferences and attitudes about the environment of abortion care were informed by stigma and differential perceptions of risk. Those who traveled most often emphasized legal and medical risks of abortion at home, while those who self-managed emphasized social, financial, and emotional risks of pursuing clinical abortion care abroad. Given the increase in reproductive self-care alternatives, these findings situate self-managed abortion in the literature of (de)medicalization and reveal the ways technology and structural factors shape perceptions and beliefs about pain, the fetus, method, and environment. For some, self-managed medication abortion may be a preferred pathway to care. Policies that consider medication self-management as part of a spectrum of legitimate options can improve abortion access for marginalized groups while also offering an improved abortion experience for those who prefer medication abortion and an out-of-clinic environment.

Twelve years after abortion decriminalization in Mexico City: Can we still remain an island of liberties?

Latin America hosts the most restrictive abortion legislation globally. In 2007, Mexico, the second largest Catholic country in the world, decriminalized elective abortion within the first twelve weeks of pregnancy in the capital: Mexico City (also known as Federal District of Mexico). Following the reform, the Mexico City Ministry of Health (MX-MOH) implemented safe and legal services. Free services are provided to Mexico City residents and a sliding fee of up to $100 is applied to women from other Mexican states. Conscientious objection (CO) was addressed and included in service provision guidelines. Since 2007, 18 of 32 states amended their penal codes to restrict abortion. The road toward increasing access to abortion services at the MX-MOH included a shift from dilation and curettage (D&C) to medical abortion (MA), first with the misoprostol-alone regimen, followed by the combined mifepristone-misoprostol regimen. Manual vacuum aspiration is offered to out-of-state-women or to those beyond the gestational age where MA is less effective. Contraceptive uptake among abortion seekers is high (up to 95% of them prefer a free method of their choice). The Legal Interruption of Pregnancy program at the MX-MOH continues to provide effective, safe, reliable, and free services. However, women from indigenous groups residing in rural areas, those with low schooling, and adolescents with an unintended pregnancy who live in rural, urban, peri-urban districts, and at the state level are underserved despite being legally eligible to receive abortion services. Therefore, information and services for the disadvantaged groups need to be strengthened.

A harm-reduction model of abortion counseling about misoprostol use in Peru with telephone and in-person follow-up: A cohort study

BACKGROUND

In Peru, abortion is legal only to preserve the life and health of the woman. A non-profit clinic system in Peru implemented a harm-reduction model for women with unwanted pregnancy that included pre-abortion care with instructions about misoprostol use and post-abortion care; they started offering telephone follow-up for clients in 2011. This study aimed to evaluate the effectiveness and safety of the harm-reduction model, and to compare outcomes by type of follow-up obtained.

METHODS

Between January 2012 and March 2013, 500 adult women seeking harm-reduction services were recruited into the study. Telephone surveys were conducted approximately four weeks after their initial harm-reduction counseling session with 262 women (response rate 52%); 9 participants were excluded. The survey focused on whether women pursued an abortion, and if so, what their experience was. Demographic and clinical data were also extracted from clinic records.

RESULTS

Eighty-six percent of participants took misoprostol; among those taking misoprostol, 89% reported a complete abortion at the time of the survey. Twenty-two percent obtained an aspiration after taking misoprostol and 8% self-reported adverse events including hemorrhage without transfusion, infection, or severe pain. Among women who took misoprostol, 46% reported receiving in-person follow-up (in some cases both telephone and in-person), 34% received telephone only, and 20% did not report receiving any form of follow-up. Those who had in-person follow-up with the counselor were most likely to report a complete abortion (<0.001). Satisfaction with both types of follow-up was very high, with 81%-89% reporting being very satisfied.

CONCLUSIONS

Liberalization of restrictive abortion laws is associated with improvements in health outcomes, but the process of legal reform is often lengthy. In the interim, giving women information about evidence-based regimens of misoprostol, as well as offering a range of follow-up options to ensure high quality post-abortion care, may reduce the risks associated with unsafe abortion.

Abortion Stigma Among Low-Income Women Obtaining Abortions in Western Pennsylvania: A Qualitative Assessment

CONTEXT

Abortion stigma may cause psychological distress in women who are considering having an abortion or have had one. This phenomenon has been relatively underexplored in low-income women, who may already be at an increased risk for poor abortion-related outcomes because of difficulties accessing timely and safe abortion services.

METHODS

A qualitative study conducted between 2010 and 2013 used semistructured interviews to explore pregnancy intentions among low-income women recruited from six reproductive health clinics in Western Pennsylvania. Transcripts from interviews with 19 participants who were planning to terminate a pregnancy or had had an abortion in the last two weeks were examined through content analysis to identify the range of attitudes they encountered that could contribute to or reflect abortion stigma, the sources of these attitudes and women's responses to them.

RESULTS

Women commonly reported that partners, family members and they themselves held antiabortion attitudes. Such attitudes communicated that abortion is morally reprehensible, a rejection of motherhood, rare and thus potentially deviant, detrimental to future fertility and an irresponsible choice. Women reacted to external and internal negative attitudes by distinguishing themselves from other women who obtain abortions, experiencing negative emotions, and concealing or delaying their abortions.

CONCLUSIONS

Women's reactions to antiabortion attitudes may perpetuate abortion stigma. Further research is needed to inform interventions to address abortion stigma and improve women's abortion experiences.

Safe, accessible medical abortion in a rural Tamil Nadu clinic, India, but what about sexual and reproductive rights?

Women's control over their own bodies and reproduction is a fundamental prerequisite to the achievement of sexual and reproductive health and rights. A woman's ability to terminate an unwanted pregnancy has been seen as the exercise of her reproductive rights. This study reports on interviews with 15 women in rural South India who had a medical abortion. It examines the circumstances under which they chose to have an abortion and their perspectives on medical abortion. Women in this study decided to have an abortion when multiple factors like lack of spousal support for child care or contraception, hostile in-laws, economic hardship, poor health of the woman herself, spousal violence, lack of access to suitable contraceptive methods, and societal norms regarding reproduction and sexuality converged to oppress them. The availability of an easy and affordable method like medical abortion pills helped the women get out of a difficult situation, albeit temporarily. Medical abortion also fulfilled their special needs by ensuring confidentiality, causing least disruption of their domestic schedule, and dispensing with the need for rest or a caregiver. The study concludes that medical abortion can help women in oppressive situations. However, this will not deliver gender equality or women's empowerment; social conditions need to change for that.

Women's experiences with the use of medical abortion in a legally restricted context: the case of Argentina

This article presents the findings of a qualitative study exploring the experiences of women living in Buenos Aires Metropolitan Area, Argentina, with the use of misoprostol for inducing an abortion. We asked women about the range of decisions they had to make, their emotions, the physical experience, strategies they needed to use, including seeking health care advice and in dealing with a clandestine medical abortion, and their overall evaluation of the experience. An in-depth interview schedule was used. The women had either used misoprostol and sought counselling or care at a public hospital (n=24) or had used misoprostol based on the advice of a local hotline, information from the internet or from other women (n=21). Four stages in the women's experiences were identified: how the decision to terminate the pregnancy was taken, how the medication was obtained, how the tablets were used, and reflections on the outcome whether or not they sought medical advice. Safety and privacy were key in deciding to use medical abortion. Access to the medication was the main obstacle, requiring a prescription or a friendly drugstore. Correct information about the number of pills to use and dosage intervals was the least easy to obtain and caused concerns. The possibility of choosing a time of privacy and having the company of a close one was highlighted as a unique advantage of medical abortion. Efforts to improve abortion law, policy and service provision in Argentina in order to ensure the best possible conditions for use of medical abortion by women should be redoubled.

The role of auxiliary nurse-midwives and community health volunteers in expanding access to medical abortion in rural Nepal

Medical abortion was introduced in Nepal in 2009, but rural women's access to medical abortion services remained limited. We conducted a district-level operations research study to assess the effectiveness of training 13 auxiliary nurse-midwives as medical abortion providers, and 120 female community health volunteers as communicators and referral agents for expanding access to medical abortion for rural women. Interviews with service providers and women who received medical abortion were undertaken and service statistics were analysed. Compared to a neighbouring district with no intervention, there was a significant increase in the intervention area in community health volunteers' knowledge of the legal conditions for abortion, the advantages and disadvantages of medical abortion, safe places for an abortion, medical abortion drugs, correct gestational age for home use of medical abortion, and carrying out a urine pregnancy test. In a one-year period in 2011-12, the community health volunteers did pregnancy tests for 584 women and referred 114 women to the auxiliary nurse-midwives for abortion; 307 women in the intervention area received medical abortion services from auxiliary nurse-midwives. There were no complications that required referral to a higher-level facility except for one incomplete abortion. Almost all women who opted for medical abortion were happy with the services provided. The study demonstrated that auxiliary nurse-midwives can independently and confidently provide medical abortion safely and effectively at the sub-health post level, and community health volunteers are effective change agents in informing women about medical abortion.

Medical abortion and manual vacuum aspiration for legal abortion protect women's health and reduce costs to the health system: findings from Colombia

The majority of abortions in Colombia continue to take place outside the formal health system under a range of conditions, with the majority of women obtaining misoprostol from a thriving black market for the drug and self-administering the medication. We conducted a cost analysis to compare the costs to the health system of three approaches to the provision of abortion care in Colombia: post-abortion care for complications of unsafe abortions, and for legal abortions in a health facility, misoprostol-only medical abortion and vacuum aspiration abortion. Hospital billing records from three institutions, two large maternity hospitals and one specialist reproductive health clinic, were analysed for procedure and complication rates, and costs by diagnosis. The majority of visits (94%) were to the two hospitals for post-abortion care; the other 6% were for legal abortions. Only one minor complication was found among the women having legal abortions, a complication rate of less than 1%. Among the women presenting for post-abortion care, 5% had complications during their treatment, mainly from infection or haemorrhage. Legal abortions were associated not only with far fewer complications for women, but also lower costs for the health system than for post-abortion care. We calculated based on our findings that for every 1,000 women receiving post-abortion care instead of a legal abortion within the health system, 16 women experienced avoidable complications, and the health system spent US $48,000 managing them. Increasing women's access to safe abortion care would not only reduce complications for women, but would also be a cost-saving strategy for the health system.

[Psychological aspects of abortion]

OBJECTIVE

To propose recommendations for women's counseling in abortion request and the psychological experience of orthogenic teams.

MATERIALS AND METHODS

Bibliographic search in the Medline database, PubMed, Cochrane Database Library, EM Premium bases, ENT Unistra and Cairn from 1990 to 2016.

RESULTS

During the pre-abortion consultations, it is recommended to respect the choice of the woman on to see or not the ultrasound images (gradeC) and determine with her the time it needs to perform abortion (professional agreement). Women's satisfaction seems greater when they have the possibility to choose the abortion method (grade B). It is therefore important that both methods are available to all gestational ages (professional agreement). There is no relationship between an increase in psychiatric disorders and induced abortion (NP2). Meetings for professionals are useful and should, to the extent possible, be established (professional agreement).

CONCLUSION

Improving psychological support for women involve listening them and respect their choice. This also involves thinking as a team.

Women's experiences with medication for menstrual regulation in Bangladesh

Menstrual regulation has been legal in Bangladesh since 1974, but the use of medication for menstrual regulation is new. In this study, we sought to understand women's experiences using medication for menstrual regulation in Bangladesh. We conducted 20 in-depth interviews with rural and urban women between December 2013 and February 2014. All interviews were audiotaped, transcribed, translated, computer recorded and coded for analysis. The majority of women in our study had had positive experiences with medication for menstrual regulation and successful outcomes, regardless of whether they obtained their medication from medicine sellers/pharmacies, doctors or clinics. Women were strongly influenced by health providers when deciding which method to use. There is a need to educate not only women of reproductive age, but also communities as a whole, about medication for menstrual regulation, with a particular emphasis on cost and branding the medication. Continued efforts to improve counselling by providers about the dose, medication and side-effects of medication for menstrual regulation, along with education of the community about medication as an option for menstrual regulation, will help to de-stigmatise the procedure and the women who seek it.

Women's perspectives on termination service delivery in Vietnam: a cross-sectional survey in three provinces

Objective

To explore the perspectives of abortion service users regarding termination methods and abortion service delivery in Vietnam.

Materials and methods

Structured exit interviews were conducted between August and November 2011 with women who underwent termination of pregnancy at 62 public health facilities in Hanoi, Khanh Hoa, and Ho Chi Minh City in Vietnam. All women presenting for termination during the study period were recruited to participate in the study. Following their abortion, women were asked about their perspectives on abortion service delivery and attributes of medical abortion (MA) versus manual vacuum aspiration (MVA). Multiple logistic regression was used to assess the association between current method uptake and each attribute.

Results

A total of 1,233 women were included in the survey: 541 (43.9%) from Hanoi, 163 (13.2%) from Khanh Hoa, and 529 (42.9%) from Ho Chi Minh: 23.1% underwent MA; 78.9% reported that women should be given a choice between MA and MVA; and 77.6% thought that abortion services were accessible. Among the 48% who responded, 30.1% thought that MA should be made available at primary/secondary health care facilities. Among women who had previously undergone both methods, women who reported that MA “feels more natural” (like a menstrual regulation/period) were more likely to choose MA for their current abortion (odds ratio 2.15, 95% confidence interval 1.26–3.69).

Conclusion

MA uptake is significantly lower than MVA uptake. Further insights to women’s perceptions of MA in Vietnam could help improve abortion service delivery in the country.

Mobile phone messages to provide support to women during the home phase of medical abortion in South Africa: a randomised controlled trial

OBJECTIVES

Home use of misoprostol for medical abortion is more convenient for many women than in-clinic use but requires management of abortion symptoms at home without provider backup. This study evaluated whether automated text messages to women undergoing medical abortion can reduce anxiety and emotional discomfort, and whether the messages can better prepare women for symptoms they experience.

STUDY DESIGN

A multisite randomized controlled trial was conducted in which women undergoing early medical abortion were allocated to receive standard of care (SOC) only (n=235) or SOC+a messaging intervention (n=234). Consenting women were interviewed at the clinic after taking mifepristone and again at their follow-up clinic visit 2-3 weeks later; the intervention group received text messages over the duration of this period. Emotional outcomes were evaluated using the Hospital Anxiety and Depression Scale, Adler's 12-item emotional scale and the Impact of Event Scale-Revised. Preparedness for the abortion symptoms and overall satisfaction with the procedure were assessed using 4-point Likert-type scales.

RESULTS

Between baseline and follow-up, anxiety decreased more (p=0.013), and less emotional stress was experienced (adjusted for baseline anxiety, p=0.015), in the intervention compared to the SOC group. Participants in the intervention group were also more likely to report that they felt very well prepared for the bleeding (p<0.001), pain (p=0.042) and side effects (p=0.027) they experienced. Acceptability and other negative emotions relating to the abortion did not differ between study groups. Ninety-nine percent of the intervention group stated that they would recommend the messages to a friend having the same procedure.

CONCLUSIONS

Text messages to women following mifepristone administration for early medical abortion may assist them in managing symptoms and appear highly acceptable to recipients.

IMPLICATION STATEMENT

This randomized controlled trial provides evidence for the effectiveness of text messages following mifepristone administration in strengthening medical abortion care. The messages were associated with significant reductions in women's anxiety and stress during the abortion process; they improved preparedness for the abortion symptoms experienced and appeared highly acceptable.

Women's and providers' experiences with medical abortion provided through telemedicine: a qualitative study

BACKGROUND

In states requiring physicians to dispense mifepristone, the small number of providers offering the method limits its uptake. In 2008, Planned Parenthood of the Heartland in Iowa began providing medical abortion via telemedicine at clinics without an on-site physician. The purpose of this study was to evaluate patients' and providers' experiences with telemedicine provision of medical abortion.

METHODS

Between October 2009 and February 2010, in-depth interviews were conducted at Planned Parenthood clinics with 25 women receiving medical abortion services (20 telemedicine patients and 5 in-person patients) and 15 clinic staff. Data were analyzed qualitatively for themes related to acceptability of the telemedicine service delivery model.

FINDINGS

Patients and providers cited numerous advantages of telemedicine, including decreased travel for patients and physicians and greater availability of locations and appointment times compared with in-person provision. Overall, patients were positive or indifferent about having the conversation with the doctor take place via telemedicine, with most reporting it felt private/secure and in some cases even more comfortable than an in-person visit. However, other women preferred being in the same room with the physician, highlighting the importance of informing women about their options so they can choose their preferred service modality.

CONCLUSIONS

The findings from this study indicate that telemedicine can be used to provide medical abortion in a manner that is highly acceptable to patients and providers with minimal impact on the clinic.

PRACTICE IMPLICATIONS

This information demonstrates the feasibility of telemedicine to extend the reach of physicians and improve abortion access in rural settings.

Latin American women's experiences with medical abortion in settings where abortion is legally restricted

Abortion is legally restricted in most of Latin America where 95% of the 4.4 million abortions performed annually are unsafe. Medical abortion (MA) refers to the use of a drug or a combination of drugs to terminate pregnancy. Mifepristone followed by misoprostol is the most effective and recommended regime. In settings where mifepristone is not available, misoprostol alone is used.Medical abortion has radically changed abortion practices worldwide, and particularly in legally restricted contexts. In Latin America women have been using misoprostol for self-induced home abortions for over two decades.This article summarizes the findings of a literature review on women's experiences with medical abortion in Latin American countries where voluntary abortion is illegal.Women's personal experiences with medical abortion are diverse and vary according to context, age, reproductive history, social and educational level, knowledge about medical abortion, and the physical, emotional, and social circumstances linked to the pregnancy. But most importantly, experiences are determined by whether or not women have the chance to access: 1) a medically supervised abortion in a clandestine clinic or 2) complete and accurate information on medical abortion. Other key factors are access to economic resources and emotional support.Women value the safety and effectiveness of MA as well as the privacy that it allows and the possibility of having their partner, a friend or a person of their choice nearby during the process. Women perceive MA as less painful, easier, safer, more practical, less expensive, more natural and less traumatic than other abortion methods. The fact that it is self-induced and that it avoids surgery are also pointed out as advantages. Main disadvantages identified by women are that MA is painful and takes time to complete. Other negatively evaluated aspects have to do with side effects, prolonged bleeding, the possibility that it might not be effective, and the fact that some women eventually need to seek medical care at a hospital where they might be sanctioned for having an abortion and even reported to the police.

Mexican women seeking safe abortion services in San Diego, California

Except for in Mexico City, abortion is legally restricted throughout Mexico, and unsafe abortion is prevalent. We surveyed 1,516 women seeking abortions in San Diego, California. Of these, 87 women (5.7%) self-identified as Mexican residents. We performed in-depth interviews with 17 of these women about their experiences seeking abortions in California. The Mexican women interviewed were generally well-educated and lived near the U.S.-Mexican border; most sought care in the United States due to mistrust of services in Mexico, and the desire to access mifepristone, a drug registered in the United States for early medical abortion. Several reported difficulties obtaining health care in Mexico or reentering the United States when they had postabortion complications. Several areas for improvement were identified, including outreach to clinics in Mexico.

Clients' perceptions of the quality of care in Mexico city's public-sector legal abortion program

CONTEXT

In 2007, first-trimester abortion was legalized in Mexico City. Limited research has been conducted to understand clients' perceptions of the abortion services available in public-sector facilities.

METHODS

Perceptions of quality of care were measured among 402 women aged 18 or older who had obtained abortions at any of three public-sector sites in Mexico City in 2009. Six domains of quality of care (client-staff interaction, information provision, technical competence, postabortion contraceptive services, accessibility and the facility environment) were assessed, and ordinal logistic regression analysis was conducted to identify the domains that were important in women's overall evaluation of care.

RESULTS

Clients gave overall services a high rating, with a mean of 8.8 out of 10. In multivariate analysis, overall ratings were higher among women who said the doctor made them feel comfortable (odds ratio, 3.3), the receptionist was respectful (1.7), the staff was very careful to protect their privacy (2.5), they had received sufficient information on self-care at home following the abortion and on postabortion emotions (1.9 and 2.0, respectively) and they felt confident in the doctor's technical skill (2.5). Rating site hours as very convenient (2.4), waiting time as acceptable (2.8) and the facility as very clean (1.9) were all associated with higher overall scores. Compared with women who had given birth, those who had not rated the services lower overall (0.6).

CONCLUSION

Efforts to improve patient experiences with abortion services should focus on client-staff interaction, information provision, service accessibility, technical competence and the facility environment. The most highly significant factor appears to be whether a doctor makes a woman feel comfortable during her visit.

A qualitative assessment of the acceptability and potential demand for medical abortion among university students in Durban, South Africa

OBJECTIVES

To assess the acceptability of medical abortion as a method for pregnancy termination among young South African women, and further investigate the potential demand for medical abortion.

METHODS

Qualitative study based on in-depth interviews. The interviews were conducted with 20 sexually active, female university students in Durban, South Africa.

RESULTS

The findings suggest that there is a demand for medical abortion among this sample of young women. Most of them find medical abortion an acceptable method, and would choose it if they were faced with an unwanted pregnancy. Some of the positive aspects of medical abortion raised were: increased privacy; avoidance of surgery; and sense of greater control. Some of the negative aspects of medical abortion were: fear of adverse side effects; high cost; follow-up visits; and potential psychological stress. While the majority of women find this method acceptable, there were reservations and concerns about introducing it into the public sector such as misuse and abuse of the medication by clients and providers.

CONCLUSION

Medical abortion should be introduced into the public sector in South Africa, and this method be made affordable, accessible, and available for women.

Aborto provocado: redução da frequência e gravidade das complicações. Consequência do uso de misoprostol?

OBJETIVOS: verificar a frequência e a gravidade das complicações por abortos provocados e suas possíveis associações com o uso de misoprostol. MÉTODOS: estudo de corte transversal. Durante dez meses aplicou-se uma lista de verificação (critérios da World Health Organization) a todas as 543 mulheres internadas por aborto em dois hospitais na cidade de Campinas, São Paulo. Àquelas classificadas como aborto possível, provável ou certamente provocado foi aplicado também um questionário. RESULTADOS: dentre todas as mulheres internadas, 259 (48%) foram classificadas como aborto possível, provável ou certamente induzido e responderam ao questionário; 25 mulheres declararam a indução do aborto e, destas, nove referiram uso de misoprostol. Complicações infecciosas e hemorrágicas ocorreram respectivamente em 10% e 13% das 259 mulheres. As que usaram misoprostol se complicaram menos que as que usaram outros métodos, porém essa diferença não foi estatisticamente significativa, talvez pela baixa freqüência de complicações. CONCLUSÕES: os dados mostram redução da freqüência e da gravidade das complicações do aborto, mas não permitem avaliar o papel do misoprostol.

Experiences of abortion: a narrative review of qualitative studies

BACKGROUND

Although abortion or termination of pregnancy (TOP) has become an increasingly normalized component of women's health care over the past forty years, insufficient attention has been paid to women's experiences of surgical or medical methods of TOP.

OBJECTIVE

To undertake a narrative review of qualitative studies of women's experiences of TOP and their perspectives on surgical or medical methods.

METHODS

Keyword searches of Medline, CINAHL, ISI, and IBSS databases. Manual searches of other relevant journals and reference lists of primary articles.

RESULTS

Qualitative studies (n = 18) on women's experiences of abortion were identified. Analysis of the results of studies reviewed revealed three main themes: experiential factors that promote or inhibit the choice to seek TOP; experiences of TOP; and experiential aspects of the environment in which TOP takes place.

CONCLUSION

Women's choices about TOP are mainly pragmatic ones that are related to negotiating finite personal and family and emotional resources. Women who are well informed and supported in their choices experience good psychosocial outcomes from TOP. Home TOP using mifepristone appears attractive to women who are concerned about professionals' negative attitudes and lack of privacy in formal healthcare settings but also leads to concerns about management and safety.

Accuracy of a semi-quantitative urine pregnancy test compared to serum beta-hCG measurement: a possible screening tool for ongoing pregnancy after medication abortion

PURPOSE

Medication abortion protocols commonly rely on ultrasound or serum hCG measurement to confirm completion. In order to explore the use of a urine-based test to screen for ongoing pregnancy, we compared the diagnostic accuracy of a recently developed semi-quantitative urine pregnancy test to serum beta-hCG testing.

METHODS

We evaluated the urine test with 97 women in early pregnancy at a hospital and private clinic in Mexico City. The results of the urine test (hCG level > or <1000 IU/L) were correlated with those of a serum quantitative beta-hCG immunoradiometric assay.

RESULTS

The sensitivity of the urine test to identify individuals with a serum beta-hCG level >1000 IU/L was 88.6% (95% CI 74.6- 95.7%), and its specificity was 71.7% (95% CI 57.4-82.8%).

CONCLUSION

The reasonably high sensitivity of this urine test suggests it might be useful as a screening test to detect ongoing pregnancy after medication abortion. Future research should evaluate its utility in clinical follow-up protocols.

Reducing maternal mortality due to elective abortion: Potential impact of misoprostol in low-resource settings

Over 99% of deaths due to abortion occur in developing countries. Maternal deaths due to abortion are preventable. Increasing the use of misoprostol for elective abortion could have a notable impact on maternal mortality due to abortion. As a test of this hypothesis, this study estimated the reduction in maternal deaths due to abortion in Africa, Asia and Latin America. The estimates were adjusted to changes in assumptions, yielding different possible scenarios of low and high estimates. This simple modeling exercise demonstrated that increased use of misoprostol, an option for pregnancy termination already available to many women in developing countries, could significantly reduce mortality due to abortion. Empirical testing of the hypothesis with data collected from developing countries could help to inform and improve the use of misoprostol in those settings.

Unsafe abortion: the preventable pandemic

Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe abortions (97%) are in developing countries. An estimated 68 000 women die as a result, and millions more have complications, many permanent. Important causes of death include haemorrhage, infection, and poisoning. Legalisation of abortion on request is a necessary but insufficient step toward improving women's health; in some countries, such as India, where abortion has been legal for decades, access to competent care remains restricted because of other barriers. Access to safe abortion improves women's health, and vice versa, as documented in Romania during the regime of President Nicolae Ceausescu. The availability of modern contraception can reduce but never eliminate the need for abortion. Direct costs of treating abortion complications burden impoverished health care systems, and indirect costs also drain struggling economies. The development of manual vacuum aspiration to empty the uterus, and the use of misoprostol, an oxytocic agent, have improved the care of women. Access to safe, legal abortion is a fundamental right of women, irrespective of where they live. The underlying causes of morbidity and mortality from unsafe abortion today are not blood loss and infection but, rather, apathy and disdain toward women.

Pharmacy provision of medical abortifacients in a Latin American city

PURPOSE

Access to legal abortion services is restricted in Latin America. Nonetheless, previous research suggest that women frequently use misoprostol to self-induce abortion. In many settings, women obtain the medication from a pharmacy. This study was conducted to better understand pharmacy staff knowledge and provision practices of misoprostol and other medical abortifacients.

METHODS

We first interviewed staff at a random sample of 102 pharmacies in a Latin American city. Mystery clients were subsequently sent to the same pharmacies to ascertain prescribing practices and counseling.

RESULTS

Nearly half of the pharmacy staff interviewed reported that they were familiar with at least one abortifacient, and an abortifacient was recommended in 74% of the mystery client encounters. Hormonal injections were most frequently recommended as abortifacients in the survey (67%) and the mystery client encounters (71%), followed by misoprostol (60% and 39%, respectively). Few of the pharmacy staff (6% in the survey and 17% in the mystery client encounters) recommended a misoprostol dosing regimen that is potentially effective.

CONCLUSION

Abortifacient provision is common at pharmacies but knowledge about medications is low among pharmacy staff.

Reaching women with instructions on misoprostol use in a Latin American country

In Latin America, where restrictive laws limit women's access to safe abortion services, misoprostol is being used to induce abortions, often without correct information on dosage or regimens. This study in an unnamed Latin American country aimed to identify appropriate channels through which instructions on misoprostol use could be disseminated to women. In-depth interviews were carried out with physicians, pharmacy staff, women who had had safe abortions and women from the community, as well as focus group discussions with advocates of safe abortion. Participants considered physicians to be the most appropriate source of information and for ensuring confidentiality for both women and provider. Participants considered midwives, pharmacists and women's groups as appropriate referral points, but not providers of information. Legal restrictions and professional risk were the primary reasons why pharmacists rejected this role, though many are selling misoprostol. There was a general lack of information about misoprostol for medical abortion among both health professionals and women. Accurate information about misoprostol use for a wide range of gynaecologic and obstetric purposes, including induced abortion, could be incorporated into training and educational materials for physicians, midwives and other appropriate mid-level providers, as well as pharmacists. Without these alternative information channels, access to information would be severely restricted, especially in rural areas.