Reproductive health and the politics of abortion

"We need to confirm at least from two or three": Healthcare workers' discretion as gatekeepers in the context of the Ethiopian abortion law

INTRODUCTION

Women's access to legal and safe abortion is a vital means to reduce unsafe abortion, which in turn is known to reduce maternal morbidity and mortality. In 2005, Ethiopia enacted a relatively permissive abortion legislation. However, there is evidence that access to abortion care services may be challenging and controversial even if progressive abortion laws are in place. This article examines women's access to abortion services from the perspective of healthcare workers in a rural setting in Ethiopia. Drawing on Lipsky's theory of street-level bureaucrats, the article discusses healthcare workers' discretion and the substantial authority they hold as gatekeepers to safe abortion services.

METHODS

The study draws upon a qualitative, interpretative methodological approach, with in-depth semi-structured interviews with healthcare workers as the key method of data generation. The data was analyzed and interpreted thematically. Healthcare workers' perspectives were examined with reference to the national abortion legislation and guidelines.

RESULTS

The findings reveal that healthcare workers make decisions on behalf of the women who seek abortion, and they involve parents and partners in abortion-related decision-making processes. Moreover, they assess the social context of the pregnancy such as the marital and economic statuses of the abortion-seeking women in ways that restrict women's access to legally-endorsed abortion services.

CONCLUSIONS

Healthcare workers' practices in this rural area were found to challenge the basic provisions laid out in Ethiopia's abortion legislation. Their negative discretion of the legislation contributes to the substantial barriers Ethiopian abortion-seeking women face in gaining access to legal abortion services, despite the presence of a progressive legal framework and guidelines.

Sub-Saharan Irregular Migrant Women's Sexuality: A Qualitative Study in Humanitarian Reception Centers

Irregular female migration to Europe is a growing phenomenon, as more and more women are fleeing their countries of origin due to gender inequality and violence. During the migration process, women experience physical, psychological and social problems that affect their sex lives. The aim of our study is to describe and understand how irregular migrant women living in humanitarian reception centers experience their sexuality at different stages of the migration process. This qualitative phenomenological study collected data through sixteen in-depth interviews with irregular migrant women between January and February 2023. Data analysis was carried out using ATLAS-ti 23.0 software, from which three themes were extracted: (1) The reality of sub-Saharan women's sexuality, (2) In search of a better life: the choice between taking the risk or surrendering, and (3) The sexual revolution among migrants. Sub-Saharan women's sexuality is subject to a complex normative order. The migratory process has severe consequences on migrant women's sex life. The sexual needs of irregular migrant women admitted to humanitarian reception centers undergo a process of change that must be understood by healthcare providers in order to make improvements to care provision.

Global disease burden attributed to unsafe sex in 204 countries and territories from 1990 to 2019: results from the Global Burden of Disease Study 2019

Unsafe sex has become a public safety problem that endangers society, and research on deaths and disability-adjusted life years (DALYs) related to unsafe sex is valuable for global policy-making. We aimed to estimate the deaths and DALYs attributable to unsafe sex by country, gender, age group, and sociodemographic status from 1990 to 2019. We extracted data on disease burden from the Global Disease Burden 2019 (GBD 2019) database for unsafe sex, including deaths, DALYs and age-standardized rates (ASRs). Comparative analyses were performed on data about deaths, DALYs and the responding ASRs attributable to unsafe sex in different countries and regions using the Social Demographic Index (SDI). The global age-standardized mortality rate (ASMR) and age-standardized DALY rate (ASDR) attributable to unsafe sex were 11.98 (95% uncertainty intervals (UI): 10.97-13.52) per 100,000 people and 570.78 (95% UI: 510.24-658.10) per 100,000 people, respectively. Both the ASMRs and ASDRs were the highest in southern sub-Saharan Africa and lowest in Australasia and decreased with increasing SDI levels. About unsafe-sex-related disease, HIV/AIDS has the highest ASMR [8.48 (95% UI: 7.62-9.95)/100,000 people] and ASDR [447.44 (95% UI: 394.82-533.10)/100,000 people], followed by Cervical cancer [ASMR: 3.40 (95% UI: 2.90-3.81)/100,000 people and ASDR: 107.2 (95% UI: 90.52-119.43)/100,000 people] and sexually transmitted infections excluding HIV [ASMR: 0.10 (95% UI: 0.08-0.11)/100,000 people and ASDR: 16.14 (95% UI: 10.51-25.83)/100,000 people]. The death and DALY burden caused by these three diseases were more serious in the over 75 years old age group. The 40-44 age group for men and the 35-39 age group for women had the highest population of unsafe sex-related deaths and DALYs, respectively. In addition, the burden of unsafe sex in women was more serious than those in men. Unsafe sex is an important risk factor for global disease burden and a leading cause of substantial health loss. We found that the risk of ASMRs and ASDRs attributable to unsafe sex had negative correlation with SDI levels. These results demonstrate that the need for revised policies that focus on efforts to reduce overall unsafe sex worldwide.

Perinatal palliative care in sub-Saharan Africa: recommendations for practice, future research, and guideline development

Worldwide, sub-Saharan Africa has the highest burden of global neonatal mortality (43%) and neonatal mortality rate (NMR): 27 deaths per 1,000 live births. The WHO recognizes palliative care (PC) as an integral, yet underutilized, component of perinatal care for pregnancies at risk of stillbirth or early neonatal death, and for neonates with severe prematurity, birth trauma or congenital anomalies. Despite bearing a disproportionate burden of neonatal mortality, many strategies to care for dying newborns and support their families employed in high-income countries (HICs) are not available in low-and-middle-income countries (LMICs). Many institutions and professional societies in LMICs lack guidelines or recommendations to standardize care, and existing guidelines may have limited adherence due to lack of space, equipment, supplies, trained professionals, and high patient load. In this narrative review, we compare perinatal/neonatal PC in HICs and LMICs in sub-Saharan Africa to identify key areas for future, research-informed, interventions that might be tailored to the local sociocultural contexts and propose actionable recommendations for these resource-deprived environments that may support clinical care and inform future professional guideline development.

Mifepristone: A Safe Method of Medical Abortion and Self-Managed Medical Abortion in the Post-Roe Era

BACKGROUND

The U.S. Supreme Court's Dobbs v. Jackson Women's Health Organization decision on June 24, 2022 effectively overturned federal constitutional protections for abortion that have existed since 1973 and returned jurisdiction to the states. Several states implemented abortion bans, some of which banned abortion after 6 weeks and others that permit abortion under limited exceptions, such as if the health or the life of the woman is in danger. Other states introduced bills that define life as beginning at fertilization. As a result of these new and proposed laws, the future availability of mifepristone, one of two drugs used for medical abortion in the United States, has become the topic of intense debate and speculation.

AREAS OF UNCERTAINTY

Although its safety and effectiveness has been confirmed by many studies, the use of mifepristone has been politicized regularly since its approval. Areas of future study include mifepristone for induction termination and fetal demise in the third trimester and the management of leiomyoma.

DATA SOURCES

PubMed, Society of Family Planning, American College of Obstetrician and Gynecologists, the World Health Organization.

THERAPEUTIC ADVANCES

The use of no-touch medical abortion, which entails providing a medical abortion via a telehealth platform without a screening ultrasound or bloodwork, expanded during the COVID-19 pandemic, and studies have confirmed its safety. With the Dobbs decision, legal abortion will be less accessible and, consequently, self-managed abortion with mifepristone and misoprostol will become more prevalent.

CONCLUSIONS

Mifepristone and misoprostol are extremely safe medications with many applications. In the current changing political climate, physicians and pregnancy-capable individuals must have access to these medications.

Structural gender inequalities and symptoms of postpartum depression in 40 countries

BACKGROUND

The role of structural gender inequality in macro-level differences in women's perinatal mental health remains largely unexplored. This short communication explores structural gender inequalities and their potential as a macro-level, upstream social determinant of postpartum depression (PPD).

METHODS

We compiled meta-analytically derived national-level prevalence estimates of PPD symptoms - based on the Edinburgh Postnatal Depression Scale - with economic (e.g., income inequality), health (e.g., infant mortality rate), sociodemographic (e.g., urban population), and structural gender inequality variables (e.g., abortion policies) for 40 countries. Meta-regression techniques and traditional p-value based stepwise procedures, complemented with a Bayesian model averaging approach, were used for a robust selection of variables associated with national-level PPD symptom prevalence.

RESULTS

Income inequality (β = 0.04, 95% CI = 0.02 to 0.07) and abortion policies (β = 0.02, 95% CI = 0.00 to 0.03) were the only variables selected in the final, adjusted model, accounting for 60.7% of cross-national variations in PPD symptoms.

LIMITATIONS

Study quality of primary studies was not assessed and some national-level meta-analytical estimates were based on few primary studies. A fifth of world countries and territories could be included, with high-income regions overrepresented. High rate of missing national-level data for potential predictors of PPD. Cross-sectional analyses precludes causal inferences.

CONCLUSIONS

Abortion policies are a significant macro-level social determinant of PPD, and its liberalization might be associated with women's mental health at a population level. Our findings should be a relevant argument for clinicians to advocate for changing discriminatory social norms against women.

Determinants of abortion among youth 15-24 in Ethiopia: A multilevel analysis based on EDHS 2016

INTRODUCTION

Determinants of the magnitude of abortion among women of diverse social and economic status, particularly in Africa poorly understood because of the missing information in most countries. In this study, we addressed abortion and its determinants among youth women of 15-24 ages to provide clear direction for policymaking in Ethiopia.

METHODS

We examined the 2016 Ethiopian demographic health survey data downloaded from the EDHS website after obtaining permission on abortion among 15-24 age women. We applied bivariate and multilevel binary logistic regression. Community and Individual level abortion predictors passed through a three-level binary logistic regression analysis where we used p-value <0.05 and adjusted odds ratios (AOR) with 95% confidence intervals (CI).

RESULT

The abortion among the youth population in this study was 2.5%. Factors associated with pregnancy were age group 20-24 2.5(1.6-3.8), youth with one birth 0.65(0.44-0.96), youth with 2-5 births 0.31(0.18-0.55), age ≥18 0.50(0.33-0.76), married 38(17-84), divorced 20(7-55), birth in the last five years 0.65(0.44-0.96), middle wealth youth 1.7(1.0.4-2.8), being in Amhara0.31(0.11-0.85), and 0.30(0.12-0.77).

CONCLUSION

Less abortion occurred in economically poor youths. It is a noble finding; however, the access problem might lead to the result. We observed more abortions in age <18years; those have not given birth until the data collection date. It portrays forth clear policy direction for politicians and all other stakeholders to intervene in the problem. The analysis also showed abortion increased with age. It shows that as age increased, youths disclose abortion which is rare at an early age, and again given an essential clue for the next interventions. The fact in this study is both age and marriage affected abortion similarly. It might be because of various culture-related perceptions where it is not appropriate for an unmarried woman to appear with any pregnancy outcome as the reason behind the decreased number of abortions at a younger age. Thus, more attention is required during implementation for unmarried and lower age youth regardless of the magnitude of the abortion.