Second-trimester Abortion Services Research Articles

Health workers’ experience of providing second-trimester abortion care in Ethiopia: a qualitative study

BackgroundSecond-trimester abortions are less common than abortions in the first trimester, yet they disproportionately account for a higher burden of abortion-related mortality and morbidity worldwide. Health workers play a crucial role in granting or denying access to these services, yet little is known about their experiences. Ethiopia has been successful in reducing mortality due to unsafe abortion over the past decade, but access to second trimester abortion remains a challenge. The aim of this study is to better understand this issue by exploring the experiences of second-trimester abortion providers working in Addis Ababa, Ethiopia.MethodsA qualitative study with 13 in-depth semi-structured interviews with 16 health workers directly involved in providing second-trimester abortions, this included obstetrician and gynaecologist specialists and residents, general practitioners, nurses, and midwives. Data was collected at four public hospitals and one non-governmental clinic in Addis Ababa, Ethiopia and analysed using Malterud’s text-condensation method.ResultsThe providers recognized the critical need for second-trimester abortion services and were motivated by their empathy towards women who often sought care late due to marginalisation and poverty making it difficult to access abortion before the second trimester. However, service provision was challenging according to the providers, and barriers like lack of access to essential drugs and equipment, few providers willing to conduct abortions late in pregnancy and unclear guidelines were commonly experienced. This led to highly demanding working conditions. The providers experienced ethical dilemmas pertaining to the possible viability of the fetus and women desperately requesting the service after the legal limit.ConclusionsSecond-trimester abortion providers faced severe barriers and ethical dilemmas pushing their moral threshold and medical risk-taking in efforts to deliver second-trimester abortions to vulnerable women in need of the service. Effort is needed to minimize health system barriers and improve guidelines and support for second-trimester abortion providers in order to increase access and quality of second-trimester abortion services in Ethiopia. The barriers forcing women into second trimester abortions also need to be addressed.

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.

Utilisation of second-trimester spontaneous and induced abortion services in public hospitals in Mexico, 2007–2015

BackgroundData on utilisation of in-facility second-trimester abortion services are sparse. We describe temporal and geographical trends in utilisation of in-facility second-trimester abortion services across Mexico.MethodsWe used 2007–2015 data from Mexico’s...

The costs and cost effectiveness of providing second-trimester medical and surgical safe abortion services in Western Cape Province, South Africa

BackgroundIn South Africa, access to second-trimester abortion services, which are generally performed using medical induction with misoprostol alone, is challenging for many women. We aimed to estimate the costs and cost effectiveness of providing three safe second-trimester abortion services (dilation and evacuation (D&E)), medical induction with mifepristone and misoprostol (MI-combined), or medical induction with misoprostol alone (MI-misoprostol)) in Western Cape Province, South Africa to aid policymakers with planning for service provision in South Africa and similar settings.MethodsWe derived clinical outcomes data for this economic evaluation from two previously conducted clinical studies. In 2013–2014, we collected cost data from three public hospitals where the studies took place. We collected cost data from the health service perspective through micro-costing activities, including discussions with site staff. We used decision tree analysis to estimate average costs per patient interaction (e.g. first visit, procedure visit, etc.), the total average cost per procedure, and cost-effectiveness in terms of the cost per complete abortion. We discounted equipment costs at 3%, and present the results in 2015 US dollars.ResultsD&E services were the least costly and the most cost-effective at $91.17 per complete abortion. MI-combined was also less costly and more cost-effective (at $298.03 per complete abortion) than MI-misoprostol (at $375.31 per complete abortion), in part due to a shortened inpatient stay. However, an overlap in the plausible cost ranges for the two medical procedures suggests that the two may have equivalent costs in some circumstances.ConclusionD&E was most cost-effective in this analysis. However, due to resistance from health care providers and other barriers, these services are not widely available and scale-up is challenging. Given South Africa’s reliance on medical induction, switching to the combined regimen could result in greater access to second-trimester services due to shorter inpatient stays without increasing costs.

The costs of accessing abortion in South Africa: women’s costs associated with second-trimester abortion services in Western Cape Province

ObjectivesTo assess women’s costs of accessing second-trimester labor induction and dilation and evacuation (D&E) services at four public hospitals in Western Cape Province, South Africa. Study designFrom April to August 2010, in interviews immediately after completion of their abortion, we asked women about specific direct and indirect costs incurred. We collected information on recurring costs (i.e., per visit) and one-time expenditures and calculated total costs. ResultsIn total, 194 patients participated (136 D&E; 58 induction). Their median age was 26; 37.6% reported being employed or doing paid work. Most (73.2%) women visited two different facilities, including the study facility, while seeking the procedure. Induction women reported a median of three required visits [interquartile range (IQR) 2.0–3.0] to the study facility, while D&E women reported two required visits [IQR 1.0–2.0]. Twenty-seven percent of women missed work due to the procedure, and few (4.6%) paid for childcare. At each visit, almost all women (180, 92.8%) paid for transportation costs and reported additional one-time costs (177, 91.2%) such as sanitary supplies or doctor’s fees. The total median cost incurred per woman was $21.23 [IQR 11.94–44.68]. Roughly half (49.0%) received help with these costs. ConclusionsAlthough technically offered freely or low cost in the public sector, women accessing second-trimester abortion lost income and incurred costs for transport, fees, supplies and childcare. Their total costs could be reduced by minimizing the number of required visits to facilities and freely offering supplies such as sanitary pads and pregnancy tests. ImplicationsLimited access to second-trimester, safe abortion services in South Africa may result in some women incurring unnecessary costs. Women make multiple visits in attempting to obtain an abortion, often because of facility or health systems requirements, and incur costs for lost income, child care, transport, fees and supplies.

Notes from the field: expanding abortion services into the second trimester of pregnancy in Nepal (2007–2012)

In the past, abortion in Nepal was criminalized. In 2002, the government liberalized the law allowing abortion for any reason at 12 weeks and under, for rape or incest up to 18 weeks and for maternal mental or physical health or fetal health at any gestational age [1]. Despite decreasing restrictions, at least 13% ofwomenpresenting for safe abortion in 2006with eligible legal indications were turned away due to the lack of training and support to safely provide services in the second trimester [2]. Through a collaborative effort, the Nepali Ministry of Health, Family Health Division (FHD) and Ipas, a global nongovernmental organization working to end deaths and disabilities from unsafe abortion, initiated a program in 2007 to increase the availability of safe second-trimester abortion services, both dilation and evacuation (DE mifepristone-misoprostol). This structured comprehensive program has increased access to safe second-trimester abortion services in Nepal. This intervention [2] consisted of multiple steps starting with site and provider assessments including direct observation of the proficiency and competency of first-trimester vacuum aspiration skills. We designed and held workshops prior to hands-on training to sensitize providers to women's needs for and rights to safe abortion. These workshops also allowed providers to self-identify if they did not want to participate in the subsequent training. The trainings utilized adult learning

Self-induction of abortion among women accessing second-trimester abortion services in the public sector, Western Cape Province, South Africa: an exploratory study.

Despite South Africa's liberal abortion law permitting abortion on request in the first trimester and under restricted conditions for second-trimester pregnancies, the practice of unsafe self-induced abortion persists. However, the prevalence of this practice, the methods used and the reasons behind it are relatively under-researched. As part of a larger study seeking to improve abortion services in the Western Cape Province, we explored reports of prior attempts to self-induce abortion among women undergoing legal second-trimester abortion. To describe the prevalence and methods of and factors related to unsuccessful attempts at self-induction of abortion by women presenting without complications and seeking second-trimester abortion at public health facilities in the Western Cape. In a cross-sectional study from April to August 2010, 194 consenting women undergoing second-trimester abortion were interviewed by trained fieldworkers using structured questionnaires at four public sector facilities near Cape Town. Thirty-four women (17.5%; 95% confidence interval 12.7 - 23.4) reported an unsuccessful attempt to self-induce abortion during the current pregnancy before going to a facility for second-trimester abortion. No factors were significantly associated with self-induction, but a relatively high proportion of this small sample were unemployed and spoke an indigenous African language at home. A readily available herbal product called Stametta was most commonly used; other methods included taking tablets bought from unlicensed providers and using other herbal remedies. No use of physical methods was reported. The prevalence of unsafe self-induction of abortion is relatively high in the Western Cape. Efforts to inform women in the community about the availability of free services in the public sector and to educate them about the dangers of self-induction and unsafe providers should be strengthened to help address this public health issue.

Enablers of and barriers to abortion training.

Since the legalization of abortion services in the United States, provision of abortions has remained a controversial issue of high political interest. Routine abortion training is not offered at all obstetrics and gynecology (Ob-Gyn) training programs, despite a specific training requirement by the Accreditation Council for Graduate Medical Education. Previous studies that described Ob-Gyn programs with routine abortion training either examined associations by using national surveys of program directors or described the experience of a single program. We set out to identify enablers of and barriers to Ob-Gyn abortion training in the context of a New York City political initiative, in order to better understand how to improve abortion training at other sites. We conducted in-depth qualitative interviews with 22 stakeholders from 7 New York City public hospitals and focus group interviews with 62 current residents at 6 sites. Enablers of abortion training included program location, high-capacity services, faculty commitment to abortion training, external programmatic support, and resident interest. Barriers to abortion training included lack of leadership continuity, leadership conflict, lack of second-trimester abortion services, difficulty obtaining mifepristone, optional rather than routine training, and antiabortion values of hospital personnel. Supportive leadership, faculty commitment, and external programmatic support appear to be key elements for establishing routine abortion training at Ob-Gyn residency training programs.

Canadian rural compared to urban first- and second-trimester abortion services: findings of the British Colombia abortion provider survey

Canadian rural compared to urban first- and second-trimester abortion services: findings of the British Colombia abortion provider survey

Ensuring patient satisfaction with second-trimester abortion in resource-poor settings

Objective To evaluate patient satisfaction with the new second-trimester abortion services in Nepal. Method Depending on the patient's literacy level, a questionnaire was read and filled out by the patient herself or by an interviewer. Indicators were developed and assessed to determine the patient's experience of the services, focusing on her physical, emotional, and social comfort. Results Satisfaction was found to be high for characteristics associated with counseling and the caring attitude of the physician. However, dissatisfaction was expressed regarding some aspects of the delivery of care, especially the lack of privacy and confidentiality and the absence of a support person from the patient's own family. Conclusion The patients described privacy, confidentiality, and a support person designated by them as factors that would greatly contribute to their satisfaction with the services. Maximizing patient satisfaction is necessary for the program's success but will be challenging.

Second-trimester surgical abortion practices: a survey of National Abortion Federation members

Background The objective of this analysis was to assess the second-trimester surgical abortion practices of National Abortion Federation (NAF) members in North America and Australia. Study Design In 2002, questionnaires were mailed to 364 active member clinics of NAF for completion by their clinic administrators and individual providers. Results Two hundred eighty-nine (79%) clinics responded. Most NAF clinics (72%) offer second-trimester abortion services. The majority of second-trimester providers are obstetrician/gynecologists (63%), male (62%) and at least 50 years old (63%). We describe second-trimester surgical abortion practices in terms of patient eligibility, cervical ripening, ultrasound use, anesthesia and postoperative care. Conclusions Surgical techniques and postoperative practices for second-trimester abortions are similar among these respondents, suggesting that NAF's efforts to promulgate best practices using evidence-based guidelines are succeeding. The aging of skilled practitioners raises concerns about the future availability of second-trimester abortion.

Risk Factors Associated With Presenting for Abortion in the Second Trimester

To determine factors associated with delay of induced abortion into the second trimester of pregnancy. Using audio computer-assisted self-interviewing, 398 women from 5 to 23 weeks of gestation at an urban hospital described steps and reasons that could have led to a delayed abortion. Multivariable logistic regression identified independent contributors to delay. Half of the 70-day difference between the average gestational durations in first- and second-trimester abortions is due to later suspicion of pregnancy and administration of a pregnancy test. Delays in suspecting and testing for pregnancy cumulatively caused 58% of second-trimester patients to miss the opportunity to have a first-trimester abortion. Women presenting in the second trimester experienced more delaying factors (3.2 versus 2.0, P < .001), with logistical delays occurring more frequently for these women (63.3% versus 30.4%, P < .001). Factors associated with second-trimester abortion in logistic regression were prior second-trimester abortion, delay in obtaining state insurance, difficulty locating a provider, initial referral elsewhere, and uncertainty about last menstrual period. Factors associated with decreased likelihood of second-trimester abortion were presence of nausea or vomiting, prior abortion, and contraception use. Abortion delay results from myriad factors, many of them logistical, such as inappropriate or delayed referrals and delays in obtaining public insurance. Public health interventions could promote earlier recognition of pregnancy, more timely referrals, more easily obtainable public funding, and improved abortion access for indigent women. However, accessible second-trimester abortion services will remain necessary for the women who present late due to delayed recognition of and testing for pregnancy. II-2.