Women's satisfaction with comprehensive abortion care services and associated factors in central Gondar zone public primary hospitals, northwest Ethiopia, 2023

Background

Abortion complications are the leading causes of maternal death in low and middle-income countries, including Ethiopia. Providing quality and comprehensive abortion care services is crucial for improving the health of women and increased their satisfaction. Evaluating a client's satisfaction with abortion care is clinically relevant since women's satisfaction with health services is one of the key indicators of high-quality healthcare services. Therefore, this study aimed to assess women's satisfaction with comprehensive abortion care services and associated factors.

Methods

An institution-based cross-sectional study was implemented among 333 women in Central Gondar Zone public primary hospitals from October 1, 2022, to April 30, 2023. Eligible participants were selected using a systematic random sampling technique. The data was collected using an interviewer-administered semi-structured, and pretested questionnaire. STATA version 17 and SPSS version 25 software were used for data entry and analysis respectively. Bivariable and multivariable logistic regression models were used to identify factors associated with clients' satisfaction with comprehensive abortion care services. A P-value of ≤0.05 with a 95% confidence interval was the cutoff point for determining statistical significance.

Results

This study revealed that the level of client satisfaction with comprehensive abortion care services was 60.4% (95% CI: 55.0%, 66.0%). The use of abortion medication (AOR = 4.41, 95% CI: 2.59, 7.48), women's age 20-24 years (AOR = 2.94, 95% CI: 1.02, 8.48), and being a student (AOR = 2.88, 95% CI: 1.10, 7.51) were significantly associated with women's satisfaction with comprehensive abortion care services.

Conclusions

Women's satisfaction with comprehensive abortion care services was relatively low, and it was strongly correlated with the method of abortion, age, and occupation. To improve women's satisfaction requires a comprehensive understanding of women's values and perspectives, providing sexual and reproductive health education, and quality abortion care services are recommended.

Revolution in abortion care? Perspectives of key informants on the importance of abortion method choice in the era of telemedicine

Patient choice of medical or surgical abortion is a standard of quality abortion care, but the choice of surgical abortion is constrained in England and Wales, particularly since the COVID-19 pandemic and introduction of telemedicine. This qualitative study explored the perspectives of abortion service providers, managers, and funders on the need to offer a choice of methods within early gestation abortion services in England and Wales. Twenty-seven key informant interviews were conducted between August and November 2021, and framework analysis methods were used. Participants presented arguments both for and against offering method choice. Most participants felt that it was important to maintain choice, although they recognised that medical abortion suits most patients, that both methods are very safe and acceptable, and that the priority for abortion services is to maintain timely access to respectful care. Their arguments related to practicalities around patient needs, the risk of reinforcing inequalities in access to patient-centred care, potential impacts on patients and providers, comparisons to other services, costs, and moral issues. Participants argued that constraining choice has a greater impact on those who are less able to advocate for themselves and there were concerns that patients may feel stigmatised or isolated when unable to choose their preferred method. In conclusion, although medical abortion suits most patients, this study highlights arguments for maintaining the option of surgical abortion in the era of telemedicine. More nuanced discussion of the potential benefits and impacts of self-management of medical abortion is needed.

Structural barriers or patient preference? A mixed methods appraisal of medical abortion use in England and Wales

Although patient choice of abortion method is a key component of quality care, medical abortion (MA) has become the most common method (87%) in England and Wales, as in many countries worldwide. This research aimed to critically examine factors influencing the growth in MA use in England and Wales. Mixed methods were used, combining multi-level regression analysis of national abortion statistics (2011-2020) and key informant interviews with abortion service managers, commissioners, and providers (n=27). Overall trends have been driven by growth in MA use for abortions under 10 weeks in the private non-profit sector. Variation in MA use between patient sub-groups and regions has narrowed over time. Qualitative findings highlight health system constraints that have influenced the shift towards MA, including workforce constraints, infrastructure requirements, provider policies, cost, and commissioning practices involving under-funding and competition, which have caused the private non-profit sector to limit method choice across their services to remain financially viable. While removal of legal restrictions on MA has expanded choice, similar policy progress has not been seen for surgical methods. The study concludes that abortion method choice has been constrained by structural health system factors, with potential negative consequences for service acceptability, inequalities, and patient-centredness.

Nurse practitioners on 'the leading edge' of medication abortion care: A feminist qualitative approach

AIMS

To explore nurse practitioners' experiences of medication abortion implementation in Canada and to identify ways to further support the implementation of medication abortion by nurse practitioners in Canada.

DESIGN

A qualitative approach informed by feminist theory and integrated knowledge translation.

METHODS

Qualitative interviews with stakeholders and nurse practitioners between January 2020 and May 2021. Data were analysed using critical feminist theory.

RESULTS

Participants included 20 stakeholders, 16 nurse practitioner abortion providers, and seven nurse practitioners who did not provide abortions. We found that nurse practitioners conduct educational, communication and networking activities in the implementation of medication abortion in their communities. Nurse practitioners navigated resistance to abortion care in the health system from employers, colleagues and funders. Participants valued making abortion care more accessible to their patients and indicated that normalizing medication abortion in primary care was important to them.

CONCLUSION

When trained in abortion care and supported by employers, nurse practitioners are leaders of abortion care in their communities and want to provide accessible, inclusive services to their patients. We recommend nursing curricula integrate abortion services in education, and that policymakers and health administrators partner with nurses, physicians, midwives, social workers and pharmacists, for comprehensive provincial/territorial sexual and reproductive health strategies for primary care.

IMPACT

The findings from this study may inform future policy, health administration and curriculum decisions related to reproductive health, and raise awareness about the crucial role of nurse practitioners in abortion care and contributions to reproductive health equity.

PATIENT OR PUBLIC CONTRIBUTION

This study focused on provider experiences. In-kind support was provided by Action Canada for Sexual Health & Rights, an organization that provides direct support and resources to the public and is committed to advocating on behalf of patients and the public seeking sexual and reproductive health services.

Perspectives on high-quality interpersonal care among people obtaining abortions in Argentina

Introduction

Little is known about how people who have abortions describe high-quality interpersonal care in Argentina. This qualitative study aimed to understand preferences and priorities in their interactions with providers.

Study design

We conducted 24 in-depth interviews with people who obtained abortions at a comprehensive reproductive health clinic or with support from a feminist accompaniment group in Buenos Aires and Neuquén, Argentina. We iteratively coded transcripts using a thematic analysis approach based on interpersonal domains present in current quality of care frameworks.

Results

Participants described high-quality abortion care as feeling acompañamiento and contención from their providers – terms that imply receiving kind, caring, compassionate and emotionally supportive care throughout their abortion. They described four key elements of interpersonal interactions: attentive communication from providers and accompaniers, clear and understandable information provision, non-judgmental support, and individualized options for pain management.

Conclusions

People obtaining abortions in Argentina consistently identified receiving compassionate and supportive care throughout an abortion as a key aspect of care. The findings have implications for incorporating people’s perspectives in the development of care guidelines, training of providers, and monitoring and improving of services. This is particularly important as the government of Argentina prepares to expand legal access to abortion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01401-1.

Little is known about how people who have abortions perceive the quality of the care they receive and what aspects of interpersonal interactions with providers matter to them. This qualitative study aimed to understand preferences of  people who had abortions at both a reproductive health clinic and with an accompaniment group in Argentina. We interviewed 24 people who obtained abortion care in Buenos Aires and Neuquén, Argentina. We asked them about their preferences for and experiences of abortion care. Then we analyzed the interviews, specifically assessing aspects of interpersonal care based on quality of care frameworks from the literature. Participants described high-quality abortion care as feeling acompañamiento and contención from their providers—terms that imply receiving kind, caring, compassionate and emotionally supportive care throughout their abortions. They described four key elements of interpersonal interactions: attentive communication from providers and accompaniers, clear and understandable information provision, non-judgmental support, and individualized options for pain management. In conclusion, people obtaining abortions in two distinct models of care in Argentina consistently identified receiving compassionate and supportive care throughout an abortion as a key aspect of care. The findings have implications for incorporating people’s perspectives in the development of care guidelines, training of providers, and monitoring and improving of services. This is particularly important as the government of Argentina prepares to expand legal access to abortion.

Nonpharmacological pain management interventions in medical and surgical abortion: A scoping review

AIMS

The study aimed to present a broad overview of the research conducted and to synthesize evidence of the utility of nonpharmacological interventions for pain management in medical and surgical abortions.

BACKGROUND

High-quality care for medical and surgical abortion requires pain to be managed effectively. However, women reported low satisfaction with pain management in abortion care.

DESIGN

A scoping review design was employed.

DATA SOURCES

No date limit was set. PubMed, Cochrane Library, EMBASE, Web of Science, CINAHL, PsycINFO, ProQuest and Scopus were searched in April 2021.

REVIEW METHODS

Arksey and O'Malley's framework was used. The Preferred Reporting Items for Systematic reviews and Meta-analysis extension-Scoping Reviews was followed.

RESULTS

Fifteen studies were included. The results revealed that support interventions, music therapy, acupoint stimulation and hypnotic analgesia were nonpharmacological interventions used to decrease abortion pain.

CONCLUSIONS

Clinical nurses, nurse managers and policymakers should attach full importance to the pain management in abortion and may use the study findings to guide the pain management practice.

“I just have to hope that this abortion should go well”: Perceptions, fears, and experiences of abortion clients in Nigeria

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.

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

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

Nurse practitioners' and certified nurse midwives' experiences providing comprehensive early abortion care in New England, USA

Access to abortion is linked to better maternal health and is essential to advancing women's economic and social equality. Globally, nurses and midwives have been identified as key for increasing access to this service. In this qualitative study we describe the experiences of nurse practitioners and nurse midwives who provide comprehensive early abortion care in the New England region of the United States. In contrast to much of the existing literature from around the world on nurses who deliver abortion care, we found participants' experiences providing comprehensive early abortion was generally positive. The study has implications for theory development, research, and policy.

"Going through it together": Being accompanied by loved ones during birth and abortion

We sought to understand the meaning people who have given birth and have had an abortion ascribe to being accompanied by partners, family members and friends during these reproductive experiences. Incorporating this knowledge into clinical practice may contribute to improving the quality of these services, especially in abortion care, in which loved ones are often excluded. The study took place in Northern California in 2014. We conducted semi-structured, intensive interviews with twenty cis-women about their birth and abortion experiences and analyzed their narratives with respect to accompaniment using grounded theory. The roles of loved ones were complementary yet distinct to those of medical personnel. They were also multifaceted. Participants needed familiar individuals to bear witness, share the emotional experience and provide protection from perceived or possible harm associated with medical care. In some cases, more often in the context of abortion than childbirth, participants shielded their loved ones from emotional burdens of the reproductive process. Some pregnant people of color faced gendered racism, which also influenced their accompaniment needs. Male partners played a distinct role of upholding dominant social ideals related to pregnancy. As is commonplace in birth-related care, abortion services could be formally structured to include partners, family members and friends when desired by pregnant people to improve their experiences. Such integration should be balanced with considerations for privacy, safety and institutional resources. Working toward this goal may reduce structural abortion stigma and help alleviate pregnant people's burdens associated with reproduction.

Cross-country abortion travel to England and Wales: results from a cross-sectional survey exploring people's experiences crossing borders to obtain care

Background

The laws governing abortion access vary across Europe. Even in countries with relatively liberal laws, numerous barriers to abortion access exist. In response to these barriers, evidence suggests that people living in countries with both restrictive and liberal laws travel outside of their home country for abortion care. England and Wales are common destinations for those who travel to seek abortions, but little is known about the motivations and experiences of those who undertake cross-country travel to England or Wales to obtain care. This paper aims to describe the abortion seeking and travel experiences of women and pregnant people who traveled to England and Wales for an abortion between 2017 and 2019.

Methods

We recruited 97 participants who had traveled cross-country from both liberal and restrictive contexts to seek abortion care at three participating BPAS clinics in England and Wales. Participants completed an electronic survey about their reproductive histories, abortion decision-making, experiences seeking abortion care, and traveling. We conducted a descriptive analysis, and include comparisons between participants who traveled from liberal and restrictive contexts.

Results

Over a third of participants considered abortion four weeks or more before presenting for care at BPAS, and around two-thirds sought abortion services in their home country before traveling. The majority of participants indicated that they would have preferred to have obtained an abortion earlier and cited reasons including scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. About seventy percent of participants reported travel costs between €101–1000 and 75% of participants reported that the cost of the abortion procedure exceeded €500. About half of participants indicated that, overall, their travel was very or somewhat difficult.

Conclusions

This analysis documents the burdens associated with cross-country travel for abortion and provides insight into the factors that compel people to travel. Our findings highlight the need for expanded access to abortion care throughout Europe via the removal of legal impediments and other social or procedural barriers. Removing barriers would eliminate the need for cumbersome abortion travel, and ensure that all people can obtain necessary, high-quality healthcare in their own communities.

In Europe, people who live in countries where abortion is severely restricted or illegal altogether lack access to abortion care entirely, but even people who live in countries with more liberal laws face barriers due to gestational age limits, waiting periods, and a lack of trained and willing providers. Existing evidence suggests that restrictions and barriers compel people from both countries with restrictive laws as well as those from countries with more liberal laws to travel outside of their home country for abortion services. England and Wales are common destinations for people traveling within Europe to obtain abortion services, but little is known about the experiences of these travelers. We surveyed individuals who had traveled from another country to seek abortion services in England or Wales. Our analysis documents that many participants contemplated getting an abortion and sought care in their home countries before traveling. Likewise, many participants indicated that they would have preferred to have obtained an abortion earlier in their pregnancy, and referenced scheduling issues, a dearth of local services, delayed pregnancy recognition, and financial difficulties as causing their delay. A majority of participants indicated that covering the costs of their abortion, and the costs of travel was difficult, and that the travel experience in its entirety was difficult. Our findings document the reasons for, and burdens associated with abortion travel and highlight the need to expand access to abortion across Europe via the elimination of all legal restrictions and impediments.

Person-centred care for abortion services in private facilities to improve women's experiences in Kenya

Globally, access to good quality abortion services and post-abortion care is a critical determinant for women's survival after unsafe abortion. Unsafe abortions account for high levels of maternal death in Kenya. We explored women's experiences and perceptions of their abortion and post-abortion care experiences in Kenya through person-centred care. This qualitative study included focus group discussions and in-depth interviews with women aged 18-35 who received safe abortion services at private clinics. Through thematic analyses of women's testimonies, we identified gaps in the abortion care and person-centred domains which seemed to be important throughout the abortion process. When women received clear communication and personalised comprehensive information on abortion and post-abortion care from their healthcare providers, they reported more positive experiences overall and higher reproductive autonomy. Communication and supportive care were particularly valued during the post-abortion period, as was social support more generally. Further research is needed to design, implement and test the feasibility and acceptability of person-centred abortion care interventions in community and clinical settings with the goal of improving women's abortion experiences and overall reproductive health outcomes.

Factors influencing abortion decisions, delays, and experiences with abortion accompaniment in Mexico among women living outside Mexico City: results from a cross-sectional study

Access to abortion throughout much of Mexico has been restricted. Fondo Maria is an abortion accompaniment fund that provides informational, logistical, financial, and emotional support to people seeking abortion care in Mexico. This cross-sectional study examines the factors that influenced decision-making and contributed to delays in accessing care and explores experiences with Fondo Maria’s support among women living outside Mexico City (CDMX). We describe and compare the experiences of women across the sample (n = 103) who were either supported by Fondo Maria to travel to CDMX to obtain an abortion (n = 60), or self-managed a medical abortion in their home state (n = 43). Data were collected between January 2017 and July 2018. Seventy-seven percent of participants reported that it was difficult to access abortion care in their home state and 34% of participants indicated they were delayed in accessing care, primarily due to a lack of financial support. The majority of participants (58%) who travelled to CDMX for their abortion did so because it seemed safer. The money/cost of the trip was the most commonly cited reason (33%) why participants who self-managed stayed in their home state. Eighty-seven percent of participants said Fondo Maria’s services met or exceeded their expectations. Our data suggest that people seeking abortion and living outside CDMX face multiple and overlapping barriers that can delay care-seeking and influence decision-making. Abortion accompaniment networks, such as Fondo Maria, offer a well-received model of support for people seeking abortion in restrictive states across Mexico.

Effect of a smartphone intervention on self-managed medication abortion experiences among safe-abortion hotline clients in Indonesia: A randomized controlled trial

OBJECTIVE

To investigate the impact of a smartphone application (app) providing information and support for medication abortion (MA) on the primary outcomes of 'feelings of support' and 'preparedness' among clients of Samsara, a safe-abortion hotline in Indonesia.

METHODS

In a parallel-arm, non-clinical, randomized controlled trial, women (ages ≥15) who contacted Samsara between February 2017- July 2018 seeking information on MA for pregnancies ≤13 weeks gestation were randomized to receive either an app with abortion information, or standard of care (high-quality comprehensive and empathic counseling on pregnancy options). Participants completed a questionnaire 24 days after enrollment; Fisher exact tests and risk differences were used to assess differences in self-reported feelings of preparedness and support throughout the process of self-managed MA.

RESULTS

No differences in feelings of support or preparedness were detected between participants in the app arm versus the standard of care arm.

CONCLUSION

This study represents the first-ever randomized control trial (and prospective study) among those who contacted a safe-abortion hotline for information about and support for self-managed abortion. Levels of preparedness, confidence, and feelings of support were all extremely high among both control and intervention arms-indicative of the high-quality, evidence-based information, comprehensive, and supportive abortion counseling that safe-abortion hotline clients receive.

Experiences with pain of early medical abortion: qualitative results from Nepal, South Africa, and Vietnam

Background

Medical abortion (MA) has become an increasingly popular choice for women even where surgical abortion services are available. Pain is often cited by women as one of the worst aspects of the MA experience, yet we know little about women’s experience with pain management during the process, particularly in low resource settings. The aim of this study is to better understand women’s experiences of pain with MA and strategies for improving quality of care.

Methods

This qualitative study was conducted as part of a three-arm randomized, controlled trial in Nepal, Vietnam, and South Africa to investigate the effect of prophylactic pain management on pain during MA through 63 days’ gestation. We purposively sampled seven parous and seven nulliparous women with a range of reported maximum pain levels from each country, totaling 42 participants. Thematic content analysis focused on MA pain experiences and management of pain compared to menstruation, labor, and previous abortions.

Results

MA is relatively less painful compared to giving birth and relatively more painful than menstruation, based on four factors: pain intensity, duration, associated symptoms and side effects, and response to pain medications. We identified four types of pain trajectories: minimal overall pain, brief intense pain, intermittent pain, and constant pain. Compared to previous abortion experiences, MA pain was less extreme (but sometimes longer in duration), more private, and less frightening. There were no distinct trends in pain trajectories by treatment group, parity, or country. Methods of coping with pain in MA and menstruation are similar in each respective country context, and use of analgesics was relatively uncommon. The majority of respondents reported that counseling about pain management before the abortion and support during the abortion process helped ease their pain and emotional stress.

Conclusions

Pain management during MA is increasingly essential to ensuring quality abortion care in light of the growing proportion of abortions completed with medication around the world. Incorporating a discussion about pain expectations and pain management strategies into pre-MA counseling and providing access to information and support during the MA process could improve the quality of care and experiences of MA patients.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12613000017729, registered January 8, 2013.

Hangers, Potions, and Pills: Abortion Procedures on American Television, 2008 to 2018

BACKGROUND

Television portrayals of medical procedures may contribute to patient anxieties and cultural myths. We explored how television depicts abortion procedures, focusing on what these portrayals communicate about abortion access and safety.

METHODS

Researchers identified all abortion procedure plotlines on American television from 2008 to 2018 through Internet searches. We viewed plotlines and coded for type of abortion, health outcome, and whether the abortion occurred on or off screen. We used inductive content analysis to identify themes.

FINDINGS

We identified 96 television plotlines between 2008 and 2018 in which a character obtains or discloses an abortion. Of these, 39 plotlines (40%) depict some aspect of the abortion procedure. Twenty-three of the 39 abortion portrayals (59%) depict a surgical abortion procedure, of which about one-half were legal abortions and one-half were illegal. Only 7 of the 39 procedure plotlines (18%) portray medication abortions. Five of these plotlines depict illegal abortions; only two depict legal abortions. Four plotlines depict attempted abortions by supernatural means or ingestion of a toxic liquid.

CONCLUSION

The majority of abortions on television are surgical, contrasting with the reality of abortion practice in which one-third of U.S. abortions are by medication. Portrayals of surgical abortion often reinforce the misperception that abortion is a surgical intervention requiring hospitalization. The few portrayals of medication abortion also perpetuate inaccuracies, including that it is easily accessible, uncommon, and dangerous. Portrayals of illegal abortions are overrepresented. This misinformation may seed unnecessary fear for patients before an abortion, and may create confusion among the public about abortion access and safety.

Adapting the Interpersonal Quality in Family Planning care scale to assess patient perspectives on abortion care

Background

Women value receiving quality interpersonal care during abortion services, yet no measure exists to assess this outcome from patients’ perspectives. We sought to adapt the Interpersonal Quality in Family Planning care scale (Dehlendorf et al., American Journal of Obstetrics Gynaecology 10.1016/j.ajog.2016.01.173, 2016) for use in abortion care.

Methods

We adapted items from the original scale for the abortion context, and conducted cognitive interviews to explore the acceptability, understandability, and importance of the adapted items. Adults who spoke English and/or Spanish, had an abortion in the past year, and lived in the US were eligible to participate. Interview memos were analyzed concurrently with data collection to refine the measure in stages.

Results

We interviewed 26 participants. Items were tested over seven stages and led to four main changes. First, we revised three items to reflect concepts perceived as important to the specific decision-making context of abortion. Second, we removed two items that emerged as potentially inappropriate for this context. Third, we modified language in four items to improve their appropriateness for this context (e.g., ‘telling me’ to ‘explaining’; ‘letting me say’ to ‘listening to’). Fourth, we modified language in three items to improve their clarity. Three items remained unchanged, as there was consistent agreement on their importance, understandability, and relevance.

Conclusions

The resulting 10-item measure, the Interpersonal Quality in Abortion Care scale, was perceived to be highly important, understandable, and feasible to complete. Future psychometric evaluation can prepare it for use in clinical practice to ensure women feel adequately informed and supported during abortion care.

Expanding the Abortion Provider Workforce: A Qualitative Study of Organizations Implementing a New California Policy

CONTEXT

Access to abortion care in the United States varies according to multiple factors, including location, state regulation and provider availability. In 2013, California enacted a law that authorized nurse practitioners (NPs), certified nurse-midwives (CNMs) and physician assistants (PAs) to provide first-trimester aspiration abortions; little is known about organizations' experiences in implementing this policy change.

METHODS

Beginning 10 and 24 months after implementation of the new law, semistructured interviews were conducted with 20 administrators whose five organizations trained and employed NPs, CNMs and PAs as providers of aspiration abortions. Interview data on the organizations' experiences were analyzed thematically, and facilitators of and barriers to implementation were identified.

RESULTS

Administrators were committed to the provision of aspiration abortions by NPs, CNMs and PAs, and nearly all identified improved access to care and complication management as clear benefits of the policy change. However, integration of the new providers was uneven and depended on a variety of circumstances. Organizational disincentives included financial and logistical costs incurred in trying to deploy and integrate the different types of providers. Some administrators found that increased costs were outweighed by improved patient care, whereas others did not. In general, having a strong administrative champion within the organization made a critical difference.

CONCLUSIONS

California's expansion of the abortion-providing workforce had a positive impact on patient care in the sampled organizations. However, various organizational obstacles must be addressed to more fully realize the benefits of having NPs, CNMs and PAs provide aspiration abortions.

Mixed-methods investigation of women's experiences with second-trimester abortion care in the Midwest and Northeast United States

OBJECTIVE(S)

We studied women's experiences seeking and receiving second-trimester abortion care in two geographically and legislatively different settings to inform ways to improve abortion care access and services.

STUDY DESIGN

We conducted in-depth interviews with women who obtained second-trimester abortion care. Themes from the interviews were then used to inform a self-administered survey, which was completed by 108 women who received second-trimester abortion care in the Northeast and Midwest. We calculated descriptive statistics and used chi-squared and t-tests to compare responses.

RESULTS

We interviewed eight women and surveyed 108 women. Most interviewees and 65.2% of survey respondents reported difficulties accessing care. Although most interview and survey respondents had insurance, a slight majority reported difficulty funding care. All interviewees and 57.9% of survey respondents reported positive experiences with providers, with many interviewees and 62.0% of survey respondents saying their abortion care was better than their usual health care. Most interviewees and 75.8% of survey respondents reported pain as low to moderate, and the majority of participants reported it was the same or less than expected. Knowledge about abortion restrictions was low. Most interviewees and 68.4% survey respondents disagreed with restrictions on insurance coverage of abortion. Common recommendations to improve experiences were to ensure travel and financial support and to decrease wait times at clinics. There were few regional differences among outcomes.

CONCLUSION(S)

Women seeking second-trimester abortion in these locations reported positive abortion experiences. However, they had to overcome significant obstacles to obtain care.

IMPLICATIONS

This is the first study to systematically research women's second-trimester care experiences in two different regions of the United States. Regardless of location, women experienced barriers due to policies that impose gestational age restrictions, limit provider availability (consequently increasing wait times), and increase costs. Policy change to reduce these barriers is critical to improve access to and experiences with second trimester abortion care.

Retrospective Evaluation of the Procedural Sedation Practices of Expert Nurses During Abortion Care

OBJECTIVE

To evaluate the provision of procedural sedation during abortion by expert nurses and to describe the factors that are associated with time to discharge for women who receive this sedation.

DESIGN

Retrospective chart review.

METHODS

Descriptive statistics were generated to describe a retrospective cohort of women presenting for abortion under procedural sedation. Analysis of variance was used to determine significant characteristics that influenced time to discharge.

SETTING

A single clinical site that employs seven expert nurses.

PARTICIPANTS

A total of 194 medical records were available for this analysis.

RESULTS

All women were discharged home with accompaniment, and no incidents of respiratory distress or other adverse complications occurred. Most women (n = 136) received at least 150 μg fentanyl and 3 mg midazolam, and 71% of women in the first trimester and 83% of women in the second trimester entered the recovery area with no pain. Variables significantly associated with time spent in the recovery area were gestational age at time of abortion (t = -2.68, p = .008), pain at entry to recovery area (t = -0.254, p = .008), and pain at 15 minutes (t = 0.25, p = .038).

CONCLUSION

Expert nurses can administer procedural sedation for pain control associated with abortion and are capable of monitoring women and helping them return to baseline status after the procedure.

Determinants of abortion among clients coming for abortion service at felegehiwot referral hospital, northwest Ethiopia: a case control study

Background

According to the World Health Organization (WHO) estimate, one-third of pregnancies end in miscarriage, stillbirth, or induced abortion in the world. There are various reasons for a woman to seek induced abortion. However, limited information is available so far in the country and particularly in the study area. Therefore, the aim of the current study was to identify the determinants of induced abortion among clients coming for abortion care services at Bahirdar Felegehiwote referral hospital, Northwest Ethiopia.

Methods

Institutional based unmatched case-control study was conducted from September to December 2014. Interview administered questioner was used to collect primary data. Enumeration and systematic random sampling (K = 3) method was used to select 175 cases and 350 controls. A binary logistic regression model was fitted to identify determinant factors. Odds ratio with 95% CI was computed to assess the strength and significance of the association.

Result

All sampled cases and controls were actually interviewed. The likelihood of abortion was higher among non-married women [AOR: 18.23, 95% CI: 8.04, 41.32], students [AOR: 11.46, 95% CI: 6.29, 20.87], and women having a monthly income of less than 500 ETB [AOR: 11.46, 95% CI: 6.29, 20.87]. However, the likelihood of abortion was lower among women age greater than 24 years [AOR: 0.29, 95% CI: 0.11, 0.79] and who had the previous history of induced abortion [AOR: 0.31, 95% CI: 0.15, 0.65].

Conclusion

The study identified being non-married, student, women age less than 24 years, having the previous history of induced abortion, and low monthly income as an independent determinant of induced abortion. Interventions focused on the identified determinant factors are recommended.

Dimensions of patient satisfaction with comprehensive abortion care in Addis Ababa, Ethiopia

BACKGROUND

Patient satisfaction is a measure of the extent to which a patient is content with the health care received from health care providers. It has been recognized as one of the most vital indicators of quality. Hence, it has been studied and measured extensively as part of service quality and as a standalone construct. In spite of this, there has been limited or no studies in Ethiopia that describe factors of abortion care contributed to women's satisfaction. This study aimed to identifying the underlying factors that contribute to patient satisfaction with comprehensive abortion care and at exploring relationships between total satisfaction scores and socio-demographic and care-related variables in Addis Ababa, Ethiopia.

METHODS

At the beginning of the study in-depth interviews with 16 participants and a focus group discussion of 8 participants were conducted consecutively at the time of discharge to generate questions used to evaluate women's satisfaction with abortion care. Following generation of the perceived indicators, expert review, pilot study, and item analysis were performed in order to produce the reduced and better 26 items used to measure abortion care satisfaction. A total sample size of 450 participants from eight health facilities completed the survey. Principal component exploratory factor analysis and confirmatory factor analysis were conducted respectively to identify and confirm the factors of abortion care contributing to women's satisfaction. Mean satisfaction scores were compared across socio demographic and care-related variables such as age, educational level, gestational age (first trimester and second trimester), and facility type using analysis of variance.

RESULTS

Exploratory factor analysis of the 26 items indicated that satisfaction with abortion care consisted of five main components accounting for 60.48% of the variance in total satisfaction scores. Factor loadings of all items were found to be greater than 0.4. These factors are named as follows: "art of care" which means interpersonal relationships with the care-provider, "physical environment" which means the perceived quality of physical surroundings in which care is delivered, including cleanliness of facilities and equipment, "information" which means the information received related to abortion procedures, "privacy and confidentiality", "quality of care" which refers to technical quality of the care provider. Furthermore, analysis of variance showed that overall satisfaction is found to be related to facility type, relationship status, gestational age, and procedural type.

CONCLUSION

The findings provided support that women's satisfaction with comprehensive abortion care has five major factors. Therefore, to improve the overall quality of comprehensive abortion care, attention should be given to the advancement of these components namely, positive interpersonal communication with care-receiver, pleasantness of physical environment, offering enough information related to the procedure, securing clients' privacy during counseling and treatment, and technical quality of the providers.

Male Partners' Involvement in Abortion Care: A Mixed-Methods Systematic Review

CONTEXT

Although some women may desire the involvement of their partners when obtaining abortion care, male partners are not routinely included in the abortion process. A review of the literature on how male involvement relates to women's abortion experiences may help guide facilities that are considering incorporating male partners in abortion care.

METHODS

PubMed, PsycINFO (Ovid), the Cumulative Index to Nursing and Allied Health Literature, the Latin American and Caribbean Health Sciences Literature database, and the Cochrane Library were systematically searched without restrictions through September 23, 2015, to identify qualitative and quantitative primary studies investigating male partner accompaniment during the abortion process in noncoercive situations. Analysis focused on identifying different types of male involvement and their associations with women's abortion experiences.

RESULTS

Some 1,316 unique articles were reviewed; 15 were analyzed. These studies were conducted in six countries and published between 1985 and 2012, primarily with observational designs. Four types of male partner involvement emerged: presence in the medical facility, participation in preabortion counseling, presence in the room during the surgical abortion procedure or while the woman is experiencing the effects of abortifacient medications, and participation in postabortion care. Studies explored relationships between type of involvement and women's access to abortion care and their emotional and physical well-being. Most findings suggested that male involvement was positively associated with women's well-being and their assessment of the experience; no negative associations were found.

CONCLUSION

In noncoercive circumstances, women who include their male partners in the abortion process may find this involvement beneficial.

The Stratified Legitimacy of Abortions

Roe v. Wade was heralded as an end to unequal access to abortion care in the United States. However, today, despite being common and safe, abortion is performed only selectively in hospitals and private practices. Drawing on 61 interviews with obstetrician-gynecologists in these settings, we examine how they determine which abortions to perform. We find that they distinguish between more and less legitimate abortions, producing a narrative of stratified legitimacy that privileges abortions for intended pregnancies, when the fetus is unhealthy, and when women perform normative gendered sexuality, including distress about the abortion, guilt about failure to contracept, and desire for motherhood. This stratified legitimacy can perpetuate socially-inflected inequality of access and normative gendered sexuality. Additionally, we argue that the practice by physicians of distinguishing among abortions can legitimate legislative practices that regulate and restrict some kinds of abortion, further constraining abortion access.

[Survey of 319 women satisfaction using abortion in centers of Pays de la Loire in France]

CONTEXT

Perinatal network the "Security birth" Pays de la Loire (RSN), in collaboration with the regional network "Sexual health" (RRSS) organized a satisfaction survey in 2014 among women who had an induced abortion in the centers in Pays de la Loire. The objective of the study is to evaluate the satisfaction of women who resort to abortion centers, study the factors and propose actions for improvement.

METHODS

A questionnaire, developed with professionals, was offered to women after the end of the abortion act. The scales of satisfaction were based on Likert scales to 4 degrees. They were collected for the period of contact centers, for the abortion itself, and overall. Data were collected on the civil status, the care pathway to get to the abortion center, features centers and professionals met, acts anesthesia and end of abortion, wait times and overall satisfaction of women. The women with rather poor satisfaction were compared with other women by univariate analysis with odds ratios (OR) and multivariate with adjusted odds ratios (ORa).

RESULTS

Of the 18 centers, 13 participated and 319 responses were analyzed. The abortions were performed on average 8±SA 2. Among the methods, 40.1 % were drug, and 59.9 % with anesthesia (14.0 % with general anesthesia [AG] and 45.9 % under local anesthesia [AL]). The first contacts on average to 5.7 SA were mostly general practitioners (38 %), then the abortion centers directly (22 %), and planning centers (16 %). The information was considered clear (94 %), the appropriate orientation (97 %), with respect to the application (98 %). The first meeting at the center was done 7 days after the call (6.7 SA), and met women overall. The abortion was performed 16 days after the first call center (8.0 SA) with satisfaction by field 78 % (waiting time) to 98 % (confidentiality, privacy…). The overall satisfaction rate was 89.0 % and 8.2 % were not satisfied. Factors related to the non-satisfaction in multivariate analysis were the least easy access to the center (ORa=0.31 [.11 to 0.86; p=0.02]), pain perceived≥4 (ORa=3 50 [1.32 to 9.28], p=0.02), the lack of explanation (ORa=0.23 [0.05 to 0.97]; p=0.04), and the accompanying inability (ORa=0.27 [0.10 to 0.70], p=0.007). Finally, 12.6 % of women reported for improvement with clear remarks.

DISCUSSION

This is the first regional survey on the satisfaction of women resorting to abortion. Delays from the first contact are satisfactory and show no organizational problem. The various dimensions of satisfaction showed a high satisfaction rate in the 13 participating centers. The least satisfactory factors are related to organizational problems (waiting circuits especially trips to the operating room and maternity) and problems related to the care itself (not enough explanations, reduced ability to reassure and support Savory absence, lack of choice of the method of anesthesia, pain experienced). Five areas for improvement have been proposed to the care-givers of the centers.

How women perceive abortion care: A study focusing on healthy women and those with mental and posttraumatic stress

Objectives To identify perceived deficiencies in the quality of abortion care among healthy women and those with mental stress. Methods This multi-centre cohort study included six obstetrics and gynaecology departments in Sweden. Posttraumatic stress (PTSD/PTSS) was assessed using the Screen Questionnaire-Posttraumatic Stress Disorder; anxiety and depressive symptoms, using the Hospital Anxiety Depression Scale; and abortion quality perceptions, using a modified version of the Quality from the Patient's Perspective questionnaire. Pain during medical abortion was assessed in a subsample using a visual analogue scale. Results Overall, 16% of the participants assessed the abortion care as being deficient, and 22% experienced intense pain during medical abortion. Women with PTSD/PTSS more often perceived the abortion care as deficient overall and differed from healthy women in reports of deficiencies in support, respectful treatment, opportunities for privacy and rest, and availability of support from a significant person during the procedure. There was a marginally significant difference between PTSD/PTSS and the comparison group for insufficient pain alleviation. Conclusions Women with PTSD/PTSS perceived abortion care to be deficient more often than did healthy women. These women do require extra support, relatively simple efforts to provide adequate pain alleviation, support and privacy during abortion may improve abortion care.

Experiences, feelings and thoughts of women undergoing second trimester medical termination of pregnancy

Main Objective

The objective of this study was to explore women's expectations and experiences of undergoing second trimester abortion.

Methods

This is a cross-sectional study using a screening questionnaire and semi-structured interviews for data collection. Thirty-one women filled out the questionnaire and 23 of them were later interviewed. The questionnaires were analyzed by descriptive statistics. The interviews were recorded, transcribed verbatim and analyzed with qualitative content analysis.

Most Important Findings

Indications for the abortion were fetal malformation or unintended pregnancy. The women expressed similar feelings and these were irrespective for the reason for having an abortion. Both physical and mental pain was experienced during the abortion process and described by the women. Taking the mifepristone-pill was experienced as especially emotionally difficult for many participants. Professional support from the staff together with support from the partner, a friend or relative helped in transforming the worries related to something unknown to feelings of coping with a new and hard experience. Prior to the abortion most women stated that they did not want to view the fetus but women who chose to view the fetus described this as a way of confronting the reality and an opportunity to say farewell to the pregnancy/fetus. The analysis of the interview transcripts revealed five themes mirroring the women's experiences, thoughts and feelings related to the abortion.

Conclusions

The decision to undergo second trimester abortion sometimes exposes women to strong and conflicting emotions which are irrespective for the reason for having an abortion. Despite this women do not regret their decision to terminate the pregnancy. This analysis shows that their rational thinking outweighs their emotionally difficult feelings. It is important for the attending staff to be responsive to the needs of each individual woman whatever the indication is for the abortion.