Provision Of Abortion Services Research Articles

Conscientious refusal or conscientious provision: We can't have both.

Some authors argue that it is permissible for clinicians to conscientiously provide abortion services because clinicians are already allowed to conscientiously refuse to provide certain services. Call this the symmetry thesis. We argue that on either of the two main understandings of the aim of the medical profession-what we will call "pathocentric" and "interest-centric" views-conscientious refusal and conscientious provision are mutually exclusive. On pathocentric views, refusing to provide a service that takes away from a patient's health is professionally justified because there are compelling reasons, based on professional standards, to refuse to provide that service (e.g., it does not heal, and it is contrary to the goals of medicine). However, providing that same service is not professionally justified when providing that service would be contrary to the goals of medicine. Likewise, the thesis turns out false on interest-centric views. Refusing to provide a service is not professionally justified when that service helps the patient fulfill her autonomous preferences because there are compelling reasons, based on professional standards, to provide that service (e.g., it helps her achieve her autonomous preferences, and it would be contrary to the goals of medicine to deny her that service). However, refusing to provide that same service is not professionally justified when refusing to provide that service would be contrary to the goals of medicine. As a result, on either of the two most plausible views on the goals of medicine, the symmetry thesis turns out false.

Healthcare professionals’ attitudes towards the termination of pregnancy: a qualitative analysis of survey data in Northern Ireland

Abortion was decriminalised in Northern Ireland in October 2019. Following decriminalisation, the new regulations set out legal provision for abortion up until 12 weeks, with conditions thereafter. This cross-sectional descriptive survey, conducted in late 2019 in Northern Ireland, gathered the views of health professionals on decriminalisation, and their willingness to provide abortion services. This article provides a thematic analysis of answers to narrative questions from the online survey, and identifies priority areas of engagement with healthcare professionals. We assess how healthcare professional roles and responsibilities, abortion procedures, the foetus, and women and pregnant people were discursively constructed by respondents who are willing or unwilling to provide abortion services in Northern Ireland. We identify a narrow understanding of ‘harm’, and gendered norms of women as irresponsible or duplicitous, as inhibitory factors to the normalisation of abortion services in Northern Ireland.

Can mid-level providers manage medical abortion after 12 weeks' gestation as safely and effectively as physicians? A non-inferiority, randomized controlled trial in Addis Ababa, Ethiopia.

To determine whether clinical outcomes among clients undergoing medical abortion after 12 weeks' gestation differ by provider cadre. Randomized controlled trial conducted among eligible clients seeking abortion between 13 and 20 weeks' gestation. Participants seeking in-facility abortion were randomized to receive care from a mid-level provider (nurse/midwife) or physician. The primary outcome was median time to expulsion with non-inferiority margin of -1.5 h between provider groups. Quantile median regression models assessed non-inferiority. Secondary outcomes included retained placenta, complications, and patient acceptability. After randomization and eligibility assessment by the provider, 171 women participated in the study: 81 in the physician group and 90 in the mid-level provider group. Their average age was 24 years, the mean gestational age was 16 weeks, and 65% were nulliparous in both groups. The median time to expulsion did not differ significantly, being 8.1 h for the mid-level group and 6.6 h for the physician group. The adjusted median difference was 0.8 h (95% confidence interval [CI] -1.15 to 2.66), within the non-inferiority margin. Retained placenta occurred similarly: 30.0% (n = 24) of the physician group and 20.5% (n = 18) of the mid-level provider group (adjusted risk difference [ARD] 7.6%, 95% CI -2.81 to 18.06). Complications occurred in 7% of cases, including 5.0% (n = 4) of patients in the physician group and 8.9% (n = 8) in the mid-level provider group (ARD -4.7%, 95% CI -12.43 to 3.12). Patient acceptability did not differ by group. Training mid-level providers to provide abortion services after 12 weeks' gestation independently of physicians is feasible and may result in comparable clinical outcomes.

Resilience Amid Chaos: Abortion Provision Across the United States During COVID-19.

Background: Pregnant people face many challenges to obtaining abortion services, including cost, stigma, administrative requirements, and legislative barriers. In 2020, the COVID-19 pandemic added additional barriers for clients and abortion service providers to overcome. Methods: The current study uses the Family Planning Visits During COVID-19 longitudinal dataset to explore abortion service provision from April 2020 through November 2020 from a sample of clinics (N = 63) providing abortion services across the United States. Results: Clinics in the sample were 49.2% academic/hospital-based, based in urban counties (96.8%), with a majority (82.5%) utilizing in-house providers for abortion care. Results show that the majority of clinics (59%) experienced staffing changes in response to COVID-19, including staff and clinicians who took extended leave, quit, were furloughed, or hired. Although the volume of overall abortion service provision decreased March through July 2020, the volume returned to pre-COVID numbers by August and surpassed pre-COVID volume in September and October 2020. Conclusion: Findings from this study demonstrate the adaptability and resilience shown by providers to ensure the continued availability of abortion services. Strategies adopted during COVID-19, such as telehealth and mail-delivery of abortion medication, may prove useful in a post-Roe legislative landscape.

The Provision of Abortion Care via Telehealth in the United States: A Rapid Review.

The recent Supreme Court decision Dobbs v. Jackson Women's Health that has overruled Roe v. Wade has resulted in severe limitations of abortion access throughout the United States. Telehealth has been put forth as one solution for improving access for reproductive health care, including abortion services. Telehealth has demonstrated safety and efficacy in several health care disciplines; however, its use for abortion care and services has not been explored and synthesized. As part of a larger review on telehealth and general reproductive health, our team identified a moderate amount of literature on telehealth and abortion care. We conducted a rapid review searching for eligible studies in MEDLINE, Embase, and CINAHL. Information was extracted from each included study to explore 4 key areas of inquiry: (1) clinical effectiveness, (2) patient and provider experiences, (3) barriers and facilitators, and (4) the impact of the coronavirus disease 2019 (COVID-19) pandemic. Twenty-five studies on the use of telehealth for providing abortion services published between 2011 and 2022 were included. Telehealth for medical abortion increased during the COVID-19 pandemic and was found to be safe and clinically effective, with high patient satisfaction. Overall, telehealth improved access and removed barriers for patients including lack of transportation. Legal restrictions in certain states were cited as the primary barriers. Studies contained limited information on the perspectives and experiences of health care providers and diverse patient populations. Abortion care via telehealth is safe and effective with high satisfaction and may also remove barriers to care including transportation and fear. Removing restrictions on telehealth for the provision of abortion services may further improve access to care and promote greater health equity.

Privileging Midwives for Abortion Care.

Since the US Supreme Court overturned Dobbs v Jackson, expanded access to abortion has been critical. Abortion is safe, and related complications are rare. The safety of abortion provision by advanced practice clinicians (APCs) is well documented. Despite the increase in targeted restrictions for patients and clinicians in many states post-Dobbs, in recent years there have been meaningful gains in recognition and codification of abortion as part of an expanded scope of practice for APCs. Thus, creating a formal written pathway for midwives to obtain privileges in abortion provision could also improve abortion access. In New York City's public health care system, the largest in the United States, midwives provide a significant portion of perinatal and gynecologic care. Yet, until recently, a process to privilege midwives in the provision of abortion services did not exist. In response, midwives and physicians at a large New York City hospital system sought key stakeholder support to develop a pathway for certified nurse-midwives and certified midwives, licensed midwives in New York state, to obtain the necessary training needed for independent abortion provision. This article describes the development of a midwifery-led pilot program to improve abortion access by increasing the availability of trained midwifery abortion providers, along with the results of staff meetings exploring attitudes toward abortion care by APCs. We report our safety statistics from this pilot program and share existing evidence for safety of abortion provision by midwives and other APCs.

A Focus on Contraception in the Wake of Dobbs.

A Focus on Contraception in the Wake of Dobbs.

Impacts of Protecting Life in Global Health Assistance policy in Nepal: a qualitative study

BackgroundDespite the legalization of abortion in 2002 and the concerted efforts of the Ministry of Health and Population, abortion services remain inaccessible for many Nepali women. In 2017, the United States government enacted the Protecting Life in Global Health Assistance (PLGHA) policy, which prohibited international non-governmental organizations (INGOs) from receiving United States global health assistance from providing abortion services or referrals or engaging in advocacy on liberalizing abortion laws that may have had an impact on abortion services. Though this policy was revoked in January 2021, there is a need to assess its impacts in Nepal and mitigate its lingering effects, if any.MethodsWe conducted in-depth interviews with 21 national-level stakeholders selected purposively on the basis of their experiences and expertise in sexual and reproductive health and rights (SRHR) in Nepal. Interviews were conducted two times: first between August and November 2020 when PLGHA was in place, and then between July and August 2021 after PLGHA was revoked. Interviews were digitally recorded, transcribed, translated and analysed thematically.ResultsMost participants reported that the implementation of PLGHA created gaps in SRHR services, affecting marginalized and underserved populations in Nepal. Participants reported that this policy has compromised the work of INGOs and civil society organizations (CSOs), posing additional risk to the sustainability of SRHR program achievements made so far. Beyond funding loss, participants also mentioned that PLGHA curtailed their freedom, with limited working areas and partnerships for CSOs leading to low or no utilization of services. Most participants welcomed the revocation of PLGHA and hoped it would have positive impacts on SRHR services by permanently repealing PLGHA. Most participants believed that the revocation of PLGHA opened opportunities for new funding and could re-establish partnerships and collaboration, though immediate results had not yet been seen.ConclusionsPLGHA had negative impacts on access to and quality of SRHR services. The Nepal government and other donor agencies need to bridge the funding gap created by the policy. The revocation of the policy has created the hope of bringing positive impacts in SRHR sector; however, the implementation of revocation at the ground level and impacts made on SRHR programs in Nepal remains to be explored.

Abortion care availability, readiness, and access: linking population and health facility data in Kinshasa and Kongo Central, DRC

BackgroundThe Democratic Republic of Congo (DRC) legalized abortion in 2018 to preserve health and pledged to provide quality postabortion care (PAC), yet little is known about the availability of abortion care services and if facilities are prepared to provide them; even less is known about the accessibility of these services. Using facility and population-based data in Kinshasa and Kongo Central, this study examined the availability of abortion services, readiness of facilities to provide them, and inequities in access.MethodsData on 153 facilities from the 2017–2018 DRC Demographic and Health Survey Service Provision Assessment (SPA) were used to examine signal functions and readiness of facilities to provide services across three abortion care domains (termination of pregnancy, basic treatment of abortion complications, and comprehensive treatment of abortion complications). To examine PAC and medication abortion provision before and after abortion decriminalization, we compared estimates from the 2017–2018 SPA facilities to estimates from the Performance Monitoring for Action (PMA) data collected in 2021 (n = 388). Lastly, we assessed proximity to PAC and medication abortion using PMA by geospatially linking facilities to representative samples of 2,326 and 1,856 women in Kinshasa and Kongo Central, respectively.ResultsFew facilities had all the signal functions under each abortion care domain, but most facilities had many of the signal functions: overall readiness scores were > 60% for each domain. In general, readiness was higher among referral facilities compared to primary facilities. The main barriers to facility readiness were stock shortages of misoprostol, injectable antibiotics, and contraception. Overall, provision of services was higher post-decriminalization. Access to facilities providing PAC and medication abortion was almost universal in urban Kinshasa, but patterns in rural Kongo Central showed a positive association with education attainment and wealth.ConclusionMost facilities had many of the necessary signal functions to provide abortion services, but the majority experienced challenges with commodity availability. Inequities in accessibility of services also existed. Interventions that address supply chain challenges may improve facility readiness to provide abortion care services, and further efforts are needed to narrow the gap in accessibility, especially among poor women from rural settings.

Systemic delays to abortion access undermine the health and rights of abortion seekers across Australia.

Systemic delays to abortion access undermine the health and rights of abortion seekers across Australia.

Barriers and facilitators to accessing and using sexual and reproductive health services during the COVID-19 pandemic outbreak in Africa: a protocol for a systematic review and meta-analysis

IntroductionAccess and utilisation of sexual and reproductive health services remain an important component in averting adverse sexual and reproductive health outcomes. However, the unprecedented emergence of the 2019 coronavirus disease...

Knowledge of Ghana Abortion Laws and Factors Hindering Access to Safe Abortion Services by Female Students at the University for Development Studies (UDS)

Young women in the universities have an independence streak and have no restraints from parents, or school authorities regarding their sex lives, and can have as much sex as desired. If they have little knowledge on how to prevent unwanted pregnancies, they can pick seed and conceive. Lack of support from partners and/or family and limited monetary support lead them to make wrong choices regarding the termination of an unwanted pregnancy. The aim of this study was to assess the knowledge and factors hindering access to safe abortion services among female students at the U.D.S. This was a descriptive cross-sectional study conducted at the U.D.S. 100 female students between the ages of 15 and 45 years were conveniently selected from a database of 187 female students. A questionnaire containing the relevant research questions related to the topic was designed using google forms, pre-tested on randomly selected 20 participants out of the total study population and subsequently self-administered to 100 female students through a web-based electronic platform. Data were analyzed using SPSS version 20.0. Age distribution of study participants: 15-20 Years, 18 (18%), 21-25 Years, 67 (67%), 26-30 years, 15 (15%). Knowledge of abortion laws in Ghana: 71 (71%) Yes, 29 (29%) No. Revision of the current abortion law in Ghana: 72 (72%) Yes, 28 (28%) No. Reasons for change in abortion Laws: Infringes on basic human rights of women 89 (89%), Contents are obsolete 11 (11%). Knowledge of safe abortion methods: 95 (95%) Yes, 5 (5%) No. Knowledge of safe abortion centers: 69 (69%) Yes, 31 (31%) No. Knowledge of qualified safe abortion service providers: Gynecologists 50 (50%), Midwives 28 (28%), Pharmacists 15 (15%), General Nurses 7 (7%). Factors hindering access to safe abortion services: Religious beliefs 50 (50%), Cost of services 30 (30%), Fear of stigmatization 22 (22%), Lack of knowledge about services 8 (8%). Most student participants were between the ages of 21 and 25 years. Majority of the students have knowledge about abortion laws in Ghana, the different methods of safe abortion, and the availability of safe abortion service centers and providers. Half of the students think religious beliefs interfere with their willingness to access safe abortion services and that the Gynecologist is usually the most qualified specialist to provide safe abortion services.

The Impact of New and Renewed Restrictive State Abortion Laws on Pregnancy-Capable People with Diabetes.

When the Supreme Court handed down its decision in Dobbs v Jackson Women's Health Organization in June 2022, the constitutional right to abortion was no longer protected by Roe v Wade. Fifteen states now have total or near-total bans on abortion care or no clinics providing abortion services. We review how these restrictions affect the medical care of people with pregestational diabetes. Of the ten states with the highest percent of adult women living with diabetes, eight currently have complete or 6-week abortion bans. People with diabetes are at high risk of diabetes-related pregnancy complications and pregnancy-related diabetes complications and are disproportionately burdened by abortion bans. Abortion is an essential part of comprehensive, evidence-based diabetes care, yet no medical society has published guidelines on pregestational diabetes that explicitly discuss the importance and role of safe abortion care. Medical societies enacting standards for diabetes care and clinicians providing diabetes care must advocate for access to abortion to reduce pregnancy-related morbidity and mortality for pregnant people with diabetes.

“In some clinics, they said it’s elective, and then they would refuse”: A Mixed-Methods Study on the impact of the COVID-19 pandemic on access to abortion services in Germany

ObjectiveThe World Health Organization recognizes abortion as essential health care and has encouraged governments to ensure access to abortion services throughout the COVID-19 pandemic. However, the threat of infection combined with government responses to COVID-19 have impacted access to abortion services globally. This study explores access to abortion in Germany during the pandemic. MethodsThis study used a mixed-methods design. An analysis of data collected by Women on Web (WoW) was carried out to assess women’s reasons for choosing telemedicine abortion outside the formal health system in Germany during the pandemic. Descriptive statistics were generated for 2057 requests for telemedicine abortion received by WoW between March 2020-March 2021. Semi-structured interviews were conducted with eight healthcare professionals involved in the provision of abortion services to explore how they perceive of women’s access to abortion services in Germany during the pandemic. ResultsThe quantitative analysis found that preferences and needs for privacy (47.3%), secrecy (44.4%) and comfort (43.9%) were the most common reasons for choosing telemedicine abortion. COVID-19 was another important reason (38.8%). The thematic analysis of the interviews was organized into two overarching themes: service provision, and axes of difference. ConclusionsThe pandemic affected the provision of abortion services as well as the circumstances of women seeking abortion. The main barriers to access were financial constraints, privacy issues, and lack of abortion providers. Throughout the pandemic, accessing abortion services was more difficult for many women in Germany, especially women experiencing multiple and overlapping forms of discrimination.

Policy change to improve access to safe abortion care in federal Nepal.

In Nepal's constitution, safe abortion care is recognized as an essential component of a comprehensive approach to fulfill individuals' sexual and reproductive health and rights. In the current context of transition to a three-level governance (federal, provincial, and local), there are opportunities to accelerate decentralization and devolution of decision-making power, increase access to and coverage of safe abortion services, and improve health outcomes. This article documents the processes and results of the policy change undertaken by the Ministry of Health and Population in collaboration with development partners to decentralize the approval process of safe abortion sites and providers with the objective to increase access to and coverage of safe abortion services. With the decentralization of certification, the approval process for safe abortion service sites and providers has become simpler, less time consuming, and less expensive by reducing cost of traveling to Kathmandu or approaching authorities at the federal level. This has resulted in expanding safe abortion services across the country including remote areas with marginalized populations. Evidence-based advocacy enabled policy change for decentralization of the approval process. Collaboration among stakeholders has been vital for implementing the policy change, including issuing directives from the federal to provincial levels and capacity strengthening of provincial level officials in understanding the requirements for approval of sites and providers.

Terrorist Attacks against Health Care Targets that Provide Abortion Services.

Terrorist attacks against hospitals and health care providers have disproportionally increased during the last decades. A significant proportion of these attacks targeted abortion clinics and abortion providers. In the light of the overturning of Roe v. Wade in 2022, an increase of anti-abortion terrorist attacks is anticipated. Therefore, it becomes imperative to gain further insight into the risk and characteristics of past terrorist attacks. This study aimed to review terrorist attacks against health care targets providing abortion services from 1970 through 2020. Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database functions for all terrorist attacks against abortion health care providers from January 1, 1970 - December 31, 2020. Temporal factors, location, attack and weapon type, and number of casualties or hostages were analyzed using descriptive statistics. In total, 262 terrorist attacks were identified in five different countries. The majority (96.6%) occurred in the United States, with the highest counts during the last 20 years of the 20th century. Facility and infrastructure attacks were the most common attack types, followed by bombings and explosions. The attacks resulted in 34 injuries and nine fatalities. Kidnapping took place in three incidents. Of all successful attacks, 96.9% resulted in property damage. Abortion-related health care facilities and providers have repeatedly been the target of terrorists over the past decades. Nearly all of these attacks took place in the United States, with the highest counts during the last 20 years of the 20th century.

Structural barriers or patient preference? A mixed methods appraisal of medical abortion use in England and Wales

Although patient choice of abortion method is a key component of quality care, medical abortion (MA) has become the most common method (87%) in England and Wales, as in many countries worldwide. This research aimed to critically examine factors influencing the growth in MA use in England and Wales. Mixed methods were used, combining multi-level regression analysis of national abortion statistics (2011-2020) and key informant interviews with abortion service managers, commissioners, and providers (n=27). Overall trends have been driven by growth in MA use for abortions under 10 weeks in the private non-profit sector. Variation in MA use between patient sub-groups and regions has narrowed over time. Qualitative findings highlight health system constraints that have influenced the shift towards MA, including workforce constraints, infrastructure requirements, provider policies, cost, and commissioning practices involving under-funding and competition, which have caused the private non-profit sector to limit method choice across their services to remain financially viable. While removal of legal restrictions on MA has expanded choice, similar policy progress has not been seen for surgical methods. The study concludes that abortion method choice has been constrained by structural health system factors, with potential negative consequences for service acceptability, inequalities, and patient-centredness.

Revolution in abortion care? Perspectives of key informants on the importance of abortion method choice in the era of telemedicine

Patient choice of medical or surgical abortion is a standard of quality abortion care, but the choice of surgical abortion is constrained in England and Wales, particularly since the COVID-19 pandemic and introduction of telemedicine. This qualitative study explored the perspectives of abortion service providers, managers, and funders on the need to offer a choice of methods within early gestation abortion services in England and Wales. Twenty-seven key informant interviews were conducted between August and November 2021, and framework analysis methods were used. Participants presented arguments both for and against offering method choice. Most participants felt that it was important to maintain choice, although they recognised that medical abortion suits most patients, that both methods are very safe and acceptable, and that the priority for abortion services is to maintain timely access to respectful care. Their arguments related to practicalities around patient needs, the risk of reinforcing inequalities in access to patient-centred care, potential impacts on patients and providers, comparisons to other services, costs, and moral issues. Participants argued that constraining choice has a greater impact on those who are less able to advocate for themselves and there were concerns that patients may feel stigmatised or isolated when unable to choose their preferred method. In conclusion, although medical abortion suits most patients, this study highlights arguments for maintaining the option of surgical abortion in the era of telemedicine. More nuanced discussion of the potential benefits and impacts of self-management of medical abortion is needed.

Availability of Safe Second-Trimester Abortion Services in Health Facilities in Accra, Ghana.

We examined providers, methods employed, cost, and other determinants of availability of second-trimester abortion services in health facilities in Accra, Ghana in 2019 to inform policy and program decisions. A two-stage mixed quantitative and qualitative study designs were employed in the conduct of the study. The first stage was a short interaction of the mystery client with a clinical care provider to identify health facilities that provide second trimester induced abortion, the cost, and referral practices, where the facility did not have the service. The second stage was in-depth interviews of second-trimester abortion care providers and non-providers in various health facilities. For internal validity, it also explored the procedure cost, referral, and other practices at the health facilities included in the study, independent of what was captured in the mystery client survey. Second-trimester abortion services in Accra, Ghana are widely unavailable even in most facilities that provided abortion services. Referral policies and practices indicated by the service providers at various facility levels were inadequate. Criminalization of the procedure, social stigma, and fear of complications are the main factors that adversely influence the availability of second-trimester abortion in health facilities in Accra. Albeit increasing demand for second-trimester abortion in health facilities in Accra, services are not readily available due to the ambiguity of the law, its interpretation, and limited flow of accurate information on providers. Policies and programs that limit access to Second-trimester abortions in Ghana are amendable to ensure safe services.

Informal healthcare providers of abortion services among three scheduled tribes of Jharkhand.

There is a dominant role of informal healthcare providers (IHPs) in the current cultural and sociological context of tribal communities. They outnumber formal health-care providers, thus bridging the gap between existing and nonexisting public health facilities despite not having formal training or accreditation. The study examines the role, relevance, and extent of abortion services provided by IHPs- in Jharkhand among three Scheduled Tribe groups. Based on in-depth interviews with 15 IHPs and 42 married women among three Scheduled Tribe groups in three districts of Jharkhand, a qualitative study was conducted. Interview guidelines addressed reasons for preferring IHP services, their scope of practice, dissemination, and quality of services. The majority of women seeking abortions used traditional contraceptives, which often resulted in unwanted pregnancies. The economic, cultural, social, access to services, and confidence factors encouraged women to seek abortion services from IHPs. There were differences in the nature of access to abortion services among tribal groups. The Chero and Korwa tribes continued to rely heavily on simpler life technologies that shaped their beliefs and practices regarding reproduction. The Ho tribe, however, preferred to use the formal health-care system since they were close to a more complex society. IHP plays a significant role in the social structure of Tribes, demonstrating their marginalization in access to formal health-care services. Eventually, they replaced traditional healers with their function as physicians.