Relationships between contraception and abortion: a review of the evidence

Level and Timing of Implanon Discontinuation and Associated Factors among Women Who Used Implanon in Andabet District, Public Health Facilities, North-West Ethiopia

Background

Implanon discontinuation is unacceptably high in developing countries, including Ethiopia. Furthermore, there is an observed problem of high unintended pregnancy after method discontinuation that strides to program failure. Therefore, the purpose of this study was to assess the level and determinants of Implanon discontinuation among women who used Implanon in Andabet district, public health facilities, North-West Ethiopia, 2017.

Methods

Facility-based cross-sectional study design was employed among 537 women from Feb. 03 to April 28, 2017. Study participants were selected using a systematic random sampling technique. A face-to-face interview was employed to collect data. Epi-Info version 7 was used for data entry and SPSS version 20 for analysis. Both descriptive and analytical statistical analysis was computed. On multivariable binary logistic regression, a p value of less than 0.05 was used to declare statistical significance.

Results

About 37% of Implanon users have discontinued the method before the intended time. About 86% of them discontinued Implanon before two years of insertion. Women who had no live child (AOR = 2.17, 95% CI: 1.25-3.77), women who did not receive preinsertion counseling (AOR = 1.85, 95% CI: 1.15-2.97), women who developed Implanon-related side effect (AOR = 5.17, 95% CI: 3.18-8.40), and women who did not satisfy by the service provided (AOR = 5.40, 95% CI: 3.04-9.57) had higher odds of Implanon discontinuation. On the other hand, women who received appointment follow-up (AOR = 0.23, 95% CI: 0.13-0.41) had lower odds of Implanon discontinuation.

Conclusions

The level of Implanon discontinuation before its intended time was high in the district. Hence, strengthening preinsertion counseling and appointment follow-up as well as improving the clients' level of service satisfaction could increase Implanon's continuation.

Protocol for a scoping review of research on abortion in sub-Saharan Africa

Introduction

Unsafe abortion is a leading cause of maternal mortality, and access to safe abortion services remains a public health priority in sub-Saharan Africa (SSA). A considerable amount of abortion research exists in the region; however, the spread of existing evidence is uneven such that some countries have an acute shortage of data with others over-researched. The imbalance reflects the complexities in prioritization among researchers, academics, and funders, and undeniably impedes effective policy and advocacy efforts. This scoping review aims to identify and map the landscape of abortion research in SSA, summarize existing knowledge, and pinpoint significant gaps, both substantive and geographic, requiring further investigation. This review will provide direction for future research, investments, and offer guidance for policy and programming on safe abortion.

Materials and methods

We utilize the Joanna Briggs Institute’s methodology for conducting scoping reviews. We will perform the search for articles in 8 electronic databases (i.e., PubMed, AJOL, Science Direct, SCOPUS, HINARI, Web of Knowledge, CINAHL, and WHO Regional Databases). We will include studies written in English or French language, produced or published between January 1, 2011, and July 31, 2021, and pertain directly to the subject of abortion in SSA. Using a tailored extraction frame, we will extract relevant information from publications that meet the inclusion criteria. Data will be analyzed using descriptive statistics and thematic analysis in response to key review questions.

Ethics and dissemination

Formal ethical approval is not required, as no primary data will be collected. The findings of this study will be disseminated through peer-reviewed publications and conference presentations.

Unsafe abortion and abortion-related death among 1.8 million women in India

Introduction

Unsafe abortion is a preventable cause of maternal mortality. While studies report high number of abortions in India, the population-level rates of unsafe abortion and their risk factors are not well understood. Our objective was to analyse the rates of and risk factors for unsafe abortion and abortion-related maternal death in India.

Methods

We conducted a secondary analysis of data from 1 876 462 pregnant women aged 15–58 years from nine states in the Indian Annual Health Survey (2010–2013). We calculated the rate of unsafe abortion and abortion-related mortality with 95% CI. Multivariable logistic regression models examined the associations of sociodemographic characteristics, health seeking behaviours and family planning with unsafe abortion and abortion-related mortality.

Results

There were 89 447 abortions among 1 876 462 pregnant women in 2007–2011 (4.8%; 95% CI 4.8 to 4.9). Of these, 58 266 were classified as unsafe (67.1%; 95% CI 66.7 to 67.5). There were 253 abortion-related maternal deaths (0.3%; 95% CI 0.2 to 0.3). Factors associated with unsafe abortion: maternal age 20–24 years (adjusted OR (aOR): 1.13; 95% CI 1.09 to 1.18), illiteracy (aOR: 1.48; 95% CI 1.39 to 1.59), rural residence (aOR: 1.26; 95% CI 1.21 to 1.32), Muslim religion (aOR: 1.16; 95% CI 1.12 to 1.22), Schedule caste social group (aOR: 1.08; 95% CI 1.04 to 1.12), poorest asset quintile (aOR: 1.45; 95% CI 1.38 to 1.53), antenatal care (aOR: 0.69; 95% CI 0.67 to 0.72), no surviving children (aOR: 1.30; 95% CI 1.16 to 1.46), all surviving children being female (aOR: 1.12; 95% CI 1.07 to 1.17), use of family planning methods (aOR: 0.69; 95% CI 0.66 to 0.71). Factors associated with abortion-related deaths: maternal age 15–19 (aOR: 7.79; 95% CI 2.73 to 22.23), rural residence (aOR: 3.28; 95% CI 1.76 to 6.11), Schedule tribe social group (aOR: 4.06; 95% CI 1.39 to 11.87).

Conclusion

Despite abortion being legal, the high estimated prevalence of unsafe abortion demonstrates a major public health problem in India. Socioeconomic vulnerability and inadequate access to healthcare services combine to leave large numbers of women at risk of unsafe abortion and abortion-related death.

Spatial and socio-economic correlates of effective contraception among women seeking post-abortion care in healthcare facilities in Kenya

Introduction

Information, counseling, availability of contraceptives, and their adoption by post-abortion care (PAC) patients are central to the quality of PAC in healthcare facilities. Effective contraceptive adoption by these patients reduces the risks of unintended pregnancy and repeat abortion.

Methods

This study uses data from the Incidence and Magnitude of Unsafe Abortion Study of 2012 to assess the level and determinants of highly effective contraception among patients treated with complications from an unsafe abortion in healthcare facilities in Kenya. Highly effective contraception was defined as any method adopted by a PAC patient that reduces pregnancy rate by over 99%.

Results

Generally, contraceptive counseling was high among all PAC patients (90%). However, only 54% of them received a modern family planning method—45% a short-acting method and 9% a long-acting and permanent method. Adoption of highly effective contraception was determined by patient’s previous exposure to unintended pregnancies, induced abortion and modern family planning (FP). Facility level factors associated with the uptake of highly effective contraceptives included: facility ownership, availability of evacuation procedure room, whether the facility had a specialized obstetric-gynecologist, a facility that also had maternity services and the number of FP methods available for PAC patients.

Discussion and conclusion

For better adoption of highly effective FP, counseling of PAC patients requires an understanding of the patient’s past experience with contraception and their future fertility intentions and desires in order to meet their reproductive needs more specifically. Family planning integration with PAC can increase contraceptive uptake and improve the reproductive health of post-abortion care patients.

Is Repeat Abortion a Public Health Problem among Chinese Adolescents? A Cross-Sectional Survey in 30 Provinces

The Chinese Family Planning (FP) programme mainly focuses on married couples, and young unmarried women have limited access. This cross-sectional study aims to identify risk factors related to repeat abortions in Chinese adolescents receiving abortions. Data were collected using a questionnaire for all women seeking abortions within 12 weeks of pregnancy during a period of 2 months in 297 participating hospitals randomly selected across 30 provinces of China in 2013. Only the adolescents (younger than the minimum legal married age of 20 years) were included in this study. Of the 2370 adolescents who were receiving abortions, 927 (39%) were undergoing repeat abortions. The primary reason for the current unintended pregnancies was non-use of contraception (68%). Adolescents receiving abortions who had an increased risk of repeat abortions were those who had children (OR 2.57, 95% CI 1.80⁻3.67), those who resided in a middle-developed region (OR 1.81, 95% CI 1.30⁻2.50), those who resided in a relatively poor region (OR 2.40, 95% CI 1.78⁻3.23), and those who had used contraception during the 6 months preceding the survey (OR 1.38, 95% CI 1.12⁻1.71 for condom use). The occupation as a student was a protective factor for adolescents (OR 0.64, 95% CI 0.50⁻0.83). Adolescents should be offered equal access to FP to that of married women in China to reduce unintended pregnancies and repeat abortions. Correct and consistent contraception practice should be promoted.

Population Policy: Abortion and Modern Contraception Are Substitutes

A longstanding debate exists in population policy about the relationship between modern contraception and abortion. Although theory predicts that they should be substitutes, the empirical evidence is difficult to interpret. What is required is a large-scale intervention that alters the supply (or full price) of one or the other and, importantly, that does so in isolation (reproductive health programs often bundle primary health care and family planning—and in some instances, abortion services). In this article, we study Nepal’s 2004 legalization of abortion provision and subsequent expansion of abortion services, an unusual and rapidly implemented policy meeting these requirements. Using four waves of rich individual-level data representative of fertile-age Nepalese women, we find robust evidence of substitution between modern contraception and abortion. This finding has important implications for public policy and foreign aid, suggesting that an effective strategy for reducing expensive and potentially unsafe abortions may be to expand the supply of modern contraceptives.

Incidence of induced abortion in Malawi, 2015

Background

In Malawi, abortion is legal only if performed to save a woman’s life; other attempts to procure an abortion are punishable by 7–14 years imprisonment. Most induced abortions in Malawi are performed under unsafe conditions, contributing to Malawi’s high maternal mortality ratio. Malawians are currently debating whether to provide additional exceptions under which an abortion may be legally obtained. An estimated 67,300 induced abortions occurred in Malawi in 2009 (equivalent to 23 abortions per 1,000 women aged 15–44), but changes since 2009, including dramatic increases in contraceptive prevalence, may have impacted abortion rates.

Methods

We conducted a nationally representative survey of health facilities to estimate the number of cases of post-abortion care, as well as a survey of knowledgeable informants to estimate the probability of needing and obtaining post-abortion care following induced abortion. These data were combined with national population and fertility data to determine current estimates of induced abortion and unintended pregnancy in Malawi using the Abortion Incidence Complications Methodology.

Results

We estimate that approximately 141,044 (95% CI: 121,161–160,928) induced abortions occurred in Malawi in 2015, translating to a national rate of 38 abortions per 1,000 women aged 15–49 (95% CI: 32 to 43); which varied by geographical zone (range: 28–61). We estimate that 53% of pregnancies in Malawi are unintended, and that 30% of unintended pregnancies end in abortion. Given the challenges of estimating induced abortion, and the assumptions required for calculation, results should be viewed as approximate estimates, rather than exact measures.

Conclusions

The estimated abortion rate in 2015 is higher than in 2009 (potentially due to methodological differences), but similar to recent estimates from nearby countries including Tanzania (36), Uganda (39), and regional estimates in Eastern and Southern Africa (34–35). Over half of pregnancies in Malawi are unintended. Our findings should inform ongoing efforts to reduce maternal morbidity and mortality and to improve public health in Malawi.

Understanding low uptake of contraceptives in resource-limited settings: a mixed-methods study in rural Burundi

Background

Family planning can reduce deaths, improve health, and facilitate economic development in resource-limited settings. Yet, modern contraceptive methods are often underused. This mixed-methods study, conducted in rural Burundi, sought to explain low uptake of contraceptives by identifying utilization barriers. Results may inform development of family planning interventions in Burundi and elsewhere.

Methods

We investigated uptake of contraceptives among women of reproductive age in two rural districts of Burundi, using an explanatory sequential, mixed-methods research design. We first assessed availability and utilization rates of modern contraceptives through a facility-based survey in 39 health clinics. Barriers to uptake of contraceptives were then explored through qualitative interviews (N = 10) and focus groups (N = 7).

Results

Contraceptives were generally available in the 39 clinics studied, yet uptake of family planning averaged only 2.96%. Greater uptake was positively associated with the number of health professionals engaged and trained in family planning service provision, and with the number of different types of contraceptives available. Four uptake barriers were identified: (1) lack of providers to administer contraception, (2) lack of fit between available and preferred contraceptive methods, (3) a climate of fear surrounding contraceptive use, and (4) provider refusal to offer family planning services.

Conclusions

Where resources are scarce, availability of modern contraceptives alone will likely not ensure uptake. Interventions addressing multiple uptake barriers simultaneously have the greatest chance of success. In rural Burundi, examples are community distribution of contraceptive methods, public information campaigns, improved training for health professionals and community health workers, and strengthening of the health infrastructure.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2144-0) contains supplementary material, which is available to authorized users.

Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends

BACKGROUND

Information about the incidence of induced abortion is needed to motivate and inform efforts to help women avoid unintended pregnancies and to monitor progress toward that end. We estimate subregional, regional, and global levels and trends in abortion incidence for 1990 to 2014, and abortion rates in subgroups of women. We use the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion.

METHODS

We requested abortion data from government agencies and compiled data from international sources and nationally representative studies. With data for 1069 country-years, we estimated incidence using a Bayesian hierarchical time series model whereby the overall abortion rate is a function of the modelled rates in subgroups of women of reproductive age defined by their marital status and contraceptive need and use, and the sizes of these subgroups.

FINDINGS

We estimated that 35 abortions (90% uncertainty interval [UI] 33 to 44) occurred annually per 1000 women aged 15-44 years worldwide in 2010-14, which was 5 points less than 40 (39-48) in 1990-94 (90% UI for decline -11 to 0). Because of population growth, the annual number of abortions worldwide increased by 5.9 million (90% UI -1.3 to 15.4), from 50.4 million in 1990-94 (48.6 to 59.9) to 56.3 million (52.4 to 70.0) in 2010-14. In the developed world, the abortion rate declined 19 points (-26 to -14), from 46 (41 to 59) to 27 (24 to 37). In the developing world, we found a non-significant 2 point decline (90% UI -9 to 4) in the rate from 39 (37 to 47) to 37 (34 to 46). Some 25% (90% UI 23 to 29) of pregnancies ended in abortion in 2010-14. Globally, 73% (90% UI 59 to 82) of abortions were obtained by married women in 2010-14 compared with 27% (18 to 41) obtained by unmarried women. We did not observe an association between the abortion rates for 2010-14 and the grounds under which abortion is legally allowed.

INTERPRETATION

Abortion rates have declined significantly since 1990 in the developed world but not in the developing world. Ensuring access to sexual and reproductive health care could help millions of women avoid unintended pregnancies and ensure access to safe abortion.

FUNDING

UK Government, Dutch Ministry of Foreign Affairs, Norwegian Agency for Development Cooperation, The David and Lucile Packard Foundation, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

Health knowledge, attitudes and practices of family planning service providers and clients in Akwapim North District of Ghana

BACKGROUND

Family planning services help save lives by reducing women's exposure to risks of child birth and abortion. While family planning services provide measures to prevent unintended pregnancies and time the formation of families, the acceptability and coverage is still very low worldwide. Some of the reasons for this include poor quality of service, unavailability of range of methods, fear of opposition from partners, side effects and health concerns among others.About 40 % of the world's 215,000 annual deaths in childbirth occur in the Sub-Saharan region. In Ghana, urban-rural fertility differences range from two to three children. The acceptability and coverage of family planning are still low and in the study area in particular.

METHODS

We sought to examine factors that contribute to low acceptability and coverage of family planning services in a sub-urban community with a design of quantitative cross-sectional. Ethical approval was given by the Ghana Health Service. Midwives and community health nurses who provide family planning services were interviewed. Exit-interview was also conducted with women receiving a variety of outpatient services.

RESULTS

Most of the women in this study (48.7 %) were in the 25-34 age range and were either married (42.8 %) or cohabiting (40.5 %). Majority of these women (67.7 %) have middle/Junior high level of formal education with a modal parity of two. Sixty eight (68) clients were identified as current family planning users. About 6.0 % and 4.5 % were dissatisfied about auditory and visual privacy during counselling respectively. This was confirmed by providers who attributed it to inappropriate facility layout. Most of the clients (79.1 %) were not given educational materials although 88.8 % were talked to about family planning and this could be due to unavailability of these hand-outs.Though clients show satisfaction of services received, providers did not follow standard protocols with as much as 73.7 % faced with challenges in provision of services which were attributed to improper facility layout and lack of furniture. About 77.2 % were willing to provide short term methods, while 91.2 % wanted to provide long term methods. As much as 93.3 % of the women said they would have liked providers give more detailed information on family planning. While most of the women (88.3 %) used injectables, only 6.1 % and 0.9 % used Implants and IUD respectively.

CONCLUSIONS

Finding ways to improve client privacy through good facility layout will ensure visual and auditory privacy to enhance family planning service provision and uptake. Continuous competency training will assist providers design innovative action plans and meet client satisfaction needs.

Knowledge and factors determining choice of contraception among Singaporean women

INTRODUCTION

The study aimed to assess the level of awareness and knowledge of contraception among women in Singapore, and identify the factors that influence contraception choice.

METHODS

We conducted a cross-sectional survey of 259 female patients, aged 21-49 years, who attended the Obstetrics and Gynaecology Clinic at National University Hospital, Singapore. An original questionnaire on nine contraceptive methods was used. Respondents who had ≥ 2 correct answers for a method (out of four questions) were considered to have good knowledge of the method. Participants were asked to rate factors known to influence contraceptive choice as important or not important.

RESULTS

Awareness of the following methods was high: condom (100.0%), oral contraception pill (89.2%), tubal ligation (73.0%) and copper intrauterine device (IUD) (72.2%). The women were least aware of hormonal IUD (24.3%). Women who were parous, had a previous abortion, had completed their family or used contraception previously were more likely to have a higher awareness of contraception. 89.2% of the women had good knowledge of the condom; among those aware of hormonal IUD, only 46.0% had good knowledge of it. Women who had used hormonal IUD and the condom were more likely to have good knowledge of them. Many rated efficacy (90.5%) and a healthcare professional's advice (90.1%) as important in contraceptive choice. Few considered peer influence (21.0%) and cultural practices (16.3%) to be important.

CONCLUSION

Women in Singapore have poor awareness and knowledge of contraception, especially long-acting reversible methods. More effective ways are needed to educate women about contraceptive methods.

Prevalence and correlates of contraceptive use among female adolescents in Ghana

Background

Adolescence is a critical stage in the life course and evidence suggests that even though contraceptive use has been steadily increasing among women in Ghana over the past years, contraceptive prevalence and determinants among female adolescents is quite lacking. This paper examines the prevalence and correlates of contraceptive use among female adolescents in Ghana.

Methods

The paper used data from the 2008 Ghana Demographic and Health survey. Bivariate analysis was carried out to determine the contraceptive prevalence among female adolescents while logistic regression analysis was applied to examine the correlates of female adolescent contraceptive use.

Results

The study founded that female adolescent contraceptive use was significantly determined by age of adolescent, education, work status, knowledge of ovulatory cycle, visit of health facility and marital status.

Conclusions

This has implications for adolescent sexual and reproductive health programmes in Ghana. It is therefore essential to intensify girl child education and strengthen the provision of family planning information and services for female adolescents in the country.

Contraception and abortion: Fruits of the same rotten tree?

This article seeks to show how contraception, when generally accepted in a society, helps to bring about a radical change in social perceptions of sexual intercourse, human life, the human person, science, and morality in general. On account of this, contraception helps to ingrain abortion and other anti-life practices into the culture that accepts it and, therefore, in no sense can be considered as a panacea for abortion. Particular attention is given to the thought of John Paul II on this matter who noted that "despite their differences of nature and moral gravity, contraception and abortion are often closely connected, as fruits of the same tree" (Evangelium vitae, n. 13). Lay summary: The article considers the connection between contraception and abortion and defends Pope John Paul II's claim that "despite their differences of nature and moral gravity, contraception and abortion are often closely connected, as fruits of the same tree." The thesis is that contraception is a "game-changer" in the sense that it changes the way we think about some very fundamental realities such as attitudes to sex, to life, to science, to the human person, and to morality. Any one of these changes would have a significant impact on a society in terms of promoting a culture of death: together they are devastating.

Delivering medical abortion at scale: a study of the retail market for medical abortion in Madhya Pradesh, India

BACKGROUND

Medical abortion (mifepristone and misoprostol) has the potential to contribute to reduced maternal mortality but little is known about the provision or quality of advice for medical abortion through the private retail sector. We examined the availability of medical abortion and the practices of pharmacists in India, where abortion has been legal since 1972.

METHODS

We interviewed 591 pharmacists in 60 local markets in city, town and rural areas of Madhya Pradesh. One month later, we returned to 359 pharmacists with undercover patients who presented themselves unannounced as genuine customers seeking a medical abortion.

RESULTS

Medical abortion was offered to undercover patients by 256 (71.3%) pharmacists and 24 different brands were identified. Two thirds (68.5%) of pharmacists stated that abortion was illegal in India. Only 106 (38.5%) pharmacists asked clients the timing of the last menstrual period and 38 (13.8%) requested to see a doctor's prescription - a legal requirement in India. Only 59 (21.5%) pharmacists correctly advised patients on the gestational limit for medical abortion, 97 (35.3%) provided correct information on how many and when to take the tablets in a combination pack, and 78 (28.4%) gave accurate advice on where to seek care in case of complications. Advice on post-abortion family planning was almost nonexistent.

CONCLUSIONS

The retail market for medical abortion is extensive, but the quality of advice given to patients is poor. Although the contribution of medical abortion to women's health in India is poorly understood, there is an urgent need to improve the practices of pharmacists selling medical abortion.

Explaining the role of proximate determinants on fertility decline among poor and non-poor in Asian countries

OBJECTIVES

We examined the overall contributions of the poor and non-poor in fertility decline across the Asian countries. Further, we analyzed the direct and indirect factors that determine the reproductive behaviour of two distinct population sub-groups.

DESIGN

Data from several new rounds of DHS surveys are available over the past few years. The DHS provides cross-nationally comparable and useful data on fertility, family planning, maternal and child health along with the other information. Six selected Asian countries namely: Bangladesh, India, Indonesia, Nepal, Philippines, and Vietnam are considered for the purpose of the study. Three rounds of DHS surveys for each country (except Vietnam) are considered in the present study.

METHODS

Economic status is measured by computing a "wealth index", i.e. a composite indicator constructed by aggregating data on asset ownership and housing characteristics using principal components analysis (PCA). Computed household wealth index has been broken into three equal parts (33.3 percent each) and the lowest and the highest 33.3 percent is considered as poor and non-poor respectively. The Bongaarts model was employed to quantify the contribution of each of the proximate determinants of fertility among poor and non-poor women.

RESULTS

Fertility reduction across all population subgroups is now an established fact despite the diversity in the level of socio-economic development in Asian countries. It is clear from the analysis that fertility has declined irrespective of economic status at varying degrees within and across the countries which can be attributed to the increasing level of contraceptive use especially among poor women. Over the period of time changing marriage pattern and induced abortion are playing an important role in reducing fertility among poor women.

CONCLUSIONS

Fertility decline among majority of the poor women across the Asian countries is accompanied by high prevalence of contraceptive use followed by changing marriage pattern and induced abortion.

Medical students' knowledge, attitudes and perceptions towards contraceptive use and counselling: a cross-sectional survey in Maharashtra, India

OBJECTIVES

This study aimed to investigate the knowledge, attitudes and perceptions towards contraceptive use and counselling among medical students in Maharashtra, India.

SETTING

Considerable global maternal mortality and morbidity could be avoided through the use of effective contraception. In India, contraception services are frequently unavailable or there are obstacles to obtaining modern, reversible contraceptives.

PARTICIPANTS

A cross-sectional descriptive study using a self-administered questionnaire was conducted among 1996 medical students in their fifth year of study at 27 medical colleges in the state of Maharashtra, India. Descriptive and analytical statistics interpreted the survey instrument and significant results were presented with 95% CI.

RESULTS

Respondents expressed a desire to provide contraceptive services. A few students had experienced training in abortion care. There were misconceptions about modern contraceptive methods and the impact of sex education. Attitudes towards contraception were mainly positive, premarital counselling was supported and the influence of traditional values and negative provider attitudes on services was recognised. Gender, area of upbringing and type of medical college did not change the results.

CONCLUSIONS

Despite mostly positive attitudes towards modern contraceptives, sex education and family planning counselling, medical students in Maharashtra have misconceptions about modern methods of contraception. Preservice and in-service training in contraceptive counselling should be implemented in order to increase women's access to evidence-based maternal healthcare services.

Medical students' attitudes toward abortion education: Malaysian perspective

BACKGROUND

Abortion is a serious public health issue, and it poses high risks to the health and life of women. Yet safe abortion services are not readily available because few doctors are trained to provide such services. Many doctors are unaware of laws pertaining to abortion. This article reports survey findings on Malaysian medical students' attitudes toward abortion education and presents a case for including abortion education in medical schools.

METHODS AND RESULTS

A survey on knowledge of and attitudes toward abortion among medical students was conducted in two public universities and a private university in Malaysia in 2011. A total of 1,060 students returned the completed questionnaires. The survey covered about 90% of medical students in Years 1, 3, and 5 in the three universities. About 90% of the students wanted more training on the general knowledge and legal aspects of abortion, and pre-and post-abortion counseling. Overall, 75.9% and 81.0% of the students were in favor of including in medical education the training on surgical abortion techniques and medical abortion, respectively. Only 2.4% and 1.7% were opposed to the inclusion of training of these two methods in the curriculum. The remaining respondents were neutral in their stand. Desire for more abortion education was associated with students' pro-choice index, their intention to provide abortion services in future practice, and year of study. However, students' attitudes toward abortion were not significantly associated with gender, type of university, or ethnicity.

CONCLUSIONS

Most students wanted more training on abortion. Some students also expressed their intention to provide abortion counseling and services in their future practice. Their desire for more training on abortion should be taken into account in the new curriculum. Abortion education is an important step towards making available safe abortion services to enable women to exercise their reproductive rights.

"Sometimes they used to whisper in our ears": health care workers' perceptions of the effects of abortion legalization in Nepal

Background

Unsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers’ views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care.

Methods

To complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data.

Results

Overall, participants had positive views of abortion legalization – many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment.

Conclusions

Providers were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications.

The sociocultural context of family size preference, ideal sex composition, and induced abortion in India: findings from India's National Family Health surveys

In this study, the author examined the effect of family size preference and sex composition of living children as determinants of induced abortion among women in India by analyzing 90,303 ever-married women aged 15-49, included in India's second National Family Health Survey, conducted in 1998-99. Multivariate logistic regression methods were used to examine the association between induced abortion and possible determinants. The results indicated that a woman's desire to limit family size with preferred sex composition of children, coupled with her autonomy and the sociocultural context, largely determines her experience of induced abortion in India.

Sociodemographic variables of contraceptive practice in Sikkim

Objectives:

The objective was to assess sociodemographic characteristics of men who use contraceptive and to compare them with men whose wives use contraceptive.

Materials and Methods:

Study design: A population-based cross-sectional study was performed. Study setting: It was performed in rural setting of the Sang PHC and Pakyong PHC service areas in Sikkim, India. Study participants: A total of 596 currently married men enrolled in the eligible couple registers. Interventions: No interventions occurred. Measurements: Sociodemographic correlates of contraceptive use were analyzed: occupation, religion, ethnicity, literacy, age, loss of children, and distance from health facility.

Results:

The use of contraceptive was high among the cultivators - men (44.45%), spouse (36.01%) followed by persons in Government service, respectively, 31.49% and 31.55%. Hindu men (55.42%), women (69.25%), and other backward communities (OBC) men (47.53%) and their wives (52.31%) were the majority users. A significantly higher number of users of contraceptive were literate men (72.33%) and their wives (86.17%) (χ²=0.021, P> 0.05). Highest use was found in men and women (44.47%) in the 35 years and above (43.83) age group. But this difference was not significant. With the increase in the number of losses of children the contraceptive use declined among men and their spouses. Contraceptive users were higher at distances 1 hour and above from the health center compared to others.

Conclusions:

The finding of the research indicated that sociodemographic correlates determine the magnitude of the contraceptive use among couples in a rural community. A research agenda should define factors at both macro and micro levels that interact to adversely impinge on reproductive health outcomes.

Peri-abortion contraceptive use in the French islands of Guadeloupe and La Réunion: variation in the management of post-abortion care

OBJECTIVES

The abortion rate varies greatly within the French overseas territories including the Caribbean island of Guadeloupe and La Réunion in the Indian Ocean. We compare women's contraceptive paths surrounding an abortion in both territories.

METHODS

The data for this study are part of a nationally representative survey of women undergoing abortion in France in 2007. The analysis included 1,211 women from Guadeloupe and 1531 from La Réunion.

RESULTS

Results show differences in women's use of contraception before the abortion by study location. Women in Guadeloupe were more likely not to have used contraception in the month they conceived (40% vs. 32%, p < 0.0001). Among those using no contraception or less effective contraception before the abortion, 74% in Guadeloupe and 86% in La Réunion received a prescription for a very effective method such as a hormonal method or intrauterine device after the procedure. In both settings, women with no health insurance or a government health plan were 70% less likely to have received a prescription for a very effective method.

CONCLUSIONS

While this study shows a significant increase in the prescription of very effective methods, it also indicates the ineffectiveness of the health care system in closing the gap in the pre-abortion contraceptive disparities observed between Guadeloupe and La Réunion.

Trends in inequalities in induced abortion according to educational level among urban women

This study aims to describe trends in inequalities by women's socioeconomic position and age in induced abortion in Barcelona (Spain) over 1992-1996 and 2000-2004. Induced abortions occurring in residents in Barcelona aged 20 and 44 years in the study period are included. Variables are age, educational level, and time periods. Induced abortion rates per 1,000 women and absolute differences for educational level, age, and time period are calculated. Poisson regression models are fitted to obtain the relative risk (RR) for trends. Induced abortion rates increased from 10.1 to 14.6 per 1,000 women aged 20-44 (RR = 1.44; 95% confidence interval (CI) 1.41-1.47) between 1992-1996 and 2000-2004. The abortion rate was highest among women aged 20-24 and 25-34 and changed little among women aged 35-44. Among women aged 20-24 and 25-34, those with a primary education or less had higher rates of induced abortion in the second period. Induced abortion rates also grew in those women with secondary education. In the 35-44 age group, the induced abortion rate declined among women with a secondary education (RR = 0.66; 95% CI 0.60-0.73) and slightly among those with a greater level of education. Induced abortion is rising most among women in poor socioeconomic positions. This study reveals deep inequalities in induced abortion in Barcelona, Spain. The trends identified in this study suggest that policy efforts to reduce unintended pregnancies are failing in Spain. Our study fills an important gap in literature on recent trends in Southern Europe.

The panorama and outcomes of pregnancies within a well-defined population in rural Vietnam 1999-2004

BACKGROUND

Pregnancy outcomes in the general population are important public health indicators.

PURPOSE

The overall aim of this study was to investigate the outcomes of reported pregnancies within a well-defined population, to identify risk groups for adverse pregnancy outcomes, and to suggest preventive measures.

METHOD

A prospective population-based cohort study of pregnant women in Bavi district, Vietnam between 1 January 1999 and 30 June 2004.

RESULTS

Pregnancy outcome was reported for 5,259 cases; 4,152 (79%) resulted in a live birth, 67 (1.3%) in a stillbirth, 733 (14%) in an induced abortion, and 282 (5.4%) in a spontaneous abortion. There was an increased risk of home delivery for women from ethnic minorities (OR = 1.85; 95%CI = 1.06-3.24) or with less than 6 years of schooling (OR = 7.36; 95%CI = 3.54-15.30). The risk of stillbirth was increased for ethnic minorities (OR = 6.34; 95%CI = 1.33-30.29) and women delivering at home (OR = 6.81; 95%CI = 2.40-19.30). The risk of induced abortion increased with maternal age.

CONCLUSION

Our findings emphasize the public health significance of access to adequate family planning, counselling, and maternal health care for all women. Policies should specifically target women from high-risk groups.