Reducing the harms of unsafe abortion: a systematic review of the safety, effectiveness and acceptability of harm reduction counselling for pregnant persons seeking induced abortion

BackgroundGlobally, access to safe abortion is limited. We aimed to assess the safety, effectiveness and acceptability of harm reduction counselling for abortion, which we define as the provision of information about safe abortion methods to pregnant persons seeking abortion.MethodsWe searched PubMed, EMBASE, ClinicalTrials.gov, Cochrane, Global Index Medicus and the grey literature up to October 2021. We included studies in which healthcare providers gave pregnant persons information on safe use of abortifacient medications without providing the actual medications. We conducted a descriptive summary of results and a risk of bias assessment using the ROBINS-I tool. Our primary outcome was the proportion of pregnant persons who used misoprostol to induce abortion rather than other methods among those who received harm reduction counselling.ResultsWe included four observational studies with a total of 4002 participants. Most pregnant persons who received harm reduction counselling induced abortion using misoprostol (79%–100%). Serious complication rates were low (0%–1%). Uterine aspiration rates were not always reported but were in the range of 6%–22%. Patient satisfaction with the harm reduction intervention was high (85%–98%) where reported. We rated the risk of bias for all studies as high due to a lack of comparison groups and high lost to follow-up rates.DiscussionBased on a synthesis of four studies with serious methodological limitations, most recipients of harm reduction counselling use misoprostol for abortion, have low complication rates, and are satisfied with the intervention. More research is needed to determine abortion success outcomes from the harm reduction approach.FundingThis work did not receive any funding.PROSPERO registration numberWe registered the review in the PROSPERO database of systematic reviews (ID number: CRD42020200849).

The Domestication of Misoprostol for Abortion in Burkina Faso: Interactions Between Caregivers, Drug Vendors and Women

Misoprostol has been hailed as a revolution within global maternal health research and policy communities because of its potential to reduce maternal mortality from post-partum haemorrhage and unsafe abortion, allowing relatively safe abortion in legal and illegal settings. However, we know little about how women who want to use misoprostol access it to induce abortion. Based on 15 months of ethnographic fieldwork in Ouagadougou, Burkina Faso, this chapter describes and analyses how women gain access to misoprostol to induce abortion within a setting where induced abortion is legally restrictive and where the legal use of misoprostol is limited to post-abortion care and post-partum haemorrhage. The findings show that women seeking abortions in Ouagadougou are able to access misoprostol through unofficial channels, specifically through health workers and drug vendors. While this unofficial use of misoprostol is relatively safer, and more affordable than other options, access is not equally distributed and the cost women pay for the drug varies significantly. While women with strong social networks and financial resources can access misoprostol easily, other women who do not have money to buy misoprostol may become victims of sexual violence from men from whom they seek abortion services. In Ouagadougou, access to abortion with misoprostol is shaped by health workers and the social and economic conditions of the women who seek it. The study uses the concepts of ‘pharmaceutical diversion’ and ‘domestication’ as adjacent analytical frameworks to emphasize the changing pattern of access to misoprostol. The chapter introduces the importance of looking at safe access to safe abortion.

Abortion care-seeking and reproductive rights violation in health facilities: evidence from six states of India

Background: Unsafe abortion continues to draw the researcher's attention due to its close association with maternal morbidity and mortality. Empirical evidence on the role of health facilities in providing safe abortion care addressing the reproductive rights of Indian women is limited.Methods: Using data from the 2015 ‘unintended pregnancy and abortion in India’ study, the present paper aimed to understand the violation of the reproductive rights of abortion care seekers in health facilities (n=4001) in six states of India. The health facilities were sampled using a stratified random sampling strategy. Univariate and bivariate analysis was carried out using SPSS (V 25) on cleaned and weighted data.Results: A sizeable percentage of public and private health facilities across states found seeking the consent of the husband or family members before abortion provision, compel women to adopt contraception and turn away abortion seekers, commonly citing non-medical reasons. The provision of post-abortion complications services is usually not 24/7, even at the primary health centre level, hindering access to an urgent health care need.Conclusions: There is a need to improve access to facility-based abortion services, especially in underserved rural areas, by ensuring that all public-sector facilities have adequate equipment and supplies, including MMA drugs and trained providers. Sensitization of health care providers about the importance of ethical issues and women’s reproductive rights is urgently required to ensure safe, legal, and accessible abortion care.

Looking ahead in the COVID-19 pandemic: emerging lessons learned for sexual and reproductive health services in low- and middle-income countries

The COVID-19 pandemic has caused widespread disruption to essential health service provision globally, including in low- and middle-income countries (LMICs). Recognising the criticality of sexual and reproductive health (SRH) services, we review the actual reported impact of the COVID-19 pandemic on SRH service provision and evidence of adaptations that have been implemented to date. Across LMICs, the available data suggests that there was a reduction in access to SRH services, including family planning (FP) counselling and contraception access, and safe abortion during the early phase of the pandemic, especially when movement restrictions were in place. However, services were quickly restored, or alternatives to service provision (adaptations) were explored in many LMICs. Cases of gender-based violence (GBV) increased, with one in two women reporting that they have or know a woman who has experienced violence since the beginning of the pandemic. As per available evidence, many adaptations that have been implemented to date have been digitised, focused on getting SRH services closer to women. Through the pandemic, several LMIC governments have provided guidelines to support SRH service delivery. In addition, non-governmental organisations working in SRH programming have played significant roles in ensuring SRH services have been sustained by implementing several interventions at different levels of scale and to varying success. Most adaptations have focused on FP, with limited attention placed on GBV. Many adaptations have been implemented based on guidance and best practices and, in many cases, leveraged evidence-based interventions. However, some adaptations appear to have simply been the sensible thing to do. Where evaluations have been carried out, many have highlighted increased outputs and efficiency following the implementation of various adaptations. However, there is limited published evidence on their effectiveness, cost, value for money, acceptability, feasibility, and sustainability. In addition, the pandemic has been viewed as a homogenous event without recognising its troughs and waves or disentangling effects of response measures such as lockdowns from the pandemic itself. As the pandemic continues, neglected SRH services like those targeting GBV need to be urgently scaled up, and those being implemented with any adaptations should be rigorously tested.

Access and utilization of the youth-friendly sexual and reproductive health services in Nepal: What does literature show?

This study has attempted to assess the access and utilization of youth-friendly sexual and reproductive health services in Nepal. Different literature regarding youth-friendly sexual and reproductive health services has been reviewed using online databases. A total of 125 relevant articles were assessed for the study. The literature was categorized and analyzed with five key thematic areas: knowledge on SRH among youths, the prevalence of child marriage and teenage pregnancy, attitudes towards premarital sex, utilization of SRHs, and barriers to utilizing the SRHS. This study has found that youths do not always utilize SRHS. Various barriers exist for providing and using YFSRHs in Nepal. Nepal's adolescents and youths face problems of STIs, HIV/AIDS, early pregnancy and parenthood, difficulties accessing contraception, and safe abortion. The study has also found that many countries have single youth-friendly sexual and reproductive health policies and that utilization of SRHS is also high in those countries. Moreover, this review has also found that because of inadequate knowledge and information on SRHS, Nepalese youths are facing numerous reproductive health problems. Multiple factors contribute as barriers to utilizing the SRHS. Therefore, there is a need for a program to motivate youths to respect their right to access reproductive health information and service, ensure the availability of peer counselors in the health centers, and increase the awareness level of the community so that they can utilize the quality of SRHS.

Global Epidemiology of Induced Abortion

Induced abortion is a common reproductive experience, with more than 73 million abortions occurring each year globally. Worldwide, the annual abortion incidence decreased in the 1990s and the early decades of the 21st century, but this decline has been driven by high-resource settings, whereas abortion rates in low- and middle-resource countries have remained stable. Induced abortion is a very safe procedure when performed according to World Health Organization guidelines; however, legal restrictions, stigma, cost, lack of resources, and poor health system accountability limit the availability, accessibility, and use of quality abortion care services. Even as women’s use of safer self-managed medication abortion options becomes more common in some parts of the world, 45% of all abortions annually are unsafe, nearly all of which occur in low- and middle-resource settings, where unsafe abortion remains a primary cause of maternal death. Beyond country-level legal and health care system factors, significant disparities exist in women’s reliance on unsafe abortion. Even among women who receive a safe abortion, quality of care is often poor. Yet abortion’s precarious status as a health care service and its clandestine practice have precluded a systematic focus on quality monitoring and evaluation of service inputs. Improving abortion and postabortion care quality is essential to meeting this reproductive health need, as are efforts to prevent abortion-related mortality and morbidity more broadly. This requires a three-tier approach: primary prevention to reduce unintended pregnancy, secondary prevention to make abortion procedures safer, and tertiary prevention to reduce the negative sequelae of unsafe abortion procedures. Strategies include two complementary approaches: vulnerability reduction and harm reduction, the first focusing on the root causes of unsafe abortion by addressing the determinants of unwanted pregnancy and clandestine abortion, while the latter addresses the harmful consequences of clandestine abortion. Political commitments to extend service coverage of abortion and postabortion care need to be implemented through actions that build the public health system’s capacity. Beyond the model of receiving care exclusively in clinical settings, models of guided self-managed abortion are expanding the capacity of individuals to take evidence-based actions to terminate their pregnancies safely and without the threat of judgment. Research has strived to keep up with the changes in the abortion care landscape, but there remains a continuing need to improve methodologies to generate robust evidence to identify and address inequities in abortion care and its health consequences in a diversified landscape. Doing so will provide information for stakeholders to take actions toward a new era of health care reforms that repositions abortion as an integral component of sexual and reproductive health care.

Safe abortion practice and knowledge on abortion legalization among Nepalese undergraduate female students

Background: Unsafe abortion remains one of the major public health problems, especially in developing countries. The objective of this study was to assess the level of knowledge on the legalization of abortion and the practice of abortion among Nepalese undergraduate female students. Methods: An analytical cross-sectional study was conducted among the 490 female students of Pokhara Valley, Nepal. Study populations from the 10 colleges were selected through purposive and systematic random sampling. The semi-structured questionnaire was used as a data collection technique. Results: Only 34% of students have a good knowledge of abortion legalization, compared to 42% who have poor knowledge. While two-thirds of the participants (66.6%) were aware that abortion is legal in Nepal, only a few were aware of the conditions for legalized safe abortion. During sexual intercourse, almost half of the participants (51.3%) did not use any form of contraception. Unintended conception was the primary cause of abortion (53.3%). Conclusion: The level of knowledge about the abortion law, safe abortion practice, and utilization of abortion services were found to be poor. Age of the participant, autonomy level for decision making, religion, and study background were the associated factors with the level of knowledge and practice of abortion. Community-based health promotion and awareness programs focusing on the youth population should be conducted.

Second Trimester Abortion practices in Eastern Hilly District of Nepal: A Cross-Sectional Study

Introduction: Second-trimester abortion comprises 10-15% of total cases worldwide because of maternal disease, fetal anomalies, and delay in obtaining first trimester services during unintended pregnancies. The availability of legal safe abortion services with skilled hands is limited in rural hilly areas of Nepal. Unsafe and delays in seeking abortion services in resources poor countries like Nepal are contributing to maternal mortality and morbidity. This study aims to describe the demographic profile of patients, indications, and methods of second-trimester abortion with possible complications and family planning acceptance in the rural hilly areas of Nepal. Methods: A retrospective cross-sectional study was conducted at Ilam District Hospital in Province 1 of Nepal. The study sample comprises 75 patients who were admitted for abortion services in 1 fiscal year period from 16th July 2017 to 15th July 2018. Data for all the patients who received second-trimester abortion services were retrieved from Health Management Information System (HMIS) logbook maintained by the Hospital. Descriptive analysis was performed. Ethical approval for this study was obtained from the Nepal Health Research Council (Ref. No- 1921). Results: Most common age group seeking second-trimester abortion were 20-24 years(26.66%) and the majority of women who participated in this study were literate up to secondary level education(58.66%). Most participants belonged to janajati/adibasi caste(73.33%) and were from Ilam districts(72%).Most of the cases were in the early second trimester (62.66%) and were multiparous (60%). Common indications for termination of pregnancy were mental/maternal cause(82.66%) and medical induction was most (69.33%) common method. No major complications were found following abortion. The majority of participants chose short-term contraception (36%) following the termination of pregnancy. Conclusions: Awareness and availability of legal safe abortion services at local health facilities can reduce delays in seeking abortion services, prevent unsafe abortion practices, and reduce maternal morbidity and mortality.