Abortion-related Complications Research Articles

Women at crossroads: a qualitative study of induced abortion and violence in a Ghanaian region

Unsafe abortions contribute significantly to maternal mortality and morbidity in Ghana. To reduce this, in 1982 abortion laws in Ghana underwent reform to broaden the conditions under which abortion is accessed. Although, evidence in other contexts highlights the contribution of violence to women’s experience of unwanted pregnancy and abortion, such evidence is limited within the Ghanaian abortion literature. This study aims to fill that gap. Informed by phenomenology, interviews were conducted with 10 women who had experienced various forms of violence leading to unwanted pregnancy and unsafe abortions. Participants were recruited between June 2017 and March 2018 in the Ashanti region of Ghana where they sought hospital care for unsafe abortion related complications. Participants mentioned intimate partners as the main perpetrators of violence. Financial challenges were also identified as important in increasing women’s vulnerability to violence. Verbal abuse from health workers contributed to denying women access to safe abortion. This paper advances dialogue about the ways in which women’s experience of violence from intimate/non-intimate partners and healthcare workers impacts their overall abortion experience. It advocates the empowerment of women to enable them to leave violent relationships, and the retraining of health workers to enable them to adopt respectful and empathetic care practices.

Striving towardsafe abortion services in Nepal: A review of barriers and facilitators.

Despite the decriminalization of abortion in Nepal in 2002, unsafe abortion is still a significant contributor to maternal morbidity and mortality. Nepal has witnessed a significant drop in abortion-related severe complications and maternal deaths owing to the legalization of abortion laws, lowered financial costs, and wider accessibility of safe abortion services (SAS). However, various factors such as sociocultural beliefs, financial constraints, geographical difficulties, and stigma act as barriers to the liberal accessibility of SAS. This review aimed to determine key barriers obstructing women's access to lawful, safe abortion care and identify facilitators that have improved access to and quality of abortion services. A systematic search strategy utilizing the databases PubMed, CINAHL, Scopus, and Embase was used to include studies on the accessibility and safety of abortion services in Nepal. Data were extracted from included studies through close reading. Barriers and facilitators were then categorized into various themes and analyzed. Of 223 studies, 112 were duplicates, 73 did not meet the inclusion criteria, and 18 did not align with the research question; thus, 20 studies were included in the review. Various barriers to SAS in Nepal were categorized as economic, geographic, societal, legal/policy, socio-cultural, health systems, and other factors. Facilitators improving access were categorized as economic/geographic/societal, legal/policy, socio-cultural, and health systems factors. The patterns and trends of barriers and facilitators were analyzed, grouping them under legal/policy, socio-cultural, geographic/accessibility, and health systems factors. The review identifies financial constraints, unfavorable geography, lack of infrastructure, and social stigmatization as major barriers to SAS. Economics and geography, legalization, improved access, reduced cost and active involvement of auxiliary nurse-midwives and community health volunteers are key facilitators.

Facility assessment of the best functioning facility providing emergency obstetric care in the selected blocks of Varanasi, Uttar Pradesh

ABSTRACT Background: UP has the 2nd highest MMR which is 197 compared with national average of 113 (RGI-SRS-2016-2018).Although institutional deliveries in India has been increased from 78.9% (NFHS-4) to 89% (NFHS-5) [ UP from 67.8% to 83.4%] but still we are far away from SDG -3 target. It reflects that there may be increase in crude coverage but not in effective coverage. Materials and Methods: It is a cross sectional study conducted in May – June 2017. Out of 8 blocks of rural Varanasi, 4 blocks were selected randomly. Best functioning facility for EmOC services in each selected block were assessed using Facility Gap Assessment Schedule of IPHS. Result: None of the facility met the recommended standard for BEmOC .Tracking of drop out of ANC and PNC services, use of Partograph, treatment of abortion-related complications, were not found at all the 4 facility. Blood grouping and RH typing was also not functional at 2 of the 4 centers. Caesarean section and availability of blood bank were also lacking in CHC (FRU). Conclusion: If condition of best functioning facility in a block is not according to the recommendation then how can we expect to provide a good maternal health service to public.

The Association Between Self-Managed versus Clinician-Managed Abortion and Self-Reported Abortion Complications: A Cross-Sectional Analysis in India.

To examine the association between self-managed abortion and the self-reported experience of abortion complications in India, a country with a high incidence of self-managed abortion. The study used a cross-sectional multivariable logistic regression analysis of data from the National Family Health Survey (NFHS-4) of 2015-2016 to compare the odds of self-reported complications experienced during abortion between self-managed and clinician-managed abortions in India. On average, self-managed abortions occurred earlier in gestation than clinician-managed abortions, 7.8 weeks and 11.3 weeks, respectively (p < 0.001). Self-managed abortion was associated with fewer self-reported abortion-related complications than clinician-managed abortions when adjusted for covariates not including gestational age (Adjusted Odds Ratio (aOR) 0.82, 95% confidence interval (CI) 0.69, 0.97). However, once adjusted for gestational age, there was no longer a clinically meaningful or statistically significant difference in the odds of self-reported complications between self-managed and clinician-managed abortions (aOR = 0.98, 95% CI 0.81, 1.18). These findings suggest that people in India are using safe methods to self-manage abortions and support the hypothesis that self-managed abortion can improve access to abortion and reproductive choice without increasing risk.

Reasons for delay in reaching healthcare with severe abortion-related morbidities: Qualitative results from women in the fragile context of Jigawa state, Nigeria (AMoCo)

Maternal near-miss events are a key measure of maternal health; abortion-related complications are one source of near-miss events. To understand the pathway to care of women with severe abortion-related events in a fragile context, we conducted in-depth semi-structured interviews with women who obtained treatment at a referral hospital in Jigawa State, Nigeria, in 2020–2021 (n = 61). We used the Three Delays Model (Thaddeus & Maine, 1994) to examine impediments in reaching care.The first delay (from the onset of symptoms of the pregnancy loss to the decision to seek care) was characterized by the duration of time it took to recognize the pregnancy and pregnancy loss in addition to religious beliefs that it is the will of a higher power that she lost the pregnancy. The second delay (from the decision to seek care to arriving at a place that could provide adequate care for her complication, i.e. the study site); was due to lack of money, lack of passable roads and transport, use of traditional healers, challenges being seen by providers at lower-level facilities, referrals not being facilitated and misdirection by healthcare providers. The third delay was not present in our results. No respondent said she knowingly interfered with the pregnancy; understanding why these pregnancy losses resulted in near-miss complications is critical to reducing maternal morbidity and mortality in Northern Nigeria. Addressing health literacy as well as social and financial barriers holds the potential to get women to care sooner and avert these near-miss or potentially life-threatening events.

Factors Associated with Poorer Post-Abortion Care Quality at Ouidah-Kpomassè-Tori Bossito District Hospital in Benin, 2022

Background: Managing abortion-related complications remains a health concern despite the insertion of postabortion care into Benin's family health service guidelines and protocols, not with standing that abortion up to 12 weeks of pregnancy has been legalized in Benin. This study aimed to investigate factors associated with poor quality of postabortion care in the Ouidah-Kpomassè-Tori-Bossito district hospital in 2022. Subjects dan Method: This was a cross-sectional, analytical study carried out from March 21 to April 8, 2022. Records of all patients admitted for abortion at Ouidah-Kpomassè-Tori-Bossito district hospital from January 1, 2021, to April 8, 2022, were reviewed, as well as the providers involved in postabortion care and administrative staff, chosen through a reasoned choice. The dependent variable was the quality of postabortion care, defined by the six components: interview, physical examination, complementary examination, diagnosis, treatment and follow-up; according to the Benin postabortion care guidelines. Independent variables were provider features, patient features, and abortion features. Information collected through literature review and questionnaire survey was analyzed using STATA 15 software. Associated factors were then identified by bivariate analysis and multiple logistic regression at 5% threshold. Results: A total of 130 records of women admitted for abortion were evaluated. The mean age was (Mean= 27.56; SD= 7.33). Postabortion care was poor in 39.23% and good in 60.77% of the patients. Factors associated with this poor quality of postabortion care were religion (p= 0.021), abortion history (p= 0.012), miscarriage history (p= 0.026) and abortion type (p= 0.007). Conclusion: Addressing these factors will help ensure a better quality of postabortion care in order to support legalized abortion and significantly reduce maternal mortality related to abortion in Benin. Keywords: postabortion care, associated factors, Benin Correspondence: Mongbo Virginie. Department of Policies and Health Systems, Regional Institute of Public Health of Ouidah, University of Abomey-Calavi, Benin. Email: vmongade@yahoo.com. Mobile: 00229 95403790.

Delays in obtaining hospital care and abortion-related complications within a context of illegality.

Abortion, particularly when illegal, highlights inequities in different populations. Although abortion-related mortality is lower compared to other obstetric causes, abortion complications tend to be more lethal. Delays in seeking and obtaining care are determinants of negative outcomes. This study, nested within the GravSus-NE, analyzed healthcare delays and their association with abortion-related complications in three cities of northeastern Brazil (Salvador, Recife and São Luís). Nineteen public maternity hospitals were involved. All eligible women ≥18 years old hospitalized between August and December 2010 were evaluated. Descriptive, stratified and multivariate analyses were performed. Youden's index was used to determine delay. One model was created with all the women and another with those admitted in good clinical conditions, thus determining complications that occurred during hospitalization and their associated factors. Of 2,371 women, most (62.3%) were ≤30 years old (median 27 years) and 89.6% reported being black or brown-skinned. Most (90.5%) were admitted in good condition, 4.0% in fair condition and 5.5% in poor/very poor condition. Median time between admission and uterine evacuation was 7.9 hours. After a cut-off time of 10 hours, the development of complications increased considerably. Black women and those admitted during nightshifts were more likely to experience a wait time ≥10 hours. Delays were associated with severe complications (OR 1.97; 95%CI: 1.55-2.51), including in the women admitted in good condition (OR 2,56; 95%CI: 1.85-3.55), and even following adjustment for gestational age and reported abortion type (spontaneous/induced). These findings corroborate the literature, highlighting the social vulnerability of women hospitalized within Brazil's public healthcare system in a situation of abortion. The study strongpoints include having objectively measured the time between admission and uterine evacuation and having established a cut-off time defining delay based on conceptual and epidemiological criteria. Further studies should evaluate other settings and new measurement tools for effectively preventing life-threatening complications.

Exploring the reasons for unsafe abortion among women in the reproductive age group in western Ethiopia

BackgroundUnsafe abortion, even though it is preventable, remains a significant cause of mortality and morbidity among women in the developing world. It has always been a dilemma for researchers to explore the reasons for unsafe abortion in communities due to the sensitive nature of the subject. As a result, the aim of this study was to explore the reasons for unsafe abortion in women of reproductive age in western Ethiopia, 2022. MethodsA qualitative study with a purposive sampling technique was used to explore the reasons for unsafe abortion. The sample size was determined by the data theoretical saturation. Thematic data analysis was used to analyse the data, which was aided by Open Code 4.03 software. ResultsFive thematic categories were drawn from the collected data. The categories were: lack of knowledge of safe abortion policy and services; socioeconomic conditions; safe abortion as a real religious and cultural taboo; stigma of unplanned pregnancy; and a desire to pursue education. ConclusionThe obtained evidence in this study revealed that lack of knowledge, poor socioeconomic conditions, cultural and religious beliefs, stigma of unplanned pregnancy, and a desire to pursue education were quoted by participants as reasons to unsafe abortion practices. As a result, it is critical to improve family planning education, raise awareness about safe abortion services, and educate young women about the consequences of unsafe; abortion to reduce the rate of unwanted pregnancy and unsafe abortion-related complications.

Women leaders perceived barriers and consequences of safe abortion in Rwanda: a qualitative study

BackgroundBetween 2010 and 2014, approximately 25 million unsafe abortions were performed annually across the globe. Africa alone accounted for 29% of all unsafe abortions, and 62% of the related deaths. Women living in poverty, especially adolescents, lack information about where and how to access safe abortion services. They often lack adequate insight to make informed decisions. The purpose of this study was to explore the empowered perspectives of women leaders in Rwanda about the recent policy change for safe abortion. The study identifies women leaders’ perceived barriers and their attitudes about resulting consequences toward safe abortion.MethodIn this qualitative study, seven focus group discussions and eight key informant interviews were performed in October 2019. A total of 51 women leaders participated, their age ranging from 38 to 60 years. Participants were drawn from three districts, namely Gasabo, Kicukiro, and Nyarugenge. For variability of data, participants came from parliament, government ministries, government parastatals, and civil society organizations. All interviews were conducted in Kinyarwanda and later translated into English. Data were analyzed using qualitative content analysis.ResultsThe emerging theme Strong barriers and numerous consequences of safe abortion illustrates how women leaders perceive barriers to safe abortion and its related consequences in Rwanda. The theme is divided into two categories: (1) Perceived barriers of safe abortion and (2) Consequences of providing safe abortion. The sub-categories for the first category are Reluctance to fully support safe abortion due to perceived unjustified abortions”, Abortion-related stigma, Abortion is against cultural and religious beliefs, Emotional attachment to the unborn and Lack of awareness of abortion. The sub-categories for the second category are Perceived physiological trauma, Cause for barrenness/infertility, Increase in services abuse by adolescents/women, Increase of workload for healthcare providers, “Increase in sexual activities and STIs, and Abortion-related physiological trauma.ConclusionThe subject of safe abortion evokes mixed reactions among participants, and is entangled with unsafe abortion in most cases. Participants stress that the word ‘abortion’ disturbs, regardless of whether it relates to being safe or unsafe. Participants believe the word ‘abortion’ outweighs the word ‘safe’. Societal expectations play a major role in the decision-making process of any adolescent or a family member faced with a pregnant adolescent regardless of the existing safe abortion law. Community mobilization and sensitization are crucial if safe abortion in accordance with abortion law is to be embraced. Messages that reinforce safe abortion as acceptable and address stigma, fears of trauma, and barrenness should be developed to educate adolescents, parents, and women leaders about safe abortion, to mitigate unsafe abortion-related complications.

Causes of death, three delays, and factors associated with Delay 1 among maternal deaths in Myanmar: The maternal death surveillance in 2019

ObjectiveThe maternal mortality ratio (MMR) in Myanmar was the highest in Southeast Asia in 2017. The Three Delay Model is used to evaluate delays that contribute to maternal deaths. This study aims to identify MMR, causes of death, the three delays related to maternal deaths, and the factors associated with Delay 1, which is the time of delay in deciding to seek health care (from the start of the woman's illness to the time when the problem is recognized to be requiring care), in Myanmar. Study designA cross-sectional study. ParticipantThis study included 934 cases of maternal deaths reported from all states and regions throughout Myanmar in 2019 that were not caused by accidents and injuries. Materials and methodsSocio-demographic factors, obstetrical factors, information about deaths, and assessment of delays were obtained from the Maternal Death Surveillance and Response System, the database of maternal deaths. Distribution of maternal deaths by states and regions, causes of maternal death, and types of delay that contributed to maternal deaths were descriptively summarized. Logistic regression analysis was performed to identify factors associated with Delay 1 among 567 maternal deaths without any missing data and unknown information on delays. FindingsIn 2019, the MMR was 106 (95% confidence interval, 99–112) per 100,000 live births. Of the 934 maternal deaths, 80.5% of deaths had at least one delay, and Delay 1 was the major delay (72.9%). Eclampsia/pre-eclampsia (21.6%), postpartum hemorrhage (18.2%), and abortion-related complications (13.2%) were the major causes of maternal death. The husband's low education, low household income, unplanned pregnancy, and no antenatal care were associated with Delay 1. Key conclusions and implication for practiceThe MMR was lower in 2019 than that in 2017 but remained high. Moreover, we demonstrate that most maternal deaths had at least one delay, mostly Delay 1. To prevent maternal deaths caused by Delay 1, the family planning should be promoted to prevent unplanned pregnancies. Educational training for healthcare providers who deliver antenatal care should be strengthened. Furthermore, education on the danger signs of pregnancy and during childbirth should be provided not only to pregnant women and their husbands in communities at health facilities.

Improving safe post-abortion care practices: A study on interventions implemented by Ipas Pakistan.

An estimated 50 million induced abortions occur in developing countries annually, and an estimated 7 million women are treated for complications associated with unsafe abortions. According to a 2012 estimate, 15 per 1,000 women aged 15-49 years seek treatment for abortion-related health complications in both private and public sectors. A high unmet need for family planning in Pakistan and a low percentage of women adopting a contraceptive method in the post-partum period led to unwanted pregnancy becoming one of the reasons for unsafe abortion. Post-abortion care (PAC) is an integrated service delivery model that includes both maternal health and family planning interventions. The study aims to examine improvement in abortion-related practices through the implementation of the PAC model at all tiers of public health service delivery systems in the two most populous provinces-Punjab, Sindh, Khyber Pakhtunkhwa, and Islamabad Capital Territory (ICT) region-of Pakistan. The improvement model comprises clinical training of healthcare providers, community engagement, and counseling of community women on safe post-abortion practices. It was a descriptive study utilizing data of 27,616 PAC clients recorded and reported by the service providers on the logbooks from 104 selected public health facilities from March 2018 to December 2021 in ICT, Punjab, Sindh, and Khyber Pakhtunkhwa provinces of Pakistan. Women who received PAC services were older than 25 years, 22,652 (82%), with a mean age of 29 years. Most of these women were in their first trimester, 26,110 (95%), and the majority diagnosed with PAC (incomplete, missed, or threatened abortion), 26,838 (97%). The majority of women, 25,324 (92%), received safe methods for post-abortion care that included the use of misoprostol, 15,804 (58%), and manual vacuum aspiration, 8,898 (32%). In total, 17,105 (72%) of women opted for a contraceptive method that included long-acting reversible contraceptives, 2,313 (10%); short-term excluding condoms, 3,436 (27%); and condoms, 8,113 (34%). The key predictors identified for uptake of the post-abortion family planning method indicated that women more than 25 years of age, in the early second trimester, and who were counseled on post-abortion family planning were more likely to adopt the contraceptive method than others. Increased access to post-abortion care and family planning could potentially reduce the incidence of unsafe abortion, unintended pregnancies, and associated maternal mortality. The experience of Pakistan suggests that the integrated post-abortion care service delivery model can be effectively implemented across the public health systems.

High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study)

BackgroundAbortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR).MethodsWe used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records’ reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity.ResultsWe analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%).ConclusionOur data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

The Impact of the COVID-19 Pandemic on the Care of Women Experiencing Abortion in a University Hospital in Brazil.

To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with miscarriage and legal termination of pregnancy in a university hospital in Brazil. A cross-sectional study of women admitted for abortion due to any cause at Hospital da Mulher Prof. Dr. J. A. Pinotti of Universidade Estadual de Campinas (UNICAMP), Brazil, between July 2017 and September 2021. Dependent variables were abortion-related complications and legal interruption of pregnancy. Independent variables were prepandemic period (until February 2020) and pandemic period (from March 2020). The Cochran-Armitage test, Chi-squared test, Mann-Whitney test, and multiple logistic regression were used for statistical analysis. Five-hundred sixty-one women were included, 376 during the prepandemic period and 185 in the pandemic period. Most patients during pandemic were single, without comorbidities, had unplanned pregnancy, and chose to initiate contraceptive method after hospital discharge. There was no significant tendency toward changes in the number of legal interruptions or complications. Complications were associated to failure of the contraceptive method (odds ratio [OR] 2.44; 95% confidence interval [CI] 1.23-4.84), gestational age (OR 1.126; 95% CI 1.039-1.219), and preparation of the uterine cervix with misoprostol (OR 1.99; 95% CI 1.01-3.96). There were no significant differences in duration of symptoms, transportation to the hospital, or tendency of reducing the number of legal abortions and increasing complications. The patients' profile probably reflects the impact of the pandemic on family planning.

“They talked to me rudely”. Women perspectives on quality of post-abortion care in public health facilities in Kenya

BackgroundAccess to safe abortion is legally restricted in Kenya. Therefore, majority women seeking abortion services in such restrictive contexts resort to unsafe methods and procedures that result in complications that often require treatment in health facilities. Most women with abortion-related complications end up in public health facilities. Nevertheless, evidence is limited on the quality of care provided to patients with abortion complications in public health facilities in Kenya.MethodsData for this paper are drawn from a qualitative study that included interviews with 66 women who received post-abortion care in a sample of primary, secondary and tertiary public health facilities in Kenya between November 2018 and February 2019. The interviews focused on mechanisms of decision-making while seeking post-abortion care services, care pathways within facilities, and perceptions of patients on quality of care received including respect, privacy, confidentiality, communication and stigma.FindingsThe participants’ perceptions of the quality of care were characterized as either “bad care” or “good care”, with the good care focusing on interpersonal aspects such as friendliness, respect, empathy, short waiting time before receiving services, as well as the physical or functional aspects of care such as resolution of morbidity and absence of death. Majority of participants initially reported that they received “good care” because they left the facility with their medical problem resolved. However, when probed, about half of them reported delays in receiving care despite their condition being an emergency (i.e., severe bleeding and pain). Participants also reported instances of abuse (verbal and sexual) or absence of privacy during care and inadequate involvement in decisions around the nature and type of care they received. Our findings also suggest that healthcare providers treated patients differently based on their attributes (spontaneous versus induced abortion, single versus married, young versus older). For instance, women who experienced miscarriages reported supportive care whereas women suspected to have induced their abortions felt stigmatized.ConclusionThese findings have far reaching implications on efforts to improve uptake of post-abortion care, care seeking behaviors and on how to assess quality of abortion care. There should be emphasis on interventions meant to enhance processes and structural indicators of post-abortion care services meant to improve patients’ experiences throughout the care process. Moreover, more efforts are needed to advance the tools and approaches for assessing women experiences during post-abortion care beyond just the overriding clinical outcomes of care.

Legal Limits Relaxed: Time to Look at Other Barriers Faced by Women Seeking Termination of Pregnancy for Fetal Anomalies.

Introduction Advancements in prenatal diagnostic techniques have led to an increase in demand for termination of pregnancy for fetal anomalies (TOPFA). While relaxation in the legal gestational age limits across various countries relieves an important barrier, there is a need to identify the reasons that lead to delays in seeking abortion for fetal anomalies, because abortion-related complications increase with gestational age. Methods In this hospital-based qualitative study, antenatal women referred to a tertiary care institute in North India because of major fetal anomalieswere explained about the study. Those women who fulfilled the inclusion criteria were recruited after taking consent. Details of antenatal care and prenatal tests were recorded. An in-depth inquiry was made into the reasons for the delay in prenatal tests, the delay in the decision for abortion, and specific problems that they faced in seeking TOPFA. Results Out of 80 women who met the inclusion criteria and consented to participate, more than 75%had received antenatal care in public healthcare facilities. Less than 50% of women received folic acid in the first trimester while 26% had first contact with healthcare facilities in the second trimester. Only 21 women underwent screening for common aneuploidies. Second-trimester anomaly scan was delayed in 35 women due to women-centered reasons (n = 17) or provider-centered (n = 19) reasons. Only 37.5% of women were counseled about fetal anomalies by their primary care provider. Owing to delay at multiple levels, 40 women (50%) could receive counseling about fetal abnormality for the first time after 20 weeks. These women could not be offered abortion because this study was carried out before theamendments in the Medical Termination of Pregnancy Act in India. The older act allowed abortion up to 20 weeks of gestation. Seventeen women could obtain permission for an abortion from a court of law. Arrangements for travel and stayand dependence on family members were the main problems faced by women seeking TOPFA. Conclusions Delay in diagnosis of a fetal anomaly due to delay in seeking antenatal care, irregular follow-up, and lack of pre-test counseling are the major reasons for the delay in the decision for abortion. This is further compounded by inadequate post-test counseling. Lack of awareness, failure or delay in counseling, need to travel to another facility for abortion, dependence on family members, and financial issues are the major barriers.

Male perceptions of post-abortion care in Karachi, Pakistan

Background/Aims The high maternal mortality in Pakistan stems from pregnancy- or abortion-related complications. Pakistan's patriarchal society, where men are key decision-makers, makes it necessary to involve men in maternal and child reproductive health care initiatives. This study aimed to understand men's perceptions of post-abortion care in Karachi, Pakistan. Methods A descriptive qualitative exploratory research design was used. Data were collected from 10 participants through in-depth interviews, and were analysed thematically. Results The themes were ‘men's understanding of post-abortion care’, ‘barriers to post-abortion care’ and ‘men's role in enhancing postabortion care practices: a missing link’. The participants believed that abortion was allowed only on medical grounds, and that most women could not use post-abortion care services because of the associated cost. Conclusions Men are key decision-makers in Pakistan. There is a need to educate and provide men with adequate information on post-abortion care. Male health workers should be recruited in the community. Stakeholders should ensure the availability and accessibility of post-abortion care services in the public health setting so women can receive care in a timely manner.

O10The association between self-managed abortion and abortion complications: A national cross-sectional analysis in india

<h3>Objectives</h3> Despite abortion being legal in India since 1971, the rate of abortion complications remains high. This high rate of complications has been attributed, at least in part, to abortions occurring outside of the legal facility-based system. We assessed the association between self-managed abortion and abortion complications among women in India. <h3>Methods</h3> This is a cross-sectional analysis among women in India who participated in the National Family Health Survey (NFHS-4) of 2015–2016. We used two multivariable binomial logistic regression models to assess the association between self-managed abortion and abortion-related complications (with and without gestational age as a covariate). <h3>Results</h3> Of the 1,027 pregnancies that ended in abortion, 332 (32%) were reported as self-managed. After adjusting for age, parity, having a living son, caste, intimate partner violence, education and income, self-managed abortion was associated with fewer abortion-related complications than clinician-managed abortions (adjusted OR (aOR), 0.53; 95% CI, 0.31–0.92). The trend remained but the difference was no longer statistically significant after further adjusting for gestational age at the time of abortion (aOR, 0.63; 95% CI, 0.36–1.10). <h3>Conclusions</h3> After we adjusted for gestational age, self-managed and clinician-managed abortion in India had similar complication rates. Women who self-manage abortion likely use safe methods, such as misoprostol with or without mifepristone, and face fewer barriers in accessing care resulting in abortion access at an earlier gestational age, which decreases risk of complications. These findings highlight the importance of self-managed abortion as an affordable, safe and private option.

Health-related reasons patients transfer from a clinic or health post to the Emergency Department in a District Hospital in Botswana.

IntroductionRural health clinics in low-resource settings worldwide are usually staffed with health care workers with limited knowledge and skills in managing acute emergencies. The Emergency Centre (EC) at the district hospital or primary hospital serves as an entry point for patients with diverse medical needs from health posts and community clinics. The study described the socio-demographic characteristics, primary diagnosis, and disposition of patients transferred from the clinics and health posts to the district hospital in the Kweneng district.MethodThis study is a chart audit of the triage sheets and admitting medical records (Botswana Integrated Patient Management System, IPMS) conducted for the period June through to December 2020. Descriptive statistics were used to analyze the quantitative data. Frequencies, percentages, and measures of central tendency were calculated using the software, SPSS version 27.ResultsA total of 1565 charts were reviewed; 56% (n = 877) were females and 43.5% (n = 681) were males. Half of the patients presenting to the EC ranged from ages 21 to 50, with a mean age of 36.49. The most frequently reported reason for referral was “trauma,” (23.5%, n = 368) whereas the second common reason for referral was abortion-related complications (14.2%, n = 222). The highest admissions were from abortion-related complications (20.2%, n = 169). Most patients’ transfers were from clinics and health posts outside Molepolole (59.4%, n = 930). More than half of the patients (64.2%, n = 537) transferred from outside Molepolole were admitted than discharged from the EC.DiscussionOur study has shown significant transfers to a higher facility for emergency care. The higher number of transfers are trauma-related cases, whereas most patients were admitted for abortion-related complications indicating the need for skill-building in trauma care and management of abortions.

Strengthening access to long-acting reversible contraception within postabortion care in Tanzania: A pre-post evaluation.

Postabortion care services provide lifesaving treatment for abortion-related complications and addresses women's needs by offering family planning (FP) counseling and voluntary access to contraception. Between 2016 and 2020, the Government of Tanzania sought to strengthen its PAC program by enhancing FP counseling and clients' access to a wide range of contraceptive options. The project team conducted a pre-post evaluation in 17 public sector healthcare facilities in mainland Tanzania and 8 in Zanzibar. It comprised structured client exit interviews (CEIs), completed first in 2016 (n=412) and again in 2020 (n=484). These data complemented an evaluation that used routine service statistics to demonstrate the intervention's effects on client-reported outcomes. Primary outcomes of the CEIs reflected client experience and satisfaction with services, and researchers compared pre-post differences using chi-square tests. There were improvements in numerous indicators, including client waiting times, recall of emergency procedure counseling, contraceptive uptake, and satisfaction with the quality of overall counseling and FP information and services; however, triangulation of CEI data with service statistics indicated that some outcomes, though still improved since baseline, attenuated. Strengthening the FP component of PAC is feasible in Tanzania and Zanzibar, but strategies to sustain quality improvements over time are needed.

Health systems\u2019 preparedness to provide post-abortion care: assessment of health facilities in Burkina Faso, Kenya and Nigeria

BackgroundIn many parts of sub-Saharan Africa, access to abortion is legally restricted, which partly contributes to high incidence of unsafe abortion. This may result in unsafe abortion-related complications that demand long hospital stays, treatment and attendance by skilled health providers. There is however, limited knowledge on the capacity of public health facilities to deliver post-abortion care (PAC), and the spread of PAC services in these settings. We describe and discuss the preparedness and capacity of public health facilities to deliver complete and quality PAC services in Burkina Faso, Kenya and Nigeria.MethodsA cross-sectional survey of primary, secondary and tertiary-level public health facilities was conducted between November 2018 and February 2019 in the three countries. Data on signal functions (including information on essential equipment and supplies, staffing and training among others) for measuring the ability of health facilities to provide post-abortion services were collected and analyzed.ResultsAcross the three countries, fewer primary health facilities (ranging from 6.3–12.1% in Kenya and Burkina Faso) had the capacity to deliver on all components of basic PAC services. Approximately one-third (26–43%) of referral facilities across Burkina Faso, Kenya and Nigeria could provide comprehensive PAC services. Lack of trained staff, absence of necessary equipment and lack of PAC commodities and supplies were a main reason for inability to deliver specific PAC services (such as surgical procedures for abortion complications, blood transfusion and post-PAC contraceptive counselling). Further, the lack of capacity to refer acute PAC cases to higher-level facilities was identified as a key weakness in provision of post-abortion care services.ConclusionsOur findings reveal considerable gaps and weaknesses in the delivery of basic and comprehensive PAC within the three countries, linked to both the legal and policy contexts for abortion as well as broad health system challenges in the countries. There is a need for increased investments by governments to strengthen the capacity of primary, secondary and tertiary public health facilities to deliver quality PAC services, in order to increase access to PAC and avert preventable maternal mortalities.