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In 2013 California passed legislation that expanded the pool of eligible aspiration abortion providers to include advanced practice nurses, nurse-midwives, and physician-assistants. This law, enacted in 2014, is based on evidence generated by the Health Workforce Pilot Project #171, which examined the safety and effectiveness of aspiration abortion care provided by these clinicians as well as patient acceptability and satisfaction. This evidence and the resulting policy change build on international research and established workforce strategies used to expand access to safe abortion services for women worldwide, representing a radical departure from the legislative trend of constricting access in the United States.

Although abortion is legal in Zambia under a variety of broad conditions, unsafe abortion remains common. The purpose of this project was to compare the financial costs for women when they have an induced abortion at a facility, with costs for an induced abortion outside a facility, followed by care for abortion-related complications. We gathered household wealth data at one point in time (T1) and longitudinal qualitative data at two points in time (T1 and T2, three-four months later), in Lusaka and Kafue districts, between 2014 and 2015. The data were collected from women (n = 38) obtaining a legal termination of pregnancy (TOP), or care for unsafe abortions (CUA). The women were recruited from four health facilities (two hospitals and two private clinics, one of each per district). At T2, CUA cost women, on average, 520 ZMW (USD 81), while TOP cost women, on average, 396 ZMW (USD 62). About two-thirds of the costs had been incurred by T1, while an additional one-third of the total costs was incurred between T1 and T2. Women in all three wealth tertiles sought a TOP in a health facility or an unsafe abortion outside a facility. Women who obtained CUA tended to be further removed from the money that was used to pay for their abortion care. Women's financial dependence leaves them unequipped to manage a financial shock such as an abortion. Improved TOP and post-abortion care are needed to reduce the health sequelae women experience after both types of abortion-related care. [ABSTRACT FROM AUTHOR]

Despite Tunisia's historically progressive reproductive health policies, Tunisian women now face significant challenges accessing legal abortion. Through in-depth interviews with providers at six facilities, we explored factors influencing provider attitudes about abortion and provider perspectives about abortion morality, safety, and legality. We found that gatekeepers (counsellors and front office staff) generally believed abortion was immoral, while obstetricians and gynecologists were more likely to support an individual's right to access abortion. However, providers' actions do not necessarily align with their stated beliefs regarding abortion; some providers who said they support abortion access generally held personal beliefs about when and for whom abortion is appropriate which influenced their provision of care. System-level barriers to abortion provision, such as a lack of resources, hinder some providers who may otherwise be willing to provide the service. These system-level barriers may also account for inconsistencies between providers' beliefs and actions related to abortion. Illuminating the complexity in provider beliefs and attitudes about abortion can help us to better understand whether and why abortion care is provided, as well as the factors that ultimately determine whether a woman can obtain an abortion. [ABSTRACT FROM AUTHOR]

Although abortion is now legal in Kenya under expanded circumstances, access is limited and many providers and individuals still believe it is illegal. This study aimed to characterise Kenyan women's perceptions and experiences with abortion and post-abortion care (PAC) services in Nairobi regarding barriers to care, beliefs about abortion, and perceived stigma. We conducted 15 semi-structured in-depth interviews with Kenyan women aged 18-24 years who recently received abortion and PAC services at four Marie Stopes Kenya clinic sites in Nairobi. The most significant psychosocial barrier respondents faced in promptly seeking abortion and PAC was perceived stigma. In response to stigma, participants developed a sense of agency and self-reliance, which allowed them to prioritise their own healthcare needs over the concerns of others. To adequately address perceived stigma as a barrier to abortion- and PAC-seeking, significant cultural norm shifting is required. [ABSTRACT FROM AUTHOR]

Recent globally compiled evidence suggests that one-quarter of pregnancies end in abortions. However, abortions remain illegal in many countries, resulting in unsafe practices. Debates have largely stalled with the pro-life, pro-choice epithets. To provide further arguments in support of legalising abortion services, we argue that the state cannot demand of a woman that she maintains an unwanted pregnancy because that demand places her in a state of involuntary servitude. Involuntary servitude would put states in breach of international human rights law (Article 8 of International Covenant on Civil and Political Rights). Furthermore, we argue that the fact that a life may be forfeit when a woman withdraws her service is no basis for enforcing the servitude. We draw on the 13th Amendment of the US Constitution as an example to extend the argument and highlight the need to test involuntary servitude in international human rights law through mechanisms offered in the international periodic review of member states. This could provide a robust approach to support and strengthen access to safe abortion services. [ABSTRACT FROM AUTHOR]

Sexual and reproductive health (SRH) has increasingly gained importance in the field of international human rights law. The work of the United Nations (UN) bodies, in particular the recently adopted General Comment 22 (GC 22), has been instrumental in signalling the importance of the SRH legal framework and in setting clear guidelines to steer countries into enacting/modifying/repealing national laws in order to comply with their international obligations vis-à-vis SRH. Although within the region Uruguay is regarded as a pioneer in terms of women's status and rights, including sexual and reproductive health and rights, evidence points to a number of challenges. This article explores the extent to which the Uruguayan abortion law complies with the country's international human rights obligations as conceptualised by GC 22. It uses the Uruguayan abortion law, its regulatory decree, and the highest administrative court's decision in Alonso et al v. Poder Ejecutivo as the main pivots for the discussion. The results reveal that - in spite of the praise it receives at the international level and the adoption of a less restrictive abortion law - Uruguay has fallen short in adopting a legal framework that complies with the international standards and guarantees effective access to abortion services. [ABSTRACT FROM AUTHOR]

This paper explores sexual and reproductive health and rights (SRHR) among young people, identifying intersecting factors that create inequities in access to services, health-seeking behaviour, and ultimately health outcomes. Based on qualitative interviews with young people in the Maldives, it demonstrates how these intersectional experiences are contrary to what is often assumed in official data, policies, and services. Three factors were found to shape young people's experiences: marital status, gender, and urban/rural differences. Non-marital sexual activity is illegal in the Maldives, but it is somewhat expected of unmarried men, while unmarried women are stigmatised for being sexually active. Although access to SRH services is restricted for all unmarried people, young women face additional difficulties, as the risk of being exposed is much greater in small island communities. Maldivian island communities are extremely small and characterised by an inward-looking culture that exerts considerable social pressure, particularly on unmarried women. For an unmarried woman, being known to be sexually active, or worse, pregnant outside of marriage, has severe social consequences including stigma and isolation from the community, and their own family. This concern is more prevalent among rural young women, as they live in smaller communities where stigma is inescapable. The need to avoid public scrutiny and humiliation contributes to making unsafe abortion a common solution for many unintended pregnancies. Failure to acknowledge these intersecting factors in SRHR experience and access has led to inequities among an already overlooked population, shaping their experiences, knowledge, health-seeking behaviour, and health outcomes. [ABSTRACT FROM AUTHOR]

This paper comments on the views of the UN Human Rights Committee (hereafter the Committee) in the cases Mellet v. Ireland [1] and Whelan v. Ireland [2]. It focuses on the Committee's findings regarding a violation of the prohibition of discrimination. The interpretation presented by the Committee, although much welcomed and undeniably tackling reproductive health and rights in a progressive way, still leaves room for future improvements. It is argued herein that the Committee's reasoning is marked by some inaccuracies due to its inconsistent approach regarding gender equality. Whereas the Committee seems to have fully integrated a "substantive equality" approach when providing general interpretation of States' obligations under the International Covenant on Civil and Political Rights (hereafter the ICCPR), its assessment of individual cases remains to some extent influenced by the "formal equality" approach. [ABSTRACT FROM AUTHOR]

How rurality relates to women's abortion decision-making in the United States remains largely unexplored in existing literature. The present study relies on qualitative methods to analyze rural women's experiences related to pregnancy decision-making and pathways to abortion services in Central Appalachia. This analysis examines narratives from 31 participants who disclosed experiencing an unwanted pregnancy, including those who continued and terminated a pregnancy. Results suggest that women living in rural communities deal with unwanted pregnancy in three phases: (1) the simultaneous assessment of the acceptability of continuing the pregnancy and the acceptability of terminating the pregnancy, (2) deciding whether to seek services, and (3) navigating a pathway to service. Many participants who experience an unwanted pregnancy ultimately decide not to seek abortion services. When women living in rural communities assess their pregnancy as unacceptable but abortion services do not appear feasible to obtain, they adjust their emotional orientation towards continuing pregnancy, shifting the continuation of pregnancy to be an acceptable outcome. The framework developed via this analysis expands the binary constructs around abortion access - for example, decide to seek an abortion/decide not to seek an abortion, obtain abortion services/do not obtain abortion services - and critically captures the dynamic, often internal, calculations women make around unwanted pregnancy. It captures the experiences of rural women, a gap in the current literature. [ABSTRACT FROM AUTHOR]

Despite persistent international attention, adolescent pregnancy remains a major public health concern in low- and middle-income countries, like Papua New Guinea (PNG), where health inequities related to social and cultural norms, gender power imbalance, education and socio-economic deprivation affect young and unmarried women in particular. In PNG - where there is high adolescent fertility, high early childbearing and high maternal mortality ratio, and evidence of high rates of unintended pregnancy and abortion among young women - adolescent pregnancy is a policy priority. Yet there are no youth-specific sexual, reproductive and maternal health services or community-based outreach programmes. There is limited in-depth qualitative data on young women's and young men's experiences of pregnancy, the social contexts within which these pregnancies occur, young people's contraception practices and experiences with existing sexual, reproductive and maternal health services. These issues inhibit the design and delivery of youth-friendly health services and outreach support programmes that could prevent or mitigate adverse health and social outcomes associated with adolescent pregnancy. In this commentary article, we propose the need for novel youth-centred research to inform the development of policies, health services and outreach programmes that pay honest and respectful attention to young people's lived experiences of pregnancy. Whilst we focus on the situation in PNG, these ideas are relevant to diverse low resource settings where the harmful impacts of health inequities among young people persist and are particularly detrimental. [ABSTRACT FROM AUTHOR]

This commentary explores how self-managed abortion (SMA) has transformed understandings of and discourses on safe abortion and associated health inequities through an intersection of harm reduction, human rights and collective activism. The article examines three primary understandings of the relationship between SMA and safe abortion: first SMA as health inequity, second SMA as harm reduction, and third SMA as social change, including health system innovation and reform. A more dynamic understanding of the relationship between SMA, safe abortion and health inequities can both improve the design of interventions in the field, and more radically reset reform goals for health systems and other state institutions towards the full realisation of sexual and reproductive health and human rights. [ABSTRACT FROM AUTHOR]

Following two decades of civil war, Somalia recently entered the post-conflict rebuilding phase that has resulted in the rapid proliferation of higher education institutions. Given the high maternal mortality ratio, the federal government has identified the reproductive health education of health service professionals as a priority. Yet little is known about the coverage of contraception, abortion, pregnancy, childbirth, and sexual and gender-based violence (SGBV) in medicine, nursing, or midwifery. In 2016, we conducted a multi-methods study to understand the reproductive health education and training landscape and identify avenues by which development of the next generation of health service professionals could be improved. Our study comprised two components: interviews with 20 key informants and 7 focus group discussions (FGDs) with 48 physicians, nurses, midwives, and medical students. Using the transcripts, memos, and field notes, we employed a multi-phased approach to analyse our data for content and themes. Our findings show that reproductive health education for medical and nursing students is inconsistent and significant content gaps, particularly in abortion and SGBV, exist. Students have few clinical training opportunities and the overarching challenges plaguing higher education in Somalia also impact health professions programmes in Mogadishu. There is currently a window of opportunity to develop creative strategies to improve the breadth and depth of evidence-based education and training, and multi-stakeholder engagement and the promotion of South–South exchanges appear warranted. [ABSTRACT FROM PUBLISHER]

Women and girls are increasingly the direct and targeted victims of armed conflict and studies show that they are disproportionately and differentially affected. However, humanitarian laws, policies, and protocols have yet to be meaningfully interpreted and adapted to respond to their specific needs, including to sexual and reproductive health services and rights. In particular, safe abortion services are routinely omitted from sexual and reproductive health services in humanitarian settings for a variety of reasons, including improper deference to national law, the disproportionate influence of restrictive funding policies, and the failure to treat abortion as medical care. However, properly construed, abortion services fall within the purview of the universal and non-derogable protections granted under international humanitarian and human rights law. This commentary considers the protections of international humanitarian law and explains how abortion services fall within a category of protected medical care. It then outlines contemporary challenges affecting the realisation of these rights. Finally, it proposes a unification of current approaches through the use of international humanitarian law to ensure comprehensive care for those affected by armed conflict. [ABSTRACT FROM PUBLISHER]

Since the 1990s, the Inter-agency field manual on reproductive health in humanitarian settings (IAFM) has provided authoritative guidance on reproductive health service provision during different phases of complex humanitarian emergencies. In 2018, the Inter-Agency Working Group on Reproductive Health in Crises will release a new edition of this global resource. In this article, we describe the collaborative and inter-sectoral revision process and highlight major changes in the 2018 IAFM. Key revisions to the manual include repositioning unintended pregnancy prevention within and explicitly incorporating safe abortion care into the Minimum Initial Service Package (MISP) chapter, which outlines a set of priority activities to be implemented at the outset of a humanitarian crisis; stronger guidance on the transition from the MISP to comprehensive sexual and reproductive health services; and the addition of a logistics chapter. In addition, the IAFM now places greater and more consistent emphasis on human rights principles and obligations, gender-based violence, and the linkages between maternal and newborn health, and incorporates a diverse range of field examples. We conclude this article with an outline of plans for releasing the 2018 IAFM and facilitating uptake by those working in refugee, crisis, conflict, and emergency settings. [ABSTRACT FROM AUTHOR]

Unsafe abortion is responsible for at least 9% of all maternal deaths worldwide; however, in humanitarian emergencies where health systems are weak and reproductive health services are often unavailable or disrupted, this figure is higher. In Puntland, Somalia, Save the Children International (SCI) implemented postabortion care (PAC) services to address the issue of high maternal morbidity and mortality due to unsafe abortion. Abortion is explicitly permitted by Somali law to save the life of a woman, but remains a sensitive topic due to religious and social conservatism that exists in the region. Using a multipronged approach focusing on capacity building, assurance of supplies and infrastructure, and community collaboration and mobilisation, the demand for PAC services increased as did the proportion of women who adopted a method of family planning post-abortion. From January 2013 to December 2015, a total of 1111 clients received PAC services at the four SCI-supported health facilities. The number of PAC clients increased from a monthly average of 20 in 2013 to 38 in 2015. During the same period, 98% (1090) of PAC clients were counselled for postabortion contraception, of which 955 (88%) accepted a contraceptive method before leaving the facility, with 30% opting for long-acting reversible contraception. These results show that comprehensive PAC services can be implemented in politically unstable, culturally conservative settings where abortion and modern contraception are sensitive and stigmatised matters among communities, health workers, and policy makers. However, like all humanitarian settings, large unmet needs exist for PAC services in Somalia. [ABSTRACT FROM PUBLISHER]

For displaced and migrant women in northern Thailand, access to health care is often limited, unwanted pregnancy is common, and unsafe abortion is a major contributor to maternal death and disability. Based on a pilot project and situational analysis research, in 2015 a multinational team introduced the Safe Abortion Referral Programme (SARP) in Chiang Mai, Thailand, to reduce the socio-linguistic, economic, documentation, and transportation barriers women from Burma face in accessing safe and legal abortion care in Thailand. Our qualitative study documented the experiences of women with unwanted pregnancies who accessed the SARP in order to inform programme improvement and expansion. We conducted 22 in-depth, in-person interviews and analysed them for content and themes using deductive and inductive techniques. Women were overwhelmingly positive about their experiences using the SARP. They reported lack of costs, friendly programme staff, accompaniment to and interpretation at the providing facility, and safety of services as key features. Financial and legal circumstances shaped access to the programme and women learned about the SARP through word-of-mouth and community workshops. After accessing the SARP and receiving support, women became community advocates for reproductive health. Efforts to expand the programme and raise awareness in migrant communities appear warranted. Our findings suggest that referral programmes for safe and legal abortion can be successful in settings with large displaced and migrant populations. Identifying ways to work within legal constraints to expand access to safe services has the potential to reduce harm from unsafe abortion even in humanitarian settings. [ABSTRACT FROM PUBLISHER]

This paper is a sequel to a 2004 article that reviewed South Africa’s introduction of new sexual and reproductive health (SRH) and rights laws, policies and programmes, a decade into democracy. Similarly to the previous article, this paper focuses on key areas of women’s SRH: contraception and fertility, abortion, maternal health, HIV, cervical and breast cancer and sexual violence. In the last decade, South Africa has retained and expanded its sexual and reproductive health and rights (SRHR) policies in the areas of abortion, contraception, youth and HIV treatment (with the largest antiretroviral treatment programme in the world). These are positive examples within the SRHR policy arena. These improvements include fewer unsafe abortions, AIDS deaths and vertical HIV transmission, as well as the public provision of a human papillomavirus vaccine to prevent cervical cancer. However, persistent socio-economic inequities and gender inequality continue to profoundly affect South African women’s SRHR. The state shows mixed success over the past two decades in advancing measurable SRH social justice outcomes, and in confronting and ameliorating social norms that undermine SRHR. [ABSTRACT FROM AUTHOR]

Evidence suggests that there is widespread home use of abortion pills in Ireland and that ending a pregnancy in this way is potentially safer than the alternatives available to many women. This paper argues that there is a strong case for women with unwanted pregnancies to be offered truthful and objective information regarding the use of abortion pills by trusted local professionals and, further, that this is possible within existing law. A move in this direction would not, however, negate the need for legal reform to address the fundamental moral incoherence of a law that treats women who terminate pregnancies within Ireland as criminals but those who travel to access services overseas as victims in need of support. In support of these arguments, the paper draws on both library research and a small number of interviews with government officials, service providers and activists. [ABSTRACT FROM AUTHOR]

Turkey has maintained liberal contraception and abortion policies since the 1980s. In 2012, the government proposed to restrict abortion; a bill limiting abortion was later drafted but never passed into law. Since the proposed restriction, women have reported difficulty accessing abortion services across Turkey. We aimed to better understand the current availability of abortion and reproductive health services in Istanbul and explore whether access to services has changed since 2012. In 2015, we completed 14 in-depth interviews with women and 11 semi-structured interviews with key informants. We transcribed all interviews and completed content and thematic analyses of the data. Key informants had good knowledge about the political discourse and the current abortion law. In contrast, women were familiar with the political discourse but had mixed information about the current status of abortion and were unsure about the legality of their own abortions. There was consensus that access to services has become more limited in the last five years due to the political climate, thus advocacy to prioritize reproductive health services, and abortion care in particular, in the public health system are needed. [ABSTRACT FROM AUTHOR]

The prevalence of violence against women worldwide raises the question of the desirability and feasibility of integrating interpersonal violence (IPV) services within abortion care. By examining present services and context in an Inner London borough in the UK, this situation analysis explored the hypothesis that an established, integrated, health-based service (comprising raised awareness, staff training in routine IPV enquiry and referral to a community-based in-reach IPV service) would be transferable into abortion services. Four sources of qualitative data investigated views on integrating services: key stakeholder in-depth interviews including with providers of abortion and IPV services and commissioners and IPV survivors with past abortion service use (3 user, 15 provider); qualitative analysis of the open-ended part of a survey of current abortion service users with and without experience of IPV; feedback from an interactive workshop and data from field observations. While there was consensus among all informants that women experiencing IPV and seeking abortion have unidentified, unaddressed needs, how any intervention might be organised to address these needs was contested; thus questions remain about whether, when and how to raise the topic of IPV and what to offer. Two major anxieties surfaced: a practical concern in terms of interrupting a streamlined abortion service that suits the majority of staff and patients, and a conceptual concern about risk of stigmatising abortion seekers as ‘victims in crisis’. Thus, our findings indicate: when integrating IPV interventions into abortion services, local context, the integrity of separate pathways, and women’s safety and agency must be considered, especially when abortion rights are under attack. Novel approaches are required and should be researched. [ABSTRACT FROM AUTHOR]

Pregnant women routinely undergo prenatal screening in Australia and this has become a common experience of motherhood. When prenatal screening or prenatal testing results in diagnosis of a serious fetal abnormality, women are presented with a decision to continue or terminate their pregnancy. Few recent studies have explored women’s psychosocial experience of prenatal diagnosis and pregnancy termination for fetal abnormality, and within this small group of studies it is rare for research to consider the embodied aspect of women’s experiences. This paper reports on qualitative findings from in-depth interviews with 59 women in Melbourne, Australia who received a prenatal diagnosis of a significant abnormality and decided to terminate the pregnancy. Interview transcripts were coded inductively through thematic analysis. Two themes about embodiment were generated from the interviews: transitioning embodiment, and vulnerable bodies in un/comfortable spaces. Theory of pregnant embodiment was drawn on in interpreting women’s narratives. Recommendations arising from the analysis include health professionals recognising, acknowledging and accommodating the transitioning embodied state of women as they consider, prepare for, undergo and recover from pregnancy termination for fetal abnormality. Further recommendations address the connections and disconnections between this transitioning embodied state and the spaces of clinics, hospitals and home. [ABSTRACT FROM AUTHOR]

Medical abortion is a method of pregnancy termination that by its nature enables more active involvement of women in the process of managing, and sometimes even administering the medications for, their abortions. This qualitative evidence synthesis reviewed the global evidence on experiences with, preferences for, and concerns about greater self-management of medical abortion with lesser health professional involvement. We focused on qualitative research from multiple perspectives on women’s experiences of self-management of first trimester medical abortion (< 12 weeks gestation). We included research from both legal and legally-restricted contexts whether medical abortion was accessed through formal or informal systems. A review team of four identified 36 studies meeting inclusion criteria, extracted data from these studies, and synthesized review findings. Review findings were organized under the following themes: general perceptions of self-management, preparation for self-management, logistical considerations, issues of choice and control, and meaning and experience. The synthesis highlights that the qualitative evidence base is still small, but that the available evidence points to the overall acceptability of self-administration of medical abortion. We highlight particular considerations when offering self-management options, and identify key areas for future research. Further qualitative research is needed to strengthen this important evidence base. [ABSTRACT FROM AUTHOR]

This commentary discusses Ireland's 25 May 2018 Referendum result to repeal the Eighth Amendment and has two key aims. Firstly, it encourages policy-makers to grasp the full potential of legislative reform by enabling and protecting women's access to abortion care within a continuum of sexual and reproductive healthcare options. Secondly, it calls for urgent clarity about access to abortion care in the interim period of legislative transition. [ABSTRACT FROM AUTHOR]

Surgical abortion has been provided liberally in Australia since the early 1970s, mainly in privately owned specialist clinics. The introduction of medical abortion, however, was deliberately obstructed and consequently significantly delayed when compared to similar countries. Mifepristone was approved for commercial import only in 2012 and listed as a government subsidised medicine in 2013. Despite optimism from those who seek to improve women’s access to abortion, the increased availability of medical abortion has not yet addressed the disadvantage experienced by poor and non-metropolitan women. After telling the story of medical abortion in Australia, this paper considers the context through which it has become available since 2013. It argues that the integration of medical abortion into primary health care, which would locate abortion provision in new settings and expand women’s access, has been constrained by the stigma attached to abortion, overly cautious institutionalised frameworks, and the lack of public health responsibility for abortion services. The paper draws on documentary sources and oral history interviews conducted in 2013 and 2015. [ABSTRACT FROM AUTHOR]

In recent decades, attitudes in many parts of the Arab region have hardened towards non-conforming sexualities and gender roles, a shift fuelled in part by a rise in Islamic conservatism and exploited by authoritarian regimes. While political cultures have proved slow to change in the wake of the ‘Arab Spring’, a growing freedom of expression, and increasing activity by civil society, is opening space for discreet challenges to sexual taboos in a number of countries, part of wider debates over human rights and personal liberties in the emerging political and social order. [ABSTRACT FROM AUTHOR]

Fertility-related research encompasses fertility intentions, preconception care, research amongst pregnant women, and post-partum outcomes of mothers and children. However, some women remain under-represented within this domain of study. Women frequently missing within fertility-related research include those who are already the most vulnerable to health disparities, including female sex workers, lesbian, gay, bisexual, and transgender women, women living with HIV, and women who use drugs. Yet characterization of the needs of these women is important, given their unique fertility-related concerns, including risks and barriers to care emanating from social stigmas and discrimination. This synthesis provides an overview of fertility-related evidence, highlighting where there are clear research gaps among marginalized women and the potential implications of these data shortfalls. Overall, research among marginalized women to date has addressed pregnancy prevention and in some cases fertility intentions, but the majority of studies have focused on post-conception pregnancy safety and the well-being of the child. However, among female sex workers specifically, data on pregnancy safety and the well-being of the child are largely unavailable. Within each marginalized group, preconception care and effectiveness of conception methods are consistently understudied. Ultimately, the absence of epidemiologic, clinical and programmatic evidence limits the availability and quality of reproductive health services for all women and prevents social action to address these gaps. [ABSTRACT FROM AUTHOR]

In India, safe abortion services are sought mainly in the private sector for reasons of privacy, confidentiality, and the absence of delays and coercion to use contraception. In recent years, the declining sex ratio has received much attention, and implementation of the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act (2003) has become stringent. However, rather than targeting sex determination, many inspection visits target abortion services. This has led to many private medical practitioners facing negative media publicity, defamation and criminal charges. As a result, they have started turning women away not only in the second trimester but also in the first. Samyak, a Pune-based, non-governmental organization, came across a number of cases of refusal of abortion services during its work and decided to explore the experiences of private medical practitioners with the regulatory mechanisms and what happened to the women. The study showed that as a fallout from the manner of implementation of the PCPNDT Act, safe abortion services were either difficult for women to access or outright denied to them. There is an urgent need to recognize this impact of the current regulatory environment, which is forcing women towards illegal and unsafe abortions. [ABSTRACT FROM AUTHOR]

This paper describes the implementation of five Safe Abortion Information Hotlines (SAIH), a strategy developed by feminist collectives in a growing number of countries where abortion is legally restricted and unsafe. These hotlines have a range of goals and take different forms, but they all offer information by telephone to women about how to terminate a pregnancy using misoprostol. The paper is based on a qualitative study carried out in 2012-2014 of the structure, goals and experiences of hotlines in five Latin American countries: Argentina, Chile, Ecuador, Peru and Venezuela. The methodology included participatory observation of activities of the SAIH, and in-depth interviews with feminist activists who offer these services and with 14 women who used information provided by these hotlines to induce their own abortions. The findings are also based on a review of materials obtained from the five hotline collectives involved: documents and reports, social media posts, and details of public demonstrations and statements. These hotlines have had a positive impact on access to safe abortions for women whom they help. Providing these services requires knowledge and information skills, but little infrastructure. They have the potential to reduce the risk to women’s health and lives of unsafe abortion, and should be promoted as part of public health policy, not only in Latin America but also other countries. Additionally, they promote women’s autonomy and right to decide whether to continue or terminate a pregnancy. [ABSTRACT FROM AUTHOR]

The majority of abortions in Colombia continue to take place outside the formal health system under a range of conditions, with the majority of women obtaining misoprostol from a thriving black market for the drug and self-administering the medication. We conducted a cost analysis to compare the costs to the health system of three approaches to the provision of abortion care in Colombia: post-abortion care for complications of unsafe abortions, and for legal abortions in a health facility, misoprostol-only medical abortion and vacuum aspiration abortion. Hospital billing records from three institutions, two large maternity hospitals and one specialist reproductive health clinic, were analysed for procedure and complication rates, and costs by diagnosis. The majority of visits (94%) were to the two hospitals for post-abortion care; the other 6% were for legal abortions. Only one minor complication was found among the women having legal abortions, a complication rate of less than 1%. Among the women presenting for post-abortion care, 5% had complications during their treatment, mainly from infection or haemorrhage. Legal abortions were associated not only with far fewer complications for women, but also lower costs for the health system than for post-abortion care. We calculated based on our findings that for every 1,000 women receiving post-abortion care instead of a legal abortion within the health system, 16 women experienced avoidable complications, and the health system spent US $48,000 managing them. Increasing women’s access to safe abortion care would not only reduce complications for women, but would also be a cost-saving strategy for the health system. [ABSTRACT FROM AUTHOR]

In Nepal, despite policy restrictions, both registered and unregistered brands of mifepristone and misoprostol can easily be obtained at pharmacies. Since many women visit pharmacies for abortion information, ensuring that they receive effective care from pharmacy workers remains an important challenge. We conducted an operations research study to examine whether trained pharmacy workers can correctly provide information on safe use of mifepristone and misoprostol for early first trimester medical abortion. Pharmacy workers in one district were given orientation and training using a harm-reduction approach, and compared with a non-equivalent comparison group in the second district. Overall, trained pharmacy workers’ knowledge increased substantially, but no increase was found in the comparison group. Compared to the baseline (65%), 97% of trained pharmacy workers knew up to what stage of pregnancy and how women should use mifepristone and misoprostol. A higher percentage of pharmacy workers in the intervention group (77%) compared to the comparison group (49%) were knowledgeable at follow-up about determining whether an abortion was successful, implying a need for improving this aspect of training. As many mid-level health providers run their own pharmacies and offer medical abortion pills, it is important for the government to consider training these providers and registering their pharmacies as safe medical abortion service outlets. [ABSTRACT FROM AUTHOR]

Medical abortion was introduced in Nepal in 2009, but rural women’s access to medical abortion services remained limited. We conducted a district-level operations research study to assess the effectiveness of training 13 auxiliary nurse-midwives as medical abortion providers, and 120 female community health volunteers as communicators and referral agents for expanding access to medical abortion for rural women. Interviews with service providers and women who received medical abortion were undertaken and service statistics were analysed. Compared to a neighbouring district with no intervention, there was a significant increase in the intervention area in community health volunteers’ knowledge of the legal conditions for abortion, the advantages and disadvantages of medical abortion, safe places for an abortion, medical abortion drugs, correct gestational age for home use of medical abortion, and carrying out a urine pregnancy test. In a one-year period in 2011–12, the community health volunteers did pregnancy tests for 584 women and referred 114 women to the auxiliary nurse-midwives for abortion; 307 women in the intervention area received medical abortion services from auxiliary nurse-midwives. There were no complications that required referral to a higher-level facility except for one incomplete abortion. Almost all women who opted for medical abortion were happy with the services provided. The study demonstrated that auxiliary nurse-midwives can independently and confidently provide medical abortion safely and effectively at the sub-health post level, and community health volunteers are effective change agents in informing women about medical abortion. [ABSTRACT FROM AUTHOR]

There is only limited evidence on whether certified and uncertified health care providers in India support reforming the Medical Termination of Pregnancy (MTP) Act to expand the abortion provider base to allow trained nurses and AYUSH physicians (who are trained in Indian systems of medicine) to provide medical abortion. To explore their views, we conducted a survey of 1,200 physicians and other health care providers in Maharashtra and Bihar states and in-depth interviews with 34 of them who had used medical abortion in their practices. Findings indicate that obstetrician-gynaecologists and other allopathic physicians were less supportive than non-physicians of nurses and AYUSH physicians providing early medical abortion. The physicians did not think that these providers would be able to assess women’s eligibility for medical abortion correctly. In contrast, the majority of non-physicians found task shifting of medical abortion provision to trained nurses and AYUSH physicians acceptable, and they were confident that these providers would be able to provide medical abortion as safely and effectively as trained physicians. Assuming the reforms are passed, efforts will need to be made by government and medical professional bodies to train these new providers to undertake this role, prepare the health infrastructure to include them, and create an environment, including among physicians, that is conducive to enabling non-physicians to provide medical abortion. [ABSTRACT FROM AUTHOR]

In Armenia, abortion is the main means of fertility regulation; however, before research activities were initiated only surgical methods were available and the quality of services was low in some areas. Our clinical study from 2008–2011 aimed to show that early medical abortion is an acceptable and feasible option. A total of 700 eligible women with pregnancies up to 63 days LMP presenting for abortion were recruited for the study in five locations. Participants took 200 mg mifepristone and 800 μg buccal misoprostol 24–48 hours later. They returned for a follow-up visit two weeks after mifepristone administration. 95% of the women had successful abortions and 95% were satisfied with the method. In 2012–2013, we conducted a follow-up assessment to examine the ongoing provision and quality of medical abortion services at the former research sites. Medical record reviews, interviews and observations were carried out three times approximately six months apart. The assessment found that all five sites had continued providing medical abortion, with about half of eligible women choosing the medical method. Four of the five sites were achieving high success rates. Staff turnover and the lack of trained providers likely contributed to the higher failure rate at the fifth site. These findings provide evidence that first trimester medical abortion is an acceptable and feasible option for Armenian women and providers, and that high quality services are being delivered. [ABSTRACT FROM AUTHOR]

In spite of wide availability of menstrual regulation services, women often resort to a variety of medicines for inducing abortion. The Bangladeshi Government is now supporting attempts to investigate the introduction of medical menstrual regulation in the public sector. This study examined the acceptability of medical menstrual regulation in public sector urban-based clinics, public sector rural-based clinics and urban-based clinics run by Marie Stopes, a non-governmental organization. Of the 2,976 women who attended for menstrual regulation services during the eight-month study period, 68% attended urban Maternal and Child Welfare Centres and the Marie Stopes clinics, while 32% went to the rural public facilities of the Union Health and Family Welfare Centre. Women were offered both medical and manual vacuum aspiration methods of menstrual regulation; 1,875 (63%) chose the medical method and 1,101 (37%) chose manual vacuum aspiration. Around 7.1% of women at Maternal and Child Welfare centres and 11.9% at the Marie Stopes clinics knew about medical menstrual regulation before taking the service, compared to a much higher proportion (43%) at the rural facilities. Overall 61.4% of women who used medical menstrual regulation found the method satisfactory, and 34.2% were very satisfied. Of the 3.9% of women who were not satisfied, most received services from rural facilities. [ABSTRACT FROM AUTHOR]

Women’s control over their own bodies and reproduction is a fundamental prerequisite to the achievement of sexual and reproductive health and rights. A woman’s ability to terminate an unwanted pregnancy has been seen as the exercise of her reproductive rights. This study reports on interviews with 15 women in rural South India who had a medical abortion. It examines the circumstances under which they chose to have an abortion and their perspectives on medical abortion. Women in this study decided to have an abortion when multiple factors like lack of spousal support for child care or contraception, hostile in-laws, economic hardship, poor health of the woman herself, spousal violence, lack of access to suitable contraceptive methods, and societal norms regarding reproduction and sexuality converged to oppress them. The availability of an easy and affordable method like medical abortion pills helped the women get out of a difficult situation, albeit temporarily. Medical abortion also fulfilled their special needs by ensuring confidentiality, causing least disruption of their domestic schedule, and dispensing with the need for rest or a caregiver. The study concludes that medical abortion can help women in oppressive situations. However, this will not deliver gender equality or women’s empowerment; social conditions need to change for that. [ABSTRACT FROM AUTHOR]

Extensive evidence exists regarding the efficacy and acceptability of medical abortion through 63 days since last menstrual period (LMP). In Mexico City’s Secretariat of Health (SSDF) outpatient facilities, mifepristone-misoprostol medical abortion is the first-line approach for abortion care in this pregnancy range. Recent research demonstrates continued high rates of complete abortion through 70 days LMP. To expand access to legal abortion services in Mexico City (where abortion is legal through 12 weeks LMP), this study sought to assess the efficacy and acceptability of the standard outpatient approach through 70 days in two SSDF points of service. One thousand and one women seeking pregnancy termination were enrolled and given 200 mg mifepristone followed by 800 μg misoprostol 24–48 hours later. Women were asked to return to the clinic one week later for evaluation. The great majority of women (93.3%; 95% CI: 91.6–94.8) had complete abortions. Women with pregnancies ≤8 weeks LMP had significantly higher success rates than women in the 9th or 10th weeks (94.9% vs. 90.5%; p = 0.01). The difference in success rates between the 9th and 10th weeks was not significant (90.0% vs. 91.2%; p = 0.71). The majority of women found the side effects (82.9%) and the use of misoprostol (84.4%) to be very acceptable or acceptable. This study provides additional evidence supporting an extended outpatient medical abortion regimen through 10 weeks LMP. [ABSTRACT FROM AUTHOR]

In 2010, following its approval by the Ministry of Health, the medical abortion combination pack Medabon (containing mifepristone and misoprostol) was made available at pharmacies and in a restricted number of health facilities in Cambodia. The qualitative study presented in this paper was conducted in 2012 as a follow-up to longer-term ethnographical research related to reproductive health and fertility regulation between 2008 and 2012. Observations were carried out at several clinic and pharmacy sites and in-depth interviews were conducted with a purposive sample of 20 women who attended two MSI Cambodia centres and 10 women identified through social networks; six men (women’s male partners); eight health care providers at the two MSI centres and four pill sellers at private or informal pharmacies (who also provided health care services in private clinics). Although the level of training among the drug sellers and providers varied, their knowledge about medical abortion regimens, correct usage and common side effects was good. Overall, women were satisfied with the services provided. Medical abortion was not always a women-only process in this study as some male partners were also involved in the care process. The study illustrates positive steps forward being taken in making abortion safe and preventing and reducing unsafe abortion practices in Cambodia. [ABSTRACT FROM AUTHOR]

In Zimbabwe, abortions are legally restricted and complications from unsafe abortions are a major public health concern. This study in 2012 explored women’s and providers’ perspectives in Zimbabwe on the acceptability of the use of misoprostol as a form of treatment for complications of abortion in post-abortion care. In-depth interviews were conducted with 115 participants at seven post-abortion care facilities. Participants included 73 women of reproductive age who received services for incomplete abortion and 42 providers, including physicians, nurses, midwives, general practitioners and casualty staff. Only 29 providers had previously used misoprostol with their own patients, and only 21 had received any formal training in its use. Nearly all women and providers preferred misoprostol to surgical abortion methods because it was perceived as less invasive, safer and more affordable. Women also generally preferred the non-surgical method, when given the option, as fears around surgery and risk were high. Most providers favoured removing legal restrictions on abortion, particularly medical abortion. Approving use of misoprostol for post-abortion care in Zimbabwe is important in order to reduce unsafe abortion and its related sequelae. Legal, policy and practice reforms must be accompanied by effective reproductive health curricula updates in medical, nursing and midwifery schools, as well as through updated training for current and potential providers of post-abortion care services nationwide. Our findings support the use of misoprostol in national post-abortion care programmes, as it is an acceptable and potentially life-saving treatment option. [ABSTRACT FROM AUTHOR]

In-clinic follow-up to assess completion of medical abortion is no longer a requirement according to World Health Organization guidance, provided adequate counselling is given. However, timely recognition of ongoing pregnancy, complications or incomplete abortion, which require treatment, is important. As part of a larger trial, this study aimed to establish whether women having a medical abortion could self-assess whether their abortion was complete using an automated, interactive questionnaire on their mobile phones. All 469 participants received standard abortion care and all returnees filled in a self-assessment on paper at clinic follow-up 2–3 weeks later. The 234 women allocated to receive the phone messages were also asked to do a mobile phone assessment at home ten days post-misoprostol. Completion of the mobile assessment was tracked by computer and all completed assessments, paper and mobile, were compared to providers’ assessments at clinic follow-up. Of the 226 women able to access the mobile phone assessment, 176 (78%) completed it; 161 of them (93%) reported it was easy to do so. Neither mobile nor paper self-assessments predicted all cases needing additional treatment at follow-up. Prediction of complete procedures was good; 71% of mobile assessments and 91% of paper assessments were accurate. We conclude that an interactive questionnaire assessing completion of medical abortion on mobile phones is feasible in the South African setting; however, it should be done later than day 10 and combined with an appropriate pregnancy test to accurately detect incomplete procedures. [ABSTRACT FROM AUTHOR]

Despite broad grounds for legal abortion in Zambia, access to abortion services remains limited. Pharmacy workers, a primary source of health care for communities, present an opportunity to bridge the gap between policy and practice. As part of a larger operations study, 80 pharmacy workers, both registered pharmacists and their assistants, participated in a training on medical abortion in 2009 and 2010. Fifty-five of the 80 pharmacy workers completed an anonymous, structured training pre-test, treated as a baseline questionnaire; 53 of the 80 trainees were interviewed 12–24 months post-training in face-to-face interviews to measure the retention of information and training effectiveness. Survey questions were selected to illustrate the principles of a harm reduction approach to unsafe abortion. Bivariate analysis was used to examine pharmacy worker knowledge, attitudes and dispensing behaviours pre-training and at follow-up. A higher percentage of pharmacy workers reported referring women to a health care facility between surveys (47% to 68%, p = 0.03). The number of pharmacy workers who reported dispensing ineffective abortifacients decreased from baseline to end-line (30% to 25%) but the difference was non-significant. However, study results demonstrate that Zambian pharmacy workers have a role to play in safe abortion services and some are willing to play that role. [ABSTRACT FROM AUTHOR]

In Armenia, abortion is the main means of fertility regulation; however, before research activities were initiated only surgical methods were available and the quality of services was low in some areas. Our clinical study from 2008–2011 aimed to show that early medical abortion is an acceptable and feasible option. A total of 700 eligible women with pregnancies up to 63 days LMP presenting for abortion were recruited for the study in five locations. Participants took 200 mg mifepristone and 800 μg buccal misoprostol 24–48 hours later. They returned for a follow-up visit two weeks after mifepristone administration. 95% of the women had successful abortions and 95% were satisfied with the method. In 2012–2013, we conducted a follow-up assessment to examine the ongoing provision and quality of medical abortion services at the former research sites. Medical record reviews, interviews and observations were carried out three times approximately six months apart. The assessment found that all five sites had continued providing medical abortion, with about half of eligible women choosing the medical method. Four of the five sites were achieving high success rates. Staff turnover and the lack of trained providers likely contributed to the higher failure rate at the fifth site. These findings provide evidence that first trimester medical abortion is an acceptable and feasible option for Armenian women and providers, and that high quality services are being delivered. RésuméEn Arménie, l’avortement est le principal moyen de régulation de la fécondité ; néanmoins, avant le début des activités de recherche, seules les méthodes chirurgicales étaient disponibles et la qualité des services était faible dans certaines régions. Notre étude clinique de 2008 à 2011 souhaitait montrer que l’avortement médicamenteux précoce est une option acceptable et faisable. Un total de 700 femmes réunissant les conditions requises, avec une grossesse de moins de 63 jours depuis la DDR, qui s’étaient présentées pour un avortement ont été recrutées pour l’étude dans cinq sites. Les participantes ont pris 200 mg de mifépristone et 800 μg de misoprostol par voie buccale 24–48 heures après. Elles sont revenues pour une visite de suivi deux semaines après l’administration de la mifépristone. 95% des femmes avaient avorté et 95% étaient satisfaites de la méthode. En 2012–2013, nous avons mené une évaluation complémentaire pour examiner la prestation et la qualité des services d’avortement médicamenteux dans les précédents sites de recherche. Un examen des dossiers médicaux, des entretiens et des observations ont été réalisés à trois reprises à environ six mois d’intervalle. L’évaluation a révélé que les cinq sites avaient continué à pratiquer des avortements médicamenteux et que près de la moitié des femmes pouvant y prétendre choisissaient cette méthode. Quatre des cinq sites obtenaient des taux élevés de réussite. Le roulement du personnel et le manque de prestataires formés ont probablement contribué au taux plus élevé d’échec dans le cinquième site. Ces conclusions montrent que l’avortement médicamenteux du premier trimestre est une option acceptable et faisable pour les femmes et les prestataires arméniens et que des services de qualité sont assurés. ResumenEn Armenia, el aborto es el principal medio para regular la fertilidad; sin embargo, antes de que se iniciaran las actividades de investigación, solo había métodos quirúrgicos disponibles y los servicios eran de baja calidad en algunas regiones. Nuestro estudio clínico realizado de 2008 a 2011 tuvo como objetivo mostrar que el aborto con medicamentos temprano es una opción aceptable y factible. En cinco lugares, se reclutó para el estudio un total de 700 mujeres elegibles con embarazos de hasta 63 días desde la FUM, que acudieron a la unidad de salud para tener un aborto. Las participantes tomaron 200 mg de mifepristona y 800 μg de misoprostol por vía bucal 24 a 48 horas después. Regresaron para una consulta de seguimiento dos semanas después de administrada la mifepristona. El 95% de las mujeres tuvo un aborto completo y el 95% estuvo satisfecha con el método. En 2012–2013, realizamos una evaluación de seguimiento para examinar la prestación continua y calidad de los servicios de aborto con medicamentos en los lugares donde se realizó la investigación. Se llevaron a cabo revisiones de los expedientes médicos, entrevistas y observaciones tres veces, a intervalos de aproximadamente seis meses. La evaluación encontró que los cinco lugares habían continuado prestando servicios de aborto con medicamentos, y que aproximadamente la mitad de las mujeres elegibles eligieron el método con medicamentos. Cuatro de los cinco lugares estaban logrando altas tasas de aborto completo. La rotación de personal y la falta de profesionales de la salud capacitados probablemente contribuyeron a una mayor tasa de aborto fallido en el quinto lugar. Estos hallazgos ofrecen evidencia de que el aborto con medicamentos en el primer trimestre es una opción aceptable y factible para las mujeres y profesionales de la salud en Armenia, y que se están prestando servicios de alta calidad. [ABSTRACT FROM PUBLISHER]

Extensive evidence exists regarding the efficacy and acceptability of medical abortion through 63 days since last menstrual period (LMP). In Mexico City’s Secretariat of Health (SSDF) outpatient facilities, mifepristone-misoprostol medical abortion is the first-line approach for abortion care in this pregnancy range. Recent research demonstrates continued high rates of complete abortion through 70 days LMP. To expand access to legal abortion services in Mexico City (where abortion is legal through 12 weeks LMP), this study sought to assess the efficacy and acceptability of the standard outpatient approach through 70 days in two SSDF points of service. One thousand and one women seeking pregnancy termination were enrolled and given 200 mg mifepristone followed by 800 μg misoprostol 24–48 hours later. Women were asked to return to the clinic one week later for evaluation. The great majority of women (93.3%; 95% CI: 91.6–94.8) had complete abortions. Women with pregnancies ≤8 weeks LMP had significantly higher success rates than women in the 9th or 10th weeks (94.9% vs. 90.5%; p = 0.01). The difference in success rates between the 9th and 10th weeks was not significant (90.0% vs. 91.2%; p = 0.71). The majority of women found the side effects (82.9%) and the use of misoprostol (84.4%) to be very acceptable or acceptable. This study provides additional evidence supporting an extended outpatient medical abortion regimen through 10 weeks LMP. RésuméDe nombreuses données existent sur l’efficacité et l’acceptabilité de l’avortement médicamenteux jusqu’à 63 jours depuis la date des dernières règles (DDR). Dans les centres ambulatoires du Secrétariat de la santé de Mexico (SSDF), l’avortement médicamenteux sous mifépristone et misoprostol est la méthode de première intention pour l’interruption de grossesses de cet âge gestationnel. Des recherches récentes montrent des taux élevés d’avortement complet jusqu’à 70 jours après la DDR. Pour élargir l’accès à des services d’avortement légal à Mexico (où l’avortement est autorisé jusqu’à 12 semaines après la DDR), cette étude a tenté d’évaluer l’efficacité et l’acceptabilité de la méthode ambulatoire standard jusqu’à 70 jours dans deux centres du SSDF. Mille et une femmes souhaitant avorter ont été recrutées et ont reçu 200 mg de mifépristone suivis de 800 μg de misoprostol 24–48 heures plus tard. Elles ont été invitées à revenir au centre une semaine après pour évaluation. Chez la grande majorité des patientes (93,3% ; IC 95% : 91,6–94,8), l’avortement était complet. Les femmes enceintes ≤8 semaines après la DDR avait des taux de réussite sensiblement plus élevés que les femmes à 9 ou 10 semaines (94,9% contre 90,5% ; p = 0,01). La différence dans les taux de réussite entre la 9e et la 10e semaine était non significative (90,0% contre 91,2% ; p = 0,71). La majorité des femmes ont jugé les effets secondaires (82,9%) et l’utilisation du misoprostol (84,4%) très acceptables ou acceptables. Cette étude fournit des données supplémentaires soutenant un régime étendu d’avortement médicamenteux en ambulatoire jusqu’à 10 semaines après la DDR. ResumenExiste extensa evidencia respecto a la eficacia y aceptabilidad del aborto con medicamentos hasta los 63 días desde la fecha de la última menstruación (FUM). En las unidades de salud ambulatorias de la Secretaría de Salud del Distrito Federal de México (SSDF), el aborto con medicamentos inducido con mifepristona-misoprostol es el enfoque de primera línea en los servicios de aborto para esta etapa de la edad gestacional. Recientes investigaciones demuestran continuas altas tasas de aborto completo hasta concluidos los 70 días desde la FUM. Con el fin de ampliar el acceso a los servicios de interrupción legal del embarazo en el Distrito Federal (donde el aborto es legal hasta las 12 semanas desde la FUM), este estudio buscó evaluar la eficacia y aceptabilidad del enfoque ambulatorio estándar hasta los 70 días en dos puntos de entrega de servicios de la SSDF. Mil y una mujeres que buscaban interrumpir su embarazo fueron inscritas y administradas una dosis de 200 mg de mifepristona seguida de 800 μg de misoprostol, 24 a 48 horas después. Se les pidió a las mujeres que regresaran a la clínica una semana después para la evaluación. La gran mayoría de las mujeres (93.3%; 95% IC: 91.6–94.8) tuvo un aborto completo. Las mujeres con embarazos ≤8 semanas desde la FUM tuvieron tasas de eficacia significantemente más altas que las mujeres en la novena o décima semanas (94.9% vs. 90.5%; p = 0.01). La diferencia en las tasas de eficacia entre la novena y décima semanas no fue significante (90.0% vs. 91.2%; p = 0.71). La mayoría de las mujeres encontraron que los efectos secundarios (82.9%) y el uso de misoprostol (84.4%) eran muy aceptables o aceptables. Este estudio ofrece evidencia adicional que respalda un régimen de aborto con medicamentos extendido hasta concluidas las 10 semanas desde la FUM para usuarias ambulatorias. [ABSTRACT FROM PUBLISHER]

Despite broad grounds for legal abortion in Zambia, access to abortion services remains limited. Pharmacy workers, a primary source of health care for communities, present an opportunity to bridge the gap between policy and practice. As part of a larger operations study, 80 pharmacy workers, both registered pharmacists and their assistants, participated in a training on medical abortion in 2009 and 2010. Fifty-five of the 80 pharmacy workers completed an anonymous, structured training pre-test, treated as a baseline questionnaire; 53 of the 80 trainees were interviewed 12–24 months post-training in face-to-face interviews to measure the retention of information and training effectiveness. Survey questions were selected to illustrate the principles of a harm reduction approach to unsafe abortion. Bivariate analysis was used to examine pharmacy worker knowledge, attitudes and dispensing behaviours pre-training and at follow-up. A higher percentage of pharmacy workers reported referring women to a health care facility between surveys (47% to 68%, p = 0.03). The number of pharmacy workers who reported dispensing ineffective abortifacients decreased from baseline to end-line (30% to 25%) but the difference was non-significant. However, study results demonstrate that Zambian pharmacy workers have a role to play in safe abortion services and some are willing to play that role. RésuméMalgré de vastes motifs d’avortement légal en Zambie, l’accès aux services d’avortement demeure limité. Les pharmacies, sources primaires de soins de santé pour les communautés, offrent la possibilité de combler l’écart entre les politiques et la pratique. Dans le cadre d’une étude plus large sur les opérations, 80 employés de pharmacie (pharmaciens agréés et leurs assistants) ont participé à une formation sur l’avortement médicamenteux en 2009 et 2010. Avant la formation, 55 des 80 employés ont complété un test structuré et anonyme, traité comme questionnaire de référence ; 53 des 80 apprenants ont été interrogés 12–24 mois après la formation dans des entretiens de suivi en face à face pour mesurer la rétention de l’information et l’efficacité de la formation. Les questions de l’enquête ont été sélectionnées pour illustrer les principes de l’approche de réduction des risques de l’avortement clandestin. Une analyse bivariée a été utilisée pour examiner les connaissances, les attitudes et les comportements de dispensation des employés de pharmacie avant et après la formation. Un pourcentage plus élevé d’employés ont répondu qu’ils avaient orienté des femmes vers des centres de soins de santé entre les enquêtes (47% à 68%, p = 0.03). Le nombre d’employés ayant indiqué qu’ils avaient dispensé des produits abortifs inefficaces a diminué entre les chiffres de référence et les données finales (30% à 25%), mais la différence était non significative. Néanmoins, les résultats de l’étude démontrent que les employés de pharmacie zambiens ont un rôle à jouer dans des services d’avortement sûr et que certains sont prêts à l’assumer. ResumenA pesar de que el aborto es permitido por amplias causales en Zambia, el acceso a los servicios de aborto continúa siendo limitado. El personal de farmacias, una fuente principal de servicios de salud para las comunidades, presenta una oportunidad para llenar la brecha entre políticas y práctica. Como parte de un estudio más extenso de operaciones, 80 trabajadores de farmacias, tanto farmaceutas titulados como sus asistentes, participaron en una capacitación sobre aborto con medicamentos en los años 2009 y 2010. Cincuenta y cinco de los 80 trabajadores de farmacias contestaron un examen preliminar estructurado anónimo, el cual fue tratado como cuestionario de línea base; 53 de las 80 personas que recibieron capacitación fueron entrevistadas cara a cara 12 a 24 meses después de la capacitación, con el fin de medir la retención de información y eficacia de la capacitación. Las preguntas de la encuesta fueron seleccionadas para ilustrar los principios de un enfoque de reducción de daños con relación al aborto inseguro. Se utilizó el análisis bivariado para examinar los conocimientos, actitudes y comportamientos del personal de farmacias relacionados con despachar medicamentos, antes de la capacitación y durante el seguimiento. Un mayor porcentaje de trabajadores de farmacias informaron referir a las mujeres a una unidad de salud entre encuestas (47% al 68%, p = 0.03). El número de trabajadores de farmacias que informaron despachar abortivos ineficaces disminuyó desde la línea base hasta la línea final (30% al 25%), pero la diferencia fue insignificante. Sin embargo, los resultados del estudio demuestran que los trabajadores de farmacias en Zambia pueden desempeñar un papel en la prestación de servicios de aborto seguro, y algunos están dispuestos a hacerlo. [ABSTRACT FROM PUBLISHER]

In 2010, following its approval by the Ministry of Health, the medical abortion combination pack Medabon (containing mifepristone and misoprostol) was made available at pharmacies and in a restricted number of health facilities in Cambodia. The qualitative study presented in this paper was conducted in 2012 as a follow-up to longer-term ethnographical research related to reproductive health and fertility regulation between 2008 and 2012. Observations were carried out at several clinic and pharmacy sites and in-depth interviews were conducted with a purposive sample of 20 women who attended two MSI Cambodia centres and 10 women identified through social networks; six men (women’s male partners); eight health care providers at the two MSI centres and four pill sellers at private or informal pharmacies (who also provided health care services in private clinics). Although the level of training among the drug sellers and providers varied, their knowledge about medical abortion regimens, correct usage and common side effects was good. Overall, women were satisfied with the services provided. Medical abortion was not always a women-only process in this study as some male partners were also involved in the care process. The study illustrates positive steps forward being taken in making abortion safe and preventing and reducing unsafe abortion practices in Cambodia. RésuméEn 2010, après son approbation par le Ministère de la Santé, le produit pour l’avortement médicamenteux Medabon, conditionnement qui associe la mifépristone et le misoprostol, a été commercialisé dans les pharmacies et dans un nombre restreint de centres de santé au Cambodge. L’étude qualitative présentée dans cet article s’est déroulée en 2012, comme prolongement d’une recherche ethnographique à plus long terme relative à la santé génésique et la régulation de la fécondité entre 2008 et 2012. Les observations ont été réalisées dans plusieurs dispensaires et pharmacies. Des entretiens approfondis ont été menés avec un échantillon raisonné de 20 femmes qui s’étaient rendues dans deux centres MSI Cambodge et dix femmes identifiées par les réseaux sociaux ; six hommes (des partenaires des femmes) ; huit prestataires de soins de santé dans les deux centres MSI et quatre vendeurs de comprimés dans des pharmacies privées ou informelles (qui assuraient également des soins de santé dans des dispensaires privés). Le niveau de formation des vendeurs de comprimés et des prestataires était divers, mais leur connaissance des schémas d’avortement médicamenteux, de leur utilisation correcte et des effets secondaires fréquents était bonne. Dans l’ensemble, les femmes étaient satisfaites des services fournis. L’avortement médicamenteux n’était pas toujours une « affaire de femmes » dans cette étude puisque certains partenaires masculins participaient également au processus. L’étude illustre les progrès accomplis pour rendre les avortements plus sûrs, tout en prévenant et réduisant les pratiques abortives à risque au Cambodge. ResumenEn el año 2010, después de ser aprobado por el Ministerio de Salud, el paquete combinación para el aborto con medicamentos Medabon (que contiene mifepristona y misoprostol) se hizo disponible en farmacias y en un número limitado de unidades de salud en Camboya. El estudio cualitativo presentado en este artículo fue realizado en 2012 como seguimiento a investigaciones etnográficas más extensas relacionadas con la salud reproductiva y la regulación de la fertilidad del 2008 al 2012. Se realizaron observaciones en varias clínicas y farmacias, así como entrevistas a profundidad con una muestra intencional de 20 mujeres que asistieron a dos centros de MSI Camboya y 10 mujeres identificadas por medio de redes sociales; seis hombres (parejas de mujeres); ocho profesionales de la salud en los dos centros de MSI y cuatro vendedores de píldoras en farmacias privadas o informales (que también prestaban servicios de salud en clínicas privadas). Aunque el nivel de capacitación entre los vendedores de medicamentos y profesionales de la salud varió, tenían buenos conocimientos acerca de los regímenes de aborto con medicamentos, uso correcto y efectos secundarios comunes. En general, las mujeres estaban satisfechas con los servicios que recibieron. En este estudio, el aborto con medicamentos no siempre fue un proceso solo para mujeres, ya que algunas parejas de sexo masculino también participaron en el proceso de brindar cuidados. El estudio ilustra los pasos positivos hacia adelante que se están realizando para lograr que el aborto sea más seguro y para prevenir y reducir las prácticas de aborto inseguro en Camboya. [ABSTRACT FROM PUBLISHER]

In spite of wide availability of menstrual regulation services, women often resort to a variety of medicines for inducing abortion. The Bangladeshi Government is now supporting attempts to investigate the introduction of medical menstrual regulation in the public sector. This study examined the acceptability of medical menstrual regulation in public sector urban-based clinics, public sector rural-based clinics and urban-based clinics run by Marie Stopes, a non-governmental organization. Of the 2,976 women who attended for menstrual regulation services during the eight-month study period, 68% attended urban Maternal and Child Welfare Centres and the Marie Stopes clinics, while 32% went to the rural public facilities of the Union Health and Family Welfare Centre. Women were offered both medical and manual vacuum aspiration methods of menstrual regulation; 1,875 (63%) chose the medical method and 1,101 (37%) chose manual vacuum aspiration. Around 7.1% of women at Maternal and Child Welfare centres and 11.9% at the Marie Stopes clinics knew about medical menstrual regulation before taking the service, compared to a much higher proportion (43%) at the rural facilities. Overall 61.4% of women who used medical menstrual regulation found the method satisfactory, and 34.2% were very satisfied. Of the 3.9% of women who were not satisfied, most received services from rural facilities. RésuméMalgré la large disponibilité de services de régulation menstruelle, les femmes ont souvent recours à différents médicaments pour induire l’avortement. Le Gouvernement bangladeshi soutient maintenant les activités de recherche sur l’introduction de la régulation menstruelle médicamenteuse dans le secteur public. Cette étude a examiné l’acceptabilité de la régulation menstruelle médicamenteuse dans les dispensaires urbains du secteur public, les dispensaires ruraux du secteur public et les dispensaires urbains gérés par Marie Stopes, une organisation non gouvernementale. Des 2976 femmes ayant utilisé les services de régulation menstruelle pendant les huit mois de l’étude, 68% s’étaient rendues dans les dispensaires urbains des Maternal and Child Welfare Centres et Marie Stopes, alors que 32% étaient allées dans les dispensaires publics ruraux de l’Union Health and Family Welfare Centre. Les femmes avaient le choix entre des méthodes de régulation menstruelle médicamenteuses et par aspiration manuelle ; 1875 (63%) ont choisi la méthode médicamenteuse, alors que 1101 (37%) optaient pour l’aspiration manuelle. Près de 7,1% des femmes dans les centres de bien-être maternel et infantile et 11,9% dans les dispensaires Marie Stopes connaissaient la régulation menstruelle médicamenteuse avant de bénéficier du service, contre une proportion beaucoup plus élevée (43%) dans les centres ruraux. Dans l’ensemble, 61,4% des femmes qui ont utilisé la régulation menstruelle médicamenteuse ont jugé la méthode satisfaisante, et 34,2% en étaient très satisfaites. La plupart des 3,9% des femmes qui n’étaient pas satisfaites avaient été traitées dans des centres ruraux. ResumenA pesar de la amplia disponibilidad de servicios de regulación menstrual, las mujeres a menudo recurren a una variedad de medicamentos para inducir el aborto. El Gobierno de Bangladesh está respaldando intentos por investigar la introducción de la regulación menstrual con medicamentos en el sector público. Este estudio examinó la aceptabilidad de la regulación menstrual con medicamentos en clínicas urbanas del sector público, clínicas rurales del sector público y clínicas urbanas dirigidas por Marie Stopes, una organización no gubernamental. De las 2976 mujeres que asistieron para recibir servicios de regulación menstrual durante los ocho meses del estudio, el 68% asistió a un Maternal and Child Welfare Centre urbano o a una clínica de Marie Stopes, mientras que el 32% acudió a una unidad de salud pública rural del Union Health and Family Welfare Centre. A las mujeres se les ofrecieron tanto el método con medicamentos como la aspiración manual endouterina para la regulación menstrual; 1875 (63%) eligieron el método con medicamentos y 1101 (37%) eligieron la aspiración manual endouterina. Aproximadamente el 7.1% de las mujeres en Maternal and Child Welfare Centres y el 11.9% en las clínicas de Marie Stopes habían oído hablar de la regulación menstrual con medicamentos antes de recibir el servicio, comparado con un porcentaje mucho mayor (43%) en las unidades de salud rurales. En general, el 61.4% de las mujeres que reciberon medicamentos para la regulación menstrual encontraron que el método fue satisfactorio, y el 34.2% de ellas estaban muy satisfechas. Del 3.9% de las mujeres que no estaban satisfechas, la mayoría recibió servicios de unidades de salud rurales. [ABSTRACT FROM PUBLISHER]

Global statistics on unplanned pregnancies, abortions and STIs show that unprotected sex is still widely practised. More needs to be done to provide women and men with a wider choice of convenient protective options. To address this need, international efforts are focusing on developing multipurpose prevention technologies (MPTs) that address two or more indications simultaneously. These technologies would have significant advantages over single-indication products. They include inter alia novel barrier devices, drugs administered either as oral tablets or vaginal/rectal gels, drugs used in combination with medical devices, and genetically engineered organisms which secrete antimicrobial substances. As an example of progress in the MPT field, this paper describes an on-demand contraceptive/antimicrobial vaginal gel, Amphora (previously known as Acidform), now in an advanced stage of development. Clinical trials are currently being planned to find out whether this product's promising antimicrobial profile translates into protective and preventive choices. [ABSTRACT FROM AUTHOR]

In-clinic follow-up to assess completion of medical abortion is no longer a requirement according to World Health Organization guidance, provided adequate counselling is given. However, timely recognition of ongoing pregnancy, complications or incomplete abortion, which require treatment, is important. As part of a larger trial, this study aimed to establish whether women having a medical abortion could self-assess whether their abortion was complete using an automated, interactive questionnaire on their mobile phones. All 469 participants received standard abortion care and all returnees filled in a self-assessment on paper at clinic follow-up 2–3 weeks later. The 234 women allocated to receive the phone messages were also asked to do a mobile phone assessment at home ten days post-misoprostol. Completion of the mobile assessment was tracked by computer and all completed assessments, paper and mobile, were compared to providers’ assessments at clinic follow-up. Of the 226 women able to access the mobile phone assessment, 176 (78%) completed it; 161 of them (93%) reported it was easy to do so. Neither mobile nor paper self-assessments predicted all cases needing additional treatment at follow-up. Prediction of complete procedures was good; 71% of mobile assessments and 91% of paper assessments were accurate. We conclude that an interactive questionnaire assessing completion of medical abortion on mobile phones is feasible in the South African setting; however, it should be done later than day 10 and combined with an appropriate pregnancy test to accurately detect incomplete procedures. RésuméSelon les directives de l’Organisation mondiale de la santé, le suivi dans le centre de santé pour s’assurer que l’avortement médicamenteux est complet n’est plus nécessaire, pourvu que des conseils adaptés soient prodigués. Néanmoins, il est important de déceler rapidement une poursuite de la grossesse, des complications ou un avortement incomplet, qui exigent un traitement. Dans le cadre d’un essai plus large, cette étude visait à déterminer si femmes ayant eu un avortement médicamenteux pouvaient évaluer elles-mêmes si leur avortement était complet, à l’aide d’un questionnaire interactif automatisé sur leur téléphone portable. Toutes les 469 participantes ont reçu des soins types liés à l’avortement et toutes les patientes revenues au centre ont rempli une autoévaluation sur papier lors du suivi dans ce centre, deux ou trois semaines plus tard. Les 234 femmes sélectionnées pour recevoir les messages téléphoniques ont aussi été invitées à faire une évaluation sur téléphone portable chez elles dix jours après la prise de misoprostol. L’achèvement de l’évaluation sur le portable a été contrôlé par ordinateur et toutes les évaluations complétées, sur papier et téléphone, ont été comparées à l’évaluation des praticiens lors du suivi dans le centre. Des 226 femmes ayant eu accès à l’évaluation sur portable, 176 (78%) l’ont complétée ; 161 d’entre elles (93%) ont indiqué que cela avait été facile. Les autoévaluations, que ce soit sur portable ou sur papier, n’ont pas prévu tous les cas nécessitant un traitement complémentaire lors du suivi. Les prédictions de la complétude de la procédure étaient bonnes : 71% des évaluations sur portable et 91% sur papier étaient exactes. Nous avons conclu qu’un questionnaire interactif évaluant la complétude de l’avortement médicamenteux sur le téléphone portable est faisable dans le contexte sud-africain ; néanmoins, il devrait être soumis plus tard que le dixième jour et associé à un test de grossesse approprié pour détecter rigoureusement les procédures incomplètes. ResumenEl seguimiento en la unidad de salud para determinar si la mujer tuvo un aborto con medicamentos completo ya no es un requisito, según la guía de la Organización Mundial de la Salud, siempre y cuando se brinde consejería adecuada. Sin embargo, es importante reconocer con prontitud la continuación del embarazo, complicaciones o aborto incompleto, que requiere tratamiento. Como parte de un ensayo clínico más extenso, este estudio tuvo como objetivo establecer si mujeres en proceso de aborto con medicamentos podrían determinar por sí mismas si tuvieron un aborto completo, utilizando un cuestionario interactivo automatizado en su teléfono móvil. Todas las 469 participantes recibieron servicios estándares de aborto y todas las que regresaron llenaron un formulario de autoevaluación durante el seguimiento en la unidad de salud 2 o 3 semanas después. A las 234 mujeres asignadas para recibir los mensajes por teléfono también se les pidió que hicieran una evaluación domiciliaria por teléfono móvil diez días post-misoprostol. La conclusión de la evaluación móvil fue seguida por computadora y todas las evaluaciones terminadas, en versión impresa y móvil, fueron comparadas con las evaluaciones de los prestadores de servicios durante el seguimiento en la unidad de salud. De las 226 mujeres que tenían acceso a su evaluación por teléfono móvil, 176 (78%) la concluyeron; 161 de ellas (93%) informaron que fue fácil de hacer. Ni la autoevaluación móvil ni la impresa previeron todos los casos que necesitaban tratamiento adicional en el seguimiento. La predicción de procedimientos completos fue buena; el 71% de las evaluaciones móviles y el 91% de las evaluaciones impresas fueron precisas. Concluimos que un cuestionario interactivo que evalúa la finalización del aborto con medicamentos por teléfono móvil es factible en Sudáfrica; sin embargo, debe hacerse después del décimo día y combinarse con una prueba de embarazo apropiada para detectar con precisión los procedimientos incompletos. [ABSTRACT FROM PUBLISHER]