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Hall C, Daire J, Hendrie D. A scoping review considering the processes involved in changing abortion laws in low- and middle-income countries. Health Policy Plan 2023; 38:1181-1197. [PMID: 37702199 DOI: 10.1093/heapol/czad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 09/01/2023] [Accepted: 09/07/2023] [Indexed: 09/14/2023] Open
Abstract
Providing legal and safe abortion is promoted as one of the key global strategies for reducing maternal mortality. Following the landmark 1994 International Conference on Population and Development, low- and middle-income countries (LMICs) are shifting towards more liberal abortion legislation. Whilst the existing literature has predominantly focused on agenda setting and individual country contexts, there is a need to understand the universal policy process of changing abortion laws. Drawing on the heuristic policy stages model and policy analysis triangle, this paper explores the processes involved in changing abortion laws in LMICs and discusses the influencing factors. We conducted a search for peer-reviewed literature in ProQuest, Scopus, Global Health (Ovid), PubMed and CINAHL. Initially, the search was conducted in February 2021 and was then re-run in May 2023. A total of 25 studies were included in the analysis. Following a descriptive, thematic and interpretive analysis of the extracted data, we have drawn out the key stages involved in changing abortion laws in LMICs: (1) establishing the need for changing abortion laws in a local context; (2) generating local evidence to support changes in abortion laws; (3) drafting of new and/or amendments of existing abortion laws; (4) adoption and enactment of changes in abortion laws; (5) translating the legal provisions into services and (6) assessing the impact of changes in abortion laws on maternal health. Our analysis explores the influence of actors and contextual factors, and we also discuss the policy solutions and decisions made by governments. The findings demonstrate that while the timing of change in abortion law was found to be dependent on the context of individual settings, the process and factors that influenced the change were remarkably consistent across geographies. Further research is required to evaluate the link between changes in abortion laws and maternal health outcomes.
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Affiliation(s)
- Carmen Hall
- School of Population Health, Curtin University, Kent Street, Bentley, Western Australia 6102, Australia
| | - Judith Daire
- School of Population Health, Curtin University, Kent Street, Bentley, Western Australia 6102, Australia
| | - Delia Hendrie
- School of Population Health, Curtin University, Kent Street, Bentley, Western Australia 6102, Australia
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Sriram V, Brophy SA, Sharma K, Elias MA, Mishra A. Associations, unions and everything in between: contextualising the role of representative health worker organisations in policy. BMJ Glob Health 2023; 8:e012661. [PMID: 37758667 PMCID: PMC10537963 DOI: 10.1136/bmjgh-2023-012661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/20/2023] [Indexed: 09/29/2023] Open
Abstract
Associations, unions and other organised groups representing health workers play a significant role in the development, adoption and implementation of health policy. These representative health worker organisations (RHWOs) are a key interface between employers, governments and their members (both actual and claimed), with varying degrees of influence and authority within and across countries. Existing research in global health often assumes-rather than investigates-the roles played by RHWOs in policy processes and lacks analytical specificity regarding the definitional characteristics of RHWOs. In this article, we seek to expand and complicate conceptualisations of RHWOs as key actors in global health by unpacking the heterogeneity of RHWOs and their roles in policy processes and by situating RHWOs in context. First, we define RHWOs, present a typology of RHWO dimensions and discuss perceived legitimacy of RHWOs as policy actors. Next, we unpack the roles of RHWOs in policy processes and distinguish RHWO roles in regulation from those of regulatory agencies. The final sections situate RHWOs in political and labour relations contexts, and in sociohistorical contexts, with attention to institutional frameworks, professional hierarchies and intersectional factors such as race, gender, sexuality, class, caste and religion. We conclude by outlining research gaps in the study of RHWOs and policy, and by encouraging global health researchers and practitioners to incorporate an expanded focus on these actors. Taking this approach will generate a wider range of strategies to better engage these organisations in policy processes and will ensure stronger health workforce policies globally.
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Affiliation(s)
- Veena Sriram
- School of Public Policy and Global Affairs, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Sorcha A Brophy
- Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Kartik Sharma
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Maya Annie Elias
- School of Development, Azim Premji University, Bengaluru, Karnataka, India
- Sociology, University of Antwerp, Antwerpen, Belgium
| | - Arima Mishra
- School of Development, Azim Premji University, Bengaluru, Karnataka, India
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Abebe M, Mersha A, Degefa N, Molla W, Wudneh A. Magnitude of second-trimester-induced abortion and associated factors among women who received abortion service at public hospitals of Arba Minch and Wolayita Sodo towns, southern Ethiopia: A cross-sectional study. Front Glob Womens Health 2022; 3:969310. [PMID: 36312870 PMCID: PMC9614144 DOI: 10.3389/fgwh.2022.969310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Second-trimester abortion accounts for 10-15% of all induced abortions, with varying rates across countries, and is responsible for two-thirds of major abortion complications. It is also associated with higher medical costs, morbidity, and mortality rates than first-trimester abortion. Even though it is a significant burden, there is a lack of adequate information about second-trimester-induced abortion, especially in the study area. As a result, the primary purpose of this study is to fill this research gap and assess the magnitude and associated factors of second-trimester-induced abortion in the public hospitals of Arba Minch and Wolayita Sodo towns, southern Ethiopia. Methods A facility-based cross-sectional study was conducted. Systematic sampling was used to select 353 study participants. Data were collected through face-to-face interviews using a structured questionnaire and record review by using Kobo collect version 3.1. Analysis was done by STATA 14. Logistic regression was used to identify associated factors of the second-trimester-induced abortion. Results The magnitude of second-trimester-induced abortion in the study setting was 23% (95%CI: 18.5%, 27.4%). The factors associated with second-trimester-induced abortion among women received abortion care services were respondent's age 25-29 and 30-34 years old (AOR = 0.38, 95%CI:0.15, 0.96 and (AOR = 0.31, 95%CI:0.10, 0.97, respectively), planned pregnancy (AOR = 0.22, 95%CI:0.11, 0.44), and delay confirming pregnancy (AOR = 2.21, 95%CI:1.15, 4.23). Conclusion This study showed that more than one-fifth of women who presented for abortion care services had second-trimester-induced abortions. Health institution organizations working on maternal health at various levels should provide counseling to women to help them early confirm their pregnancy and make decisions about whether or not to continue it as early as possible.
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Affiliation(s)
- Mesfin Abebe
- Department of Midwifery, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia,*Correspondence: Mesfin Abebe
| | - Abera Mersha
- School of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Nega Degefa
- School of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Wondwosen Molla
- Department of Midwifery, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Aregahegn Wudneh
- Department of Midwifery, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
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Holcombe SJ, Kidanemariam Gebru S. Agenda setting and socially contentious policies: Ethiopia's 2005 reform of its law on abortion. Reprod Health 2022; 19:218. [PMID: 35698196 PMCID: PMC9195348 DOI: 10.1186/s12978-021-01255-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/04/2021] [Indexed: 11/10/2022] Open
Abstract
Background In 2005, Ethiopia took a bold step in reforming its abortion law as part of the overhaul of its Penal Code. Unsafe abortion is one of the three leading causes of maternal mortality in low-income countries; however, few countries have liberalized their laws to permit safer, legal abortion. Methods This retrospective case study describes the actors and processes involved in Ethiopia’s reform and assesses the applicability of theories of agenda setting focused on internal versus external explanations. It draws on 54 interviews conducted in 2007 and 2012 with informants from civil society organizations, health professionals, government, international nongovernmental organizations and donors, and others familiar with the reproductive health policy context in Ethiopia as well as on government data, national policies, and media reports. The analytic methodology is within-case analysis through process tracing: using causal process observations (pieces of data that provide information about context, process, or mechanism and can contribute to causal inference) and careful description and sequencing of factors in order to describe a novel political phenomenon and evaluate potential explanatory hypotheses. Results The analysis of key actors and policy processes indicates that the ruling party and its receptiveness to reform, the energy of civil society actors, the “open windows” offered by the vehicle of the Penal Code reform, and the momentum of reforms to improve women’s status, all facilitated liberalization of law on abortion. Results suggest that agenda setting theories focusing on national actors—rather than external causes—better explain the Ethiopian case. In addition, the stronger role for government across areas of policy work (policy specification and politics, mobilization for enactment and for implementation), and the collaborative civil society and government policy relationships working toward implementation are largely internal, unlike those predicted by theories focusing on external forces behind policy adoption. Conclusions Ethiopia’s policymaking process can inform policy reform efforts related to abortion in other sub-Saharan Africa settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01255-z. Globally, deaths of women due to unsafe abortion remain high. However, few countries have changed their laws to allow safer, legal abortion. In 2005, Ethiopia reformed its law to permit women to obtain an abortion for a significantly greater number of reasons, and this reform has resulted in a real expansion of women’s access to services. This retrospective case study uses information from interviews with 54 people involved in Ethiopia’s reform and from government and research documents to see whether explanations of the reform that focus on the roles of national actors versus on the roles of external actors and influences better explain how Ethiopia’s reform took place. This study finds that national actors and processes were most central to Ethiopia’s reform. In particular, a ruling party open to reform, the work of the women’s movement and of reproductive health nongovernmental organizations, the ability to take advantage of political events, and the collaborative relationship between government and nongovernmental organizations all supported reform. At the time, many major external actors were either against the reform (the U.S. government) or stayed neutral. Findings can help those seeking to understand or plan policy reform efforts in other sub-Saharan Africa countries.
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Affiliation(s)
- Sarah Jane Holcombe
- Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
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Fekadu A, Berhe A, Belgu B, Yimer I, Tesfaye Y, Holcombe SJ, Burrowes S. Professionalism, stigma, and willingness to provide patient-centered safe abortion counseling and care: a mixed methods study of Ethiopian midwives. Reprod Health 2022; 19:197. [PMID: 35698144 PMCID: PMC9195199 DOI: 10.1186/s12978-021-01238-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/06/2021] [Indexed: 11/19/2022] Open
Abstract
Background Midwives are a large proportion of Ethiopia’s health care workforce, and their attitudes and practices shape the quality of reproductive health care, including safe abortion care (SAC) services. This study examines how midwives’ conceptions of their professional roles and views on women who have abortions relate to their willingness to provide respectful SAC. Methods This study uses a cross-sectional, mixed methods design to conduct a regionally representative survey of midwives in Ethiopia’s five largest regions (Oromia; Amhara; Southern Nations, Nationalities, and Peoples [SNNP]; Tigray; and Addis Ababa) with a multistage, cluster sampling design (n = 944). The study reports survey-weighted population estimates and the results of multivariate logistic regression analyzing factors associated with midwives’ willingness to provide SAC. Survey data were triangulated with results from seven focus group discussions (FGDs) held with midwives in the five study regions. Deductive and inductive codes were used to thematically analyze these data. Results The study surveyed 960 respondents. An estimated half of midwives believed that providing SAC was a professional duty. Slightly more than half were willing to provide SAC. A belief in right of refusal was common: two-thirds of respondents said that midwives should be able to refuse SAC provision on moral or religious grounds. Modifiable factors positively associated with willingness to provide SAC were SAC training (AOR 4.02; 95% CI 2.60, 6.20), agreeing that SAC refusal risked women’s lives (AOR 1.69; 95% CI 1.20, 2.37), and viewing SAC provision as a professional duty (AOR 1.72; 95% CI 1.23, 2.39). In line with survey findings, a substantial number of FGD participants stated they had the right to refuse SAC. Responses to client scenarios revealed “directive counseling” to be common: many midwives indicated that they would actively attempt to persuade clients to act as they (the midwives) thought was best, rather than support clients in making their own decisions. Conclusion Findings suggest a need for new guidelines to clarify procedures surrounding conscientious objection and refusal to provide SAC, as well as initiatives to equip midwives to provide rights-based, patient-centered counseling and avoid directive counseling. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01238-0. When health care workers refuse to provide safe abortion care (SAC) for religious, moral, or personal reasons, they jeopardize their clients’ health and violate the right to care. Scholars believe that health care workers’ professional commitments to patient care and to their profession’s goals can help them prioritize patient care over their personal biases. The Ethiopian government has assigned midwives a central responsibility to provide SAC, but there is no comprehensive understanding of Ethiopian midwives’ willingness to provide SAC and allied rationales, or the relationships between their sense of professional duty and willingness to provide. To answer these questions, a survey and focus groups with midwives in Ethiopia’s five most populated regions were conducted. Almost half of midwives were unwilling to provide SAC, and half disbelieved that it was midwives’ duty to do so. Most believed that midwives should be able to refuse to provide SAC based on religious or moral objections. Midwives were motivated to provide care by a belief that clients would die without care and by a sense of professional duty. When asked about how they would treat women requesting abortion care and contraceptives, many midwives said that they would encourage the woman to do what the midwife him- or herself thought best, rather than support her in making her own decision. These regionally representative findings suggest the need for new provider guidelines to clarify practices surrounding conscientious objection and refusal to provide safe abortion care and for programs to better train midwives to provide respectful counseling.
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Affiliation(s)
- Addisu Fekadu
- Ethiopian Midwives Association, Equatorial Guinea Road, Behind Elsa Kolo, Addis Ababa, Ethiopia
| | - Aster Berhe
- UNFPA, Old ECA Building, 5th Floor, Menelik Avenue, Addis Ababa, Ethiopia
| | - Belete Belgu
- Ethiopian Midwives Association, Equatorial Guinea Road, Behind Elsa Kolo, Addis Ababa, Ethiopia
| | - Ibrahim Yimer
- Ethiopian Midwives Association, Equatorial Guinea Road, Behind Elsa Kolo, Addis Ababa, Ethiopia
| | - Yeshitila Tesfaye
- Ethiopian Midwives Association, Equatorial Guinea Road, Behind Elsa Kolo, Addis Ababa, Ethiopia
| | - Sarah Jane Holcombe
- Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Sahai Burrowes
- Touro University, California Public Health Program, 1310 Club Drive, Vallejo, CA, 94592, USA
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Abebe M, Mersha A, Degefa N, Gebremeskel F, Kefelew E, Molla W. Determinants of induced abortion among women received maternal health care services in public hospitals of Arba Minch and Wolayita Sodo town, southern Ethiopia: unmatched case-control study. BMC Womens Health 2022; 22:107. [PMID: 35397584 PMCID: PMC8994190 DOI: 10.1186/s12905-022-01695-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background About 210 million women become pregnant per year, with one out of every ten pregnancies terminating unsafely worldwide. In developing countries, unsafe induced abortion is a leading cause of maternal mortality and morbidity. In addition, the burden of public health is also greatest in developing regions. In Ethiopia, abortion was responsible for 8.6% of maternal deaths. Despite the problem's significance, little is known about the factors that lead to women terminating their pregnancies. Therefore, this study aims to identify the factors associated with having induced abortion in public hospitals of Arba Minch and Wolayita Sodo town, Southern Ethiopia. Methods An institutional-based unmatched case–control study was conducted among 413 women from 15th April to 15th June 2021 in selected public hospitals of Arba Minch and Wolayita Sodo town, Southern Ethiopia. Cases were women who received induced abortion care services or who received post-abortion care services after being presented to the selected public hospital with an attempt of induced abortion whereas controls were women who came for maternal health care (antenatal or postnatal care) services in selected public hospitals and never had history of induced abortion. The data were collected by pretested and structured questionnaires with face-to-face interviews via Kobo Collect v3.1 mobile tools and analyzed by STATA version14. Logistic regression model was used to identify factors associated with induced abortion. In this study P-value less than 0.05 with 95% CI was declared a result as statistically significant. Results In this study, 103 cases and 309 controls were participated. Urban residence (AOR = 2.33, 95%CI:1.26, 4.32), encountered first sex at age of 20–24 years (AOR = 0.51, 95%CI:0.27,0.97), multiple sexual partner (AOR = 5.47, 95%CI: 2.98,10.03), women who had one child (AOR = 0.32, 95%CI: 0.10, 0.99), and good knowledge of contraceptives (AOR = 0.12, 95%CI: 0.03, 0.46) were identified as determinants of induced abortion. Conclusions Interventions focusing on those identified factors could probably reduce the burden and consequences of induced abortion. Sexual and reproductive health education and family planning programs would target urban dwellers, women who start sexual intercourse between the ages of 15 and 19, women with more than one sexual partner, women with a desire to limit childbearing, and women with poor contraceptive knowledge in order to reduce induced abortion. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01695-0.
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Affiliation(s)
- Mesfin Abebe
- Department of Midwifery, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia.
| | - Abera Mersha
- School of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Nega Degefa
- School of Nursing, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Feleke Gebremeskel
- School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Etenesh Kefelew
- School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia
| | - Wondwosen Molla
- Department of Midwifery, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
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Mishra A, Elias MA, Sriram V. A Draconian Law: Examining the Navigation of Coalition Politics and Policy Reform by Health Provider Associations in Karnataka, India. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2021; 46:703-730. [PMID: 33493290 DOI: 10.1215/03616878-8970895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A comprehensive picture of provider coalitions in health policy making remains incomplete because of the lack of empirically driven insights from low- and middle-income countries. The authors examined the politics of provider coalitions in the health sector in Karnataka, India, by investigating policy processes between 2016 and 2018 for developing amendments to the Karnataka Private Medical Establishments Act. Through this case, they explore how provider associations function, coalesce, and compete and the implications of their actions on policy outcomes. They conducted in-depth interviews, document analysis, and nonparticipant observations of two conferences organized by associations. They found that provider associations played a major role in drafting the amendments and negotiating competing interests within and between doctors and hospital associations. Despite the fragmentation, the associations came together to reinterpret the intentions of the amendments as being against the interests of the profession, culminating in a statewide protest and strike. Despite this show of strength, provider associations only secured modest modifications. This case demonstrates the complex and unpredictable influence of provider associations in health policy processes in India. The authors' analysis highlights the importance of further empirical study on the influence of professional and trade associations across a range of health policy cases in low- and middle-income countries.
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Brophy SA, Sriram V. Introduction to "Recontextualizing Physician Associations: Revisiting Context, Scope, Methodology". JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2021; 46:641-652. [PMID: 33493296 DOI: 10.1215/03616878-8970852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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Suh S. A Stalled Revolution? Misoprostol and the Pharmaceuticalization of Reproductive Health in Francophone Africa. FRONTIERS IN SOCIOLOGY 2021; 6:590556. [PMID: 33954164 PMCID: PMC8091168 DOI: 10.3389/fsoc.2021.590556] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 01/14/2021] [Indexed: 06/12/2023]
Abstract
Misoprostol entered the global market under the name Cytotec in the mid-1980s for the treatment of gastric ulcers. Decades of research have since demonstrated the safety and effectiveness of off-label use of misoprostol as a uterotonic in pregnant women to prevent and treat post-partum hemorrhage, treat incomplete abortion, or terminate first-trimester pregnancy. Global health experts emphasize misoprostol's potential to revolutionize access to reproductive health care in developing countries. Misoprostol does not require refrigeration, can be self-administered or with the aid of a non-physician, and is relatively inexpensive. It holds particular promise for improving reproductive health in sub-Saharan Africa, where most global maternal mortality related to post-partum hemorrhage and unsafe abortion occurs. Although misoprostol has been widely recognized as an essential obstetric medication, its application remains highly contested precisely because it disrupts medical and legal authority over pregnancy, delivery, and abortion. I draw on fieldwork in Francophone Africa to explore how global health organizations have negotiated misoprostol's abortifacient qualities in their reproductive health work. I focus on this region not only because it has some of the world's highest rates of maternal mortality, but also fertility, thereby situating misoprostol in a longer history of family planning programs in a region designated as a zone of overpopulation since the 1980s. Findings suggest that stakeholders adopt strategies that directly address safe abortion on the one hand, and integrate misoprostol into existing clinical protocols and pharmaceutical supply systems for legal obstetric indications on the other. Although misoprostol has generated important partnerships among regional stakeholders invested in reducing fertility and maternal mortality, the stigma of abortion stalls its integration into routine obstetric care and availability to the public. I demonstrate the promises and pitfalls of pharmaceuticalizing reproductive health: despite the availability of misoprostol in some health facilities and pharmacies, low-income and rural women continue to lack access not only to the drug, but to quality reproductive health care more generally.
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Kangaude G, Coast E, Fetters T. Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia. Sex Reprod Health Matters 2020; 28:1832291. [PMID: 33121392 PMCID: PMC7887923 DOI: 10.1080/26410397.2020.1832291] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Universal Health Coverage (UHC) forces governments to consider not only how services will be provided – but which services – and to whom, when, where, how and at what cost. This paper considers the implications for achieving UHC through the lens of abortion-related care for adolescents. Our comparative study design includes three countries purposively selected to represent varying levels of restriction on access to abortion: Ethiopia (abortion is legal and services implemented); Zambia (legal, complex services with numerous barriers to implementations and provision of information); Malawi (legally highly restricted). Our policy and legal analyses are supplemented by comparative vignettes based on interviews (n = 330) in 2018/2019 with adolescents aged 10–19 who have sought abortion-related care in each country. We focus on an under-considered but critical legal framing for adolescents – the age of consent. We compare legal and political commitments to advancing adolescent sexual and reproductive health and rights, including abortion-related care. Ethiopia appears to approach UHC for safe abortion care, and the legal provision for under 18-year-olds appears to be critical. In Malawi, the most restrictive legal environment for abortion, little progress appears to have been made towards UHC for adolescents. In Zambia, despite longstanding legal provision for safe abortion on a wide range of grounds, the limited services combined with low levels of knowledge of the law mean that the combined rights and technical agendas of UHC have not yet been realised. Our comparative analyses showing how policies and laws are framed have critical implications for equity and justice.
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Affiliation(s)
- Godfrey Kangaude
- Postdoctoral Fellow, Centre for Human Rights, University of Pretoria, Pretoria, South Africa
| | - Ernestina Coast
- Professor of Health and International Development, London School of Economics, London, UK. Correspondence :
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de Vries I, van Keizerswaard LJ, Tolboom B, Bulthuis S, van der Kwaak A, Tank J, de Koning K. Advocating safe abortion: outcomes of a multi-country needs assessment on the potential role of national societies of obstetrics and gynecology. Int J Gynaecol Obstet 2019; 148:282-289. [PMID: 31859365 PMCID: PMC7027546 DOI: 10.1002/ijgo.13092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/03/2022]
Abstract
In 2019 the International Federation of Gynecology and Obstetrics (FIGO) embarked on an initiative that aims to strengthen the capacity of 10 national societies of obstetrics and gynecology (ObGyn) in advocacy for safe abortion. In 2018 needs assessments that entailed a desk study, interviews, and stakeholder workshops were conducted in Benin, Cameroon, Côte d'Ivoire, Kenya, Mali, Mozambique, Panama, Peru, Uganda, and Zambia. The general aim of the needs assessments was to gain a deeper understanding of the contextual situation and identify the needs of ObGyn societies in relation to safe abortion advocacy. This paper provides a cross‐country analysis of the outcomes of the needs assessments and reflects on the capabilities, barriers, and opportunities to strengthen this role of ObGyn societies. Common barriers, such as unavailability of services, lack of technical guidance, unawareness and ambiguity about the legal framework, provider attitudes, and abortion stigma, pose challenges for ObGyn societies to work constructively on safe abortion advocacy. However, ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers’ advocacy role. Five strategies were developed to strengthen the capacity of ObGyn societies in safe abortion advocacy. ObGyn societies have the potential to advance women's health and rights to safe abortion care by strengthening their advocacy role through a multi‐strategy approach.
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Affiliation(s)
| | | | | | | | | | - Jaydeep Tank
- Chair of the Safe Abortion CommitteeFIGOMumbaiIndia
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Freeman E, Coast E. Conscientious objection to abortion: Zambian healthcare practitioners' beliefs and practices. Soc Sci Med 2019; 221:106-114. [DOI: 10.1016/j.socscimed.2018.12.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 11/27/2022]
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Bain LE, Kongnyuy EJ. Eliminating the high abortion related complications and deaths in Cameroon: the restrictive legal atmosphere on abortions is no acceptable excuse. BMC WOMENS HEALTH 2018; 18:71. [PMID: 29793462 PMCID: PMC5968528 DOI: 10.1186/s12905-018-0564-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 05/15/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND The abortion law in Cameroon is highly restrictive. The law permits induced abortions only when the woman's life is at risk, to preserve her physical and mental health, and on grounds of rape or incest. Unsafe abortions remain rampant with however rare reported cases of persecution, even when these abortions are proven to have been carried out illegally. DISCUSSION Available public health interventions are cheap and feasible (Misoprostol and Manual Vacuum Aspiration in post abortion care, modern contraception, post-abortion counseling), and must be implemented to reduce unacceptably high maternal mortality rates in the country which still stand at as high as 596/100.000. Changes in the legal status of abortions might take a long time to come by. Albeit, advocacy efforts must be reinforced to render the law more liberal to permit women to seek safe abortion services. The frequency of abortions, generally clandestine, in this restrictive legal atmosphere has adverse economic, health and social justice implications. CONCLUSION We argue that a non-optimal or restrictive legal atmosphere is not an acceptable excuse to justify these high maternal deaths resulting from unsafe abortions, especially in Cameroon where unsafe abortions remain rampant. Implementing currently available, cheap and effective evidence based practice guidelines are possible in the country. Expansion and use of Manual Vacuum Aspiration kits in health care facilities, post-abortion misoprostol and carefully considering the content of post abortion counseling packages deserve keen attention. More large scale qualitative and quantitative studies nationwide to identify and act on context specific barriers to contraception use and abortion related stigma are urgently needed.
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Affiliation(s)
- Luchuo Engelbert Bain
- Centre for Population Studies and Health Promotion, CPSHP, Yaounde, Cameroon. .,Athena Institute for Research on Innovation and Communication in Health & Life Sciences, Faculty of Earth and Life Sciences, Vrije Universiteit, Amsterdam, The Netherlands.
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