International support for abortion education in medical schools: results of a global online survey to explore abortion willingness, intentions, and attitudes among medical students in 85 countries.

Introduction: Access to safe abortion has been recognized as a fundamental human right and important public health priority. Medical schools provide a rare opportunity to expose medical students to comprehensive sexual and reproductive health (SRH) topics and normalize abortion care early in a physician's career. Methods: This cross-sectional descriptive study used an online survey to explore abortion content in medical curricula and medical student intentions, attitudes, and beliefs regarding abortion provision among 1,699 medical students from 85 countries. Results: Results demonstrate positive attitudes towards abortion provision, with 83% reporting that "access to safe abortion is every woman's right". Students also reported a relatively high willingness to provide abortion professionally despite few opportunities to learn about this care. Only one-third of students surveyed reported having taken a gynecology course (n = 487; 33%); among these, one-third said they had no content on abortion care in their programs thus far (n = 155; 32%), including instruction on postabortion care. Among the two-thirds of students who had some content on abortion care (n = 335), either on induced abortion, postabortion care (PAC), or both, 55% said content was limited to one lecture and only 19% reported having an opportunity to participate in any practical training on abortion provision. Despite most students having no or very limited didactic and practical training on abortion, 42% intended to provide this care after graduation. Three-quarters of student respondents were in favor of mandatory abortion education in medical curricula. Discussion: The findings of this study offer new evidence about abortion care education in medical curricula around the globe, indicating that there is no lack of demand or interest in increasing medical knowledge on comprehensive abortion care, merely a lack of institutional will to expand course offerings and content.

Contraception and abortion in times of crisis: results from an online survey of Venezuelan women.

Introduction: In the last decade, Venezuela has experienced a complex humanitarian crisis that has limited access to healthcare. We set out to describe Venezuelan women's experiences accessing sexual and reproductive health services, including abortion, which is heavily restricted by law. Methods: We fielded an online survey in July of 2020 among Venezuelan women recruited through social media advertisements. We conducted descriptive statistical analyses using Excel and STATA SE Version 16.0. Results: We received 851 completed survey responses. Almost all respondents experienced significant hardship in the last year, including inflation (99%), worries about personal safety (86%), power outages (76%), and lack of access to clean water (74%) and medications (74%). Two thirds of respondents used contraception in the last two years, and almost half (44%) of respondents had difficulty accessing contraception during that same time period. About one fifth of respondents reported having had an abortion; of these, 63% used abortion pills, and 72% reported difficulties in the process. Half of those who had an abortion did it on their own, while the other half sought help - either from family members or friends (34%), from providers in the private health sector (14%), or from the Internet (12%). Conclusions: Venezuelan women who responded to our survey describe a harsh context with limited access to sexual and reproductive health services. However, they report relatively high rates of contraceptive use, and abortion seems to be common despite the restrictive legal setting.

High severity of abortion complications in fragile and conflict-affected settings: a cross-sectional study in two referral hospitals in sub-Saharan Africa (AMoCo study).

BACKGROUND: Abortion-related complications are one of the five main causes of maternal mortality. However, research about abortion is very limited in fragile and conflict-affected settings. Our study aims to describe the magnitude and severity of abortion-related complications in two referral hospitals supported by Médecins Sans Frontières and located in such settings in northern Nigeria and Central African Republic (CAR). METHODS: We used a methodology similar to the World Health Organization (WHO) near-miss approach adapted in the WHO multi-country study on abortion (WHO-MCS-A). We conducted a cross-sectional study in the two hospitals providing comprehensive emergency obstetric care. We used prospective medical records' reviews of women presenting with abortion-related complications between November 2019 and July 2021. We used descriptive analysis and categorized complications into four mutually exclusive categories of increasing severity. RESULTS: We analyzed data from 520 and 548 women respectively in Nigerian and CAR hospitals. Abortion complications represented 4.2% (Nigerian hospital) and 19.9% (CAR hospital) of all pregnancy-related admissions. The severity of abortion complications was high: 103 (19.8%) and 34 (6.2%) women were classified as having severe maternal outcomes (near-miss cases and deaths), 245 (47.1%) and 244 (44.5%) potentially life-threatening, 39 (7.5%) and 93 (17.0%) moderate, and 133 (25.6%) and 177 (32.3%) mild complications, respectively in Nigerian and CAR hospitals. Severe bleeding/hemorrhage was the main type of complication in both settings (71.9% in the Nigerian hospital, 57.8% in the CAR hospital), followed by infection (18.7% in the Nigerian hospital, 27.0% in the CAR hospital). Among the 146 women (Nigerian hospital) and 231 women (CAR hospital) who did not report severe bleeding or hemorrhage before or during admission, anemia was more frequent in the Nigerian hospital (66.7%) compared to the CAR hospital (37.6%). CONCLUSION: Our data suggests high severity of abortion-related complications in these two referral facilities of fragile and conflict-affected settings. Factors that could contribute to this high severity in these contexts include greater delays in accessing post-abortion care, decreased access to contraceptive and safe abortion care that result in increased unsafe abortions; as well as increased food insecurity leading to iron-deficiencies and chronic anaemia. The results highlight the need for better access to safe abortion care, contraception, and high quality postabortion care to prevent and manage complications of abortion in fragile and conflict-affected settings.

"I was waiting for my period": Understanding pregnancy recognition among adolescents seeking abortions in Ethiopia, Malawi, and Zambia.

OBJECTIVES: For a person seeking an abortion, the ability to recognize a pregnancy is a critical first step. Pregnancy recognition is complex and shaped by numerous factors. This paper explores the experiences of pregnancy recognition among adolescents in Ethiopia, Malawi, and Zambia. STUDY DESIGN: The final sample included 313 adolescents aged 10 to 19 who had sought abortion-related care at urban public facilities in Ethiopia (N = 99), Malawi (N = 104), and Zambia (N = 110). Researchers collected mixed-method data on how adolescents came to recognize that they were pregnant and thematically analyzed qualitative data alongside descriptive statistics from quantitative data. RESULTS: Most adolescents reported that their main mode of recognizing a pregnancy was medical pregnancy tests or late menstruation. Reasons for not recognizing a pregnancy included irregular menses or recent menarche and attribution of signs and symptoms to other medical conditions. Psychological barriers to pregnancy recognition were important, including the refusal to accept a pregnancy and denial of a pregnancy. Timing of recognition shaped the abortion care available for adolescents and the affordability of care. For some adolescents, their capacity to recognize their pregnancy led to involuntary or voluntary disclosure, which decreased their reproductive autonomy. CONCLUSIONS: Adolescent experiences of pregnancy recognition complement existing evidence, illustrating critical barriers across age and context. Interrogating pregnancy recognition among adolescents exposed the critical implications for the availability, accessibility, affordability, and autonomy of their abortion trajectory. IMPLICATIONS: Pregnancy recognition is complex and can influence adolescents' ability to exercise their reproductive rights and access abortion care of their choosing. Programmes to improve awareness of the signs of a pregnancy, increasing the provision of affordable and accessible pregnancy testing and further research on pregnancy recognition are necessary to support adolescents' reproductive autonomy.

Integrating child rights standards in contraceptive and abortion care for minors in Africa.

Minor girls in Africa face challenges in accessing high-quality contraceptive and abortion services because laws and policies are not child-friendly. Many countries maintain restrictive laws, policies, or hospital practices that make it difficult for minors to access contraception and safe abortion even when the pregnancy would risk their life or health. Further, the clinical guidelines on contraceptive and abortion care are silent, vague, or ambiguous regarding minors' consent. African states should remedy the situation by ensuring that clinical guidelines integrate child rights principles and standards articulated in child rights treaties to enable health providers to facilitate full, unencumbered access to contraceptive and abortion care for minor girls. A sample of clinical guidelines is analyzed to demonstrate the importance of explicit, consistent, and unambiguous language about children's consent to ensure that healthcare workers provide sexual and reproductive health care in a manner that respects child rights.

The Potential of Self-Managed Abortion to Expand Abortion Access in Humanitarian Contexts.

Refugees and displaced people face uniquely challenging barriers to abortion access, including the collapse of health systems, statelessness, and a lack of prioritization of sexual and reproductive health services by humanitarian agencies. This article summarizes the evidence around abortion access in humanitarian contexts, and highlights the opportunities for interventions that could increase knowledge and support around self-managed abortion. We explore how lessons learned from other contexts can be applied to the development of effective interventions to reduce abortion-related morbidity and mortality, and may improve access to information about safe methods of abortion, including self-management, in humanitarian settings. We conclude by laying out a forward-thinking research agenda that addresses gaps in our knowledge around abortion access and experiences in humanitarian contexts.

An examination of the characteristics and contraceptive acceptance of post-abortion clients in Ethiopia.

This national study examined the socio-demographic, health facility, and provider characteristics associated with the use of postabortion contraception in Ethiopia in 2014. We used data from a Prospective Morbidity Survey (PMS) conducted in Ethiopia in 2014 to measure abortion incidence and morbidity nationally. Data were collected on the presentation, care and treatment of 5,604 women who sought abortion services in 365 health facilities over 30 days. Descriptive and multivariate logistic regression analysis were used to examine postabortion contraceptive uptake. Nearly 75% of abortion clients received postabortion contraception. The majority received short-acting methods, around one-third chose a long-acting or permanent method. Most women sought abortion services at public health centers (61.8%) and were cared for by midlevel providers (82.5%). Multivariate regression results showed that women who sought services during the first trimester (odds ratio/OR = 1.44; 95% confidence interval/CI 1.06, 1.95), for induced abortions (OR = 3.55; 95% CI 2.52, 4.99), from public sector facilities, and those served by midlevel providers, had greater odds of receiving postabortion contraception. We conclude that providing strong contraceptive services postabortion in government facilities, including long-acting methods in the method mix, and providing this care by midlevel providers could further reduce unmet need for contraception and repeat abortions.

Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia.

Universal Health Coverage (UHC) forces governments to consider not only how services will be provided - but which services - and to whom, when, where, how and at what cost. This paper considers the implications for achieving UHC through the lens of abortion-related care for adolescents. Our comparative study design includes three countries purposively selected to represent varying levels of restriction on access to abortion: Ethiopia (abortion is legal and services implemented); Zambia (legal, complex services with numerous barriers to implementations and provision of information); Malawi (legally highly restricted). Our policy and legal analyses are supplemented by comparative vignettes based on interviews (n = 330) in 2018/2019 with adolescents aged 10-19 who have sought abortion-related care in each country. We focus on an under-considered but critical legal framing for adolescents - the age of consent. We compare legal and political commitments to advancing adolescent sexual and reproductive health and rights, including abortion-related care. Ethiopia appears to approach UHC for safe abortion care, and the legal provision for under 18-year-olds appears to be critical. In Malawi, the most restrictive legal environment for abortion, little progress appears to have been made towards UHC for adolescents. In Zambia, despite longstanding legal provision for safe abortion on a wide range of grounds, the limited services combined with low levels of knowledge of the law mean that the combined rights and technical agendas of UHC have not yet been realised. Our comparative analyses showing how policies and laws are framed have critical implications for equity and justice.

Navigating the crisis landscape: engaging the ministry of health and United Nations agencies to make abortion care available to Rohingya refugees.

BACKGROUND: Unintended and unwanted pregnancies likely increase during displacement, making the need for sexual and reproductive health (SRH) services, especially safe abortion, even greater. Attention is growing around barriers to safe abortion care for displaced women as donor, non-governmental and civil society actors become more convinced of this need and reports of systematic sexual violence against women are more widely documented around the world. Yet a reluctance to truly change practice remains tied to some commonly reported reasons: 1) There is no need; 2) Abortion is illegal in the setting; 3) Donors do not fund abortion services, and; 4) Abortion is too complicated during acute emergencies. While there is global progress towards acknowledging the deficit of attention and evidence on abortion services in humanitarian settings, improvements in actual services have yet to follow. CASE PRESENTATION: In August 2017, over 700,000 Rohingya refugees fled Myanmar for Bangladesh. Women and girls fled homes and communities - many experienced terrible violence - and arrived at camps in Bangladesh with SRH needs, including unwanted pregnancies. With funding from UNFPA and others, Ipas trained providers and established safe induced abortion (called menstrual regulation (MR) in Bangladesh) and contraception services in October 2017.Ipas Bangladesh initiated the trainings in coordination with the government's health system and international aid agencies. Training approaches were modified so that providers could be trained quickly with minimal disruption to their ability to provide care. Within one month of the arrival of refugees, MR services had been established in eight facilities, for the first time during an acute emergency. By mid-2019, over 300 health workers from 37 health facilities had attended training in MR, postabortion care (PAC), and contraception. Over 8000 Rohingya refugees have received abortion-related care, more than three-quarters of which were MR procedures; over 26,000 women and girls have received contraception at these facilities. CONCLUSIONS: This study demonstrates demand for abortion care exists among refugees. It also illustrates that these needs could have been easily overlooked in the complex environment of competing priorities during an emergency. When safe abortion services were made available, with relative ease and institutional support, women sought assistance, saving them from complications of unsafe abortions.

Playing it Safe: Legal and Clandestine Abortions Among Adolescents in Ethiopia.

PURPOSE: The 2005 expansion of the Ethiopian abortion law provided minors access to legal abortions, yet little is known about abortion among adolescents. This paper estimates the incidence of legal and clandestine abortions and the severity of abortion-related complications among adolescent and nonadolescent women in Ethiopia in 2014. METHODS: This paper uses data from three surveys: a Health Facility Survey (n = 822) to collect data on legal abortions and postabortion complications, a Health Professionals Survey (n = 82) to estimate the share of clandestine abortions that resulted in treated complications, and a Prospective Data Survey (n = 5,604) to collect data on abortion care clients. An age-specific variant of the Abortion Incidence Complications Method was used to estimate abortions by age-group. RESULTS: Adolescents have the lowest abortion rate among all women below age 35 (19.6 per 1,000 women). After adjusting for lower levels of sexual activity among adolescents however, we find that adolescents have the highest abortion rate among all age-groups. Adolescents also have the highest proportion (64%) of legal abortions compared with other age-groups. We find no differences in the severity of abortion-related complications between adolescent and nonadolescent women. CONCLUSIONS: We find no evidence that adolescents are more likely than older women to have clandestine abortions. However, the higher abortion and pregnancy rates among sexually active adolescents suggest that they face barriers in access to and use of contraceptive services. Further work is needed to address the persistence of clandestine abortions among adolescents in a context where safe and legal abortion is available.

Doing more for less: identifying opportunities to expand public sector access to safe abortion in South Africa through budget impact analysis.

OBJECTIVE(S): To estimate the costs of public-sector abortion provision in South Africa and to explore the potential for expanding access at reduced cost by changing the mix of technologies used. STUDY DESIGN: We conducted a budget impact analysis using public sector abortion statistics and published cost data. We estimated the total costs to the public health service over 10 years, starting in South Africa's financial year 2016/17, given four scenarios: (1) holding service provision constant, (2) expanding public sector provision, (3) changing the abortion technologies used (i.e. the method mix), and (4) expansion plus changing the method mix. RESULTS: The public sector performed an estimated 20% of the expected total number of abortions in 2016/17; 26% and 54% of all abortions were performed illegally or in the private sector respectively. Costs were lowest in scenarios where method mix shifting occurred. Holding the proportion of abortions performed in the public-sector constant, shifting to more cost-effective service provision (more first-trimester services with more medication abortion and using the combined regimen for medical induction in the second trimester) could result in savings of $28.1 million in the public health service over the 10-year period. Expanding public sector provision through elimination of unsafe abortions would require an additional $192.5 million. CONCLUSIONS: South Africa can provide more safe abortions for less money in the public sector through shifting the methods provided. More research is needed to understand whether the cost of expanding access could be offset by savings from averting costs of managing unsafe abortions. IMPLICATIONS: South Africa can provide more safe abortions for less money in the public sector through shifting to more first-trimester methods, including more medication abortion, and shifting to a combined mifepristone plus misoprostol regimen for second trimester medical induction. Expanding access in addition to method mix changes would require additional funds.

The effects of a community-based intervention on women's knowledge and attitudes about safe abortion in intervention and comparison towns in Oromia, Ethiopia.

The aim of this post-intervention assessment was to measure the effects of community intervention on the knowledge and attitudes of women regarding safe abortion in Ethiopia. In 2014, following implementation of an educational intervention on sexual and reproductive health from December 2012 to December 2013, 800 women were interviewed about their knowledge, attitudes, and practices regarding abortion. Multivariate regression analyses of respondents' demographics, sources of abortion information, knowledge, and attitudes about safe abortion were conducted. More women in the intervention community knew safe abortion was available in the community (76 percent vs. 57 percent; p < 0.001). Women in the intervention community had greater odds of feeling that women should have access to safe abortion services (adjusted odds ratio [aOR]: 1.55, 95 percent confidence interval [CI]: 1.06, 2.28) after adjusting for socio-demographic characteristics. They had significantly greater odds of feeling comfortable and confident talking to a healthcare provider (aOR: 2.44, 95 percent CI: 1.55, 3.84) and/or her partner (aOR: 2.47, 95 percent CI: 1.58, 3.85) about abortion. Increased mobilization of community networks in disseminating sexual health and abortion information was followed by increased knowledge of abortion services in the intervention community and improved reproductive choices for women.

The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa.

BACKGROUND: Despite a liberal abortion law, access to safe abortion services in South Africa is challenging for many women. Medication abortion was introduced in 2013, but its reach remains limited. We aimed to estimate the costs and cost effectiveness of providing first-trimester medication abortion and manual vacuum aspiration (MVA) services to inform planning for first-trimester service provision in South Africa and similar settings. METHODS: We obtained data on service provision and outcomes from an operations research study where medication abortion was introduced alongside existing MVA services in public hospitals in KwaZulu-Natal province. Clinical data were collected through interviews with first-trimester abortion clients and summaries completed by nurses performing the procedures. In parallel, we performed micro-costing at three of the study hospitals. Using a model built in Excel, we estimated the average cost per medical and surgical procedure and determined the cost per complete abortion performed. Results are presented in 2015 US dollars. RESULTS: A total of 1,129 women were eligible for a first trimester abortion at the three study sites. The majority (886, 78.5%) were eligible to choose their abortion procedure; 94.1% (n = 834) chose medication abortion. The total average cost per medication abortion was $63.91 (52.32-75.51). The total average cost per MVA was higher at $69.60 (52.62-86.57); though the cost ranges for the two procedures overlapped. Given average costs, the cost per complete medication abortion was lower than the cost per complete MVA despite three (0.4%) medication abortion women being hospitalized and two (0.3%) having ongoing pregnancies at study exit. Personnel costs were the largest component of the total average cost of both abortion methods. CONCLUSION: This analysis supports the scale-up of medication abortion alongside existing MVA services in South Africa. Women can be offered a choice of methods, including medication abortion with MVA as a back-up, without increasing costs.

Accessing medical and surgical first-trimester abortion services: women's experiences and costs from an operations research study in KwaZulu-Natal Province, South Africa.

OBJECTIVE(S): To explore women's experiences accessing services and estimate costs incurred for first-trimester abortion at four public hospitals in KwaZulu-Natal Province, South Africa. STUDY DESIGN: Subanalysis from a prospective cohort study (2009-2011) of women aged 18-49years accessing abortion services through 12weeks' gestation. Trained study personnel conducted structured interviews with women about their reason for having an abortion, experiences accessing services and costs incurred. Women who were 9weeks' gestation or less were eligible to choose medication abortion or manual vacuum aspiration (MVA); women 10-12weeks' gestation all had MVA. RESULTS: We enrolled 1167 women; 923 (79.1%) were eligible to choose their procedure. The median age was 25years; most were black African, single and unemployed. Many women reported concerns about the affordability of raising a(nother) child (58.9%) or not being ready for (more) children (43.4%) as their reason for having an abortion. In total, women incurred a median cost of US$9.99 (interquartile range 6.46-14.85) for their procedure which usually required two facility visits. Many had to pay for transportation, a pregnancy test, sanitary pads or pain medication. CONCLUSIONS: Despite the availability of government assistance for children through South Africa's "child grant," the affordability of raising a child was a major concern for women. Although theoretically available free of charge in the public sector, women experienced challenges accessing abortion services and incurred costs which may have been burdensome given average local earnings. These potential barriers could be addressed by reducing the number of required visits and improving availability of pregnancy tests and supplies in public facilities. IMPLICATIONS: Many women cited concerns about the affordability of having a(nother) child when requesting an abortion. Although public services are technically free or low-cost in South Africa, women incurred costs for first-trimester abortions. Women's costs could be lowered by reducing facility visits and improving availability of pregnancy tests and supplies.

A decade of progress providing safe abortion services in Ethiopia: results of national assessments in 2008 and 2014.

BACKGROUND: Ethiopia has one of the highest maternal mortality ratios in the world (420 per 100,000 live births in 2013), and unsafe abortion continues to be one of the major causes. To reduce deaths and disabilities from unsafe abortion, Ethiopia liberalized its abortion law in 2005 to allow safe abortion under certain conditions. This study aimed to measure how availability and utilization of safe abortion services has changed in the last decade in Ethiopia. METHODS: This paper draws on results from nationally representative health facility studies conducted in Ethiopia in 2008 and 2014. The data come from three sources at two points in time: 1) interviews with 335 health providers in 2008 and 822 health care providers in 2014, 2) review of facility logbooks, and 3) prospective data on 3092 women in 2008 and 5604 women in 2014 seeking treatment for abortion complications or induced abortion over a one month period. The Safe Abortion Care Model was used as a framework of analysis. RESULTS: There has been a rapid expansion of health facilities eligible to provide legal abortion services in Ethiopia since 2008. Between 2008 and 2014, the number of facilities reporting basic and comprehensive signal functions for abortion care increased. In 2014, access to basic abortion care services exceeded the recommended level of available facilities providing the service, increasing from 25 to 117%, with more than half of regions meeting the recommended level. Comprehensive abortion services increased from 20% of the recommended level in 2008 to 38% in 2014. Smaller regions and city administrations achieved or exceeded the recommended level of comprehensive service facilities, yet larger regions fall short. Between 2008 and 2014, the use of appropriate technology for conducting first and second trimester abortion and the provision of post abortion family planning has increased at the same time that abortion-related obstetric complications have decreased. CONCLUSION: Ten years after the change in abortion law, service availability and quality has increased, but access to lifesaving comprehensive care still falls short of recommended levels.

Moving from legality to reality: how medical abortion methods were introduced with implementation science in Zambia.

BACKGROUND: Although abortion is technically legal in Zambia, the reality is far more complicated. This study describes the process and results of galvanizing access to medical abortion where abortion has been legal for many years, but provision severely limited. It highlights the challenges and successes of scaling up abortion care using implementation science to document 2 years of implementation. METHODS: An intervention between the Ministry of Health, University Teaching Hospital and the international organization Ipas, was established to introduce medical abortion and to address the lack of understanding and implementation of the country's abortion law. An implementation science model was used to evaluate effectiveness and glean lessons for other countries about bringing safe and legal abortion services to scale. The intervention involved the provision of Comprehensive Abortion Care services in 28 public health facilities in Zambia for a 2 year period, August 2009 to September 2011. The study focused on three main areas: building health worker capacity in public facilities and introducing medical abortion, working with pharmacists to provide improved information on medical abortion, and community engagement and mobilization to increase knowledge of abortion services and rights through stronger health system and community partnerships. RESULTS: After 2 years, 25 of 28 sites provided abortion services, caring for more than 13,000 women during the intervention. For the first time, abortion was decentralized, 19% of all abortion care was performed in health centers. At the end of the intervention, all providing facilities had managers supportive of continuing legal abortion services. When asked about the impact of medical abortion provision, a number of providers reported that medical abortion improved their ability to provide affordable safe abortion. In neighboring pharmacies only 19% of mystery clients visiting them were offered misoprostol for purchase at baseline, this increased to 47% after the intervention. Despite progress in attitudes towards abortion clients, such as empathy, and improved community engagement, the evaluation revealed continuing stigma on both provider and client sides. CONCLUSIONS: These findings provide a case study of the medical abortion introduction in Zambia and offer important lessons for expanding safe and legal abortion access in similar settings across Africa.

Strengthening Postabortion Family Planning Services in Ethiopia: Expanding Contraceptive Choice and Improving Access to Long-Acting Reversible Contraception.

Where unmet need for the safest, most effective, and long-acting reversible contraceptives (LARCs) is very high, the health system and partners need to implement problem-solving, locally feasible, and comprehensive family planning delivery strategies. Because young and unmarried women are most at risk for unintended pregnancy and repeat abortion due to poor access to contraceptive services, postabortion family planning (PAFP) is a key component in such strategies. In Southern Nations, Nationalities, and People's Region, Ethiopia, Ipas implemented health system strengthening efforts from fiscal year (FY) 2010 (July 2009 to June 2010) to FY 2014 (July 2013 to June 2014) to improve the quality of PAFP services and expand method choice in 101 public facilities. The intervention significantly improved PAFP uptake at the project sites. Specifically, the proportion of abortion clients receiving LARCs progressively improved during the intervention period. The proportion of abortion clients who left the facilities with a contraceptive method increased from 58% in FY 2010 to 83% in FY 2014. The share of method mix for LARCs rose from 2% in FY 2010 to 55% in FY 2014, while the share for condoms, injectables, and oral contraceptives declined from 98% to 45%. Implant use rose from 2% in FY 2010 to 43% in FY 2014, while the use of intrauterine devices increased from 0.1% in FY 2010 to 12% in FY 2014. A larger proportion of PAFP users received LARCs at health centers, where midwives and nurses are the primary providers, than at hospitals (59% versus 37%, respectively). A broader method mix can satisfy clients with a variety of needs, a key factor for higher uptake of more effective methods and program success. Further evidence-based interventions need to be implemented to improve the quality of PAFP in a feasible and replicable strategy that addresses unmet need for modern contraceptive methods.

Client-pharmacy worker interactions regarding medical abortion in Zambia in 2009 and 2011.

OBJECTIVE: To examine sales practices, knowledge, and behavior of pharmacy workers regarding medical abortion in 2009 and 2011 in Zambia, where hostile and stigmatizing attitudes still result in high rates of unsafe abortion. METHODS: Four mystery clients visited pharmacies during 2009 and 2011, and recorded their experiences following their interactions using a standardized form. Bivariate analysis examined pharmacy workers' attitudes, behavior, and medical abortion-dispensing practices. RESULTS: Mystery clients visited 76 pharmacies in 2009 and 80 pharmacies in 2011. In 2011, mystery clients reported hostile interactions with pharmacy workers at 8 (10%) pharmacy visits, a relative decrease from 7 (22%) in 2009 (P=0.0353). In 2009, less than half (35 [46%]) of clients received information or had the opportunity to purchase medical abortion drugs in comparison with 53 (66%) in 2011 (P=0.0110). In 2011, more pharmacy workers mentioned a valid medical abortion drug in comparison with 2009 (42 [53%] vs 31 [41%], respectively); however, guidance for women on misoprostol use was minimal. CONCLUSION: Pharmacy workers exhibited increased awareness of misoprostol, less hostility, and a willingness to sell medical abortion drugs; however, they continued to provide inadequate information on misoprostol for medical abortion. Effective training of pharmacy employees is vital in increasing access to safe induced-abortion care.

Changes in Morbidity and Abortion Care in Ethiopia After Legal Reform: National Results from 2008 and 2014.

CONTEXT: In Ethiopia, liberalization of the abortion law in 2005 led to changes in abortion services. It is important to examine how levels and types of abortion care-i.e., legal abortion and treatment of abortion complications-changed over time. METHODS: Between December 2013 and May 2014, data were collected on symptoms, procedures and treatment from 5,604 women who sought abortion care at a sample of 439 public and private health facilities; the sample did not include lower-level private facilities-some of which provide abortion care-to maintain comparability with the sample from a 2008 study. These data were combined with monitoring data from 105,806 women treated in 74 nongovernmental organization facilities in 2013. Descriptive analyses were conducted and annual estimates were calculated to compare the numbers and types of abortion care services provided in 2008 and 2014. RESULTS: The estimated annual number of women seeking a legal abortion in the types of facilities sampled increased from 158,000 in 2008 to 220,000 in 2014, and the estimated number presenting for postabortion care increased from 58,000 to 125,000. The proportion of abortion care provided in the public sector increased from 36% to 56% nationally. The proportion of women presenting for postabortion care who had severe complications rose from 7% to 11%, the share of all abortion procedures accounted for by medical abortion increased from 0% to 36%, and the proportion of abortion care provided by midlevel health workers increased from 48% to 83%. Most women received postabortion contraception. CONCLUSIONS: Ethiopia has made substantial progress in expanding comprehensive abortion care; however, eradication of morbidity from unsafe abortion has not yet been achieved.