Global Abortion Policies Database: a descriptive analysis of the legal categories of lawful abortion

Laws governing access to sexual health services and information: contents, protections, and restrictions

Access to sexual health services and information is critical to achieving the highest attainable standard of sexual health, and enabling legal environments are key to advancing progress in this area. In determining overall alignment with human rights standards to respect, protect, and fulfil sexual health-related rights without discrimination, there are many aspects of laws, including their specificity and content, which impact which sexual health services and information are availed, which are restricted, and for whom. To understand the nature of existing legal provisions surrounding access to sexual health services and information, we analysed the content of 40 laws in English, French, and Spanish from 18 countries for the specific sexual health services and information to which access is ensured or prohibited, and the non-discrimination provisions within these laws. Overall, there was wide variation across countries in the types of laws covering these services and the types and number of services and information ensured. Some countries covered different services through multiple laws, and most of the laws dedicated specifically to sexual health addressed only a narrow aspect of sexual health and covered a small range of services. The protected characteristics in non-discrimination provisions and the specificity of these provisions with regard to sexual health services also varied. Findings may inform national legal and policy dialogues around sexual health to identify opportunities for positive change, as well as to guide further investigation to understand the relationship between such legal provisions, the implementation of these laws within countries, and relevant sexual health outcomes.

Post-Roe v Wade psychiatry: legal, clinical, and ethical challenges in psychiatry under abortion bans

In recent history, the world has witnessed a trend towards liberalization of abortion laws driven by an increasing understanding of the negative personal and public health consequences of criminalizing abortion. By contrast, several countries have recently implemented restrictive reproductive laws, joining the 112 countries where access to abortion care is banned completely or with narrow exceptions. On June 24, 2022, the US Supreme Court ruling in Dobbs v Jackson Women's Health Organization overturned its landmark decisions in Roe v Wade that established abortion until the point of viability of the fetus as a constitutional right. After Roe v Wade having been overturned, it is projected that many women in the USA will be prevented from accessing safe abortion care. Importantly, abortion bans not only impose constraints on patient autonomy, they also restrict physicians' ability to practice evidence-based medicine, which will negatively impact psychiatric care. It is therefore crucial for the practicing psychiatrist to be familiar with this new legal landscape. In this Personal View, we aim to provide a topical overview to help clinicians gain a clear understanding of legal, clinical, and ethical responsibilities, focusing on the USA. We also discuss the reality that psychiatrists might be called upon to determine medical necessity for an abortion on psychiatric grounds, which is new for most US psychiatrists. We predict that psychiatrists will be confronted with very difficult situations in which lawful and ethical conduct might be incongruent, and that abortion bans will result in greater numbers of patients needing psychiatric care from a system that is ill-prepared for additional demands.

Antenatal screening for fetal structural anomalies - Routine or targeted practice?

Antenatal screening with ultrasound identifies fetal structural anomalies in 3-6% of pregnancies. Identification of anomalies during pregnancy provides an opportunity for counselling, targeted imaging, genetic testing, fetal intervention and delivery planning. Ultrasound is the primary modality for imaging the fetus in pregnancy, but magnetic resonance imaging (MRI) is evolving as an adjunctive tool providing additional structural and functional information. Screening should start from the first trimester when more than 50% of severe defects can be detected. The mid-trimester ultrasound balances the benefits of increased fetal growth and development to improve detection rates, whilst still providing timely management options. A routine third trimester ultrasound may detect acquired anomalies or those missed earlier in pregnancy but may not be available in all settings. Targeted imaging by fetal medicine experts improves detection in high-risk pregnancies or when an anomaly has been detected, allowing accurate phenotyping, access to advanced genetic testing and expert counselling.

Understanding maternal Ethnomedical Folklore in Central Uganda: a cross-sectional study of herbal remedies for managing Postpartum hemorrhage, inducing uterine contractions and abortion in Najjembe sub-county, Buikwe district

Pregnant women in rural Uganda largely rely on medicinal plants for inducing labor, treating postpartum hemorrhage (PPH), and inducing abortion. 90% of the women in both rural and urban Uganda use plants to manage pregnancy symptoms like constipation, heartburn, morning sickness, body aches, nausea, and vomiting. After delivery women continue using plants to manage postpartum complications and for infant care especially herbal baths. This study documented how ethnomedical folklore has been used to aid childbirth, manage postpartum hemorrhage, and induce abortion.

METHODS

A cross-sectional ethnobotanical survey was conducted from May - December 2023 in Najjemebe sub-county, Buikwe district. 206 respondents from 12 villages were selected using snowball sampling. Key informants included Traditional Birth Attendants (TBAs) and herbalists. Data was collected using semi-structured questionnaires and focus group discussions. Voucher specimens of the plants were identified and authenticated at Makerere University Herbarium. Data were analyzed using descriptive statistics, Informant Consensus factor (ICF), Use Reports (URs), paired comparisons, and GraphPad Prism® version 9.0.0 software.

RESULTS

All respondents (N = 206, 100%), used plants to induce labour, treat PPH, and induce abortion. One hundred four plant species were documented: most cited or preferred were: Hoslundia opposita (N = 109, 53%), Phytolacca dodecandra (N = 72, 35%), and Commelina erecta (N = 47, 23%). The plants belonged to 49 families, Lamiaceae (16.3%) and Fabaceae (14.3%) having the majority of the species. Herbs were 42 (40%) and trees 23 (22%). Oral administration 95(72%) was the commonest, then topical 19 (14.4%) and vaginal 14(10.6%).

CONCLUSION

Health surveys revealed that about 27% of deliveries in Uganda take place outside a health facility. Due to the oxytocic effects of plant species reported in this study, they play a triple role of being uterotonics, abortifacients, and treating postpartum haemmorhage. The dilemma lies in the unknown dosages and toxicity levels that could endanger both the mother's and the unborn child's lives. Due to Uganda's high rates of population growth, overall fertility, maternal mortality, and morbidity, policies, and programmes on gendered health provision need to be reevaluated. Integrating herbal medicine into health care systems appears to be a feasible solution.

Strengthening regional commitment to ensuring access to medical abortion medicines in WHO's South-East Asia region: report of a participatory assessment and workshop

BACKGROUND

In 2019, the World Health Organization identified improving access to safe abortion as an important priority toward improving sexual and reproductive health and rights and achieving Sustainable Development Goals. One strategy for addressing this priority is strengthening access to medicines for medical abortion. All 11 countries in the South-East Asia Region have some indications for legal abortion and permit post-abortion care. Therefore, strengthening access to medical abortion medicines is a reasonable strategy for improving access to safe abortion for the Region.

METHODOLOGY

We applied an adapted version of an existing World Health Organization landscape assessment protocol for the availability of medical abortion medicines at the country-level in the South-East Asia Region. We collected publicly available data on the existence of national health laws, policies, and standard treatment guidelines; inclusion of medical abortion medicines in the national essential medicines list; and marketing authorization status for medical abortion medicines for each country and verified by Ministries of health. The findings were once more presented, discussed and recommendations were formulated during regional technical consultation workshop. Each country teams participated in the process, and subsequently, the suggestions were validated by representatives from Ministries of Health..

RESULTS

Few countries in the Region currently have national policies and guidelines for comprehensive safe abortion. However, either mifepristone-misoprostol in combination or misoprostol alone (for other indications) is included in national essential medicines lists in all countries except Indonesia and Sri Lanka. Few countries earmark specific public funds for procuring and distributing medical abortion commodities. In countries where abortion is legal, the private sector and NGOs support access to medical abortion information and medicines. Several countries only allow registered medical practitioners or specialists to administer medical abortion.

CONCLUSION

Following this rapid participatory assessment and technical consultation workshop, the World Health Organization South-East Asia Regional Technical Advisory and Sexual and Reproductive Health and Rights technical committee recommended priority actions for policy and advocacy, service delivery, and monitoring and evaluation, and indicated areas for support.

Diagnostic accuracy of ultrasound screening for fetal structural abnormalities during the first and second trimester of pregnancy in low-risk and unselected populations

BACKGROUND

Prenatal ultrasound is widely used to screen for structural anomalies before birth. While this is traditionally done in the second trimester, there is an increasing use of first-trimester ultrasound for early detection of lethal and certain severe structural anomalies.

OBJECTIVES

To evaluate the diagnostic accuracy of ultrasound in detecting fetal structural anomalies before 14 and 24 weeks' gestation in low-risk and unselected pregnant women and to compare the current two main prenatal screening approaches: a single second-trimester scan (single-stage screening) and a first- and second-trimester scan combined (two-stage screening) in terms of anomaly detection before 24 weeks' gestation.

SEARCH METHODS

We searched MEDLINE, EMBASE, Science Citation Index Expanded (Web of Science), Social Sciences Citation Index (Web of Science), Arts & Humanities Citation Index and Emerging Sources Citation Index (Web of Science) from 1 January 1997 to 22 July 2022. We limited our search to studies published after 1997 and excluded animal studies, reviews and case reports. No further restrictions were applied. We also screened reference lists and citing articles of each of the included studies.

SELECTION CRITERIA

Studies were eligible if they included low-risk or unselected pregnant women undergoing a first- and/or second-trimester fetal anomaly scan, conducted at 11 to 14 or 18 to 24 weeks' gestation, respectively. The reference standard was detection of anomalies at birth or postmortem.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook study selection, quality assessment (QUADAS-2), data extraction and evaluation of the certainty of evidence (GRADE approach). We used univariate random-effects logistic regression models for the meta-analysis of sensitivity and specificity.

MAIN RESULTS

Eighty-seven studies covering 7,057,859 fetuses (including 25,202 with structural anomalies) were included. No study was deemed low risk across all QUADAS-2 domains. Main methodological concerns included risk of bias in the reference standard domain and risk of partial verification. Applicability concerns were common in studies evaluating first-trimester scans and two-stage screening in terms of patient selection due to frequent recruitment from single tertiary centres without exclusion of referrals. We reported ultrasound accuracy for fetal structural anomalies overall, by severity, affected organ system and for 46 specific anomalies. Detection rates varied widely across categories, with the highest estimates of sensitivity for thoracic and abdominal wall anomalies and the lowest for gastrointestinal anomalies across all tests. The summary sensitivity of a first-trimester scan was 37.5% for detection of structural anomalies overall (95% confidence interval (CI) 31.1 to 44.3; low-certainty evidence) and 91.3% for lethal anomalies (95% CI 83.9 to 95.5; moderate-certainty evidence), with an overall specificity of 99.9% (95% CI 99.9 to 100; low-certainty evidence). Two-stage screening had a combined sensitivity of 83.8% (95% CI 74.7 to 90.1; low-certainty evidence), while single-stage screening had a sensitivity of 50.5% (95% CI 38.5 to 62.4; very low-certainty evidence). The specificity of two-stage screening was 99.9% (95% CI 99.7 to 100; low-certainty evidence) and for single-stage screening, it was 99.8% (95% CI 99.2 to 100; moderate-certainty evidence). Indirect comparisons suggested superiority of two-stage screening across all analyses regarding sensitivity, with no significant difference in specificity. However, the certainty of the evidence is very low due to the absence of direct comparisons.

AUTHORS' CONCLUSIONS

A first-trimester scan has the potential to detect lethal and certain severe anomalies with high accuracy before 14 weeks' gestation, despite its limited overall sensitivity. Conversely, two-stage screening shows high accuracy in detecting most fetal structural anomalies before 24 weeks' gestation with high sensitivity and specificity. In a hypothetical cohort of 100,000 fetuses, the first-trimester scan is expected to correctly identify 113 out of 124 fetuses with lethal anomalies (91.3%) and 665 out of 1776 fetuses with any anomaly (37.5%). However, 79 false-positive diagnoses are anticipated among 98,224 fetuses (0.08%). Two-stage screening is expected to correctly identify 1448 out of 1776 cases of structural anomalies overall (83.8%), with 118 false positives (0.1%). In contrast, single-stage screening is expected to correctly identify 896 out of 1776 cases before 24 weeks' gestation (50.5%), with 205 false-positive diagnoses (0.2%). This represents a difference of 592 fewer correct identifications and 88 more false positives compared to two-stage screening. However, it is crucial to acknowledge the uncertainty surrounding the additional benefits of two-stage versus single-stage screening, as there are no studies directly comparing them. Moreover, the evidence supporting the accuracy of first-trimester ultrasound and two-stage screening approaches primarily originates from studies conducted in single tertiary care facilities, which restricts the generalisability of the results of this meta-analysis to the broader population.

Abortion Legal Reform and Neonatal Mortality in Mozambique

INTRODUCTION

Abortion law reforms have been hypothesized to influence reproductive, maternal, and neonatal health services and health outcomes, as well as social inequalities in health. In 2014, Mozambique legalized abortion in specific circumstances. However, due to challenges implementing the law, there is concern that it may have negatively influenced neonatal outcomes.

METHODS

Using a difference-in-differences design, we used birth history data collected via the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) between 2004 and 2018 to assemble a panel of 476 939 live births across 17 countries including Mozambique. We estimated the effect of the abortion reform on neonatal mortality by comparing Mozambique to a series of control countries that did not change their abortion policies. We also conducted stratified analyses to examine heterogeneity in effect estimates by household wealth, educational attainment, and rural/urban residence.

RESULTS

The reform was associated with an additional 5.6 (95% CI = 1.3, 9.9) neonatal deaths per 1,000 live birth. There was evidence of a differential effect of the reform, with a negative effect of the reform on neonatal outcomes for socially disadvantaged women, including those with no schooling, in poorer households, and living in rural areas.

DISCUSSION

Given the delay in implementation, our analyses suggest that abortion reform in Mozambique was associated with an initial increase in neonatal mortality particularly among socially disadvantaged women. This may be due to the delay in effective implementation, including the dissemination of clear guidelines and expansion of safe abortion services. Longer-term follow-up is needed to assess the impact of the reform after 2018, when services were expanded. Abortion legal reform without adequate implementation and enforcement is unlikely to be sufficient to improve abortion access and health outcomes.

A scoping review considering the processes involved in changing abortion laws in low- and middle-income countries

Providing legal and safe abortion is promoted as one of the key global strategies for reducing maternal mortality. Following the landmark 1994 International Conference on Population and Development, low- and middle-income countries (LMICs) are shifting towards more liberal abortion legislation. Whilst the existing literature has predominantly focused on agenda setting and individual country contexts, there is a need to understand the universal policy process of changing abortion laws. Drawing on the heuristic policy stages model and policy analysis triangle, this paper explores the processes involved in changing abortion laws in LMICs and discusses the influencing factors. We conducted a search for peer-reviewed literature in ProQuest, Scopus, Global Health (Ovid), PubMed and CINAHL. Initially, the search was conducted in February 2021 and was then re-run in May 2023. A total of 25 studies were included in the analysis. Following a descriptive, thematic and interpretive analysis of the extracted data, we have drawn out the key stages involved in changing abortion laws in LMICs: (1) establishing the need for changing abortion laws in a local context; (2) generating local evidence to support changes in abortion laws; (3) drafting of new and/or amendments of existing abortion laws; (4) adoption and enactment of changes in abortion laws; (5) translating the legal provisions into services and (6) assessing the impact of changes in abortion laws on maternal health. Our analysis explores the influence of actors and contextual factors, and we also discuss the policy solutions and decisions made by governments. The findings demonstrate that while the timing of change in abortion law was found to be dependent on the context of individual settings, the process and factors that influenced the change were remarkably consistent across geographies. Further research is required to evaluate the link between changes in abortion laws and maternal health outcomes.

"Factors associated with provider unwillingness to perform induced abortion in Argentina: A cross-sectional study in four provinces following the legalization of abortion on request"

BACKGROUND

The 2020 Law on Access to the Voluntary Interruption of Pregnancy is a landmark piece of legislation regarding access to abortion in Argentina. Under the new law, abortion is legal up to 14 weeks and 6 days gestation, with exceptions made to the gestational age limit to save a woman´s life, to preserve a woman´s health, and in case of rape. However, widespread refusal to provide care by authorized health providers (due to conscientious objection or lack of awareness of the new law) could hinder access to legal abortion. This study aimed to assess knowledge of the current legal framework and willingness to perform abortions by authorized professionals in Argentina, to compare perceptions about any requirements necessary to perform abortions on legal grounds between willing and unwilling providers and to explore factors associated with refusal to provide care.

METHODS

We conducted a cross-sectional study based on a self-administered, anonymous survey to authorized abortion providers in public health facilities in four provinces of Argentina.

FINDINGS

Most authorized providers knew the grounds upon which it is currently legal to perform abortions; however, almost half reported being unwilling to perform abortions, mainly due to conscientious objection. Both willing and unwilling providers believed there were additional requirements not actually stipulated by law. Using logistic regression, we found that province where providers serve, working in a tertiary level facility, and older age were factors associated with unwillingness to provide care.

CONCLUSIONS

The results of our study indicate that, even in a favorable legal context, barriers at the provider level may hinder access to abortion in Argentina. They help to demonstrate the need for specific actions that can improve access such as training, further research and public policies that guarantee facilities have sufficient professionals willing to provide abortion care.

The WHO abortion care guideline: Law and policy-Past, present, and future

In the 2022 Abortion Care Guideline, the World Health Organization (WHO) undertook systematic evidence reviews of seven law and policy interventions to assess their health and social impacts. Distinct recommendations were formulated for each. The present article highlights how the Guideline reconceptualizes abortion regulation as a complex structural intervention that shapes clinical care and service delivery and distributes risks and resources within these systems and in the care relations that define them. It then presents the Guideline recommendations and summarizes their evidence base, drawing on recent legal and policy developments to emphasize their real-world significance. The article concludes by anticipating the future of abortion law and policy, focusing on service delivery innovations and diverse care models, drug regulation and the supply of abortion pills, and protective interventions crafted in the context of political crisis and immediate need that serve policy objectives and take regulatory forms different from the past.

The role of legal medicine professionals in preventing pregnancy and sexually transmitted infections among female victims of sexual assault

Sexual violence can have an overwhelming impact on the victim's physical and mental health; the consequences include unintended pregnancy and sexually transmitted infections (STIs). Therefore, the examiners must assess victims for possible pregnancy and sexually transmitted infections as a part of the sexual assault examination. This article aims to orient the medico-legal examiners towards their role in preventing unintended pregnancy and sexually transmitted infections among victims of sexual assault. Prompt detection of pregnancy or STIs is critical, as any delay would adversely affect the successful administration of emergency contraception and post-exposure prophylaxis (PEP) against human immunodeficiency virus (HIV) and other sexually transmitted infections.

Knowledge of the abortion law and key legal issues of sexual and reproductive health and rights among recently arrived migrants in Sweden: a cross-sectional survey

Background

Sexual and reproductive health and rights (SRHR), including access and information on the laws and policies related to abortion, varies considerably between countries. Migrants may have limited knowledge of SRHR and related resources in their new country. This study investigates migrants’ knowledge of the right to safe and legal abortion and other associated factors including the recent law on sexual consent, the legal age for sexual consent and age to marry in Sweden.

Methods

We conducted a cross-sectional study from 2018 to 2019 among recent migrants attending high schools or Swedish language schools. Descriptive statistics were computed on the knowledge of the Swedish abortion law and other legal aspects. Univariable and multivariable logistic regression analyses were conducted to assess if migrants’ socio-demographic characteristics were associated with knowledge (i.e. correct/incorrect) of the Swedish abortion law and other key SRHR-related legal issues.

Results

Of the total 6,263 participants, 3,557 (57%) responded about whether it is legal to have an induced abortion in Sweden, and of these, 2,632 (74%) answered incorrectly. While more than half (61%) of the respondents knew the sexual consent law, nearly half (48%) did not know that sexual consent is also required for married couples. About 90% correctly responded that it is illegal to have sex with a minor (under the age of 15) and were aware of the legal age (18 years) to marry in Sweden. Incorrect knowledge of the Swedish abortion law was associated with being religious (adjusted odds ratio (AOR), 2.12; 95% confidence interval (CI), 1.42–3.15), not having previous sexual health education (AOR, 1.68; 95% CI, 1.38–2.05), coming from a country with predominantly restrictive abortion laws (AOR, 1.46; 95% CI, 1.16–1.84), low level of education (AOR, 1.29; 95% CI, 1.04–1.61) and having a temporary residence permit (AOR, 1.27; 95% CI, 1.02–1.57).

Conclusion

We found a substantial lack of knowledge among migrants of reproductive age in Sweden regarding important laws and policies of SRHR, particularly the right to abortion. SRHR-related programmes and comprehensive sexual health education for recently arrived migrants could include components to increase knowledge of legal and safe abortions and other laws concerning SRHR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-023-15399-z.

Second trimester fetal MRI of the brain: Through the ground glass

Fetal MRI is an important tool for the prenatal diagnosis of brain malformations and is often requested after second-trimester ultrasonography reveals a possible abnormality. Despite the immature state of the fetal brain at this early stage, early suggestive signs of the presence of brain malformations can be recognized. To differentiate between the normal dynamics of the growing brain and the developing pathological conditions can be challenging and requires extensive knowledge of normal central nervous system developmental stages and their neuroradiological counterparts at those different stages. This article reviews the second-trimester appearances of some commonly encountered brain malformations, focusing on helpful tricks and subtle signs to aid in the diagnosis of such conditions as rhombencephalosynapsis, various causes of vermian rotation, molar tooth spectrum anomalies, diencephalic-mesencephalic junction dysplasia, ganglionic eminence anomalies, and the most common malformations of cortical development.

Improving measures of access to legal abortion: A validation study triangulating multiple data sources to assess a global indicator

BACKGROUND

Global mechanisms have been established to monitor and facilitate state accountability regarding the legal status of abortion. However, there is little evidence describing whether these mechanisms capture accurate data. Moreover, it is uncertain whether the "legal status of abortion" is a valid proxy measure for access to safe abortion, pursuant to the global goals of reducing preventable maternal mortality and advancing reproductive rights. Therefore, this study sought to assess the accuracy of reported monitoring data, and to determine whether evidence supports the consistent application of domestic law by health care professionals such that legality of abortion functions as a valid indicator of access.

METHODS AND FINDINGS

We conducted a validation study using three countries as illustrative case examples: Argentina, Ghana, and India. We compared data reported by two global monitoring mechanisms (Countdown to 2030 and the Global Abortion Policies Database) against domestic source documents collected through in-depth policy review. We then surveyed health care professionals authorized to perform abortions about their knowledge of abortion law in their countries and their personal attitudes and practices regarding provision of legal abortion. We compared professionals' responses to the domestic legal frameworks described in the source documents to establish whether professionals consistently applied the law as written. This analysis revealed weaknesses in the criterion validity and construct validity of the "legal status of abortion" indicator. We detected discrepancies between data reported by the global monitoring and accountability mechanisms and the domestic policy reviews, even though all referenced the same source documents. Further, provider surveys unearthed important context-specific barriers to legal abortion not captured by the indicator, including conscientious objection and imposition of restrictions at the provider's discretion.

CONCLUSIONS

Taken together, these findings denote weaknesses in the indicator "legal status of abortion" as a proxy for access to safe abortion, as well as inaccuracies in data reported to global monitoring mechanisms. This information provides important groundwork for strengthening indicators for monitoring access to abortion and for renewed advocacy to assure abortion rights worldwide.

Disruptions to the procurement of medical abortion medicines during COVID-19: a scoping review

OBJECTIVES

This scoping review aimed to systematically search, retrieve and map the extent and characteristics of available literature on the evidenced disruptions to medical abortion (MA) medicine procurement caused by the COVID-19 outbreak.

DESIGN

Scoping review using Arksey and O'Malley's methodology and Levac et al's methodological enhancement with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

DATA SOURCES

PubMed, Embase, PMC, Science Direct, the Cochrane Library and Google Scholar were searched from January 2020 to April 2022.

ELIGIBILITY CRITERIA

We included articles in English that: (1) contained information on MA medicines; (2) included descriptions of procurement disruptions, including those with examples, characteristics and/or statistics; (3) documented events during the COVID-19 pandemic; and (4) presented primary data.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened search results, performed a full-text review of preliminarily included articles and completed data extraction in a standard Excel spreadsheet. Extracted data from was compared for validation and synthesised qualitatively.

RESULTS

The two articles included are unpublished grey literature demonstrating evidence of short-lived disruptions in sexual and reproductive health commodity procurement, including MA medicines, in sub-Saharan Africa during the early months of the pandemic. Findings from the two included grey literature articles show that in sub-Saharan contexts, emergency preparedness, stockpiling, adaptations and flexibility of key actors, including donors, alleviated COVID-19 disruptions allowing for resumption of services within weeks.

CONCLUSION

There is a need for increased empirical evidence of MA procurement challenges to understand which barriers to MA procurement may persist and impact continuity of supply while others can fuel resilience and preparedness efforts at the country and subregional levels. The lack of evidence from social marketing organisations and their networks is a significant gap as these actors constitute a vital artery in the distribution of MA commodities in low-income and middle-income countries.

Policy surveillance for a global analysis of national abortion laws

Policy surveillance offers a novel and important method for comparing law across jurisdictions. We used policy surveillance to examine abortion laws across the globe. Self-managed abortion, which generally takes place outside formal healthcare settings, is increasing in prevalence and can be safe. We analysed provisions that do not account for the prevalence of self-managed abortion and evidence of its safety. Such provisions require that abortion take place in a formal healthcare setting. We also analysed criminal penalties for non-compliance. Our method included development of a legal framework, an iterative process of refining coding schemes and procedures, and rigorous quality control. We limited our analysis to liberal abortion laws for two reasons. Abortion laws globally trend towards less restrictive. In addition, we aimed to focus on how laws relate to abortion outside a formal healthcare setting specifically and excluded laws that prohibit abortion more broadly. We found that in all countries with liberal national abortion laws, the law permits only healthcare professionals or trained health workers to perform legal abortion and the majority require the abortion to take place in a specified health facility. With policy surveillance methods we can illuminate characteristics of law across many jurisdictions and the need for widespread reform, toward laws that reflect scientific evidence and the way people have abortions.

The impact of 'grounds' on abortion-related outcomes: a synthesis of legal and health evidence

Where abortion is legal, it is often regulated through a grounds-based approach. A grounds-based approach to abortion provision occurs when law and policy provide that lawful abortion may be provided only where a person who wishes to have an abortion satisfies stipulated 'grounds', sometimes described as 'exceptions' or 'exceptional grounds'. Grounds-based approaches to abortion are, prima facie, restrictive as they limit access to abortion based on factors extraneous to the preferences of the pregnant person. International human rights law specifies that abortion must be available (and not 'merely' lawful) where the life or health of the pregnant woman or girl is at risk, or where carrying a pregnancy to term would cause her substantial pain or suffering, including but not limited to situations where the pregnancy is the result of rape or incest or the pregnancy is not viable. However, international human rights law does not specify a grounds-based approach as the way to give effect to this requirement. The aim of this review is to address knowledge gaps related to the health and non-health outcomes plausibly related to the effects of a grounds-based approach to abortion regulation. The evidence from this review shows that grounds have negative implications for access to quality abortion and for the human rights of pregnant people. Further, it shows that grounds-based approaches are insufficient to meet states' human rights obligations. The evidence presented in this review thus suggests that enabling access to abortion on request would be more rights-enhancing than grounds-based approaches to abortion regulation.

From Public Eugenics to Private Eugenics: What Does the Future Hold?

Traditional public eugenics, which was ordered by the State, has been replaced by a kind of private eugenics conducted by parents using reproductive techniques, genetic testing and, eventually in the future, genetic engineering. While traditional eugenics strived to improve the species, the new model aims to satisfy parents' reproductive aspirations. The association between public and private eugenics is an ongoing issue, mostly due to its relation to nazi eugenics. This paper will state that both are eugenics; however, with different characteristics, and thus worthy of different legal and ethical assessments. The paper will contextualize private eugenics in the framework of reproductive rights (legal and ethical perspective) and in the development of genetics and reproductive techniques (scientific perspective). Finally, it will analyze some of the legal consequences of a broader acceptance of private eugenics, namely in terms of liability and tort law. Throughout the paper, the different legal solutions in place in Europe will contextualize its considerations.

Unintended pregnancy, induced abortion and abortion care-seeking experiences among adolescents in Kinshasa, Democratic Republic of Congo: a cross-sectional study

OBJECTIVES

To estimate age-specific abortion incidence and unintended pregnancy in Kinshasa, Democratic Republic of Congo and compare care experiences between adolescents (15-19 years) and older women (20-49 years).

DESIGN

We used the age-specific variant of the Abortion Incidence Complications Method to estimate abortion and unintended pregnancy, with data from three primary sources: Health Facility Survey (n=361) provided postabortion care (PAC) caseloads; Prospective Morbidity Survey (n=1031) provided the age distribution and characteristics of women presenting for PAC and Health Professional Survey (n=115) provided an estimate of the proportion of abortions resulting in facility-based treatment of complications. Bivariate (χ², t-test) and multivariable (binary logistic regression, Cox proportional hazard) analyses were used to compare abortion care experiences.

SETTING

Health facilities proving PAC in Kinshasa.

PARTICIPANTS

Women who presented to PAC facilities with abortion complications and their care providers.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary measures were abortion incidence and proportion of pregnancies unintended. The secondary measures were the odd of reporting specific abortion care experiences.

RESULTS

Adolescents had an estimated 27 590 induced abortions, constituting 18.8% of abortions in Kinshasa in 2016. Adolescents had the lowest abortion rate among women less than 35 years (55.2/1000 women) but the highest rate among ever sexually active women (138.4/1000) and recently sexually active women (167.2/1000). Also, adolescents had the highest abortion ratio (82.4/100 live births), proportion of pregnancies unintended (80%) and proportion of unintended pregnancies ending in abortion (49%). Compared with older women, adolescents had higher odds of reporting pregnancy unintendedness (adjusted OR, AOR 1.36, 95% CI 1.75 to 2.24), seeking abortion at later than first trimester (AOR 1.34, 95% CI 1.09 to 1.63) and from non-medical professionals (AOR 1.68, 95% CI 1.31 to 2.14), and not using contraceptives before pregnancy (AOR 2.23, 95% CI 2.77 to 3.43) or postabortion (AOR 2.46, 95% CI 1.87 to 3.29).

CONCLUSIONS

Interventions are needed to reduce unintended pregnancy among adolescents in Kinshasa and improve their abortion care experiences.

Contraception needs and pregnancy termination in sub-Saharan Africa: a multilevel analysis of demographic and health survey data

BACKGROUND

Women in sub-Saharan Africa (SSA) have a higher risk of unintended pregnancies that are more likely to be terminated, most of which are unsafe with associated complications. Unmet need for contraception is highest in SSA and exceeds the global average. This study investigates the association between unmet/met need for contraception and pregnancy termination SSA.

METHODS

We used pooled data from Demographic and Health Surveys conducted from January 2010 to December 2018 in 32 countries in SSA. Our study involved 265,505 women with diverse contraception needs and with complete data on all variables of interest. Multilevel logistic regression at 95% CI was used to investigate the association between individual and community level factors and pregnancy termination.

RESULTS

We found an overall pregnancy termination rate of 16.27% ranging from 9.13% in Namibia to 38.68% in Gabon. Intriguingly, women with a met need for contraception were more likely to terminate a pregnancy [aOR = 1.11; 95% CI 1.07-1.96] than women with unmet needs. Women with secondary education were more likely to terminate a pregnancy as compared to those without education [aOR = 1.23; 95% CI 1.19-1.27]. With regards to age, we observed that every additional age increases the likelihood of terminating a pregnancy. At the contextual level, the women with female household heads were less likely to terminate a pregnancy [aOR = 0.95; 95% CI 0.92-0.97]. The least socio-economically disadvantaged women were less likely to terminate a pregnancy compared to the moderately and most socio-economically disadvantaged women.

CONCLUSIONS

Our study contributes towards the discussion on unmet/met need for contraception and pregnancy termination across SSA. Women with met need for contraception have higher odds of terminating a pregnancy. The underlying cause of this we argued could be poor adherence to the protocols of contraceptives or the reluctance of women to utilise contraceptives after experiencing a failure. Governments of SSA and non-governmental organisations need to take pragmatic steps to increase met needs for contraception and also utilise mass media to encourage women to adhere to the prescription of contraceptives in order to reduce the incidence of unplanned pregnancies and unsafe abortions.

Diagnostic accuracy of ultrasound screening for fetal structural abnormalities during the first and second trimester of pregnancy in low‐risk and unselected populations

This is a protocol for a Cochrane Review (diagnostic). The objectives are as follows:

The main objectives of this review are to assess the diagnostic accuracy of first‐ and second‐trimester fetal anomaly screening in low‐risk pregnant women, and to compare overall performance of single‐ and two‐stage screening approaches with regards to the number of cases detected before birth, as well as the proportion of false positive diagnoses.

Women's Health Decline Following (Some) Unintended Births: A Prospective Study

BACKGROUND

As many as one-in-three unintended births occur in Africa. These births have the potential to adversely impact women's health, but data and design limitations have complicated efforts to understand their consequences. Moreover, there is growing evidence that women often feel happy about an unintended pregnancy and this heterogeneity may be important for identifying the births that are - and those that are not - harmful to women's health.

OBJECTIVE

To assess whether having an unintended birth precipitates health declines for young women in a high-fertility, high-morbidity context, and whether women's emotional reaction to the pregnancy foreshadows the consequences of the resulting birth.

METHODS

We use closely spaced panel data from 896 young women in Malawi that include prospective measures of fertility timing desires captured only months before conception and a contemporaneous measure of emotional reaction to the pregnancy. We run lagged dependent variable regression models of self-rated health that account for health and sociodemographic conditions prior to pregnancy and compare women with unintended births to women with intended births and to an alternative comparison group: women who avoid an unintended birth. We then disaggregate unintended births by women's emotional reaction after learning of the pregnancy.

RESULTS

Women who had an unintended birth but initially had a positive reaction to the pregnancy did not experience a decline in health after birth. Women who had a more negative reaction, however, experienced marked reductions in self-rated health, even years after the birth.

CONTRIBUTION

Our findings highlight meaningful heterogeneity in the consequences of unintended fertility for women's health and offer insights into the unintended births that put women at greatest risk of health decline.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019126927.

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

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

Renal Failure among Women of Reproductive Age in Burundi: Estimating the Prevalence and Associated Factors Using Population-Based Data

Background

Renal failure is a leading cause of morbidity and mortality in many resource-constrained settings. In developing countries, little has been known about the prevalence and predisposing factors of renal failure using population-based data. The objective of this study was to examine the prevalence and associated factors of renal failure among women of reproductive age in Burundi.

Methods

We used nationally representative cross-sectional data from the 2016-2017 Burundi Demographic and Health Survey (BDHS). Data on 17,269 women of reproductive age were included. The outcome variable was a renal failure as determined by the patient's report. Percentage, chi-square test, and multivariable logistic regression model were used to analyze the data. The results from the logistic regression model were presented as adjusted odds ratio (AOR) and confidence interval (95% CI). The significance level was set at p < 0.05.

Results

The overall prevalence of renal failure was 5.0% (95% CI: 4.4%, 5.7%). Higher-aged women were more likely to have a renal failure when compared with women aged 15-19 years. Rural dwellers were 1.65 times as likely to have a renal failure when compared with women in the urban residence (AOR = 1.65; 95% CI: 1.24, 2.20). Women who had secondary + education had a 39% reduction in the odds of renal failure when compared with women with no formal education (AOR = 0.61; 95% CI: 0.46, 0.81). Health insurance coverage accounted for a 23% reduction in the odds of renal failure when compared with women who were not covered by health insurance (AOR = 0.77; 95% CI: 0.63, 0.93). Women who had a terminated pregnancy were 1.50 times as likely to have a renal failure when compared with women with no history of terminated pregnancy (AOR = 1.50; 95% CI: 1.24, 1.82). Furthermore, women with a history of contraceptive use were 1.32 times as likely to have a renal failure when compared with women without a history of contraceptive use (AOR = 1.32; 95% CI: 1.11, 1.57).

Conclusion

Lack of formal education, having no health insurance coverage, and ever used anything or tried to delay or avoid getting pregnant were the modifiable risk factors of renal failure. The nonmodifiable risk factors were old age, rural residence, certain geographical regions, and having a history of pregnancy termination. Understanding the risk factors of renal failure will help to instigate early screening, detection, and prompt treatment initiation. In addition, early detection of the risk factors can help to reduce the adverse health impact including maternal death.

Prognostic factors of time to first abortion after sexual debut among fragile state Congolese women: a survival analysis

BACKGROUND

Despite the common restrictive abortion laws, abortion remains widespread in sub-Saharan Africa (SSA) countries. Women still utilize abortion services and put their lives and health at risk because abortion can only be procured illegally in private facilities such as mid-level or small patent medicine store that may be manned by unskilled providers or through a non-medicated approach. The objective of this study was to investigate the prevalence of abortion, the reasons women had abortions, median years to first abortion after sexual debut and examine the factors of time to first abortion among women of reproductive age in the Republic of Congo.

METHODS

We used data from the most recent Republic of Congo Demographic and Health Survey (DHS). A total sample of 3622 women aged 15-49 years was analyzed. We estimated the overall prevalence of abortion and median years to first abortion. Furthermore, we examined the factors of time to first abortion after sexual debut using multivariable Cox regression and reported the estimates using adjusted Hazard Ratio (aHR) and 95% confidence intervals (CI). Statistical significance was determined at p < 0.05.

RESULTS

The prevalence of abortion was 60.0% and median years of time to first abortion after sexual debut was 9.0. The prominent reasons for abortion were due to too short birth interval (23.8%), lack of money (21.0%) and that husband/partner did not need a child at that time (14.0%). Women's age and region were notable factors in timing to first abortion. Furthermore, women from poorer, middle, richer and richest households had 34, 67, 86 and 94% higher risk of abortion respectively, when compared with women from poorest households (all p < 0.05). Women currently in union/living with a man and formerly in union had 41 and 29% reduction in the risk of abortion respectively, when compared with those never in union (all p < 0.05). In addition, women with primary and secondary+ education had 42 and 76% higher risk of abortion respectively, when compared with women with no formal education (all p < 0.05).

CONCLUSION

There was high prevalence of abortion with short years at first abortion. Abortion was associated with women's characteristics. There is need for unwanted pregnancy prevention intervention and the improvement in pregnancy care to reduce adverse pregnancy outcomes among women.

Legal Determinants of Health: Regulating Abortion Care

In The legal determinants of health: Harnessing the power of law for global health and sustainable development, Gostin et al. provide a sustained account of how law can and should be used as an instrument of health promotion. We pick up on the themes of this report with a specific focus of the importance of abortion for women’s sexual and reproductive health and the impact that particular ways of framing abortion in law can have on the lives of women and girls. In this short comment, we wish to emphasize that abortion regulations need to move beyond frameworks based on narrow understandings of harm towards more progressive agendas that take into account the social determinants of health in order to reduce barriers to care. This contribution is particularly relevant to the Commission’s criticism that those ‘[l]aws that stigmatise or discriminate against marginalized populations are especially harmful and exacerbate health disparities’.

Global Abortion Policies Database: a Descriptive Analysis of Financial Coverage for Abortion Care

Purpose of the Review

The purpose of this review is to report on data available in the Global Abortion Policies Database (GAPD) as of February 2020. The GAPD is a repository of publicly available sources related to abortion for all countries.

Recent Findings

Research indicates that where individuals must pay for abortion procedures, costs can often be unaffordable and catastrophic for households. Faced with financial barriers, individuals may be deterred from seeking healthcare or may resort to clandestine practices.

Summary

There are limited countries with publicly available sources related to financial protection for abortion services. Even where legal access may be available on paper, several countries restrict actual access by limiting financial protection to specific types of individuals seeking abortion or certain legal categories of abortion, thus raising questions of equity and possible human rights violations. As countries advance towards universal health coverage (UHC), there is an urgent need to expand the GAPD to include additional data, building the evidence base on national health systems financing, and to consider the implications of financial protection with respect to access to abortion services.

Global Abortion Policies Database: A descriptive analysis of the regulatory and policy environment related to abortion

The World Health Organization (WHO) Safe abortion: technical and policy guidance for health systems states that regulatory, policy, and programmatic barriers that hinder access to and timely provision of safe abortion care should be removed. Although some regulatory requirements facilitate access, where they act as barriers, they can deter women from seeking safe abortion care. We use data available in the Global Abortion Policies Database as of February 2019 to review policies related to regulatory requirements identified as access barriers in the Safe abortion guidance. We include only countries where such policies apply, i.e., where abortion is lawful on the woman's request, with no requirement for justification and/or for one or more legal grounds. The results demonstrate the variation that exists in regulatory requirements, but little remains known about how they are implemented in practice and the implications on how women access and how providers offer safe abortion services.

Decriminalization of abortion - A human rights imperative

This chapter reviews the evolving consensus in international human rights law, first supporting the liberalization of criminal abortion laws to improve access to care and now supporting their repeal or decriminalization as a human rights imperative to protect the health, equality, and dignity of people. This consensus is based on human rights standards or the authoritative interpretations of U.N. and regional human rights treaties in general comments and recommendations, individual communications and inquiry reports of treaty monitoring bodies, and in the thematic reports of special rapporteurs and working groups of the U.N. and regional human rights systems. This chapter explores the reach and influence of human rights standards, especially how high courts in many countries reference these standards to hold governments accountable for the reform and repeal of criminal abortion laws.

Safe abortion: The public health rationale

It is now more than 50 years since the World Health Assembly recognized abortion as a serious public health problem. The challenge still stands. Addressing the problem of unsafe abortion is a national and global public health imperative, dictated by the magnitude of the problem and its impact on individuals and society, inequity of the burden of disease, and an international consensus of the global health community. Almost every abortion death and disability could be prevented through cost-effective public health interventions including sexuality education, use of effective contraception, provision of safe, legal induced abortion, and quality humane postabortion care. Safe abortion continues to be a challenge to public health because of diverse national restrictive legal regulations, prevailing stigma, and lack of political commitment. Health professionals have a social responsibility to educate policymakers, legislators, and the public at large about adverse impacts of restrictive abortion regulations, laws, and policies on women's health.