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Grossman A, Prata N, Jones S, Läser L, Ganatra B, Lavelanet A, Williams N, Asmani C, Elamin H, Ouedraogo L, Maribe LS, Gbenou DV, Hien YC, Dadjoari M, Dao F, Adame Gbanzi MC, Mulunda Kanke R, Biayi Kanumpepa F, Dlamini D, Mefane GM, Bantiewalu SH, Brantuo MNA, Sentumbwe-Mugisa O, Mugahi R, Ojo OA, Aderoba AK, Rehnström Loi U. A descriptive summary of the WHO availability assessments of medical abortion medicines in eight African countries. Reprod Health 2024; 20:195. [PMID: 39731093 DOI: 10.1186/s12978-024-01898-8] [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: 01/25/2024] [Accepted: 10/25/2024] [Indexed: 12/29/2024] Open
Abstract
BACKGROUND The use of medical abortion using either a combination of mifepristone and misoprostol, or misoprostol alone has contributed to increased safety and decreased mortality and morbidity. The availability of quality medical abortion medicines is an essential component in the provision of quality abortion care. Understanding the factors that influence the availability of medical abortion medicines is important to help in-country policymakers, program planners, and providers improve availability and use of medical abortion. METHODS Using a national assessment protocol and an availability framework, we assessed the availability of medical abortion medicines across five elements (Registration & Quality Assurance, Policy & Financing, Procurement & Distribution, Provider Knowledge, and End-user Knowledge) in eight countries: Botswana, Burkina Faso, Central African Republic, Democratic Republic of the Congo, Eswatini, Lesotho, Namibia and Uganda between November 2020 and November 2021. The assessment included an online desk review and virtual or telephone-based key informant interviews. RESULTS Registration of medical abortion medicines-misoprostol or co-packaged mifepristone and misoprostol products (combi-pack)-was established in all countries, except the Central African Republic. In Lesotho and Eswatini, the national regulatory agency is still in development and importation of Cytotec™ misoprostol is permitted for off-label use in obstetrics/gynecology. Misoprostol was included in all countries' essential medicines lists, except Botswana. Burkina Faso and Democratic Republic of the Congo also include mifepristone on their essential medicines list and medical abortion regimens in national abortion care service and delivery guidelines. Additionally, guidelines clarified health worker roles in the provision of abortion care specific to the legal context of each country and permitted task-shifting of abortion service provision. Where guidelines did not exist, medical abortion medicines and their use were not well integrated into the public health care system. Community awareness activities on abortion rights and services have been limited in scope across the countries assessed, however, end-users' awareness of misoprostol as a medical abortion medicine was reported. CONCLUSION The national landscape assessments identified several cross-cutting opportunities to improve availability of medical abortion medicines, including importing quality-assured medical abortion medicines; developing nationally approved abortion service and delivery guidelines that optimize healthcare worker roles; and expanding communication strategies to reach end-users and pharmacists.
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Affiliation(s)
- Amy Grossman
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Ndola Prata
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
- Bixby Center for Population, Health & Sustainability, School of Public Health, University of California, Berkeley, CA, USA
| | - Sarah Jones
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Laurence Läser
- UNDP‑UNFPA‑UNICEF‑WHO‑World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland.
| | - Bela Ganatra
- UNDP‑UNFPA‑UNICEF‑WHO‑World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Antonella Lavelanet
- UNDP‑UNFPA‑UNICEF‑WHO‑World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Natalie Williams
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Chilanga Asmani
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Hayfa Elamin
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Leopold Ouedraogo
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Lucy Sejo Maribe
- World Health Organization, Botswana Country Office, Gaborone, Botswana
| | | | | | | | - Fousséni Dao
- World Health Organization, Central African Republic Country Office, Bangui, Central African Republic
| | | | - Robert Mulunda Kanke
- World Health Organization, Democratic Republic of the Congo Country Office, Kinshasa, Democratic Republic of the Congo
| | - Franck Biayi Kanumpepa
- Ministère de la Santé Publique, Hygiène et Prévention, Democratic Republic of the Congo, Kinshasa, Democratic Republic of the Congo
| | - Dudu Dlamini
- World Health Organization, Eswatini Country Office, Mbabane, Eswatini
| | | | | | | | | | - Richard Mugahi
- Ministry of Health, Reproductive Health and Infant Health, Uganda, Kampala, Uganda
| | | | | | - Ulrika Rehnström Loi
- UNDP‑UNFPA‑UNICEF‑WHO‑World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
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Kapp N, Bawah AA, Agula C, Menzel JL, Antobam SK, Asuming PO, Eckersberger E, Pearson EE. Medical abortion in Ghana: A non-randomized, non-inferiority study of access through pharmacies compared with clinics. Contraception 2024; 140:110538. [PMID: 39002625 DOI: 10.1016/j.contraception.2024.110538] [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: 04/22/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVES To compare self-reported clinical outcomes following medical abortion with mifepristone and misoprostol sourced from either a pharmacy or health clinic. STUDY DESIGN We conducted a prospective, non-randomized, non-inferiority cohort study across four regions in Ghana, from high-volume pharmacies and health clinics. Participants seeking medical abortion (less than nine weeks' gestation) who met usual medical abortion eligibility criteria were recruited. Data collection included baseline surveys, follow-up phone interviews, and self-reported assessments of medical abortion outcomes. The study aimed to enroll 2000 medical abortion users (1000 from each source). RESULTS Complete outcome data was available and analyzed from 1958 participants (of 2208 enrolled), with the adjusted risk difference of need for additional treatment to complete the abortion indicating non-inferiority of the pharmacy group compared to the clinic group [-2.3% (95% CI -5.3% to 0.7%)]. Both groups reported low rates of additional treatment (4.9%) and adhered similarly to the abortion regimen. Secondary outcomes showed no significant differences, with moderate acceptability in both groups (65.4% pharmacy, 52.3% facility). Adverse outcomes were rare: one ectopic pregnancy, one blood transfusion and no deaths or other major complications were reported. CONCLUSIONS Accessing medical abortion pills directly from pharmacies without prior consultation from a provider demonstrated non-inferior self-reported clinical outcomes compared to seeking care from health clinics. The findings align with the growing global evidence supporting the safety and effectiveness of medical abortion self-care. IMPLICATIONS This study contributes data which support future registration of over-the-counter use of medical abortion drugs up to nine weeks' gestation. Such measures could expand options for safe abortion care, especially in regions where unsafe abortion poses a substantial maternal health risk. TRIAL REGISTRATION ClinicalTrials.gov (NCT03727308).
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Affiliation(s)
| | - Ayaga A Bawah
- Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana
| | - Caesar Agula
- Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana
| | | | - Samuel K Antobam
- Regional Institute for Population Studies (RIPS), University of Ghana, Accra, Ghana
| | - Patrick O Asuming
- University of Ghana Business School (UGBS), University of Ghana, Accra, Ghana
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Yared G, Younis A, Al Hajj K, El Hajjar C, Alakrah W, Nakib H, Massaad C, Ghazal K. Haematometra arising from multiple abortions: a comprehensive case report. J Int Med Res 2024; 52:3000605241304576. [PMID: 39648845 PMCID: PMC11626672 DOI: 10.1177/03000605241304576] [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: 07/24/2024] [Accepted: 11/14/2024] [Indexed: 12/10/2024] Open
Abstract
Haematometra, a rare and delayed complication, can emerge following medical termination of pregnancy, also known as 'postabortal post-caesarean syndrome' or 'redo syndrome'. Treatment requires the immediate evacuation of both liquid and clotted blood for quick resolution, followed by administration of an oxytocic agent to ensure complete recovery. This current report describes a female patient in her mid-30s who presented with colicky lower abdominal pain following a medically-induced abortion at 10 weeks. The case underscores the critical need for vigilance in detecting haematometra after abortion or caesarean delivery. Prompt recognition through symptoms and ultrasound, followed by immediate treatment, is essential to prevent severe complications such as infertility and ensure ongoing reproductive health.
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Affiliation(s)
- Georges Yared
- Department of Obstetrics and Gynaecology, The Gilbert and Rose-Marie Chagoury School of Medicine Lebanese American University, Beirut, Lebanon
| | - Ali Younis
- Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Khodor Al Hajj
- Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Charlotte El Hajjar
- Department of Obstetrics and Gynaecology, Rafik Hariri Hospital, Beirut, Lebanon
- Department of Obstetrics and Gynaecology, Lebanese American University Medical Centre, Rizk Hospital, Beirut, Lebanon
| | - Wardah Alakrah
- Department of Obstetrics and Gynaecology, The Gilbert and Rose-Marie Chagoury School of Medicine Lebanese American University, Beirut, Lebanon
| | - Hamza Nakib
- Department of Business and Marketing, Lebanese American University, Beirut, Lebanon
| | - Christopher Massaad
- Department of Medicine, Faculty of Medicine, Saint George University of Beirut, Rmeil, Lebanon
| | - Kariman Ghazal
- Department of Obstetrics and Gynaecology, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
- Department of Obstetrics and Gynaecology, Rafik Hariri Hospital, Beirut, Lebanon
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Giorgio M, Shiferaw S, Makumbi F, Seme A, Kibira SPS, Nabukeera S, Anjur‐Dietrich S, Yihdego M, Tadele N, Sully E. Estimating the Social Visibility of Abortions in Uganda and Ethiopia Using the Game of Contacts. Stud Fam Plann 2024; 55:291-314. [PMID: 39533531 PMCID: PMC11636778 DOI: 10.1111/sifp.12278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
Social network-based data collection methods that rely on third-party reporting have emerged as a promising approach for measuring abortion in restrictive settings. In order for these methods to accurately measure abortion incidence, they must also assess the visibility of abortions within social networks. Failure to do so may result in estimates affected by transmission bias, caused by imperfect knowledge of all abortions within one's social network. In this paper, we present exploratory research that uses respondent-driven sampling (RDS) and the game of contacts method to measure abortion visibility in four sites in Uganda and Ethiopia. We assess the existence of potential biases in the game of contacts estimate of abortion visibility in each site by conducting several internal and external validity tests. While these tests provided some promising results, other factors such as the representativeness of the RDS samples, direct versus indirect abortion knowledge transfers, and the generalizability of the study sites may have introduced biases into the final estimates of abortion visibility in this study. We conclude by making recommendations on how applications of this methodology could be improved to better estimate abortion-related transmission bias.
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Affiliation(s)
| | - Solomon Shiferaw
- Department of Reproductive Health and Health Service Management, School of Public HealthAddis Ababa UniversityAddis AbabaEthiopia
| | | | - Assefa Seme
- Department of Reproductive Health and Health Service Management, School of Public HealthAddis Ababa UniversityAddis AbabaEthiopia
| | | | | | | | - Mahari Yihdego
- Department of Reproductive Health and Health Service Management, School of Public HealthAddis Ababa UniversityAddis AbabaEthiopia
| | - Niguse Tadele
- Department of Reproductive Health and Health Service Management, School of Public HealthAddis Ababa UniversityAddis AbabaEthiopia
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Oleffe A, Paul E, Mahieu C. The use of medicine retailers by people of Goma as an alternative healthcare provider: a risky but rational practice. BMC PRIMARY CARE 2024; 25:343. [PMID: 39300370 PMCID: PMC11412008 DOI: 10.1186/s12875-024-02596-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 09/10/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Medicine retailers, considered here as any person or setting dedicated to the sale of retail medicines, fill an important gap in terms of access to healthcare in areas where population are not covered by universal healthcare schemes. In Goma in the Democratic Republic of the Congo, such retailers have proliferated and are consulted as the first port of call by more than half of the population, playing therefore a key role as an alternative source of healthcare for any type of health condition. The objective of this study is to understand people of Goma's rationale for using the medicine retailers over the formal healthcare system. METHODS Twelve focus groups, gathering 147 participants in total, were conducted in four worship communities, covering the most common faiths practised in Goma. Three focus group discussions were organised per worship community: one with fathers, another with mothers, and another with chronic patients and/or highly vulnerable people. We used a qualitative and inductive approach to analyse the participants' practices and perceptions in terms of their use of medicine retailers. We identified central categories explaining the reasons for using medicine retailers and the choice of a specific medicine retailer. RESULTS When facing a health problem, most of the participants in our study tended to first buy medicines at medicine retailers because it was cheap, quick, and easily accessible. Most were aware of the risks and limitations of such practices and had developed a number of mitigation strategies in order to reduce those risks: evaluating medicine retailers' expertise; developing a "medical expertise"; and seeking proactively out empathetic care. CONCLUSIONS People in Goma make a conscious and rational choice when resorting to medicine retailers as it is seen as the least-worst option in a complex situation. In order to reduce the risks, they have developed a number of mitigation strategies. Future research should focus on the organisation of medicine retailers as a professional group to improve their supervision in a sensitive context such as Goma and on modalities to articulate them to the formal health system to guarantee a financial accessibility to healthcare for all.
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Affiliation(s)
- Amandine Oleffe
- School of Public Health, Université Libre de Bruxelles Route de Lennik, Brussels, 808 1070, Belgium.
| | - Elisabeth Paul
- School of Public Health, Université Libre de Bruxelles Route de Lennik, Brussels, 808 1070, Belgium
| | - Céline Mahieu
- School of Public Health, Université Libre de Bruxelles Route de Lennik, Brussels, 808 1070, Belgium
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Jacobson LE, Jayaweera R, Footman K, Goodman JM, Gerdts C, Darney BG. Self-reported follow-up care needs can be met in both facility and self-managed abortion: Evidence from low- and middle-income countries. Contraception 2024:110700. [PMID: 39233025 DOI: 10.1016/j.contraception.2024.110700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 09/06/2024]
Abstract
OBJECTIVES To understand in-facility follow-up care-seeking behavior among both people who self-managed medication abortions and those who obtained facility-managed care in low-and-middle-income countries. We explore factors that contribute to meeting individual self-reported follow-up care needs, core to person-centered care. STUDY DESIGN We conducted a qualitative, codebook thematic analysis of 67 in-depth interviews conducted with people who self-managed medication abortions or obtained facility-managed medication abortion care. We first classified individuals as having their follow-up care needs met (not seeking care when the participant felt confident that additional care was not warranted or desired or receiving care if it was desired) or not. Our a priori analytic domains came from the Anderson model of health services utilization - predisposing, enabling, or need factors (perceived and evaluated need for health services) that contributed to having follow-up care needs met or not. We also describe emergent themes within each domain. RESULTS Most participants (n=59, 88%) had their follow-up care needs met; half (n=33, 49%) sought follow-up care in a facility. Prior birth or abortion experiences emerged as predisposing factors for having follow-up care needs met. Having accompaniment support (from activists or hotlines who provide abortion guidance outside of clinical settings), knowing what to expect, and information sources were key enabling factors for having follow-up care needs met. Need factors included flexible follow-up care guidelines. Those who did not have their follow-up care needs met described predisposing negative health system experiences; enabling factors including health system challenges, stigma from providers, and legal risk; and need factors of required follow-up care guidelines. CONCLUSIONS Medication abortion follow-up care experiences are diverse, and individual needs can be met both in and outside of health facilities. Understanding prior experiences, enabling accompaniment support, and considering flexible follow-up care guidelines can support meeting individual follow-up care needs, which is essential to person-centered abortion care. IMPLICATIONS Follow-up care needs, essential to ensuring access to high-quality abortion services, can be met in both self-managed and in-facility medication abortion models. Policies that require follow-up care when it is not needed or desired by the person can reinforce ideas that self-managed abortion is not safe or effective, despite existing evidence.
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Affiliation(s)
- Laura E Jacobson
- Health Systems & Policy, OHSU-PSU School of Public Health, Portland, OR, United States; Oregon Health and Science University, Department of Obstetrics and Gynecology, Portland, OR, United States; Ibis Reproductive Health, Oakland, CA, United States.
| | | | - Katy Footman
- Department of Social Policy, London School of Economics and Political Science, London, UK
| | - Julia M Goodman
- Health Systems & Policy, OHSU-PSU School of Public Health, Portland, OR, United States
| | | | - Blair G Darney
- Health Systems & Policy, OHSU-PSU School of Public Health, Portland, OR, United States; Oregon Health and Science University, Department of Obstetrics and Gynecology, Portland, OR, United States; Insituto Nacional de Salud Publica (INSP), Centro de Investigacion en Salud Poblacional (CISP), Cuernavaca, Mexico
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7
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Sitefane GG, Mariano E, Essén B, Axemo P, Munguambe K. 'Better taking the risk than a lifetime punishment of early forced marriage': Young people's perceptions and experiences towards voluntary termination of pregnancy in northern Mozambique. SEXUAL & REPRODUCTIVE HEALTHCARE 2024; 41:101007. [PMID: 39029134 DOI: 10.1016/j.srhc.2024.101007] [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: 12/15/2023] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 07/21/2024]
Abstract
OBJECTIVE This study aimed to explore young people's perceptions and experiences on access to voluntary termination of pregnancy (VTP) in northern Mozambique. METHODS A qualitative study of twelve focus group discussions was conducted from June to September 2021 in Nampula province, northern Mozambique. A total of 94 purposively selected 15-24-year-old males and females participated in the study. Data was inductively coded and reflexive thematic analysis inspired by Braun and Clarke was applied. Socio-Ecological theory was used to frame the discussion. RESULTS Despite VTP being decriminalized and by law to be provided free of charge, unsafe abortion remains a common choice among young people towards unintended pregnancy. Barriers to help-seeking access to safe VTP include: 1) fear, 2) sociocultural gendered norms and power dynamics, 3) lack of VTP service provision at nearest health facilities, and 4) unaffordable services where available. Fear associated with early forced marriage, a parental corrective action towards premarital pregnancy coupled with lack of male financial autonomy to afford illicit charges, remain the most important factors preventing young people seeking for help at family and safe VTP services at facility level. CONCLUSIONS Amidst multiple barriers in accessing health services, unsafe abortion is viewed by young people as a better option than facing a lifetime punishment of early forced marriage, a common parental corrective action towards premarital pregnancy.
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Affiliation(s)
- Gilda Gondola Sitefane
- Department of Women and Children's Health, International Maternal Health, and Migration Unit (IMHm), MTC-huset, Dag Hammarskjölds Väg 14B, 752 37 Uppsala, Sweden.
| | - Esmeralda Mariano
- Faculty of Arts and Social Sciences, Department of Archaeology and Anthropology, Eduardo Mondlane University, Mozambique.
| | - Birgitta Essén
- Department of Women and Children's Health, International Maternal Health, and Migration Unit (IMHm), MTC-huset, Dag Hammarskjölds Väg 14B, 752 37 Uppsala, Sweden.
| | - Pia Axemo
- Department of Women and Children's Health, International Maternal Health, and Migration Unit (IMHm), MTC-huset, Dag Hammarskjölds Väg 14B, 752 37 Uppsala, Sweden.
| | - Khátia Munguambe
- Faculty of Medicine, Department of Community Health, Sexual and Reproductive Health Unit, Eduardo Mondlane University, Mozambique.
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Harrison L, Puri M, Greene Foster D, Karkia S, Diamond-Smith NG. Predictors and experiences of seeking abortion services from pharmacies in Nepal. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003144. [PMID: 38722984 PMCID: PMC11081245 DOI: 10.1371/journal.pgph.0003144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/03/2024] [Indexed: 05/12/2024]
Abstract
Abortion was legalized in Nepal in 2002; however, despite evidence of safety and quality provision of medical abortion (MA) pills by pharmacies in Nepal and elsewhere, it is still not legal for pharmacists to provide medication abortion in Nepal. However, pharmacies often do provide MA, but little is known about who seeks abortions from pharmacies and their experiences and outcomes. The purpose of this study is to understand the experiences of women seeking MA from a pharmacy, abortion complications experienced, and predictors for denial of MA. Data was collected from women seeking MA from four pharmacies in two districts of Nepal in 2021-2022. Data was collected at baseline (N = 153) and 6 weeks later (N = 138). Using descriptive results and multi-variable regression models, we explore differences between women who received and did not receive MA and predictors of denial of services. Most women requesting such pills received MA (78%), with those who were denied most commonly reporting denial due to the provider saying they were too far along. There were few socio-demographic differences between groups, with the exception of education and gestational age. Women reported receiving information on how to take pills and what to do about side effects. Just under half (45%) of women who took pills reported no adverse symptoms after taking them and only 13% sought care. Most women seeking MA from pharmacists in Nepal are receiving services, information, and having few post-abortion symptoms. This study expands the previous limited research on pharmacy provision of MA in Nepal using a unique dataset that recruits women at the time of abortion seeking and follows them over time, overcoming potential biases present in other study designs. This suggests that expansion of the law to allow pharmacy distribution would increase accessibility and reflect current practice.
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Affiliation(s)
- Leila Harrison
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Mahesh Puri
- Center for Research on Environment, Health and Population Activities (CREHPA), Kathmandu, Nepal
| | - Diana Greene Foster
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Sunita Karkia
- Center for Research on Environment, Health and Population Activities (CREHPA), Kathmandu, Nepal
| | - Nadia G. Diamond-Smith
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, United States of America
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Ngondo D, Karp C, Kayembe D, Basile KS, Moreau C, Akilimali P, Bell SO. Abortion information-seeking experiences among women who obtained abortions in Kinshasa, DRC: Results from a qualitative study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002383. [PMID: 38381761 PMCID: PMC10880974 DOI: 10.1371/journal.pgph.0002383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/22/2023] [Indexed: 02/23/2024]
Abstract
Little is known about the process of seeking information related to abortion care options among women in the Democratic Republic of Congo (DRC). Understanding how women obtain information can help identify opportunities for intervention to increase awareness and use of safe pregnancy termination options. Using qualitative data collected from women in Kinshasa, DRC who reported having an abortion in the last 10 years, this study aims to determine how women navigate obtaining information about their options for abortion and the role of their social network in their information-seeking processes. Data for this analysis come from a mixed-method study of abortion in Kinshasa conducted from December 2021 to April 2022. Fifty-two qualitative interviews followed a structured interview guide, including open-ended questions and probes, developed by a multidisciplinary team of researchers in Kinshasa and the United States. Inductive thematic analysis was conducted using Atlas.ti, and a thematic analysis matrix was used to describe the major themes and subthemes. Thematic analysis revealed two main themes with nested subthemes. The first and most salient theme highlighted the highly selective and narrow information search process women engaged in, involving no others or very few individuals (e.g., partners, women in one's community, or providers) that the pregnant woman chose strategically. The second theme revealed the heterogeneous and often stigmatizing nature of these interactions, including attempts at deterrence from many sources and information of varying completeness and accuracy. While the recent liberalization of the abortion law in the DRC is essential to improve access to safe abortion, public health gains will not materialize unless they are accompanied by community-level actions to raise awareness about the legality and availability of safe abortions services, including medication abortion pills for safe self-managed abortion.
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Affiliation(s)
- Denise Ngondo
- Department of Biostatistical Epidemiology, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Dynah Kayembe
- Department of Biostatistical Epidemiology, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Kisulu Samyonga Basile
- Department of Biostatistical Epidemiology, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France
| | - Pierre Akilimali
- Department of Nutrition, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Jacobson LE, Baum SE, Pearson E, Chowdhury R, Chakraborty NM, Goodman JM, Gerdts C, Darney BG. Client-reported quality of facility-managed medication abortion compared with pharmacy-sourced self-managed abortion in Bangladesh. BMJ SEXUAL & REPRODUCTIVE HEALTH 2024; 50:33-42. [PMID: 37699668 DOI: 10.1136/bmjsrh-2023-201931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVE We used the newly developed Abortion Care Quality Tool (ACQTool) to compare client-reported quality of medication abortion care by source (facility-managed vs pharmacy-sourced self-managed abortion (SMA)) in Bangladesh. METHODS We leveraged exit and 30-day follow-up surveys collected to develop and validate the ACQTool collected at nongovernmental organisation (NGO)-supported or -operated facilities in the public and private sector and pharmacies from three districts in Bangladesh. We used bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by source (facility vs pharmacy). We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client sociodemographic characteristics. RESULTS Of 550 abortion clients, 146 (26.5%) received a facility-managed medication abortion and 404 (73.5%) had a pharmacy-sourced SMA. Clients reported higher quality in facilities for five indicators, and higher in pharmacies for two indicators; the remaining 11 indicators were not different by source. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (adjusted odds ratio (aOR) 3.55; 95% CI 2.27 to 5.58) but lower odds of reporting high information provision (aOR 0.14; 95% CI 0.09 to 0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse event occurred (aOR 0.45; 95% CI 0.23 to 0.82). CONCLUSIONS In Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable.
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Affiliation(s)
- Laura E Jacobson
- OHSU-PSU School of Public Health, Health Systems & Policy, Portland, Oregon, USA
| | - Sarah E Baum
- Ibis Reproductive Health, Oakland, California, USA
| | - Erin Pearson
- University of California San Diego, Center on Gender Equity and Health, La Jolla, California, USA
| | | | | | - Julia M Goodman
- OHSU-PSU School of Public Health, Health Systems & Policy, Portland, Oregon, USA
| | | | - Blair G Darney
- Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
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Akilimali P, Moreau C, Byrne M, Kayembe D, Larson E, Bell SO. Estimating induced abortion incidence and the use of non-recommended abortion methods and sources in two provinces of the Democratic Republic of the Congo (Kinshasa and Kongo Central) in 2021: results from population-based, cross-sectional surveys of reproductive-aged women. Sex Reprod Health Matters 2023; 31:2207279. [PMID: 37216481 PMCID: PMC10208208 DOI: 10.1080/26410397.2023.2207279] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
The changing abortion legal and practice landscape in the DRC in recent years calls for a re-examining of induced abortion experiences. The current study provides population-level estimates of induced abortion incidence and safety by women's characteristics in two provinces using direct and indirect approaches to assess indirect method performance. We use representative survey data on women aged 15-49 in Kinshasa and Kongo Central collected from December 2021 to April 2022. The survey had questions on respondents' and their closest friends' experience with induced abortion, including methods and sources used. We estimated one-year abortion incidence and proportion using non-recommended methods and sources overall and by background characteristics for each province separately for respondents and friends. The fully adjusted one-year friend abortion rate was 105.3 per 1000 women of reproductive age in Kinshasa and 44.3 per 1000 in Kongo Central in 2021; these were substantially higher than corresponding respondent estimates. Women earlier in their reproductive lifespan were more likely to have had a recent abortion. Approximately 17.0% of abortions in Kinshasa and one-third of abortions in Kongo Central involved non-recommended methods and sources according to respondent and friend estimates. The more accurate friend abortion incidence estimates indicate that women in the DRC often rely on abortion to regulate their fertility. Many use non-recommended means and sources to terminate, thus, significant work remains to actualise the commitments made in the Maputo Protocol to provide comprehensive reproductive health services that combine primary and secondary prevention services to reduce unsafe abortion and its consequences.
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Affiliation(s)
- Pierre Akilimali
- Professor, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, DRC
| | - Caroline Moreau
- Associate Professor, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, VillejuifF-94800, France
| | - Meagan Byrne
- Senior Program Officer, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dynah Kayembe
- Field Coordinator, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, DRC
| | - Elizabeth Larson
- PhD Student, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Suzanne O. Bell
- Assistant Professor, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Bell SO, Oumarou S, Larson EA, Alzouma S, Moreau C. Abortion incidence and safety in Niger in 2021: Findings from a nationally representative cross-sectional survey of reproductive-aged women using direct and indirect measurement approaches. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002353. [PMID: 37831640 PMCID: PMC10575533 DOI: 10.1371/journal.pgph.0002353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/07/2023] [Indexed: 10/15/2023]
Abstract
Niger is a country in which legal restrictions and a dearth of research has long limited our understanding of the extent and safety of induced abortion. The current study is the first national study of induced abortion in Niger. It uses direct (self-report) and indirect (best friend method) to provide nationally representative estimates of induced abortion incidence and safety and evaluates the performance of the indirect measurement approach. We used cross-sectional, representative survey data on women aged 15-49 in Niger collected between January and May 2022; final sample included 3,696 women. The survey included questions on respondents' and their closest female friends' experience with abortion, including methods and sources used. We calculated one-year abortion incidence and the proportion of abortions involving non-recommended methods and/or sources to determine safety separately for respondents and friends, overall and by background characteristics. The fully adjusted one-year friend abortion rate was 6.7 abortions per 1,000 women in 2021, which was substantially higher than the corresponding respondent rate of 0.4 per 1,000 women. Confidence intervals were wide, but friend estimates suggest higher abortion rates among women in their 20s, those with secondary or higher education, and those with no children. Nearly all abortions were unsafe (97% respondents, 100% friends), involving non-recommended methods and/or sources. While abortion numbers were small, unsafe abortion appeared more common among older women, married women, those with children, and those residing in rural areas. Our findings indicate that, despite legal restrictions, some women undergo abortions in Niger at great risk to their physical safety. Ensuring adequate access to quality voluntary family planning services to prevent unintended pregnancy and postabortion care to treat complications is essential to reducing the risk of unsafe abortion in the country.
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Affiliation(s)
- Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Sani Oumarou
- Institut National de la Statistique, Niamey, Niger
| | - Elizabeth A. Larson
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Soins Primaires et Prévention, Centre de Recherche en Epidémiologie et Santé des Populations, U1018, Inserm, Villejuif, France
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Kapp N, Mao B, Menzel J, Eckersberger E, Saphonn V, Rathavy T, Pearson E. A prospective, comparative study of clinical outcomes following clinic-based versus self-use of medical abortion. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:300-307. [PMID: 36894309 PMCID: PMC10579469 DOI: 10.1136/bmjsrh-2022-201722] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/12/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND To determine whether clinical outcomes differ among women accessing a combined medical abortion regimen from a health clinic when compared with those accessing it from a pharmacy. METHODS We conducted a multicentre, prospective, comparative, non-inferiority study of participants aged ≥15 years seeking medical abortion from five clinics and five adjacent pharmacy clusters in three provinces of Cambodia. Participants were recruited in-person at the point of purchase (clinic or pharmacy). Follow-up for self-reported pill use, acceptability, and clinical outcomes occurred by telephone at days 10 and 30 after mifepristone administration. RESULTS Over 10 months, we enrolled 2083 women with 1847 providing outcome data: 937 from clinics and 910 from pharmacies. Most were early in their pregnancy (mean gestational age of 6.3 and 6.1 weeks, respectively) and almost all took the pills correctly (98% and 96%,). Additional treatment needed to complete the abortion was non-inferior for the pharmacy group (9.3%) compared with the clinic group (12.7%). More from the clinic group received additional care from a provider, such as antibiotics or diagnostics tests, than those from the pharmacy group (11.5% and 3.2%,), and one ectopic pregnancy (pharmacy group) was successfully treated. Most said they felt prepared for what happened after taking the pills (90.9% and 81.3%, respectively, p=0.273). CONCLUSIONS Self-use of a combined medical abortion product resulted in comparable clinical outcomes as use following a clinical visit, consistent with existing literature on its safety and efficacy. Registration and availability of medical abortion as an over-the-counter product would likely increase women's access to safe abortion.
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Affiliation(s)
| | - Bunsoth Mao
- University of Health Sciences, Phnom Penh, Cambodia
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14
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Goemans S, Singh A, Yadav AK, McDougal L, Raj A, Averbach SH. The Association Between Self-Managed versus Clinician-Managed Abortion and Self-Reported Abortion Complications: A Cross-Sectional Analysis in India. Int J Womens Health 2023; 15:1467-1473. [PMID: 37795194 PMCID: PMC10545903 DOI: 10.2147/ijwh.s414599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/15/2023] [Indexed: 10/06/2023] Open
Abstract
Purpose To examine the association between self-managed abortion and the self-reported experience of abortion complications in India, a country with a high incidence of self-managed abortion. Patients and Methods The study used a cross-sectional multivariable logistic regression analysis of data from the National Family Health Survey (NFHS-4) of 2015-2016 to compare the odds of self-reported complications experienced during abortion between self-managed and clinician-managed abortions in India. Results On average, self-managed abortions occurred earlier in gestation than clinician-managed abortions, 7.8 weeks and 11.3 weeks, respectively (p < 0.001). Self-managed abortion was associated with fewer self-reported abortion-related complications than clinician-managed abortions when adjusted for covariates not including gestational age (Adjusted Odds Ratio (aOR) 0.82, 95% confidence interval (CI) 0.69, 0.97). However, once adjusted for gestational age, there was no longer a clinically meaningful or statistically significant difference in the odds of self-reported complications between self-managed and clinician-managed abortions (aOR = 0.98, 95% CI 0.81, 1.18). Conclusion These findings suggest that people in India are using safe methods to self-manage abortions and support the hypothesis that self-managed abortion can improve access to abortion and reproductive choice without increasing risk.
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Affiliation(s)
- Sophie Goemans
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA
| | - Abhishek Singh
- Department of Public Health & Mortality Studies, International Institute for Population Sciences, Mumbai, Maharashtra, India
- Centre of Demography of Gender, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Ajit Kumar Yadav
- GENDER Project, International Institute for Population Sciences, Mumbai, Maharashtra, India
| | - Lotus McDougal
- Center on Gender Equity and Health, University of California San Diego, La Jolla, CA, USA
| | - Anita Raj
- Center on Gender Equity and Health, University of California San Diego, La Jolla, CA, USA
| | - Sarah H Averbach
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, La Jolla, CA, USA
- Center on Gender Equity and Health, University of California San Diego, La Jolla, CA, USA
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Giorgio M, Makumbi F, Kibira SPS, Shiferaw S, Seme A, Bell SO, Sully E. Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002340. [PMID: 37682781 PMCID: PMC10490852 DOI: 10.1371/journal.pgph.0002340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 08/08/2023] [Indexed: 09/10/2023]
Abstract
Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda.
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Affiliation(s)
| | - Fredrick Makumbi
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Suzanne O. Bell
- Johns Hopkins Bloomberg School of Public Health, Department of Population, Family, and Reproductive Health, Baltimore, MD, United States of America
| | - Elizabeth Sully
- Guttmacher Institute, New York, NY, United States of America
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Ouma OJ, Ngoga EO, Odongo I, Sigu BS, Akol A. Pathways to medical abortion self-use (MASU): results from a cross-sectional survey of women's experiences in Kenya and Uganda. BMC Womens Health 2023; 23:412. [PMID: 37542313 PMCID: PMC10403870 DOI: 10.1186/s12905-023-02570-2] [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: 08/24/2022] [Accepted: 07/25/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND In Kenya and Uganda, unsafe abortions are a leading cause of maternal mortality. The new WHO policy guidelines on the safe termination of pregnancies up to 9 weeks lack information on women's experiences with self-administered medical abortion (MA), impeding the development of interventions to increase MA use. This study aimed to comprehend women's experiences with MA in Kenyan and Ugandan pharmacies. METHODS A cross-sectional mixed-methods survey utilized data from medical registers in 71 purposefully identified pharmacies and clinics dispensing MA drugs between September and October 2021. Forty women who were MA users participated in focus group discussions. The main outcome variables were: sources of MA information, costs of MA services, complications from MA, pain management, follow-up rates, and use of post-MA contraception. Quantitative data were analyzed using Stata 15, while qualitative thematic analysis was conducted using Dedoose qualitative analysis software. RESULTS 73.6% of 2,366 women got an MA, both in Kenya (79%) and Uganda (21%). Most (59.1%) were walk-in clients. Kenya had significantly more women referred for MA (49.9%) than Uganda (10.1%) (p 0.05). Friends and family members were the main sources of MA information. The median cost of MA was USD 18 (IQR 10-60.5) in Kenya and USD 4.2 (IQR 2-12) in Uganda. Most MA clients received pain management (89.6%), were followed up (81%), and received post-MA contraception (97.6%). Qualitative results indicated a lack of medicines, high costs of MA, complications, stigma, and inadequate training of providers as barriers to MA use. CONCLUSIONS AND RECOMMENDATIONS Communities are a valuable information resource for MA, but only if they have access to the right information. A relatively weak health referral system in Uganda highlights the importance of pharmacies and clinicians collaborating to support clients' abortion needs and contraceptive use after medical abortion (MA). Low client follow-up rates show how important it is to make sure pharmacy technicians know how to give MA correctly. Finally, it is crucial to strengthen the supply chain for MA products in order to eliminate cost barriers to access.
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Affiliation(s)
- Ogol Japheth Ouma
- Ipas Africa Alliance, Research and Learning Advisor, P.O. Box 1192-00200, City Square, Nairobi, Kenya.
| | - Edward O Ngoga
- Ipas Africa Alliance, Quality of Care Manager, P.O. Box 1192-00200, City Square, Nairobi, Kenya
| | - Isaac Odongo
- Ipas Africa Alliance, Quality of Care Manager, Uganda, P.O. Box 1192-00200, City Square, Nairobi, Kenya
| | - Biko Steve Sigu
- Ipas Africa Alliance, Quality of Care Advisor-UCD, P.O. Box 1192-00200, City Square, Nairobi, Kenya
| | - Angela Akol
- Ipas Africa Alliance, P.O. Box 1192-00200, City Square, Nairobi, Kenya
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Grossman A, Prata N, Williams N, Ganatra B, Lavelanet A, Läser L, Asmani C, Elamin H, Ouedraogo L, Rahman MM, Conneh-Duworko MJ, Tehoungue BZ, Chanza H, Phiri H, Bhattarai B, Dhakal NP, Ojo OA, Afolabi K, Kabuteni TJ, Hailu BG, Moses F, Dlamini-Nqeketo S, Zulu T, Rehnström Loi U. Availability of medical abortion medicines in eight countries: a descriptive analysis of key findings and opportunities. Reprod Health 2023; 20:58. [PMID: 37041543 PMCID: PMC10091522 DOI: 10.1186/s12978-023-01574-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND In recent years a growing number of manufacturers and medical abortion products have entered country markets and health systems, with varying degrees of quality and accessibility. An interplay of factors including pharmaceutical regulations, abortion laws, government policies and service delivery guidelines and provider's knowledge and practices influence the availability of medical abortion medicines. We assessed the availability of medical abortion in eight countries to increase understanding among policymakers of the need to improve availability and affordability of quality-assured medical abortion products at regional and national levels. METHODS Using a national assessment protocol and an availability framework, we assessed the availability of medical abortion medicines in Bangladesh, Liberia, Malawi, Nepal, Nigeria, Rwanda, Sierra Leone and South Africa between September 2019 and January 2020. RESULTS Registration of abortion medicines-misoprostol or a combination of mifepristone and misoprostol-was established in all countries assessed, except Rwanda. Mifepristone and misoprostol regimen for medical abortion was identified on the national essential medicines list/standard treatment guidelines for South Africa as well as in specific abortion care service and delivery guidelines for Bangladesh, Nepal, Nigeria, and Rwanda. In Liberia, Malawi, and Sierra Leone-countries with highly restrictive abortion laws and no abortion service delivery guidelines or training curricula-no government-supported training on medical abortion for public sector providers had occurred. Instead, training on medical abortion was either limited in scope to select private sector providers and pharmacists or prohibited. Community awareness activities on medical abortion have been limited in scope across the countries assessed and where abortion is broadly legal, most women do not know that it is an option. CONCLUSION Understanding the factors that influence the availability of medical abortion medicines is important to support policymakers improve availability of these medicines. The landscape assessments documented that medical abortion commodities can be uniquely impacted by the laws, policies, values, and degree of restrictions placed on service delivery programs. Results of the assessments can guide actions to improve access.
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Affiliation(s)
- Amy Grossman
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Ndola Prata
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
- Bixby Center for Population, Health & Sustainability, School of Public Health, University of California, Berkeley, CA, USA
| | - Natalie Williams
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Bela Ganatra
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Antonella Lavelanet
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Laurence Läser
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Chilanga Asmani
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Hayfa Elamin
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Leopold Ouedraogo
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | | | | | | | - Harriet Chanza
- World Health Organization, Malawi Country Office, Lilongwe, Republic of Malawi
| | - Henry Phiri
- Ministry of Health, Lilongwe, Republic of Malawi
| | - Bharat Bhattarai
- Department of Drug Administration, Ministry of Health and Population, Kathmandu, Nepal
| | | | | | - Kayode Afolabi
- Reproductive Health, Federal Ministry of Health, Abuja, Federal Republic of Nigeria
| | | | | | - Francis Moses
- Reproductive Health/Family Planning Programme Manager, Ministry of Health, Freetown, Sierra Leone
| | | | - Thembi Zulu
- National Department of Health, Pretoria, Republic of South Africa
| | - Ulrika Rehnström Loi
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland.
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18
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Skuster P, Moseson H, Perritt J. Self-managed abortion: Aligning law and policy with medical evidence. Int J Gynaecol Obstet 2023; 160:720-725. [PMID: 36458802 DOI: 10.1002/ijgo.14607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
People have always and will always find ways to try to end their pregnancies when necessary. Many do so safely without the involvement or direct supervision of healthcare professionals by self-managing their abortions. In 2022, the well-established safety and efficacy of abortion medications prompted WHO to fully endorse self-managed medication abortion as part of a comprehensive range of safe, effective options for abortion care. But despite robust evidence supporting the safety and effectiveness of the self-use of medications for abortion, abortion laws and policies around the world remain at odds with clinical evidence and with the realities of self-managed medication abortion in the present day. The present article considers legal issues related to self-managed abortion and addresses the role of obstetricians, gynecologists, and other healthcare professionals in promoting clinical and legal safety in abortion care through support of self-managed abortion.
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Affiliation(s)
- Patty Skuster
- Temple University Beasley School of Law, Pennsylvania, Philadelphia, USA
| | | | - Jamila Perritt
- Physicians for Reproductive Health, New York, New York, USA
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Sigdel A, Angdembe MR, Khanal P, Adhikari N, Maharjan A, Paudel M. Medical abortion drug dispensing practices among private pharmacy workers in Nepal: A mystery client study. PLoS One 2022; 17:e0278132. [PMID: 36417473 PMCID: PMC9683563 DOI: 10.1371/journal.pone.0278132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 11/09/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pharmacies are the first point of contact for women seeking medical abortion (MA) and act as important sources of information and referral in Nepal. Over the counter sale of MA drugs is not currently allowed in Nepal. This study aimed to assess the MA drug dispensing practices of pharmacy workers using mystery clients in Nepal. METHODS A cross-sectional study using the mystery client approach was conducted in 266 pharmacies in September-October 2019. These pharmacies had either received harm reduction training or medical detailing visits. A total of 532 visits were conducted by six male and six female mystery clients. Mystery clients without prescription approached the sample pharmacy and filled out a standard digital survey questionnaire using the SurveyCTO application immediately after each interaction. RESULTS Pharmacy workers dispensed MA drugs in 35.7% of the visits while they refused to provide MA drugs to the mystery clients in 39.3% of visits. Lack of evidence of prior consultation with a physician (27.5%), referral to other health facilities (21.8%), unavailability of MA drugs in the pharmacy (21.3%) and lack of prescription (16.4%) were the main reasons for refusal. Seventy percent of the pharmacy workers inquired clients about last menstrual period/months of pregnancy while 38.1% asked whether the pregnancy status was confirmed. During 65.1% of the visits, mystery clients were told about when to take the MA drugs while in 66.4% of visits, they were told about the route of drug administration. Similarly, mystery clients were briefed about what to expect during the abortion process in half of the visits, and information about the possible side effects of the MA drug was provided in 55.9% of the visits. Pharmacy workers provided correct information on taking MA drugs to mystery clients in 70.7% of visits. CONCLUSION Despite legal provision of sale of MA drugs only on prescription, pharmacy workers dispensed MA drug in one out of three visits. As pharmacies are the initial contacts of women for abortion services in Nepal, correct supplementary information through pharmacy workers can be an effective strategy to expand access to quality safe abortion services.
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Affiliation(s)
- Anil Sigdel
- Population Services International, Lalitpur, Nepal
| | | | - Pratik Khanal
- Population Services International, Lalitpur, Nepal
- * E-mail:
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Hinson L, Bhatti AM, Sebany M, Bell SO, Steinhaus M, Twose C, Izugbara C. How, when and where? A systematic review on abortion decision making in legally restricted settings in sub-Saharan Africa, Latin America, and the Caribbean. BMC Womens Health 2022; 22:415. [PMID: 36217197 PMCID: PMC9552475 DOI: 10.1186/s12905-022-01962-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/19/2022] [Indexed: 11/07/2022] Open
Abstract
Background With increasing global availability of medication abortion drugs, a safer option exists for many women to terminate a pregnancy even in legally restrictive settings. However, more than 22,000 women die each year from unsafe abortion, most often in developing countries where abortion is highly legally restricted. We conducted a systematic review to compile existing evidence regarding factors that influence women’s abortion-related decision making in countries where abortion is highly legally restricted.
Methods We searched ten databases in two languages (English and Spanish) for relevant literature published between 2000 and 2019 that address women’s decision-making regarding when, where and how to terminate a pregnancy in sub-Saharan African, Latin American and the Caribbean countries where abortion is highly legally restricted.
Results We identified 46 articles that met the review’s inclusion criteria. We found four primary factors that influenced women’s abortion-related decision-making processes: (1) the role of knowledge, including of laws, methods and sources; (2) the role of safety, including medical, legal and social safety; (3) the role of social networks and the internet, and; (4) cost affordability and convenience. Conclusions The choices women make after deciding to terminate a pregnancy are shaped by myriad factors, particularly in contexts where abortion is highly legally restricted. Our review catalogued the predominant influences on these decisions of when, where and how to abort. More research is needed to better understand how these factors work in concert to best meet women’s abortion needs to the full limit of the law and within a harm reduction framework for abortions outside of legal indications. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01962-0.
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Affiliation(s)
- Laura Hinson
- grid.419324.90000 0004 0508 0388International Center for Research on Women, Washington, DC USA
| | | | | | - Suzanne O. Bell
- grid.21107.350000 0001 2171 9311Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Claire Twose
- grid.21107.350000 0001 2171 9311Welch Medical Library, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Chimaraoke Izugbara
- grid.419324.90000 0004 0508 0388International Center for Research on Women, Washington, DC USA
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Arora N, Singh N. Medical abortion in India - An imperative need for task sharing. J Family Med Prim Care 2022; 11:5473-5478. [PMID: 36505611 PMCID: PMC9730964 DOI: 10.4103/jfmpc.jfmpc_86_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/18/2022] [Accepted: 04/26/2022] [Indexed: 12/15/2022] Open
Abstract
Background Over-the-counter (OTC) sale of medical abortion (MA) inducing drugs is a common practice. Exploring its impact on women's health and the barriers to avail free MA services at hospital by these women is essential to improve upon policy decision. Methods A prospective observational study included 112 women following ingestion of MA drugs from nonformal providers. Demography, clinical details, and reasons for not availing free abortion services at hospital were recorded. Results Among 112 women, mean age was 28.63 (SD 4.7) years. Seventy one (63.39%) women were from rural region; 70.54% were educated below high school; 44 (39.28%) had prior induced abortion; 62.5% had never used any contraception. Majority (101; 90%) took two drugs (Mifepristone and Misoprostol), 28 (25%) used correct dosage. Drugs were consumed beyond 9 weeks of gestation by 25 (22.4%) women. Abnormal vaginal bleeding was commonest 105 (93.75%) presentation. Haemorrhagic shock was noted in 21 (18.75%) women, while 21 (18.7%) women required blood transfusion. "Easy and quick availability of these drugs OTC" was the commonest statement for not attending hospital. Conclusion Easy and quick availability of OTC drugs, distance to hospital were major barriers. Incorrect dosage and lack of gestational age calculation were two most common errors in the risk assessment protocol. Expanding provider base, by training midlevel providers, can overcome these and unmask the full potential of MA to make abortion safer.
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Affiliation(s)
- Nalini Arora
- Department of Obstetrics and Gynaecology, ESI-Post Graduate Institute of Medical Sciences and Research and ESIC Medical College, Kolkata, West Bengal, India,Address for correspondence: Dr. Nalini Arora, Department of Obstetrics and Gynaecology, ESI-PGIMSR and ESIC Medical College, Kolkata - 700 104, West Bengal, India. E-mail:
| | - Nita Singh
- Department of Obstetrics and Gynaecology, ESI-Post Graduate Institute of Medical Sciences and Research and ESIC Medical College, Kolkata, West Bengal, India
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Akinyemi A, Owolabi OO, Erinfolami T, Stillman M, Bankole A. Quality of information offered to women by drug sellers providing medical abortion in Nigeria: Evidence from providers and their clients. Front Glob Womens Health 2022; 3:899662. [PMID: 36060610 PMCID: PMC9428275 DOI: 10.3389/fgwh.2022.899662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Akanni Akinyemi
- Center for Research, Evaluation Resources, and Development, Abuja, Nigeria
- Department of Demography and Social Statistics, Obafemi Awolowo University, Ife, Nigeria
- *Correspondence: Akanni Akinyemi
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Magalona S, Byrne M, OlaOlorun FM, Mosso R, Omoluabi E, Moreau C, Bell SO. Contraceptive Use Before and After Abortion: A Cross-Sectional Study from Nigeria and Côte d'Ivoire. Stud Fam Plann 2022; 53:433-453. [PMID: 35856923 PMCID: PMC9545736 DOI: 10.1111/sifp.12208] [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] [Indexed: 11/27/2022]
Abstract
Post‐abortion contraception enables women to effectively manage their fertility to prevent unintended pregnancies. Using data from population‐based surveys of women aged 15–49 in Nigeria and Côte d'Ivoire, we examined contraceptive dynamics immediately before and after an abortion and examined factors associated with these changes using multivariable logistic regressions. Covariates included sociodemographic characteristics, abortion source, post‐abortion contraceptive communication (wanting to and actually talking to someone about contraception after abortion), and perceived contraceptive autonomy. We observed higher contraceptive use after abortion than before abortion. In Nigeria, wanting to talk to someone about contraception post‐abortion was associated with increased adoption and decreased discontinuation, whereas talking to someone about contraception post‐abortion was associated with increased adoption. Obtaining care from a clinical abortion source was associated with increased adoption and decreased discontinuation. Both post‐abortion contraceptive communication variables were associated with post‐abortion contraceptive use in both countries, whereas clinical source was only associated with post‐abortion contraceptive use in Nigeria. Our findings suggest that ensuring that women have access to safe abortion as part of the formal health care system and receive comprehensive, high‐quality post‐abortion care services that include contraceptive counseling enables them to make informed decisions about their fertility that align with their reproductive goals.
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Affiliation(s)
- Sophia Magalona
- Sophia Magalona is a PhD student, Meagan Byrne is PMA Survey Operations Lead, Caroline Moreau is Associate Professor, and Suzanne O. Bell is Assistant Professor, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Meagan Byrne
- Sophia Magalona is a PhD student, Meagan Byrne is PMA Survey Operations Lead, Caroline Moreau is Associate Professor, and Suzanne O. Bell is Assistant Professor, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Funmilola M OlaOlorun
- Funmilola M. OlaOlorun is Senior Lecturer, Department of Community Medicine, University of Ibadan, Ibadan, Oyo, Nigeria
| | - Rosine Mosso
- Rosine Mosso is Lecturer and Researcher, École Nationale Supérieure de Statistique et d'Économie Appliquée, Abidjan, Côte d'Ivoire
| | - Elizabeth Omoluabi
- Elizabeth Omoluabi is Managing Director, Centre for Research, Evaluation Resources and Development, Ile-Ife, Nigeria
| | - Caroline Moreau
- Sophia Magalona is a PhD student, Meagan Byrne is PMA Survey Operations Lead, Caroline Moreau is Associate Professor, and Suzanne O. Bell is Assistant Professor, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Caroline Moreau is Epidemiologist, CESP Centre for Research in Epidemiology and Population Health, INSERM (Institut National de la Santé et de la Recherche Médicale), Villejuif, France
| | - Suzanne O Bell
- Sophia Magalona is a PhD student, Meagan Byrne is PMA Survey Operations Lead, Caroline Moreau is Associate Professor, and Suzanne O. Bell is Assistant Professor, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Feyssa MD, Gebru SK. Liberalizing abortion to reduce maternal mortality: expanding access to all Ethiopians. Reprod Health 2022; 19:151. [PMID: 35761348 PMCID: PMC9237962 DOI: 10.1186/s12978-022-01457-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Mekdes Daba Feyssa
- St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. .,Center for International Reproductive Health Training, Addis Ababa, Ethiopia.
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25
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Baldwin A, Johnson DM, Broussard K, Tello-Pérez LA, Madera M, Ze-Noah C, Padron E, Aiken ARA. U.S. Abortion Care Providers' Perspectives on Self-Managed Abortion. QUALITATIVE HEALTH RESEARCH 2022; 32:788-799. [PMID: 35322703 PMCID: PMC9152602 DOI: 10.1177/10497323221077296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
State-level restrictions on abortion access may prompt greater numbers of people to self-manage their abortion. The few studies exploring perspectives of providers towards self-managed abortion are focused on physicians and advanced practice clinicians. Little is known about the wider spectrum of abortion care providers who encounter self-managed abortion in their clinic-based work. To gain a deeper understanding of this issue and inform future care delivery, we conducted in-depth interviews with 46 individuals working in a range of positions in 46 abortion clinics across 29 states. Our interpretative analysis resulted in themes shaped by beliefs about safety and autonomy, and a tension between the two: that self-managed abortion is too great a risk, that people are capable of self-managing an abortion, and that people have a right to a self-managed abortion. Our findings highlight the importance of increasing knowledge and clarifying values among all abortion care providers, including clinic staff.
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Affiliation(s)
- Aleta Baldwin
- Department of Public Health, California State University
Sacramento, USA
| | - Dana M. Johnson
- Lyndon B Johnson School of Public Affairs, The University of Texas at Austin, USA
| | | | | | - Melissa Madera
- Lyndon B Johnson School of Public Affairs, The University of Texas at Austin, USA
| | - Carol Ze-Noah
- Department of Political Science, University of California Berkeley, USA
| | | | - Abigail R. A. Aiken
- Lyndon B Johnson School of Public Affairs, The University of Texas at Austin, USA
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26
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Veldhuis S, Sánchez-Ramírez G, Darney BG. Locating Autonomous Abortion Accompanied by Feminist Activists in the Spectrum of Self-Managed Medication Abortion. Stud Fam Plann 2022; 53:377-387. [PMID: 35347718 DOI: 10.1111/sifp.12194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Diverse models of self-managed medication abortion exist-ranging from some interaction with medical personnel to completely autonomous abortion. In this commentary, we propose a new classification of self-managed medication abortion and describe the different modalities. We highlight autonomous abortion accompanied by feminist activists, called "acompañantes," as a community- and rights-based strategy that can be a safe alternative to clinical abortion services in clandestine as well as legal settings. To improve access, abortion needs to be decriminalized and governments must acknowledge and facilitate the diversity of safe abortion options so women may choose where, when, how, and with whom to abort.
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Affiliation(s)
- Suzanne Veldhuis
- Department of Health, El Colegio de la Frontera Sur (ECOSUR), San Cristóbal de las Casas, Chiapas 29290, México
| | - Georgina Sánchez-Ramírez
- Department of Health, El Colegio de la Frontera Sur (ECOSUR), San Cristóbal de las Casas, Chiapas 29290, México
| | - Blair G Darney
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR 97239, USA.,Centro de Investigación en Salud Poblacional (CISP), Instituto Nacional de Salud Publica (INSP), 62100 Cuernavaca, Morelos, México
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27
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“I just have to hope that this abortion should go well”: Perceptions, fears, and experiences of abortion clients in Nigeria. PLoS One 2022; 17:e0263072. [PMID: 35130269 PMCID: PMC8820635 DOI: 10.1371/journal.pone.0263072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/10/2022] [Indexed: 01/23/2023] Open
Abstract
This qualitative study aimed to examine how abortion clients in Nigeria perceive abortion and explore the role their beliefs and fears play in their care-seeking experiences and interactions with providers. Abortion is severely legally restricted in Nigeria but remains common. We conducted in-depth interviews with 25 people who obtained abortion services through three distinct models of care. We coded interview transcripts and conducted thematic analysis. Clients perceived negative attitudes toward abortion in their communities, though clients’ own beliefs were more nuanced. Clients recounted a range of fears, and nearly all mentioned worrying that they might die as a result of their abortion. Despite their concerns, clients relied on social networks and word-of-mouth recommendations to identify providers they perceived as trustworthy and safe. Kind and non-judgmental treatment, clear instructions, open communication, and reassurance of privacy and confidentiality by providers alleviated client fears and helped clients feel supported throughout their abortion process. Within restrictive contexts, the mobilization of information networks, provision of high-quality care through innovative models, and personalization of care to individual needs can assuage fears and contribute to reducing stigma and increasing access to safe abortion services.
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Logie CH, Berry I, Ferguson L, Malama K, Donkers H, Narasimhan M. Uptake and provision of self-care interventions for sexual and reproductive health: findings from a global values and preferences survey. Sex Reprod Health Matters 2022; 29:2009104. [PMID: 35100942 PMCID: PMC8812803 DOI: 10.1080/26410397.2021.2009104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Self-care interventions hold the potential to improve sexual and reproductive health (SRH) and well-being. Yet key knowledge gaps remain regarding how knowledge and uptake vary across different types of self-care interventions. There is also limited understanding of health workers’ confidence in promoting SRH self-care interventions, and how this may differ based on personal uptake experiences. To address these knowledge gaps, we conducted a web-based cross-sectional survey among health workers and laypersons from July to November 2018. We investigated the following information about SRH self-care interventions: knowledge and uptake; decisions for use; and associations between health workers’ uptake and providing prescriptions, referrals, and/or information for these interventions. Participants (n = 837) included laypersons (n = 477) and health workers (n = 360) from 112 countries, with most representation from the WHO European Region (29.2%), followed by the Americas (28.4%) and African (23.2%) Regions. We found great heterogeneity in knowledge and uptake by type of SRH self-care intervention. Some interventions, such as oral contraception, were widely known in comparison with interventions such as STI self-sampling. Across interventions, participants perceived benefits of privacy, convenience, and accessibility. While pharmacies and doctors were preferred access points, this varied by type of self-care intervention. Health workers with knowledge of the self-care intervention, and who had themselves used the self-care intervention, were significantly more likely to feel confident in, and to have provided information or referrals to, the same intervention. This finding signals that health workers can be better engaged in learning about self-care SRH interventions and thereby become resources for expanding access.
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Affiliation(s)
- Carmen H Logie
- Associate Professor, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Correspondence: .,Adjunct Professor, United Nations University Institute for Water, Environment and Health, Hamilton, Ontario, Canada
| | - Isha Berry
- Doctoral Candidate, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Laura Ferguson
- Adjunct Professor, United Nations University Institute for Water, Environment and Health, Hamilton, Ontario, Canada
| | - Kalonde Malama
- Associate Professor, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Correspondence:
| | - Holly Donkers
- Associate Professor, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Correspondence:
| | - Manjulaa Narasimhan
- Scientist, Department of Sexual and Reproductive Health and Research, includes the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction - HRP, World Health Organization, Geneva, Switzerland
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OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:315-325. [DOI: 10.1093/ijpp/riac038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/08/2022] [Indexed: 11/14/2022]
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30
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Adojutelegan YA, Coughlin AJ, Shellenberg K, Oginni AB, Okeke B, Ogueji O. Drug sellers' knowledge and practices, and client perspectives after an intervention to improve the quality of safe abortion care outside of formal clinics in Nigeria. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:e44-e52. [PMID: 33972396 PMCID: PMC8685617 DOI: 10.1136/bmjsrh-2020-200955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/30/2021] [Accepted: 04/05/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND In Nigeria, where abortion is legally restricted, individuals seek medication abortion drugs, including misoprostol, directly from pharmacies or drug sellers. However, knowledge of drug sellers or patent medicine vendors (PMVs) dispensation practices and women's experience with self-management is limited and research suggests poor quality of services. This study assesses the knowledge and practices of PMVs and women's experiences after a harm reduction intervention to improve the provision of medication abortion using misoprostol. METHODS We conducted a retrospective descriptive analysis of anonymised logbook data collected from 141 Nigerian PMVs who provided misoprostol for abortion to 4924 clients between February 2015 and July 2018. We conducted a descriptive analysis of self-reported misoprostol dispensation practices with data from a cross-sectional survey of PMVs (n=120) from June 2016 to December 2018. We collected data on women's experience obtaining misoprostol from 37 PMVs through a cross-sectional survey of women (n=260) from 4-19 June 2018. RESULTS For clients where the misoprostol dose dispensed was recorded (n=3784), 86% of clients were given 800 μg or more misoprostol, pain medication (97%) and a contraceptive method (92%). Most clients with an outcome recorded in the logbook (n=4431) had a complete abortion (86%). Almost all women reported that they would return to the PMV for future services (99%). CONCLUSIONS The majority of PMVs dispensed misoprostol in appropriate dosages and provided clients with information on drug administration and methods of contraception. Interventions designed to improve PMVs' best practices around the provision of abortion care may help ensure the quality of services received by clients.
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Durocher J, Kilfedder C, Frye LJ, Winikoff B, Srinivasan K. A descriptive analysis of medical abortion commodity availability and pricing at retail outlets in 44 countries across four regions globally. Sex Reprod Health Matters 2021; 29:1982460. [PMID: 34719353 PMCID: PMC8567879 DOI: 10.1080/26410397.2021.1982460] [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] [Indexed: 11/24/2022] Open
Abstract
Pharmacies in low- and middle-income countries play an important role in increasing the availability of medical abortion to individuals for self-use. We aimed to document the costs to users of medical abortion products at outlets across geographies and understand the diversity of available products, primarily in low- and middle-income countries or in places where access to abortion is restricted. A descriptive analysis of price data was completed for identified medical abortion products at retail outlets visited in 44 countries from November 2017 to February 2018. Median prices and ranges are reported in $US for mifepristone 200 mg tablets, misoprostol 200 mcg tablets, and combipacks. Misoprostol, mifepristone, and combipacks were found in 44, 19, and 16 countries, respectively. Nearly two-thirds of products (321/508) required a prescription. The median price of misoprostol was $0.63 per tablet (range $0.09–$27.63) based on 304 price points. Mifepristone and combipacks had fewer price points available (n = 59 and n = 44, respectively). Median prices were $11.78 per mifepristone tablet (range $1.77–$37.83) and $11.18 per combipack (range $3.50–$35.86). Overall, prices were highest in Latin America and lowest in South/Southeast Asia. Only 11.5% (7/61) of the total unique misoprostol brands were quality-assured (i.e. approved by a stringent regulatory authority or pre-qualified by the World Health Organization), compared to 25.0% (4/16) of unique combipack products. There was wide variation in product pricing and availability across settings. The infrequent availability of mifepristone and combipacks, in addition to the limited availability of quality-assured medicines and high cost of abortion medications, are important factors affecting access to high-quality abortion care.
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Affiliation(s)
- Jill Durocher
- Senior Director, Gynuity Health Projects, New York, NY, USA. Correspondence:
| | - Catherine Kilfedder
- Senior Programme Adviser, International Planned Parenthood Federation, London, UK
| | - Laura J Frye
- Director, Gynuity Health Projects, New York, NY, USA
| | | | - Karthik Srinivasan
- Chief Medical Adviser, International Planned Parenthood Federation, London, UK
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Miller C. Maternal Mortality from Induced Abortion in Malawi: What Does the Latest Evidence Suggest? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910506. [PMID: 34639806 PMCID: PMC8507663 DOI: 10.3390/ijerph181910506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/15/2022]
Abstract
It is commonly claimed that thousands of women die every year from unsafe abortion in Malawi. This commentary critically assesses those claims, demonstrating that these estimates are not supported by the evidence. On the contrary, the latest evidence—itself from 15 to 20 years ago—suggests that 6–7% of maternal deaths in Malawi are attributable to induced and spontaneous abortion combined, totalling approximately 70–150 deaths per year. I then offer some evidence suggesting that a substantial proportion of these are attributable to spontaneous abortion. To reduce maternal mortality by large margins, emergency obstetric care should be prioritised, which will also save women from complications of induced and spontaneous abortion.
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Affiliation(s)
- Calum Miller
- St. Benet's Hall, University of Oxford, Oxford OX1 3LN, UK
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Jayaweera R, Powell B, Gerdts C, Kakesa J, Ouedraogo R, Ramazani U, Wado YD, Wheeler E, Fetters T. The Potential of Self-Managed Abortion to Expand Abortion Access in Humanitarian Contexts. Front Glob Womens Health 2021; 2:681039. [PMID: 34816230 PMCID: PMC8593970 DOI: 10.3389/fgwh.2021.681039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
Refugees and displaced people face uniquely challenging barriers to abortion access, including the collapse of health systems, statelessness, and a lack of prioritization of sexual and reproductive health services by humanitarian agencies. This article summarizes the evidence around abortion access in humanitarian contexts, and highlights the opportunities for interventions that could increase knowledge and support around self-managed abortion. We explore how lessons learned from other contexts can be applied to the development of effective interventions to reduce abortion-related morbidity and mortality, and may improve access to information about safe methods of abortion, including self-management, in humanitarian settings. We conclude by laying out a forward-thinking research agenda that addresses gaps in our knowledge around abortion access and experiences in humanitarian contexts.
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Affiliation(s)
| | | | | | - Jessica Kakesa
- International Rescue Committee, Kinshasa, Democratic Republic of the Congo
| | | | | | | | - Erin Wheeler
- International Rescue Committee, New York, NY, United States
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Rodriguez MI, Edelman AB, Hersh A, Gartoulla P, Henderson JT. Medical abortion offered in pharmacy versus clinic-based settings: A systematic review. Contraception 2021; 104:478-483. [PMID: 34175269 DOI: 10.1016/j.contraception.2021.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Expanding access to medical abortion through pharmacies is a potential strategy to promote safe abortion care. To compare the effectiveness and safety of medical abortion offered in pharmacy settings with clinic-based medical abortion. STUDY DESIGN We searched multiple databases and the gray literature through November 2020. No language restrictions were applied. We included randomized and nonrandomized comparative studies. We applied standard risk of bias tools to each included study and used GRADE methodology to assess certainty of evidence. The primary outcomes were completion of abortion without additional intervention, need for blood transfusion, and presence of uterine or systemic infection within 30 days of medical abortion. RESULTS Our search yielded 2030 studies. One prospective cohort study from Nepal met inclusion criteria. This study collected data on 605 women obtaining medical abortion rom either a clinic or pharmacy, and was judged to have low risk of bias for our primary outcome. For women who received medical abortion in a pharmacy compared to a clinic there was probably little or no difference in complete abortion rates (adjusted risk difference 1.5%; 95% confidence interval [CI] -0.8 to 3.8, 1 study, 600 participants; low certainty of evidence). No cases of blood transfusion were reported in the study and a composite outcome comprised mainly of infection complications showed little or no difference between settings (adjusted risk difference 0.8; 95% CI -1.0 to 2.8, 1 study, 600 participants; very low certainty of evidence). CONCLUSION Evidence from just one nonrandomized study provides low certainty evidence that the effectiveness of medical abortion is probably not different between the pharmacy or clinic setting. IMPLICATIONS Provision of medical abortions through pharmacy-based models of care may improve access to safe abortion. Comparative studies examining each model of care and outcomes on safety, effectiveness, and patient experience are needed.
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Affiliation(s)
- Maria I Rodriguez
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, United States.
| | - Alison B Edelman
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - Alyssa Hersh
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - Pragya Gartoulla
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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Rodriguez MI, Edelman A, Hersh A, Gartoulla P, Henderson J. Medical abortion offered in pharmacy versus clinic-based settings. Cochrane Database Syst Rev 2021; 6:CD013566. [PMID: 34114643 PMCID: PMC8193989 DOI: 10.1002/14651858.cd013566.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Medical abortion is usually offered in a clinic or hospital, but could potentially be offered in other settings such as pharmacies. In many countries, pharmacies are a common first point of access for women seeking reproductive health information and services. Offering medical abortion through pharmacies is a potential strategy to improve access to abortion. OBJECTIVES To compare the effectiveness and safety of medical abortion offered in pharmacy settings with clinic-based medical abortion. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, four other databases, two trials registries and grey literature websites in November 2020. We also handsearched key references and contacted authors to locate unpublished studies or studies not identified in the database searches. SELECTION CRITERIA We identified studies that compared women receiving the same regimen of medical abortion or post-abortion care in either a clinic or pharmacy setting. Studies published in any language employing the following designs were included: randomized trials and non-randomized studies including a comparative group. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed both retrieved abstracts and full-text publications. A third author was consulted in case of disagreement. We intended to use the Cochrane risk of bias tool, RoB 2, for randomized studies and used the ROBINS-I tool (Risk Of Bias In Non-randomized Studies of Interventions) to assess risk of bias in non-randomized studies. GRADE methodology was used to assess the certainty of the evidence. The primary outcomes were completion of abortion without additional intervention, need for blood transfusion, and presence of uterine or systemic infection within 30 days of medical abortion. MAIN RESULTS Our search yielded 2030 records. We assessed a total of 89 full-text articles for eligibility. One prospective cohort study met our inclusion criteria. The included study collected data on outcomes from 605 women who obtained a medical abortion in Nepal from either a clinic or pharmacy setting. Both sites of care were staffed by the same auxiliary nurse midwives. Over all domains, the risk of bias was judged to be low for our primary outcome. During the pre-intervention period, the study's investigators identified a priori appropriate confounders, which were clearly measured and adjusted for in the final analysis. For women who received medical abortion in a pharmacy setting, compared to a clinic setting, there may be little or no difference in complete abortion rates (adjusted risk difference (RD)) 1.5, 95% confidence interval (CI) -0.8 to 3.8; 1 study, 600 participants; low certainty evidence). The study reported no cases of blood transfusion, and a composite outcome, comprised mainly of infection complications, showed there may be little or no difference between settings (adjusted RD 0.8, 95% CI -1.0 to 2.8; 1 study, 600 participants; very low certainty evidence). The study reported no events for hospital admission for an abortion-related event or need for surgical intervention, and there may be no difference in women reporting being highly satisfied with the facility where they were seen (38% pharmacy versus 34% clinic, P = 0.87; 1 study, 600 participants; low certainty evidence). AUTHORS' CONCLUSIONS Conclusions about the effectiveness and safety of pharmacy provision of medical abortion are limited by the lack of comparative studies. One study, judged to provide low certainty evidence, suggests that the effectiveness of medical abortion may not be different between the pharmacy and clinic settings. However, evidence for safety is insufficient to draw any conclusions, and more research on factors contributing to potential differences in quality of care is needed. It is important to note that this study included a care model where a clinician provided services in a pharmacy, not direct provision of care by pharmacists or pharmacy staff. Three ongoing studies are potentially eligible for inclusion in review updates. More research is needed because pharmacy provision could expand timely access to medical abortion, especially in settings where clinic services may be more difficult to obtain. Evidence is particularly limited on the patient experience and how the care process and quality of services may differ across different types of settings.
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Affiliation(s)
- Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Alison Edelman
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Alyssa Hersh
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Jillian Henderson
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
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Väisänen H, Moore AM, Owolabi O, Stillman M, Fatusi A, Akinyemi A. Sexual and Reproductive Health Literacy, Misoprostol Knowledge and Use of Medication Abortion in Lagos State, Nigeria: A Mixed Methods Study. Stud Fam Plann 2021; 52:217-237. [PMID: 34043236 PMCID: PMC8362169 DOI: 10.1111/sifp.12156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Little is known about the link between health literacy and women's ability to safely and successfully use misoprostol to self‐induce an abortion. While abortion is only allowed to save a woman's life in Nigeria, misoprostol is widely available from drug sellers. We interviewed 394 women in 2018 in Lagos State, Nigeria, who induced abortion using misoprostol obtained from a drug seller to determine their sexual and reproductive health literacy (SRHL) and misoprostol knowledge levels; and how these were associated with ending the pregnancy successfully or seeking care for (perceived) complications. Our results show that women's misoprostol knowledge (measured both quantitatively and qualitatively) was low, but that almost all women were nevertheless able to use the drug effectively and safely. Higher SRHL was associated with being more likely to end the pregnancy successfully and also seeking postabortion health care. Our study is the first to examine this association and adds to the scarce literature examining the relationship between health literacy and self‐use of misoprostol to induce abortions in restrictive settings.
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Affiliation(s)
- Heini Väisänen
- Heini Väisänen, Sexual and Reproductive Health and Rights unit, Institut national d'études démographiques (INED), Aubervilliers, France.,Centre for Population Change, University of Southampton, Southampton, UK
| | - Ann M Moore
- Ann M. Moore, Onikepe Owolabi, Melissa Stillman, Guttmacher Institute, New York, USA
| | - Onikepe Owolabi
- Ann M. Moore, Onikepe Owolabi, Melissa Stillman, Guttmacher Institute, New York, USA
| | - Melissa Stillman
- Ann M. Moore, Onikepe Owolabi, Melissa Stillman, Guttmacher Institute, New York, USA
| | - Adesegun Fatusi
- Adesegun Fatusi, Academy for Health Development (AHEAD), Ile-Ife, Nigeria.,University of Medical Sciences, Ondo, Ondo, Nigeria
| | - Akanni Akinyemi
- Akanni Akinyemi, Centre for Research, Evaluation Resources and Development (CRERD), Ile-Ife, Nigeria
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Sorhaindo A, Sedgh G. Scoping review of research on self-managed medication abortion in low-income and middle-income countries. BMJ Glob Health 2021; 6:e004763. [PMID: 33986002 PMCID: PMC8126307 DOI: 10.1136/bmjgh-2020-004763] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/03/2021] [Accepted: 03/27/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND We undertook a scoping review of recent studies on self-managed medical abortion (MA) or abortion where some or all of the process is led independently by the person having the abortion, in low-income and middle-income countries (LMICs) to uncover evidence gaps and help stakeholders leverage existing evidence. METHODS We searched five bibliographic databases for all articles published on MA between 2007 and July 2020 in LMICs. The search yielded 1294 articles. We identified 107 articles in which one or more of the three WHO-defined subtasks for MA was self-led outside of a clinic setting, and use of drugs that are part of safe, evidence-based regimens was related to the study exposure or outcome. We classified these studies by subject area, study design, country, legal context, gestational age and other categories. RESULTS The 107 studies covered research in 44 countries, of which 18 have liberal abortion laws. Seventy- four articles reported on quantitative research methods, of which 14 were randomised controlled trials. Fifty-two studies focused on MA in the first trimester. Sixty-two focused on WHO subtask two (drug administration) and 32 focused on subtask three (assessing and managing abortion completion). We found little research on self-management of the entire MA process, innovative approaches to supporting self-managed MA or the needs of underserved populations. CONCLUSION We recommend syntheses of evidence on safety and efficacy of self-managed MA and preferences of people undergoing self-managed MA. We also encourage new research on topics including self-management of the entire process, the needs and experiences of underserved populations and innovative approaches to supporting people undertaking self-managed MA. The time is opportune for amplifying and expanding evidence to inform programmes and policies on self-care.
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Affiliation(s)
| | - Gilda Sedgh
- Independent Consultant, Philadelphia, Pennsylvania, USA
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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: 0.8] [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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Affiliation(s)
- Siri Suh
- Brandeis University, Waltham, MA, United States
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Footman K, Chelwa N, Douthwaite M, Mdala J, Mulenga D, Brander C, Church K. Treading the Thin Line: Pharmacy Workers' Perspectives on Medication Abortion Provision in Lusaka, Zambia. Stud Fam Plann 2021; 52:179-194. [PMID: 33826147 DOI: 10.1111/sifp.12151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies. METHODS We conducted 16 in-depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka. RESULTS We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers' motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion, and level of desperation. CONCLUSION These findings highlight how pharmacy staff informally determine women's abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion.
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Affiliation(s)
- Katharine Footman
- MSI Reproductive Choices, London, W1T 6LP, UK.,Department of Social Policy, London School of Economics and Political Science
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Treleaven E, Pham TN, Nguyen AD, Diamond-Smith N. The list experiment: An approach to measuring stigmatized behaviours related to sex-selective abortion. Population Studies 2021; 75:363-380. [PMID: 33792524 DOI: 10.1080/00324728.2021.1900589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vietnam reports one of the highest levels of abortion globally and an increasingly skewed sex ratio at birth. Abortion and related stigmatized behaviours are notoriously difficult to measure, yet understanding women's ability and willingness to engage in sex selection is of interest to demographers and policymakers alike. We piloted the list experiment, an indirect questioning method, to estimate the prevalence of prenatal sex determination and sex-selective abortion. Respondents reported the total number of items they had engaged in from a list, reducing non-response and incentives to under-report. Among 900 women sampled at two hospitals in Hanoi, we estimated a high prevalence of prenatal sex determination. We found a low prevalence of sex-selective abortion, but higher prevalence among specific parity and children's sex composition subgroups. Responses to knowledge and attitudinal questions underscored women's perceived stigma around sex-selective abortion, suggesting the list experiment is a potentially useful tool for studying son preference.
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Affiliation(s)
- Emily Treleaven
- University of Michigan.,University of California, San Francisco
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Gambir K, Garnsey C, Necastro KA, Ngo TD. Effectiveness, safety and acceptability of medical abortion at home versus in the clinic: a systematic review and meta-analysis in response to COVID-19. BMJ Glob Health 2020; 5:e003934. [PMID: 33380413 PMCID: PMC7780419 DOI: 10.1136/bmjgh-2020-003934] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Increased access to home-based medical abortion may offer women a convenient, safe and effective abortion method, reduce burdens on healthcare systems and support social distancing during the COVID-19 pandemic. Home-based medical abortion is defined as any abortion where mifepristone, misoprostol or both medications are taken at home. METHODS A systematic review and meta-analysis of randomised controlled trials (RCTs) and non-randomised studies (NRSs) were conducted. We searched databases from inception to 10 July 2019 and 14 June 2020. Successful abortion was the main outcome of interest. Eligible studies were RCTs and NRSs studies with a concurrent comparison group comparing home versus clinic-based medical abortion. Risk ratios (RRs) and their 95% CIs were calculated. Estimates were calculated using a random-effects model. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess risk of bias by outcome and to evaluate the overall quality of the evidence. RESULTS We identified 6277 potentially eligible published studies. Nineteen studies (3 RCTs and 16 NRSs) were included with 11 576 women seeking abortion up to 9 weeks gestation. Neither the RCTs nor the NRS found any difference between home-based and clinic-based administration of medical abortion in having a successful abortion (RR 0.99, 95% CI 0.98 to 1.01, I2=0%; RR 0.99, 95% CI 0.97 to 1.01, I2=52%, respectively). The certainty of the evidence for the 16 NRSs was downgraded from low to very low due to high risk of bias and publication bias. The certainty of the evidence for the three RCTs was downgraded from high to moderate by one level for high risk of bias. CONCLUSION Home-based medical abortion is effective, safe and acceptable to women. This evidence should be used to expand women's abortion options and ensure access to abortion for women during COVID-19 and beyond. PROSPERO REGISTRATION NUMBER CRD42020183171.
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Affiliation(s)
- Katherine Gambir
- Poverty, Gender and Youth Program, Population Council, New York, New York, USA
| | - Camille Garnsey
- Poverty, Gender and Youth Program, Population Council, New York, New York, USA
| | - Kelly Ann Necastro
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thoai D Ngo
- Poverty, Gender and Youth Program, Population Council, New York, New York, USA
- The GIRL Center, Population Council, New York, New York, USA
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Moseson H, Keefe-Oates B, Jayaweera RT, Filippa S, Motana R, Bercu C, Egwuatu I, Grosso B, Kristianingrum IA, Nmezi S, Zurbriggen R, Friedman E, Gerdts C. Studying Accompaniment model Feasibility and Effectiveness (SAFE) Study: study protocol for a prospective observational cohort study of the effectiveness of self-managed medication abortion. BMJ Open 2020; 10:e036800. [PMID: 33444174 PMCID: PMC7678383 DOI: 10.1136/bmjopen-2020-036800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION A range of barriers deter or prevent people from accessing facility-based abortion care. As a result, people are obtaining and using abortifacient medications to end their pregnancies outside of the formal healthcare system, without clinical supervision. One model of self-managed abortion has come to be known as the 'accompaniment' model, in which grassroots organisations provide pregnant people with evidence-based counselling and support through the medication abortion process. Data are needed to understand the safety and effectiveness of this increasingly common model of abortion care. METHODS AND ANALYSIS This is a large, prospective, observational study in Argentina and Nigeria. All people who contact one of two accompaniment groups seeking information for their own self-managed medication abortion, are ages 13 years and older, have no contraindications for medication abortion, are within the gestational range supported by the group (up to 12 weeks' gestation for the primary outcome) and are willing to be contacted for follow-up will be recruited. Participants will respond to an interviewer-administered baseline survey at enrolment, and 1-4 additional surveys over 6 weeks to ascertain whether they obtain medications for abortion, dosing and route of administration of medications, physical and emotional experience of medication abortion self-management, and effectiveness and safety outcomes. Analyses will include estimates of the primary outcome: the proportion of participants that report a complete abortion without surgical intervention at last recorded follow-up; as well as secondary outcomes including a pseudo-experimental test of non-inferiority of the effectiveness of self-managed medication abortion as compared with clinical medication abortion. ETHICS AND DISSEMINATION We describe the ethical considerations and protections for this study, as well the creation of a study-specific Data Monitoring and Oversight Committee. We describe dissemination plans to ensure that study results are shared widely with all relevant audiences, particularly researchers, advocates, policymakers and clinicians. TRIAL REGISTRATION NUMBER ISRCTN95769543.
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Affiliation(s)
| | | | | | - Sofia Filippa
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | | | - Chiara Bercu
- Ibis Reproductive Health, Oakland, California, USA
| | - Ijeoma Egwuatu
- Generation Initiative for Women and Youth Nigeria, Lagos, Nigeria
| | - Belen Grosso
- Colectiva Feminista La Revuelta, Neuquen, Argentina
| | | | - Sybil Nmezi
- Generation Initiative for Women and Youth Nigeria, Lagos, Nigeria
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Baum SE, Ramirez AM, Larrea S, Filippa S, Egwuatu I, Wydrzynska J, Piasecka M, Nmezi S, Jelinska K. "It's not a seven-headed beast": abortion experience among women that received support from helplines for medication abortion in restrictive settings. Health Care Women Int 2020; 41:1128-1146. [PMID: 33156737 DOI: 10.1080/07399332.2020.1823981] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
There are a growing number of abortion helplines where counselors provide person-centered medication abortion services in legally restrictive settings. Few researchers have explored the perceptions and experiences of the people who obtain support from these helplines. Between April and August 2017, we conducted 30 interviews with women who had a medication abortion with support from helpline counselors in Poland, Brazil, or Nigeria. Before seeking care with the helpline, women often heard negative stories about abortion and faced enacted stigma from the formal healthcare sector, or chose not to seek services from their doctors due to fear of stigmatizing treatment. Conversely, during their care with the helpline counselors, women received clear information in a timely manner, and were treated with kindness, compassion, respect, and without judgment. Many women gained knowledge and understanding of medication abortion, and some gained a sense of community among those who experienced abortion. Helpline models can provide high-quality, person-centered abortion care to people seeking abortions in legally restrictive contexts. Evidence from these service-delivery models could help improve service within the formal healthcare systems and expand access to high-quality, safe abortion by redefining what it means to provide care.
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Affiliation(s)
- Sarah E Baum
- Ibis Reproductive Health, Oakland, California, USA
| | | | - Sara Larrea
- Women Help Women, Amsterdam, the Netherlands
| | | | - Ijeoma Egwuatu
- Generation Initiative for Youth and Women Network, Lagos, Nigeria
| | | | | | - Sybil Nmezi
- Generation Initiative for Youth and Women Network, Lagos, Nigeria
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Moseson H, Jayaweera R, Raifman S, Keefe-Oates B, Filippa S, Motana R, Egwuatu I, Grosso B, Kristianingrum I, Nmezi S, Zurbriggen R, Gerdts C. Self-managed medication abortion outcomes: results from a prospective pilot study. Reprod Health 2020; 17:164. [PMID: 33109230 PMCID: PMC7588945 DOI: 10.1186/s12978-020-01016-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the feasibility of conducting a prospective study to measure self-managed medication abortion outcomes, and to collect preliminary data on safety and effectiveness of self-managed medication abortion, we recruited callers to accompaniment groups (volunteer networks that provide counselling through the out-of-clinic medication abortion process by trained counselors over the phone or in-person). METHODS In 2019, we enrolled callers to three abortion accompaniment groups in three countries into a prospective study on the safety and effectiveness of self-managed medication abortion with accompaniment support. Participants completed up to five interview-administered questionnaires from baseline through 6-weeks after taking the pills. Primary outcomes included: (1) the number of participants enrolled in a 30-day period, (2) the proportion that had a complete abortion; and (3) the proportion who experienced any warning signs of potential or actual complications. RESULTS Over the 30-day recruitment period, we enrolled 227 participants (95% of those invited), and retained 204 participants (90%) for at least one study follow-up visit. At the 1-week follow-up, two participants (1%) reported a miscarriage prior to taking the pills, and 202 participants (89% of those enrolled and 99% of those who participated in the 1-week survey) had obtained and taken the medications. Three weeks after taking the medications, 192 (95%) participants reported feeling that their abortion was complete. Three (1.5%) received a surgical intervention, two (1%) received antibiotics, and five (3%) received other medications. Participants did not report any major adverse events. CONCLUSION These results establish the feasibility of conducting prospective studies of self-managed medication abortion in legally restrictive settings. Further, the high effectiveness of self-managed medication abortion with accompaniment support reported here is consistent with high levels of effectiveness reported in prior studies. Trial registration ISRCTN95769543.
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Affiliation(s)
- Heidi Moseson
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA.
| | - Ruvani Jayaweera
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA
| | - Sarah Raifman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | | | - Sofia Filippa
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA
| | | | - Ijeoma Egwuatu
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | - Belen Grosso
- La Revuelta Colectiva Feminista, Neuquén, Argentina
| | | | - Sybil Nmezi
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | | | - Caitlin Gerdts
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA
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Moore AM, Philbin J, Ariawan I, Budiharsana M, Murro R, Aryanty RI, Bankole A. Online Abortion Drug Sales in Indonesia: A Quality of Care Assessment. Stud Fam Plann 2020; 51:295-308. [PMID: 33079416 PMCID: PMC7821208 DOI: 10.1111/sifp.12138] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This study sought to understand the experience of buying misoprostol online for pregnancy termination in Indonesia. We conducted a mystery client study August through October, 2019. Interactions were analyzed quantitatively and qualitatively, along with the contents of the packages. One hundred ten sellers were contacted, from whom mystery clients made 76 purchases and received 64 drug packages. Almost all sellers sold “packets” containing multiple drugs; 73 percent of packets contained misoprostol, and 47 percent contained at least 800 mcg of misoprostol. Thirty‐four packets contained insufficient drugs to complete an abortion. When compared to WHO standards, 87 percent of sellers imparted incomplete information about potential physical effects; no seller provided information about possible complications. Women buying misoprostol from informal online drugs sellers will be underprepared for understanding potential side effects and complications. Educational activities are needed to increase women's access to information about safe use of misoprostol as a harm reduction strategy.
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Affiliation(s)
- Ann M Moore
- Ann M. Moore, Jesse Philbin, Rachel Murro, Akinrinola Bankole, Guttmacher Institute, New York, NY, 10038-4912
| | - Jesse Philbin
- Ann M. Moore, Jesse Philbin, Rachel Murro, Akinrinola Bankole, Guttmacher Institute, New York, NY, 10038-4912
| | - Iwan Ariawan
- Iwan Ariawan, Reconstra Utama Integra, Jakarta, Indonesia
| | - Meiwita Budiharsana
- Meiwita Budiharsana, Department of Biostatistics and Population, Faculty of Public Health, University of Indonesia, Depok, Indonesia
| | - Rachel Murro
- Ann M. Moore, Jesse Philbin, Rachel Murro, Akinrinola Bankole, Guttmacher Institute, New York, NY, 10038-4912
| | | | - Akinrinola Bankole
- Ann M. Moore, Jesse Philbin, Rachel Murro, Akinrinola Bankole, Guttmacher Institute, New York, NY, 10038-4912
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Moore AM, Blades N, Ortiz J, Whitehead H, Villarreal C. What does informal access to misoprostol in Colombia look like? A mystery client methodology in Bogotá and the Coffee Axis. BMJ SEXUAL & REPRODUCTIVE HEALTH 2020; 46:294-300. [PMID: 32624479 PMCID: PMC7569367 DOI: 10.1136/bmjsrh-2019-200572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/18/2020] [Accepted: 02/26/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION In 2006, abortion was decriminalised in Colombia under certain circumstances. Yet, women avail themselves of ways to terminate pregnancy outside of the formal health system. This study explored how drug sellers engage with women who attempt to purchase misoprostol from them. METHODS A mapping exercise was undertaken to list small-chain and independent drug stores in two regions in Colombia. A sample (n=558) of drug stores was selected from this list and visited by mystery clients between November and December 2017. Mystery clients sought to obtain a medication to bring back a delayed period, and described the experience, the information obtained and the medications proffered in exit interviews. RESULTS Misoprostol was offered for purchase in 15% of the visits; in half of visits, only information about misoprostol was shared, while no information about misoprostol was provided on the remaining visits. Over half of sellers who refused to sell any medication provided referrals, most commonly to an abortion provider. Among visits which included discussion of misoprostol, two out of five sellers provided dosage instructions with most recommending the minimum adequate dosage. Mystery clients received little information on the physical effects to expect with the use of misoprostol and possible complications. CONCLUSIONS As misoprostol is being obtained from some drug sellers without a prescription, capacitating this cadre with at least a minimum of standardised information on dosage, routes of administration and expected effects and outcomes have the potential to improve reproductive health outcomes for women who choose to terminate pregnancies this way in Colombia.
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Affiliation(s)
- Ann M Moore
- Division of Research, Guttmacher Institute, New York, New York, USA
| | - Nakeisha Blades
- Division of Research, Guttmacher Institute, New York, New York, USA
| | | | - Hannah Whitehead
- Division of Research, Guttmacher Institute, New York, New York, USA
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Moseson H, Bullard KA, Cisternas C, Grosso B, Vera V, Gerdts C. Effectiveness of self-managed medication abortion between 13 and 24 weeks gestation: A retrospective review of case records from accompaniment groups in Argentina, Chile, and Ecuador. Contraception 2020; 102:91-98. [DOI: 10.1016/j.contraception.2020.04.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
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Stillman M, Owolabi O, Fatusi AO, Akinyemi AI, Berry AL, Erinfolami TP, Olagunju OS, Väisänen H, Bankole A. Women's self-reported experiences using misoprostol obtained from drug sellers: a prospective cohort study in Lagos State, Nigeria. BMJ Open 2020; 10:e034670. [PMID: 32376752 PMCID: PMC7223139 DOI: 10.1136/bmjopen-2019-034670] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES This study aimed to assess the safety and effectiveness of self-managed misoprostol abortions obtained outside of the formal health system in Lagos State, Nigeria. DESIGN This was a prospective cohort study among women using misoprostol-containing medications purchased from drug sellers. Three telephone-administered surveys were conducted over 1 month. SETTING Data were collected in 2018 in six local government areas in Lagos State. PARTICIPANTS Drug sellers attempted to recruit all women who purchased misoprostol-containing medication. To remain in the study, participants had to be female and aged 18-49, and had to have purchased the medication for the purpose of abortion. Of 501 women initially recruited, 446 were eligible for the full study, and 394 completed all three surveys. PRIMARY AND SECONDARY OUTCOME MEASURES Using self-reported measures, we assessed the quality of information provided by drug sellers; the prevalence of potential complications; and the proportion with completed abortions. RESULTS Although drug sellers provided inadequate information about the pills, 94% of the sample reported a complete abortion without surgical intervention about 1 month after taking the medication. Assuming a conservative scenario where all individuals lost to follow-up had failed terminations, the completion rate dropped to 87%. While 86 women reported physical symptoms suggestive of complications, only six of them reported wanting or needing health facility care and four subsequently obtained care. CONCLUSIONS Drug sellers are an important source of medical abortion in this setting. Despite the limitations of self-report, many women appear to have effectively self-administered misoprostol. Additional research is needed to expand the evidence on the safety and effectiveness of self-use of misoprostol for abortion in restrictive settings, and to inform approaches that support the health and well-being of people who use this method of abortion.
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Affiliation(s)
- Melissa Stillman
- Department of Research, Guttmacher Institute, New York, New York, USA
| | - Onikepe Owolabi
- Department of Research, Guttmacher Institute, New York, New York, USA
| | - Adesegun O Fatusi
- Department of Research, Guttmacher Institute, New York, New York, USA
- Academy for Health Development (AHEAD), Ile-Ife, Nigeria
| | - Akanni I Akinyemi
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, Massachusetts, United States
- Department of Demography and Social Statistics, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Amanda L Berry
- Department of Research, Guttmacher Institute, New York, New York, USA
| | - Temitope P Erinfolami
- Department of Demography and Social Statistics, Obafemi Awolowo University, Ile-Ife, Nigeria
- Centre for Research, Evaluation, Resources and Development (CRERD), Ile-Ife, Nigeria
| | - Olalekan S Olagunju
- Department of Demography and Social Statistics, Obafemi Awolowo University, Ile-Ife, Nigeria
- Centre for Research, Evaluation, Resources and Development (CRERD), Ile-Ife, Nigeria
| | - Heini Väisänen
- Department of Social Statistics and Demography, University of Southampton, Southampton, Hampshire, UK
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Bowring AL, Schwartz S, Lyons C, Rao A, Olawore O, Njindam IM, Nzau J, Fouda G, Fako GH, Turpin G, Levitt D, Georges S, Tamoufe U, Billong SC, Njoya O, Zoung-Kanyi AC, Baral S. Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:82-99. [PMID: 32234842 PMCID: PMC7108938 DOI: 10.9745/ghsp-d-19-00330] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 02/28/2020] [Indexed: 12/19/2022]
Abstract
Female sex workers (FSWs) in Cameroon have unmet need for effective contraception, and experience of unintended pregnancy and pregnancy termination is common. Reducing barriers to accessing high-quality, voluntary family planning services in FSW-focused community services is a key strategy to promote client-centered care, promote informed choice, reduce unintended pregnancies, and improve quality of life for FSWs. Background: Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon. Methods: From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception. Results: Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use. Conclusions: Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights.
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Affiliation(s)
- Anna L Bowring
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. .,Burnet Institute, Melbourne, Australia
| | - Sheree Schwartz
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carrie Lyons
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Amrita Rao
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Oluwasolape Olawore
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Iliassou Mfochive Njindam
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Metabiota, Yaounde, Cameroon
| | | | | | | | - Gnilane Turpin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | - Ubald Tamoufe
- Metabiota, Yaounde, Cameroon.,Johns Hopkins Cameroon Program, Yaounde, Cameroon
| | - Serge C Billong
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon
| | - Oudou Njoya
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon
| | - Anne-Cécile Zoung-Kanyi
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaounde, Cameroon.,Division of Operations Research, Ministry of Health, Yaounde, Cameroon
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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50
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Medical abortion offered in pharmacy versus clinic-based settings. Hippokratia 2020. [DOI: 10.1002/14651858.cd013566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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