Determinants of women’s preferred and actual abortion provision locations in Nigeria

Background Unsafe abortion remains a leading cause of maternal mortality globally. Many factors can influence women’s decisions around where to seek abortion care; however, little research has been done on abortion care decisions at a population-level in low-resource settings, particularly where abortion is legally restricted. Methods This analysis uses data from a 2019–2020 follow-up survey of 1144 women in six Nigerian states who reported an abortion experience in a 2018 cross-sectional survey. We describe women’s preferred and actual primary abortion care provider/location by distinguishing clinical, pharmacy/chemist, or other non-clinical providers or locations. We also examine factors that influence women’s decisions about where to terminate their pregnancy and identify factors hindering women’s ability to operationalize their preferences. We then examine the characteristics of women who were not able to use their preferred provider/location. Results Non-clinical providers (55.0%) were more often used than clinical providers (45.0%); however, clinical providers were preferred by most women (55.6%). The largest discrepancies in actual versus preferred abortion provider/location were private hospitals (7.6% actual versus 37.2% preferred), government hospitals (4.3% versus 22.6%), chemists (26.5% versus 5.9%) and pharmacies (14.9% versus 6.6%). “Privacy/confidentiality” was the most common main reason driving women’s abortion provider/location choice (20.7%), followed by “convenience” (16.9%) and “recommended” by someone (12.3%), most often a friend (60.8%), although top reasons differed by type of provider/location. Cost and distance were the two most common reasons that women did not use their preferred provider/location (46.1% and 21.9%, respectively). There were no statistically significant differences in the sociodemographic characteristics between women who were able to use their preferred provider/location and those who were not able to implement their preferred choice, with the exception of state of residence. Conclusions These findings provide insights on barriers to abortion care in Nigeria, suggesting discretion is key to many women’s choice of abortion location, while cost and distance prevent many from seeking their preferred care provider/location. Results also highlight the diversity of women’s abortion care preferences in a legally restrictive environment.

What does informal access to misoprostol in Colombia look like? A mystery client methodology in Bogotá and the Coffee Axis

IntroductionIn 2006, abortion was decriminalised in Colombia under certain circumstances. Yet, women avail themselves of ways to terminate pregnancy outside of the formal health system. This study explored how drug sellers engage with women who attempt to purchase misoprostol from them.MethodsA mapping exercise was undertaken to list small-chain and independent drug stores in two regions in Colombia. A sample (n=558) of drug stores was selected from this list and visited by mystery clients between November and December 2017. Mystery clients sought to obtain a medication to bring back a delayed period, and described the experience, the information obtained and the medications proffered in exit interviews.ResultsMisoprostol was offered for purchase in 15% of the visits; in half of visits, only information about misoprostol was shared, while no information about misoprostol was provided on the remaining visits. Over half of sellers who refused to sell any medication provided referrals, most commonly to an abortion provider. Among visits which included discussion of misoprostol, two out of five sellers provided dosage instructions with most recommending the minimum adequate dosage. Mystery clients received little information on the physical effects to expect with the use of misoprostol and possible complications.ConclusionsAs misoprostol is being obtained from some drug sellers without a prescription, capacitating this cadre with at least a minimum of standardised information on dosage, routes of administration and expected effects and outcomes have the potential to improve reproductive health outcomes for women who choose to terminate pregnancies this way in Colombia.

How Far Do Women Have to Travel to Get an Abortion?

This chapter explores women’s access to abortion. Abortion is a common experience for women across the United States. According to the Guttmacher Institute, about one in four women will have an abortion by the age of 45. Access to this care can be affected by a variety of factors, including state laws and policies, socioeconomic status, and geography. Indeed, women who want to have an abortion performed in the middle of the country must travel much farther than women living on the coasts to reach a provider. Traveling these long distances can be impossible for women who cannot take time off from work or afford the transportation costs. States that have implemented abortion restrictions in recent years have increased the distance women must travel. In Texas, 20% of women have had their travel distance to the nearest abortion provider increase by about 56 miles. Other states where distance and travel times have notably increased include Iowa, Montana, and Missouri.

Impact of a case management programme for women seeking later second-trimester abortion: the case of the Massachusetts Access Program

ObjectiveThe Massachusetts Access Program is a statewide, centralised referral and case management program created to address barriers to later second-trimester abortions. This study outlines the scope of, describes provider experiences with, and evaluates provider acceptability of the Program.Study designWe invited physicians, nurses and staff working in hospitals within the later abortion provider referral network to participate in a mixed-methods study that included a web-based quantitative survey and/or a semi-structured qualitative interview. We used descriptive statistics to analyse survey data and inductive coding methods to analyse interview data.ResultsFrom 2007–2012, 15–28% of abortions performed in Massachusetts at 19 weeks or greater gestational age annually were scheduled through the Access Program. We received 16 completed surveys and conducted seven interviews with providers who routinely receive referrals for later abortions through the Program. Providers overall reported positive experiences with the Program and found it highly acceptable. They described that the transportation, accommodation and financial assistance enabled patients access to care. The specialised and updated knowledge of the Access Coordinator in regards to abortion care also allowed her to act as a resource for providers.ConclusionsThe Access Program, through its referral and case management network, was a valuable resource both to patients seeking later second-trimester abortions and providers involved in abortion care. It acts as one example of an effective, highly acceptable and potentially replicable intervention to reduce barriers to obtaining later second-trimester abortions.