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Rakereng TM, Dikgole KS, Maribe LS, Speciale AM, Lavelanet A. Assessment of unintended pregnancies, contraception, and abortion in Botswana. Int J Gynaecol Obstet 2024; 164 Suppl 1:51-60. [PMID: 38360030 DOI: 10.1002/ijgo.15336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Botswana has a policy of contraception for all that is delivered through a rights-based family planning program. The program combines a "rights-based family planning approach" with "supportive policies for contraception," and "a commitment to promote equitable access to modern contraception, and expand availability, method mix and uptake of modern contraceptive methods for all women and girls." However, abortion is legally restricted up to 16 weeks of pregnancy provided that provisions of Section 160-162 of the Botswana Penal Code Amendment Act 1991 are met, and that the termination of pregnancy is carried out by a registered medical practitioner in a health facility approved for the purpose. In 2020, the Ministry of Health and Wellness, Botswana, in collaboration with United Nations Population Fund and World Health Organization, conducted a strategic assessment of unintended pregnancies, contraception, unsafe abortion, and abortion services in Botswana. A consensus operational plan to address these issues was developed during a national stakeholder meeting in Gaborone, Botswana. The consensus reached was to avert unintended pregnancies, improve access to modern contraception, and open nationwide discussions around abortion in the community to enable positive change and decrease maternal morbidity and mortality from unsafe abortion. This article describes the findings of the assessment and outlines the foundation for new or modified services or practices to be developed and pilot tested.
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Affiliation(s)
| | | | | | | | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research and 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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Smith H, Wojcieszek AM, Gupta S, Lavelanet A, Nihlén Å, Portela A, Schaaf M, Stahlhofer M, Tunçalp Ö, Bonet M. Integrating international policy standards in the implementation of postnatal care: a rapid review. BMJ Glob Health 2024; 8:e014033. [PMID: 38267069 PMCID: PMC10846851 DOI: 10.1136/bmjgh-2023-014033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/06/2023] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION International legal and political documents can assist policy-makers and programme managers in countries to create an enabling environment to promote maternal and newborn health. This review aimed to map and summarise international legal and political documents relevant to the implementation of the WHO recommendations on maternal and newborn care for a positive postnatal experience. METHODS Rapid review of relevant international legal and political documents, including legal and political commitments (declarations, resolutions and treaties) and interpretations (general comments, recommendations from United Nations human rights treaty bodies, joint United Nations statements). Documents were mapped to the domains presented in the WHO postnatal care (PNC) recommendations; relating to maternal care, newborn care, and health systems and health promotion interventions, and by type of human right implied and/or stated in the documents. RESULTS Twenty-nine documents describing international legal and political commitments and interpretations were mapped, out of 45 documents captured. These 29 documents, published or entered into force between 1944 and 2020, contained content relevant to most of the domains of the PNC recommendations, most prominently the domains of breastfeeding and health systems interventions and service delivery arrangements. The most frequently mapped human rights were the right to health and the right to social security. CONCLUSION Existing international legal and political documents can inform and encourage policy and programme development at the country level, to create an enabling environment during the postnatal period and thereby support the provision and uptake of PNC and improve health outcomes for women, newborns, children and families. Governments and civil society organisations should be aware of these documents to support efforts to protect and promote maternal and newborn health.
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Affiliation(s)
- Helen Smith
- International Health Consulting Services Ltd, Liverpool, UK
| | - Aleena M Wojcieszek
- Department of Sexual and Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
- Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Shuchita Gupta
- Department of Maternal, Newborn, Child and Adolescent and Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Åsa Nihlén
- Department of Sexual and Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Anayda Portela
- Department of Maternal, Newborn, Child and Adolescent and Health and Ageing, World Health Organization, Geneva, Switzerland
| | | | - Marcus Stahlhofer
- Department of Maternal, Newborn, Child and Adolescent and Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Özge Tunçalp
- Department of Sexual and Reproductive Health and Research including UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Mercedes Bonet
- Department of Sexual and Reproductive Health and Research including 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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Gialdini C, Ramón Michel A, Romero M, Ramos S, Carroli G, Carroli B, Gomez Ponce de León R, Vila Ortiz M, Lavelanet A. Multicountry research on comprehensive abortion policy implementation in Latin America: a mixed-methods study protocol. BMJ Open 2024; 14:e073617. [PMID: 38245008 PMCID: PMC10806677 DOI: 10.1136/bmjopen-2023-073617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 01/08/2024] [Indexed: 01/22/2024] Open
Abstract
INTRODUCTION Access to comprehensive abortion care could prevent the death of between 13 865 and 38 940 women and the associated morbidity of 5 million women worldwide. There have been some important improvements in Latin America in terms of laws and policies on abortion. However, the predominant environment is still restrictive, and many women, adolescents and girls still face multiple barriers to exercise their reproductive rights. This research will systematically assess comprehensive abortion policies in five Latin American countries (Argentina, Colombia, Honduras, Mexico and Uruguay). The aim is to identify barriers, facilitators and strategies to the implementation of abortion policies, looking at four key dimensions-regulatory framework, abortion policy dynamics, abortion service delivery and health system and health outcomes indicators-to draw cross-cutting lessons learnt to improve current implementation and inform future safe abortion policy development. METHODS AND ANALYSIS A mixed-method design will be used in the five countries to address the four dimensions through the Availability, Accessibility, Acceptability and Quality of Care model. The data collection tools include desk reviews and semi-structured interviews with key actors. Analysis will be performed using thematic analysis and stakeholder analysis. A regional synthesis exercise will be conducted to draw lessons on barriers, facilitators and the strategies. ETHICS AND DISSEMINATION The project has been approved by the WHO Research Ethics Review Committee (ID: A66023) and by the local research ethics committees. Informed consent will be obtained from participants. Data will be treated with careful attention to protecting privacy and confidentiality. Findings from the study will be disseminated through a multipurpose strategy to target diverse audiences to foster the use of the study findings to inform the public debate agenda and policy implementation at national level. The strategy will include academic, advocacy and policy arenas and actors, including peer-reviewed publication and national and regional dissemination workshops.
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Affiliation(s)
- Celina Gialdini
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
- Blanquerna Ramon Llull University Faculty of Health Sciences, Barcelona, Spain
| | | | - Mariana Romero
- Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas, (CONICET), Buenos Aires, Argentina
| | - Silvina Ramos
- Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina
| | | | - Berenise Carroli
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Rodolfo Gomez Ponce de León
- Latin American Center of Perinatology Women and Reproductive Health (CLAP/WR), Pan American Health Organization, Montevideo, Uruguay
| | - Mercedes Vila Ortiz
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research and 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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Chakravarty D, Mishtal J, Grimes L, Reeves K, Stifani B, Duffy D, Murphy M, Favier M, Horgan P, Chavkin W, Lavelanet A. Restrictive points of entry into abortion care in Ireland: a qualitative study of expectations and experiences with the service. Sex Reprod Health Matters 2023; 31:2215567. [PMID: 37326515 PMCID: PMC10281397 DOI: 10.1080/26410397.2023.2215567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
This article focuses on access to early medical abortion care under Section 12 of the Health (Regulation of Termination of Pregnancy) Act 2018, in Ireland and identifies existing barriers resulting from gaps in current policy design. The article draws primarily on qualitative interviews with 24 service users, 20 primary healthcare providers in the community and 27 key informants, including from grassroots groups that work with women from different migrant communities, to examine service users' experiences accessing early medical abortions on request up to 12 weeks gestation. The interviews were part of a wider mixed-methods study from 2020-2021 examining the barriers and facilitators to the implementation of abortion policy in Ireland. Our findings highlight care seekers' experiences with the GP-led service provision, including delays, facing non-providers, the mandatory three-day waiting period, and oversubscribed women's health and family planning clinics. Our findings also highlight the compounding challenges for migrants and additional barriers posed by the geographical distribution of the service and the 12-week gestational limit. Finally, it focuses on the remaining challenges for racialised and other marginalised groups. In order to provide a "thick description" of women's lives and the complexity of their experiences with abortion services in Ireland, we also present two narrative vignettes of service users, and their experiences with delays and navigating the healthcare system as migrants. To this effect, this article applies a reproductive justice framework to the results to highlight the compounding effects of these barriers on people located along multiple axes of social inequality.
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Affiliation(s)
- Dyuti Chakravarty
- Postdoctoral Researcher, School of Sociology, University College Cork, Cork, Republic of Ireland
| | - Joanna Mishtal
- Professor, Department of Anthropology, University of Central Florida, Orlando, FL, USA
| | - Lorraine Grimes
- Postdoctoral Researcher, Social Sciences Institute, Maynooth University, Maynooth, Republic of Ireland
| | - Karli Reeves
- Research Specialist, Department of Population Health Sciences, University of Central Florida, Orlando, FL, USA
| | - Bianca Stifani
- Complex Family Planning Specialist, Westchester Medical Center / Clinical Assistant Professor, New York Medical College, New York, NY, USA
| | - Deirdre Duffy
- Senior Lecturer in Global Inequalities, Department of Sociology, Lancaster University, Lancaster, UK
| | - Mark Murphy
- General Practitioner, Eldon Family Practice, Dublin, Republic of Ireland
| | - Mary Favier
- General Practitioner, Parklands Surgery, Cork, Republic of Ireland
| | - Patricia Horgan
- General Practitioner, Broad Lane Family Practice, Cork, Republic of Ireland
| | - Wendy Chavkin
- Co-Founder, Global Doctors for Choice, New York, NY, USA
| | - Antonella Lavelanet
- Medical Officer, 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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Schaaf M, Lavelanet A, Codjia L, Nihlén Å, Rehnstrom Loi U. A narrative review of challenges related to healthcare worker rights, roles and responsibilities in the provision of sexual and reproductive services in health facilities. BMJ Glob Health 2023; 8:e012421. [PMID: 37918835 PMCID: PMC10626880 DOI: 10.1136/bmjgh-2023-012421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 10/07/2023] [Indexed: 11/04/2023] Open
Abstract
INTRODUCTION This paper identifies and summarises tensions and challenges related to healthcare worker rights and responsibilities and describes how they affect healthcare worker roles in the provision of sexual and reproductive health (SRH) care in health facilities. METHOD The review was undertaken in a two-phase process, namely: (1) development of a list of core constructs and concepts relating to healthcare worker rights, roles and responsibilities to guide the review and (2) literature review. RESULT A total of 110 papers addressing a variety of SRH areas and geographical locations met our inclusion criteria. These papers addressed challenges to healthcare worker rights, roles and responsibilities, including conflicting laws, policies and guidelines; pressure to achieve coverage and quality; violations of the rights and professionalism of healthcare workers, undercutting their ability and motivation to fulfil their responsibilities; inadequate stewardship of the private sector; competing paradigms for decision-making-such as religious beliefs-that are inconsistent with professional responsibilities; donor conditionalities and fragmentation; and, the persistence of embedded practical norms that are at odds with healthcare worker rights and responsibilities. The tensions lead to a host of undesirable outcomes, ranging from professional frustration to the provision of a narrower range of services or of poor-quality services. CONCLUSION Social mores relating to gender and sexuality and other contested domains that relate to social norms, provider religious identity and other deeply held beliefs complicate the terrain for SRH in particular. Despite the particularities of SRH, a whole of systems response may be best suited to address embedded challenges.
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Affiliation(s)
- Marta Schaaf
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Laurence Codjia
- Department of Health Workforce, World Health Organization, Geneva, Switzerland
| | - Åsa Nihlén
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Ulrika Rehnstrom Loi
- Department of Sexual and Reproductive Health and Research and 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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Grossman A, Prata N, Williams N, Ganatra B, Lavelanet A, Läser L, Asmani C, Elamin H, Ouedraogo L, Rahman MM, Conneh-Duworko MJ, Tehoungue BZ, Chanza H, Phiri H, Bhattarai B, Dhakal NP, Ojo OA, Afolabi K, Kabuteni TJ, Hailu BG, Moses F, Dlamini-Nqeketo S, Zulu T, Rehnström Loi U. Correction: Availability of medical abortion medicines in eight countries: a descriptive analysis of key findings and opportunities. Reprod Health 2023; 20:160. [PMID: 37884974 PMCID: PMC10604516 DOI: 10.1186/s12978-023-01691-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Affiliation(s)
- Amy Grossman
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Ndola Prata
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
- Bixby Center for Population, Health & Sustainability, School of Public Health, University of California, Berkeley, CA, USA
| | - Natalie Williams
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Bela Ganatra
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Antonella Lavelanet
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Laurence Läser
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Chilanga Asmani
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Hayfa Elamin
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Leopold Ouedraogo
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | | | | | | | - Harriet Chanza
- World Health Organization, Malawi Country Office, Lilongwe, Republic of Malawi
| | - Henry Phiri
- Ministry of Health, Lilongwe, Republic of Malawi
| | - Bharat Bhattarai
- Department of Drug Administration, Ministry of Health and Population, Kathmandu, Nepal
| | | | | | - Kayode Afolabi
- Reproductive Health, Federal Ministry of Health, Abuja, Federal Republic of Nigeria
| | | | | | - Francis Moses
- Reproductive Health/Family Planning Programme Manager, Ministry of Health, Freetown, Sierra Leone
| | | | - Thembi Zulu
- National Department of Health, Pretoria, Republic of South Africa
| | - Ulrika Rehnström Loi
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland.
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Grossman A, Prata N, Williams N, Ganatra B, Lavelanet A, Läser L, Asmani C, Elamin H, Ouedraogo L, Rahman MM, Conneh-Duworko MJ, Tehoungue BZ, Chanza H, Phiri H, Bhattarai B, Dhakal NP, Ojo OA, Afolabi K, Kabuteni TJ, Hailu BG, Moses F, Dlamini-Nqeketo S, Zulu T, Rehnström Loi U. Availability of medical abortion medicines in eight countries: a descriptive analysis of key findings and opportunities. Reprod Health 2023; 20:58. [PMID: 37041543 PMCID: PMC10091522 DOI: 10.1186/s12978-023-01574-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND In recent years a growing number of manufacturers and medical abortion products have entered country markets and health systems, with varying degrees of quality and accessibility. An interplay of factors including pharmaceutical regulations, abortion laws, government policies and service delivery guidelines and provider's knowledge and practices influence the availability of medical abortion medicines. We assessed the availability of medical abortion in eight countries to increase understanding among policymakers of the need to improve availability and affordability of quality-assured medical abortion products at regional and national levels. METHODS Using a national assessment protocol and an availability framework, we assessed the availability of medical abortion medicines in Bangladesh, Liberia, Malawi, Nepal, Nigeria, Rwanda, Sierra Leone and South Africa between September 2019 and January 2020. RESULTS Registration of abortion medicines-misoprostol or a combination of mifepristone and misoprostol-was established in all countries assessed, except Rwanda. Mifepristone and misoprostol regimen for medical abortion was identified on the national essential medicines list/standard treatment guidelines for South Africa as well as in specific abortion care service and delivery guidelines for Bangladesh, Nepal, Nigeria, and Rwanda. In Liberia, Malawi, and Sierra Leone-countries with highly restrictive abortion laws and no abortion service delivery guidelines or training curricula-no government-supported training on medical abortion for public sector providers had occurred. Instead, training on medical abortion was either limited in scope to select private sector providers and pharmacists or prohibited. Community awareness activities on medical abortion have been limited in scope across the countries assessed and where abortion is broadly legal, most women do not know that it is an option. CONCLUSION Understanding the factors that influence the availability of medical abortion medicines is important to support policymakers improve availability of these medicines. The landscape assessments documented that medical abortion commodities can be uniquely impacted by the laws, policies, values, and degree of restrictions placed on service delivery programs. Results of the assessments can guide actions to improve access.
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Affiliation(s)
- Amy Grossman
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Ndola Prata
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
- Bixby Center for Population, Health & Sustainability, School of Public Health, University of California, Berkeley, CA, USA
| | - Natalie Williams
- Venture Strategies for Health & Development/OASIS, Berkeley, CA, USA
| | - Bela Ganatra
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Antonella Lavelanet
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Laurence Läser
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland
| | - Chilanga Asmani
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Hayfa Elamin
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | - Leopold Ouedraogo
- World Health Organization, Regional Office for Africa, Brazzaville, Republic of Congo
| | | | | | | | - Harriet Chanza
- World Health Organization, Malawi Country Office, Lilongwe, Republic of Malawi
| | - Henry Phiri
- Ministry of Health, Lilongwe, Republic of Malawi
| | - Bharat Bhattarai
- Department of Drug Administration, Ministry of Health and Population, Kathmandu, Nepal
| | | | | | - Kayode Afolabi
- Reproductive Health, Federal Ministry of Health, Abuja, Federal Republic of Nigeria
| | | | | | - Francis Moses
- Reproductive Health/Family Planning Programme Manager, Ministry of Health, Freetown, Sierra Leone
| | | | - Thembi Zulu
- National Department of Health, Pretoria, Republic of South Africa
| | - Ulrika Rehnström Loi
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland.
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Ambast S, Atay H, Lavelanet A. A global review of penalties for abortion-related offences in 182 countries. BMJ Glob Health 2023; 8:bmjgh-2022-010405. [PMID: 36941005 PMCID: PMC10030558 DOI: 10.1136/bmjgh-2022-010405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/25/2022] [Indexed: 03/22/2023] Open
Abstract
Public health research and human rights bodies have demonstrated the risks involved with criminalising abortion services and noted a need for full decriminalisation. Despite this, abortions are criminalised in some circumstances in almost all countries in the world today. This paper uses data from the Global Abortion Policies Database (GAPD) to analyse what criminal penalties exist for those who are seeking, providing and assisting in abortions in 182 countries.This paper uses data on abortion-related penalties available on the GAPD as of October 2022. It includes which actors are penalised, whether specific penalties exist for negligence, non-consensual abortions, whether any secondary additional considerations/judicial discretion exist in sentencing and the legal sources for these penalties.134 countries penalise abortion-seekers, 181 countries penalise abortion-providers and 159 countries penalise persons assisting in abortions. The maximum penalty is between 0 and 5 years of imprisonment in a majority of countries; however, it can be much higher in other countries. Some countries further prescribe fines, and professional sanctions for providers and those who assist. 34 countries restrict the dissemination of information about abortion.The range of possible penalties across countries and associated aggravating and mitigating factors for imposing these penalties support arguments for the decriminalisation of abortion on the grounds of arbitrariness. Abortions are also predominantly regulated through the criminal law, which may compound the stigma associated with seeking, assisting with and/or providing abortions when it is criminalised.There has been no comprehensive study of penalties for abortion at a global level. This article describes what specific penalties abortion seekers and providers face, what factors may increase or decrease these penalties, and the legal sources for these penalties. The findings provide additional evidence of the arbitrariness and potential for stigma associated with the criminalisation of abortion and strengthen the case for decriminalisation.
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Affiliation(s)
- Sanhita Ambast
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
| | - Hazal Atay
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
| | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
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Rehnström Loi U, Prata N, Grossman A, Lavelanet A, Williams N, Ganatra B. In-country availability of medical abortion medicines: a description of the framework and methodology of the WHO landscape assessments. Reprod Health 2023; 20:20. [PMID: 36694182 PMCID: PMC9875387 DOI: 10.1186/s12978-022-01530-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Availability of quality-assured medical abortion medicines plays a crucial role in providing comprehensive abortion care. However, access to these medicines is still restricted for many abortion seekers. Increasing availability of affordable, quality-assured mifepristone and misoprostol is important to improve access to safe medical abortion services. Driven by the outcomes of a global consultation hosted by the World Health Organization and the Swedish International Development Cooperation Agency in 2018, we decided to holistically examine access to medical abortion medicines from supply to demand. The overarching principle of the national landscape assessments was to generate evidence to support policy dialog and policymaking that is contextual to the needs of the country. This paper aims to describe the framework and methodological approach used in the World Health Organization landscape assessments of medical abortion medicines at country-level. METHODS A country assessment protocol was developed to guide the methodology of the World Health Organization landscape assessments. The assessment protocol included adaptation of an existing availability framework, an online desk review and literature review for existing data available for the country of interest, country-level key informant interviews, and analysis of the data to identify barriers and opportunities to improve medical abortion availability. CONCLUSION The availability framework and methodology will allow the identification of key barriers that limit readiness of medical abortion medicines, and the development of opportunities to overcome those barriers. The national landscape assessments will provide directions for future investments and offer guidance for policy and programming on medical abortion care.
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Affiliation(s)
- Ulrika Rehnström Loi
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland.
| | - Ndola Prata
- Venture Strategies for Health & Development/OASIS, Berkeley, CA USA ,grid.47840.3f0000 0001 2181 7878Bixby Center for Population, Health & Sustainability, University of California, Berkeley, USA
| | - Amy Grossman
- Venture Strategies for Health & Development/OASIS, Berkeley, CA USA
| | - Antonella Lavelanet
- 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, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Natalie Williams
- Venture Strategies for Health & Development/OASIS, Berkeley, CA USA
| | - 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, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland
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10
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Macleod CI, Reuvers M, Reynolds JH, Lavelanet A, Delate R. Comparative situational analysis of comprehensive abortion care in four Southern African countries. Glob Public Health 2023; 18:2217442. [PMID: 37272354 DOI: 10.1080/17441692.2023.2217442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 05/18/2023] [Indexed: 06/06/2023]
Abstract
We report on a comparative situational analysis of comprehensive abortion care (CAC) in Botswana, Eswatini, Lesotho and Namibia. We conducted systematic literature searches and country consultations and used a reparative health justice approach (with four dimensions) for the analysis. The following findings pertain to all four countries, except where indicated. Individual material dimension: pervasive gender-based violence (GBV); unmet need for contraception (15-17%); high HIV prevalence; poor abortion access for rape survivors; fees for sexual and reproductive health (SRH) services (Eswatini). Collective material dimension: no clear national budgeting for SRH; over-reliance on donor funding (Eswatini; Lesotho); no national CAC guidelines or guidance on legal abortion access; poor data collection and management systems; shortage and inequitable distribution of staff; few facilities providing abortion care. Individual symbolic dimension: gender norms justify GBV; stigma attached to both abortion and unwed or early pregnancies. Collective symbolic dimension: policy commitments to reducing unsafe abortion and to post-abortion care, but not to increasing access to legal abortion; inadequate research; contradictions in abortion legislation (Botswana); inadequate staff training in CAC. Political will to ensure CAC within the country's legislation is required. Reparative health justice comparisons provide a powerful tool for foregrounding necessary policy and practice change.
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Affiliation(s)
- Catriona Ida Macleod
- Critical Studies in Sexualities and Reproduction, Rhodes University, Makhanda, South Africa
| | - Megan Reuvers
- Critical Studies in Sexualities and Reproduction, Rhodes University, Makhanda, South Africa
| | | | - Antonella Lavelanet
- Department of Reproductive Health and Research and the 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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11
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de Londras F, Cleeve A, Rodriguez MI, Farrell A, Furgalska M, Lavelanet A. The impact of criminalisation on abortion-related outcomes: a synthesis of legal and health evidence. BMJ Glob Health 2022; 7:bmjgh-2022-010409. [PMID: 36581332 PMCID: PMC9806079 DOI: 10.1136/bmjgh-2022-010409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/24/2022] [Indexed: 12/31/2022] Open
Abstract
Abortion is criminalised to at least some degree in most countries. International human rights bodies have recognised that criminalisation results in the provision of poor-quality healthcare goods and services, is associated with lack of registration and unavailability of essential medicines including mifepristone and misoprostol, obstructs the provision of abortion information, obstructs training for abortion provision, is associated with delayed and unsafe abortion, and does not achieve its apparent aims of ether protecting abortion seekers from unsafe abortion or preventing abortion. Human rights bodies recommend decriminalisation, which is generally associated with reduced stigma, improved quality of care, and improved access to safe abortion. Drawing on insights from reproductive health, law, policy, and human rights, this review addresses knowledge gaps related to the health and non-health outcomes of criminalisation of abortion. This review identified evidence of the impacts of criminalisation of people seeking to access abortion and on abortion providers and considered whether, and if so how, this demonstrates the incompatibility of criminalisation with substantive requirements of international human rights law. Our analysis shows that criminalisation is associated with negative implications for health outcomes, health systems, and human rights enjoyment. It provides a further underpinning from empirical evidence of the harms of criminalisation that have already been identified by human rights bodies. It also provides additional evidence to support the WHO's recommendation for full decriminalisation of abortion.
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Affiliation(s)
- Fiona de Londras
- Birmingham Law School, University of Birmingham, Birmingham, UK .,ANU College of Law, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Amanda Cleeve
- Womens and Childrens Health, Karolinska Institute, Stockholm, Sweden
| | - Maria Isabel Rodriguez
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Alana Farrell
- Birmingham Law School, University of Birmingham, Birmingham, Birmingham, UK
| | | | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, Switzerland
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12
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Stifani BM, Mishtal J, Chavkin W, Reeves K, Grimes L, Chakravarty D, Duffy D, Murphy M, Horgan T, Favier M, Lavelanet A. Abortion policy implementation in Ireland: successes and challenges in the establishment of hospital-based services. SSM Qual Res Health 2022; 2:None. [PMID: 36531297 PMCID: PMC9748298 DOI: 10.1016/j.ssmqr.2022.100090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/04/2022] [Accepted: 04/17/2022] [Indexed: 11/29/2022]
Abstract
Objective To describe successes and highlight remaining challenges in the establishment of hospital-based abortion services after legal change in the Republic of Ireland. Methods We conducted a mixed-methods study on the implementation of abortion policy in Ireland. In this manuscript, we present the results from a qualitative analysis of in-depth interviews conducted with hospital-based providers, service users, and key informants. We used Dedoose software to conduct a thematic analysis of the data. Results We report findings from interviews with 28 obstetrician gynecologists, midwives, psychiatrists, anesthesiologists, and nurses; a subset of 7 service users who sought care in hospitals; and 27 key informants. In this analysis, we describe how key themes that pertain to information, capacity and power, facilitated and hindered the implementation of hospital-based abortion services. We found that individual champions are key to establishing the service, but their motivation is not always sufficient to integrate abortion into existing clinical services, and conscientious objection is a persistent barrier to expanding abortion services. The main challenges highlighted here are lack of abortion provision at some hospitals and limited access to surgical abortion at most hospitals due to provider-level, logistical, and infrastructure barriers. Conclusions This study presents new information on how abortion policy is implemented on the ground in hospital settings. Its findings can inform public health officials and providers in Ireland and other countries wishing to establish abortion services.
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Affiliation(s)
- Bianca M. Stifani
- Albert Einstein College of Medicine / Montefiore Medical Center, Bronx, NY, USA,New York Medical College / Westchester Medical Center, Valhalla, NY, USA,Corresponding author. 19 Bradhurst Avenue, Suite 2700S, Hawthorne, NY, 10532, USA.
| | - Joanna Mishtal
- Department of Anthropology, University of Central Florida, Orlando, FL, USA
| | - Wendy Chavkin
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - Karli Reeves
- College of Medicine, University of Central Florida, Orlando, FL, USA
| | | | | | - Deirdre Duffy
- Department of Social Work and Social Care, Manchester Metropolitan University, UK
| | | | | | - Mary Favier
- Doctors for Choice, Cork, Ireland,Southern Task Force for Abortion and Reproductive Topics, Cork, Ireland
| | - Antonella Lavelanet
- 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, 20 Avenue Appia, 1211, Geneva, Switzerland
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13
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Cassinath N, Titulaer P, Läser L, Lavelanet A, Ahsan S, Kwankam Toedtli F, Mawa S, Rehnstrom Loi U. Disruptions to the procurement of medical abortion medicines during COVID-19: a scoping review. BMJ Open 2022; 12:e064848. [PMID: 36302580 PMCID: PMC9621154 DOI: 10.1136/bmjopen-2022-064848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES This scoping review aimed to systematically search, retrieve and map the extent and characteristics of available literature on the evidenced disruptions to medical abortion (MA) medicine procurement caused by the COVID-19 outbreak. DESIGN Scoping review using Arksey and O'Malley's methodology and Levac et al's methodological enhancement with adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. DATA SOURCES PubMed, Embase, PMC, Science Direct, the Cochrane Library and Google Scholar were searched from January 2020 to April 2022. ELIGIBILITY CRITERIA We included articles in English that: (1) contained information on MA medicines; (2) included descriptions of procurement disruptions, including those with examples, characteristics and/or statistics; (3) documented events during the COVID-19 pandemic; and (4) presented primary data. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened search results, performed a full-text review of preliminarily included articles and completed data extraction in a standard Excel spreadsheet. Extracted data from was compared for validation and synthesised qualitatively. RESULTS The two articles included are unpublished grey literature demonstrating evidence of short-lived disruptions in sexual and reproductive health commodity procurement, including MA medicines, in sub-Saharan Africa during the early months of the pandemic. Findings from the two included grey literature articles show that in sub-Saharan contexts, emergency preparedness, stockpiling, adaptations and flexibility of key actors, including donors, alleviated COVID-19 disruptions allowing for resumption of services within weeks. CONCLUSION There is a need for increased empirical evidence of MA procurement challenges to understand which barriers to MA procurement may persist and impact continuity of supply while others can fuel resilience and preparedness efforts at the country and subregional levels. The lack of evidence from social marketing organisations and their networks is a significant gap as these actors constitute a vital artery in the distribution of MA commodities in low-income and middle-income countries.
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Affiliation(s)
- Natasha Cassinath
- 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, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Patricia Titulaer
- 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, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Laurence Läser
- 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, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Antonella Lavelanet
- 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, 20 Avenue Appia, 1211 Geneva, Switzerland
| | - Safia Ahsan
- Reproductive Health Supplies Coalition, Washington, DC, USA
| | | | - Stephen Mawa
- Technical Division, United Nations Population Fund, New York, New York, USA
| | - Ulrika Rehnstrom Loi
- 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, 20 Avenue Appia, 1211 Geneva, Switzerland
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14
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de Londras F, Cleeve A, Rodriguez MI, Farrell A, Furgalska M, Lavelanet A. The impact of mandatory waiting periods on abortion-related outcomes: a synthesis of legal and health evidence. BMC Public Health 2022; 22:1232. [PMID: 35725439 PMCID: PMC9210763 DOI: 10.1186/s12889-022-13620-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
This review follows an established methodology for integrating human rights to address knowledge gaps related to the health and non-health outcomes of mandatory waiting periods (MWPs) for access to abortion. MWP is a requirement imposed by law, policy, or practice, to wait a specified amount of time between requesting and receiving abortion care. Recognizing that MWPs “demean[] women as competent decision-makers”, the World Health Organization recommends against MWPs. International human rights bodies have similarly encouraged states to repeal and not to introduce MWPs, which they recognize as operating as barriers to accessing sexual and reproductive healthcare. This review of 34 studies published between 2010 and 2021, together with international human rights law, establishes the health and non-health harms of MWPs for people seeking abortion, including delayed abortion, opportunity costs, and disproportionate impact. Impacts on abortion providers include increased workloads and system costs.
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Affiliation(s)
- Fiona de Londras
- Birmingham Law School, University of Birmingham (UK), B15 2TT, Birmingham, UK.
| | - Amanda Cleeve
- Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.,Department of Sexual and Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Maria I Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - Alana Farrell
- Birmingham Law School, University of Birmingham (UK), B15 2TT, Birmingham, UK
| | | | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research, 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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15
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Kim CR, Lavelanet A, Ganatra B. Enabling access to quality abortion care: WHO's Abortion Care guideline. The Lancet Global Health 2022; 10:e467-e468. [PMID: 35303448 PMCID: PMC8938763 DOI: 10.1016/s2214-109x(21)00552-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Caron R Kim
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva 1211, Switzerland.
| | - Antonella Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva 1211, Switzerland
| | - Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, Geneva 1211, Switzerland
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16
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de Londras F, Cleeve A, Rodriguez MI, Lavelanet A. Integrating rights and evidence: a technical advance in abortion guideline development. BMJ Glob Health 2021; 6:bmjgh-2020-004141. [PMID: 33558339 PMCID: PMC7871678 DOI: 10.1136/bmjgh-2020-004141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 11/04/2022] Open
Abstract
As part of its core work, the WHO generates, translates and disseminates knowledge, including through guideline development. In recent years, substantial work has been undertaken to revise the Evidence to Decision framework in order to fully integrate inter alia human rights. This paper describes an innovative methodological approach taken by the authors to inform law and policy recommendations for the forthcoming third edition of the Safe Abortion: Technical and Policy Guidance for Health Systems. The methodology described here effectively integrates human rights protection and enjoyment as part of health outcomes and analysis, ensuring that subsequent recommendations are consistent with international human rights standards. This will allow guideline users to make informed decisions on interventions, including legal and policy reform, to fulfil relevant human rights including the right to health.
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Affiliation(s)
- Fiona de Londras
- Birmingham Law School, University of Birmingham, Birmingham, UK .,College of Law, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Amanda Cleeve
- Womens and Childrens Health, Karolinska Institute, Stockholm, Sweden.,Consultant, 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, GE, Switzerland
| | - Maria Isabel Rodriguez
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Antonella Lavelanet
- 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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17
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Burris S, Ghorashi AR, Cloud LF, Rebouché R, Skuster P, Lavelanet A. Identifying data for the empirical assessment of law (IDEAL): a realist approach to research gaps on the health effects of abortion law. BMJ Glob Health 2021; 6:bmjgh-2021-005120. [PMID: 34117010 PMCID: PMC8202112 DOI: 10.1136/bmjgh-2021-005120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 05/13/2021] [Indexed: 11/28/2022] Open
Abstract
Reproductive rights have been the focus of United Nations consensus documents, a priority for agencies like the WHO, and the subject of judgments issued by national and international courts. Human rights approaches have galvanised abortion law reform across numerous countries, but human rights analysis is not designed to empirically assess how legal provisions regulating abortion shape the actual delivery of abortion services and outcomes. Reliable empirical measurement of the health and social effects of abortion regulation is vital input for policymakers and public health guidance for abortion policy and practice, but research focused explicitly on assessing the health effects of abortion law and policy is limited at the global level. This paper describes a method for Identifying Data for the Empirical Assessment of Law (IDEAL), to assess potential health effects of abortion regulations. The approach was applied to six critical legal interventions: mandatory waiting periods, third-party authorisation, gestational limits, criminalisation, provider restrictions and conscientious objection. The IDEAL process allowed researchers to link legal interventions and processes that have not been investigated fully in empirical research to processes and outcomes that have been more thoroughly studied. To the extent these links are both transparent and plausible, using IDEAL to make them explicit allows both researchers and policy stakeholders to make better informed assessments and guidance related to abortion law. The IDEAL method also identifies gaps in scientific research. Given the importance of law to public health generally, the utility of IDEAL is not limited to abortion law.
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Affiliation(s)
- Scott Burris
- Center for Public Health Law Research, Beasley School of Law, Temple University, Philadelphia, Pennsylvania, USA
| | - Adrienne R Ghorashi
- Center for Public Health Law Research, Beasley School of Law, Temple University, Philadelphia, Pennsylvania, USA
| | - Lindsay Foster Cloud
- Center for Public Health Law Research, Beasley School of Law, Temple University, Philadelphia, Pennsylvania, USA
| | - Rachel Rebouché
- Center for Public Health Law Research, Beasley School of Law, Temple University, Philadelphia, Pennsylvania, USA
| | | | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneve, GE, Switzerland
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18
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Ghosh J, Papadopoulou A, Devall AJ, Jeffery HC, Beeson LE, Do V, Price MJ, Tobias A, Tunçalp Ö, Lavelanet A, Gülmezoglu AM, Coomarasamy A, Gallos ID. Methods for managing miscarriage: a network meta-analysis. Cochrane Database Syst Rev 2021; 6:CD012602. [PMID: 34061352 PMCID: PMC8168449 DOI: 10.1002/14651858.cd012602.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Miscarriage, defined as the spontaneous loss of a pregnancy before 24 weeks' gestation, is common with approximately 25% of women experiencing a miscarriage in their lifetime. An estimated 15% of pregnancies end in miscarriage. Miscarriage can lead to serious morbidity, including haemorrhage, infection, and even death, particularly in settings without adequate healthcare provision. Early miscarriages occur during the first 14 weeks of pregnancy, and can be managed expectantly, medically or surgically. However, there is uncertainty about the relative effectiveness and risks of each option. OBJECTIVES To estimate the relative effectiveness and safety profiles for the different management methods for early miscarriage, and to provide rankings of the available methods according to their effectiveness, safety, and side-effect profile using a network meta-analysis. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth's Trials Register (9 February 2021), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (12 February 2021), and reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials assessing the effectiveness or safety of methods for miscarriage management. Early miscarriage was defined as less than or equal to 14 weeks of gestation, and included missed and incomplete miscarriage. Management of late miscarriages after 14 weeks of gestation (often referred to as intrauterine fetal deaths) was not eligible for inclusion in the review. Cluster- and quasi-randomised trials were eligible for inclusion. Randomised trials published only as abstracts were eligible if sufficient information could be retrieved. We excluded non-randomised trials. DATA COLLECTION AND ANALYSIS At least three review authors independently assessed the trials for inclusion and risk of bias, extracted data and checked them for accuracy. We estimated the relative effects and rankings for the primary outcomes of complete miscarriage and composite outcome of death or serious complications. The certainty of evidence was assessed using GRADE. Relative effects for the primary outcomes are reported subgrouped by the type of miscarriage (incomplete and missed miscarriage). We also performed pairwise meta-analyses and network meta-analysis to determine the relative effects and rankings of all available methods. MAIN RESULTS Our network meta-analysis included 78 randomised trials involving 17,795 women from 37 countries. Most trials (71/78) were conducted in hospital settings and included women with missed or incomplete miscarriage. Across 158 trial arms, the following methods were used: 51 trial arms (33%) used misoprostol; 50 (32%) used suction aspiration; 26 (16%) used expectant management or placebo; 17 (11%) used dilatation and curettage; 11 (6%) used mifepristone plus misoprostol; and three (2%) used suction aspiration plus cervical preparation. Of these 78 studies, 71 (90%) contributed data in a usable form for meta-analysis. Complete miscarriage Based on the relative effects from the network meta-analysis of 59 trials (12,591 women), we found that five methods may be more effective than expectant management or placebo for achieving a complete miscarriage: · suction aspiration after cervical preparation (risk ratio (RR) 2.12, 95% confidence interval (CI) 1.41 to 3.20, low-certainty evidence), · dilatation and curettage (RR 1.49, 95% CI 1.26 to 1.75, low-certainty evidence), · suction aspiration (RR 1.44, 95% CI 1.29 to 1.62, low-certainty evidence), · mifepristone plus misoprostol (RR 1.42, 95% CI 1.22 to 1.66, moderate-certainty evidence), · misoprostol (RR 1.30, 95% CI 1.16 to 1.46, low-certainty evidence). The highest ranked surgical method was suction aspiration after cervical preparation. The highest ranked non-surgical treatment was mifepristone plus misoprostol. All surgical methods were ranked higher than medical methods, which in turn ranked above expectant management or placebo. Composite outcome of death and serious complications Based on the relative effects from the network meta-analysis of 35 trials (8161 women), we found that four methods with available data were compatible with a wide range of treatment effects compared with expectant management or placebo: · dilatation and curettage (RR 0.43, 95% CI 0.17 to 1.06, low-certainty evidence), · suction aspiration (RR 0.55, 95% CI 0.23 to 1.32, low-certainty evidence), · misoprostol (RR 0.50, 95% CI 0.22 to 1.15, low-certainty evidence), · mifepristone plus misoprostol (RR 0.76, 95% CI 0.31 to 1.84, low-certainty evidence). Importantly, no deaths were reported in these studies, thus this composite outcome was entirely composed of serious complications, including blood transfusions, uterine perforations, hysterectomies, and intensive care unit admissions. Expectant management and placebo ranked the lowest when compared with alternative treatment interventions. Subgroup analyses by type of miscarriage (missed or incomplete) agreed with the overall analysis in that surgical methods were the most effective treatment, followed by medical methods and then expectant management or placebo, but there are possible subgroup differences in the effectiveness of the available methods. AUTHORS' CONCLUSIONS: Based on relative effects from the network meta-analysis, all surgical and medical methods for managing a miscarriage may be more effective than expectant management or placebo. Surgical methods were ranked highest for managing a miscarriage, followed by medical methods, which in turn ranked above expectant management or placebo. Expectant management or placebo had the highest chance of serious complications, including the need for unplanned or emergency surgery. A subgroup analysis showed that surgical and medical methods may be more beneficial in women with missed miscarriage compared to women with incomplete miscarriage. Since type of miscarriage (missed and incomplete) appears to be a source of inconsistency and heterogeneity within these data, we acknowledge that the main network meta-analysis may be unreliable. However, we plan to explore this further in future updates and consider the primary analysis as separate networks for missed and incomplete miscarriage.
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Affiliation(s)
- Jay Ghosh
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Argyro Papadopoulou
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Adam J Devall
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Hannah C Jeffery
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Leanne E Beeson
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Vivian Do
- University of Birmingham, Birmingham, UK
| | - Malcolm J Price
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aurelio Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Özge Tunçalp
- 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
| | - Antonella Lavelanet
- 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
| | | | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
| | - Ioannis D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research (IMSR), WHO Collaborating Centre for Global Women's Health Research, University of Birmingham, Birmingham, UK
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19
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Endler M, Cleeve A, Lavelanet A, Gemzell-Danielsson K. The use of telemedicine services for medical abortion. Hippokratia 2020. [DOI: 10.1002/14651858.cd013764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Margit Endler
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
| | - Amanda Cleeve
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
| | - Antonella Lavelanet
- Department of Sexual and Reproductive Health and Research; World Health Organization; Geneva Switzerland
| | - Kristina Gemzell-Danielsson
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
- Karolinska University Hospital; Stockholm Sweden
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Whitehouse K, Brant A, Fonhus MS, Lavelanet A, Ganatra B. Medical regimens for abortion at 12 weeks and above: a systematic review and meta-analysis. Contracept X 2020; 2:100037. [PMID: 32954250 PMCID: PMC7484538 DOI: 10.1016/j.conx.2020.100037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 01/14/2023] Open
Abstract
Background Mifepristone and misoprostol are recommended for second-trimester medical abortion, but consensus is unclear on the ideal regimen. Objectives The objectives were to systematically review randomized controlled trials (RCTs) investigating efficacy, safety and satisfaction of medical abortion at ≥ 12 weeks' gestation. Data sources We searched PubMed, Popline, Embase, Global Index Medicus, Cochrane Controlled Register of Trials and International Clinical Trials Registry Platform from January 2008 to May 2017. Study eligibility participants and interventions We included RCTs on medical abortion at ≥ 12 weeks' gestation using mifepristone and/or misoprostol. We excluded studies with spontaneous abortion, fetal demise and mechanical cervical ripening and those not reporting ongoing pregnancy (OP). Study appraisal and synthesis methods After extracting prespecified data and assessing risk of bias in accordance with the Cochrane handbook, we used Revman5 software to combine data and GRADE to assess certainty of evidence. Results We included 43 of the 1894 references identified. Combination mifepristone-misoprostol had lower rates of OP [risk ratio (RR) 0.12, 95% confidence interval (CI) 0.04-0.35] vs. misoprostol only. A 24-h interval between mifepristone and misoprostol had lower OP rate at 24 h than simultaneous dosing (RR 3.13, 95% CI 1.23-7.94). Every 3-h dosing had lower OP rate at 48 h (RR 0.39, 95% CI 0.17-0.88). Limitations Direct comparisons of buccal misoprostol to sublingual or vaginal routes after mifepristone were limited. Evidence from clinical trials on how to best manage women with prior uterine incisions was lacking. Conclusion Our analysis supports the use of mifepristone 200 mg 1 to 2 days before misoprostol 400 mcg vaginally every 3 h at ≥ 12 weeks' gestation. Implications Where available, providers should use mifepristone plus misoprostol for second-trimester medical abortion. Vaginal misoprostol appears to be most efficacious with fewest side effects, but sublingual and buccal routes are also acceptable.
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Affiliation(s)
- Katherine Whitehouse
- The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Ashley Brant
- MedStar Washington Hospital Center, 110 Irving St., Washington, DC, 20010, USA
| | | | - Antonella Lavelanet
- The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211 Geneva, Switzerland
| | - Bela Ganatra
- The UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Department of Reproductive Health and Research, Avenue Appia 20, 1211 Geneva, Switzerland
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Abubeker FA, Lavelanet A, Rodriguez MI, Kim C. Medical termination for pregnancy in early first trimester (≤ 63 days) using combination of mifepristone and misoprostol or misoprostol alone: a systematic review. BMC Womens Health 2020; 20:142. [PMID: 32635921 PMCID: PMC7339463 DOI: 10.1186/s12905-020-01003-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 06/26/2020] [Indexed: 11/10/2022]
Abstract
Background A wide range of drugs have been studied for first trimester medical abortion. Studies evaluating different regimens, including combination mifepristone and misoprostol and misoprostol alone regimens, show varying results related to safety, efficacy and other outcomes. Thus, the objectives of this systematic review were to compare the safety, effectiveness and acceptability of medical abortion and to compare medical with surgical methods of abortion ≤63 days of gestation. Methods Pubmed and EMBASE were systematically searched from database inception through January 2019 using a combination of MeSH, keywords and text words. Randomized controlled trials on induced abortion at ≤63 days that compared different regimens of medical abortion using mifepristone and/or misoprostol and trials that compared medical with surgical methods of abortion were included. We extracted data into a pre-designed form, calculated effect estimates, and performed meta-analyses where possible. The primary outcomes were ongoing pregnancy and successful abortion. Results Thirty-three studies composed of 22,275 participants were included in this review. Combined regimens using mifepristone and misoprostol had lower rates of ongoing pregnancy, higher rates of successful abortion and satisfaction compared to misoprostol only regimens. In combined regimens, misoprostol 800 μg was more effective than 400 μg. There was no significant difference in dosing intervals between mifepristone and misoprostol and routes of misoprostol administration in combination or misoprostol alone regimens. The rate of serious adverse events was generally low. Conclusion In this systematic review, we find that medical methods of abortion utilizing combination mifepristone and misoprostol or misoprostol alone are effective, safe and acceptable. More robust studies evaluating both the different combination and misoprostol alone regimens are needed to strengthen existing evidence as well as assess patient perspectives towards a particular regimen.
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Affiliation(s)
- Ferid A Abubeker
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
| | - Antonella Lavelanet
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Maria I Rodriguez
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Oregon, Portland, USA
| | - Caron Kim
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Cleeve A, Fønhus MS, Lavelanet A. A systematic review of the effectiveness, safety, and acceptability of medical management of intrauterine fetal death at 14-28 weeks of gestation. Int J Gynaecol Obstet 2019; 147:301-312. [PMID: 31493314 DOI: 10.1002/ijgo.12964] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/28/2019] [Accepted: 09/05/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Optimal dose, interval, and administration route of misoprostol with added benefit of mifepristone for management of second trimester intrauterine fetal death (IUFD) are not established. OBJECTIVES To assess effectiveness, safety, and acceptability of medical management of second trimester IUFD. SEARCH STRATEGY Research databases from January 2006 to October 2018. SELECTION CRITERIA Randomized controlled trials with IUFD cases at 14-28 weeks of gestation. DATA COLLECTION AND ANALYSIS We screened and extracted data, assessed risk of bias, conducted analyses, and assessed overall certainty of the evidence. MAIN RESULTS Sixteen trials from 1695 citations. When misoprostol is used alone, 400 μg is more effective than 200 μg (RR 0.78; 95% CI, 0.66-0.92, moderate certainty evidence); the sublingual route is more effective than the oral route (RR 0.88; 95% CI, 0.70-1.11, low certainty evidence). There may be little to no difference between the sublingual and vaginal route (RR 0.93; 95% CI, 0.85-1.03, low certainty evidence). Certainty of evidence related to mifepristone-misoprostol regimens and safety and acceptability is very low. CONCLUSIONS Misoprostol 400 μg every 4 hours, sublingually or vaginally, may be effective. We cannot draw conclusions about safety and acceptability, or about the added benefits of mifepristone.
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Affiliation(s)
- Amanda Cleeve
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Marita Sporstøl Fønhus
- Department of Global Health, Norwegian Institute of Public Health, Nydalen, Oslo, Norway
| | - Antonella Lavelanet
- Department of Reproductive Health and Research and 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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Abstract
Background Telemedicine is increasingly being used to access abortion services. Objective To assess the success rate, safety, and acceptability for women and providers of medical abortion using telemedicine. Search strategy We searched PubMed, EMBASE, ClinicalTrials.gov, and Web of Science up until 10 November 2017. Study criteria We selected studies where telemedicine was used for comprehensive medical abortion services, i.e. assessment/counselling, treatment, and follow up, reporting on success rate (continuing pregnancy, complete abortion, and surgical evacuation), safety (rate of blood transfusion and hospitalisation) or acceptability (satisfaction, dissatisfaction, and recommendation of the service). Data collection and analysis Quantitative outcomes were summarised as a range of median rates. Qualitative data were summarised in a narrative synthesis. Main results Rates relevant to success rate, safety, and acceptability outcomes for women ≤10+0 weeks’ gestation (GW) ranged from 0 to 1.9% for continuing pregnancy, 93.8 to 96.4% for complete abortion, 0.9 to 19.3% for surgical evacuation, 0 to 0.7% for blood transfusion, 0.07 to 2.8% for hospitalisation, 64 to 100% for satisfaction, 0.2 to 2.3% for dissatisfaction, and 90 to 98% for recommendation of the service. Rates in studies also including women >10+0GW ranged from 1.3 to 2.3% for continuing pregnancy, 8.5 to 20.9% for surgical evacuation, and 90 to 100% for satisfaction. Qualitative studies on acceptability showed no negative impacts for women or providers. Conclusion Based on a synthesis of mainly self‐reported data, medical abortion through telemedicine seems to be highly acceptable to women and providers, success rate and safety outcomes are similar to those reported in literature for in‐person abortion care, and surgical evacuation rates are higher. Tweetable abstract A systematic review of medical abortion through telemedicine shows outcome rates similar to in‐person care. A systematic review of medical abortion through telemedicine shows outcome rates similar to in‐person care.
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Affiliation(s)
- M Endler
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden.,Department of Public Health, Women's Health Research Unit, University of Cape Town, Cape Town, South Africa
| | - A Lavelanet
- Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - A Cleeve
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - B Ganatra
- Department of Reproductive Health and Research, UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Geneva, Switzerland
| | - R Gomperts
- Women on Web, Amsterdam, the Netherlands
| | - K Gemzell-Danielsson
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
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Lavelanet A. Telemedicine: are we still falling short? BJOG 2019; 126:618. [PMID: 30734448 DOI: 10.1111/1471-0528.15597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A Lavelanet
- Department of Reproductive Health and Research and 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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Thaxton L, Lavelanet A. Systematic review of efficacy with extending contraceptive implant duration. Int J Gynaecol Obstet 2018; 144:2-8. [PMID: 30343503 PMCID: PMC7379677 DOI: 10.1002/ijgo.12696] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/28/2018] [Accepted: 10/19/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Extending contraceptive implant duration of use increases accessibility by maximizing the lifetime of devices. OBJECTIVES To review the contraceptive efficacy during extended use of progestin implants. SEARCH STRATEGY PubMed and EMBASE were searched for articles in any language, 1996-2017, utilizing terms for devices and contraceptive efficacy. SELECTION CRITERIA Randomized clinical trials (RCTs), cohort studies, and case-control studies were included; abstracts, posters, and presentations were excluded. Studies evaluating Norplant and implants currently in pre-marketing trials were excluded. DATA COLLECTION AND ANALYSIS Titles and abstracts of articles were reviewed; those that met inclusion and exclusion criteria underwent full text review and data abstraction. MAIN RESULTS The search identified 2951 articles; six met inclusion and exclusion criteria. Five studies evaluated the etonogestrel implant (Implanon), and one the levonorgestrel implant (Jadelle). One RCT randomized to method, not duration; the remaining studies were prospective cohort studies. Three studies analyzed efficacy among women beyond currently approved duration separately. All studies were of poor to fair quality by United States Preventative Services Task Force (USPTF) grading. Limitations include lack of generalizability and control of important confounders. CONCLUSION These studies provide limited data for extended duration of contraceptive implants.
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Affiliation(s)
- Lauren Thaxton
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Antonella Lavelanet
- Department of Reproductive Health and Research and 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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Kapp N, Eckersberger E, Lavelanet A, Rodriguez MI. Medical abortion in the late first trimester: a systematic review. Contraception 2018; 99:77-86. [PMID: 30444970 PMCID: PMC6367561 DOI: 10.1016/j.contraception.2018.11.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/02/2018] [Accepted: 11/06/2018] [Indexed: 12/02/2022]
Abstract
Objective To describe the efficacy, safety, and acceptability of medical abortion in the late first trimester. Study design We searched PubMed and Cochrane databases for articles in any language that examined the success of medical abortion at gestational ages (>63 to≤84 days gestation). We sought articles that compared: medical abortion with surgical abortion at this gestational age, combination mifepristone and misoprostol and/or misoprostol alone); different dosages of misoprostol; different routes of misoprostol administration; frequency of dosing; and location of medical abortion (in health care facility vs. outpatient management). Our primary outcome was complete abortion. Data was independently abstracted by two authors, graded for evidence quality, and assessed for risk of bias. Results The search strategy returned 3384 articles, nine of which met inclusion criteria. Medical abortion, as compared with surgical abortion, was effective in the late first trimester (94.6% versus 97.9% complete abortion). A combined regimen of mifepristone and misoprostol was significantly more effective than misoprostol alone (90.4 versus 81.6% complete abortion). Complete abortion rates for all regimens investigated ranged from 78.6% to 94.6%. Success rates were higher with repeat dosing of misoprostol both in combination regimens and alone, and with vaginal compared with oral administration for repeat dosing. Conclusion A limited body of evidence indicates a range of efficacy of medical abortion in the late first trimester and highlights the need for well-designed trials in this gestational age range. Implications This review highlights the need for research focused on the late first trimester to strengthen the body of evidence. The available evidence is limited but offers reassurance that adverse events are rare for later first trimester abortion. Importantly, new research demonstrates that efficacy remains unchanged in the 10th gestational week regardless of whether the medication is taken in a facility or at a woman's home.
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Affiliation(s)
| | | | - Antonella Lavelanet
- Department of Reproductive Health and Research and UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, 20 Avenue Appia, CH-1211, Geneva 27, Switzerland
| | - Maria Isabel Rodriguez
- Oregon Health & Science University, Department of Obstetrics & Gynecology, 3181 SW Sam Jackson Park Rd, Portland, OR 97239
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Khosla R, Lavelanet A, Ganatra B, Johnson BR. Improving access to safe abortion services in humanitarian crises. Confl Health 2018. [DOI: 10.1186/s13031-018-0160-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Khalifeh A, Malone F, Lavelanet A, Chamchad D, Gerson A. 353: Comparative analysis of two- versus three-dimensional sonography for nuchal translucency (NT) measurement. Am J Obstet Gynecol 2013. [DOI: 10.1016/j.ajog.2012.10.518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Armenti VT, Radomski JS, Moritz MJ, Gaughan WJ, Hecker WP, Lavelanet A, McGrory CH, Coscia LA. Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl 2004:103-14. [PMID: 16704142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
The NTPR maintains an ongoing active database to study the safety of pregnancy in transplant recipients and currently includes the outcomes of more than 900 female recipients who became pregnant after their transplant and just over 700 male recipients who fathered one or more pregnancies after receiving a transplant. Analyses include the long-term follow-up of the recipient's graft status and their offspring. Successful pregnancy outcomes have been noted for each solid organ recipient group. The Registry includes information on 1,097 pregnancies in 716 kidney recipients, 187 pregnancies in 111 liver recipients, 56 pregnancies in 38 P/K recipients and smaller numbers for other organs and combinations of organs. There are periodic reports of recipients with graft dysfunction, rejection, or graft loss that may be related to pregnancy events, though the majority of outcomes reported to the NTPR appear favorable for parent and newborn. Organ-specific issues and comorbidities must also be considered in analyzing outcomes. The pregnancy issues that face recipients and caretakers with the current newer adjunctive therapies and newer immunosuppressive regimens require ongoing study. The potential risk of teratogenicity must be weighed against the potential risk of rejection when altering drug regimens before planned conceptions or in making dosage adjustments during pregnancy. Unplanned pregnancies present obvious concerns. Pregnancy safety has not been established for either MMF or sirolimus and all centers are encouraged to report pregnancies with exposures to these agents to the NTPR. Continuing analyses are directed at potential effects of the newer immunosuppressive regimens, not only to identify any risks to the pregnancy from immediate exposure, but also for potential postpartum exposures such as from breastfeeding. As the registry study design allows for continued contact, efforts continue to accrue long-term follow-up of both parent and child.
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Affiliation(s)
- Vincent T Armenti
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
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