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Dempsey B, Callaghan S, Higgins MF. Providers' experiences with abortion care: A scoping review. PLoS One 2024; 19:e0303601. [PMID: 38950040 PMCID: PMC11216598 DOI: 10.1371/journal.pone.0303601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 04/27/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Induced abortion is one of the most common gynecological procedures in the world, with as many as three in every ten pregnancies ending in abortion. It, however, remains controversial. The objective of this scoping review was to explore and map existing literature on the experiences of those who provide abortion care. METHODS AND FINDINGS This exploratory review followed the Levac et al. guidelines and was reported in accordance with the PRISMA-ScR checklist. CINAHL, Cochrane, EMBASE, PsycInfo, PubMed, and Web of Science were used to identify peer-reviewed, original research articles published on providers' experience of abortion. We identified 106 relevant studies, which include a total sample of 4,250 providers from 28 countries and six continents. Most of the studies were qualitative (n = 83), though quantitative (n = 15) and mixed methods (n = 8) studies were also included. We identified two overarching themes: (1) Providers' experiences with abortion stigma and (2) Providers' reflections on their abortion work. Our findings suggest that providers from around the world experience challenges within society and their communities and workplaces which reinforce the stigmatization and marginalization of abortion and pose questions about the morality of this work. Most, however, are proud of their work, believe abortion care to be socially important and necessary, and remain committed to the provision of care. CONCLUSIONS The findings of this review provide a comprehensive overview on the known experiences of providing abortion care. It is a key point of reference for international providers, researchers, and advocates to further this area of research or discussion in their own territories. The findings of this review will inform future work on how to support providers against stigmatization and will offer providers the chance to reflect on their own experiences.
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Affiliation(s)
- B. Dempsey
- UCD Perinatal Research Centre, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - S. Callaghan
- UCD Perinatal Research Centre, National Maternity Hospital, University College Dublin, Dublin, Ireland
- National Maternity Hospital, Dublin, Ireland
| | - M. F. Higgins
- UCD Perinatal Research Centre, National Maternity Hospital, University College Dublin, Dublin, Ireland
- National Maternity Hospital, Dublin, Ireland
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Atreya A, Adhikari K, Nepal S, Bhusal M, Menezes RG, Shrestha DB, Shrestha D. Striving toward safe abortion services in Nepal: A review of barriers and facilitators. Health Sci Rep 2024; 7:e1877. [PMID: 38390351 PMCID: PMC10883100 DOI: 10.1002/hsr2.1877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/01/2024] [Accepted: 01/23/2024] [Indexed: 02/24/2024] Open
Abstract
Background and Aims Despite the decriminalization of abortion in Nepal in 2002, unsafe abortion is still a significant contributor to maternal morbidity and mortality. Nepal has witnessed a significant drop in abortion-related severe complications and maternal deaths owing to the legalization of abortion laws, lowered financial costs, and wider accessibility of safe abortion services (SAS). However, various factors such as sociocultural beliefs, financial constraints, geographical difficulties, and stigma act as barriers to the liberal accessibility of SAS. This review aimed to determine key barriers obstructing women's access to lawful, safe abortion care and identify facilitators that have improved access to and quality of abortion services. Methods A systematic search strategy utilizing the databases PubMed, CINAHL, Scopus, and Embase was used to include studies on the accessibility and safety of abortion services in Nepal. Data were extracted from included studies through close reading. Barriers and facilitators were then categorized into various themes and analyzed. Results Of 223 studies, 112 were duplicates, 73 did not meet the inclusion criteria, and 18 did not align with the research question; thus, 20 studies were included in the review. Various barriers to SAS in Nepal were categorized as economic, geographic, societal, legal/policy, socio-cultural, health systems, and other factors. Facilitators improving access were categorized as economic/geographic/societal, legal/policy, socio-cultural, and health systems factors. The patterns and trends of barriers and facilitators were analyzed, grouping them under legal/policy, socio-cultural, geographic/accessibility, and health systems factors. Conclusion The review identifies financial constraints, unfavorable geography, lack of infrastructure, and social stigmatization as major barriers to SAS. Economics and geography, legalization, improved access, reduced cost and active involvement of auxiliary nurse-midwives and community health volunteers are key facilitators.
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Affiliation(s)
- Alok Atreya
- Department of Forensic Medicine Lumbini Medical College Palpa Nepal
| | - Kishor Adhikari
- Department of Community Medicine, School of Public Health Chitwan Medical College Bharatpur Nepal
| | - Samata Nepal
- Department of Community Medicine Lumbini Medical College Palpa Nepal
| | - Milan Bhusal
- Medical Officer Gulmi Hospital Tamghas, Gulmi Nepal
| | - Ritesh G Menezes
- Department of Pathology, College of Medicine Imam Abdulrahman Bin Faisal University Dammam Saudi Arabia
| | - Dhan B Shrestha
- Department of Internal Medicine Mount Sinai Hospital Chicago Illinois USA
| | - Deepak Shrestha
- Department of Obstetrics and Gynaecology Lumbini Medical College Palpa Nepal
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Mitchell A, Puri MC, Dahal M, Cornell A, Upadhyay UD, Diamond-Smith NG. Impact of Sumadhur intervention on fertility and family planning decision-making norms: a mixed methods study. Reprod Health 2023; 20:80. [PMID: 37231469 DOI: 10.1186/s12978-023-01619-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Mindful of social norms shaping health among women pressured to prove early fertility in Nepal, a bi-national research team developed and piloted a 4-month intervention engaging household triads (newly married women, their husbands, and mothers-in-law) toward advancing gender equity, personal agency, and reproductive health. This study evaluates the impact on family planning and fertility decision-making. METHODS In 2021, Sumadhur was piloted in six villages with 30 household triads (90 participants). Pre/post surveys of all participants were analyzed using paired sample nonparametric tests and in-depth interviews with a subset of 45 participants were transcribed and analyzed thematically. RESULTS Sumadhur significantly impacted (p < .05) norms related to pregnancy spacing and timing, and sex preference of children, as well as knowledge about family planning benefits, pregnancy prevention methods, and abortion legality. Family planning intent also increased among newly married women. Qualitative findings revealed improved family dynamics and gender equity, and shed light on remaining challenges. CONCLUSIONS Entrenched social norms surrounding fertility and family planning contrasted with participants' personal beliefs, highlighting needed community-level shifts to improve reproductive health in Nepal. Engagement of influential community- and family-members is key to improving norms and reproductive health. Additionally, promising interventions such as Sumadhur should be scaled up and reassessed.
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Affiliation(s)
- Ashley Mitchell
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA.
- Bixby Center for Global Reproductive Health, San Francisco, CA, USA.
| | - Mahesh C Puri
- Center for Research On Environment, Health and Population Activities, Kathmandu, Nepal
| | - Minakshi Dahal
- Center for Research On Environment, Health and Population Activities, Kathmandu, Nepal
| | | | - Ushma D Upadhyay
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Nadia G Diamond-Smith
- Department of Epidemiology and Biostatistics and Institute for Global Health Sciences, University of California, San Francisco, CA, USA
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Puri MC, Raifman S, Daniel S, Karki S, Maharjan DC, Ahlbach C, Diamond-Smith N, Foster DG. Denial of legal abortion in Nepal. PLoS One 2023; 18:e0282886. [PMID: 36943824 PMCID: PMC10030013 DOI: 10.1371/journal.pone.0282886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION In Nepal, abortion is legal on request through 12 weeks of pregnancy and up to 28 weeks for health and other reasons. Abortion is available at public facilities at no cost and by trained private providers. Yet, over half of abortions are provided outside this legal system. We sought to investigate the extent to which patients are denied an abortion at clinics legally able to provide services and factors associated with presenting late for care, being denied, and receiving an abortion after being denied. METHODS We used data from a prospective longitudinal study with 1835 women aged 15-45. Between April 2019 and December 2020, we recruited 1,835 women seeking abortions at 22 sites across Nepal, including those seeking care at any gestational age (n = 537) and then only those seeking care at or after 10 weeks of gestation or do not know their gestational age (n = 1,298). We conducted interviewer-led surveys with these women at the time they were seeking abortion service (n = 1,835), at six weeks after abortion-seeking (n = 1523) and six-month intervals for three years. Using descriptive and multivariable logistic regression models, we examined factors associated with presenting for abortion before versus after 10 weeks gestation, with receiving versus being denied an abortion, and with continuing the pregnancy after being denied care. We also described reasons for the denial of care and how and where participants sought abortion care subsequent to being denied. Mixed-effects models was used to accounting clustering effect at the facility level. RESULTS Among those recruited when eligibility included seeking abortion at any gestational age, four in ten women sought abortion care beyond 10 weeks or did not know their gestation and just over one in ten was denied care. Of the full sample, 73% were at or beyond 10 weeks gestation, 44% were denied care, and 60% of those denied continued to seek care after denial. Nearly three-quarters of those denied care were legally eligible for abortion, based on their gestation and pre-existing conditions. Women with lower socioeconomic status, including those who were younger, less educated, and less wealthy, were more likely to present later for abortion, more likely to be turned away, and more likely to continue the pregnancy after denial of care. CONCLUSION Denial of legal abortion care in Nepal is common, particularly among those with fewer resources. The majority of those denied in the sample should have been able to obtain care according to Nepal's abortion law. Abortion denial could have significant potential implications for the health and well-being of women and their families in Nepal.
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Affiliation(s)
- Mahesh C Puri
- Center for Research on Environment, Health and Population Activities (CREHPA), Kathmandu, Nepal
| | - Sarah Raifman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
| | - Sara Daniel
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sunita Karki
- Center for Research on Environment, Health and Population Activities (CREHPA), Kathmandu, Nepal
| | - Dev Chandra Maharjan
- Center for Research on Environment, Health and Population Activities (CREHPA), Kathmandu, Nepal
| | - Chris Ahlbach
- School of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Nadia Diamond-Smith
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States of America
| | - Diana Greene Foster
- Department of Obstetrics, Gynecology, Reproductive Sciences, Advancing New Standards in Reproductive Health, University of California, San Francisco, California, United States of America
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Saengruang N, Cetthakrikul N, Kulthanmanusorn A, Chotchoungchatchai S, Pudpong N, Suphanchaimat R. Self-assessment of attitudes towards conditions to provide safe abortion among new medical graduates in Thailand, 2018: an application of cross-sectional survey with factor analysis. BMC WOMENS HEALTH 2021; 21:273. [PMID: 34315442 PMCID: PMC8314509 DOI: 10.1186/s12905-021-01412-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 07/16/2021] [Indexed: 11/29/2022]
Abstract
Background Unsafe abortion is one of the major public health problems in Thailand. Although the penal code of Thailand and the Thai Medical Council permit doctors to perform safe abortion in certain conditions, little is known about the attitudes that new medical doctors have towards abortion. The objectives of this article are to explore the attitudes towards abortion in certain conditions among new medical graduates and to identify factors related to those attitudes. Methods A cross-sectional survey was conducted in 2018 among 2017 medical graduates who attended the annual workplace selection forum. The participants came from the two main tracks of admission to Thai medical schools: normal track and special track physicians, namely, the Collaborative Project to Increase Production of Rural Doctors (CPIRD). Of these 2017 graduates, 926 returned the questionnaire with complete information. Descriptive analysis, factor analysis, and multi-variable regression analysis were performed. Results We found that most physicians agreed to perform abortions in the context of life-threatening conditions for mothers and children, but not under conditions directly related to physical health (such as pregnancy with socioeconomic problems or pregnancy in adolescents). CPIRD doctors were less amenable than normal track doctors in providing abortions if the reason for the termination of pregnancy was related to socioeconomic problems. Conclusion The study suggests that a proactive campaign for new medical graduates to raise awareness and mutual understanding of abortion services should be exercised. The CPIRD curricula relating to safe abortion should enhance the capacity of medical graduates to deal with pregnant women who face not only a physical health-related problem, but also socioeconomic difficulties and well-being as a whole. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01412-3.
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Affiliation(s)
- Nithiwat Saengruang
- International Health Policy Program, Ministry of Public Health, Nonthaburi, 11000, Thailand.,Bo Kluea Hospital, Nan, 55220, Thailand
| | - Nisachol Cetthakrikul
- International Health Policy Program, Ministry of Public Health, Nonthaburi, 11000, Thailand
| | - Anond Kulthanmanusorn
- International Health Policy Program, Ministry of Public Health, Nonthaburi, 11000, Thailand
| | | | - Nareerut Pudpong
- International Health Policy Program, Ministry of Public Health, Nonthaburi, 11000, Thailand
| | - Rapeepong Suphanchaimat
- International Health Policy Program, Ministry of Public Health, Nonthaburi, 11000, Thailand. .,Division of Epidemiology, Department of Disease Control, Nonthaburi, 11000, Thailand.
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Karkee R, Tumbahanghe KM, Morgan A, Maharjan N, Budhathoki B, Manandhar DS. Policies and actions to reduce maternal mortality in Nepal: perspectives of key informants. Sex Reprod Health Matters 2021; 29:1907026. [PMID: 33821780 PMCID: PMC8032335 DOI: 10.1080/26410397.2021.1907026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Nepal made impressive progress in reducing maternal mortality until 2015. Since then, progress has stagnated, coinciding with Nepal’s transition to a federation with significant devolution in health management. In this context, we conducted key informant interviews (KII) to solicit perspectives on policies responsible for the reduction in maternal mortality, reasons for the stagnation in maternal mortality, and interventions needed for a faster decline in maternal mortality. We conducted 36 KIIs and analysed transcripts using standard framework analysis methods. The key informants identified three policies as the most important for maternal mortality reduction in Nepal: the Safe Motherhood Policy, Skilled Birth Attendant Policy, and Safe Abortion Policy. They opined that policies were adequate, but implementation was weak and ineffective, and strategies needed to be tailored to the local context. A range of health system factors, including poor quality of care, were identified by key informants as underlying the stagnation in Nepal’s maternal mortality ratio, as well as a few demand-side aspects. According to key informants, to reduce maternal deaths further Nepal needs to ensure that the current family planning, birth preparedness, financial incentives, free delivery services, abortion care, and community post-partum care programmes reach marginalised and vulnerable communities. Facilities offering comprehensive emergency obstetric care need to be accessible, and in hill and mountain areas, access could be supported by establishing maternity waiting homes. Social accountability can be strengthened through social audits, role models, and empowerment of health and management committees.
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Affiliation(s)
- Rajendra Karkee
- Associate Professor, School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal. Correspondence:
| | | | - Alison Morgan
- Associate Professor, Nossal Institute for Global Health, University of Melbourne, Melbourne, Australia
| | - Nashna Maharjan
- Research Officer, Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Bharat Budhathoki
- Field Manager, Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Dharma S Manandhar
- Executive Director, Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
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Khatri RB, Poudel S, Ghimire PR. Factors associated with unsafe abortion practices in Nepal: Pooled analysis of the 2011 and 2016 Nepal Demographic and Health Surveys. PLoS One 2019; 14:e0223385. [PMID: 31596879 PMCID: PMC6785064 DOI: 10.1371/journal.pone.0223385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 09/19/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Unsafe abortion contributes to maternal morbidities, mortalities as well as social and financial costs to women, families, and the health system. This study aimed to examine the factors associated with unsafe abortion practices in Nepal. METHODS Data were derived from the 2011 and 2016 Nepal Demographic and Health Surveys (NDHS). A total of 911 women aged 15-49 years who aborted five years prior to surveys were included in the analysis. The multivariate logistic regression analysis was employed to determine factors associated with unsafe abortion. RESULTS Unsafe abortion rate was seven per 1000 women aged 15-49 years. This research found that women living in the Mountains (adjusted Odds Ratio (aOR) 2.36; 95% CI 1.21, 4.60), or those who were urban residents (aOR 2.11; 95% CI 1.37, 3.24) were more likely to have unsafe abortion. The odds of unsafe abortion were higher amongst women of poor households (aOR 2.16; 95% CI 1.18, 3.94); Dalit women (aOR 1.89; 95% CI 1.02, 3.52), husband with no education background (aOR 2.12; 95%CI 1.06, 4.22), or women who reported agriculture occupation (aOR 1.82; 95% CI 1.16, 2.86) compared to their reference's group. Regardless of knowledge on legal conditions of abortion, the probability of having unsafe abortion was significantly higher (aOR 5.13; 95% CI 2.64, 9.98) amongst women who did not know the location of safe abortion sites. Finally, women who wanted to delay or space childbirth (aOR 2.71; 95% CI 1.39, 5.28) or those who reported unwanted birth (aOR = 2.33; 95% CI 1.19, 4.56) were at higher risk of unsafe abortion. CONCLUSION Going forward, increasing the availability of safe abortion facilities and strengthening family planning services can help reduce unsafe abortion in Nepal. These programmatic efforts should be targeted to women of poor households, disadvantaged ethnicities, and those who reside in mountainous region.
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Rogers C, Sapkota S, Paudel R, Dantas JAR. Medical abortion in Nepal: a qualitative study on women's experiences at safe abortion services and pharmacies. Reprod Health 2019; 16:105. [PMID: 31307474 PMCID: PMC6632190 DOI: 10.1186/s12978-019-0755-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 06/17/2019] [Indexed: 11/10/2022] Open
Abstract
Background Although Nepal legalised abortion in 2002, a significant number of women continue to access unsafe abortions. An estimated 60% of all abortions performed in 2014 were unsafe, with unsafe abortion continuing to be a leading contributor to maternal mortality. Despite medical abortion access being solely permitted through government accredited safe abortion services, medical abortion pills are readily available for illegal purchase at pharmacies throughout the country. Methods Utilising an Assets Focused Rapid Participatory Appraisal (AFRPA) research methodology, underpinned by a health information pyramid conceptual framework, this qualitative exploratory study collected data from in-depth, open-ended interviews. The study explored the medical abortion and sexual and reproductive health experiences of ten women who accessed medical abortion through an accredited safe abortion service, and ten women who accessed unsafe medical abortion through pharmacies. Results Thematic content analysis revealed emerging themes relating to decision-making processes in accessing safe or unsafe medical abortion; knowledge of safe abortion services; and SRH information access and post-abortion contraceptive counselling. Findings emphasised the interconnectivity of sexual and reproductive health and rights; reproductive coercion; education; poverty; spousal separation; and women’s personal, social and economic empowerment. Conclusions While barriers to safe abortion services persist, so will the continued demand for medical abortion provision through pharmacies. Innovated and effective harm reduction implementations combined with access and information expansion strategies offer the potential to increase access to safe medical abortion while decreasing adverse health outcomes for women. Electronic supplementary material The online version of this article (10.1186/s12978-019-0755-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claire Rogers
- International Health Programme, Faculty of Health Sciences, Curtin University, Perth, 6102, Western Australia.
| | | | - Rasmita Paudel
- Independent Health Research Consultant, Kathmandu, Nepal
| | - Jaya A R Dantas
- International Health Programme, Faculty of Health Sciences, Curtin University, Perth, 6102, Western Australia
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