Provision Of Abortion Services Research Articles

Counting unreported abortions: A binomial-thinned zero-inflated Poisson model

(ProQuest: ... denotes formulae omitted.)1.IntroductionIn most demographic surveys, the number of intentional abortions is significantly underreported. For example, in the National Survey of Family Growth (NSFG), a survey of US women, only 38% of intentional abortions done during the years 20062013 are reported according to the estimates of the National Center for Health Statistics (NCHS). This estimate assumes that the data collected from abortion-service providers through a separate survey is accurate. Reporting rates of intentional abortions at the previous waves of the also have been estimated to be in the range of 35%-48%. Other major surveys of US women, such as the National Surveys of Young Women (NSYW) and the National Longitudinal Surveys of Work Experience of Youth (NLSY), too suffer from this limitation (Jones and Forrest 1992). Underreporting of this magnitude strictly limits the usefulness of self-reported abortion data. The warns that NSFG data on abortion should not be used for substantive research (USDHHS 2014: 35).When intentional abortions are underreported, the total number of reported pregnancies is also automatically underreported, even if other pregnancy outcomes are accurately reported.2 It hinders the accurate estimation of pregnancy timing, contraceptive efficiency, and many other impact-assessment studies in which the number of abortions or pregnancies could potentially be the dependent variable. Nevertheless, in many studies, self-reported abortion counts are analyzed to make strong conclusions while ignoring the impact of underreporting. For example, in Grindlay and Grossman (2013), cross-sectional data from the Department of Defense's survey of health-related behaviors among active-duty military personnel in 2005 and 2008 are analyzed to conclude that the rate of unwanted pregnancies (per 1000 women of reproductive age) has increased from 97 to 105 during the two years, notwithstanding the declared national goal of the government to reduce unwanted pregnancies. They also estimate that the unintended-pregnancy rate in the US military is 50% higher than that rate of the general US population, despite many formal and informal restrictions on sexual relationships faced by women (and men) in the military. Both of these observations could potentially be artifacts of differential reporting rates, across time periods in the first case and among the two groups in second case, due to the differences in the extent of perceived social undesirability of abortion. Another recent study, Tapales and Finer (2015), relies on the assumption that the reporting rates of intentional abortions of different subgroups do not vary across time periods.Some researchers attempt to correct the bias due to underreported abortions before producing a related estimate. Lindberg (2011), another study on the unintendedpregnancy rate in the US military that analyzes data from the same survey as Grindlay and Grossman (2013), assumes that everyone in their sample reports only a fixed percentage of intentional abortions and therefore a fixed percentage of true pregnancies. The unreported pregnancies are assumed to be 11.9% of the number of reported cases based on two previous studies that estimate the reporting rates of intentional abortions in the in comparison to provider surveys. In addition to ignoring the differences in reporting rates across various subgroups, this study simply ignores that the average reporting rate could vary significantly across different surveys.If the reporting rates of intentional abortions are known, preferably at the individual level, it is possible to correct for any potential bias due to underreporting in many studies. When the reporting rate at a particular survey is not known, researchers in most cases simply ignore misreporting, as in Grindlay and Grossman (2013), or use an estimate from a previous study, which may or may not be based on the same survey, as in Lindberg (2011). …

Induced Abortion: a Systematic Review and Meta-analysis.

Background:Induced abortion accounts for 1 in 8 of approximately 600000 maternal deaths that occur annually worldwide. Induced abortion rate can be considered as one of the indicators for assessing availability of the appropriate reproductive health plans for women and identifying needs for appropriate related health policies and programs.Material and Methods:Researchers searched Pubmed, Google Scholar, CINAHL, Embase, PsycINFO, Cochrane, Iranian Scientific Information Database (SID), Iranian biomedical journals (Iranmedex), and Iranian Research Institute of Information and Documentation (Irandoc) between January 2000 and June 2013, which reported induced abortion. Search terms from two categories including abortion and termination of pregnancy were compiled. The search terms were “induced abortion”, “illegal abortion”, “illegal abortion”, “unsafe abortion”, and “criminal abortion”. The search was also conducted with “induced termination of pregnancy”, “illegal termination of pregnancy”, “illegal termination of pregnancy”, “unsafe termination of pregnancy” and “criminal termination of pregnancy”. Meta-analysis was carried out by using OpenMeta software. Induced abortion rates were calculated based on the random effect model.Results:Overall induced abortion rate was obtained 58.1 per 1000 women (95%CI: 55.16-61.04). In continental level, rate of induced abortion was 14 per 1000 women (95%CI: 11-16). Nation-wide and local rates were obtained 67.27 per 1000 women (95% CI: 60.02-74.23) and 148.92 (95% CI: 140.06-157.79) respectively.Discussion and Conclusion:Induced abortion is a major public health problem that occurs worldwide whether under the legal restriction or freedom, and it remains as reproductive health concern globally. To eliminate the need for induced abortion is at the core of any effort for preventing this issue. Option with the highest priority is to prevent unwanted pregnancies through promoting reproductive health plans for women of reproductive age. In case the prevention strategies fail, universal provision of safe abortion services should be put in place.

The influence of norms and values on the provision of termination of pregnancy services in South Africa

IntroductionAs front-line providers, nurses play an integral role in the implementation of South Africa’s Choice on Termination of Pregnancy Act and, thus, the promotion of women’s reproductive rights. In light of low levels of support for termination of pregnancy services in South Africa, it is important to understand nurses’ views of such services. The purpose of this study was to examine how nurses’ norms and values shape the provision of abortion services. MethodsQualitative interviews with nurses were conducted at seven rural hospitals in the Western Cape Province of South Africa. Data were analysed using thematic and narrative analysis. ResultsNurses, like other public service workers, make moral judgments about their clients. They classify clients seeking abortions into two groups: those ‘worthy’ of support, and those ‘unworthy’ of support. Nurses’ moral judgments are largely shaped by the circumstances of the pregnancy and the behaviour of the client. In addition, nurses’ understanding of their professional identity and their work environments may influence their decision whether a client deserves their assistance. While nurses claimed that they would offer the same services to all of their clients, further research on the availability and quality of abortion services is required to confirm these results. ConclusionThe study shows that nurses make moral judgments about abortion clients and divide them into deserving and less deserving clients. These value judgments undermine the rights-based approach of South African legislation, which provides every women with the right to choose whether they wish to terminate a pregnancy.

Cervical preparation prior to second-trimester surgical abortion and risk of subsequent preterm birth

Dilatation and evacuation, or D&E, is the safest method of second-trimester surgical abortion. It has a lower rate of immediate complications than the alternative of medical induction, causes less pain...

Post-abortion family planning counselling practice among abortion service providers in China: a nationwide cross-sectional study

Objective: To assess the practice of post-abortion family planning (PAFP) counselling among Chinese abortion service providers, and identify the influencing factors.Methods: A cross-sectional questionnaire survey was conducted between July and September 2013 among abortion services providers in 30 provinces in China. Univariate and multivariable logistic regression analyses were used to identify the factors that influenced PAFP counselling.Results: 94% of the 579 service providers responded to the questionnaire in the survey. The median age was 39 years (range 20–72), and 95% were females. 92% providers showed a positive attitude and had promoted the PAFP counselling services; however, only 57% spent more than 10 min for it. The overall knowledge on PAFP was limited to the participants. After adjusting for potential confounding factors: providers from the middle region (compared with ‘east region’, ORadj = 3.33, 95% CI: 2.12–5.21) conducted more PAFP counseling; providers with more knowledge (ORadj = 2.08, 95% CI: 1.38–3.15) provided more counseling; and compared with ‘middle school and below’, providers with higher education gave more counseling [ORadj(95% CI)] for ‘college’, ‘university’ and ‘master/doctor’ [1.99 (1.01,3.92), 2.32 (1.22,4.40) and 2.34 (1.06,5.17), respectively].Conclusions: The majority of providers could provide PAFP counselling to women undergone an abortion, but some of them had insufficient time to make it available. Education, knowledge about fertility and reproductive health and residence region were the main factors influencing the practice. Training of health providers and integrating family planning as a part of abortion services are essential to provide adequate PAFP to abortion seekers, thereby reducing the risk of unintended pregnancy.

Intended and unintended consequences of abortion law reform: perspectives of abortion experts in Victoria, Australia

IntroductionIn Victoria, Australia, abortion was decriminalised in October 2008, bringing the law in line with clinical practice and community attitudes. We describe how experts in abortion service provision perceived the...

The availability of abortion at state hospitals in Turkey: A national study

IntroductionAbortion in Turkey has been legal since 1983 and remains so today. Despite this, in 2012 the Prime Minister declared that, in his opinion, abortion was murder. Since then, there has been growing evidence that abortion access particularly in state hospitals is being restricted, although no new legislation has been offered. ObjectivesThe study aimed to determine the number of state hospitals in Turkey that provide abortions. Study designThe study employed a telephone survey in 2015–2016 where 431 state hospitals were contacted and asked a set of questions by a mystery patient. If possible, information was obtained directly from the obstetrics/gynecology department. I removed specialist hospitals from the data set and the remaining data were analyzed for frequency and cross-tabulations were performed. ResultsOnly 7.8% of state hospitals provide abortion services without regard to reason which is provided for by the current law, while 78% provide abortions when there is a medical necessity. Of the 58 teaching and research hospitals in Turkey, 9 (15.5%) provide abortion care without restriction to reason, 38 (65.5%) will do the procedure if there is a medical necessity and 11 (11.4%) of these hospitals refuse to provide abortion services under any circumstances. There are two regions, encompassing 1.5 million women of childbearing age, where no state hospital provides for abortion without restriction as to reason. ConclusionThe vast majority of state hospitals only provide abortions in the narrow context of a medical necessity, and thus are not implementing the law to its full extent. It is clear that although no new legislation restricting abortion has been enacted, state hospitals are reducing the provision of abortion services without restriction as to reason. ImplicationsThis is the only nationwide study to focus on abortion provision at state hospitals.

Stigmatized by association: challenges for abortion service providers in Ghana.

BackgroundUnsafe abortion is an issue of public health concern and contributes significantly to maternal morbidity and mortality globally. Abortion evokes religious, moral, ethical, socio-cultural and medical concerns which mean it is highly stigmatized and this poses a threat to both providers and researchers. This study sought to explore challenges to providing safe abortion services from the perspective of health providers in Ghana.MethodsA descriptive qualitative study using in-depth interviews was conducted. The study was conducted in three (3) hospitals and five (5) health centres in the capital city in Ghana. Participants (n = 36) consisted of obstetrician/gynaecologists, nurse-midwives and pharmacists.ResultsStigma affects provision of safe-abortion services in Ghana in a number of ways. The ambiguities in Ghanaian abortion law and lack of overt institutional support for practitioners increased reluctance to openly provide for fear of stigmatisation and legal threat. Negative provider attitudes that stigmatised women seeking abortion care were frequently driven by socio-cultural and religious norms that highly stigmatise abortion practice. Exposure to higher levels of education, including training overseas, seemed to result in more positive, less stigmatising views towards the need for safe abortion services. Nevertheless, physicians open to practicing abortion were still very concerned about stigma by association.ConclusionsStigma constitutes an overarching impediment for abortion service provision. It affects health providers providing such services and even researchers who study the subject. Exposure to wider debate and education seem to influence attitudes and values clarification training may prove useful. Proper dissemination of existing guidelines and overt institutional support for provision of safe services also needs to be rolled out.

The Law of Stigma, Travel, and the Abortion-Free Island

In 1988, the Supreme Court of Canada decriminalized abortion in R. v. Morgentaler. (1) Almost immediately thereafter, the Maritime province of Prince Edward Island (P.E.I.) passed a legislative resolution opposing the provision of abortion services on the Island except to save the life of a pregnant woman. (2) P.E.I. is a small pastoral province of rolling hills and ocean coves in the St. Lawrence Gulf, and since 1988, through various regulatory actions, its government has honored this policy promise to keep the Island abortion-free and to preserve its moral landscape. (3) The same year that abortion was banished from P.E.I., Prince Edward Islanders also voted yes to the building of the Confederation Bridge, which would join the Island to mainland Canada and make travel between them and convenient. (4) Opened on May 31, 1997, the Confederation Bridge is an amazing sight. Curved and eight miles long, the bridge is one of the greatest engineering feats of the twentieth century, the longest crossing over ice-covered water in the world. In its steel and concrete structure, durable and reinforcing, the bridge reflects the ingenuity of its engineers, who built a shield on the pier shafts to lift and break the ice flow under its own weight, and who built the bridge high enough to allow cruise ships to pass. (5) The story of the bridge, however, is not a single story. (6) More than steel and concrete, the bridge represents a historical problem and a vision of a solution to that problem, that is, the need for an easy and reliable crossing over a treacherous body of water. The bridge also captures more than a century of public controversy. The plebiscite vote to build the bridge followed a heated debate in which farmers, fishers, and other Islanders divided on how access to the mainland would affect their way of life. (7) The bridge challenged Islanders' sense of themselves, their past and future collective identity. (8) Likely unforeseen in 1988, the Confederation Bridge would also achieve a material and moral significance in the reproductive lives of Islanders, and the reproductive law of the province. Every year, Islanders cross the Confederation Bridge to access abortion services, with limited public funding, in neighboring provinces on the Canadian mainland. (9) The Confederation Bridge thus tells a story of abortion travel in Canada--women's long crossings over menacing, ice-covered waters, their feats of ingenuity, and their durable and reinforcing supports in this crossing. It is the story of a bridge built to break some women under their own weight, while allowing others to cruise past. It is the story of a problem and a solution to that problem. It is the story of a public controversy over how abortion challenges Islanders' sense of themselves, their past and their future--the Islander way of life. The Confederation Bridge offers a unique analytical vantage on the issue of abortion travel. Against a ground-level account of the individual traveler and her hardship, an aerial view of the bridge reveals the social and political landscape of abortion travel. It spatially represents a government policy of abortion travel as an act of banishment by and from the state. (10) A government policy that requires residents to leave the Island to access abortion services inflicts distinct harms of exclusion, disregard, and neglect, and calls forth a distinct rationale in justification for these harms, namely protection rather than only punishment. These harms and justification of abortion travel are best captured by the sociological concept of stigma, defined as a social process of devaluing or denigrating a group of people by denoting contempt or lack of respect for them, including by arousing feelings of anguish and inferiority in them. (11) Stigma begins with the labeling of some trait as socially relevant. (12) Abortion, the decision and act to terminate a pregnancy, has long been linked to undesirable moral qualities in the individual--sins of lust and gluttony, the sins of desire. …

How do women seeking abortion choose between surgical and medical abortion? Perspectives from abortion service providers.

Depending on availability, many Australian women seeking an abortion will be faced with the choice between surgical or medical abortion. Little is known about the factors that influence Australian women's choice of method. Through the perspectives of abortion service providers, this study aimed to explore the factors that contribute to Australian women's decision to have a surgical or medical abortion. In 2015, in-depth interviews were conducted with fifteen Victorian-based key informants (KIs) directly providing or working within a service offering medical abortion. Ten KIs were working at a service that also provided surgical abortion. Interviews were semi-structured, conducted face-to-face or over the telephone, transcribed verbatim and analysed thematically. KIs described varying levels of awareness of medical abortion, with poorer awareness in regional areas. When it comes to accessing information, women were informed by: their own research (often online); their own experiences and the experiences of others; and advice from health professionals. Women's reasons for choosing surgical or medical abortion range from the pragmatic (timing and location of the method, support at home) to the subjective (perceived risk, emotional impact, privacy, control, and physical ability). Women benefit from an alternative to surgical abortion and are well-placed to choose between the two methods, however, challenges remain to ensure that all women are enabled to make an informed choice. KIs identify the need to: promote the availability of medical abortion; address misconceptions about this method; and increase general practitioner involvement in the provision of medical abortion.

Repeat induced abortions in Georgia, characteristics of women with multiple pregnancy terminations: secondary analysis of the Reproductive Health Survey 2010

ObjectiveTo examine the multi-faceted characteristics of women with repeat induced abortions and assess post-abortion family planning service provision in Georgia. Study designWe performed secondary analysis of the data from the Georgian Reproductive Health Survey 2010. A logistic regression model was used to assess the socio-demographic and behavioral factors, contraceptive practices in relation to repeat induced abortions for 2203 women of reproductive age with at least one induced abortion. The Chi-Square test was used to evaluate provision of post-abortion family planning services. ResultsAmong the targeted women, 70% (n=1539) had repeat induced abortions. The odds of terminating pregnancy raised exponentially with age (OR 3.12, 95% CI: 2.11–4.61), number of complete pregnancies (3 vs. 0–1 complete pregnancies: OR 3.25, 95% CI: 2.36–4.48) and lower education (OR 1.38, 95% CI: 1.10–1.73). The current use of contraception had a protective effect on the occurrence of repeat induced abortions (OR 0.69, 95% CI: 0.53–0.89 for modern and OR 0.68, 95% CI: 0.50–0.92 for traditional methods).The contraceptive counseling and family planning method was provided only to 32% and 6% of post-abortion women, respectively before discharge from the clinic. Repeat induced abortions were found to be significantly more common (P<0.05) among women who did not receive any post-abortion contraceptive at the site of care (n=1627/1929) compared to those who left the abortion facility with family planning method (n=94/125). ConclusionLow education, higher age, high parity and non-usage of contraceptives carry an increased risk of repeat induced abortions. Post-abortion family planning service delivery is limited in Georgia. Mandating provision of universal post-abortion contraception at the sites of care has a potential to reduce repeat induced abortions and should become a standard of practice for all clinics providing abortion services in Georgia.

'…a one stop shop in their own community': Medical abortion and the role of general practice.

The introduction to Australia of modern medical abortion methods, which require less specialist expertise and equipment than the more traditional surgical methods, have brought an as yet unrealised potential to improve access to abortion services. To investigate the potential for expanding the role of general practice in the provision of medical abortion in Victoria. In 2015, in-depth interviews were conducted with 19 experts in abortion service provision in Victoria. A semi-structured interview schedule was used to guide the interviews. Interviews were transcribed verbatim and transcripts analysed thematically. Participants were largely very supportive of the provision of early medical abortion in general practice as a way of increasing abortion access for women, particularly in rural and regional communities. Access to abortion was seen as an essential component of women's comprehensive health care and therefore general practitioners (GPs) were perceived as ideally placed to provide this service. However, this would require development and implementation of new service models, careful consideration of GP and nurse roles, strengthening of partnerships with other health professionals and services in the community, and enhanced training, support and mentoring for clinicians. The application of these findings by relevant health services and agencies has the potential to increase provision of medical abortion services in general practice settings, better meeting the health-care needs of women seeking this service.

Bareras para el aborto seguro en el marco de la ley peruana

Objetivo: Examinar el proceso histórico para institucionalizar el aborto terapéutico en el Perú y precisar su situación actual. Metodología: Revisión de la información bibliográfica existente en el país en relación al proceso seguido por muchas instituciones hasta conseguir que el Ministerio de Salud apruebe la Guía Nacional para el Aborto Terapéutico. Luego el investigador principal convocó a 10 jefes de servicio/departamento de Ginecología y Obstetricia de igual número de hospitales que tienen regulada la prestación de servicios de aborto terapéutico mediante Guías o Protocolos locales desde 5 años antes, a quienes se les solicitó información. Resultados: La oficialización de la Guía Nacional para la prestación de servicios de aborto terapéutico por parte del Ministerio de Salud ha sido un trabajo persistente de muchas instituciones de la sociedad civil, pero los 10 hospitales convocados ya venían respondiendo a la demanda desde 5 años atrás. En los 5 años se atendió 257 abortos terapéuticos. La frecuencia del aborto terapéutico es aún baja, sin embargo se aprecia un aumento progresivo conforme avanzan los años. Es predominante la frecuencia de abortos terapéuticos en el segundo trimestre del embarazo, siendo la causa más frecuente las anomalías congénitas incompatibles con la vida. El uso del misoprostol en la evacuación del útero ha alcanzado el 95% de los casos y no se ha verificado más de 2% de complicaciones leves. Conclusión: El aborto legal por causales de salud se viene ofertando en forma restringida en el Perú.

Unmet counselling need amongst women accessing an induced abortion service in KwaZulu-Natal, South Africa

ObjectivesProvision of objective, evidence-based counselling in the context of induced abortion services is considered global good practise. However, there is limited understanding over the counselling needs of women accessing abortion services, particularly in sub-Saharan Africa. This study aimed to explore the content and quality of pre-abortion counselling amongst women accessing an abortion service in South Africa as well as client experience of the counselling process. Perceptions of nurse counsellors were also sought. Study designThis was a mixed methods study conducted at a Choice of Termination of Pregnancy clinic based at a district level hospital in KwaZulu-Natal, South Africa. Sixty women requesting an abortion were interviewed via a semi-structured questionnaire. In-depth interviews were conducted with four nurses who provided pre-abortion counselling at the clinic. Interviews were coded for emergent themes and categories. ResultsClinic nurses had widely variable counselling training and experience, ranging from less than 2 months to 8 years, but all clients reported that they had been treated with respect at their counselling session. The group-based counselling format and biomedical and health promotion content did not accommodate clients' differential counselling needs, which included requests for support from women experiencing intimate partner violence (IPV). There was limited provider awareness of client's additional counselling needs. ConclusionAbortion counselling services should be tailored to clients' differential counselling needs. Group-based counselling followed by optional one-on-one counselling sessions is one possible strategy to address unmet client need in South Africa. Provision of abortion provider training in IPV is recommended as well as establishment of referral pathways for women experiencing IPV. ImplicationsPaying attention to the differential counselling needs of women seeking an abortion should be a key component to the provision of abortion services. In this way, abortion services can provide a gateway to additional support for women living in violent relationships and/or other adverse social circumstances.

Population Policy: Abortion and Modern Contraception Are Substitutes.

A longstanding debate exists in population policy about the relationship between modern contraception and abortion. Although theory predicts that they should be substitutes, the empirical evidence is difficult to interpret. What is required is a large-scale intervention that alters the supply (or full price) of one or the other and, importantly, that does so in isolation (reproductive health programs often bundle primary health care and family planning—and in some instances, abortion services). In this article, we study Nepal’s 2004 legalization of abortion provision and subsequent expansion of abortion services, an unusual and rapidly implemented policy meeting these requirements. Using four waves of rich individual-level data representative of fertile-age Nepalese women, we find robust evidence of substitution between modern contraception and abortion. This finding has important implications for public policy and foreign aid, suggesting that an effective strategy for reducing expensive and potentially unsafe abortions may be to expand the supply of modern contraceptives.Electronic supplementary materialThe online version of this article (doi:10.1007/s13524-016-0492-8) contains supplementary material, which is available to authorized users.

Ensuring Access to Safe, Legal Abortion in an Increasingly Complex Regulatory Environment.

Restrictions on access to abortion in the United States have reached proportions unprecedented since the nationwide legalization of abortion in 1973. Although some restrictions aim to discourage women from having abortions, many others impede access by affecting the timeliness, affordability, or availability of services. Evidence indicates that these restrictions do not increase abortion safety; rather, they create logistic barriers for women seeking abortion, and they have the greatest effect on women with the fewest resources. In this commentary, we recall the important role that obstetrician-gynecologists (ob-gyns) have played, both before and after Roe v. Wade, in facilitating access to safe abortion care. Using the literature on abortion safety and access as a foundation, we propose several practical ideas about what we as ob-gyns can do to address the current threat to abortion access, whether or not we provide abortion services in practice. We hope that this commentary will encourage discourse within our profession and prompt other suggestions. As ob-gyns who are dedicated to addressing health disparities and promoting the health and well-being of our patients, we can make a difference.

Signal functions for measuring the ability of health facilities to provide abortion services: an illustrative analysis using a health facility census in Zambia.

BackgroundAnnually, around 44 million abortions are induced worldwide. Safe termination of pregnancy (TOP) services can reduce maternal mortality, but induced abortion is illegal or severely restricted in many countries. All abortions, particularly unsafe induced abortions, may require post-abortion care (PAC) services to treat complications and prevent future unwanted pregnancy. We used a signal-function approach to look at abortion care services and illustrated its utility with secondary data from Zambia.MethodsWe refined signal functions for basic and comprehensive TOP and PAC services, including family planning (FP), and assessed functions currently being collected via multi-country facility surveys. We then used the 2005 Zambian Health Facility Census to estimate the proportion of 1369 health facilities that could provide TOP and PAC services under three scenarios. We linked facility and population data, and calculated the proportion of the Zambian population within reach of such services.ResultsRelevant signal functions are already collected in five facility assessment tools. In Zambia, 30 % of facilities could potentially offer basic TOP services, 3.7 % comprehensive TOP services, 2.6 % basic PAC services, and 0.3 % comprehensive PAC services (four facilities). Capability was highest in hospitals, except for FP functions. Nearly two-thirds of Zambians lived within 15 km of a facility theoretically capable of providing basic TOP, and one-third within 15 km of comprehensive TOP services. However, requiring three doctors for non-emergency TOP, as per Zambian law, reduced potential access to TOP services to 30 % of the population. One-quarter lived within 15 km of basic PAC and 13 % of comprehensive PAC services. In a scenario not requiring FP functions, one-half and one-third of the population were within reach of basic and comprehensive PAC respectively. There were huge urban-rural disparities in access to abortion care services. Comprehensive PAC services were virtually unavailable to the rural population.ConclusionsSecondary data from facility assessments can highlight gaps in abortion service provision and coverage, but it is necessary to consider TOP and PAC separately. This approach, especially when combined with population data using geographic coordinates, can also be used to model the impact of various policy scenarios on access, such as requiring three medical doctors for non-emergency TOP. Data collection instruments could be improved with minor modifications and used for multi-country comparisons.

The individual level cost of pregnancy termination in Zambia: a comparison of safe and unsafe abortion

Zambia has one of the most liberal abortion laws in sub-Saharan Africa. However, rates of unsafe abortion remain high with negative health and economic consequences. Little is known about the economic burden on women of abortion care-seeking in low income countries. The majority of studies focus on direct costs (e.g. hospital fees). This article estimates the individual-level economic burden of safe and unsafe abortion care-seeking in Zambia, incorporating all indirect and direct costs. It uses data collected in 2013 from a tertiary hospital in Lusaka, (n = 112) with women who had an abortion. Three treatment routes are identified: (1) safe abortion at the hospital, (2) unsafe clandestine medical abortion initiated elsewhere with post-abortion care at the hospital and (3) unsafe abortion initiated elsewhere with post-abortion care at the hospital. Based on these three typologies, we use descriptive analysis and linear regression to estimate the costs for women of seeking safe and unsafe abortion and to establish whether the burden of abortion care-seeking costs is equally distributed across the sample. Around 39% of women had an unsafe abortion, incurring substantial economic costs before seeking post-abortion care. Adolescents and poorer women are more likely to use unsafe abortion. Unsafe abortion requiring post-abortion care costs women 27% more than a safe abortion. When accounting for uncertainty this figure increases dramatically. For safe and unsafe abortions, unofficial provider payments represent a major cost to women.This study demonstrates that despite a liberal legislation, Zambia still needs better dissemination of the law to women and providers and resources to ensure abortion service access. The policy implications of this study include: the role of pharmacists and mid-level providers in the provision of medical abortion services; increased access to contraception, especially for adolescents; and elimination of demands for unofficial provider payments.

Understanding abortion-related stigma and incidence of unsafe abortion: experiences from community members in Machakos and Trans Nzoia counties Kenya.

IntroductionThe rate of unsafe abortions in Kenya has increased from 32 per 1000 women of reproductive age in 2002 to 48 per 1000 women in 2012. This is one of the highest in Sub-Saharan Africa. In 2010, Kenya changed its Constitution to include a more enabling provision regarding the provision of abortion services. Abortion-related stigma has been identified as a key driver in silencing women's ability to reproductive choice leading to seeking to unsafe abortion. We sought to explore abortion-related stigma at the community level as a barrier to women realizing their rights to a safe, legal abortion and compare manifestations of abortion stigma at two communities from regions with high and low incidence of unsafe abortion.MethodsA qualitative study using 26 focus group discussions with general community members in Machakos and Trans Nzoia Counties. We used thematic and content analysis to analyze and compare community member's responses regarding abortion-related stigma.ResultsAlthough abortion is recognized as being very common within communities, community members expressed various ways that stigmatize women seeking an abortion. This included being labeled as killers and are perceived to be a bad influence for women especially young women. Women reported that they were poorly treated by health providers in health facilities for seeking abortion especially young unmarried women. Institutionalization of stigma especially when Ministry of Health withdrew of standards and guidelines only heightened how stigma presents at the facilities and drives women seeking an abortion to traditional birth attendants who offer unsafe abortions leading to increased morbidity and mortality as a result of abortion-related complications.ConclusionCommunity members located in counties in regions with high incidence of unsafe abortion also reported higher levels of how they would stigmatize a woman seeking an abortion compared to community members from counties in low incidence region. Young unmarried women bore the brunt of being stigmatized. They reported a lack of a supportive environment that provides guidance on correct information on how to prevent unwanted pregnancy and where to get help. Abortion-related stigma plays a major role in women's decision on whether to have a safe or unsafe abortion.

Abortion Incidence and Unintended Pregnancy in Nepal.

Although abortion has been legal under broad criteria in Nepal since 2002, a significant proportion of women continue to obtain illegal, unsafe abortions, and no national estimates exist of the incidence of safe and unsafe abortions. Data were collected in 2014 from a nationally representative sample of 386 facilities that provide legal abortions or postabortion care and a survey of 134 health professionals knowledgeable about abortion service provision. Facility caseloads and indirect estimation techniques were used to calculate the national and regional incidence of legal and illegal abortion. National and regional levels of abortion complications and unintended pregnancy were also estimated. In 2014, women in Nepal had 323,100 abortions, of which 137,000 were legal, and 63,200 women were treated for abortion complications. The abortion rate was 42 per 1,000 women aged 15-49, and the abortion ratio was 56 per 100 live births. The abortion rate in the Central region (59 per 1,000) was substantially higher than the national average. Overall, 50% of pregnancies were unintended, and the unintended pregnancy rate was 68 per 1,000 women of reproductive age. Despite legalization of abortion and expansion of services in Nepal, unsafe abortion is still common and exacts a heavy toll on women. Programs and policies to reduce rates of unintended pregnancy and unsafe abortion, increase access to high-quality contraceptive care and expand safe abortion services are warranted.