Abortion hotlines around the world: a mixed-methods systematic and descriptive review

Abortion Clients' Perceptions of Alternative Medication Abortion Service Delivery Options in Mississippi

OBJECTIVES

We assessed Mississippi abortion clients' perceptions of alternative medication abortion service delivery options that were restricted under state law but available elsewhere.

METHODS

We conducted in-depth interviews with medication abortion clients between November 2020 and March 2021 at Mississippi's only abortion facility. We described alternative service delivery models: telemedicine, medications by mail, and follow-up care in their community versus returning to the facility. We asked if participants would be interested in using any of these models, if available, and how use of each model would have changed their abortion experience. We used thematic analysis, organizing codes into common themes based on participants' preferences and concerns for each option.

RESULTS

Of the 25 participants interviewed, nearly all (n = 22) expressed interest in at least one option and reported that, had they been available, these would have alleviated cost, travel, and childcare barriers. Many believed these options would further ensure privacy, but a minority thought abortion was too sensitive for telemedicine or were concerned about mailing errors. Participants not interested in the alternative options also feared missing valued aspects of face-to-face care. Most did not return to the facility for follow-up (n = 19), citing financial and logistical barriers. Largely, participants were not interested in obtaining follow-up care in their community, citing concerns about provider judgment, stigma, and privacy.

CONCLUSIONS

Mississippi abortion clients were interested in models that would make abortion care more convenient while ensuring their privacy and allowing for meaningful client-provider interaction. These features of care should guide the development of strategies aimed at helping those in restricted settings, such as Mississippi, to overcome barriers to abortion care following the implementation of abortion bans in many states following the overturn of Roe v. Wade.

Self-managed Medication Abortion in the United States

Self-managed abortion (SMA) is ending a pregnancy without medical supervision, either by obtaining medications (known as self-managed medication abortion) or through other means. Many factors influence a person's decision to pursue self-managed abortion, such as time constraints, financial considerations, and local availability of abortion services. We present on the prevalence, methods and best practices for clinicians in the United States who may interface with individuals undergoing self-managed medication abortion at any point in the process through a harm reduction approach.

Intimacy, Anonymity, and "Care with Nothing in the Way" on an Abortion Hotline

This essay is an ethnographic account of a volunteer, anonymous hotline of physicians and advanced practice providers who offer medical advice and guidance to those who are taking medications on their own to end their pregnancies. Attending to the phenomenology of caring on the Hotline reveals a new form of medical expertise at play, which we call "care with nothing in the way." By operating outside the State's scrutiny of abortion provision, the Hotline offers its volunteers a way to practice abortion care that aligns with their professional and political commitments and that distances them from the direct harm they see caused by the political, financial, and bureaucratic constraints of their clinical work. By delineating the structure of this new regime of care, these providers call into question the notion of the "good doctor." They radically re-frame widely shared assumptions about the tenets of the ideal patient-doctor relationship and engender a new form of intimacy-one based, ironically, out of anonymity and not the familiarity that is often idealized in the caregiving relationship. We suggest the implications of "care with nothing in the way" are urgent, not only in the context of increasing hostility to abortion rights, but also for a culture of medicine plagued by physician burnout.

Trends and determinants of pregnancy loss in eastern Ethiopia from 2008 to 2019: analysis of health and demographic surveillance data

Background

Pregnancy losses remain a neglected issue and it will be taking more than a century before a pregnant woman in Sub Sahara has the same chance of her baby being born alive as a woman in a high-income country. Pregnancy loss data are limited and not universal in Sub Saharan countries. This study was aimed to assess the magnitude and determinants of pregnancy loss in eastern Ethiopia.

Methods

This study was conducted in, open continues and dynamic cohort of population, Kersa Health and Demographic Survillance site (HDSS) in Eastern Ethiopia in 2008–2019. All mothers who had known pregnancy outcomes during the period and reside in Kersa HDSS were considered. The prevalence proportions were calculated as the sum of all pregnancy loss divided by the number births in the specified year. Log-Binomial regression was used to determine factors associated with pregnancy loss. Prevalence Proportion Ratio (PPR) was used to report the magnitude and strength of association. A p-value of less than 0.05 was considered statistically significant.

Results

From 39,153 included pregnancies, 810 (20.7; 95%CI:19.32, 22.15 per 1000 births) experienced pregnancy loss. Stillbirth was higher than abortion (11.14 Vs. 9.55 per 1000 births). Lacking own income (aPPR:1.26; 95%CI: 1.01, 1.58), being daily laborer (aPPR:1.44; 95%:1.08, 306) history of previous pregnancy loss (aPPR:2.26, 95%CI:1.69, 3.03), unwanted pregnancy (aPPR:1.26; 95%CI:1.01, 1.80), not receiving antenatal care (aPPR:1.59; 95%CI: 1.19, 2.13) and not receive the TT-vaccine during pregnancy (aPPR:1.33; 95%CI: 1.08, 1.80) were positively associated with pregnancy loss.

Conclusions

The overall rate pregnancy loss was ranged between 19.32, 22.15 per 1000 births with higher still births than miscarriage or abortion. Pregnancy loss was positively associated with social factors reproductive health factors, and maternal health service utilization.

Analysing MyOptions: experiences of Ireland's abortion information and support service

BACKGROUND

In 2018, the Irish government enacted a liberalised abortion law permitting expanded access to abortion from January 2019. A dedicated information and support service - MyOptions - was established to provide non-directive counselling and clinical advice about unplanned pregnancy. MyOptions provides contact details for abortion providers but does not make appointments for abortion-seekers. In 2020, the Abortion Rights Campaign (ARC) conducted research into Irish residents' experiences of abortion care under the new law, including their experiences with MyOptions.

METHODS

Between September 2020 and March 2021, ARC administered an online survey. Qualitative data were coded using NVIVO software and analysed through thematic analysis. Quantitative data were analysed descriptively. This article analyses a subsection of these data to answer the question: What were abortion-seekers' experiences of using MyOptions?

RESULTS

Many respondents were unaware of MyOptions before becoming pregnant. Some described MyOptions as useful and compassionate. Others noted a lack of clarity from MyOptions about the scope of its service and a lack of information on accessing abortion after 12 weeks. Respondents reported frustration that the service did not arrange appointments, explaining that having to contact general practitioners (GPs) themselves was stressful and time-consuming, as was GPs' refusal to provide care or refer to a willing provider.

CONCLUSIONS

MyOptions primarily benefits abortion-seekers whose pregnancies are under 12 weeks and who are comfortable contacting a GP themselves. The addition of an appointments booking service and guidance on how to access abortion for medical reasons and abortion after 12 weeks could improve the service.

Reducing the harms of unsafe abortion: a systematic review of the safety, effectiveness and acceptability of harm reduction counselling for pregnant persons seeking induced abortion

BACKGROUND

Globally, access to safe abortion is limited. We aimed to assess the safety, effectiveness and acceptability of harm reduction counselling for abortion, which we define as the provision of information about safe abortion methods to pregnant persons seeking abortion.

METHODS

We searched PubMed, EMBASE, ClinicalTrials.gov, Cochrane, Global Index Medicus and the grey literature up to October 2021. We included studies in which healthcare providers gave pregnant persons information on safe use of abortifacient medications without providing the actual medications. We conducted a descriptive summary of results and a risk of bias assessment using the ROBINS-I tool. Our primary outcome was the proportion of pregnant persons who used misoprostol to induce abortion rather than other methods among those who received harm reduction counselling.

RESULTS

We included four observational studies with a total of 4002 participants. Most pregnant persons who received harm reduction counselling induced abortion using misoprostol (79%-100%). Serious complication rates were low (0%-1%). Uterine aspiration rates were not always reported but were in the range of 6%-22%. Patient satisfaction with the harm reduction intervention was high (85%-98%) where reported. We rated the risk of bias for all studies as high due to a lack of comparison groups and high lost to follow-up rates.

DISCUSSION

Based on a synthesis of four studies with serious methodological limitations, most recipients of harm reduction counselling use misoprostol for abortion, have low complication rates, and are satisfied with the intervention. More research is needed to determine abortion success outcomes from the harm reduction approach.

FUNDING

This work did not receive any funding.

PROSPERO REGISTRATION NUMBER

We registered the review in the PROSPERO database of systematic reviews (ID number: CRD42020200849).

In-person later abortion accompaniment: a feminist collective-facilitated self-care practice in Latin America

In Argentina, Chile and Ecuador, abortion at later durations of pregnancy is legally restricted. Feminist collectives in these contexts support people through self-managed medical abortion outside the healthcare system. The model of in-person abortion accompaniment represents an opportunity to examine a self-care practice that challenges and reimagines abortion provision. We formed a collaborative partnership built on a commitment to shared power and decision-making between researchers and partners. We conducted 28 key informant interviews with accompaniers in Argentina, Chile and Ecuador in 2019 about their model of in-person abortion accompaniment at later durations of pregnancy. We iteratively coded transcripts using a thematic analysis approach. Accompaniers premised their work in a feminist activist framework that understands accompaniment as addressing inequalities and expanding rights, especially for the historically marginalised. Through a detailed description of the process of in-person accompaniment, we show that the model, including the logistical considerations and security mechanisms put in place to ensure favourable abortion outcomes, emphasises peer-to-peer provision of supportive physical and emotional care of the accompanied person. In this way, it represents supported self-care through which individuals are centred as the protagonists of their own abortion, while being accompanied by feminist peers. This model of supported self-care challenges the idea that “self-care” necessarily means “solo care”, or care that happens alone. The model’s focus on peer-to-peer transfer of knowledge, providing emotional support, and centring the accompanied person not only expands access to abortion, but represents person-centred practices that could be scaled and replicated across contexts.

Reducing the burdens of forced abortion travel: Referrals, financial and emotional support, and opportunities for positive experiences in traveling for third-trimester abortion care

In the United States, travel is a fact of the abortion care provision landscape. This is largely due to the uneven geographical distribution of providers and state-level gestational duration bans that constrain what abortion care is available locally. When abortion travel is compelled by legal restriction, it is forced travel. Research has comprehensively documented that forced abortion travel is burdensome; people who must travel for abortion experience financial, logistical, and emotional burdens. Generally overlooked, however, is variation in the experience of travel-related burdens and whether and how such burdens can be reduced. Given current political hostility to abortion, the number of people who must travel and the distances they must travel for abortion are likely to grow, making the question of how travel-related burdens can be reduced in the absence of policy change of increasing relevance. Using thematic analysis of semi-structured interviews with 30 cisgender women in the United States who were forced to travel to obtain third-trimester abortion care, I identify three ways that the burdens of forced abortion travel can be mitigated without policy change: prompt referrals; financial and practical support for travel; and emotional support. In some instances, respondents experienced the received emotional support as so valuable as to offset the other burdens of travel, pointing to the possibility that some people might prefer to travel for abortion care whether or not they are forced to do so. Respondents also reported unexpected positive aspects of traveling, including experiences of kindness and human connection, underscoring that not all aspects of abortion travel are negative. Findings thicken our understanding of forced abortion travel and identify structural and interpersonal practices that can reduce the associated burdens, complementing legal and policy-oriented critiques of legal regulation that makes abortion travel necessary.