Metrics of Survival: Post-Abortion Care and Reproductive Rights in Senegal

Acceptance and use of mobile health technology in post-abortion care

BACKGROUND

Abortion and its complications have always been associated with challenges such as the lack of awareness, high cost of receiving in-person services, lack of access to the skilled healthcare workers, distance from healthcare centers in remote areas, and cultural sensitivities. Therefore, the use of mobile health technology in post-abortion care has been suggested. This study aimed to investigate factors influencing the acceptance and use of mhealth technology in post-abortion care.

METHOD

A mixed-methods study was completed in 2023. Initially, a literature review was conducted. Then, a five-point Likert-scale questionnaire was designed based on the results of the literature review. The research participants were gynecologists (n = 24), midwives (n = 38), and women who had experience of abortion (n = 183). Data were analyzed using descriptive and inferential statistics.

RESULTS

The findings revealed that the participants had different opinions about the importance of motivating and inhibiting factors which included individual, technical, economic, organizational, and ethico-legal aspects. It seems that the individual, organizational, economic, and ethico-legal motivating factors as well as the ethico-legal inhibiting factors were more important than other factors and had higher mean values. In addition, there was a statistically significant difference between the mean values of gynecologists and patients regarding the individual motivating (P = 0.014) and technical inhibiting factors (P = 0.016). The gynecologists' opinions regarding the technical motivating factors were also significantly different from midwives (P = 0.044) and patients (P = 0.010).

CONCLUSION

Multiple factors may influence the acceptance and use of mhealth technology in post-abortion care. Therefore, mhealth service developers must consider these factors to improve the quality of services and increase technology adoption. This will lead to saving costs, improving health, reducing abortion complications, and ultimately improving quality of life for women. However, further research in patient engagement and health interventions tailored to diverse cultural contexts are recommended.

"Beautiful Registrations": Metrics and Prenatal Care in Rural Bahia, Brazil

In Brazil, lack of quality in the delivery of prenatal care is a persistent concern. In this study, I analyze the dynamics taking place in the prenatal clinical encounter, and illuminate how the requirement to produce metrics through registration and monitoring endorses a form of bureaucratic care. This form of care develops in a context characterized by scarcity and a lack of medical resources, where healthcare professionals attempt to contain uncertainty. Ruled by notions of risk, centered in measuring practices, and saturated by an overvaluation of technology, bureaucratic care reinforces the disenfranchizement and stigmatization of Black rural women.

The effect of a postpartum intrauterine device programme on choice of contraceptive method in Tanzania: a secondary analysis of a cluster-randomized trial

Vertical global health programmes often evaluate success with a narrow focus on programmatic outcomes. However, evaluation of broader patient-centred and unintended outcomes is critical to assess impacts on patient choice and autonomy. Here, we evaluate the effects of a postpartum intrauterine device (PPIUD) intervention on outcomes related to contraceptive method choice. The stepped-wedge cluster randomized contolled trial (RCT) took place in five Tanzanian hospitals. Hospitals were randomized to receive immediate (Group 1; n = 11 483 participants) or delayed (Group 2; n = 8148 participants) intervention. The intervention trained providers on PPIUD insertion and counselling. The evaluation surveyed eligible women (18+, resided in Tanzania, gave birth at a study hospital) on provider postpartum contraceptive counselling during pregnancy or immediately postpartum. In our completed study, participants were considered exposed (n = 9786) or unexposed (n = 10 145) to the intervention based on the location and timing of their birth (no blinding). Our secondary analysis examined differences by intervention exposure on the likelihood of being counselled on IUD only, multiple methods, multiple method durations, a broad method mix; and on the number of methods women were counselled across two samples: all eligible women, and only women who reported receiving any contraceptive counselling. Among all eligible women, counselling on the IUD alone was 7% points higher among the exposed (95% confidence interal (CI): 0.02, 0.12). Among women who received any counselling, those exposed to the intervention were counselled on 1.12 fewer contraceptive methods (95% CI: 0.10, 2.34). The likelihood of receiving counselling on any non-IUD method decreased among those exposed, while the likelihood of being counselled on an IUD alone was 14% points higher among the exposed (95% CI: 0.06, 0.22), suggesting this intervention increased IUD-specific counselling but reduced informed contraceptive choice. These findings underscore the importance of broad metrics that capture autonomy and rights (in addition to programmatic goals) at all stages of health programme planning and implementation.

Building infrastructures of abortion care in an un-caring state: acompañante's carework and abortion access in Peru

For abortion seekers, Peru is an uncaring state where legal and policy interventions have resulted in violence, persecution, and neglect. This state of abortion uncare is set within historic and ongoing denials of reproductive autonomy, coercive reproductive care, and the marginalisation of abortion. Abortion is not supported, even where legally permissible. Here we explore abortion care activism within the Peruvian context, foregrounding a key mobilisation that has emerged against a state of un-care - acompañante carework. Through interviews with people involved in abortion access and activism in Peru, we argue that acompañantes have constructed an infrastructure of abortion care in Peru through the bringing together of actors, technologies, and strategies. This infrastructure is shaped by a feminist ethic of care that differs from minority world care assumptions regarding high quality abortion care in three key ways: (i) care is provided beyond the state; (ii) care is holistic; and (iii) care is collective. We argue that US feminist debates relating to the emerging hyperrestrictive state of abortion un-care as well as broader research on feminist care can learn from acompañante activism strategically and conceptually.

Abortion after Dobbs: Defendants, denials, and delays

The U.S. Supreme Court's Dobbs decision will lead to more criminalization of activities during pregnancy, more abortion denials, and more abortions after the first trimester.

Supply-Side Versus Demand-Side Unmet Need: Implications for Family Planning Programs

Despite its central importance to global family planning, the "unmet need for contraception" metric is frequently misinterpreted. Often conflated with a lack of access, misinterpretation of what unmet need means and how it is measured has important implications for family planning programs. We review previous examinations of unmet need, with a focus on the roles of access and demand for contraception, as well as the role of population control in shaping the indicator's priorities. We suggest that disaggregating unmet need into "demand-side unmet need" (stemming from lack of demand) and "supply-side unmet need" (stemming from lack of access) could allow current data to be leveraged into a more person-centered understanding of contraceptive need. We use Demographic and Health Survey data from seven sub-Saharan African countries to generate a proof-of-concept, dividing women into unmet need categories based on reason for contraceptive nonuse. We perform sensitivity analyses with varying conceptions of access and disaggregate by education and marital status. We find that demand-side unmet need far exceeds supply-side unmet need in all scenarios. Focusing on supply-side rather than overall unmet need is an imperfect but productive step toward person-centered measurement, while more sweeping changes to family planning measurement are still required.

Datafied Pregnancies: Health Information Technologies and Reproductive Governance in Turkey

Since the early 2000s, Turkey has been going through a dynamic period of health reforms where the global push toward health statistics has converged with the state's pronatalist concerns over declining birth rates. Reproductive behaviors are now monitored via health information technologies such as centralized databases. The World Health Organization and the Turkish Ministry of Health celebrate these technologies as essential steps toward evidence-based health care delivery. The everyday realities of these technologies, however, are more complicated, especially for nurses and their patients. Drawing on ethnographic fieldwork in state-run health clinics in Istanbul, this article demonstrates how these data-driven health technologies build on nurses' gendered care labor and increase surveillance on urban poor and/or ethnoracially minoritized communities. In doing so, I argue that the datafication of reproduction operates as a particular mode of "reproductive governance" (Morgan and Roberts 2012) that reflects and reproduces existing social hierarchies and inequalities.

Abortion metrics: a scoping review of abortion measures and indicators

Consensus is lacking on the most appropriate indicators to document progress in safe abortion at programmatic and country level. We conducted a scoping review to provide an extensive summary of abortion indicators used over 10 years (2008–2018) to inform the debate on how progress in the provision and access to abortion care can be best captured. Documents were identified in PubMed and Popline and supplemented by materials identified on major non-governmental organisation websites. We screened 1999 abstracts and seven additional relevant documents. Ultimately, we extracted information on 792 indicators from 142 documents. Using a conceptual framework developed inductively, we grouped indicators into seven domains (social and policy context, abortion access and availability, abortion prevalence and incidence, abortion care, abortion outcomes, abortion impact and characteristics of women) and 40 subdomains. Indicators of access and availability and of the provision of abortion care were the most common. Indicators of outcomes were fewer and focused on physical health, with few measures of psychological well-being and no measures of quality of life or functioning. Similarly, there were few indicators attempting to measure the context, including beliefs and social attitudes at the population level. Most indicators used special studies either in facilities or at population level. The list of indicators (in online supplemental appendix) is an extensive resource for the design of monitoring and evaluation plans of abortion programmes. The large number indicators, many specific to one source only and with similar concepts measured in a multitude of ways, suggest the need for standardisation.

What post-abortion care indicators don't measure: Global abortion politics and obstetric practice in Senegal

Since the early 1990s, post-abortion care (PAC) has been advocated as a harm reduction approach to maternal mortality and morbidity in countries with restrictive abortion laws. PAC indicators demonstrate that the intervention integrates safer uterine aspiration technology such as the Manual Vacuum Aspiration (MVA) syringe into obstetric practice and facilitates task-shifting from physicians to midwives. In other words, PAC not only saves women's lives, but more generally enhances the organization, quality, and cost-effectiveness of obstetric care. This article draws on my ethnography of Senegal's PAC program, conducted between 2010 and 2011, to illustrate how PAC indicators obscure the professional and technological complexities of treating abortion complications in contexts where abortion is illegal. Data collection methods include observation of PAC services and records at three hospitals; 66 in-depth interviews with health workers, government health officials, and NGO personnel; and a review of national and global PAC data. I show how anxieties about the capacity of the MVA syringe to induce abortion have engendered practices and policies that compromise the quality and availability of care throughout the health system. I explore the multivalent power of MVA statistics in strategically conveying commitments to national and global maternal mortality reduction agendas while eliding profound gaps in access to and quality of care for low-income and rural women. I argue that PAC strategies, technologies, and indicators must be situated within a global framework of reproductive governance, in which safe abortion has been omitted from maternal and reproductive health care associated with reproductive rights. Ethnographic attention to daily obstetric practices challenges globally circulating narratives about PAC as an apolitical intervention, revealing not only how anxieties about abortion ironically suppress the very rates of MVA utilization that purportedly convey PAC quality, but also how they simultaneously give rise to and obscure obstetric violence against women.

Arbitrating Abortion: Sex-selection and Care Work among Abortion Providers in England

The UK's on-going sex-selective abortion (SSA) controversy remains a major obstacle to the liberalization of national abortion governance, and is an issue broadly attributed to a "cultural" preference for sons among South Asian women. We conceptualize how healthcare professionals "arbitrate" requests for SSA by exploring the tension between its legal status and how requests are encountered by abortion providers. SSA is framed in this article as a legitimate care service that can support providers to meet the diverse reproductive health needs of women to the full extent of the law.

Availability, accessibility and utilization of post-abortion care in Sub-Saharan Africa: A systematic review

At the 1994 ICPD, sub-Saharan African (SSA) states pledged, inter alia, to guarantee quality post-abortion care (PAC) services. We synthesized existing research on PAC services provision, utilization and access in SSA since the 1994 ICPD. Generally, evidence on PAC is only available in a few countries in the sub-region. The available evidence however suggests that PAC constitutes a significant financial burden on public health systems in SSA; that accessibility, utilization and availability of PAC services have expanded during the period; and that worrying inequities characterize PAC services. Manual and electrical vacuum aspiration and medication abortion drugs are increasingly common PAC methods in SSA, but poor-quality treatment methods persist in many contexts. Complex socio-economic, infrastructural, cultural and political factors mediate the availability, accessibility and utilization of PAC services in SSA. Interventions that have been implemented to improve different aspects of PAC in the sub-region have had variable levels of success. Underexplored themes in the existing literature include the individual and household level costs of PAC; the quality of PAC services; the provision of non-abortion reproductive health services in the context of PAC; and health care provider-community partnerships.

"I was obligated to accept": A qualitative exploration of contraceptive coercion

Despite narratives about empowering women through contraception, global family planning programs are evaluated primarily by their ability to increase contraceptive uptake and reduce fertility in the developing world. Some scholars have raised concerns that this emphasis on fertility reduction and contraceptive uptake may contribute to situations where women are coerced into adopting contraceptive services they do not fully understand or want. Yet surprisingly little data have been collected to investigate whether such coercion exists or how it might manifest. In-depth interviews with 49 women of reproductive age in a sub-Saharan African country begin to fill this knowledge gap. Respondents reported a range of non-autonomous experiences including biased or directive counseling, dramatically limited contraceptive method mix, scare tactics, provision of false medical information, refusal to remove provider-dependent methods, and the non-consented provision of long-acting methods. The results show that, rather than a binary outcome, coercion sits on a spectrum and need not involve overt force or violence, but can also result from more quotidian limits to free, full, and informed choice. The study finds that global family planning policies and discourses do appear to incentivize coercive practices. It also calls into question the central role of intentionality, by demonstrating how coercion can arise from structural causes as well as interpersonal ones. By showing how contraceptive autonomy may be limited even by providers working in good faith, these results argue for an end to the instrumentalization of women's bodies, and for a radical reconceptualization of family planning goals and measurements to focus exclusively on reproductive health, rights and justice.