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Public health institutions increasingly realize the importance of creating a culture in their organizations that values ethics. When developing strategies to strengthen ethics, institutions will have to take into account that while public health research projects typically undergo thorough ethics review, activities considered public health practice may not be subjected to similar oversight. This approach, based on a research-practice dichotomy, is increasingly being criticized as it does not adequately identify and manage ethically relevant risks to those affected by nonresearch activities. As a reaction, 3 major public health institutions (the World Health Organization, US Centers for Disease Control and Prevention, and Public Health Ontario) have implemented mechanisms for ethics review of public health practice activities. In this article, we describe and critically discuss the different modalities of the 3 approaches. We argue that although further evaluation is necessary to determine the effectiveness of the different approaches, public health institutions should strive to implement procedures to ensure that public health practice adheres to the highest ethical standards.

Objective To demonstrate the feasibility and safety of training midlevel healthcare providers (midwives and family nurses) to provide medical abortion and postabortion contraception in underserved areas in Kyrgyzstan. Study design This was an implementation study at four referral facilities and 28 Felsher Obstetric Points in two districts to train their midwives and family nurses to deliver safe and effective abortion care with co-packaged mifepristone–misoprostol and provide contraceptives postabortion. The outcome of abortion — complete abortion, incomplete abortion or o-going pregnancy — was the primary end point measured. An international consultant trained 18 midwives and 14 family nurses (with midwifery diplomas) to provide medical abortion care. Supervising gynecologists based in the referral centers and study investigators based in Bishkek provided monthly monitoring of services and collection of patient management forms. A voluntary self-administered questionnaire at the follow-up visit documented women's acceptability of medical abortion services. All study data were cross-checked and entered into an online data management system for descriptive analysis. Results Between August 2014 and September 2015, midwives provided medical abortion to 554 women with a complete abortion rate of 97.8%, of whom 62% chose to use misoprostol at home. No women were lost to follow-up. Nearly all women (99.5%) chose a contraceptive method postabortion; 61% of women receiving services completed the acceptability form, of whom more than 99% indicated a high level of satisfaction with the service and would recommend it to a friend. Conclusion This study demonstrates that trained Kyrgyz midwives and nurses can provide medical abortion safely and effectively. This locally generated evidence can be used by the Kyrgyz Ministry of Health to reduce unintended pregnancy and expand safe abortion care to women in underserved periurban and rural settings. Implications Success in scaling up midwife/nurse provision of medical abortion in Kyrgyzstan will require registration of mifepristone–misoprostol, regulations permanently allowing midwife/nurse provision, strengthened procurement and distribution systems to prevent stockouts of supplies, preservice training of midwives/nurses and their involvement in district level supervision, monitoring and reporting, and support from supervisors.

The World Health Organization (WHO) Safe abortion: technical and policy guidance for health systems states that regulatory, policy, and programmatic barriers that hinder access to and timely provision of safe abortion care should be removed. Although some regulatory requirements facilitate access, where they act as barriers, they can deter women from seeking safe abortion care. We use data available in the Global Abortion Policies Database as of February 2019 to review policies related to regulatory requirements identified as access barriers in the Safe abortion guidance. We include only countries where such policies apply, i.e., where abortion is lawful on the woman's request, with no requirement for justification and/or for one or more legal grounds. The results demonstrate the variation that exists in regulatory requirements, but little remains known about how they are implemented in practice and the implications on how women access and how providers offer safe abortion services.

Background The Global Abortion Policies Database (GAPD), launched in June 2017, provides a verifiable, comprehensive, nuanced approach to information and data sources on abortion law and policy. Abortion laws, policies, and guidelines from United Nations (UN) and World Health Organization (WHO) Member States are juxtaposed to information and recommendations from WHO safe abortion guidance, national sexual and reproductive health indicators, and relevant UN human rights bodies’ concluding observations to countries. Main body The Global Abortion Policies Database aims to increase transparency of information and accountability of states for the protection of individuals’ health and human rights. The database presents current information on abortion laws and policies that goes beyond categories of lawful abortion to include information on additional access requirements, service provision, conscientious objection, and penalties. Wide-ranging variations among countries’ legal requirements and criminal penalties raise questions about the evidentiary and human rights basis for abortion laws and policies. Source documents found in the database highlight that in many jurisdictions legal and policy guidance is either non-existent, not clear, or conflicting. By juxtaposing a jurisdiction’s abortion laws and policies to relevant WHO guidance and by facilitating comparisons of countries’ sexual and reproductive health indicators, the database can enable deep policy analysis of states’ obligations to meet the health needs and human rights of individuals in the context of abortion. Policy analysis in the context of authoritative guidance on human rights standards can enable health and rights advocates to hold governments accountable for respecting, protecting, and fulfilling individuals’ human rights. Conclusion The GAPD is a comprehensive tool that can be used to strengthen knowledge, inform law and policy research to generate evidence on the impact of laws and policies in practice, and facilitate greater awareness of the many challenges to creating enabling policy environments for safe abortion.

In April 2016, the Population Council, in partnership with the World Health Organization (WHO) and the International Consortium for Emergency Contraception, convened a regional meeting in Lusaka, Zambia, geared toward supporting countries in East and Southern Africa in meeting their obligations under the Maputo Protocol. These obligations include expanding access to women’s reproductive health services – especially women survivors of sexual violence. Government and civil society representatives from six countries participated: Botswana, Ethiopia, Kenya, Malawi, Rwanda, and Zambia. Countries were selected based on to their being priority settings for the projects that sponsored the meeting, coupled with the fact that they were each far enough along in addressing post-rape care to be able to develop concrete policy, programming, and/or legal action plans by the end of the meeting. The meeting was the first activity in a joint project of technical assistance by the conveners, aimed at strengthening access to comprehensive post-rape care for survivors of sexual violence. It aimed to sensitize Member States to their obligations under the Maputo Protocol to expand women’s access to emergency contraception (EC) and safe abortion services, and to inspire them to do so by providing information, research evidence, and a platform for discussion. The meeting deliberations fostered a better understanding of opportunities to broaden access to EC and safe abortion for survivors in the region. Discussions on EC in this regard centered on strengthening EC delivery in the clinical context, decentralizing EC services, increasing community awareness, and overcoming policy barriers. Safe abortion discussions focused primarily on legislation, policy, and integrating these services into existing services for sexual violence survivors. Country-specific action plans were developed to address gaps and weaknesses. The regional technical meeting concluded with a discussion of practical steps that participants could take to facilitate legal, policy, and program reform with respect to pregnancy prevention and safe abortion in their respective countries. The steps revolved around three mainly areas, namely: establishing an evidence base to inform action; creating forums for discussing the issues; and drafting action points to carry the momentum from the meeting forward. This paper details the proceedings from this regional technical meeting – proceedings that are of interest to the field of sexual and gender-based violence (and reproductive health, more broadly) as challenges faced by countries in implementing the Maputo Protocol are outlined, and evidence-informed and practice-based strategies for addressing these challenges are provided.

Summary Background Global estimates of unsafe abortions have been produced for 1995, 2003, and 2008. However, reconceptualisation of the framework and methods for estimating abortion safety is needed owing to the increased availability of simple methods for safe abortion (eg, medical abortion), the increasingly widespread use of misoprostol outside formal health systems in contexts where abortion is legally restricted, and the need to account for the multiple factors that affect abortion safety. Methods We used all available empirical data on abortion methods, providers, and settings, and factors affecting safety as covariates within a Bayesian hierarchical model to estimate the global, regional, and subregional distributions of abortion by safety categories. We used a three-tiered categorisation based on the WHO definition of unsafe abortion and WHO guidelines on safe abortion to categorise abortions as safe or unsafe and to further divide unsafe abortions into two categories of less safe and least safe. Findings Of the 55· 7 million abortions that occurred worldwide each year between 2010–14, we estimated that 30·6 million (54·9%, 90% uncertainty interval 49·9–59·4) were safe, 17·1 million (30·7%, 25·5–35·6) were less safe, and 8·0 million (14·4%, 11·5–18·1) were least safe. Thus, 25·1 million (45·1%, 40·6–50·1) abortions each year between 2010 and 2014 were unsafe, with 24·3 million (97%) of these in developing countries. The proportion of unsafe abortions was significantly higher in developing countries than developed countries (49·5% vs 12·5%). When grouped by the legal status of abortion, the proportion of unsafe abortions was significantly higher in countries with highly restrictive abortion laws than in those with less restrictive laws. Interpretation Increased efforts are needed, especially in developing countries, to ensure access to safe abortion. The paucity of empirical data is a limitation of these findings. Improved in-country data for health services and innovative research to address these gaps are needed to improve future estimates. Funding UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction; David and Lucile Packard Foundation; UK Aid from the UK Government; Dutch Ministry of Foreign Affairs; Norwegian Agency for Development Cooperation.

Background The Zika virus epidemic in Latin America has elicited official recommendations for women to delay or avoid pregnancy in affected countries, which has increased demand for family planning services. It is likely, however, that health facilities in areas where the population is most vulnerable to the disease lack the capacity to respond to the increased demand for family planning services. Our objectives are to perform facilities assessment and understand client perceptions in areas affected by Zika virus, and to track changes in these parameters over time. Methods/design We will collaborate with local health authorities to map facilities that have the capacity to provide services in contraception and safe abortion, including induced abortion to the full extent of the law and post-abortion care for treatment of complications from unsafe abortion and post-abortion contraception. We then will carry out a survey of facilities to assess the availability of services and their readiness to provide contraception and safe abortion care. All facilities will be assessed for baseline readiness and availability of services, and a random subsample of surveyed facilities will be reassessed in second and third rounds of surveys. Focus group interviews with clients will be conducted as part of the facilities surveys in order to gain an understanding of the community’s knowledge, needs and perceived barriers to healthcare in the context of the Zika virus epidemic. Discussion The findings of this study will aid the response to Zika virus ranging from the identification of healthcare facilities that can be potentially strengthened, to the formulation of interventions to reduce barriers and improve readiness of facilities to provide contraception and safe abortion services. Lessons learned from this study will help to build and strengthen health systems that are more prepared to consistently providing reproductive healthcare services in the context of health emergencies.

Summary Background Information about the incidence of induced abortion is needed to motivate and inform efforts to help women avoid unintended pregnancies and to monitor progress toward that end. We estimate subregional, regional, and global levels and trends in abortion incidence for 1990 to 2014, and abortion rates in subgroups of women. We use the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion. Methods We requested abortion data from government agencies and compiled data from international sources and nationally representative studies. With data for 1069 country-years, we estimated incidence using a Bayesian hierarchical time series model whereby the overall abortion rate is a function of the modelled rates in subgroups of women of reproductive age defined by their marital status and contraceptive need and use, and the sizes of these subgroups. Findings We estimated that 35 abortions (90% uncertainty interval [UI] 33 to 44) occurred annually per 1000 women aged 15–44 years worldwide in 2010–14, which was 5 points less than 40 (39–48) in 1990–94 (90% UI for decline −11 to 0). Because of population growth, the annual number of abortions worldwide increased by 5·9 million (90% UI −1·3 to 15·4), from 50·4 million in 1990–94 (48·6 to 59·9) to 56·3 million (52·4 to 70·0) in 2010–14. In the developed world, the abortion rate declined 19 points (−26 to −14), from 46 (41 to 59) to 27 (24 to 37). In the developing world, we found a non-significant 2 point decline (90% UI −9 to 4) in the rate from 39 (37 to 47) to 37 (34 to 46). Some 25% (90% UI 23 to 29) of pregnancies ended in abortion in 2010–14. Globally, 73% (90% UI 59 to 82) of abortions were obtained by married women in 2010–14 compared with 27% (18 to 41) obtained by unmarried women. We did not observe an association between the abortion rates for 2010–14 and the grounds under which abortion is legally allowed. Interpretation Abortion rates have declined significantly since 1990 in the developed world but not in the developing world. Ensuring access to sexual and reproductive health care could help millions of women avoid unintended pregnancies and ensure access to safe abortion. Funding UK Government, Dutch Ministry of Foreign Affairs, Norwegian Agency for Development Cooperation, The David and Lucile Packard Foundation, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction.

OBJECTIVE: To describe the declining trend in maternal mortality observed in Mongolia from 1992 to 2007 and its acceleration after 2001 following implementation of the Maternal Mortality Reduction Strategy by the Ministry of Health and other partners. METHODS: We performed a descriptive analysis of maternal mortality data collected through Mongolia's vital registration system and provided by the Mongolian Ministry of Health. The observed declining mortality trend was analysed for statistical significance using simple linear regression. We present the maternal mortality ratios from 1992 to 2007 by year and review the basic components of Mongolia's Maternal Mortality Reduction Strategy for 2001-2004 and 2005-2010. FINDINGS: Mongolia achieved a statistically significant annual decrease in its maternal mortality ratio of almost 10 deaths per 100 000 live births over the period 1992-2007. From 2001 to 2007, the maternal mortality ratio in Mongolia decreased approximately 47%, from 169 to 89.6 deaths per 100 000 live births. CONCLUSION: Disparities in maternal mortality represent one of the major persisting health inequities between low- and high-resource countries. Nonetheless, important reductions in low-resource settings are possible through collaborative strategies based on a horizontal approach and the coordinated involvement of key partners, including health ministries, national and international agencies and donors, health-care professionals, the media, nongovernmental organizations and the general public.

Objective To estimate and describe the magnitude of abortion complications presenting at public hospitals in Kenya. Design Cross-sectional descriptive study. Setting Hospital-based. Population Records of all women presenting prior to 22 weeks of gestation with abortion-related complications at selected hospitals during a three-week study period. All public tertiary and provincial hospitals were included; stratified random sampling was employed to select a subset of 54 district hospitals nationwide. Methods Data collectors identified 809 patients with abortion complications on all hospital wards and completed a standardised questionnaire for each by extracting information from the patient's hospital record. Main outcome measures Incidence, aetiology, morbidity and mortality of abortion complications. Results Most women (80%) presented with incomplete abortion. Approximately 34% of the women had reached the second trimester of pregnancy. Adolescents (14–19 years old) accounted for approximately 16% of the study sample. Manual vacuum aspiration was used to manage 80% of first trimester cases. The projected annual number of women with abortion complications admitted to public hospitals in Kenya is 20,893. The case fatality rate was estimated to be 0.87% (95% CI 0.71–1.02%), so an estimated 182 (95% CI 148–213) of these women die annually. The annual incidence of incomplete abortion and other abortion-related complications per 1000 women aged 15 to 49 years is projected to be 3.03. Conclusions The high rate of abortion-related morbidity and mortality documented in the study highlights the critical need to address the issue of unsafe abortion in Kenya.

Background: Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the 2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this, setting global research priorities for the next decade is now required.\ud Methods. We adapted the methods of the Child Health and Nutrition Research Initiative (CHNRI) to identify and set global research priorities for maternal and perinatal health for the period 2015 to 2025. Priority research questions were received from various international stakeholders constituting a large reference group, and consolidated into a final list of research questions by a technical working group. Questions on this list were then scored by the reference working group according to five independent and equally weighted criteria. Normalized research priority scores (NRPS) were calculated, and research priority questions were ranked accordingly. Results: A list of 190 priority research questions for improving maternal and perinatal health was scored by 140 stakeholders. Most priority research questions (89%) were concerned with the evaluation of implementation and delivery of existing interventions, with research subthemes frequently concerned with training and/or awareness interventions (11%), and access to interventions and/or services (14%). Twenty-one questions (11%) involved the discovery of new interventions or technologies. Conclusions: Key research priorities in maternal and perinatal health were identified. The resulting ranked list of research questions provides a valuable resource for health research investors, researchers and other stakeholders. We are hopeful that this exercise will inform the post-2015 Development Agenda and assist donors, research-policy decision makers and researchers to invest in research that will ultimately make the most significant difference in the lives of mothers and babies.

The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating a pregnancy performed by persons lacking the necessary skills or in an environment not in conformity with minimal medical standards, or both. This definition embodies concepts first outlined in a 1992 WHO Technical Consultation.1 Although widely used, it is inconsistently interpreted. In this editorial we discuss its correct interpretation and operationalization. WHO’s definition of unsafe abortion was conceptualized within the framework of emerging guidelines on the management of the complications of induced abortion and was intended to be interpreted within that context. This linkage to technical guidelines is crucial for its correct interpretation. Nothing in the definition predetermines who should be considered a “safe” abortion provider or what the appropriate skills or standards for performing abortions should be. Such things are not static; they evolve in line with evidence-based WHO recommendations. For example, WHO guidelines now recommend mifepristone and misoprostol – or misoprostol alone if mifepristone is not available – and vacuum aspiration in lieu of the sharp curettage used formerly. They now consider induced abortions provided at the primary care level or by non-physician health-care providers as safe.2 The guidelines on task shifting that are being developed are expected to clarify who can safely provide an abortion under current standards. To ensure that “unsafe abortion” is correctly interpreted, we recommend always providing an explanatory note along with the definition, as follows: “The persons, skills and medical standards considered safe in the provision of abortion are different for medical and surgical abortion and also depend on the duration of the pregnancy. What is considered ‘safe’ should be interpreted in line with current WHO technical and policy guidance.” Although unsafe abortions are, by definition, risky, safety cannot be dichotomized because risk runs along a continuum. Risk is lowest if an evidence-based method is used to terminate an early pregnancy in a health facility;3 it is highest if a dangerous method, such as the use of caustic substances orally or vaginally or the insertion of sticks into the uterus, is employed clandestinely to terminate an advanced pregnancy. There is a spectrum of risk between these two extremes. Along that spectrum, for example, lie cases of self-administration of misoprostol or the use of outdated procedures, such as sharp curettage, by skilled health-care providers. The immediate determinants of the risks of an induced abortion, such as the termination method used and gestational age, are influenced, in turn, by underlying social determinants: i.e. the legal context, the availability of safe abortion services, the level of stigma surrounding abortion, the degree of women’s access to information on abortion, and a woman’s age and socioeconomic status. The legal context and the level of safety are closely intertwined, but the association is context-specific. For example, where restrictive laws are liberally interpreted, women can receive safe care in certain contexts; conversely, where liberal laws are poorly implemented, women sometimes abort with delay and under unsafe conditions. Thus, illegal abortion is not synonymous with unsafe abortion, as indicated by the original definition: “…legality or illegality of services, however, may not be the defining factor of their safety […] the safety of abortion must be considered within both the legal and legally restricted contexts.”1 Rates of induced abortion are difficult to measure because of frequent underreporting or misclassification in surveys, hospital records and health statistics.4 In light of this, WHO has historically used a pragmatic operational construct that measures safety in terms of only one dimension – legality – in developing its regional and global estimates of rates of unsafe abortion.4,5 However, the widespread informal use of misoprostol has added a layer of complexity to the concept of “safety”. As a result, it has become essential to apply a multi-dimensional risk continuum to measure abortion safety. The adverse outcomes associated with unsafe abortion need to be measured as well. Since deaths resulting from unsafe abortion have decreased in recent years,4 perhaps because of safer methods, the focus should now be broadened from mortality to morbidity as well. A multi-dimensional assessment of the safety of induced abortions, as described, makes estimation more difficult, but the more nuanced measures involved could generate more innovative research and improve the data collected locally and nationally. Assessing the safety of induced abortion does not suffice, however. In the longer term, global consensus will be needed on the broader indicators used to assess the provision of safe abortion in line with WHO guidance – i.e. indicators capturing access, equity, quality of care and linkages to post-abortion contraception.

Despite advances in scientific evidence, technologies, and human rights rationale for providing safe abortion, a broad range of cultural, regulatory, and health system barriers that deter access to abortion continues to exist in many countries. When conscientious objection to provision of abortion becomes one of these barriers, it can create risks to women's health and the enjoyment of their human rights. To eliminate this barrier, states should implement regulations for healthcare providers on how to invoke conscientious objection without jeopardizing women's access to safe, legal abortion services, especially with regard to timely referral for care and in emergency cases when referral is not possible. In addition, states should take all necessary measures to ensure that all women and adolescents have the means to prevent unintended pregnancies and to obtain safe abortion.

As part of efforts to achieve Millennium Development Goal 5--to reduce maternal mortality by 75% and achieve universal access to reproductive health by 2015--the Malawi Ministry of Health conducted a strategic assessment of unsafe abortion in Malawi. This paper describes the findings of the assessment, including a human rights-based review of Malawi's laws, policies and international agreements relating to sexual and reproductive health and data from 485 in-depth interviews about sexual and reproductive health, maternal mortality and unsafe abortion, conducted with Malawians from all parts of the country and social strata. Consensus recommendations to address the issue of unsafe abortion were developed by a broad base of local and international stakeholders during a national dissemination meeting. Malawi's restrictive abortion law, inaccessibility of safe abortion services, particularly for poor and young women, and lack of adequate family planning, youth-friendly and post-abortion care services were the most important barriers. The consensus reached was that to make abortion safe in Malawi, there were four areas for urgent action--abortion law reform; sexuality education and family planning; adolescent sexual and reproductive health services; and post-abortion care services.

Background ZIKV(Zika Virus) during pregnancy can result in many adverse events such as fetal deaths or newborns with congenital abnormalities including microcephaly and other neural irregularities. Due to these harmful outcomes of pregnancy associated with the Zika virus, we can expect to see a change in the type and scale of demand for family planning and safe abortion services in areas affected by the Zika virus. The monitoring and reporting capacities of the local health clinics in these areas could benefit from the introduction of infrastructural improvements necessary to establish a sentinel site network. Through these sites, the WHO will collect data on the situation from local health professionals to get real time information from the population group and act accordingly to mitigate the consequences of the Zika virus outbreak in a localized and culturally appropriate way. The objectives are to establish a sentinel sites surveillance network for reporting on uptake and utilization of contraception and safe abortion care services; to strengthen monitoring, and data quality assurance in the selected sentinel surveillance sites; and finally to assess the contraception and safe abortion care service utilization trends in the affected sites on a regular basis. Methods The proposal includes a set of objectives and actions that enable the creation of a set of criteria for the selection of the sentinel sites, as well the implementation of monitoring and reporting systems that will be used in data collection. Discussion The data collected will be used to better understand the changing demand for family planning and safe abortion needs. This will ultimately be used to inform local health workers and policy makers as to how best to track the continued Zika virus outbreak and mitigate the consequences. The learning from establishment of surveillance sentinel sites will help to strengthen health systems at regional and subregional levels that are more adaptable and capable of providing reproductive healthcare services and of responding to future emergencies.