scholarly journals Self-managed Abortion as a Medico-legal Intervention in Ghana: a Systematic Review

2021 ◽  
Author(s):  
Fred Yao Gbagbo ◽  
Renee Aku Sitsofe Morhe ◽  
Emmanuel Komla Senanu Morhe
Keyword(s):  
Induced Abortion ◽  
Google Scholar ◽  
Care Providers ◽  
Legal Intervention ◽  
Abortion Care ◽  
Maternal Morbidity And Mortality ◽  
Comprehensive Abortion Care ◽  
Unwanted Pregnancies ◽  
Good Potential ◽  
Implementation Gaps

Abstract BackgroundWe examined the potential of improving self-managed abortion as a medico-legal intervention of safely and effectively resolving unwanted pregnancies in Ghana.MethodsWe undertook a systematic literature review on self-managed or self-induced abortion within the context of Ghanaian laws. We searched for studies from Advanced PubMed Central and Google Scholar and repositories of Public Universities in Ghana. With search words of self-managed or self-induced abortion and Ghanaian law, we found 13,100 papers. The search was then narrowed to studies conducted between 2015-2020 of which 22 most related papers were selected with Six (6) from the Advanced Google Scholar search, 18 from PubMed and 1 unpublished postgraduate thesis from a public university library.ResultsDespite a liberal law that supported positive and quite well-decentralized service delivery policy, standards, and protocols development on abortion in Ghana, self-induced abortion remains criminalized. Nonetheless, the longstanding practice persists with no evidence of prosecution of the person(s) found violating the law within the period under review. The use of abortifacients procured from pharmacies and chemists that are not recognized abortion care providers has become the leading method of self-induced. Conclusion Despite criminalizing self-induced abortion, Ghana’s law on abortion is fairly liberal enough to permit the development of comprehensive abortion care policy, standards, and protocols that have a good potential of supporting improved self-managed abortion to reduce maternal morbidity and mortality in the country. Further studies are required for the exploration of ways of filling implementation gaps to harness the potentials of improving self-managed abortions in Ghana.

scholarly journals Predictors of Unsafe Induced Abortion among Women in Ghana

2019 ◽  
Vol 2019 ◽  
pp. 1-8 ◽  
Author(s):  
Michael Boah ◽  
Stephen Bordotsiah ◽  
Saadogrmeh Kuurdong
Keyword(s):  
Odds Ratio ◽  
Legal Status ◽  
Statistical Significance ◽  
Induced Abortion ◽  
Health Concern ◽  
Unsafe Abortion ◽  
Care Seeking ◽  
Safe Abortion ◽  
Maternal Morbidity And Mortality ◽  
Unwanted Pregnancies

Background. Unsafe induced abortion is a major contributor to maternal morbidity and mortality in Ghana. Objective. This study aimed to explore the predictors of unsafe induced abortion among women in Ghana. Methods. The study used data from the 2017 Ghana Maternal Health Survey. The association between women’s sociodemographic, obstetric characteristics, and unsafe induced abortion was explored using logistic regression. The analysis involved a weighted sample of 1880 women aged 15-49 years who induced abortion in the period 2012-2017. Analysis was carried out using STATA/IC version 15.0. Statistical significance was set at p <0.05. Results. Of the 1880 women, 64.1% (CI: 60.97-67.05) had an unsafe induced abortion. At the univariate level, older women (35-49 years) (odds ratio=0.50, 95% CI: 0.28-0.89) and married women (odds ratio=0.61, 95% CI:0.44-0.85) were less likely to have an unsafe induced abortion while women who did not pay for abortion service (odds ratio=4.44, 95% CI: 2.24-8.80), who had no correct knowledge of the fertile period (odds ratio =1.47, 95% CI: 1.10-1.95), who did not know the legal status of abortion in Ghana (odds ratio =2.50, 95% CI: 1.68-3.72) and who had no media exposure (odds ratio =1.34, 95% CI: 1.04-1.73) had increased odds for an unsafe induced abortion. At the multivariable level, woman’s age, payment for abortion services, and knowledge of the legal status of abortion in Ghana were predictors of unsafe induced abortion. Conclusion. Induced abortion is a universal practice among women. However, unsafe abortion rate in Ghana is high and remains an issue of public health concern. We recommend that contraceptives and safe abortion services should be made available and easily accessible to women who need these services to reduce unwanted pregnancies and unsafe abortion rates, respectively, in the context of women’s health. Also, awareness has to be intensified on abortion legislation in Ghana to reduce the stigma associated with abortion care seeking.

scholarly journals A művi abortusz a férfi partner szemszögéből

2019 ◽  
Vol 160 (18) ◽  
pp. 694-699
Author(s):  
Beáta Magda Nagy ◽  
Adrien Rigó
Keyword(s):  
Health Care Providers ◽  
Induced Abortion ◽  
Point Of View ◽  
Female Partner ◽  
Care Providers ◽  
Male Partners ◽  
Personal Support ◽  
Abortion Care ◽  
Post Abortion ◽  
Emotional Balance

Abstract: Induced abortion is an intervention that scientific research primarily addresses from the concerned women’s point of view in terms of either the causes or the consequences of the abortion decision. Nevertheless, each case of abortion involves a man as much as a woman (in the same vein as conception), which calls for the better knowledge of male partners’ needs, expectations and experiences related to induced abortion. The present summary addresses male partners’ status and importance in abortion care in a practical approach based on professional considerations. Available empirical findings suggest that male partners’ involvement in abortion care has importance both in protecting men’s emotional balance and in providing support for women in adapting to the abortion process. Male partners’ deeper involvement possibly includes roles such as seeing the female partner to the intervention, participation in pre-abortion counselling, presence during the intervention, and participation in post-abortion care. Related findings show that all of these forms of support are related to women’s positive abortion-related experiences and thus to their better recovery (provided that the female partner expresses a need for her male partner’s personal support). Furthermore, male partners’ involvement in abortion care enables health care providers to tailor counselling (information on the intervention, on possible consequences, on contraceptive methods etc.) to men’s specific needs. These practices facilitate partners’ joint and informed decision making, joint responsibility for conception or contraception, and eventually contribute to reducing the incidence of induced abortion. Orv Hetil. 2019; 160(18): 694–699.

scholarly journals Contraceptive situation and Influencing Factors in Guangdong Province: A comparative questionnaire study

2021 ◽  
Author(s):  
FAN JIANG ◽  
Yanxia Qu ◽  
Peixuan Lin ◽  
Li Li ◽  
Qingshan Xuan ◽  
...  
Keyword(s):  
Family Planning ◽  
Health Care Providers ◽  
Contraceptive Use ◽  
Induced Abortion ◽  
Care Providers ◽  
Monthly Income ◽  
Abortion Care ◽  
Post Abortion Care ◽  
Contraceptive Services ◽  
Post Abortion

Abstract BackgroundThe aim of our study is to describe the status of induced abortion and contraceptive use in reproductive women and make clear the correlated factors in Guangdong province.MethodA self-administered questionnaire survey was conducted separately in 1839 individuals aged 18–49 and 900 health care providers from Guangdong province. The content of questionnaire was based on status of induced abortion and contraceptive use for the former and problems concerning contraceptive services for the latter. Systematic random sampling was used and data were analyzed using SPSS 19.0. Descriptive statistics and binary logistic regression were used in this study.Results30.61% of participants experienced the induced abortion. The rate of repeated abortion was 19.96% and it was 20.45% in persons under 20 years old. 18.23% of 1839 individuals chose LARC as the main contraceptive method. The females with college degree(Odds ratio, OR = 1.867; 95% confidence intervals 95%CI: 1.175–2.969), technologists(OR = 2.291; 95%CI: 1.063–4.936) and the persons whose monthly income were of between 3000–5000¥(OR = 1.920; 95%CI: 1.204–3.065) were more likely to use LARC. The younger females less than 30 years old and never using PAC services had lower odds of using LARC. The rate of post abortion care performance was merely 12.23%. Age, monthly income, occupation, living conditions and obtaining free contraceptives in time were all strongerly influence factors for the use of post-abortion care(P < 0.01). The satisfaction rate of free contraceptive services was about 57.44%. Variety uniformity, obtaining inconveniently and worrying about the quality were the main reasons. 66.22% of hospitals set up the department of family planning in our study. Highly work intensity(54.67%) and less leadership (40.22%) influenced health care providers to provide family planning services.ConclusionThe abortion rate was high especially in young women. There were many problems affecting contraceptive services which damaged women’reproductive health. Increasing government investment for family planning services, strengthening the construction of the family planning department and performing post abortion care and long-acting reversible contraception by taking relevant steps would be useful measures for improving current contraceptive status.

‘Abortion’ or ‘termination of pregnancy’? Views from abortion care providers in Scotland, UK

2018 ◽  
Vol 44 (2) ◽  
pp. 122-127 ◽  
Author(s):  
Aine Kavanagh ◽  
Sally Wielding ◽  
Rosemary Cochrane ◽  
Judith Sim ◽  
Anne Johnstone ◽  
...  
Keyword(s):  
Service Provision ◽  
Care Service ◽  
Induced Abortion ◽  
Termination Of Pregnancy ◽  
Mixed Methods Study ◽  
Care Providers ◽  
Abortion Care ◽  
Medical Institutions ◽  
Patient Care Service ◽  
Depth Interviews

BackgroundThe phrase ‘termination of pregnancy’ has recently been adopted by a number of British medical institutions as a preferred descriptor of induced abortion. How it is used by abortion care providers is unclear, although the ongoing stigmatisation of abortion may play a role.MethodsA mixed methods study of the views of abortion care providers in Scotland, UK. Self-administered anonymous questionnaires were distributed to abortion care providers at a national conference (Scottish Abortion Care Providers). The main outcomes measured were the proportion of respondents reporting that they found the terms ‘abortion’ and ‘termination of pregnancy’ to be distressing, and their preferred terminology for use in consultations with women. In-depth interviews were conducted with 19 providers from a single clinic in Scotland to contextualise use of the terminology.ResultsThe questionnaire was completed by 90/118 delegates (76%). More respondents indicated they found the term ‘abortion’ distressing (28%), compared with those who found ‘termination of pregnancy’ distressing (6%; P<0.0001). Interview participants reported that ‘termination of pregnancy’ was the default phrase used in consultations. Some respondents stated that they occasionally purposely used ‘abortion’ in consultations to emphasise the seriousness of the procedure (morally, physically and/or emotionally).Conclusions‘Termination of pregnancy’ is the most commonly used term to describe induced abortion in patient consultations in Scotland. This and the term ‘abortion’ appear to play different roles, with the former being used euphemistically, and the latter as a more emphatic term. Further research is warranted to investigate how this interacts with patient care, service provision, and abortion stigma.

scholarly journals ‘Others Will Even Call us Terminators’: Barriers and Facilitators to Provision of Comprehensive Abortion Care (Cac) in Zambia – A Qualitative Study

2022 ◽  
Author(s):  
CHRISTABEL CHIGWE PHIRI ◽  
CHOOLWE JACOBS ◽  
VICTOR SICHONE ◽  
PATRICK KAONGA ◽  
MUSONDA MAKASA ◽  
...  
Keyword(s):  
Health System ◽  
Health Care Providers ◽  
Moral Dilemmas ◽  
Legal Framework ◽  
Health Facilities ◽  
Barriers And Facilitators ◽  
Care Providers ◽  
Abortion Care ◽  
Legal Provisions ◽  
Comprehensive Abortion Care

Abstract Background:It is estimated that one in every five pregnancies globally ends up as abortion, with about 40% being unsafe. Abortions account for approximately 5.9% of all maternal mortalities and 50% of gynaecological admissions in Zambia. Despite implementing Comprehensive Abortion Care (CAC), which aims to provide high quality, safe and affordable services to women, unsafe abortions rates remain high. In this study, we explored the barriers and facilitators to CAC provision in selected health facilities of Lusaka and Copperbelt provinces in Zambia.Materials and methods: A qualitative case study using in-depth interviews with health care providers was conducted between July – August, 2021 in nine selected public health facilities of Zambia. A total of 17 interviews were conducted with participants purposively sampled. The interviews were digitally recorded and transcribed verbatim. Data analysis was done using content analysis. Results: The study revealed a number of barriers and facilitators most of which are health system related. The health system related barriers included inadequate CAC providers, healthcare provider perception that provision of CAC was optional, lack of CAC dedicated space and privacy, frequent shortages of medical supplies and lack of incentives, while individual related barriers included stigma surrounding CAC provision, religious and moral dilemmas. Facilitators to CAC provision included having providers trained and mentored in CAC, availability of a liberal legal framework, accessible services, task shifting and external financial support. Conclusions: The findings of this study on the several barriers of CAC reinforces the idea that despite having appropriate legal provisions to CAC provision in Zambia, challenges in the implementation of the law and related service provision continue to persist. The identified barrriers suggests to consider incorporating CAC services into the pre-service training to ensure more trained and skilled providers are available in the public facilities.

scholarly journals Safe abortion service and post abortion care: Understanding complications

1970 ◽  
Vol 2 (1) ◽  
pp. 44-49 ◽  
Author(s):  
Sudha Thapa ◽  
Indira Satyal ◽  
Kasturi Malla
Keyword(s):  
Induced Abortion ◽  
Abortion Rate ◽  
Uterine Perforation ◽  
Safe Abortion ◽  
Abortion Care ◽  
Vacuum Aspiration ◽  
Post Abortion Care ◽  
Manual Vacuum Aspiration ◽  
Comprehensive Abortion Care ◽  
Post Abortion

Aim: To see if unsafe abortions are getting lesser after the establishment of comprehensive abortion care (CAC) Unit since March 2004. Methods: Retrospective study of women admitted with complication of abortions [induced (medically/criminal) or spontaneous] during the entire ten years period after the inception of post abortion care (PAC) Unit 2095 May -2007 April; the last 3 years overlapping the service years of CAC Unit establishment. Result: CAC and PAC units both are using manual vacuum aspiration (MVA) to procure uterine evacuation. CAC clients in the last 3 years have reached to a little less than 10,000. This is close to MVA services provided in the PAC Unit in the last 10 years amounting to 11,519. But the number (n=3958) of service provided by the PAC Unit for a complete period of three years 2058-2060 (April 2001 - April 2004) showed a slight increase to (n=4323) as the CAC Unit became functional during the 2061-2063 (15th April 2004- 2007). The complications observed in PAC unit while providing MVA are much more than CAC unit (5.75%: 2%). But the nature of complication is much more serious in CAC Unit, 10 of them needing laparotomy for 20(0.02%) cases of uterine perforation. The induced abortion rate within the hospital, three years before and during CAC services is almost similar (4.07%: 4.34%). Seriousness of the problem has definitely reduced during recent 3 year's period (Baisakh 2061-2063 Chaitra) i.e. 52: 34 except for an unfortunate rise in uterine perforation from 8 to 29 cases, 10 being from the CAC Unit. Conclusion: Though the number of complicated cases of induced abortion seeking hospitalization has not changed much after inception of CAC services in the recent three years, there is definitely a decline in the admission of more serious complicated cases of induced abortion in the recent years with unfortunate rise in number of cases of uterine perforation.   doi:10.3126/njog.v2i1.1476 N. J. Obstet. Gynaecol Vol. 2, No. 1, p. 44 - 49 May -June 2007

scholarly journals A qualitative study on health care providers’ experiences of providing comprehensive abortion care in Cox’s Bazar, Bangladesh

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Maria Persson ◽  
Elin C. Larsson ◽  
Noor Pappu Islam ◽  
Kristina Gemzell-Danielsson ◽  
Marie Klingberg-Allvin
Keyword(s):  
Health Care ◽  
Health Care Providers ◽  
Service Provision ◽  
Care Providers ◽  
Personal Beliefs ◽  
Menstrual Regulation ◽  
Humanitarian Settings ◽  
Abortion Care ◽  
Regulation Policy ◽  
Comprehensive Abortion Care

Abstract Background Humanitarian settings are characterised by limited access to comprehensive abortion care. At the same time, humanitarian settings can increase the vulnerability of women and girls to unintended pregnancies and unsafe abortions. Humanitarian actors and health care providers can play important roles in ensuring the availability and accessibility of abortion-related care. This study explores health care providers’ perceptions and experiences of providing comprehensive abortion care in a humanitarian setting in Cox’s Bazar, Bangladesh and identifies barriers and facilitators in service provision. Method In-depth interviews (n = 24) were conducted with health care providers (n = 19) providing comprehensive abortion care to Rohingya refugee women and with key informants (n = 5), who were employed by an organisation involved in the humanitarian response. Data were analysed using an inductive content analysis approach. Results The national menstrual regulation policy provided a favourable legal environment and facilitated the provision of comprehensive abortion care, while the Mexico City policy created organisational barriers since it made organisations unable or unwilling to provide the full comprehensive abortion care package. Supplies were available, but a lack of space created a barrier to service provision. Although training from organisations had made the health care providers confident and competent and had facilitated the provision of services, their knowledge of the national abortion law and menstrual regulation policy was limited and created a barrier to comprehensive abortion services. Even though the health care providers were willing to provide comprehensive abortion care and had acquired skills and applied strategies to communicate with and provide care to Rohingya women, their personal beliefs and their perceptions of Rohingya women influenced their provision of care. Conclusion The availability and accessibility of comprehensive abortion care was limited by unfavourable abortion policies, a lack of privacy, a lack of knowledge of abortion laws and policies, health care providers’ personal beliefs and a lack of cultural safety. To ensure the accessibility and availability of quality services, a comprehensive approach to sexual and reproductive health and rights is needed. Organisations must ensure that health care providers have knowledge of abortion policies and the ability to provide quality care that is woman-centred and non-judgmental.

scholarly journals Faktor-Faktor yang Mempengaruhi Self-care Behavior pada Klien dengan Hipertensi di Komunitas

2020 ◽  
Vol 11 ◽  
pp. 37
Author(s):  
Wimar Anugrah Romadhon ◽  
Bernadetta Germia Aridamayanti ◽  
Anggi Hanafiah Syanif ◽  
Gevi Melliya Sari
Keyword(s):  
Health Care Providers ◽  
Self Efficacy ◽  
Self Care ◽  
Google Scholar ◽  
Evidence Based ◽  
Care Providers ◽  
Inclusion Criteria ◽  
Salt Diet ◽  
Low Salt ◽  
Care Behavior

Background: self-care behavior is an important thing that needs to be considered by clients with hypertension which consists of several components, namely the use of drugs, low-salt diet, physical activity, smoking, weight management and alcohol consumption. Purpose: to show the factors that influence self-care behavior in clients with hypertension. Method: the database used to identify suitable articles obtained from Scopus, ProQuest and Google Scholar, limited to the last 5 years of publication from 2014 to 2019, English, and fulltext articles. The literature review used the keyword "Self-care behavior, Hypertension". In searching articles used "AND". Only 12 articles met the inclusion criteria. This review was from 12 of these articles. Results: self-care behavior in hypertensive clients were influenced by several factors, namely family support, self-efficacy, knowledge, and spirituality. Conclusion: factors related to self-care behavior and pathways can help health care providers develop and design evidence-based interventions for clients with hypertension. Recommendation: Community nurses understand the factors that influence self-care behavior in hypertensive clients in the community so they are able to provide appropriate nursing care. Keywords: factors of self-care behavior; hypertension; community ABSTRAK Latar belakang: self-care behavior merupakan hal penting yang perlu diperhatikan oleh klien dengan hipertensi yang terdiri dari beberapa komponen yaitu penggunaan obat-obatan, diet rendah garam, aktifitas fisik, merokok, manajemen berat badan dan konsumsi alkohol. Tujuan: untuk melihat adanya faktor-faktor yang mempengaruhi self-care behavior pada klien dengan hipertensi. Metode: database digunakan untuk mengidentifikasi artikel yang sesuai diperoleh dari Scopus, ProQuest dan Google Scholar terbatas untuk publikasi 5 tahun terakhir dari 2014 hingga 2019, bahasa inggris, dan fulltex article. Tinjauan literatur menggunakan kata kunci “factors of self-care behavior, Hypertension”. Dalam pencarian artikel menggunakan "AND". Hanya 12 artikel yang memenuhi kriteria inklusi. Ulasan ini berasal dari 12 artikel tersebut. Hasil: self-care behavior pada klien hipertensi dipengaruhi oleh beberapa faktor yaitu dukungan keluarga, self-efficacy, faktor personal, dan spiritualitas. Simpulan: faktor-faktor yang terkait dengan self-care behavior dan jalurnya dapat membantu penyedia layanan kesehatan mengembangkan dan mendesain intervensi bebasis bukti pada klien dengan hipertensi. Saran: Perawat komunitas memahami faktor-faktor yang mempengaruhi self-care behavior pada klien hipertensi di komunitas sehingga mampu memberikan asuhan keperawatan yang tepat. Kata kunci: factors of self-care behavior; hypertension; community

scholarly journals Reproductive awareness and recognition of unintended pregnancy: young women, key informants and health care providers perspectives in South Africa

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Oluwaseyi Dolapo Somefun ◽  
Jane Harries ◽  
Deborah Constant
Keyword(s):  
South Africa ◽  
Health Care ◽  
Unintended Pregnancy ◽  
Health Care Providers ◽  
Signs And Symptoms ◽  
Second Trimester ◽  
Care Providers ◽  
Policy Makers ◽  
Abortion Care ◽  
Pregnancy Status

Abstract Background South Africa has a liberal abortion law, yet denial of care is not uncommon, usually due to a woman being beyond the legal gestational age limit for abortion care at that facility. For women successfully obtaining care, time from last menstrual period to confirmation of pregnancy is significantly longer among those having an abortion later in the second trimester compared to earlier gestations. This study explores women’s experiences with recognition and confirmation of unintended pregnancy, their understanding of fertile periods within the menstrual cycle as well as healthcare providers’ and policy makers’ ideas for public sector strategies to facilitate prompt confirmation of pregnancy. Methods We recruited participants from July through September 2017, at an urban non-governmental organization (NGO) sexual and reproductive health (SRH) facility and two public sector hospitals, all providing abortion care into the second trimester. We conducted in-depth interviews and group discussions with 40 women to elicit information regarding pregnancy recognition and confirmation as well as fertility awareness. In addition, 5 providers at these same facilities and 2 provincial policy makers were interviewed. Data were analysed using thematic analysis. Results Uncertainties regarding pregnancy signs and symptoms greatly impacted on recognition of pregnancy status. Women often mentioned that others, including family, friends, partners or colleagues noticed pregnancy signs and prompted them to take action. Several women were unaware of the fertility window and earliest timing for accurate pregnancy testing. Health care providers and policy makers called for strategies to raise awareness regarding risk and signs of pregnancy and for pregnancy tests to be made more readily accessible. Conclusion Early recognition of unintended pregnancy in this setting is frustrated by poor understanding and awareness of fertility and pregnancy signs and symptoms, compounded by a distrust of commercially available pregnancy tests. Improving community awareness around risk and early signs of pregnancy and having free tests readily available may help women confirm their pregnancy status promptly.

Providers’ experience of abortion care: A scoping review protocol. (Preprint)

2021 ◽  
Author(s):  
B Dempsey ◽  
S Callaghan ◽  
MF Higgins
Keyword(s):  
Lived Experience ◽  
Secondary Analysis ◽  
Cochrane Library ◽  
Care Providers ◽  
Academic Journal ◽  
Comprehensive Overview ◽  
Abortion Care ◽  
Ethical Approval ◽  
Negative Impacts ◽  
The Cochrane Library

UNSTRUCTURED Background: Despite being one of the most common gynaecological procedures in the world, abortion care remains highly stigmatized. Internationally, providers have noted negative impacts related to their involvement in the services and abortion care has been described as “dirty work”. Though much of the existing research focuses on the challenges of providing, many have also highlighted the positive aspects of working in abortion care. Despite the steadily increasing interest in this area over the past decade, however, no one has sought to systematically review the literature to date. The aim of this review is to systematically explore published studies on the experiences of abortion care providers and to create a narrative review on the lived experience of providing abortion care. Methods: The review will be conducted according to the framework outlined by Levac et al., which expanded on the popular Arksey and O’Malley framework. We will systematically search for peer-reviewed articles in literature in six electronic databases: CINAHL, the Cochrane Library, EMBASE, PsycInfo, PubMed, and Web of Science. Following a pilot exercise, we have devised a search strategy to identify relevant studies. In this protocol, we outline how citations will be assessed for eligibility and what information will be extracted from the included articles. We also highlight how this information will be combined in the review. Discussion: The findings of this review will provide a comprehensive overview on the known experiences of providing abortion care. We also pre-empt that the findings will identify aspects of care and/or experiences that are not reflected in the available literature. We will disseminate the results via a publication in a peer-reviewed, academic journal and by presenting the findings at conferences in the areas of abortion care, obstetrics, and midwifery. As this review is a secondary analysis of published articles, ethical approval was not required.

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