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Owolabi OO, Rossier C, Compaore R, Kim C, Ganatra B, Ouedraogo R, Zan M, Bangha M, Baguiya A. Searching for Needles in a Haystack: Exploring Alternative Operational Approaches to Classify the Safety of Induced Abortions Using Respondent-Driven Sampling Data From Two Sub-Saharan African Settings. Stud Fam Plann 2024. [PMID: 39325587 DOI: 10.1111/sifp.12276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
This study aims to describe the circumstances under which women obtained abortions in two sites, explore more nuanced approaches to classify abortion safety and examine the relationship between safety and self-reported health outcomes. We analyze data on the most recent abortion or only abortion reported by 551 women in Nairobi slums and 479 women in rural Kaya ages 15-49 years within the three years preceding the study, recruited via respondent-driven sampling. Using the most liberal safety classification, there were very few safe abortions (8 percent in Nairobi and 5 percent in Burkina Faso). A significant proportion of women reported using unidentified pills which we hypothesize may be medication abortion. Although a smaller proportion of women with safe abortions reported side effects, more of them reported side effects suggestive of infections and sought care for their symptoms. It is important that we explore and move towards more nuanced global safety classifications that more accurately reflect the risk associated with different methods and can capture women's access to comprehensive abortion care and its impact on their health.
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Suárez-Baquero DF, Dzuba IG, Romero M, Baba CF, Biggs MA. Failure of the Law to Grant Access to Legal Abortion in Chile. Health Equity 2024; 8:189-197. [PMID: 38559845 PMCID: PMC10979664 DOI: 10.1089/heq.2023.0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction In 2017, Chile decriminalized abortion on three grounds: (i) if the pregnant person's life is at risk, (ii) fetal nonviability, and (iii) rape or incest. This multicase study explores the experiences of pregnant people legally entitled to but denied access to legal abortion in Chile. Methods Through a snowball sampling approach, we recruited adult Chilean residents who sought, were eligible for, and were denied a legal abortion after September 2017. We conducted semistructured interviews with participants to explore their experiences in seeking and being denied legal abortions. We recorded and transcribed the interviews, then coded and analyzed the transcriptions to identify common themes. Results We identified four women who met the eligibility criteria. The interviews revealed five common themes in their experiences: (i) disparate levels of social support in accessing abortion, (ii) abundant access barriers, (iii) forced pregnancy, (iv) abortion stigma, and (v) a failure of the law to provide access to abortion. Discussion and Health Equity Implications Although the 2017 law expanded legal access to abortion in Chile, significant barriers remain. Compounded with social stigma, and the socioeconomic disparities in abortion access, pregnant people continue to face insurmountable obstacles in obtaining legal abortions, even when their lives are at risk and the pregnancy is not viable. The state must prioritize equity of access to legal abortions. Future studies should continue to explore the challenges people face accessing legal abortion care to inform strategies to ensure people are able to obtain the quality care that they are legally entitled to.
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Affiliation(s)
- Daniel F.M. Suárez-Baquero
- Department of Child, Family, and Population Health, School of Nursing, University of Washington, Seattle, Washington, USA
- Postdoctoral Fellow ACTIONS Program, Department of Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, California, USA
| | | | - Mariana Romero
- National Abortion Federation, Washington, District of Columbia, USA
| | - C. Finley Baba
- Advancing New Standards in Reproductive Health, University of California San Francisco, Oakland, California, USA
| | - M. Antonia Biggs
- Advancing New Standards in Reproductive Health, University of California San Francisco, Oakland, California, USA
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Freeman C, Rodríguez S. The chemical geographies of misoprostol: Spatializing abortion access from the biochemical to the global. ANNALS OF THE AMERICAN ASSOCIATION OF GEOGRAPHERS 2024; 114:123-138. [PMID: 38204958 PMCID: PMC7615505 DOI: 10.1080/24694452.2023.2242453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/26/2023] [Indexed: 01/12/2024]
Abstract
C22W38O5 is a chemical that travels. Better known as misoprostol, it was designed as a stomach ulcer drug but is now used around the world as an abortion pill due to the self-experimentation of Latin American communities who were seeking ways to end unwanted pregnancies. We develop a chemical geography approach to misoprostol that allows us to scale inward to understand the chemical properties of this medication while also being able to scale out to understand how medicinal effects are interwoven with and determined by global politics. Misoprostol as a chemical alone does not guarantee a successful abortion and instead 'scaffolding' in the form of mobility and information is required to transform misoprostol from a chemical to a safe and effective technology of abortion. First, we examine how misoprostol is moved by feminist networks in Mexico and Peru. Second, we argue that in order to be useful it is not enough just to access the pills, information on how to use them is required. These themes culminate in our contribution of 'pharmacokinetical geographies'; the micro-geography of the placement of pharmaceuticals in and on a body and its ramifications. The chemical geographies of misoprostol tell a story of power, bodily autonomy, and resistance.
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Affiliation(s)
- Cordelia Freeman
- Department of Geography, University of Exeter. Amory Building, Rennes Drive, Exeter, EX4 4RJ
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Kapp N, Mao B, Menzel J, Eckersberger E, Saphonn V, Rathavy T, Pearson E. A prospective, comparative study of clinical outcomes following clinic-based versus self-use of medical abortion. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:300-307. [PMID: 36894309 PMCID: PMC10579469 DOI: 10.1136/bmjsrh-2022-201722] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 02/12/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND To determine whether clinical outcomes differ among women accessing a combined medical abortion regimen from a health clinic when compared with those accessing it from a pharmacy. METHODS We conducted a multicentre, prospective, comparative, non-inferiority study of participants aged ≥15 years seeking medical abortion from five clinics and five adjacent pharmacy clusters in three provinces of Cambodia. Participants were recruited in-person at the point of purchase (clinic or pharmacy). Follow-up for self-reported pill use, acceptability, and clinical outcomes occurred by telephone at days 10 and 30 after mifepristone administration. RESULTS Over 10 months, we enrolled 2083 women with 1847 providing outcome data: 937 from clinics and 910 from pharmacies. Most were early in their pregnancy (mean gestational age of 6.3 and 6.1 weeks, respectively) and almost all took the pills correctly (98% and 96%,). Additional treatment needed to complete the abortion was non-inferior for the pharmacy group (9.3%) compared with the clinic group (12.7%). More from the clinic group received additional care from a provider, such as antibiotics or diagnostics tests, than those from the pharmacy group (11.5% and 3.2%,), and one ectopic pregnancy (pharmacy group) was successfully treated. Most said they felt prepared for what happened after taking the pills (90.9% and 81.3%, respectively, p=0.273). CONCLUSIONS Self-use of a combined medical abortion product resulted in comparable clinical outcomes as use following a clinical visit, consistent with existing literature on its safety and efficacy. Registration and availability of medical abortion as an over-the-counter product would likely increase women's access to safe abortion.
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Affiliation(s)
| | - Bunsoth Mao
- University of Health Sciences, Phnom Penh, Cambodia
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Duffy D, Freeman C, Rodríguez S. Building infrastructures of abortion care in an un-caring state: acompañante's carework and abortion access in Peru. SIGNS 2023; 48:585-608. [PMID: 37324651 PMCID: PMC7614643 DOI: 10.1086/723296] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
For abortion seekers, Peru is an uncaring state where legal and policy interventions have resulted in violence, persecution, and neglect. This state of abortion uncare is set within historic and ongoing denials of reproductive autonomy, coercive reproductive care, and the marginalisation of abortion. Abortion is not supported, even where legally permissible. Here we explore abortion care activism within the Peruvian context, foregrounding a key mobilisation that has emerged against a state of un-care - acompañante carework. Through interviews with people involved in abortion access and activism in Peru, we argue that acompañantes have constructed an infrastructure of abortion care in Peru through the bringing together of actors, technologies, and strategies. This infrastructure is shaped by a feminist ethic of care that differs from minority world care assumptions regarding high quality abortion care in three key ways: (i) care is provided beyond the state; (ii) care is holistic; and (iii) care is collective. We argue that US feminist debates relating to the emerging hyperrestrictive state of abortion un-care as well as broader research on feminist care can learn from acompañante activism strategically and conceptually.
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Affiliation(s)
- Deirdre Duffy
- Faculty of Health Psychology and Social Care, Manchester Metropolitan University, Manchester
| | - Cordelia Freeman
- Department of Geography, University of Exeter. Amory Building, Rennes Drive, Exeter, EX4 4RJ
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Rossier C, Owolabi O, Kouanda S, Bangha M, Kim CR, Ganatra B, Feehan D, Breen C, Zan M, Compaoré R, Baguiya A, Ouédraogo R, Oduor C, Bagnoa V, Athero S. Describing the safety of abortion at the population level using network-based survey approaches. Reprod Health 2022; 19:231. [PMID: 36575489 PMCID: PMC9795788 DOI: 10.1186/s12978-022-01518-3] [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: 04/14/2021] [Accepted: 10/21/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Despite the negative impact of unsafe abortions on women's health and rights, the degree of abortion safety remains strikingly undocumented for a large share of abortions globally. Data on how women induce abortions (method, setting, provider) are central to the measurement of abortion safety. However, health-facility statistics and direct questioning in population surveys do not yield representative data on abortion care seeking pathways in settings where access to abortion services is highly restricted. Recent developments in survey methodologies to study stigmatized / illegal behaviour and hidden populations rely on the fact that such information circulates within social networks; however, such efforts have yet to give convincing results for unsafe abortions. OBJECTIVE This article presents the protocol of a study whose purpose is to apply and develop further two network-based methods to contribute to the generation of reliable population-level information on the safety of abortions in contexts where access to legal abortion services is highly restricted. METHODS This study plans to obtain population-level data on abortion care seeking in two Health and Demographic Surveillance Systems in urban Kenya and rural Burkina Faso by applying two methods: Anonymous Third-Party Reporting (ATPR) (also known as confidantes' method) and Respondent Driven Sampling (RDS). We will conduct a mixed methods formative study to determine whether these network-based approaches are pertinent in the study contexts. The ATPR will be refined notably by incorporating elements of the Network Scale-Up Method (NSUM) to correct or account for certain of its biases (transmission, barrier, social desirability, selection). The RDS will provide reliable alternative estimates of abortion safety if large samples and equilibrium can be reached; an RDS multiplex variant (also including social referents) will be tested. DISCUSSION This study aims at documenting abortion safety in two local sites using ATPR and RDS. If successful, it will provide data on the safety profiles of abortion seekers across sociodemographic categories in two contrasted settings in sub-Saharan Africa. It will advance the formative research needed to determine whether ATPR and RDS are applicable or not in a given context. It will improve the questionnaire and correcting factors for the ATPR, improve the capacity of RDS to produce quasi-representative data on abortion safety, and advance the validation of both methods.
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Affiliation(s)
- Clémentine Rossier
- Institute of Demography and Socioeconomics, University of Geneva, 40 Bd du Pont d'Arve, 1211, Geneva, Switzerland. .,Institut National d'Etudes Démographiques, Paris, France.
| | - Onikepe Owolabi
- grid.417837.e0000 0001 1019 058XGuttmacher Institute, New York, USA
| | - Seni Kouanda
- grid.457337.10000 0004 0564 0509IRSS, Ouagadougou, Burkina Faso
| | - Martin Bangha
- grid.413355.50000 0001 2221 4219APHRC, Nairobi, Kenya
| | - Caron R. Kim
- grid.3575.40000000121633745UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Bela Ganatra
- grid.3575.40000000121633745UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Dennis Feehan
- grid.47840.3f0000 0001 2181 7878University of California, Berkeley, Berkeley USA
| | - Casey Breen
- grid.47840.3f0000 0001 2181 7878University of California, Berkeley, Berkeley USA
| | - Moussa Zan
- grid.8591.50000 0001 2322 4988Institute of Demography and Socioeconomics, University of Geneva, 40 Bd du Pont d’Arve, 1211 Geneva, Switzerland
| | | | - Adama Baguiya
- grid.457337.10000 0004 0564 0509IRSS, Ouagadougou, Burkina Faso
| | | | - Clement Oduor
- grid.413355.50000 0001 2221 4219APHRC, Nairobi, Kenya
| | - Vincent Bagnoa
- grid.457337.10000 0004 0564 0509IRSS, Ouagadougou, Burkina Faso
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Bercu C, Filippa S, Ramirez AM, Katz A, Grosso B, Zurbriggen R, Vázquez S, Baum SE. Perspectives on high-quality interpersonal care among people obtaining abortions in Argentina. Reprod Health 2022; 19:107. [PMID: 35501904 PMCID: PMC9059438 DOI: 10.1186/s12978-022-01401-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 03/24/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Little is known about how people who have abortions describe high-quality interpersonal care in Argentina. This qualitative study aimed to understand preferences and priorities in their interactions with providers. Study design We conducted 24 in-depth interviews with people who obtained abortions at a comprehensive reproductive health clinic or with support from a feminist accompaniment group in Buenos Aires and Neuquén, Argentina. We iteratively coded transcripts using a thematic analysis approach based on interpersonal domains present in current quality of care frameworks. Results Participants described high-quality abortion care as feeling acompañamiento and contención from their providers – terms that imply receiving kind, caring, compassionate and emotionally supportive care throughout their abortion. They described four key elements of interpersonal interactions: attentive communication from providers and accompaniers, clear and understandable information provision, non-judgmental support, and individualized options for pain management. Conclusions People obtaining abortions in Argentina consistently identified receiving compassionate and supportive care throughout an abortion as a key aspect of care. The findings have implications for incorporating people’s perspectives in the development of care guidelines, training of providers, and monitoring and improving of services. This is particularly important as the government of Argentina prepares to expand legal access to abortion. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-022-01401-1. Little is known about how people who have abortions perceive the quality of the care they receive and what aspects of interpersonal interactions with providers matter to them. This qualitative study aimed to understand preferences of people who had abortions at both a reproductive health clinic and with an accompaniment group in Argentina. We interviewed 24 people who obtained abortion care in Buenos Aires and Neuquén, Argentina. We asked them about their preferences for and experiences of abortion care. Then we analyzed the interviews, specifically assessing aspects of interpersonal care based on quality of care frameworks from the literature. Participants described high-quality abortion care as feeling acompañamiento and contención from their providers—terms that imply receiving kind, caring, compassionate and emotionally supportive care throughout their abortions. They described four key elements of interpersonal interactions: attentive communication from providers and accompaniers, clear and understandable information provision, non-judgmental support, and individualized options for pain management. In conclusion, people obtaining abortions in two distinct models of care in Argentina consistently identified receiving compassionate and supportive care throughout an abortion as a key aspect of care. The findings have implications for incorporating people’s perspectives in the development of care guidelines, training of providers, and monitoring and improving of services. This is particularly important as the government of Argentina prepares to expand legal access to abortion.
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Stifani BM, Gill R, Kim CR. Reducing the harms of unsafe abortion: a systematic review of the safety, effectiveness and acceptability of harm reduction counselling for pregnant persons seeking induced abortion. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:137-145. [PMID: 35017226 PMCID: PMC9016246 DOI: 10.1136/bmjsrh-2021-201389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/11/2021] [Indexed: 05/04/2023]
Abstract
BACKGROUND Globally, access to safe abortion is limited. We aimed to assess the safety, effectiveness and acceptability of harm reduction counselling for abortion, which we define as the provision of information about safe abortion methods to pregnant persons seeking abortion. METHODS We searched PubMed, EMBASE, ClinicalTrials.gov, Cochrane, Global Index Medicus and the grey literature up to October 2021. We included studies in which healthcare providers gave pregnant persons information on safe use of abortifacient medications without providing the actual medications. We conducted a descriptive summary of results and a risk of bias assessment using the ROBINS-I tool. Our primary outcome was the proportion of pregnant persons who used misoprostol to induce abortion rather than other methods among those who received harm reduction counselling. RESULTS We included four observational studies with a total of 4002 participants. Most pregnant persons who received harm reduction counselling induced abortion using misoprostol (79%-100%). Serious complication rates were low (0%-1%). Uterine aspiration rates were not always reported but were in the range of 6%-22%. Patient satisfaction with the harm reduction intervention was high (85%-98%) where reported. We rated the risk of bias for all studies as high due to a lack of comparison groups and high lost to follow-up rates. DISCUSSION Based on a synthesis of four studies with serious methodological limitations, most recipients of harm reduction counselling use misoprostol for abortion, have low complication rates, and are satisfied with the intervention. More research is needed to determine abortion success outcomes from the harm reduction approach. FUNDING This work did not receive any funding. PROSPERO REGISTRATION NUMBER We registered the review in the PROSPERO database of systematic reviews (ID number: CRD42020200849).
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Affiliation(s)
- Bianca Maria Stifani
- Obstetrics, Gynecology & Women's Health, Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, USA
- Obstetrics & Gynecology, New York Medical College / Westchester Medical Center, Valhalla, NY, USA
| | - Roopan Gill
- Obstetrics & Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Caron Rahn Kim
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Veldhuis S, Sánchez-Ramírez G, Darney BG. Locating Autonomous Abortion Accompanied by Feminist Activists in the Spectrum of Self-Managed Medication Abortion. Stud Fam Plann 2022; 53:377-387. [PMID: 35347718 DOI: 10.1111/sifp.12194] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Diverse models of self-managed medication abortion exist-ranging from some interaction with medical personnel to completely autonomous abortion. In this commentary, we propose a new classification of self-managed medication abortion and describe the different modalities. We highlight autonomous abortion accompanied by feminist activists, called "acompañantes," as a community- and rights-based strategy that can be a safe alternative to clinical abortion services in clandestine as well as legal settings. To improve access, abortion needs to be decriminalized and governments must acknowledge and facilitate the diversity of safe abortion options so women may choose where, when, how, and with whom to abort.
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Affiliation(s)
- Suzanne Veldhuis
- Department of Health, El Colegio de la Frontera Sur (ECOSUR), San Cristóbal de las Casas, Chiapas 29290, México
| | - Georgina Sánchez-Ramírez
- Department of Health, El Colegio de la Frontera Sur (ECOSUR), San Cristóbal de las Casas, Chiapas 29290, México
| | - Blair G Darney
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR 97239, USA.,Centro de Investigación en Salud Poblacional (CISP), Instituto Nacional de Salud Publica (INSP), 62100 Cuernavaca, Morelos, México
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Jacobson LE, Saavedra-Avendano B, Fuentes-Rivera E, Schiavon R, Darney BG. Travelling for abortion services in Mexico 2016-2019: community-level contexts of Mexico City public abortion clients. BMJ SEXUAL & REPRODUCTIVE HEALTH 2022; 48:e81-e87. [PMID: 34321256 PMCID: PMC8685658 DOI: 10.1136/bmjsrh-2021-201079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/06/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To describe the community context of women who travel to access Mexico City's public sector abortion programme and identify factors associated with travelling from highly marginalised settings. METHODS We used data from the Interrupción Legal de Embarazo (ILE) programme (2016-2019) and identified all abortion clients who travelled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to describe ILE clients' individual characteristics and municipalities on several measures of vulnerability. We also compared municipalities that ILE clients travelled from with those where no one travelled from. We used logistic regression to identify factors associated with travelling to access ILE services from highly marginalised versus less marginalised municipalities. RESULTS Our sample included 21 629 ILE clients who travelled to Mexico City from 491 municipalities within all 31 states outside Mexico City. The majority of clients travelled from the least marginalised (81.9%) and most populated (over 100 000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom three quintiles. Clients with a primary or secondary education (vs high school or more) and those from a municipality with a high adolescent fertility rate (top two quintiles) had higher odds of travelling from a highly marginalised (vs less) municipality (adjusted odds ratio (aOR) 1.46, 95% CI 1.35 to 1.58 and aOR 1.89, 95% CI 1.68 to 2.12, respectively). CONCLUSION ILE clients travel from geographically and socioeconomically diverse communities. There is an unmet need for legal abortion across Mexico.
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Affiliation(s)
- Laura E Jacobson
- Oregon Health and Science University-Portland State University (OHSU-PSU) School of Public Health, Portland, Oregon, USA
| | - Biani Saavedra-Avendano
- Public Administration, Centro de Investigación y Docencia Económicas (CIDE), Mexico, Mexico City, Mexico
| | - Evelyn Fuentes-Rivera
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Morelos, Mexico
| | | | - Blair G Darney
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
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Bercu C, Moseson H, McReynolds-Pérez J, Wilkinson Salamea E, Grosso B, Trpin M, Zurbriggen R, Cisternas C, Meza M, Díaz V, Kimport K. In-person later abortion accompaniment: a feminist collective-facilitated self-care practice in Latin America. Sex Reprod Health Matters 2021; 29:2009103. [PMID: 34928196 PMCID: PMC8725943 DOI: 10.1080/26410397.2021.2009103] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
In Argentina, Chile and Ecuador, abortion at later durations of pregnancy is legally restricted. Feminist collectives in these contexts support people through self-managed medical abortion outside the healthcare system. The model of in-person abortion accompaniment represents an opportunity to examine a self-care practice that challenges and reimagines abortion provision. We formed a collaborative partnership built on a commitment to shared power and decision-making between researchers and partners. We conducted 28 key informant interviews with accompaniers in Argentina, Chile and Ecuador in 2019 about their model of in-person abortion accompaniment at later durations of pregnancy. We iteratively coded transcripts using a thematic analysis approach. Accompaniers premised their work in a feminist activist framework that understands accompaniment as addressing inequalities and expanding rights, especially for the historically marginalised. Through a detailed description of the process of in-person accompaniment, we show that the model, including the logistical considerations and security mechanisms put in place to ensure favourable abortion outcomes, emphasises peer-to-peer provision of supportive physical and emotional care of the accompanied person. In this way, it represents supported self-care through which individuals are centred as the protagonists of their own abortion, while being accompanied by feminist peers. This model of supported self-care challenges the idea that “self-care” necessarily means “solo care”, or care that happens alone. The model’s focus on peer-to-peer transfer of knowledge, providing emotional support, and centring the accompanied person not only expands access to abortion, but represents person-centred practices that could be scaled and replicated across contexts.
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Affiliation(s)
- Chiara Bercu
- Senior Project Manager, Ibis Reproductive Health, Oakland, CA, USA. Correspondence:
| | - Heidi Moseson
- Senior Research Scientist, Ibis Reproductive Health, Oakland, CA, USA
| | | | | | - Belén Grosso
- Activist and Researcher, La Colectiva Feminista La Revuelta, Neuquén, Argentina
| | - María Trpin
- Activist and Researcher, La Colectiva Feminista La Revuelta, Neuquén, Argentina
| | - Ruth Zurbriggen
- Activist and Researcher, La Colectiva Feminista La Revuelta, Neuquén, Argentina
| | | | - Milena Meza
- Activist and Researcher, Con las Amigas y en la Casa, Santiago, Chile
| | - Viviana Díaz
- Activist and Researcher, Con las Amigas y en la Casa, Santiago, Chile
| | - Katrina Kimport
- Associate Professor, Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, CA, USA
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Miani C. Medical abortion ratios and gender equality in Europe: an ecological correlation study. Sex Reprod Health Matters 2021; 29:1985814. [PMID: 34730066 PMCID: PMC8567957 DOI: 10.1080/26410397.2021.1985814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Medical abortion (MA) is recommended by the WHO as a safe and effective pregnancy termination method in the first trimester. From a feminist perspective, it is a non-medicalised, self-managed, emancipating procedure allowing persons seeking abortion to be more in control of their abortion, as opposed to surgical procedures. In European countries where MA is legal, the proportion of MA (relative to surgical abortions) varies greatly. We hypothesised that this ratio may be partly explained by country-level dimensions of gender equality. We assessed the association between MA ratios and gender equality in Europe in correlation and regression analyses, using several country-level gender equality indices. The relevance of other factors, i.e. date of introduction of MA and pregnancy week until which MA is permitted, was also investigated. MA ratios ranged from 24.4% (Italy) to 97.7% (Finland). MA was more frequent relative to surgical abortion in countries with higher levels of gender equality. All gender equality indices were associated with MA ratios (e.g. Global Gender Gap Index corr. coeff: 0.761, p < 0.0001). Specifically, markers of economic and political gender equality seemed to drive the correlations. The pregnancy week until which MA is permitted was associated with both gender equality and MA ratios. Our study suggests that women’s participation in the economic and political sphere may have repercussions on the methods offered and used through abortion services. It highlights the link between feminist perspectives, reproductive health policies and practices, and gender equality, especially in terms of access to economic resources and political representation.
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Affiliation(s)
- Céline Miani
- Junior Research Group Leader, School of Public Health, Department of Epidemiology and International Public Health, Bielefeld University, Bielefeld, Germany. Correspondence:
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Miller C. Maternal Mortality from Induced Abortion in Malawi: What Does the Latest Evidence Suggest? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910506. [PMID: 34639806 PMCID: PMC8507663 DOI: 10.3390/ijerph181910506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/15/2022]
Abstract
It is commonly claimed that thousands of women die every year from unsafe abortion in Malawi. This commentary critically assesses those claims, demonstrating that these estimates are not supported by the evidence. On the contrary, the latest evidence—itself from 15 to 20 years ago—suggests that 6–7% of maternal deaths in Malawi are attributable to induced and spontaneous abortion combined, totalling approximately 70–150 deaths per year. I then offer some evidence suggesting that a substantial proportion of these are attributable to spontaneous abortion. To reduce maternal mortality by large margins, emergency obstetric care should be prioritised, which will also save women from complications of induced and spontaneous abortion.
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Affiliation(s)
- Calum Miller
- St. Benet's Hall, University of Oxford, Oxford OX1 3LN, UK
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14
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Assis MP, Erdman JN. Abortion rights beyond the medico-legal paradigm. Glob Public Health 2021; 17:2235-2250. [PMID: 34487487 DOI: 10.1080/17441692.2021.1971278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abortion rights in international law have historically been framed within a medico-legal paradigm, the belief that regulated systems of legal and medical control guarantee safe abortion. However, a growing worldwide practice of self-managed abortion (SMA) supported by feminist activism challenges key precepts of this paradigm. SMA activism has shown that more than medical service delivery matters to safe abortion and has called into question the legal regulation of abortion beyond criminal prohibitions. This article explores how abortion rights have begun to depart from the medico-legal paradigm and to support the novel norms and practices of SMA activism in a transformation of the abortion field. Abortion rights as reimagined in SMA activism increasingly feature in human rights agendas related to structural violence and inequality, collective organising and international solidarity, and democratic engagement.
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Affiliation(s)
| | - Joanna N Erdman
- Schulich School of Law, Dalhousie University, Halifax, Canada
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15
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Zanini G, Mishtal J, De Zordo S, Ziegler AK, Gerdts C. Abortion information governance and women's travels across European borders. WOMENS STUDIES INTERNATIONAL FORUM 2021. [DOI: 10.1016/j.wsif.2021.102496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Väisänen H, Moore AM, Owolabi O, Stillman M, Fatusi A, Akinyemi A. Sexual and Reproductive Health Literacy, Misoprostol Knowledge and Use of Medication Abortion in Lagos State, Nigeria: A Mixed Methods Study. Stud Fam Plann 2021; 52:217-237. [PMID: 34043236 PMCID: PMC8362169 DOI: 10.1111/sifp.12156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Little is known about the link between health literacy and women's ability to safely and successfully use misoprostol to self‐induce an abortion. While abortion is only allowed to save a woman's life in Nigeria, misoprostol is widely available from drug sellers. We interviewed 394 women in 2018 in Lagos State, Nigeria, who induced abortion using misoprostol obtained from a drug seller to determine their sexual and reproductive health literacy (SRHL) and misoprostol knowledge levels; and how these were associated with ending the pregnancy successfully or seeking care for (perceived) complications. Our results show that women's misoprostol knowledge (measured both quantitatively and qualitatively) was low, but that almost all women were nevertheless able to use the drug effectively and safely. Higher SRHL was associated with being more likely to end the pregnancy successfully and also seeking postabortion health care. Our study is the first to examine this association and adds to the scarce literature examining the relationship between health literacy and self‐use of misoprostol to induce abortions in restrictive settings.
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Affiliation(s)
- Heini Väisänen
- Heini Väisänen, Sexual and Reproductive Health and Rights unit, Institut national d'études démographiques (INED), Aubervilliers, France.,Centre for Population Change, University of Southampton, Southampton, UK
| | - Ann M Moore
- Ann M. Moore, Onikepe Owolabi, Melissa Stillman, Guttmacher Institute, New York, USA
| | - Onikepe Owolabi
- Ann M. Moore, Onikepe Owolabi, Melissa Stillman, Guttmacher Institute, New York, USA
| | - Melissa Stillman
- Ann M. Moore, Onikepe Owolabi, Melissa Stillman, Guttmacher Institute, New York, USA
| | - Adesegun Fatusi
- Adesegun Fatusi, Academy for Health Development (AHEAD), Ile-Ife, Nigeria.,University of Medical Sciences, Ondo, Ondo, Nigeria
| | - Akanni Akinyemi
- Akanni Akinyemi, Centre for Research, Evaluation Resources and Development (CRERD), Ile-Ife, Nigeria
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17
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Rodgers YVDM, Coast E, Lattof SR, Poss C, Moore B. The macroeconomics of abortion: A scoping review and analysis of the costs and outcomes. PLoS One 2021; 16:e0250692. [PMID: 33956826 PMCID: PMC8101771 DOI: 10.1371/journal.pone.0250692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/25/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although abortion is a common gynecological procedure around the globe, we lack synthesis of the known macroeconomic costs and outcomes of abortion care and abortion policies. This scoping review synthesizes the literature on the impact of abortion-related care and abortion policies on economic outcomes at the macroeconomic level (that is, for societies and nation states). METHODS AND FINDINGS Searches were conducted in eight electronic databases. We conducted the searches and application of inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined one of the following macroeconomic outcomes: costs, impacts, benefits, and/or value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 189 data extractions with macroeconomic evidence, costs at the national level are the most frequently reported economic outcome (n = 97), followed by impacts (n = 66), and benefits/value (n = 26). Findings show that post-abortion care services can constitute a substantial portion of national expenditures on health. Public sector coverage of abortion costs is sparse, and individuals bear most of the costs. Evidence also indicates that liberalizing abortion laws can have positive spillover effects for women's educational attainment and labor supply, and that access to abortion services contributes to improvements in children's human capital. However, the political economy around abortion legislation remains complicated and controversial. CONCLUSIONS Given the highly charged political nature of abortion around the global and the preponderance of rhetoric that can cloud reality in policy dialogues, it is imperative that social science researchers build the evidence base on the macroeconomic outcomes of abortion services and regulations.
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Affiliation(s)
- Yana van der Meulen Rodgers
- Department of Labor Studies and Employment Relations, Rutgers University, Piscataway, New Jersey, United States of America
- Department of Women’s and Gender Studies, Rutgers University, Piscataway, New Jersey, United States of America
| | - Ernestina Coast
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Cheri Poss
- Ipas, Chapel Hill, North Carolina, United States of America
| | - Brittany Moore
- Ipas, Chapel Hill, North Carolina, United States of America
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18
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Berro Pizzarossa L, Nandagiri R. Self-managed abortion: a constellation of actors, a cacophony of laws? Sex Reprod Health Matters 2021; 29:1899764. [PMID: 33764856 PMCID: PMC8009018 DOI: 10.1080/26410397.2021.1899764] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lucía Berro Pizzarossa
- Postdoctoral Fellow, O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC, USA
| | - Rishita Nandagiri
- ESRC Postdoctoral Fellow, Department of Methodology, London School of Economics and Political Science, London, UK
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19
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Garnsey C, Wollum A, Garduño Huerta S, Uribe OL, Keefe-Oates B, Baum SE. Factors influencing abortion decisions, delays, and experiences with abortion accompaniment in Mexico among women living outside Mexico City: results from a cross-sectional study. Sex Reprod Health Matters 2021; 29:2038359. [PMID: 35262471 PMCID: PMC8920378 DOI: 10.1080/26410397.2022.2038359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Access to abortion throughout much of Mexico has been restricted. Fondo Maria is an abortion accompaniment fund that provides informational, logistical, financial, and emotional support to people seeking abortion care in Mexico. This cross-sectional study examines the factors that influenced decision-making and contributed to delays in accessing care and explores experiences with Fondo Maria’s support among women living outside Mexico City (CDMX). We describe and compare the experiences of women across the sample (n = 103) who were either supported by Fondo Maria to travel to CDMX to obtain an abortion (n = 60), or self-managed a medical abortion in their home state (n = 43). Data were collected between January 2017 and July 2018. Seventy-seven percent of participants reported that it was difficult to access abortion care in their home state and 34% of participants indicated they were delayed in accessing care, primarily due to a lack of financial support. The majority of participants (58%) who travelled to CDMX for their abortion did so because it seemed safer. The money/cost of the trip was the most commonly cited reason (33%) why participants who self-managed stayed in their home state. Eighty-seven percent of participants said Fondo Maria’s services met or exceeded their expectations. Our data suggest that people seeking abortion and living outside CDMX face multiple and overlapping barriers that can delay care-seeking and influence decision-making. Abortion accompaniment networks, such as Fondo Maria, offer a well-received model of support for people seeking abortion in restrictive states across Mexico.
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Affiliation(s)
- Camille Garnsey
- Research Assistant, Ibis Reproductive Health, Cambridge MA & Oakland, CA, USA
| | - Alexandra Wollum
- Senior Associate Research Scientist, Ibis Reproductive Health, Cambridge MA & Oakland, CA, USA
| | | | | | - Brianna Keefe-Oates
- Senior Project Manager, Ibis Reproductive Health, Cambridge MA & Oakland, CA, USA
| | - Sarah E Baum
- Senior Research Scientist, Ibis Reproductive Health, Cambridge MA & Oakland, CA, USA
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20
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Lattof SR, Coast E, Rodgers YVDM, Moore B, Poss C. The mesoeconomics of abortion: A scoping review and analysis of the economic effects of abortion on health systems. PLoS One 2020; 15:e0237227. [PMID: 33147223 PMCID: PMC7641432 DOI: 10.1371/journal.pone.0237227] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/08/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite the high incidence of abortion around the globe, we lack synthesis of the known economic consequences of abortion care and abortion policies at the mesoeconomic level (i.e. health systems and communities). This scoping review examines the mesoeconomic costs, benefits, impacts, and values of abortion care and policies. METHODS AND FINDINGS Searches were conducted in eight electronic databases. We conducted the searches and application of inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined at least one of the following outcomes: costs, benefits, impacts, and value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 150 included mesoeconomic studies, costs to health systems are the most frequently reported mesoeconomic outcome (n = 116), followed by impacts (n = 40), benefits (n = 17), and values (n = 11). Within health facilities and health systems, the costs of providing abortion services vary greatly, particularly given the range with which researchers identify and cost services. Financial savings can be realized while maintaining or even improving quality of abortion services. Adapting to changing laws and policies is costly for health facilities. American policies on abortion economically impact health systems and facilities both domestically and abroad. Providing post-abortion care requires a disproportionate amount of health facility resources. CONCLUSIONS The evidence base has consolidated around abortion costs to health systems and health facilities in high-income countries more than in low- or middle-income countries. Little is known about the economic impacts of abortion on communities or the mesoeconomics of abortion in the Middle East and North Africa. Methodologically, review papers are the most frequent study type, indicating that researchers rely on evidence from a core set of costing papers. Studies generating new primary data on mesoeconomic outcomes are needed to strengthen the evidence base.
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Affiliation(s)
- Samantha R. Lattof
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Ernestina Coast
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Yana van der Meulen Rodgers
- Department of Labor Studies and Employment Relations, Rutgers University, Piscataway, New Jersey, United States of America
- Department of Women’s and Gender Studies, Rutgers University, Piscataway, New Jersey, United States of America
| | - Brittany Moore
- Ipas, Chapel Hill, North Carolina, United States of America
| | - Cheri Poss
- Ipas, Chapel Hill, North Carolina, United States of America
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21
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Moseson H, Jayaweera R, Raifman S, Keefe-Oates B, Filippa S, Motana R, Egwuatu I, Grosso B, Kristianingrum I, Nmezi S, Zurbriggen R, Gerdts C. Self-managed medication abortion outcomes: results from a prospective pilot study. Reprod Health 2020; 17:164. [PMID: 33109230 PMCID: PMC7588945 DOI: 10.1186/s12978-020-01016-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To evaluate the feasibility of conducting a prospective study to measure self-managed medication abortion outcomes, and to collect preliminary data on safety and effectiveness of self-managed medication abortion, we recruited callers to accompaniment groups (volunteer networks that provide counselling through the out-of-clinic medication abortion process by trained counselors over the phone or in-person). METHODS In 2019, we enrolled callers to three abortion accompaniment groups in three countries into a prospective study on the safety and effectiveness of self-managed medication abortion with accompaniment support. Participants completed up to five interview-administered questionnaires from baseline through 6-weeks after taking the pills. Primary outcomes included: (1) the number of participants enrolled in a 30-day period, (2) the proportion that had a complete abortion; and (3) the proportion who experienced any warning signs of potential or actual complications. RESULTS Over the 30-day recruitment period, we enrolled 227 participants (95% of those invited), and retained 204 participants (90%) for at least one study follow-up visit. At the 1-week follow-up, two participants (1%) reported a miscarriage prior to taking the pills, and 202 participants (89% of those enrolled and 99% of those who participated in the 1-week survey) had obtained and taken the medications. Three weeks after taking the medications, 192 (95%) participants reported feeling that their abortion was complete. Three (1.5%) received a surgical intervention, two (1%) received antibiotics, and five (3%) received other medications. Participants did not report any major adverse events. CONCLUSION These results establish the feasibility of conducting prospective studies of self-managed medication abortion in legally restrictive settings. Further, the high effectiveness of self-managed medication abortion with accompaniment support reported here is consistent with high levels of effectiveness reported in prior studies. Trial registration ISRCTN95769543.
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Affiliation(s)
- Heidi Moseson
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA.
| | - Ruvani Jayaweera
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA
| | - Sarah Raifman
- Department of Epidemiology and Biostatistics, University of California, San Francisco, USA
| | | | - Sofia Filippa
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA
| | | | - Ijeoma Egwuatu
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | - Belen Grosso
- La Revuelta Colectiva Feminista, Neuquén, Argentina
| | | | - Sybil Nmezi
- Generation Initiative for Women and Youth, Lagos, Nigeria
| | | | - Caitlin Gerdts
- Ibis Reproductive Health, 1736 Franklin Street, Suite 600, Oakland, CA, 94612, USA
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22
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Solheim IH, Moland KM, Kahabuka C, Pembe AB, Blystad A. Beyond the law: Misoprostol and medical abortion in Dar es Salaam, Tanzania. Soc Sci Med 2019; 245:112676. [PMID: 31810016 DOI: 10.1016/j.socscimed.2019.112676] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 10/25/2022]
Abstract
Misoprostol has during the past few years become an important obstetric drug used for different purposes both within and outside hospitals in Tanzania. In this paper, we analyze how misoprostol is perceived, accessed and used off-label as an abortion drug in the city and region of Dar es Salaam. The study took place in Dar es Salaam's three districts from July to November 2015, and had a qualitative explorative approach. We carried out in-depth interviews (42) with the following main categories of informants: women having undergone medical abortion (15), health care workers with experiences from post abortion care (16) and drug vendors (11). Focus group discussions (10) were carried out with young women. A client simulation study was carried out in 64 drugstores across Dar es Salaam assessing the availability of misoprostol and the advice given concerning its use. In addition, shorter qualitative interviews were carried out with representatives of NGOs and public agencies working with sexual and reproductive health issues (17). Our findings reveal that in Dar es Salaam, misoprostol is well known, available and accessed for abortion purposes through drugstores and health providers. Women tend to prefer misoprostol over other abortion methods since it allows for a private, low-cost, safer and less uncomfortable abortion experience. But, while misoprostol facilitates women's agency in the process of seeking abortion, a series of obstacles shaped by a restrictive abortion law and an unregulated pharmaceutical market hinder its safe use. Central obstacles are profit-seeking providers, suboptimal user instructions and poor provider follow-up. In the discussion of the material we draw upon Van der Geest, Hardon and Whyte's concept of the 'social life of pharmaceuticals' and indicate the ways in which misoprostol acts as an agent of change in the social relations connected to abortion.
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Affiliation(s)
- I H Solheim
- Global Health Anthropology Research Group at the Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen (UiB), Norway.
| | - K M Moland
- Global Health Anthropology Research Group at the Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen (UiB), Norway; Centre for Intervention Science in Maternal and Child Health (CISMAC), UiB, Norway
| | - C Kahabuka
- CSK Research Solutions, Dar es Salaam, Tanzania
| | - A B Pembe
- Muhimbili University of Health and Associated Sciences, Dar es Salaam, Tanzania
| | - A Blystad
- Global Health Anthropology Research Group at the Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen (UiB), Norway; Centre for Intervention Science in Maternal and Child Health (CISMAC), UiB, Norway
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23
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Endler M, Cleeve A, Gemzell-Danielsson K. Online access to abortion medications: a review of utilization and clinical outcomes. Best Pract Res Clin Obstet Gynaecol 2019; 63:74-86. [PMID: 31383555 DOI: 10.1016/j.bpobgyn.2019.06.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 11/25/2022]
Abstract
We performed a search in PubMed and Web of Science on the self-use of abortion medication after online access. Studies published between January 1, 1995, and March 31, 2019, were considered. We included studies of online services that were (i) led by healthcare staff (n = 14), (ii) led by non-healthcare staff (n = 4), and (iii) providing noninteractive access (n = 17). Our outcomes were utilization (frequency and demand for services), acceptability for women, safety, and success rate. Key findings: Women are increasingly using the Internet to access abortion medication. Available services are of varying quality. Women accessing noninteractive services report feelings of distress related to the lack of medical guidance, and the demand for interactive guidance through the abortion process is high. Women using services led by healthcare staff report high rates of satisfaction and similar rates of clinical outcomes as those of in-person abortion care.
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Affiliation(s)
- Margit Endler
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Tomtebodavägen 18b, 171 77 Stockholm, Sweden; Department of Public Health, and Women's Health Research Unit, University of Cape Town, Falmouth Road, 7950 Cape Town, South Africa.
| | - Amanda Cleeve
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Tomtebodavägen 18b, 171 77 Stockholm, Sweden
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Tomtebodavägen 18b, 171 77 Stockholm, Sweden
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Sheldon WR, Durocher J, Dzuba IG, Sayette H, Martin R, Velasco MC, Winikoff B. Early abortion with buccal versus sublingual misoprostol alone: a multicenter, randomized trial. Contraception 2019; 99:272-277. [DOI: 10.1016/j.contraception.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 02/07/2019] [Accepted: 02/13/2019] [Indexed: 11/28/2022]
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Latt SM, Milner A, Kavanagh A. Abortion laws reform may reduce maternal mortality: an ecological study in 162 countries. BMC Womens Health 2019; 19:1. [PMID: 30611257 PMCID: PMC6321671 DOI: 10.1186/s12905-018-0705-y] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 12/25/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Unsafe abortion is one of the commonest causes of maternal mortality. Abortion-related maternal deaths are higher in countries with the most restrictive abortion laws. We assess whether maternal mortality varies within and between countries over time according to the flexibility of abortion laws (the number of reasons a woman can have an abortion). METHOD We conducted an ecological study to assess the association between abortion laws and maternal mortality in 162 countries between 1985 and 2013. Aggregate-level data on abortion laws and maternal mortality were extracted from United Nations (UN), and World Health Organization's (WHO) database respectively. A flexibility score of abortion laws (Score 0-7) was calculated by summing the number of reasons for which abortion was legally allowed in each country. The outcome was maternal mortality ratio (MMR), which represented maternal deaths per 100,000 live births. MMR was modelled as a continuous variable and flexibility score as an ordinal ranked variable (categories 0-7 with 0 as the reference, and < 3 vs > = 3). We used fixed effects linear regression models to estimate the association between flexibility score and MMR, adjusting for gross domestic product per capita (GDP per capita), and time in five-year intervals. RESULTS Compared to when a country's flexibility score was < 3, maternal deaths were reduced by 45 per 100,000 live births (95% CI: -64, - 26) when the flexibility score increased ≥3, after adjusting for the GDP per capita and five-year time intervals. With the exception of a flexibility score 6, MMR was lower when higher than zero. This may indicate the role of other country- specific effects. CONCLUSION This study provides evidence that abortion law reform in countries with restricted abortion laws may reduce maternal mortality.
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Affiliation(s)
- Su Mon Latt
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Allison Milner
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Anne Kavanagh
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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26
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Mutua MM, Manderson L, Musenge E, Achia TNO. Policy, law and post-abortion care services in Kenya. PLoS One 2018; 13:e0204240. [PMID: 30240408 PMCID: PMC6150499 DOI: 10.1371/journal.pone.0204240] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 08/14/2018] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Unsafe abortion is still a leading cause of maternal death in most Sub-Saharan African countries. Post-abortion care (PAC) aims to minimize morbidity and mortality following unsafe abortion, addressing incomplete abortion by treating complications, and reducing possible future unwanted pregnancies by providing contraceptive advice. In this article, we draw on data from PAC service providers and patients in Kenya to illustrate how the quality of PAC in healthcare facilities is impacted by law and government policy. METHODS A cross-sectional design was used for this study, with in-depth interviews conducted to collect qualitative data from PAC service providers and seekers in healthcare facilities. Data were analyzed both deductively and inductively, with diverse sub-themes related to specific components of PAC quality. RESULTS The provision of quality PAC in healthcare facilities in Kenya is still low, with access hindered by restrictions on abortion. Negative attitudes towards abortion result in the continued undirected self-administration of abortifacients. Intermittent service interruptions through industrial strikes and inequitable access to care also drive unsafe terminations. Poor PAC service availability and lack of capacity to manage complications in primary care facilities result in multiple referrals and delays in care following abortion, leading to further complications. Inefficient infection control exposes patients and caregivers to unrelated infections within facilities, and the adequate provision of contraception is a continued challenge. DISCUSSION Legal, policy and cultural restrictions to access PAC increase the level of complications. In Kenya, there is limited policy focus on PAC, especially at primary care level, and no guidelines for health providers to provide legal, safe abortion. Discrimination at the point of care discourages women from presenting for care, and discourages providers from freely offering post-abortion contraceptive guidance and services. Poor communication between facilities and communities continues to result in delayed care and access-related discrimination. CONCLUSION Greater emphasis should be placed on the prevention of unsafe abortion and improved access to post-abortion care services in healthcare facilities. There is a definite need for service guidelines for this to occur.
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Affiliation(s)
- Michael Mbithi Mutua
- African Population and Health Research Center (APHRC), Nairobi, Kenya
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Lenore Manderson
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Institute at Brown for Environment & Society (IBES), Brown University, Providence, Rhode Island, United States of America
| | - Eustasius Musenge
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Thomas Noel Ochieng Achia
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Centers for Disease Control and Prevention, Nairobi, Kenya
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27
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Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, Coll-Seck AM, Grover A, Laski L, Roa M, Sathar ZA, Say L, Serour GI, Singh S, Stenberg K, Temmerman M, Biddlecom A, Popinchalk A, Summers C, Ashford LS. Accelerate progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission. Lancet 2018; 391:2642-2692. [PMID: 29753597 DOI: 10.1016/s0140-6736(18)30293-9] [Citation(s) in RCA: 480] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/02/2018] [Accepted: 02/08/2018] [Indexed: 01/10/2023]
Affiliation(s)
| | - Alex C Ezeh
- African Population and Health Research Center, Nairobi, Kenya; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Center for Global Development, Washington, DC, USA
| | | | - Alaka Basu
- Department of Development Sociology, Cornell University, Ithaca, NY, USA
| | - Jane T Bertrand
- Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Robert Blum
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Monica Roa
- Independent Consultant, Islamabad, Pakistan
| | | | - Lale Say
- World Health Organization, Geneva, Switzerland
| | - Gamal I Serour
- International Islamic Center For Population Studies And Research, Al Azhar University, Cairo, Egypt
| | | | | | - Marleen Temmerman
- Department of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya
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Ganatra B, Gerdts C, Rossier C, Johnson BR, Tunçalp Ö, Assifi A, Sedgh G, Singh S, Bankole A, Popinchalk A, Bearak J, Kang Z, Alkema L. Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model. Lancet 2017; 390:2372-2381. [PMID: 28964589 PMCID: PMC5711001 DOI: 10.1016/s0140-6736(17)31794-4] [Citation(s) in RCA: 427] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/30/2017] [Accepted: 06/06/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Global estimates of unsafe abortions have been produced for 1995, 2003, and 2008. However, reconceptualisation of the framework and methods for estimating abortion safety is needed owing to the increased availability of simple methods for safe abortion (eg, medical abortion), the increasingly widespread use of misoprostol outside formal health systems in contexts where abortion is legally restricted, and the need to account for the multiple factors that affect abortion safety. METHODS We used all available empirical data on abortion methods, providers, and settings, and factors affecting safety as covariates within a Bayesian hierarchical model to estimate the global, regional, and subregional distributions of abortion by safety categories. We used a three-tiered categorisation based on the WHO definition of unsafe abortion and WHO guidelines on safe abortion to categorise abortions as safe or unsafe and to further divide unsafe abortions into two categories of less safe and least safe. FINDINGS Of the 55· 7 million abortions that occurred worldwide each year between 2010-14, we estimated that 30·6 million (54·9%, 90% uncertainty interval 49·9-59·4) were safe, 17·1 million (30·7%, 25·5-35·6) were less safe, and 8·0 million (14·4%, 11·5-18·1) were least safe. Thus, 25·1 million (45·1%, 40·6-50·1) abortions each year between 2010 and 2014 were unsafe, with 24·3 million (97%) of these in developing countries. The proportion of unsafe abortions was significantly higher in developing countries than developed countries (49·5% vs 12·5%). When grouped by the legal status of abortion, the proportion of unsafe abortions was significantly higher in countries with highly restrictive abortion laws than in those with less restrictive laws. INTERPRETATION Increased efforts are needed, especially in developing countries, to ensure access to safe abortion. The paucity of empirical data is a limitation of these findings. Improved in-country data for health services and innovative research to address these gaps are needed to improve future estimates. FUNDING UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction; David and Lucile Packard Foundation; UK Aid from the UK Government; Dutch Ministry of Foreign Affairs; Norwegian Agency for Development Cooperation.
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Affiliation(s)
- Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland.
| | | | - Clémentine Rossier
- University of Geneva, Geneva, Switzerland; Institut National d'Etudes Démographiques, Paris, France
| | - Brooke Ronald Johnson
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Anisa Assifi
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
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Palma Manríquez I, Moreno Standen C, Álvarez Carimoney A, Richards A. Experience of clandestine use of medical abortion among university students in Chile: a qualitative study. Contraception 2017; 97:100-107. [PMID: 28947389 DOI: 10.1016/j.contraception.2017.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 09/11/2017] [Accepted: 09/17/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To explore the ways in which medical abortion pills are obtained and used by university students in Chile in a clandestine context. STUDY DESIGN Using a qualitative approach, we conducted in-depth interviews with 30 young women who had had a medical abortion between 2006 and 2016 while attending university. We recorded the details of their pathways to abortion and their experience of abortion, and how they used networks in the university to find the pills and learn how to use them. The interviews were analyzed using narrative content analysis. RESULTS The findings show that medical abortion did not take place completely outside the healthcare system for these students, who accessed ultrasound scans pre- and post-abortion and post-abortion care. However, even with help and support from contacts, partners and friends, the clandestine situation created uncertainty and fear, which dominated the whole process, from finding and purchasing the pills, to uncertainty about correct doses and whether the abortion was going as it should and was complete or not. There was a high perception that failure and complications might be occurring, which led many of them to seek post-abortion care. The process was very demanding, requiring information, time, privacy to have the abortion, support and resources, and the ability to deal with risk. CONCLUSIONS Medical abortion allowed these young women to have safe abortions in terms of reduced risks to health and autonomy through self-management. However, clandestinity made them physically, socially and emotionally vulnerable and exposed them to the risk of normative, violent judgments during post-abortion care. IMPLICATIONS Access to medical abortion has transformed the experience of abortion in Chile, where abortion is illegal, because it is possible to use it safely and effectively outside healthcare settings. However, uncertainty, fear and risk will continue to dominate the experience, which can only be transformed by making abortion legal and available.
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Affiliation(s)
- Irma Palma Manríquez
- Facultad de Ciencias Sociales, Universidad de Chile, Avda. Capitán Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile
| | - Claudia Moreno Standen
- Facultad de Ciencias Sociales, Universidad de Chile, Avda. Capitán Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile.
| | - Andrea Álvarez Carimoney
- Facultad de Ciencias Sociales, Universidad de Chile, Avda. Capitán Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile
| | - Alondra Richards
- Facultad de Ciencias Sociales, Universidad de Chile, Avda. Capitán Ignacio Carrera Pinto 1045, Ñuñoa, 7800284, Santiago, Chile
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30
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Kapp N, Blanchard K, Coast E, Ganatra B, Harries J, Footman K, Moore A, Owolabi O, Rossier C, Shellenberg K, Wahlin B, Woodsong C. Developing a forward-looking agenda and methodologies for research of self-use of medical abortion. Contraception 2017; 97:184-188. [PMID: 28935218 DOI: 10.1016/j.contraception.2017.09.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 09/04/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
Affiliation(s)
| | | | | | - Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Jane Harries
- University of Cape Town, Cape Town, South Africa
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31
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Zurbriggen R, Keefe-Oates B, Gerdts C. Accompaniment of second-trimester abortions: the model of the feminist Socorrista network of Argentina. Contraception 2017; 97:108-115. [PMID: 28801052 DOI: 10.1016/j.contraception.2017.07.170] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 07/02/2017] [Accepted: 07/29/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Legal restrictions on abortion access impact the safety and timing of abortion. Women affected by these laws face barriers to safe care that often result in abortion being delayed. Second-trimester abortion affects vulnerable groups of women disproportionately and is often more difficult to access. In Argentina, where abortion is legally restricted except in cases of rape or threat to the health of the woman, the Socorristas en Red, a feminist network, offers a model of accompaniment wherein they provide information and support to women seeking second-trimester abortions. This qualitative analysis aimed to understand Socorristas' experiences supporting women who have second-trimester medication abortion outside the formal health care system. STUDY DESIGN We conducted 2 focus groups with 16 Socorristas in total to understand experiences accompanying women having second-trimester medication abortion who were at 14-24 weeks' gestational age. We performed a thematic analysis of the data and present key themes in this article. RESULTS The Socorristas strived to ensure that women had the power of choice in every step of their abortion. These cases required more attention and logistical, legal and medical risks than first-trimester care. The Socorristas learned how to help women manage the possibility of these risks and were comfortable providing this support. They understood their work as activism through which they aim to destigmatize abortion and advocate against patriarchal systems denying the right to abortion. CONCLUSION Socorrista groups have shown that they can provide supportive, women-centered accompaniment during second-trimester medication abortions outside the formal health care system in a setting where abortion access is legally restricted. IMPLICATIONS Second-trimester self-use of medication abortion outside of the formal health system supported by feminist activist groups could provide an alternative model for second-trimester care worldwide. More research is needed to document the safety and effectiveness of this accompaniment service-provision model.
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Affiliation(s)
| | - Brianna Keefe-Oates
- Ibis Reproductive Health, 1330 Broadway Street, Suite 1100, Oakland, CA 94612, USA.
| | - Caitlin Gerdts
- Ibis Reproductive Health, 1330 Broadway Street, Suite 1100, Oakland, CA 94612, USA.
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32
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Putting abortion pills into women's hands: realizing the full potential of medical abortion. Contraception 2017; 97:86-89. [PMID: 28780241 DOI: 10.1016/j.contraception.2017.05.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/04/2017] [Accepted: 05/29/2017] [Indexed: 11/23/2022]
Abstract
The promise of medical abortion to both reduce maternal mortality and morbidity from unsafe abortion and to expand the reproductive rights of women can only be realized if information and reliable medicines are available to all women, regardless of their location or the restrictions of their legal system. Activist strategies to actualize the full potential of abortion pills are highlighted.
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33
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Ortiz-Prado E, Simbaña K, Gómez L, Stewart-Ibarra AM, Scott L, Cevallos-Sierra G. Abortion, an increasing public health concern in Ecuador, a 10-year population-based analysis. Pragmat Obs Res 2017; 8:129-135. [PMID: 28761387 PMCID: PMC5516879 DOI: 10.2147/por.s129464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES To describe the epidemiology of abortion in Ecuador from 2004 to 2014 and compare the prevalence between the public and the private health care systems. METHODS This is a cross-sectional analysis of the overall mortality and morbidity rate due to abortion in Ecuador, based on public health records and other government databases. RESULTS From 2004 to 2014, a total of 431,614 spontaneous abortions, miscarriage and other types of abortions were registered in Ecuador. The average annual rate of abortion was 115 per 1,000 live births. The maternal mortality rate was found to be 43 per 100,000 live births. CONCLUSIONS Abortion is a significant and wide-ranging problem in Ecuador. The study supports the perception that in spite of legal restrictions to abortion in Ecuador, women are still terminating pregnancies when they feel they need to do so. The public health system reported >84% of the national overall prevalence.
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Affiliation(s)
- Esteban Ortiz-Prado
- OneHealth Research Group, Faculty of Medicine, Universidad De Las Americas, Quito, Ecuador.,Department of Cellular Biology, Physiology and Immunology, Institute of Biomedicine, Universitat de Barcelona, Spain.,Department of Physiology, Faculty of Medicine "Eugenio Espejo", Universidad Tecnologica Equinoccial, Quito, Ecuador.,Department of Medicine, College of Medicine
| | - Katherine Simbaña
- Center for Global Health and Translational Science, Upstate Medical University, State University of New York, Syracuse, NY, USA.,Faculty of Medical Science, School of Medicine, Universidad Central del Ecuador
| | - Lenin Gómez
- Center for Global Health and Translational Science, Upstate Medical University, State University of New York, Syracuse, NY, USA.,Faculty of Medical Science, School of Medicine, Universidad Central del Ecuador
| | - Anna M Stewart-Ibarra
- Department of Medicine, College of Medicine.,Prometeo Program, SENESCYT, Quito, Ecuador
| | - Lisa Scott
- Graduate College of Biomedical Sciences, Western University of Health Sciences, Lebanon, OR, USA
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34
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Kapp N, Grossman D, Jackson E, Castleman L, Brahmi D. A research agenda for moving early medical pregnancy termination over the counter. BJOG 2017; 124:1646-1652. [PMID: 28317327 PMCID: PMC5637897 DOI: 10.1111/1471-0528.14646] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2017] [Indexed: 11/30/2022]
Abstract
Given the overall safety profile and increasing availability of medical pregnancy termination drugs, we asked: would the mifepristone-misoprostol regimen for medical termination at ≤10 weeks of gestation meet US Food and Drug Administration regulatory criteria for over-the-counter (OTC) approval, and if not, what are the present research gaps? We conducted a literature review of consumer behaviours necessary for a successful OTC application for medical termination at ≤10 weeks of gestation and identified crucial research gaps. If we were to embark on a development programme for OTC or more generally, self-use of medical termination, the critical elements missing are the label comprehension, self-selection and actual use studies. TWEETABLE ABSTRACT Considering medical pregnancy termination through the over-the-counter regulatory lens clarifies critical evidence gaps.
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Affiliation(s)
- N Kapp
- Ipas, Chapel Hill, NC, USA
| | - D Grossman
- Advancing New Standards in Reproductive Health (ANSIRH), Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, CA, USA
| | - E Jackson
- Independent Consultant, Los Angeles, CA, USA
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Kahabuka C, Pembe A, Meglioli A. Provision of harm-reduction services to limit unsafe abortion in Tanzania. Int J Gynaecol Obstet 2016; 136:210-214. [PMID: 28099731 DOI: 10.1002/ijgo.12035] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/19/2016] [Accepted: 11/03/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate the feasibility of providing harm-reduction services to reduce unsafe abortion in Tanzania. METHODS A cross-sectional study was conducted among 110 women who received harm-reduction counseling at a public health center in Dar es Salaam between February 10 and October 10, 2014. Background and clinical information was collected for all women; a subgroup (n=50) undertook a semi-structured survey that measured the type of services women received, women's perception of the services, and pregnancy outcome. The main study outcomes were attendance at the follow-up visit, type and quality of information women received on both visits, and misoprostol use for pregnancy termination. RESULTS Overall, 55 (50.0%) women attended follow-up services. Misoprostol was used for induced abortion among 54 (98.2%); 38 (70.4%) of these women had obtained contraception at the follow-up visit. Likelihood of attendance for follow-up was increased among women who were older than 34 years (odds ratio [OR] 2.2, 95% confidence interval [CI] 0.1-35.8), were married (OR 2.1, 95% CI 0.8-5.7), and had a post-primary education level (OR 2.0, 95% CI 0.8-5.3). On average, 44 (87.0%) women received all required information at the initial counseling session and none reported major complications that required hospitalization. CONCLUSION Harm-reduction services for unsafe abortion are feasible and acceptable, and could provide an excellent opportunity to fight abortion-related morbidity and mortality in Tanzania.
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Affiliation(s)
| | - Andrea Pembe
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Alejandra Meglioli
- International Planned Parenthood Federation/Western Hemisphere Region, New York, NY, USA
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36
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Role of birth spacing, family planning services, safe abortion services and post-abortion care in reducing maternal mortality. Best Pract Res Clin Obstet Gynaecol 2016; 36:145-155. [PMID: 27640082 DOI: 10.1016/j.bpobgyn.2016.07.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 07/27/2016] [Indexed: 11/20/2022]
Abstract
Access to contraception reduces maternal deaths by preventing or delaying pregnancy in women who do not intend to be pregnant or those at higher risk of complications. However, not all unintended pregnancies can be prevented through increase in contraceptive use, and access to safe abortion is needed to prevent unsafe abortions. Despite not preventing the problem, provision of emergency care for complications can help prevent deaths from such unsafe abortions. Safe abortion in early pregnancy can be provided at primary care level and by non-physician providers, and the risks of mortality associated with such safe, legal abortions are minimal. Although entirely preventable, unsafe abortions continue to occur because of numerous barriers such as legal and policy restrictions, service delivery issues and provider attitudes to abortion stigma. Overall, the provision of contraception and safe abortion is important not just to prevent maternal deaths but as a measure of our ability to respect women's decisions and ensure that they have access to timely, evidence-based care that protects their health and human rights.
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37
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Rouhani SA, Scott J, Burkhardt G, Onyango MA, Haider S, Greiner A, Albutt K, VanRooyen M, Bartels SA. A quantitative assessment of termination of sexual violence-related pregnancies in eastern Democratic Republic of Congo. Confl Health 2016; 10:9. [PMID: 27053946 PMCID: PMC4822240 DOI: 10.1186/s13031-016-0073-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 02/19/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Sexual violence is prevalent in eastern Democratic Republic of Congo (DRC), and has resulted in sexual violence-related pregnancies (SVRPs). Despite restrictive laws, women may seek to terminate SVRPs; however, there are limited data on termination of SVRPs. METHODS A mixed methods study was conducted in 2012 in Bukavu, DRC. Adult women who self-reported an SVRP and termination of that SVRP were recruited using respondent-driven sampling (RDS). Trained female interviewers verbally administered a quantitative survey to all participants and a semi-structured qualitative survey to a subset. Quantitative data on characteristics and complications of pregnancy termination, including mental health outcomes, were analyzed using SAS. RESULTS In total, 86 women completed quantitative surveys. Most SVRPs (93 %) involved two or more assailants; 73 % occurred while in captivity. Most women (82 %) terminated the SVRPs at 3 months gestation or earlier; 79 % reported one attempt at pregnancy termination and 21 % more than one attempt. The most common methods of termination were an oral medicine (55 %) or herb (35 %); cimpokolo (31 %) and quinine (18 %) were most frequently reported. These methods were accessed through friends (37 %), healthcare providers (18 %), family (16 %), or self-obtained (12 %). Following the termination, 79 % of women reported subsequent physical symptoms, including abdominal pain (74 %), bleeding (47 %), vaginal discharge (35 %) and fever (18 %); 44 % sought medical care for their symptoms. Varied emotional responses to the termination were reported and included relief (34 %), anxiety (21 %), anger (19 %), guilt (19 %), and regret (10 %). At the time of the study, many women met symptom criteria for post-traumatic stress disorder (57 %), depression (50 %), and generalized anxiety disorder (33 %). CONCLUSION Most women terminated SVRPs using medications or herbs not recognized as evidence-based methods of pregnancy termination and sought these methods outside of the formal healthcare sector. These data suggest that access to safe abortion methods is needed for women with SVRPs in DRC. Physical symptoms and emotional reactions related to the termination varied. While it is not possible to differentiate the impacts of sexual violence, SVRP, and pregnancy termination on mental health outcomes, the findings highlight the complex needs of women with SVRPs and opportunities for integrative health services.
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Affiliation(s)
- Shada A. Rouhani
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA USA
- />Harvard Medical School, Boston, MA USA
| | - Jennifer Scott
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Harvard Medical School, Boston, MA USA
- />Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA USA
- />Division of Women’s Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Gillian Burkhardt
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA USA
| | - Monica A. Onyango
- />Department of Global Health, Boston University School of Public Health, Boston, MA USA
| | - Sadia Haider
- />Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, USA
| | - Ashley Greiner
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Harvard Medical School, Boston, MA USA
- />Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Katherine Albutt
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Harvard Medical School, Boston, MA USA
- />Department of Surgery, Massachusetts General Hospital, Boston, MA USA
| | - Michael VanRooyen
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA USA
- />Harvard Medical School, Boston, MA USA
- />Harvard School of Public Health, Boston, MA USA
| | - Susan A. Bartels
- />Harvard Humanitarian Initiative, Cambridge, MA USA
- />Harvard Medical School, Boston, MA USA
- />Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA
- />Department of Emergency Medicine, Queen’s University, Kingston, Canada
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Mark AG, Wolf M, Edelman A, Castleman L. What can obstetrician/gynecologists do to support abortion access? Int J Gynaecol Obstet 2015; 131 Suppl 1:S53-5. [PMID: 26433507 DOI: 10.1016/j.ijgo.2015.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Unsafe abortion causes approximately 13% of all maternal deaths worldwide, with higher rates in areas where abortion access is restricted. Because safe abortion is so low risk, if all women who needed an abortion could access safe care, this rate would drop dramatically. As women's health providers and advocates, obstetrician/gynecologists can support abortion access. By delivering high-quality, evidence-based care ourselves, supporting other providers who perform abortion, helping women who access abortion in the community, providing second-trimester care, and improving contraceptive uptake, we can decrease morbidity and mortality from unsafe abortion.
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Affiliation(s)
| | | | - Alison Edelman
- Ipas, Chapel Hill, NC, USA; Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
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Larrea S, Palència L, Perez G. [Medical abortion provided by telemedicine to women in Latin America: complications and their treatment]. GACETA SANITARIA 2015; 29:198-204. [PMID: 25770915 DOI: 10.1016/j.gaceta.2015.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 01/30/2015] [Accepted: 02/04/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To analyze reported complications and their treatment after a medical abortion with mifepristone and misoprostol provided by a telemedicine service to women living in Latin America. METHODS Observational study based on the registry of consultations in a telemedicine service. A total of 872 women who used the service in 2010 and 2011 participated in the study. The dependent variables were overall complications, hemorrhage, incomplete abortion, overall treatments, surgical evacuation, and antibiotics. Independent variables were age, area of residence, socioeconomic deprivation, previous children, pregnancies and abortions, and week of pregnancy. We fitted Poisson regression models with robust variance to estimate incidence ratios and 95% confidence intervals (95%CI). RESULTS Complications were reported by 14.6% of the participants: 6.2% reported hemorrhage and 6.8% incomplete abortion. Nearly one-fifth (19.0%) received postabortion treatment: 10.9% had a surgical evacuation and 9.3% took antibiotics. Socioeconomic deprivation increased the risk of complications by 64% (95%CI: 15%-132%), and, among these, the risk of incomplete abortion by 82% (95%CI: 8%-206%) and the risk of surgical intervention by 62% (95%CI: 7%-144%). Previous pregnancies increased the risk of complications and, specifically, the risk of hemorrhage by 2.29 times (95%CI: 1.33-3.95%). Women with a pregnancy of 12 or more weeks had a 2.45 times higher risk of receiving medical treatment and a 2.94 times higher risk of taking antibiotics compared with women with pregnancies of 7 or less weeks. CONCLUSION Medical abortion provided by telemedicine seems to be a safe and effective alternative in contexts where it is legally restricted.
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Affiliation(s)
- Sara Larrea
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, España
| | - Laia Palència
- CIBER de Epidemiología y Salud Pública (CIBERESP), España; Agència de Salut Pública de Barcelona, Barcelona, España
| | - Glòria Perez
- Departament de Ciències Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, España; CIBER de Epidemiología y Salud Pública (CIBERESP), España; Agència de Salut Pública de Barcelona, Barcelona, España.
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Snow RC, Laski L, Mutumba M. Sexual and reproductive health: progress and outstanding needs. Glob Public Health 2015; 10:149-73. [PMID: 25555027 PMCID: PMC4318113 DOI: 10.1080/17441692.2014.986178] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 11/06/2014] [Indexed: 10/25/2022]
Abstract
We examine progress towards the 1994 International Conference on Population and Development (ICPD) commitment to provide universal access to sexual and reproductive health (SRH) services by 2014, with an emphasis on changes for those living in poor and emerging economies. Accomplishments include a 45% decline in the maternal mortality ratio (MMR) between 1990 and 2013; 11.5% decline in global unmet need for modern contraception; ~21% increase in skilled birth attendance; and declines in both the case fatality rate and rate of abortion. Yet aggregate gains mask stark inequalities, with low coverage of services for the poorest women. Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 80 developing countries highlight persistent disparities in skilled birth attendance by household wealth: in 70 of 80 countries (88%), ≥80% of women in the highest quintile were attended by a skilled provider at last birth; in only 23 of the same countries (29%) was this the case for women in the lowest wealth quintile. While there have been notable declines in HIV incidence and prevalence, women affected by HIV are too often bereft of other SRH services, including family planning. Achieving universal access to SRH will require substantially greater investment in comprehensive and integrated services that reach the poor.
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Affiliation(s)
- Rachel C. Snow
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Laura Laski
- Sexual and Reproductive Health Branch, UNFPA, New York, NY, USA
| | - Massy Mutumba
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
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