Provision Of Safe Abortion Services Research Articles

Availability, Utilization, and Health Providers' Attitudes Towards Safe Abortion Services in Public Health Facilities of a District in West Bengal, India.

Background: The provision of safe abortion services upholds the realization of justice in sexual and reproductive health. Many state-level studies in India have identified poor availability of abortion services in the public sector and negative attitudes toward abortion among health providers, as potential barriers to access.Materials and Methods: A cross-sectional study was done to document the availability and utilization of medical termination of pregnancy (MTP or abortion) services and to assess public sector health providers' attitudes towards safe abortion. It was carried out in a representative district of West Bengal, using a facility checklist and a validated attitude scale.Results: Only 11 of 42 public health facilities had both trained doctors and equipment to provide MTP services. Twelve facilities provided MTP services, of which only three urban-based secondary-level facilities provided second trimester MTPs. There were female providers in just 2 of the 12 MTP-providing facilities. Among the 64 health providers interviewed, 40% were trained to provide MTP. According to the attitude scale, 38% had a negative attitude toward the provision of safe abortion services. There was no statistically significant association between attitudes of health providers and provision of MTP. However, there appeared to be a subtle process of gatekeeping in operation, such as making MTP conditional on acceptance of contraception, requiring the husband's consent, and so on.Conclusions: The study shows the poor availability of abortion services in public sector facilities in a district of West Bengal, although all public health facilities from the primary health center level upwards are authorized to provide abortion services.

How Do Pronatalist Policies Impact Women's Access to Safe Abortion Services in Turkey?

A pronatalist discourse and anti-abortion rhetoric used by prominent politicians in Turkey, prior to and following the proposed ban of abortion in 2012, have resulted in reports of women facing difficulty accessing safe abortion services (SAS), risking the resurgence of unsafe abortions. We conducted a qualitative study to identify the impact of the ongoing pronatalist discourse on women’s access to SAS, using semi-structured interviews with 19 experts (16 female, 3 male) in reproductive health, including academics, doctors, midwives, and health authorities. Participants from 4 cities (Ankara, Istanbul, Izmir, and Manisa) were identified through a combined snowball and purposive sampling technique. The findings show that the pronatalist discourse has directly and indirectly inhibited access to SAS. Women’s and health professionals’ perception of abortion services has been tainted by rhetoric; provision of SAS in the public sector is slowly ceasing; and health reform-related organizational changes have diminished access to family planning services and contraceptive methods. Provision of SAS in the private sector continues but is only accessible for women with sufficient financial means. Preventing women’s access to SAS risks a rise in unwanted pregnancies and—consequently—in the number of women who may seek dangerous alternatives, including unsafe, life-threatening abortions.

SURVEY OF UNSAFE ABORTION IN SELECTED HEALTH FACILITIES IN

AbstractIn order to fill the gap in evidence based information, and help in programming for the reduction ofmaternal deaths due to unsafe abortion, a nationwide hospital based survey in 9 of the 11administrative regions of Ethiopia was conducted from June to December 2000.A total of 1075 women presenting with abortion to the 15 hospitals during the study period wereconsecutively enrolled . About 58 percent of the cases were in the age range of 20-29 years, 26.5percent were illiterate, and 27.5 percent were with secondary education. Three-fourth of patientshad spontaneous abortion and one fourth (25.6 percent) of them had induced abortion. Themajority of women (87 percent) were aware of contraceptive methods, but only about half of themever used a family planning method. Of those pregnancies that ended in abortion 60 percent wereunplanned and 50 percent were unwanted. Method non-use was responsible for 78 percent ofpregnancies that occurred. Among those with induced abortion, the most common reason fortermination of pregnancy was contraceptive need. Rape accounted only for 3 percent of allpregnancies that ended in abortion (i.e. 2.5 percent of all reasons for termination of pregnancies).Fifty eight percent of women who induced abortion terminated the current pregnancy either byseeking the help of untrained personnel or by themselves with no assistance. The most frequentreason for hospital visit was vaginal bleeding and abdominal pain. Evacuation and curettage (E &C) was the commonest method (83.6 percent) of evacuating the contents of the uterus. The majorcategories of complications identified were infection (28 percent), genital tract injuries (12percent), foreign bodies in the genital tract (1.6 percent) and organ failure (13.1 percent). Therewere 13 deaths, which made an overall procedure related deaths of 1,209 per 100,000 abortions.Using a modified Delphi technique, and taking the six months study period, it was found out that thetotal cost to treat incomplete abortion by health facilities under this survey was Birr 332,259.9. Inconclusion, there is a need for a strong family planning program for the country, to preventunwanted and unplanned pregnancies. There is a also an urgent need for improvement of providersknowledge and skills, provision of safe abortion services, and liberalization of the abortion law.(Ethiop. J. Reproductive Health May 2007, 1(1), 28-43)

Complications with use of misoprostol for abortion in Madagascar: between ease of access and lack of information

ObjectiveThe objective was to learn what complications some women experienced in Madagascar following use of misoprostol for abortion and what treatment they received post misoprostol use. Study designThis was a qualitative study in 2015–2016 among women who had experienced complications after use of misoprostol, with or without additional methods, for abortion; what information they received before use; what dosage and regimens they used; what complications they experienced; and what treatment they received postuse. We initially conducted in-depth, semistructured interviews with 60 women who had undergone an abortion that resulted in complications. The results presented here are based on interviews with the subset of 19 women who had used misoprostol. ResultsThe 19 women were aged 16–40, with an average age of 21–26 at interview and average age of 18–21 at abortion. To obtain an abortion, they sought advice from partners, friends, family members, and/or traditional practitioners and health care providers. Misoprostol was easily accessible through the formal and informal sectors, but the dosages and regimens the women used on the advice of others were extremely variable, did not match WHO guidelines and were apparently ineffective, resulting in failed abortion, incomplete abortion, heavy bleeding/hemorrhage, strong pain and/or infection. ConclusionsThis study provides data on complications from the use of misoprostol as an abortifacient in Madagascar. Health care providers need training in correct misoprostol use and how to treat complications. Law and policy reforms are needed to support such training and to ensure the provision of safe abortion services in the public health system. ImplicationsHealth care providers who provide abortion care and treatment of abortion complications need training in correct misoprostol use and treatment of complications. Women and pharmacy workers also need this information. Law and policy reforms are needed to allow training and provision of safe services. Further research is needed on the extent and impact of incorrect misoprostol administration.

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.

World Health Organization Advocates for Expansion in the Role of Health Workforce to Prevent Unsafe Abortions.

DEAR EDITOR, An abortion is considered unsafe when it is performed either by individuals who do not possess the necessary skills or is executed in such an environment which does not comply with recommended minimal medical standards, or both.[1] In-fact, the recent estimates suggest that almost 22 million unsafe abortions are being performed every year on a global scale, a major proportion of which is contributed by low and middle income nations.[1,2] Further, close to 5 million women every year are hospitalized due to unsafe abortion in developing nations and another 3 million women are devoid of desired medical attention following unsafe abortion.[1] It is very important to understand that any unsafe abortion is the outcome of unsuitable situations before, during or after an abortion (viz. availability/acceptance of contraceptives, nil or poor preabortion advice, septic environment, induction by an untrained individual or by an object/medication with no subsequent follow-up care, etc.).[1,2] A wide range of adverse effects, including complications, impact on women's ability to conceive, deaths of thousands of women (among adolescent girls/women who are either unmarried, or less educated, or belong to the lower socioeconomic class and resides in rural settings) and augmented financial burden on the individual or the health care delivery system have been reported.[1,3,4] Even though, multiple factors (like prevailing stigma in society, restrictive laws, dissent from health care providers, limited availability of health services, expensive nature, requirements of third-party authorization/unnecessary tests, etc.), have prevented access of women to safe abortion services, the lack of trained providers remains the critical barrier among all.[1,5,6] In-fact, it has been estimated that there will be a dearth of almost 13 million skilled health care workers by the year 2035, with a great disparity within the nations itself (shortage being more in rural areas and in the public sector).[5,7] This has been indirectly attributed to the current strategy of provision of safe abortion services through gynaecologists alone in most of the settings, despite the presence of the infrastructure and resources at the primary level of health care.[7] In order to address the issue of shortage of trained health providers in extending safe abortion services, the World Health Organization (WHO) has released a new set of guidelines to ensure that different activities are shared appropriately among the available health workforce.[5] Further, it has been emphasized that it is high time to move beyond specialists and enable the involvement of a wide range of health workers (like practitioners, nurses, midwives, auxiliaries, etc.) in safe abortion care so that the ultimate goal of providing equitable and timely health care to all sections of community can be achieved.[5] This strategy is indispensable in settings with an enormous shortage of skilled workers, and is of great importance even in developed nations to address sub-national imbalances.[5,7] However, the key perquisite for the success is to ensure task-specific competency-based training of health workers and the presence of a clear mechanism to enable monitoring, mentoring and support to health workers taking on these additional roles.[7,8,9] The WHO has stressed that abortion and postabortion care, especially in the first trimester (interventions like vacuum aspiration or drug induced medical abortion) can be easily delivered through the trained health worker like associate clinicians, midwives, nurses, etc.[7] These trained workforce members can even assist the specialist in the assessment of the gestational age of women, providing information on the appropriate use of drugs, and insertion of intrauterine devices.[1,5] Similarly, for providing care in the later stages of pregnancy, these nonphysician health workers can play supportive roles by assisting in cervical priming before dilatation and evacuation or in extending care throughout the process of abortion.[5,7] At the same time, it has been envisaged that as women themselves can manage their own health care, they should be empowered and equally involved in task sharing, provided they have access to appropriate information and to back-up health care.[1,5,6] To conclude, despite the existence of safe and effective primary health care level interventions, most of the women from developing nations have no access to them, placing their lives unnecessarily at risk. Hence, by ensuring the involvement of different cadres of health workforce it will not only help specialists in reducing their workload, but will even enhance the accessibility of women towards safe abortion and postabortion care.

The impact of Ghana's R3M programme on the provision of safe abortions and postabortion care.

In 2006, in response to the high maternal mortality, driven largely by unsafe abortions, the government of Ghana, in partnership with other organizations, launched the reducing maternal mortality and morbidity (R3M) programme in seven districts in Greater Accra, Ashanti and Eastern, to improve comprehensive abortion care services. This article examines whether this intervention made a difference to the provision of safe abortion services and postabortion care (PAC). We also examine the role played by provider attitudes and knowledge of the abortion law, on providers with clinical training in service provision. Primary data on health care providers in Ghana, collected using a quasi-experimental design, were analysed using propensity score weighting. Apart from the treatment group, the sample included two controls: (1) Districts in Accra, Ashanti and Eastern, not exposed to the treatment; and (2) Districts from distant Brong Ahafo, also not exposed to the treatment. The findings show that providers in the treatment group are nearly 16 times as likely to provide safe abortions compared with their peers in Brong Ahafo, and ∼2.5 times as likely compared with providers in the other control group. R3M providers were also different from their peers in providing PAC. Associations between provider attitudes and knowledge of the law on both outcomes were either non-significant or inconsistent including for providers with clinical knowledge of abortion provision. Provider confidence however is strongly associated with service provision. We conclude that the R3M programme is helping safe abortion provision, with the differences being greater with control groups that are geographically distant, perhaps owing to lower contamination from movement of providers between facilities. Increasing provider confidence is key to improving both safe abortion provision and PAC.

Maternal Mortality: Sharing Experience from Nobel Medical College Teaching Hospital

Aims: To analyse causes of maternal deaths and to identify avoidable factors. Methods: This was a retrospective analysis of maternal deaths, during a period of one year from 15th April, 2011-15th April, 2012, at Nobel Medical College Teaching Hospital, Biratnagar in the Eastern Region of Nepal case files and hospital records being the data sources. All the maternal deaths were recorded. Results: In one year study period, out of a total of 2,754 deliveries, there were 8 maternal deaths giving maternal mortality ratio of 310/100,000 live births. Three of them resulted from an induced abortion mishap and five of them were obstetric deaths. Four of the direct obstetric deaths resulted from complications of pregnancy induced hypertension (PIH) of which one case died due to traumatic post partum hemorrhage postpartum hemorrhage (PPH) as a result of torrential bleeding from extensive vaginal wall tear. One indirect obstetric death occurred in a case of twin pregnancy with severe anemia and congestive cardiac failure. Conclusions: Provision of safe abortion services is still not available to many women despite of legalization of abortion in Nepal. Quality antenatal care services would be helpful in avoiding maternal mortality in many situations by detecting and managing medical complications of pregnancy. DOI: http://www.dx.doi.org/10.3126/njog.v7i2.11140 Nepal Journal of Obstetrics and Gynaecology / Vol 7 / No. 2 / Issue 14 / July-Dec, 2012 / 33-35

WHO technical and policy guidance emphasizes the health systems' responsibility to provide safe abortion services

Despite widespread availability and use of modern contraception, among 208 million pregnancies each year worldwide, 41% (85 million) are unintended. Many of these women will seek abortion, whether under safe or unsafe conditions [1]. Indeed, the likelihood that a woman will seek an abortion for an unintended pregnancy is about the same regardless of legal restrictions [2]. The rate of safe induced abortion has declined over recent years from 35 per 1000 women aged 15–44 in 1995 to 26 per 1000 in 2008. In contrast, the rate of unsafe abortion has remained relatively constant since 2000 at around 14 per 1000 women aged 15– 44 [3]. Unsafe abortion occurs almost exclusively in low and middle income countries, where maternal mortality rates are high and access to safe services is limited. Deaths resulting from unsafe procedures number approximately 47,000 per year while an additional 5 million women are left disabled [3]. Tragically, almost every one of these deaths and disabilities could have been prevented with the provision of safe abortion services. Use of contraceptive methods and services decreases the chance of unintended pregnancy substantially, but even universal contraceptive use would never eliminate the need for induced abortion given the intrinsic failure rates, however small, of modern methods. Approximately 36 million women worldwide annually experience an unintended accidental pregnancy while using a contraceptive method [4]. Additionally, contraception is not available in cases of forced sexual intercourse. Lack of access to contraception

“Sometimes they used to whisper in our ears”: health care workers’ perceptions of the effects of abortion legalization in Nepal

BackgroundUnsafe abortion has been a significant cause of maternal morbidity and mortality in Nepal. Since legalization in 2002, more than 1,200 providers have been trained and 487 sites have been certified for the provision of safe abortion services. Little is known about health care workers’ views on abortion legalization, such as their perceptions of women seeking abortion and the implications of legalization for abortion-related health care.MethodsTo complement a quantitative study of the health effects of abortion legalization in Nepal, we conducted 35 in-depth interviews with physicians, nurses, counsellors and hospital administrators involved in abortion care and post-abortion complication treatment services at four major government hospitals. Thematic analysis techniques were used to analyze the data.ResultsOverall, participants had positive views of abortion legalization – many believed the severity of abortion complications had declined, contributing to lower maternal mortality and morbidity in the country. A number of participants indicated that the proportion of women obtaining abortion services from approved health facilities was increasing; however, others noted an increase in the number of women using unregulated medicines for abortion, contributing to rising complications. Some providers held negative judgments about abortion patients, including their reasons for abortion. Unmarried women were subject to especially strong negative perceptions. A few of the health workers felt that the law change was encouraging unmarried sexual activity and carelessness around pregnancy prevention and abortion, and that repeat abortion was becoming a problem. Many providers believed that although patients were less fearful than before legalization, they remained hesitant to disclose a history of induced abortion for fear of judgment or mistreatment.ConclusionsProviders were generally positive about the implications of abortion legalization for the country and for women. A focus on family planning and post-abortion counselling may be welcomed by providers concerned about multiple abortions. Some of the negative judgments of women held by providers could be tempered through values-clarification training, so that women are supported and comfortable sharing their abortion history, improving the quality of post-abortion treatment of complications.

Post induced abortion morbidity and mortality in Oleh, Nigeria

The aim of this retrospective study was to determine the maternal morbidity and mortality among 87patient treated at the Central Hospital, Oleh, Delta State, Nigeria, for complications of induced abortion from January 1st 2004 to December 31st 2008. The total number of maternal admissions and deaths, over the period, were, respectively, 3,680 and 34(8 from induced abortion). Induced abortion accounted for 2.4% and 23.5%, respectively, of the total maternal morbidity (admissions) and mortality. The mean age of the patients was 20.4±5.6years (range of 15 –36years). Majority were, in age group 15 – 19years (71.2%), students/young school leavers (85.1%), unmarried (82.8%), unemployed (89.7%) and had had second trimester abortion (64.4%). It is significant that of those who had second trimester abortion, 66.1% were teenagers. Most (94.3%) of the patients presented with multiple complications which included genital sepsis (94.3%), retained products of conception (90.8%), anaemia (17.2%), pelvic infection with peritonitis (17.2%) and abscess formation (15%), uterine (3.5%) and intestinal (2.3%) perforations. The commonest cause of death (n = 8) was generalised septicaemia (37.5%). Policy makers and health managers should formulate initiatives to prevent unwanted pregnancy including health education/contraceptive utilization and provision of safe abortion services. Keywords: abortion, induced, maternal, morbidity, mortality, law.

The Context of Informal Abortions in Rural Ghana

This qualitative study explores the context of unsafe abortion in rural Ghana with the aim of identifying areas that should be considered when operationalizing abortion-related reproductive health strategies. Data come from eleven narratives about planned or attempted abortions and seven narratives of abortion-related deaths. These individual data are supplemented by data from ten focus group discussions. Communities describe abortions as dangerous and, if they become public knowledge, shameful. Despite this, abortions were understood as necessary for some women in some situations, but secrecy was paramount. Women carefully chose their confidants based on the anticipated reaction and did so for advice about cheap and effective methods or for financial assistance. Complications were usually managed at home. When complications were taken to the health facility, the abortion was often not disclosed. Women reported trying sequential abortion methods, starting with cheaper milder methods and, if these attempts failed, resorting to harsher more expensive methods. Access to pharmaceuticals and finances also determined the method used. Financial hardship, interruption of education, and being unmarried were the most frequently cited reasons for abortions. Unsafe abortion is an important public health issue in Ghana. Current strategies to reduce abortion-related deaths include increasing the provision of safe abortion services. For the strategy to be successful, services should be accessible, affordable, and confidential, and discourse with communities and health workers to break the public silence about abortion is needed.

Attitude of Women with Abortion-Related Complications toward Provision of Safe Abortion Services in Ghana

To determine the attitude and perception of women with abortion-related complications toward the provision of safe abortion services, their sociodemographic characteristics, and their awareness of the law permitting abortion under certain circumstances in Ghana. A cross-sectional study using a standardized questionnaire was conducted over a 2-month period among patients admitted with abortion-related complications at Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. Abortion-related complications accounted for 42.7% of admissions to the gynecological ward. The median age of the women was 26 years. Of the 296 patients interviewed, 28% reported induced abortion in the index pregnancy, 29% were not married, 30% had no formal education, and 92% were not aware of the current legal status of abortion in Ghana. They thought there was the need to provide safe abortion services in the country, and almost all of them were willing to patronize such services. Awareness of the current legal status of abortion was lacking among women with abortion-related complications attending a tertiary center in Kumasi. However, the provision of safe abortion services was much needed in this population.

Attitudes of doctors toward establishing safe abortion units in Ghana

Objectives To assess physician knowledge of the current legal status of abortion in Ghana and determine the proportion physicians in favor of establishing units where safe abortion would be provided, and the proportion of those willing to offer such services. Methods A survey conducted at Komfo Anokye Teaching Hospital, Ghana, in August 2003. Using a self-administered questionnaire, 74 randomly selected physicians expressed their views on whether abortion units should be established within national health facilities in Ghana, and what role they would play in them. Results Of the 59 physicians (80%) who favored the establishment of safe abortion units within national health facilities, 27 (36%) indicated a willingness to take part in counseling only, 33 (45%) were prepared to carry out abortions, and 14 (19%) said they would play no role in these units. Conclusion Most physicians participating in this study conducted in Ghana were willing to play some role in the provision of safe abortion services.

A politico-medical perspective of induced abortion in a semi-urban community of Ile-Ife, Nigeria

This study is designed to document a semi-urban community perspective on induced abortion in Ile-Ife, Nigeria, with a view to estimating community awareness, attitudes and implications of its existence in the community and providing relevant sociopolitical policies and pragmatic educational guidelines for policy makers to solve some of its problems within the Nigerian landscape and beyond. This was a cross-sectional study conducted in April 2000, at Oranfe community in Ile-Ife, South West, Nigeria, which has an estimated population of 5250 inhabitants. We used the survey method with the aid of a well-structured questionnaire. One hundred and eighty residents of the community were sampled as our subjects for this study. We used the cluster random sampling technique. The main outcome measures were the sociodemographic characteristics of the respondents, knowledge, attitude with perceived solutions to the problems of abortion and relationship of the sociodemographic factors to respondents' knowledge and attitude. The respondents were highly literate, as only 18 (11·04%) had no formal education. Eighty-five (52·79%) had good knowledge of abortion while 45 (27·95%) and 31 (19·25%) had fair and poor knowledge, respectively. Thirty-eight (24·05%) respondents felt that the solution to the problems of induced abortion can be obtained through its legalisation; 31 (19·62%) respondents believed that the solution lies in liberalising laws on abortion; provision of safe abortion services was suggested by 30 (18·98%) respondents. One hundred and seven (66·88%) felt that legalisation of abortion will increase its practice while 53 (31·12%) felt that such legalisation will not increase the practice. Similarly, 55 (34·37%) of the respondents emphasised that legalisation would reduce the problems of induced abortion compared with 82 (51·25%) who felt otherwise. One hundred and twenty (73·61%) of the respondents did not believe that the position of the law in Nigeria can stop the practice of induced abortion. Solving the problems of induced abortion in Nigeria requires pragmatic and non-hypocritical sex educational policies, which are widely embracing to sensitise people in the community through public enlightment programmes.

Complications of unsafe abortion in sub-Saharan Africa: a review.

The Commonwealth Regional Health Community Secretariat undertook a study in 1994 to document the magnitude of abortion complications in Commonwealth member countries. The results of the literature review component of that study, and research gaps identified as a result of the review, are presented in this article. The literature review findings indicate a significant public health problem in the region, as measured by a high proportion of incomplete abortion patients among all hospital gynaecology admissions. The most common complications of unsafe abortion seen at health facilities were haemorrhage and sepsis. Studies on the use of manual vacuum aspiration for treating abortion complications found shorter lengths of hospital stay (and thus, lower resource costs) and a reduced need for a repeat evacuation. Very few articles focused exclusively on the cost of treating abortion complications, but authors agreed that it consumes a disproportionate amount of hospital resources. Studies on the role of men in supporting a woman's decision to abort or use contraception were similarly lacking. Articles on contraceptive behaviour and abortion reported that almost all patients suffering from abortion complications had not used an effective, or any, method of contraception prior to becoming pregnant, especially among the adolescent population; studies on post-abortion contraception are virtually nonexistent. Almost all articles on the legal aspect of abortion recommended law reform to reflect a public health, rather than a criminal, orientation. Research needs that were identified include: community-based epidemiological studies; operations research on decentralization of post-abortion care and integration of treatment with post-abortion family planning services; studies on system-wide resource use for treatment of incomplete abortion; qualitative research on the role of males in the decision to terminate pregnancy and use contraception; clinical studies on pain control medications and procedures; and case studies on the provision of safe abortion services where legally allowed.