THE CHALLENGES OF OFFERING PUBLIC SECOND TRIMESTER ABORTION SERVICES IN SOUTH AFRICA: HEALTH CARE PROVIDERS' PERSPECTIVES

Delays in seeking abortion and its determinants among reproductive-age women based on the Ethiopian Demographic and health survey

Introduction

Delaying in seeking abortion services causes adverse public health outcomes, which increases maternal mortality rates due to complications from abortion. However, evidence shows that there are limited factors associated with delayed abortion. Therefore, the study aims to determine the magnitude and identify factors associated with delayed seeking abortion among reproductive-aged women in Ethiopia.

Methods

Secondary cross-sectional data analysis was conducted on the Ethiopian Demographical and Health Survey dataset. A total weighted sample of 2198 reproductive-aged women was considered in this study. All data processing and statistical analyses were performed using R-software version 4.2.3. Multilevel binary logistic regression analysis was used to identify a significant predictor for delays in seeking abortion. An adjusted odds ratio with a 95 % confidence interval was used to measure a statistical association.

Result

The prevalence of delays in seeking abortion among women in Ethiopia was 32 %. Educational status (AOR = 0.63; 95 % CI: 0.37-0.78), marital status (AOR = 2.12; 95 % CI: 1.38-3.74), wealth index (AOR = 0.54; 95 % CI: 0.41-0.75), frequency of listening a radio (AOR = 0.61; 95 % CI: 0.45-0.75), live births (AOR = 0.43; 95 % CI: 0.25-0.72), pregnancy wanted status (AOR = 0.59; 95 % CI: 0.4-0.79), contraceptive use (AOR = 0.46; 95 % CI: 0.34-0.69), and place of residence (AOR = 2.31; 95 % CI: 1.67-3.19) were statistically significantly variables associated with delays in seeking abortion.

Conclusions

Delayed seeking abortion remains high in Ethiopia. The study is vital for policymakers, healthcare providers, and advocates to improve training on the importance of early abortion care, develop targeted interventions for better accessibility to abortion services, expand health education programs to raise awareness about reproductive rights and empower women with information for informed reproductive health decisions. Health education programs, specifically targeting uneducated women, poorer women, rural resident women, and women who do not use contraceptives, would decrease delays in accessing abortion services.

Providers' experiences with abortion care: A scoping review

BACKGROUND

Induced abortion is one of the most common gynecological procedures in the world, with as many as three in every ten pregnancies ending in abortion. It, however, remains controversial. The objective of this scoping review was to explore and map existing literature on the experiences of those who provide abortion care.

METHODS AND FINDINGS

This exploratory review followed the Levac et al. guidelines and was reported in accordance with the PRISMA-ScR checklist. CINAHL, Cochrane, EMBASE, PsycInfo, PubMed, and Web of Science were used to identify peer-reviewed, original research articles published on providers' experience of abortion. We identified 106 relevant studies, which include a total sample of 4,250 providers from 28 countries and six continents. Most of the studies were qualitative (n = 83), though quantitative (n = 15) and mixed methods (n = 8) studies were also included. We identified two overarching themes: (1) Providers' experiences with abortion stigma and (2) Providers' reflections on their abortion work. Our findings suggest that providers from around the world experience challenges within society and their communities and workplaces which reinforce the stigmatization and marginalization of abortion and pose questions about the morality of this work. Most, however, are proud of their work, believe abortion care to be socially important and necessary, and remain committed to the provision of care.

CONCLUSIONS

The findings of this review provide a comprehensive overview on the known experiences of providing abortion care. It is a key point of reference for international providers, researchers, and advocates to further this area of research or discussion in their own territories. The findings of this review will inform future work on how to support providers against stigmatization and will offer providers the chance to reflect on their own experiences.

Health workers' experience of providing second-trimester abortion care in Ethiopia: a qualitative study

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.

Availability of Safe Second-Trimester Abortion Services in Health Facilities in Accra, Ghana

BACKGROUND

We examined providers, methods employed, cost, and other determinants of availability of second-trimester abortion services in health facilities in Accra, Ghana in 2019 to inform policy and program decisions.

METHODS

A two-stage mixed quantitative and qualitative study designs were employed in the conduct of the study. The first stage was a short interaction of the mystery client with a clinical care provider to identify health facilities that provide second trimester induced abortion, the cost, and referral practices, where the facility did not have the service. The second stage was in-depth interviews of second-trimester abortion care providers and non-providers in various health facilities. For internal validity, it also explored the procedure cost, referral, and other practices at the health facilities included in the study, independent of what was captured in the mystery client survey.

RESULTS

Second-trimester abortion services in Accra, Ghana are widely unavailable even in most facilities that provided abortion services. Referral policies and practices indicated by the service providers at various facility levels were inadequate. Criminalization of the procedure, social stigma, and fear of complications are the main factors that adversely influence the availability of second-trimester abortion in health facilities in Accra.

CONCLUSION

Albeit increasing demand for second-trimester abortion in health facilities in Accra, services are not readily available due to the ambiguity of the law, its interpretation, and limited flow of accurate information on providers. Policies and programs that limit access to Second-trimester abortions in Ghana are amendable to ensure safe services.

Could routine pregnancy self-testing facilitate earlier recognition of unintended pregnancy? A feasibility study among South African women

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.

Reproductive awareness and recognition of unintended pregnancy: young women, key informants and health care providers perspectives in South Africa

BACKGROUND

South Africa has a liberal abortion law, yet denial of care is not uncommon, usually due to a woman being beyond the legal gestational age limit for abortion care at that facility. For women successfully obtaining care, time from last menstrual period to confirmation of pregnancy is significantly longer among those having an abortion later in the second trimester compared to earlier gestations. This study explores women's experiences with recognition and confirmation of unintended pregnancy, their understanding of fertile periods within the menstrual cycle as well as healthcare providers' and policy makers' ideas for public sector strategies to facilitate prompt confirmation of pregnancy.

METHODS

We recruited participants from July through September 2017, at an urban non-governmental organization (NGO) sexual and reproductive health (SRH) facility and two public sector hospitals, all providing abortion care into the second trimester. We conducted in-depth interviews and group discussions with 40 women to elicit information regarding pregnancy recognition and confirmation as well as fertility awareness. In addition, 5 providers at these same facilities and 2 provincial policy makers were interviewed. Data were analysed using thematic analysis.

RESULTS

Uncertainties regarding pregnancy signs and symptoms greatly impacted on recognition of pregnancy status. Women often mentioned that others, including family, friends, partners or colleagues noticed pregnancy signs and prompted them to take action. Several women were unaware of the fertility window and earliest timing for accurate pregnancy testing. Health care providers and policy makers called for strategies to raise awareness regarding risk and signs of pregnancy and for pregnancy tests to be made more readily accessible.

CONCLUSION

Early recognition of unintended pregnancy in this setting is frustrated by poor understanding and awareness of fertility and pregnancy signs and symptoms, compounded by a distrust of commercially available pregnancy tests. Improving community awareness around risk and early signs of pregnancy and having free tests readily available may help women confirm their pregnancy status promptly.

The unmet needs for modern family planning methods among postpartum women in Sub-Saharan Africa: a systematic review of the literature

BACKGROUND

Sub-Saharan Africa has the highest fertility rate in the world, with the highest unmet need for family planning (FP). Yet, there is a lack of knowledge about the determinants for non-utilisation of modern contraceptive methods among women of reproductive age. This systematic review of literature assessed factors affecting the unmet need and reasons for non-utilisation of modern contraceptive methods during the postpartum period in Sub-Saharan African women.

METHODS

An online literature search was conducted in several databases: MEDLINE, Cochrane Review, PubMed, Elsevier's Science Direct and Web of Science. The search was completed by hand searching. Data were extracted and summarised using the Arksey and O'Malley methodology.

RESULTS

In total, 19 studies were included; one qualitative study, seventeen quantitative, and one used a mixed-methods approach. Studies were conducted in Ethiopia (n = 11), Nigeria (n = 3), Kenya (n = 2), Malawi (n = 2) and Uganda (n = 1). Factors affecting the unmet need for modern contraceptive methods were described at three levels: (a) individual; (b) household; and (c) healthcare facility level. Reasons for non-use of FP included: fear of side effects; husband's disapproval; the absence of menses; abstinence; and low perception of risk of pregnancy.

CONCLUSION

Unmet needs in postpartum FP in women from Sub-Saharan Africa were associated with health-system and socio-demographic determinants. We suggest that there is a need to improve the awareness of modern contraceptive methods through effective interventions. Further research is needed for under-studied countries in this continent.

Barriers to access second-trimester abortion: A case report

Despite the implementation of the Choice on Termination of Pregnancy (CTOP) Act, many women continue to procure illegal abortions in South Africa. A lack of knowledge of the CTOP Act and poor access to legal abortion in public health facilities is a big challenge. In the scope of the CTOP Act, the termination of pregnancy is a time-restricted health service, and women presented to a health care facility in the second trimester have encounter more obstacles to access the services.

An analysis of delays among women accessing second-trimester abortion in the public sector in South Africa

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.

Safe abortion in South Africa: "We have wonderful laws but we don't have people to implement those laws"

In South Africa, abortion was legalized in 1996, during the nation's transition from apartheid to independence and democracy, under the Choice on Termination of Pregnancy Act (CTOPA). The law drew from both a public health and rights-based framework. A coalition of advocates played a key role in passage. In the years after the CTOPA was passed, abortion services were expanded-in part through a 2008 amendment that allowed trained registered nurses to provide abortions-and deaths from unsafe abortions decreased. However, there have been hurdles to implementation, including competing health priorities such as HIV/AIDS, and a high number of conscientious objectors. There is a geographic disparity in accessibility of abortion services between provinces as well as between urban and rural areas. Women seeking legal abortions face a lack of accessible information on where to obtain an abortion, often experience stigma at facilities, and many obtain illegal procedures.

The costs and cost effectiveness of providing second-trimester medical and surgical safe abortion services in Western Cape Province, South Africa

Background

In South Africa, access to second-trimester abortion services, which are generally performed using medical induction with misoprostol alone, is challenging for many women. We aimed to estimate the costs and cost effectiveness of providing three safe second-trimester abortion services (dilation and evacuation (D&E)), medical induction with mifepristone and misoprostol (MI-combined), or medical induction with misoprostol alone (MI-misoprostol)) in Western Cape Province, South Africa to aid policymakers with planning for service provision in South Africa and similar settings.

Methods

We derived clinical outcomes data for this economic evaluation from two previously conducted clinical studies. In 2013–2014, we collected cost data from three public hospitals where the studies took place. We collected cost data from the health service perspective through micro-costing activities, including discussions with site staff. We used decision tree analysis to estimate average costs per patient interaction (e.g. first visit, procedure visit, etc.), the total average cost per procedure, and cost-effectiveness in terms of the cost per complete abortion. We discounted equipment costs at 3%, and present the results in 2015 US dollars.

Results

D&E services were the least costly and the most cost-effective at $91.17 per complete abortion. MI-combined was also less costly and more cost-effective (at $298.03 per complete abortion) than MI-misoprostol (at $375.31 per complete abortion), in part due to a shortened inpatient stay. However, an overlap in the plausible cost ranges for the two medical procedures suggests that the two may have equivalent costs in some circumstances.

Conclusion

D&E was most cost-effective in this analysis. However, due to resistance from health care providers and other barriers, these services are not widely available and scale-up is challenging. Given South Africa’s reliance on medical induction, switching to the combined regimen could result in greater access to second-trimester services due to shorter inpatient stays without increasing costs.

'If You Choose to Abort, You Have Acted As an Instrument of Satan': Zimbabwean Health Service Providers' Negative Constructions of Women Presenting for Post Abortion Care

PURPOSE

Health service providers play a crucial role in providing post abortion care in countries where abortion legislation is restrictive and abortion is stigmatised. Research in countries where these factors apply has shown that health service providers can be barriers to women accessing post abortion services. Much of this research draws from attitude theory. In this paper, we utilise positioning theory to show how the ways in which Zimbabwean health service providers' position women and themselves are rooted in cultural and social power relations. In light of recent efforts by the Zimbabwean Ministry of Health and foreign organisations to improve post abortion care, we explore the implications that these positionings have for post abortion care.

METHOD

As part of a larger study on abortion decision-making, the data featured in this article were collected using in-depth semi-structured interviews with six health service providers working in different facilities in Harare, Zimbabwe. Discursive and positioning thematic analysis was used to analyse the data.

RESULTS

Our analysis points to women who have abortions being positioned in negative terms, as transgressors of acceptable norms; irresponsible and manipulative; and ignorant. The health service providers drew from cultural, religious, gender and trauma discourses that portray abortion as evil and socially unacceptable. Reflexive positions taken up by the health service providers include positions as being experts, helpers and protectors of culture/religion, sympathisers and professional positions as health care providers.

CONCLUSION

The continued strengthening of post abortion services should be conducted in conjunction with dialogical interventions that challenge health service providers to reflect on the power relations within which women who terminate pregnancies are located, that contest their negative positionings of these women and that present alternative narratives and subject positionings for both the women who have abortions and the health service providers.

Women's experiences seeking informal sector abortion services in Cape Town, South Africa: a descriptive study

Background

In settings where abortion is legally restricted, or permitted but not widely accessible, women face significant barriers to abortion access, sometimes leading them to seek services outside legal facilities. The advent of medication abortion has further increased the prevalence of informal sector abortion. This study investigates the reasons for attempting self-induction, methods used, complications, and sources of information about informal sector abortion, and tests a specific recruitment method which could lead to improved estimates of informal sector abortion prevalence among an at-risk population.

Methods

We recruited women who have sought informal sector abortion services in Cape Town, South Africa using respondent driven sampling (RDS). An initial seed recruiter was responsible for initiating recruitment using a structured coupon system. Participants completed face-to-face questionnaires, which included information about demographics, informal sector abortion seeking, and safe abortion access needs.

Results

We enrolled 42 women, nearly one-third of whom reported they were sex workers. Thirty-four women (81%) reported having had one informal sector abortion within the past 5 years, 14% reported having had two, and 5% reported having had three. These women consumed home remedies, herbal mixtures from traditional healers, or tablets from an unregistered provider. Twelve sought additional care for potential warning signs of complications. Privacy and fear of mistreatment at public sector facilities were among the main reported reasons for attempting informal sector abortion. Most women (67%) cited other community members as their source of information about informal sector abortion; posted signs and fliers in public spaces also served as an important source of information.

Conclusions

Women are attempting informal sector abortion because they seek privacy and fear mistreatment and stigma in health facilities. Some were unaware how or where to seek formal sector services, or believed the cost was too high. Many informal methods are ineffective and unsafe, leading to potential warning signs of complications and continued pregnancy. Sex workers may be at particular risk of unsafe abortion. Based on these results, it is essential that future studies sample women outside of the formal health sector. The use of innovative sampling methods would greatly improve our knowledge about informal sector abortion in South Africa.

Electronic supplementary material

The online version of this article (10.1186/s12905-017-0443-6) contains supplementary material, which is available to authorized users.

Implementation considerations when expanding health worker roles to include safe abortion care: a five-country case study synthesis

Background

Allowing a broader range of trained health workers to deliver services can be an important way of improving access to safe abortion care. However, the expansion of health worker roles may be challenging to implement. This study aimed to explore factors influencing the implementation of role expansion strategies for non-physician providers to include the delivery of abortion care.

Methods

We conducted a multi-country case study synthesis in Bangladesh, Ethiopia, Nepal, South Africa and Uruguay, where the roles of non-physician providers have been formally expanded to include the provision of abortion care. We searched for documentation from each country related to non-physician providers, abortion care services and role expansion through general internet searches, Google Scholar and PubMed, and gathered feedback from 12 key informants. We carried out a thematic analysis of the data, drawing on categories from the SURE Framework of factors affecting the implementation of policy options.

Results

Several factors appeared to affect the successful implementation of including non-physician providers to provide abortion care services. These included health workers’ knowledge about abortion legislation and services; and health workers’ willingness to provide abortion care. Health workers’ willingness appeared to be influenced by their personal views about abortion, the method of abortion and stage of pregnancy and their perceptions of their professional roles. While managers’ and co-workers’ attitudes towards the use of non-physician providers varied, the synthesis suggests that female clients focused less on the type of health worker and more on factors such as trust, privacy, cost, and closeness to home. Health systems factors also played a role, including workloads and incentives, training, supervision and support, supplies, referral systems, and monitoring and evaluation. Strategies used, with varying success, to address some of these issues in the study countries included values clarification workshops, health worker rotation, access to emotional support for health workers, the incorporation of abortion care services into pre-service curricula, and in-service training strategies.

Conclusions

To increase the likelihood of success for role expansion strategies in the area of safe abortion, programme planners must consider how to ensure motivation, support and reasonable working conditions for affected health workers.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4764-z) contains supplementary material, which is available to authorized users.

Doing more for less: identifying opportunities to expand public sector access to safe abortion in South Africa through budget impact analysis

OBJECTIVE(S)

To estimate the costs of public-sector abortion provision in South Africa and to explore the potential for expanding access at reduced cost by changing the mix of technologies used.

STUDY DESIGN

We conducted a budget impact analysis using public sector abortion statistics and published cost data. We estimated the total costs to the public health service over 10 years, starting in South Africa's financial year 2016/17, given four scenarios: (1) holding service provision constant, (2) expanding public sector provision, (3) changing the abortion technologies used (i.e. the method mix), and (4) expansion plus changing the method mix.

RESULTS

The public sector performed an estimated 20% of the expected total number of abortions in 2016/17; 26% and 54% of all abortions were performed illegally or in the private sector respectively. Costs were lowest in scenarios where method mix shifting occurred. Holding the proportion of abortions performed in the public-sector constant, shifting to more cost-effective service provision (more first-trimester services with more medication abortion and using the combined regimen for medical induction in the second trimester) could result in savings of $28.1 million in the public health service over the 10-year period. Expanding public sector provision through elimination of unsafe abortions would require an additional $192.5 million.

CONCLUSIONS

South Africa can provide more safe abortions for less money in the public sector through shifting the methods provided. More research is needed to understand whether the cost of expanding access could be offset by savings from averting costs of managing unsafe abortions.

IMPLICATIONS

South Africa can provide more safe abortions for less money in the public sector through shifting to more first-trimester methods, including more medication abortion, and shifting to a combined mifepristone plus misoprostol regimen for second trimester medical induction. Expanding access in addition to method mix changes would require additional funds.

The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa

Background

Despite a liberal abortion law, access to safe abortion services in South Africa is challenging for many women. Medication abortion was introduced in 2013, but its reach remains limited. We aimed to estimate the costs and cost effectiveness of providing first-trimester medication abortion and manual vacuum aspiration (MVA) services to inform planning for first-trimester service provision in South Africa and similar settings.

Methods

We obtained data on service provision and outcomes from an operations research study where medication abortion was introduced alongside existing MVA services in public hospitals in KwaZulu-Natal province. Clinical data were collected through interviews with first-trimester abortion clients and summaries completed by nurses performing the procedures. In parallel, we performed micro-costing at three of the study hospitals. Using a model built in Excel, we estimated the average cost per medical and surgical procedure and determined the cost per complete abortion performed. Results are presented in 2015 US dollars.

Results

A total of 1,129 women were eligible for a first trimester abortion at the three study sites. The majority (886, 78.5%) were eligible to choose their abortion procedure; 94.1% (n = 834) chose medication abortion. The total average cost per medication abortion was $63.91 (52.32–75.51). The total average cost per MVA was higher at $69.60 (52.62–86.57); though the cost ranges for the two procedures overlapped. Given average costs, the cost per complete medication abortion was lower than the cost per complete MVA despite three (0.4%) medication abortion women being hospitalized and two (0.3%) having ongoing pregnancies at study exit. Personnel costs were the largest component of the total average cost of both abortion methods.

Conclusion

This analysis supports the scale-up of medication abortion alongside existing MVA services in South Africa. Women can be offered a choice of methods, including medication abortion with MVA as a back-up, without increasing costs.

'I am all alone': factors influencing the provision of termination of pregnancy services in two South African provinces

BACKGROUND

Globally, universal access to sexual and reproductive health care services has been re-emphasised. One-third of maternal deaths could be averted by improving access to safe abortion services. Anecdotal evidence suggests that the implementation of the Choice of Termination of Pregnancy Act has been suboptimal in South Africa.

OBJECTIVES

In two South African provinces, determine: the proportion of designated termination of pregnancy (TOP) facilities that provide these services; explore the factors that influence the provision of TOP services; and explore the work experiences of health care providers at designated TOP facilities.

METHODS

During 2014 and 2015, we conducted a cross-sectional study at designated TOP facilities in Gauteng and North West provinces. A combination of methods was used, consisting of: site visits to, and observation of, each of the designated facilities using a checklist, and in-depth interviews with a sub-set of 30 TOP service providers, using a semi-structured interview schedule. The interview questions focused on the factors influencing TOP service provision, and the work experiences of TOP service providers. We used interpretative phenomenological analysis to analyse the data from the interviews.

RESULTS

Overall, 77% (47/61) of designated facilities were providing TOP services, with 87.5% (28/32) in Gauteng Province, compared with 65.5% (19/29) in North West Province. Service provision was influenced by health system deficiencies, human resource challenges, lack of prioritisation and lack of management support. Study participants reported a heavy burden of care provision and expressed an overwhelming feeling of loneliness, courtesy stigma and lack of support from other nurses and doctors, which further influence TOP service provision.

CONCLUSIONS

South Africa has an enabling legal environment for the provision of TOP services. Supportive management, prioritisation of TOP services and employee wellness programmes to address the psychosocial issues experienced by providers are critical elements of an enabling health policy environment.

Clinical Outcomes and Women's Experiences before and after the Introduction of Mifepristone into Second-Trimester Medical Abortion Services in South Africa

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.

A critical review of sanctioned knowledge production concerning abortion in Africa: Implications for feminist health psychology

Taking a feminist health psychology approach, we conducted a systematic review of published research on abortion featured in PsycINFO over a 7-year period. We analysed the 39 articles included in the review in terms of countries in which the research was conducted, types of research, issues covered, the way the research was framed and main findings. Despite 97 per cent of abortions performed in Africa being classifiable as unsafe, there has been no engagement in knowledge production about abortion in Africa from psychologists, outside of South Africa. Given this, we outline the implications of the current knowledge base for feminism, psychology and feminist health psychology in Africa.

An exploratory study of what happens to women who are denied abortions in Cape Town, South Africa

Background

Despite the change in legal status of abortion in South Africa in 1996, barriers to access remain. Stigma associated with abortion provision and care, privacy concerns, and negative provider attitudes often discourage women from seeking legal abortion services and sometimes force women outside of the legal system.

What happens when women present for abortion at a designated abortion facility and are denied abortions due to gestational limits or other factors–is unknown. Whether women seek care at referral facilities, seek illegal abortion, or carry pregnancies to term has never been documented. This study, part of a multi-country Global Turnaway Study, explored the experiences of women after denial of legal abortion services.

Methods

Qualitative research methods were used to collect data at two non-governmental organization health care facilities providing abortion services. In depth interviews were held with women 2 to 3 months after they were denied an abortion. Data were analyzed using a thematic analysis approach.

Results

The most common reason for being turned away was due to gestational age over 12 weeks with some women denied abortions that day because they did not have enough money to pay for the procedure. Almost all women were extremely upset at being denied an abortion on the day that they visited the health care facility. Some women were so distressed that they openly discussed the option of seeking an illegal provider or exploring the possibility of securing another health care professional who would assist them.

Conclusions

Despite South Africa’s liberal abortion law and the relatively widespread availability of abortion services in urban settings, women in South Africa are denied abortion services largely due to being beyond the legal limits to obtain an abortion. A high proportion of women who were initially denied an abortion at legal facilities went on to seek options for pregnancy termination outside of the legal system through internet searches--some of which could have led to unsafe abortion practices. Further efforts should be directed towards informing women in all communities about the availability of free services in the public sector and educating them about the dangers of unsafe methods of pregnancy termination.

Health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data

BACKGROUND

Unsafe abortions are a serious public health problem and a major human rights issue. In low-income countries, where restrictive abortion laws are common, safe abortion care is not always available to women in need. Health care providers have an important role in the provision of abortion services. However, the shortage of health care providers in low-income countries is critical and exacerbated by the unwillingness of some health care providers to provide abortion services. The aim of this study was to identify, summarise and synthesise available research addressing health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia.

METHODS

A systematic literature search of three databases was conducted in November 2014, as well as a manual search of reference lists. The selection criteria included quantitative and qualitative research studies written in English, regardless of the year of publication, exploring health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The quality of all articles that met the inclusion criteria was assessed. The studies were critically appraised, and thematic analysis was used to synthesise the data.

RESULTS

Thirty-six studies, published during 1977 and 2014, including data from 15 different countries, met the inclusion criteria. Nine key themes were identified as influencing the health care providers' attitudes towards induced abortions: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence 8) quality of care and 9) stigma and victimisation.

CONCLUSIONS

Health care providers in sub-Saharan Africa and Southeast Asia have moral-, social- and gender-based reservations about induced abortion. These reservations influence attitudes towards induced abortions and subsequently affect the relationship between the health care provider and the pregnant woman who wishes to have an abortion. A values clarification exercise among abortion care providers is needed.

How risky are second trimester clandestine abortions in Cameroon: a retrospective descriptive study

BACKGROUND

Complications of clandestine abortions increase with gestational age. The aim of this study was to identify complications of second trimester clandestine abortions (STA) and those of first trimester clandestine abortions (FTA).

METHODS

This retrospective descriptive study was conducted between March 1st and August 31st, 2012 in the University Teaching Hospital and the Central Hospital, Yaoundé (Cameroon). The files of women with clandestine abortions carried out outside our units, but received in our settings for some complications were reviewed. Variables studied were maternal age, parity, marital status, gestational age at the time of abortion, the abortion provider and the method used, the duration of antibiotic coverage, the time interval between abortion and consultation, the complications presented and the duration of hospital stay. Data of 20 women with STA (≥13 weeks 1 day) and those of 74 women with FTA (≤13 complete weeks) were analyzed and compared. The t-test was used to compare continuous variables. P value <0.05 was considered statistically significant.

RESULTS

Women with STA had high parities (P = 0.0011). STAs were mostly performed by nurses and were usually done by dilatation and curettage or dilatation and evacuation, manual vacuum aspiration, intramuscular injection of an unspecified medication, transcervical foreign body insertion, amniotomy and misoprostol. STA complications were severe anemia, hypovolemic shock, uterine perforation and maternal death.

CONCLUSIONS

Clandestine abortions, especially second trimester abortions, are associated with risks of maternal morbidity and mortality especially when done by nurses. Therefore, women should seek for help directly from trained health personnel (Gynecologists & Obstetricians). Moreover, nurses should be trained in uterine evacuation procedures. They should also refer women who want to carry out STA to Gynecologists and Obstetricians. Finally, to reduce the prevalence of abortion in general, the government should make contraception available to all women, as well as use public media to sensitize women on the dangers of abortion and on the need to use family planning services.