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Wollum A, De Zordo S, Zanini G, Mishtal J, Garnsey C, Gerdts C. Barriers and delays in access to abortion care: a cross-sectional study of people traveling to obtain care in England and the Netherlands from European countries where abortion is legal on broad grounds. Reprod Health 2024; 21:7. [PMID: 38221617 PMCID: PMC10789034 DOI: 10.1186/s12978-023-01729-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 12/19/2023] [Indexed: 01/16/2024] Open
Abstract
INTRODUCTION This study characterized the extent to which (1) financial barriers and (2) abortion care-seeking within a person's country of residence were associated with delays in abortion access among those travelling to England and the Netherlands for abortion care from European countries where abortion is legal on broad grounds in the first trimester but where access past the first trimester is limited to specific circumstances. METHODOLOGY We drew on cross-sectional survey data collected at five abortion clinics in England and the Netherlands from 2017 to 2019 (n = 164). We assessed the relationship between difficulty paying for the abortion/travel, acute financial insecurity, and in-country care seeking on delays to abortion using multivariable discrete-time hazards models. RESULTS Participants who reported facing both difficulty paying for the abortion procedure and/or travel and difficulty covering basic living costs in the last month reported longer delays in accessing care than those who had no financial difficulty (adjusted hazard odds ratio: 0.39 95% CI 0.21-0.74). This group delayed paying other expenses (39%) or sold something of value (13%) to fund their abortion, resulting in ~ 60% of those with financial difficulty reporting it took them over a week to raise the funds needed for their abortion. Having contacted or visited an abortion provider in the country of residence was associated with delays in presenting abroad for an abortion. DISCUSSION These findings point to inequities in access to timely abortion care based on socioeconomic status. Legal time limits on abortion may intersect with individuals' interactions with the health care system to delay care.
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Affiliation(s)
- Alexandra Wollum
- Ibis Reproductive Health, 1111 Broadway, Oakland, CA, 94607, USA.
| | - Silvia De Zordo
- Department of Anthropology, University of Barcelona, Montalegre 6-8, 08001, Barcelona, Spain
| | - Giulia Zanini
- Department of Philosophy and Cultural Heritage, Ca' Foscari University of Venice, Venice, Italy
| | - Joanna Mishtal
- Department of Anthropology, University of Central Florida, 4297 Andromeda Loop, Orlando, FL, 32816, USA
| | - Camille Garnsey
- Ibis Reproductive Health, 1111 Broadway, Oakland, CA, 94607, USA
| | - Caitlin Gerdts
- Ibis Reproductive Health, 1111 Broadway, Oakland, CA, 94607, USA
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McLean E, Blystad A, Mirkuzie AH, Miljeteig I. Health workers' experience of providing second-trimester abortion care in Ethiopia: a qualitative study. Reprod Health 2023; 20:154. [PMID: 37848942 PMCID: PMC10580537 DOI: 10.1186/s12978-023-01698-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 10/10/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Second-trimester abortions are less common than abortions in the first trimester, yet they disproportionately account for a higher burden of abortion-related mortality and morbidity worldwide. Health workers play a crucial role in granting or denying access to these services, yet little is known about their experiences. Ethiopia has been successful in reducing mortality due to unsafe abortion over the past decade, but access to second trimester abortion remains a challenge. The aim of this study is to better understand this issue by exploring the experiences of second-trimester abortion providers working in Addis Ababa, Ethiopia. METHODS A qualitative study with 13 in-depth semi-structured interviews with 16 health workers directly involved in providing second-trimester abortions, this included obstetrician and gynaecologist specialists and residents, general practitioners, nurses, and midwives. Data was collected at four public hospitals and one non-governmental clinic in Addis Ababa, Ethiopia and analysed using Malterud's text-condensation method. RESULTS The providers recognized the critical need for second-trimester abortion services and were motivated by their empathy towards women who often sought care late due to marginalisation and poverty making it difficult to access abortion before the second trimester. However, service provision was challenging according to the providers, and barriers like lack of access to essential drugs and equipment, few providers willing to conduct abortions late in pregnancy and unclear guidelines were commonly experienced. This led to highly demanding working conditions. The providers experienced ethical dilemmas pertaining to the possible viability of the fetus and women desperately requesting the service after the legal limit. CONCLUSIONS Second-trimester abortion providers faced severe barriers and ethical dilemmas pushing their moral threshold and medical risk-taking in efforts to deliver second-trimester abortions to vulnerable women in need of the service. Effort is needed to minimize health system barriers and improve guidelines and support for second-trimester abortion providers in order to increase access and quality of second-trimester abortion services in Ethiopia. The barriers forcing women into second trimester abortions also need to be addressed.
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Affiliation(s)
- Emily McLean
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, 5020, Bergen, Norway.
| | - Astrid Blystad
- Global Health Anthropology Research Group, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, 5020, Bergen, Norway
| | - Alemnesh H Mirkuzie
- John Snow Research and Training, Inc, Edna Mall Area, Addis Ababa, Ethiopia
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave, Seattle, WA, 98195, USA
| | - Ingrid Miljeteig
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, 5020, Bergen, Norway
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Constant D, Lopes S, Grossman D. Could routine pregnancy self-testing facilitate earlier recognition of unintended pregnancy? A feasibility study among South African women. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:e60-e66. [PMID: 33972398 DOI: 10.1136/bmjsrh-2020-201017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION We explored whether routine pregnancy self-testing is feasible and acceptable to women at risk of late recognition of pregnancy as a strategy to facilitate early entry into either antenatal or abortion care. METHODS A feasibility study among South African sexually active women not desiring pregnancy within 1 year, and not using long-acting or injectable contraceptives. At recruitment, we provided five free urine pregnancy tests for self-testing on the first day of each of the next 3 months. We sent monthly text reminders to use the tests with requests for no-cost text replies. Our main outcome was the proportion of participants self-testing within 5 days of the text reminder over three consecutive months. Other outcomes were ease of use of tests, preference for self-testing versus clinic testing, acceptability of routine self-testing (all binary responses followed by open response options) and response to text messages (four-point Likert scale). RESULTS We followed up 71/76 (93%) participants. Two confirmed new pregnancies at the first scheduled test and completed exit interviews, and 64/69 (93%) self-reported completing all three monthly tests. Self-testing was easy to do (66/71, 93%); advantages were convenience (21/71, 30%) and privacy (18/71, 25%), while the main disadvantage was no nurse present to advise (17/71, 24%). Most would recommend monthly testing (70/71, 99%). Text reminders were generally not bothersome (57/71, 80%); 35/69 (51%) participants replied with test results over all three months. CONCLUSION Providing free pregnancy tests to women at risk of late recognition of pregnancy is feasible to strengthen early confirmation of pregnancy status.
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Affiliation(s)
- Deborah Constant
- Women's Health Research Unit, School of Public Health & Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sofia Lopes
- Women's Health Research Unit, School of Public Health & Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, California, USA
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Zanini G, Mishtal J, De Zordo S, Ziegler AK, Gerdts C. Abortion information governance and women's travels across European borders. WOMENS STUDIES INTERNATIONAL FORUM 2021. [DOI: 10.1016/j.wsif.2021.102496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Van de Velde S, Van Eekert N, Van Assche K, Sommerland N, Wouters E. Characteristics of Women Who Present for Abortion Beyond the Legal Limit in Flanders, Belgium. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2019; 51:175-183. [PMID: 31509652 DOI: 10.1363/psrh.12116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 04/24/2019] [Accepted: 05/08/2019] [Indexed: 06/10/2023]
Abstract
CONTEXT Women who seek abortion care beyond the first trimester of gestation are often in a vulnerable socioeconomic position with limited social support, and in Belgium, the details of their circumstances are insufficiently understood. A better understanding of this group is essential to a critical evaluation of Belgian abortion policy, which restricts abortions on request after the first trimester. METHODS Anonymized patient records were collected between 2013 and 2016 from LUNA centers, which are non-hospital-based abortion clinics in Flanders. Logistic regression analyses were used to identify associations between women's characteristics and whether they presented within or beyond the legal limit, which was 13 weeks and 1 day at the time of the study. RESULTS A total of 28,741 women requested an abortion, and 972 individuals (3.4%) presented beyond the legal limit; 29% of these latter women were unable to receive abortion care as a result of the mandatory six-day waiting period. Characteristics positively associated with presenting beyond the limit, instead of beforehand, were being younger than 20, as opposed to 20-24 (odds ratio, 1.7); receiving a primary, lower secondary, upper secondary or special-needs education, rather than a higher education (1.8-3.1); being unemployed, rather than employed (1.3); and holding Belgian rather than a foreign nationality (0.8). Being accompanied by someone to the LUNA center (0.8), having irregularly (0.6) or regularly used contraceptives (0.7), and having ever had an abortion (0.8) were negatively associated with presenting beyond, rather than before, the limit. CONCLUSIONS A fuller consideration of patients' characteristics when evaluating Belgian abortion policy is needed to ensure that the needs and rights of socioeconomically vulnerable women are addressed.
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Affiliation(s)
- Sarah Van de Velde
- Centre for Population, Family and Health and the Department of Sociology, University of Antwerp, Antwerp, Belgium
| | - Nina Van Eekert
- Centre for Population, Family and Health and the Department of Sociology, University of Antwerp, Antwerp, Belgium
- Centre for Population, Family and Health
- Department of Sociology, University of Antwerp, and International Centre for Reproductive Health, Ghent University, Ghent, Belgium
| | | | - Nina Sommerland
- Centre for Population, Family and Health and the Department of Sociology, University of Antwerp, Antwerp, Belgium
| | - Edwin Wouters
- Centre for Population, Family and Health and the Department of Sociology, University of Antwerp, Antwerp, Belgium
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Constant D, Kluge J, Harries J, Grossman D. An analysis of delays among women accessing second-trimester abortion in the public sector in South Africa. Contraception 2019; 100:209-213. [PMID: 31029655 DOI: 10.1016/j.contraception.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 04/11/2019] [Accepted: 04/14/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify key delays and associated factors in women's pathway to second-trimester abortion that could inform strategies to increase earlier presentation. STUDY DESIGN We performed a secondary analysis using data collected from May 2012 to June 2013 as part of a randomized controlled trial among women having abortion at 13.0-20.0 weeks at a public hospital in South Africa. We used ultrasound and participant interview data to calculate 3 key intervals: (1) conception to suspicion of pregnancy, (2) suspicion to first healthcare visit for abortion, and (3) first healthcare visit to abortion procedure. We compared intervals for women at 13-15.0 weeks versus 15.1-20.0 weeks gestation at abortion using Wilcoxon rank-sum tests and tested for associations between gestational age at key events using multivariable linear regression. RESULTS Median (interquartile range[IQR]) durations for the 3 intervals among women at 13-15 weeks (n=93) compared to 15.1-20 weeks (n=63) gestation were: (1) 36 days (IQR 21-53 days) versus 62 days (36-71 days), p<.001; (2) 29 days (IQR 15-46 days) versus 23 days (IQR 11-39 days), p=.64; (3) 14 days (IQR 7-21 days) versus 14 days (IQR 12-21 days), p=.32. Multivariable logistic regression showed marginal associations between gestational age at suspicion of pregnancy and no prior pregnancy (aOR=3.8, 95% CI 1.0-14.6) and living in informal housing (aOR=3.1, 95% CI 1.0-9.1). Gestational age on the day of the abortion procedure was significantly associated with living in informal housing (aOR=3.1, 95% CI 1.4-6.6). CONCLUSION The only differences in delay in obtaining second trimester abortion between South African women having an earlier and later second trimester procedure is due to longer time to suspect pregnancy. IMPLICATIONS Interventions to improve early pregnancy recognition should be explored and referral processes should be streamlined to avoid unnecessary delays accessing abortion care and possibly reduce the proportion of abortions performed later in the second trimester in South Africa.
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Affiliation(s)
- Deborah Constant
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Judy Kluge
- Department of Obstetrics & Gynaecology, University of Stellenbosch and Tygerberg Hospital, Cape Town, South Africa.
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Daniel Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, California, USA.
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Marecek J, Macleod C, Hoggart L. Abortion in legal, social, and healthcare contexts. FEMINISM & PSYCHOLOGY 2017. [DOI: 10.1177/0959353516689521] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Constant D, Harries J, Malaba T, Myer L, Patel M, Petro G, Grossman D. Clinical Outcomes and Women's Experiences before and after the Introduction of Mifepristone into Second-Trimester Medical Abortion Services in South Africa. PLoS One 2016; 11:e0161843. [PMID: 27583448 PMCID: PMC5008795 DOI: 10.1371/journal.pone.0161843] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 08/12/2016] [Indexed: 11/18/2022] Open
Abstract
Objective To document clinical outcomes and women’s experiences following the introduction of mifepristone into South African public sector second-trimester medical abortion services, and compare with historic cohorts receiving misoprostol-only. Methods Repeated cross-sectional observational studies documented service delivery and experiences of women undergoing second-trimester medical abortion in public sector hospitals in the Western Cape, South Africa. Women recruited to the study in 2008 (n = 84) and 2010 (n = 58) received misoprostol only. Those recruited in 2014 (n = 208) received mifepristone and misoprostol. Consenting women were interviewed during hospitalization by study fieldworkers with respect to socio-demographic information, reproductive history, and their experiences with the abortion. Clinical details were extracted from medical charts following discharge. Telephone follow-up interviews to record delayed complications were conducted 2–4 weeks after discharge for the 2014 cohort. Results The 2014 cohort received 200 mg mifepristone, which was self-administered 24–48 hours prior to admission. For all cohorts, following hospital admission, initial misoprostol doses were generally administered vaginally: 800 mcg in the 2014 cohort and 600 mcg in the earlier cohorts. Women received subsequent doses of misoprostol 400 mcg orally every 3–4 hours until fetal expulsion. Thereafter, uterine evacuation of placental tissue was performed as needed. With one exception, all women in all cohorts expelled the fetus. Median time-to-fetal expulsion was reduced to 8.0 hours from 14.5 hours (p<0.001) in the mifepristone compared to the 2010 misoprostol-only cohort (time of fetal expulsion was not recorded in 2008). Uterine evacuation of placental tissue using curettage or vacuum aspiration was more often performed (76% vs. 58%, p<0.001) for those receiving mifepristone; major complication rates were unchanged. Hospitalization duration and extreme pain levels were reduced (p<0.001), but side effects of medication were similar or more common for the mifepristone cohort. Overall satisfaction remained unchanged (95% vs. 91%), while other acceptability measures were higher (p<0.001) for the mifepristone compared to the misoprostol-only cohorts. Conclusion The introduction of a combined mifepristone-misoprostol regimen into public sector second-trimester medical abortion services in South Africa has been successful with shorter time-to-abortion events, less extreme pain and greater acceptability for women. High rates of uterine evacuation for placental tissue need to be addressed.
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Affiliation(s)
- Deborah Constant
- Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Jane Harries
- Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Thokozile Malaba
- Women’s Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Landon Myer
- Division of Epidemiology & Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Malika Patel
- Department of Obstetrics & Gynaecology, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Gregory Petro
- Department of Obstetrics & Gynaecology, University of Cape Town and New Somerset Hospital, Cape Town, South Africa
| | - Daniel Grossman
- Ibis Reproductive Health, Oakland, California, United States of America
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Gerdts C, DeZordo S, Mishtal J, Barr-Walker J, Lohr PA. Experiences of women who travel to England for abortions: an exploratory pilot study. EUR J CONTRACEP REPR 2016; 21:401-7. [DOI: 10.1080/13625187.2016.1217325] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Silvia DeZordo
- Department of Anthropology, University of Sussex, Brighton, UK
| | - Joanna Mishtal
- Department of Anthropology, University of Central Florida, Orlando, FL, USA
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Boland R. Second trimester abortion laws globally: actuality, trends and recommendations. REPRODUCTIVE HEALTH MATTERS 2010; 18:67-89. [DOI: 10.1016/s0968-8080(10)36521-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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