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

Assessment of relevance and actual implementation of person-centeredness in healthcare and social support services for women with unintended pregnancy in Germany (CarePreg): results of expert workshops

INTRODUCTION

Person-centeredness is a key principle in the German healthcare system. However, access to high-quality care for women with unintended pregnancy is limited due to social stigma and legal restrictions. There is little research on the adoption of person-centeredness in care for women with unintended pregnancy. The aim of this study was to analyze relevance and actual implementation of dimensions of person-centeredness in psycho-social and medical abortion care from the view of abortion care providers.

METHODS

Counselors and gynecologist working in psycho-social or medical abortion care participated in one of two digital workshops. Discussions were semi-structured based on the 16 dimensions of an integrative model of person-centeredness, audio-recorded and transcribed verbatim. During qualitative content analysis, deductive categories based on the integrative model of person-centeredness were applied and inductive categories were developed. Additionally, participants rated relevance and actual implementation of the dimensions in an online survey.

RESULTS

The 18 workshop participants most intensively discussed the dimensions "access to care", "person-centered characteristics of healthcare providers" and "personally tailored information". Four additional categories on a macro level ("stigmatization of women with unintended pregnancy", "stigmatization of healthcare providers", "political and legal aspects" and "corona pandemic") were identified. Most dimensions were rated as highly relevant but implementation status was described as rather low.

CONCLUSIONS

In Germany, high quality person-centered care for women with unintended pregnancy is insufficiently implemented through limited access to information, a lack of abortion care providers, and stigmatization. There is a need for changes in health care structures to enable nationwide person-centered care for women with unintended pregnancy. Those changes include a more easy access to evidence-based information and person-centered abortion care, more education on abortion care for healthcare providers, integration of topics of abortion care in medical schools and promotion of de-stigmatizing actions to enable abortions as part of the general healthcare.

How do we measure unmet need within sexual and reproductive health? A systematic review

BACKGROUND

Addressing health inequality with sexual and reproductive health requires an understanding of unmet need within a range of populations. This review examined the methods and definitions that have been used to measure unmet need, and the populations most frequently assessed.

METHODS

Five databases (PubMed, Web of Science, Scopus, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Health Management and Policy Database (HMIC)) were searched for studies that described quantitative measurement of unmet need within sexual and/or reproductive health between 2010 and 2021. A narrative synthesis was then undertaken to ascertain themes within the literature.

RESULTS

The database search yielded 19,747 papers; 216 papers were included after screening. 190 studies assessed unmet reproductive health need, of which 137 were analyses of trends among people living in low/lower-middle income countries; 181 used cross-sectional data, with only nine analyses being longitudinal. Eighteen studies analysed unmet sexual health need, of which 12 focused on high and upper-middle income populations. 16 papers used cross-sectional analyses. The remaining 10 studies examined unmet need for a combination of sexual and reproductive health services, eight among populations from upper-middle or high income countries. All were cross-sectional analyses. 165 studies used the Demographic and Health Surveys (DHS) definition of unmet need; no other standardised definition was used among the remaining papers.

DISCUSSION

There is a significant focus on unmet need for contraception among women in low income countries within the published literature, leaving considerable evidence gaps in relation to unmet need within sexual health generally and among men in particular, and unmet reproductive health need in high income settings. In addition, using an increased range of data collection methods, analyses and definitions of unmet need would enable better understanding of health inequality in this area.

Barriers and delays in access to abortion care: a cross-sectional study of people traveling to obtain care in England and the Netherlands from European countries where abortion is legal on broad grounds

INTRODUCTION

This study characterized the extent to which (1) financial barriers and (2) abortion care-seeking within a person's country of residence were associated with delays in abortion access among those travelling to England and the Netherlands for abortion care from European countries where abortion is legal on broad grounds in the first trimester but where access past the first trimester is limited to specific circumstances.

METHODOLOGY

We drew on cross-sectional survey data collected at five abortion clinics in England and the Netherlands from 2017 to 2019 (n = 164). We assessed the relationship between difficulty paying for the abortion/travel, acute financial insecurity, and in-country care seeking on delays to abortion using multivariable discrete-time hazards models.

RESULTS

Participants who reported facing both difficulty paying for the abortion procedure and/or travel and difficulty covering basic living costs in the last month reported longer delays in accessing care than those who had no financial difficulty (adjusted hazard odds ratio: 0.39 95% CI 0.21-0.74). This group delayed paying other expenses (39%) or sold something of value (13%) to fund their abortion, resulting in ~ 60% of those with financial difficulty reporting it took them over a week to raise the funds needed for their abortion. Having contacted or visited an abortion provider in the country of residence was associated with delays in presenting abroad for an abortion.

DISCUSSION

These findings point to inequities in access to timely abortion care based on socioeconomic status. Legal time limits on abortion may intersect with individuals' interactions with the health care system to delay care.

Travel for abortion care: implications for clinical practice

PURPOSE OF REVIEW

Traveling long distances to obtain abortion care due to restrictions and scarce availability is associated with significant obstacles. We review clinical strategies that can facilitate abortion access and outline considerations to ensure person-centered and equitable care.

RECENT FINDINGS

Establishing a patient's gestational duration prior to travel may be beneficial to ensure they are eligible for their desired abortion method at the preferred facility or to determine if a multiday procedure is required. If a local ultrasound cannot be obtained prior to travel, evidence demonstrates people can generally estimate their gestational duration accurately. If unable to provide care, clinicians should make timely referrals for abortion. Integration of telemedicine into abortion care is safe and well regarded by patients and should be implemented into service delivery where possible to reduce obstacles to care. Routine in-person follow-up care is not necessary. However, for those who want reassurance, formalized pathways to care should be established to ensure people have access to care in their community. To further minimize travel-related burdens, facilities should routinely offer information about funding and practical support, emotional support, and legal resources.

SUMMARY

There are many opportunities to optimize clinical practice to support those traveling for abortion care.

Out-of-State Travel for Abortion among Texas Residents following an Executive Order Suspending In-State Services during the Coronavirus Pandemic

During the COVID-19 pandemic, existing and new abortion restrictions constrained people's access to abortion care. We assessed Texas abortion patients' out-of-state travel patterns before and during implementation of a state executive order that prohibited most abortions for 30 days in 2020. We received data on Texans who obtained abortions between February and May 2020 at 25 facilities in six nearby states. We estimated weekly trends in the number of out-of-state abortions related to the order using segmented regression models. We compared the distribution of out-of-state abortions by county-level economic deprivation and distance traveled. The number of Texas out-of-state abortions increased 14% the week after (versus before) the order was implemented (incidence rate ratio [IRR] = 1.14; 95% CI: 0.49, 2.63), and increased weekly while the order remained in effect (IRR = 1.64; 95% CI: 1.23, 2.18). Residents of the most economically disadvantaged counties accounted for 52% and 12% of out-of-state abortions before and during the order, respectively (p < 0.001). Before the order, 38% of Texans traveled ≥250 miles one way, whereas during the order 81% traveled ≥250 miles (p < 0.001). Texans' long-distance travel for out-of-state abortion care and the socioeconomic composition of those less likely to travel reflect potential burdens imposed by future abortion bans.

French women's experiences and opinions with in-country versus cross-border abortion travel: a mixed-methods paper

OBJECTIVES

This is the first study contrasting the experience of women residing in France and travelling for abortion services inside and outside their country of residence. We compare travel reasons and costs as well as our study participants' opinions of abortion legislation. The article documents legal and procedural barriers related to accessing local and timely abortions and provides policy recommendations to broaden care options.

METHODS

The study is based on a mixed-methods research design. Quantitative data were descriptively analysed using Stata and drawn from 100 surveys with in-country abortion seekers collected from 3 Parisian hospitals, and 57 surveys with French residents seeking abortion care in the Netherlands (42), Spain (10) and the UK (5). Qualitative data were thematically analysed using ATLAS.ti and drawn from 36 interviews with French residents (23 in-country abortion seekers and 13 cross-border abortion travellers).

FINDINGS

Gestational age (GA) limits were the key reason for cross-border travel, while lack of close-by, timely and good quality abortion care was the main driver for in-country abortion travel. Unlike in-country travellers, cross-border abortion seekers faced significant financial costs and burdens related to such travel. Partners, family members and service providers offered important support structures to both cross-border and in-country travellers.

CONCLUSIONS

Legal time limits appeared to be the key driver for abortion-related travel of French residents. Having passed or being at risk of exceeding the GA limit caused women to travel outside their country or department of residence for abortion care.