Evolving capacity and decision-making in practice: adolescents' access to legal abortion services in Mexico City

Validation of the Adolescent Health Quality of Care (AHQOC) index for mystery client studies

The Adolescent Health Quality of Care (AHQOC) index is a tool designed to evaluate the quality of facility-based adolescent sexual and reproductive health (ASRH) services. This descriptive cross-sectional study aimed to validate the AHQOC index in 27 primary and secondary public health facilities located in a rural and an urban local government area (LGA) of Ogun State, Nigeria. To conduct the study, 12 mystery clients (MCs) were recruited and performed 144 visits to the health facilities. The MCs were young males and females who were seeking information on premarital sex, pregnancy prevention, sexually transmitted infections (STIs), and contraception. The validity, and reliability of the AHQOC index were evaluated using exploratory factor analysis, Cronbach's Alpha, and intra-class correlation coefficient tests. The Kaiser-Meyer-Olkin test result for the initial 37-item pool was 0.7169, and the final tool retained 27 items with a Cronbach's Alpha of 0.80. Two subscales of the index had Cronbach's Alpha of 0.76 and 0.85. The intra-rater consistency assessed by the intra-class correlation coefficient was 0.66 (0.10-0.92) p = 0.001 for the urban LGA and 0.72 (0.37-0.91) p = 0.001 for the rural LGA. Positive and statistically significant relationships were observed between the full scales and subscales and the validity item (MC ranking of health worker on proficiency from 1 to 10). The results of this study demonstrate that the validated AHQOC index is a valuable tool for assessing the quality of ASRH services in public health facilities.

“Sigue siendo un sistema precario”. Barreras de acceso a abortos clínicos: la experiencia de acompañantes en tres regiones mexicanas

El objetivo de esta investigación fue la identificación de las barreras más recurrentes de acceso a abortos en contextos clínicos (clandestinos o legales), desde la perspectiva de acompañantes, activistas feministas que acompañan a mujeres que optaron por abortos autogestionados con medicamentos. Realizamos 14 entrevistas semiestructuradas con acompañantes en tres regiones mexicanas: Baja California y Chiapas, ambos contextos restrictivos, y la Ciudad de México, donde el aborto por voluntad es legal hasta las 12 semanas. Identificamos cuatro categorías en las cuales se entretejen las vulnerabilidades sociales de las mujeres que deciden abortar, la falta de información, persistencia de estigma, y la influencia del marco legal, los fallos en la atención del aborto, incluso en las clínicas de interrupción legal de embarazo (en la Ciudad de México), y mala calidad de los servicios prestados -maltrato, objeción de conciencia y denuncia de los proveedores de salud-, y, por último, los grupos anti-derechos y sus estrategias. En las tres regiones, el acceso a abortos clínicos sigue siendo un privilegio reservado para las mujeres que cuentan con los recursos económicos, logísticos y sociales indispensables para realizarlo en esos espacios. La existencia de un programa Interrupción Legal de Embarazo en solamente una entidad denota la existencia de una desigualdad jurídica y sanitaria. Los hallazgos de este estudio sobre mujeres acompañantes de abortos aportan elementos para que el Estado mexicano mejore el acceso a abortos seguros para todas las mujeres, sobre todo ahora que la Suprema Corte de la Justicia de la Nación decretó la despenalización, y la legalización inminente en todo el país.

Abortion knowledge, attitudes and experiences among adolescent girls: a review of the literature

Adolescent girls comprise a considerable proportion of annual abortion deaths, worldwide, with 15% of all unsafe abortions taking place among girls under 20 years of age. Despite recent global attention to the health and welfare of adolescent girls, little is known about their abortion experience, particularly of those under the age of 15 years. This review examines existing peer-reviewed and grey literature on abortion-related experiences of adolescent girls, paying particular attention to girls ages 10-14. In December 2019, the authors conducted a comprehensive search of five major online resource databases, using a two-part keyword search strategy for articles from 2003 to 2019. Of the original 3,100+ articles, 1,228 were individually screened and 35 retained for inclusion in the analysis. Findings show that while adolescent girls may have knowledge of abortion in general, they lack specific knowledge of sources of care and delay care-seeking due to the fear of stigma, lack of resources and provider bias. Adolescent girls do not experience higher rates of physical complications compared to older cohorts, but they are at risk of psychosocial harm. For girls ages 10-14, abortion experience may be compounded by pregnancy due to sexual abuse or transactional sex, and they face even more barriers to care than older adolescents in terms of provider bias and lack of agency. Adolescents have unique needs and experiences around abortion, which should be accounted for in programming and advocacy. Adolescent girls need information about safe abortion at an early age and a responsive and stigma-free health system.

Reasons for Abortion: Religion, Religiosity/Spirituality and Attitudes of Male Secondary School Youth in South Africa

This study focused on the relationship between religion, religiosity/spirituality (R/S), and attitudes of a sample of South African male secondary school youth toward women's rights to legal abortion in different situations. We distributed 400 self-administered questionnaires assessing the main variables (attitudes toward reasons for abortion and R/S) to the target sample in six different secondary schools in KwaZulu-Natal, South Africa. The responses of a final sample of 327 learners were then analyzed using the Statistical Package for the Social Sciences (SPSS) software. The findings revealed that religion and R/S play a role in the youths' attitudes toward abortion. While the Hindu subsample indicated higher overall support across the different scenarios, the Muslim subsample reported greater disapproval than the other groups on 'Elective reasons' and in instances of 'Objection by significant others.' The Christian youth had the most negative attitudes to abortion for 'Traumatic reasons' and 'When women's health/life' was threatened. Across the sample, higher R/S levels were linked with more negative attitudes toward reasons for abortion.

Abortion experience and self-efficacy: exploring socioeconomic profiles of GHANAIAN women

Background

Unsafe abortions remain a major global public health concern and despite its prevalence, unsafe abortions remain one of the most neglected global health challenges. The proportion of women in Ghana who have experienced unsafe abortions has increased from 45% in 2007 to 62% in 2017. Given the noted consequences of (unsafe) abortions on women health, it is important to explore factors correlated with women’s abortion decisions and why they opt for safe or unsafe methods. The study also examines determinants of over 6,000 Ghanaian women’s self-efficacy in abortion decision-making, given that this is likely to affect the likelihood of future abortions.

Methods

Using cluster-level Geographic Information System data from the 2017 Ghana Maternal Health Survey, the study provides a hot spot analysis of the incidence of abortion in the country. The study also makes use of Probit multivariate analyses also show the correlates of abortion with socio-economic factors.

Results

Results suggest that abortion among women is positively correlated with the absence of partners, low education levels, higher household wealth, lower parity and family size, polygyny and Christian religious background.

Conclusion

It is observed that the groups of women with higher abortion self-efficacy are the same groups of women who are more likely to opt for safer abortion methods, indicating some correlation, albeit indirect, between abortion self-efficacy and women’s abortion behaviors in Ghana. Relevant policy applications are adduced from these research findings.

A systematic review of the use of adolescent mystery clients in assessing the adolescent friendliness of health services in high, middle, and low-income countries

Background: Mystery client methodology is a form of participatory research that provides a unique opportunity to monitor and evaluate the performance of health care providers or health facilities from the perspective of the service user. However, there are no systematic reviews that analyse the use of mystery clients in adolescent sexual and reproductive health (ASRH) research and monitoring and evaluation of programmes.

Objective: To assess the use of adolescent mystery clients in examining health care provider and facility performance in providing ASRH services in high, middle, and low-income countries.

Methods: We carried out a systematic review of published journal articles and reports from the grey literature on this topic from 2000 to 2017 (inclusive). Thirty research evaluations/studies were identified and included in the analysis. We identified common themes through thematic analysis.

Results: The findings reveal that researchers and evaluators used mystery client methodology to observe client-provider relationships, and to reduce observation bias, in government or private health facilities, NGOs, and pharmacies. The mystery clients in the evaluations/studies were young people who played varying roles; in most cases, they were trained for these roles. Most reported good experiences and friendly providers; however, some reported lack of privacy and confidentiality, lack of sufficient written/verbal information, and unfavourable experiences such as sexual harassment and judgmental comments. Female mystery clients were more likely than males to report unfavourable experiences. Generally, the methodology was considered useful in monitoring and evaluating the attitudes of health service providers and ASRH service provision.

Conclusions: The research evaluations/studies in this review highlight the usefulness of mystery clients as a method to gain insight, from an adolescent perspective, on the quality of ASRH services for research and monitoring and evaluation of programmes.

Trajectories of women's abortion-related care: A conceptual framework

We present a new conceptual framework for studying trajectories to obtaining abortion-related care. It assembles for the first time all of the known factors influencing a trajectory and encourages readers to consider the ways these macro- and micro-level factors operate in multiple and sometimes conflicting ways. Based on presentation to and feedback from abortion experts (researchers, providers, funders, policymakers and advisors, advocates) (n = 325) between 03/06/2014 and 22/08/2015, and a systematic mapping of peer-reviewed literature (n = 424) published between 01/01/2011 and 30/10/2017, our framework synthesises the factors shaping abortion trajectories, grouped into three domains: abortion-specific experiences, individual contexts, and (inter)national and sub-national contexts. Our framework includes time-dependent processes involved in an individual trajectory, starting with timing of pregnancy awareness. This framework can be used to guide testable hypotheses about enabling and inhibiting influences on care-seeking behaviour and consideration about how abortion trajectories might be influenced by policy or practice. Research based on understanding of trajectories has the potential to improve women's experiences and outcomes of abortion-related care.

Role-players in abortion decision-making in the Accra Metropolis, Ghana

BACKGROUND

Making the final decision to terminate a pregnancy can be influenced by different circumstances involving various individuals. This paper describes the key players involved in the decision-making process regarding abortions among women who elected to undergo an induced abortion in a cosmopolitan urban setting in Ghana.

METHODS

A retrospective cross-sectional mixed method study was conducted between January and December 2011. A total of 401 women with records in abortion logbooks were selected for an interviewer-administered questionnaire and an in-depth interview. Descriptive and multinomial logistic regression analyses were used to assess the quantitative data, and a thematic analysis was applied to the qualitative data.

RESULTS

The findings of the study reveal that pregnant individuals, mothers of abortion-seekers, male partners, and "Others" (for example, friends, employers) were instrumental in making a decision to terminate unplanned/unwanted pregnancies. Several key factors influenced the decision-making processes, including aversion from the men responsible for the pregnancy, concerns about abnormalities/deformities in future births due to unprofessionally conducted abortions, and economic considerations.

CONCLUSION

A number of individuals, such as friends, mothers, and male partners, influence the decision-making process regarding abortion among the participants of the study. Various targeted messages are needed for the various participants in the decision.