Legal restrictions and complications of abortion: Insights from data on complication rates in the United States

Women’s Perceived Barriers to Accessing Post-Abortion Care Services in Selected Districts in KwaZulu Natal Province, South Africa: A Qualitative Study

Background:

Despite different interventions to curb unwanted pregnancies, repositioning Family Planning and post-abortion care services as critical priorities in health programme in Kwa-Zulu Natal, women are still admitted with induced abortion complications.

Aim:

The aim was to explore challenges experienced by women who are accessing post-abortion care services at selected public hospitals.

Methods:

A qualitative explorative, descriptive, and contextual approach was used. The population comprised all women who presented with incomplete abortion and had accessed PAC services in the selected hospitals. Purposive convenience sampling was used to select the 23 participants. Data were collected through in-depth interviews with all participants on discharge and analysed through open-coding method. Trustworthiness was ensured, by considering the criteria of credibility, dependability, applicability, and transferability. Ethical considerations were secured by requesting consent and permission to conduct the study. All interviews were voluntarily conducted following the ethically approved informed consent, anonymity and confidentiality were maintained.

Findings:

Three themes emerged reflecting challenges from women’s perspectives on accessing post abortion care. These themes were: transportation barriers, stigma, and mistreatment (lack of analgesics, early discharge).

Conclusion:

Conclusion showed the description of perceived barriers and experiences related to accessing, seeking and care received during the process of PAC. Inaccessibility to PAC was due to poor road, poor mode, lack of transport and long distance from the community to the hospital, long waiting queues, stigma, and discrimination. The PAC services should be accessible with the increased number of facilities and adequately trained staff with functional equipment and guidelines. Value clarification workshops for health professionals are essential.

Maternal and procedural factors associated with estimated blood loss in second trimester surgical uterine evacuation: a retrospective cohort analysis

BACKGROUND

Prior studies examining bleeding with uterine evacuation have focused on high-volume centers performing over 1100 procedures annually. The aim of this study was to examine associations between blood loss and patient and procedural characteristics in a center performing fewer than 50 procedures annually.

METHODS

This retrospective cohort study, with institutional review board approval, utilized procedural codes to identify patients undergoing uterine evacuation procedures between 14 weeks' and 24 weeks' gestational age across a 50-month period. The primary outcome was estimated blood loss; secondary outcomes were hemorrhage, transfusion and hospital re-admission. Associations between blood loss and other variables were examined using linear regression models.

RESULTS

Charts of 161 women met inclusion criteria. Median estimated blood loss was 400 mL (IQR 300 mL) with 37% of patients having blood loss of ≥500 mL. In univariate analyses, increased blood loss was associated with later gestational age (P <0.001) and pregnancy termination (P <0.001). In a multiple linear regression model, both remained significant. Each one-week increase in gestational age was associated with a 7.1% mean increase in estimated blood loss (95% CI 2.47% to 11.9%; P=0.003). Patients whose uterine evacuation was indicated for pregnancy termination had an 80.6% increase in blood loss compared with those with pre-operative fetal demise (95% CI 37.5% to 137.2%; P <0.001). Rates of peri-operative transfusion and re-admission for bleeding were <4%.

CONCLUSION

While blood loss may be greater in low volume centers, our transfusion and re-admission rates were low following second trimester uterine evacuation.

Association between prophylactic oxytocin use during dilation and evacuation and estimated blood loss

OBJECTIVES

Some providers use oxytocin during dilation and evacuation (D&E) to prevent or treat hemorrhage, although evidence to support this is scarce. We sought to describe the association between prophylactic oxytocin use, estimated blood loss (EBL), and surgical outcomes during D&E.

STUDY DESIGN

We performed a chart review of 730 women at 14 to 26 weeks' gestation who had a D&E at our institution between May 2010 and May 2014 to assess the association between prophylactic oxytocin use and EBL. We determined whether sociodemographic and health-related factors were associated with excessive blood loss (EBL≥250 mL) and whether oxytocin use was associated with complications, including hemorrhage (i.e., EBL≥500 mL or interventions for bleeding). We performed univariate analyses and multivariable regression models to evaluate the relationship between health-related factors and EBL≥250 mL.

RESULTS

Providers used prophylactic oxytocin in 59.9% of procedures. Asian (p=.005 and Native Hawaiian/Pacific Islander (p=.005) race, nulliparity (p=.007) and higher gestational age (p<.001) were associated with prophylactic oxytocin use. We found no difference in mean EBL (116.2±105.5 mL versus 130.7±125.5 mL, p=.09), EBL≥250 mL (31.4% vs. 68.6%, p=.15) or complications (6.1% vs. 7.1%, p=.73) including hemorrhage (1.4% vs. 5.3%, p=.14) between those who did not receive prophylactic oxytocin and those who did. No transfusions occurred in either group. In multivariable regression modeling, the adjusted OR for excessive blood loss was 0.42 (95% confidence interval 0.16-1.07) with prophylactic oxytocin use.

CONCLUSIONS

Prophylactic oxytocin use during D&E was not associated with hemorrhage or transfusion in our population.

IMPLICATIONS

Routine use of interventions for bleeding, such as intravenous oxytocin, should be based on scientific evidence or not performed. Findings from our study provide information on how oxytocin use is associated with blood loss during D&E.

Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states

OBJECTIVE

To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health.

DESIGN

Population-based natural experiment.

SETTING AND DATA SOURCES

Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011.

MAIN OUTCOMES

Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR).

INDEPENDENT VARIABLES

Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence.

MAIN RESULTS

Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=-0.061 to -1.100), skilled attendance at birth (β=-0.032 to -0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=-0.566 to -0.962), clean water (β=-0.048 to -0.730), sanitation (β=-0.052 to -0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=-14.329) and MMRAO (β=-1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates.

CONCLUSIONS

Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.

Abortion policy and science: can controversy and evidence co-exist?

Abortion policies should be based on evidence. Over the past four decades in the United States, we have accumulated more data about the practice of legal abortion than any other surgical procedure. This evidence has documented the public health impact of increased access to safer abortion. In recent years, state laws to restrict abortion access have gained momentum. An accompanying article in this issue of JPHP uses extant data to examine whether two restrictive policies have had a measurable effect on abortion morbidity. The analysis found an unexpected result – states which imposed restrictions had lower levels of abortion complications than those who did not. Various explanations exist for these findings. Caution is needed to interpret observational findings, especially with polarizing issuess like abortion.

Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later

During the 40 years since the US Supreme Court decision in Doe versus Wade and Doe versus Bolton, restrictions on termination of pregnancy (TOP) were overturned nationwide. The use of TOP was much wider than predicted and a substantial fraction of reproductive age women in the U.S. have had one or more TOPs and that widespread uptake makes the downstream impact of any possible harms have broad public health implications. While short-term harms do not appear to be excessive, from a public perspective longer term harm is conceiving, and clearly more study of particular relevance concerns the associations of TOP with subsequent preterm birth and mental health problems. Clearly more research is needed to quantify the magnitude of risk and accurately inform women with the crisis of unintended pregnancy considering TOP. The current US data-gathering mechanisms are inadequate for this important task.