Determination of medical abortion success by women and community health volunteers in Nepal using a symptom checklist.

BACKGROUND: We sought to determine if female community health volunteers (FCHVs) and literate women in Nepal can accurately determine success of medical abortion (MA) using a symptom checklist, compared to experienced abortion providers. METHODS: Women undergoing MA, and FCHVs, independently assessed the success of each woman's abortion using an 8-question symptom checklist. Any answers in a red-shaded box indicated that the abortion may not have been successful. Women's/FCHVs' assessments were compared to experienced abortion providers using standard of care. RESULTS: Women's (n = 1153) self-assessment of MA success agreed with abortion providers' determinations 85% of the time (positive predictive value = 90, 95% CI 88, 92); agreement between FCHVs and providers was 82% (positive predictive value = 90, 95% CI 88, 92). Of the 92 women (8%) requiring uterine evacuation with manual vacuum aspiration (n = 84, 7%) or medications (n = 8, 0.7%), 64% self-identified as needing additional care; FCHVs identified 61%. However, both women and FCHVs had difficulty recognizing that an answer in a red-shaded box indicated that the abortion may not have been successful. Of the 453 women with a red-shaded box marked, only 35% of women and 41% of FCHVs identified the need for additional care. CONCLUSION: Use of a checklist to determine MA success is a promising strategy, however further refinement of such a tool, particularly for low-literacy settings, is needed before widespread use.

Values clarification workshops to improve abortion knowledge, attitudes and intentions: a pre-post assessment in 12 countries.

BACKGROUND: Women's access to abortion care is often denied or hampered due to a range of barriers, many of which are rooted in abortion stigma. Abortion values clarification and attitude transformation (VCAT) workshops are conducted with abortion providers, trainers, and policymakers and other stakeholders to mitigate the effects of abortion stigma and increase provision of and access to abortion care. This study assesses changes in knowledge, attitudes, and behavioral intentions of VCAT workshop participants. METHODS: Pre- and post-workshop surveys from 43 VCAT workshops conducted in 12 countries in Asia, Africa, and Latin America between 2006 and 2011 were analyzed to assess changes in three domains: knowledge, attitudes and behavioral intentions related to abortion care. A score was created for each domain (range: 0-100), and paired t-tests or Wilcoxon matched-pairs signed-ranks tests were used to test for significant differences between the pre- and post-workshop scores overall and by region and participant type (providers, trainers, and policymakers/other stakeholders). We also assessed changes in pre- and post-workshop scores for participants with the lowest knowledge and negative attitudes on the pre-workshop survey. RESULTS: Overall, the mean knowledge score increased significantly from 49.0 to 67.1 (p < 0.001) out of a total possible score of 100. Attitudes and behavioral intentions showed more modest, but still statistically significant improvements between the pre- and post-workshop surveys. The mean attitudes score increased from 78.2 to 80.9 (p < 0.001), and the mean behavioral intentions score rose from 82.2 to 85.4 (p = 0.03). Among participants with negative attitudes pre-workshop, most shifted to positive attitudes on the post-workshop survey, ranging from 35.2% who switched to supporting unrestricted access to second-trimester abortion to 90.9% who switched to feeling comfortable working to increase access to contraceptive services in their country. Participants who began the workshop with the lowest level of knowledge experienced the greatest increase in mean knowledge score from 20.0 to 55.0 between pre- and post-workshop surveys (p < 0.001). CONCLUSIONS: VCAT workshop participants demonstrated improvements in knowledge, attitudes, and behavioral intentions related to abortion care. Participants who entered the workshops with the lowest levels of knowledge and negative attitudes had the greatest gains in these domains.

Integrating postabortion care, menstrual regulation and family planning services in Bangladesh: a pre-post evaluation.

BACKGROUND: In Bangladesh, abortion is restricted except to save the life of a woman, but menstrual regulation is allowed to induce menstruation and return to non-pregnancy after a missed period. MR services are typically provided through the Directorate General of Family Planning, while postabortion care services for incomplete abortion are provided by facilities under the Directorate General of Health Services. The bifurcated health system results in reduced quality of care, particularly for postabortion care patients whose procedures are often performed using sub-optimal uterine evacuation technology and typically do not receive postabortion contraceptive services. This study evaluated the success of a pilot project that aimed to integrate menstrual regulation, postabortion care and family planning services across six Directorate General of Health Services and Directorate General of Family Planning facilities by training providers on woman-centered abortion care and adding family planning services at sites offering postabortion care. METHODS: A pre-post evaluation was conducted in the six large intervention facilities. Structured client exit interviews were administered to all uterine evacuation clients presenting in the 2-week data collection period for each facility at baseline (n = 105; December 2011-January 2012) and endline (n = 107; February-March 2013). Primary outcomes included service integration indicators such as provision of menstrual regulation, postabortion care and family planning services in both facility types, and quality of care indicators such as provision of pain management, provider communication and women's satisfaction with the services received. Outcomes were compared between baseline and endline for Directorate General of Family Planning and Directorate General of Health Services facilities, and chi-square tests and t-tests were used to test for differences between baseline and endline. RESULTS: At the end of the project there was an increase in menstrual regulation service provision in Directorate General of Health Services facilities, from none at baseline to 44.1% of uterine evacuation services at endline (p < 0.001). The proportion of women accepting a postabortion contraceptive method increased from 14.3% at baseline to 69.2% at endline in Directorate General of Health Services facilities (p = 0.006). Provider communication and women's rating of the care they received increased significantly in both Directorate General of Health Services and Directorate General of Family Planning facilities. CONCLUSIONS: Integration of menstrual regulation, postabortion care and family planning services is feasible in Bangladesh over a relatively short period of time. The intervention's focus on woman-centered abortion care also improved quality of care. This model can be scaled up through the public health system to ensure women's access to safe uterine evacuation services across all facility types in Bangladesh.

Associations Between Abortion Services and Acceptance of Postabortion Contraception in Six Indian States.

Women receiving induced abortions or postabortion care are at high risk of subsequent unintended pregnancy, and intervals of less than six months between abortion and subsequent pregnancy may be associated with adverse outcomes. This study highlights the prevalence and attributes of postabortion contraceptive acceptance from 2,456 health facilities in six major Indian states, among 292,508 women who received abortion care services from July 2011 through June 2014. Eighty-one percent of the women accepted postabortion contraceptive methods: 53 percent short-term, 11 percent intrauterine devices, and 16 percent sterilization. Postabortion contraceptive acceptance was highest among women who were aged 25 years and older, received first-trimester services, received induced abortion, attended primary-level health facilities, and had medical abortions. Doctors receiving post-training support were more likely to offer contraceptives, but no association was observed between such support and acceptance of IUDs or sterilization. Comprehensive service-delivery interventions, including ensuring availability of skilled providers and contraceptive commodities, offering clinical mentoring for providers, identifying and addressing provider bias, and improving provider counseling skills, can increase postabortion contraceptive acceptance and reduce unintended pregnancy.

Marital status and abortion among young women in Rupandehi, Nepal.

BACKGROUND: Despite liberalization of the Nepal abortion law, young women continue to experience barriers to safe abortion services. We hypothesize that marital status may differentially impact such barriers, given the societal context of Nepal. METHODS: We evaluated differences in reproductive knowledge and attitudes by marital status with a probability-based, cross-sectional survey of young women in Rupandehi district, Nepal. Participants (N = 600) were surveyed in 2012 on demographics, romantic experiences, media habits, reproductive information, and abortion knowledge and attitudes. We used logistic regression to assess differences by marital status, controlling for age. RESULTS: Participants, who comprised never-married (54%) and ever-married women (45%), reported good access to basic reproductive health and abortion information. Social desirability bias might have prevented reporting of premarital romantic and sexual activity given that participants reported more premarital activities for their friends than for themselves. Only 45% knew that abortion was legal, and fewer ever-married women were aware of abortion legality. Never-married women expected more negative responses from having an abortion than ever-married women. CONCLUSIONS: Findings highlight the need for providing sexual and reproductive health care information and services to young women regardless of marital status.

How prepared are young, rural women in India to address their sexual and reproductive health needs? a cross-sectional assessment of youth in Jharkhand.

BACKGROUND: Young, rural Indian women lack sexual and reproductive health (SRH) information and agency and are at risk of negative sexual and reproductive health outcomes. Youth-focused interventions have been shown to improve agency and self-efficacy of young women to make decisions regarding their sexual and reproductive health. The objectives of this study were to assess young women's sexual and reproductive health knowledge; describe their health-seeking behaviors; describe young women's experiences with sexual and reproductive health issues, including unwanted pregnancy and abortion; and identify sources of information, including media sources. METHOD: A cross-sectional survey with a representative sample of 1381 married and unmarried women young women (15-24 years) from three rural community development blocks in Jharkhand, India was conducted in 2012. Participants were asked a series of questions related to their SRH knowledge and behavior, as well as questions related to their agency in several domains related to self-efficacy and decision-making. Linear regression was used to assess factors associated with greater or less individual agency and to determine differences in SRH knowledge and behavior between married and unmarried women. RESULTS: Despite national policies, participants married young (mean 15.7 years) and bore children early (53 % with first birth by 17 years). Women achieved low composite scores on knowledge around sex and pregnancy, contraception, and abortion knowledge. Around 3 % of married young women reported experiencing induced abortion; 92 % of these women used private or illegal providers. Married and unmarried women also had limited agency in decision-making, freedom of mobility, self-efficacy, and financial resources. Most of the women in the sample received SRH information by word of mouth. CONCLUSIONS: Lack of knowledge about sexual and reproductive health in this context indicates that young rural Indian women would benefit from a youth-friendly SRH intervention to improve the women's self-efficacy and decision-making capacity regarding their own health. A communication intervention using outreach workers may be a successful method for delivering this intervention.

Evaluation of a multi-pronged intervention to improve access to safe abortion care in two districts in Jharkhand.

BACKGROUND: Despite the adoption of the Medical Termination of Pregnancy Act in 1972, access to safe abortion services remains limited in India. Awareness of the legality of abortion also remains low, leading many women to seek services outside the health system. Medical abortion (MA) is an option that has the potential to expand access to safe abortion services. A multi-pronged intervention covering a population of 161,000 in 253 villages in the Silli and Khunti blocks of Jharkhand was conducted between 2007 and 2009, seeking to improve medical abortion services and create awareness at the community level by providing information through community intermediaries and creating an enabling environment through a behavior change communication campaign. The study evaluates the changes in knowledge about abortion-related issues, changes in abortion care-seeking, and service utilization as a result of this intervention. METHODS: A baseline cross-sectional survey was conducted pre-intervention (n = 1,253) followed by an endline survey (n = 1,290) one year after the completion of the intervention phase. In addition, monitoring data from intervention facilities was collected monthly over the study period. RESULTS: Nearly 85% of respondents reported being exposed to safe abortion messaging as a result of the intervention. Awareness of the legality of abortion increased significantly from 19.7% to 57.6% for women, as did awareness of the specific conditions for which abortion is allowed. Results were similar for men. There was also a significant increase in the proportion of men and women who knew of a legal and safe provider and place from where abortion services could be obtained. Multivariate analysis showed positive associations between exposure to any component of the intervention and increased knowledge about legality and gestational age limits, however only interpersonal communication was associated with a significant increase in knowledge of where to obtain safe services (OR 4.8, SE 0.67). Utilization of safe abortion services, and in particular MA, increased at all intervention sites over the duration of the intervention with a shift towards women seeking care earlier in pregnancy. CONCLUSION: The evaluation demonstrates the success of the intervention and its potential for replication in similar contexts within India.

Woman-centered research on access to safe abortion services and implications for behavioral change communication interventions: a cross-sectional study of women in Bihar and Jharkhand, India.

BACKGROUND: Unsafe abortion in India leads to significant morbidity and mortality. Abortion has been legal in India since 1971, and the availability of safe abortion services has increased. However, service availability has not led to a significant reduction in unsafe abortion. This study aimed to understand the gap between safe abortion availability and use of services in Bihar and Jharkhand, India by examining accessibility from the perspective of rural, Indian women. METHODS: Two-stage stratified random sampling was used to identify and enroll 1411 married women of reproductive age in four rural districts in Bihar and Jharkhand, India. Data were collected on women's socio-demographic characteristics; exposure to mass media and other information sources; and abortion-related knowledge, perceptions and practices. Multiple linear regression models were used to explore the association between knowledge and perceptions about abortion. RESULTS: Most women were poor, had never attended school, and had limited exposure to mass media. Instead, they relied on community health workers, family and friends for health information. Women who had knowledge about abortion, such as knowing an abortion method, were more likely to perceive that services are available (ß = 0.079; p < 0.05) and have positive attitudes toward abortion (ß = 0.070; p < 0.05). In addition, women who reported exposure to abortion messages were more likely to have favorable attitudes toward abortion (ß = 0.182; p < 0.05). CONCLUSIONS: Behavior change communication (BCC) interventions, which address negative perceptions by improving community knowledge about abortion and support local availability of safe abortion services, are needed to increase enabling resources for women and improve potential access to services. Implementing BCC interventions is challenging in settings such as Bihar and Jharkhand where women may be difficult to reach directly, but interventions can target individuals in the community to transfer information to the women who need this information most. Interpersonal approaches that engage community leaders and influencers may also counteract negative social norms regarding abortion and associated stigma. Collaborative actions of government, NGOs and private partners should capitalize on this potential power of communities to reduce the impact of unsafe abortion on rural women.

Intimate partner violence and constraints to reproductive autonomy and reproductive health among women seeking abortion services in Bangladesh.

OBJECTIVE: To understand intersections between intimate partner violence (IPV) and other constraints to women's reproductive autonomy, and the influence of IPV on reproductive health. METHODS: A secondary analysis examined cross-sectional data from a facility-based sample of women seeking abortion care (for spontaneous or induced abortion) between March 1 and October 31, 2013. Women aged 18-49 years, who received abortion services and selected a short-acting contraceptive method or no contraception completed an interviewer-administered survey after treatment. Adjusted prevalence ratios (aPRs) were calculated for associations between IPV experience and potential constraints to reproductive autonomy and health outcomes. RESULTS: There were 457 participants included in the present analysis and 118 (25.8%) had experienced IPV in the preceding year. IPV was associated with discordance in fertility intentions with husbands/partners and in-laws, with in-law opposition to contraception, with perceived religious prohibition of contraception, and with presenting unaccompanied (all P<0.05). IPV was also associated with receiving post-abortion care after an induced abortion compared with accessing legal menstrual regulation, and with the use of medication abortion compared with manual vacuum aspiration (both P<0.05). CONCLUSION: Intimate partner violence was associated with additional constraints on reproductive autonomy from husbands/partners, in-laws, and religious communities. Seeking induced abortion unaccompanied and using medication abortion could be strategies to access abortion covertly among women experiencing IPV. Ensuring women's reproductive freedom requires addressing IPV and related constraints.

Service Delivery Correlates of Choosing Short-Acting Contraceptives at the Time of Uterine Evacuation in Bangladesh.

CONTEXT: The World Health Organization recommends that contraceptives be offered on the day of a uterine evacuation procedure (i.e., induced abortion or postabortion care for an incomplete abortion). Short-acting methods can be initiated on the day of the uterine evacuation, regardless of procedure type. METHODS: Survey data from a facility-based sample of 479 Bangladeshi women aged 18-49 who did not intend to become pregnant in the four months following their uterine evacuation were used to examine women's choice of short-acting contraceptive methods (pill, condoms or injectable). Service delivery correlates of contraceptive choice were identified using sequential logistic regression models. RESULTS: Seventy-three percent of women chose a short-acting contraceptive method on the day of their uterine evacuation. The odds that a woman chose a short-acting method, rather than no method, were lower among those who had had a medication abortion (odds ratio, 0.1) or dilatation and curettage (0.3) than among those who had had a vacuum aspiration. The likelihood that a woman chose a specific type of short-acting method varied according to the type of uterine evacuation she had had, the facility level and the governmental or nongovernmental entity that managed the facility. CONCLUSIONS: Uterine evacuation service delivery characteristics may act as barriers to women's choosing a contraceptive method following an abortion. Training and monitoring providers may help ensure that all uterine evacuation clients have access to the full range of contraceptive information and services and that their choices, rather than service delivery factors, drive postabortion contraceptive use.

Correlates of contraceptive use 4 months postabortion: findings from a prospective study in Bangladesh.

OBJECTIVES: Using the social determinants framework as a guide, this study sought to understand correlates of postabortion contraceptive use at the individual, family and abortion service delivery levels. STUDY DESIGN: This prospective study assessed correlates of contraceptive use 4 months postabortion and timing of initiation using a facility-based sample of 398 abortion clients who selected pills, condoms, injectables or no method immediately following the procedure. We measured potential correlates immediately following abortion, inclusive of spontaneous or induced abortion, and assessed contraceptive use outcomes 4 months postabortion. Multivariable logistic regression models identified correlates at each level. Potential individual level correlates included contraceptive and abortion history and fertility intentions; family correlates included intimate partner violence (IPV), discordance in fertility intentions and household decision-making; and service delivery correlates included procedure type and postabortion contraceptive counseling. RESULTS: Reported contraceptive use 4 months postabortion was high (85.4%). Contraceptive use at the index pregnancy (resulting in abortion) was the primary correlate of contraceptive use 4 months postabortion (adjusted odds ratio=2.9; 95% confidence interval: 1.5-5.9). Delayed contraceptive initiation was more common among women who reported past year IPV (36.8% vs. 19.5%; p=.03) particularly with spousal accompaniment for abortion, those in relationships with discordant fertility intentions (44.4% vs. 21.9%; p=.04) and those receiving medication abortion (56.7%) or dilation and curettage (57.1%), compared to manual vacuum aspiration (12.6%; p<.01). CONCLUSIONS: Contraceptive use at the index pregnancy was the primary correlate of contraceptive use 4 months postabortion. Abortion procedure type and relationship dynamics were correlated with delayed postabortion contraceptive initiation. Women who reported IPV delayed initiation when accompanied by their spouse for abortion. IMPLICATIONS: Postabortion contraceptive counseling should assess previous use patterns and provide information on using contraception effectively. Delayed initiation among women reporting IPV could be addressed through comprehensive, confidential counseling that includes violence screening, support for contraceptive initiation and offer of woman-controlled methods.

Expansion of Safe Abortion Services in Nepal Through Auxiliary Nurse-Midwife Provision of Medical Abortion, 2011-2013.

INTRODUCTION: The termination of unwanted pregnancies up to 12 weeks' gestation became legal in Nepal in 2002. Many interventions have taken place to expand access to comprehensive abortion care services. However, comprehensive abortion care services remain out of reach for women in rural and remote areas. This article describes a training and support strategy to train auxiliary nurse-midwives (ANMs), already certified as skilled birth attendants, as medical abortion providers and expand geographic access to safe abortion care to the community level in Nepal. METHODS: This was a descriptive program evaluation. Sites and trainees were selected using standardized assessment tools to determine minimum facility requirements and willingness to provide medical abortion after training. Training was evaluated via posttests and observational checklists. Service statistics were collected through the government's facility logbook for safe abortion services (HMIS-11). RESULTS: By the end of June 2014, medical abortion service had been expanded to 25 districts through 463 listed ANMs at 290 listed primary-level facilities and served 25,187 women. Providers report a high level of confidence in their medical abortion skills and considerable clinical knowledge and capacity in medical abortion. DISCUSSION: The Nepali experience demonstrates that safe induced abortion care can be provided by ANMs, even in remote primary-level health facilities. Post-training support for providers is critical in helping ANMs handle potential barriers to medical abortion service provision and build lasting capacity in medical abortion.

Women's satisfaction with abortion care in academic family medicine centers.

BACKGROUND AND OBJECTIVES: The primary study aim was to describe patient satisfaction regarding abortion experiences in urban academic family medicine centers (FMCs). METHODS: We conducted a cross-sectional survey of 210 women obtaining a first trimester medication or aspiration abortion at four FMCs. The 32-item written survey consisted of multiple choice, open-ended questions and Likert scale measures (for satisfaction: 1=very dissatisfied, 2=somewhat dissatisfied, 3=somewhat satisfied, 4=very satisfied, for quality of care: 1=poor, 2=average, 3=good, 4=excellent). We used Fisher's exact test to examine bivariate relationships. Responses to open-ended questions were coded and categorized. RESULTS: The majority of women (93%) were very satisfied with their abortion experience in their FMC, regardless of clinical site or abortion method. Mean scores for the quality of the staff, doctor, abortion counseling, and contraceptive counseling were all at least 3.9 (out of 4). Women most commonly cited positive interactions with the staff and physicians as the best part of their experience. CONCLUSIONS: This study demonstrates that women who receive abortion services at academic FMCs are highly satisfied with their care.

Effectiveness of a behavior change communication intervention to improve knowledge and perceptions about abortion in Bihar and Jharkhand, India.

CONTEXT: Although abortion became legal in India in 1971, many women are unaware of the law. Behavior change communication interventions may be an effective way to promote awareness of the law and change knowledge of and perceptions about abortion, particularly in settings in which abortion is stigmatized. METHODS: To evaluate the effectiveness of a behavior change communication intervention to improve women's knowledge about India's abortion law and their perceptions about abortion, a quasi-experimental study was conducted in intervention and comparison districts in Bihar and Jharkhand. Household surveys were administered at baseline in 2008 and at follow-up in 2010 to independent, randomly selected cross-sectional samples of rural married women aged 15-49. Logistic regression difference-in-differences models were used to assess program effectiveness. RESULTS: Analysis demonstrated program effectiveness in improving awareness and perceptions about abortion. The changes in the odds of knowing that abortion is legal and where to obtain safe abortion services were larger between baseline and follow-up in the intervention districts than the changes in odds observed in the comparison districts (odds ratios, 16.1 and 1.9, respectively). Similarly, the increase in women's perception of greater social support for abortion within their families and the increase in perceived self-efficacy with respect to family planning and abortion between baseline and follow-up was greater in the intervention districts than in the comparison districts (coefficients, 0.17 and 0.18, respectively). CONCLUSIONS: Behavior change communication interventions can be effective in improving knowledge of and perceptions about abortion in settings in which lack of accurate knowledge hinders women's access to safe abortion services. Multiple approaches should be used when attempting to improve knowledge and perceptions about stigmatized health issues such as abortion.

Pathways and consequences of unsafe abortion: a comparison among women with complications after induced and spontaneous abortions in Madhya Pradesh, India.

This study aimed to understand women's pathways of seeking care for postabortion complications in Madhya Pradesh, India. The study recruited 786 women between July and November 2007. Data were collected on service provision, abortion-related complications, care-seeking behavior, knowledge about abortion legality and availability, methods used, symptoms, referral source, and out-of-pocket costs. Women seeking care for complications from induced abortion followed more complex pathways to treatment than women with complications of spontaneous abortion. More complex pathways were associated with higher out-of-pocket costs. Improving community awareness on legal aspects, safe abortion methods, and trained providers are necessary to reduce morbidity associated with unsafe abortion.

Clinical diagnosis of completeness of medical abortion by nurses: a reliability study in Mozambique.

BACKGROUND: The provision of medical abortion continues to rely on routine use of ultrasound to confirm expulsion of pregnancy. However, the absence of ultrasound in most of the health facilities in developing countries and the additional training required to enable providers to use ultrasound is often prohibitive. The purpose of this study was to compare clinical history and physical examination with ultrasound in confirming completion of abortion. STUDY DESIGN: A total of 718 women consented for medical abortion with misoprostol and were assessed for pregnancy expulsion by nurses and gynecologists. Nurses used history and physical examination while gynecologists used ultrasound to establish their diagnoses. RESULTS: Nurses' clinical diagnoses for complete abortion, incomplete abortion and ongoing pregnancy were 83% (SE 0.01), 15% (SE 0.01) and 2% (SE 0.01), respectively. When gynecologists used ultrasound, the diagnoses for complete abortion, incomplete abortion, an ongoing pregnancy were 80% (SE 0.01), 17% (SE 0.01) and 3% (SE 0.01), respectively. Overall, nurses agreed with gynecologist diagnoses in 84% of cases, with a κ coefficient of 0.49 (SE 0.06) and chance-corrected first-order agreement (AC(1)) of 0.81 (SE 0.02). Agreement was very high for the diagnosis of complete abortion (AC(1) 0.89; SE 0.02), while it was moderate for ongoing pregnancy (AC(1) 0.58; SE 0.22) and incomplete abortion (AC(1) 0.45; SE 0.08). CONCLUSIONS: Clinical history and physical examination alone, without the use of ultrasonography, are effective for the determination of successful pregnancy expulsion. However, greater emphasis is required on the clinical identification of ongoing pregnancy during any training of providers.