Contextualizing medication abortion in seven African nations: A literature review

Reproductive materialism and justice for women with abortion care needs in Uganda

While reproductive health justice is often assumed to be inherent in reproductive health interventions, the nature of injustices, and the reasons for and mechanisms of concealment, are often unclear. In this article, we draw on an ethnography of priority setting and healthcare practice in eastern Uganda to illuminate these injustices and the mechanisms of concealement. We focus on discursive practices as the mechanisms through which power is activated and navigated, such that health practitioners are able to evade state surveillance and retribution. While language discourses conceal and normalise reproductive health injustices, discursive practices of care and priority setting enable reproductive controls to be navigated in ways that amplify these injustices and create new ones. In interventions, precarious conditions that impact women's reproductive health and living circumstances are often overlooked or concealed. We illustrate the convergence of biopower and necropolitical strategies to illuminate these conditions. Using the concept of reproductive materialism, we show how neoliberalism cultivates particular conditions of everyday life, in which populations are positioned as instruments for pecuniary motives, and normative controls are used to further financial gain.

The impact of COVID-19 on safe abortion access in Africa: An analysis through a framework of reproductive justice and lens of structural violence

The SARS-CoV-2 virus causing the coronavirus disease (COVID-19) global pandemic heightened restrictions on sexual and reproductive health and rights (SRHR), especially concerning safe abortion access. The African region has been particularly susceptible to the impact of COVID-19 on sexual and reproductive health services. Using a framework of reproductive justice, we interviewed key informants from the Mobilizing Action around Medication Abortion (MAMA) Network regarding the impacts of structural violence and COVID-19 on SRHR programming in Africa, particularly programming on self-managed abortion. We identified themes of lacking infrastructures of support, emergent marginality, and neocolonial funding environments as facets of structural violence within the context of the MAMA Network, as heightened by the COVID-19 global pandemic.

Quality of information offered to women by drug sellers providing medical abortion in Nigeria: Evidence from providers and their clients

Background

Evidence confirmed that the demand for medical abortion (MA) increased significantly during the COVID-19 outbreak in many developing countries including Nigeria. In an abortion-restrictive setting like Nigeria, local pharmacies, and proprietary patent medicine vendors (PPMVs) continue to play a major role in the provision of MA including misoprostol. There is the need to understand these providers' knowledge about the use of misoprostol for abortion and the quality of information they provide to their clients. This analysis is focused on assessing the quality of care provided by both drug seller types, from drug sellers' and women's perspectives.

Methodology

This study utilized primary data collected from drug sellers (pharmacists and PPMVs) and women across 6 Local Government Areas in Lagos State, Nigeria. The core sample included 126 drug sellers who had sold abortion-inducing drugs and 386 women who procured abortion-inducing drugs from the drug sellers during the time of the study. We calculate quality-of-care indices for the care women received from drug sellers, drawing on WHO guidelines for medication abortion provision. The index based on information from the sellers had two domains—technical competency and information provided to clients, while the index from the women's perspectives includes an additional domain, client experience.

Results

Results show that the majority of drug sellers in the sample, 56% (n = 70), were pharmacists. However, far more than half of women 60% (n = 233) had visited PPMVs. Overall, the total quality score amongst all drug sellers (mean 0.48, SD0.15) was higher than the total score calculated based on women's responses (mean 0.39, SD 0.21). Using our quality-of-care index, pharmacies and PPMVs seem to have similar technical competency (mean score of 0.23, SD 0.13 in both groups (range 0–1), whilst PPMV's performed better on the information provided to client domain (mean score of 0.79, SD 0.17 compared with pharmacies 0.69, SD 0.25). Based on women's reports, PPMVs scored better on both quality of care domains (technical competency and information provided to clients) compared with pharmacies.

Program/Policy Implication

In resource-constrained settings such as Nigeria, particularly in the context of health emergencies like COVID-19, there is the need to continue to strengthen and engage PPMVs' capacity and skills in dispensing and administration of MA drugs as a harm reduction strategy. Also, there is the need to target frontline providers in pharmacies for training and skill upscale in MA provision.

Impact of abortion law reforms on women's health services and outcomes: a systematic review protocol

BACKGROUND

A country's abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women's access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women's health services and outcomes in LMICs.

METHODS

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women's health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

DISCUSSION

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women's health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019126927.

Impact of abortion law reforms on health services and health outcomes in low- and middle-income countries: a systematic review

While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, expanding the grounds on which abortion can be performed legally. However, the implications of these reforms on women's access to and use of health services, as well as their health outcomes, are uncertain. This systematic review aimed to evaluate and synthesize empirical research evidence concerning the effects of abortion law reforms on women's health services and health outcomes in LMICs. We searched Medline, Embase, CINAHL and Web of Science databases, as well as grey literature and reference lists of included studies. We included pre-post and quasi-experimental studies that aimed to estimate the causal effect of a change in abortion law on at least one of four outcomes: (1) use of and access to abortion services, (2) fertility rates, (3) maternal and/or neonatal morbidity and mortality and (4) contraceptive use. We assessed the quality of studies using the quasi-experimental study design series checklist and synthesized evidence through a narrative description. Of the 2796 records identified by our search, we included 13 studies in the review, which covered reforms occurring in Uruguay, Ethiopia, Mexico, Nepal, Chile, Romania, India and Ghana. Studies employed pre-post, interrupted time series, difference-in-differences and synthetic control designs. Legislative reforms from highly restrictive to relatively liberal were associated with reductions in fertility, particularly among women from 20 to 34 years of age, as well as lower maternal mortality. Evidence regarding the impact of abortion reforms on other outcomes, as well as whether effects vary by socioeconomic status, is limited. Further research is required to strengthen the evidence base for informing abortion legislation in LMICs. This review explicitly points to the need for rigorous quasi-experimental studies with sensitivity analyses to assess underlying assumptions. The systematic review was registered in PROSPERO database CRD42019126927.