Lived experiences and drivers of induced abortion among women in central Uganda.

Although unsafe abortions are preventable, they are one of the leading causes of maternal mortality and morbidity. Despite the serious potential health consequences, there is limited published information about drivers and challenges of obtaining abortions in restrictive settings such as Uganda. This limits efforts to improve programing for preventing unsafe abortion and providing comprehensive post abortion care. This study sought to understand the drivers and explain the lived abortion experiences among women from central Uganda, in an effort to promote greater access to safe reproductive healthcare services, and reduce unsafe abortions. This qualitative study included 40 purposely selected women who self-reported an abortion, living in Kampala and greater Rakai district, Uganda. They were part of a larger survey using respondent driven sampling, where seed participants were recruited from selected facilities offering post-abortion care, or through social referrals. Data were collected from May to September 2021 through in-depth interviews. Audio data were transcribed, managed using Atlas.ti 9, and analyzed thematically. The findings show that the underlying drivers stemmed from partners who were unsupportive, denied responsibility, or had raped/defiled women. Career and education decisions, stigma and fear to disappoint family also contributed. Women had feelings of confusion, neglect, betrayal, or shame after conception. Abortion and post-abortion experiences were mixed with physical and emotional pain including stigma, even when the conditions for safe abortion in the guidelines were satisfied. Although most women sought care from health facilities judged to provide safe and quality care, there was barely any counselling in these venues. Confidantes and health providers informed the choice of abortion methods, although the cost ultimately mattered most. The mental health of women whose partners are unsupportive or who conceive unintendedly need consideration. Abortion provided psychological relief from more complicated consequences of having an unplanned birth for women.

Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys.

Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda.

The confidante method to measure abortion: implementing a standardized comparative analysis approach across seven contexts.

BACKGROUND: Obtaining representative abortion incidence estimates is challenging in restrictive contexts. While the confidante method has been increasingly used to collect this data in such settings, there are several biases commonly associated with this method. Further, there are significant variations in how researchers have implemented the method and assessed/adjusted for potential biases, limiting the comparability and interpretation of existing estimates. This study presents a standardized approach to analyzing confidante method data, generates comparable abortion incidence estimates from previously published studies and recommends standards for reporting bias assessments and adjustments for future confidante method studies. METHODS: We used data from previous applications of the confidante method in Côte d'Ivoire, Ethiopia, Ghana, Java (Indonesia), Nigeria, Uganda, and Rajasthan (India). We estimated one-year induced abortion incidence rates for confidantes in each context, attempting to adjust for selection, reporting and transmission bias in a standardized manner. FINDINGS: In each setting, majority of the foundational confidante method assumptions were violated. Adjusting for transmission bias using self-reported abortions consistently yielded the highest incidence estimates compared with other published approaches. Differences in analytic decisions and bias assessments resulted in the incidence estimates from our standardized analysis varying widely from originally published rates. INTERPRETATION: We recommend that future studies clearly state which biases were assessed, if associated assumptions were violated, and how violations were adjusted for. This will improve the utility of confidante method estimates for national-level decision making and as inputs for global or regional model-based estimates of abortion.

Impact of the global gag rule on women's contraceptive use and reproductive health outcomes in Ethiopia: a pre-post and difference-in-difference analysis.

OBJECTIVE: To assess the impacts of the Protecting Life through Global Health Assistance policy (otherwise known as the expanded global gag rule (GGR)) on women's sexual and reproductive health (SRH) in Ethiopia. The GGR prohibits all non-US non-governmental organisations (NGOs) receiving US Government global health funding from providing, referring or advocating for abortion. DESIGN: Pre-post analysis and difference-in-difference analysis. SETTING: Six regions of Ethiopia (Tigray, Afar, Amhara, Oromiya, SNNPR and Addis Ababa). PARTICIPANTS: Panel of 4909 reproductive-age women recruited from the Performance Monitoring for Accountability 2018 survey, administered face-to-face surveys in 2018 and 2020. MEASURES: We assessed impacts of the GGR on contraceptive use, pregnancies, births and abortions. Due to the 2019 'Pompeo Expansion' and widespread application of the GGR, we use a pre-post analysis to investigate changes in women's reproductive outcomes. We then use a difference-in-differences design to measure the additional effect of NGOs refusal to comply with the policy and the resulting loss in funding; districts are classified as more exposed if organisations impacted by lost funding were providing services there and women are classified based on their district. RESULTS: At baseline, 27% (n=1365) of women were using a modern contraceptive (7% using long-acting reversible contraceptive methods (LARCs) and 20% using short-acting methods. The pre-post analysis revealed statistically significant declines from 2018 to 2020 in the use of LARCs (-0.9, 95% CI: -1.6 to -0.2) and short-acting methods (-1.0, 95% CI: -1.8 to -0.2). These changes were deviations from prior trends. In our difference-in-differences analysis, women exposed to non-compliant organisations experienced greater declines in LARC use (-1.5, 95% CI: -2.9 to -0.1) and short-acting method use (-1.7, 95% CI: -3.2 to -0.1) as compared with less-exposed women. CONCLUSIONS: The GGR resulted in a stagnation in the previous growth in contraceptive use in Ethiopia. Longer-term strategies are needed to ensure that SRH progress globally is protected from changes in US political administrations.

Postabortion and safe abortion care coverage, capacity, and caseloads during the global gag rule policy period in Ethiopia and Uganda.

BACKGROUND: Abortion-related complications contribute to preventable maternal mortality, accounting for 9.8% of maternal deaths globally, and 15.6% in sub-Saharan Africa. High-quality postabortion care (PAC) can mitigate the negative health outcomes associated with unsafe abortion. While the expanded Global Gag Rule policy did not prohibit the provision of PAC, other research has suggested that over-implementation of the policy has resulted in impacts on these services. The purpose of this study was to assess health facilities' capacity to provide PAC services in Uganda and PAC and safe abortion care (SAC) in Ethiopia during the time in which the policy was in effect. METHODS: We collected abortion care data between 2018 and 2020 from public health facilities in Ethiopia (N = 282) and Uganda (N = 223). We adapted a signal functions approach to create composite indicators of health facilities' capacity to provide basic and comprehensive PAC and SAC and present descriptive statistics documenting the state of service provision both before and after the GGR went into effect. We also investigate trends in caseloads over the time-period. RESULTS: In both countries, service coverage was high and improved over time, but facilities' capacity to provide basic PAC services was low in Uganda (17.8% in 2019) and Ethiopia (15.0% in 2020). The number of PAC cases increased by 15.5% over time in Uganda and decreased by 7% in Ethiopia. Basic SAC capacity increased substantially in Ethiopia from 66.7 to 82.8% overall, due in part to an increase in the provision of medication abortion, and the number of safe abortions increased in Ethiopia by 9.7%. CONCLUSIONS: The findings from this analysis suggest that public health systems in both Ethiopia and Uganda were able to maintain essential PAC/SAC services during the GGR period. In Ethiopia, there were improvements in the availability of safe abortion services and an overall improvement in the safety of abortion during this time-period. Despite loss of partnerships and potential disruptions in referral chains, lower-level facilities were able to expand their capacity to provide PAC services. However, PAC caseloads increased in Uganda which could indicate that, as hypothesized, abortion became more stigmatized, less accessible and less safe.

An investigation of the impact of the Global Gag Rule on women's sexual and reproductive health outcomes in Uganda: a difference-in-differences analysis.

In 2017, the Trump administration reinstated the Global Gag Rule (GGR), making non-U.S. non-governmental organisations ineligible for US government global health assistance if they provide access to or information about abortion. Little is known about the impact of the Trump administration's GGR on women's outcomes. Data for this analysis come from a panel of women surveyed in 2018 and 2019 in Uganda (n = 2755). We also used data from meetings with key stakeholders to create a detailed measure of exposure to the GGR within Uganda, classifying districts as more or less exposed to the GGR. Multivariable regression models were used to assess changes in contraceptive use, all births, unplanned births, and abortion from before to during implementation of the GGR. Difference-in-differences (DID) estimates were determined by calculating predicted probabilities from interaction terms for exposure/survey round. Descriptive analyses showed long-acting reversible contraceptive use increased more rapidly among women in less exposed districts after GGR implementation. DID estimates for contraceptive use were small. We observed a DID estimate of 3.5 (95% CI -0.9, 7.9) for all births and 2.9 (95% CI -0.2, 6.0) for unplanned births for women in more exposed districts during the period the policy was in effect. Our results suggest that the GGR may have attenuated Uganda's recent progress in improving SRHR outcomes, with women in less exposed districts continuing to benefit from this progress, while previously increasing trends for women in more exposed districts levelled off. Although the GGR was rescinded in January 2021, the impact of these disruptions may be felt for years to come.

Impact of the Trump Administration's Expanded Global Gag Rule Policy on Family Planning Service Provision in Ethiopia.

The Global Gag Rule (GGR) makes non-U.S. nongovernmental organizations (NGOs) ineligible for U.S. Government global health funding if they provide, refer, or promote access to abortion. This study quantitatively examines the impacts of the GGR on family planning service provision in Ethiopia. Using a panel of health facilities (2017-2020), we conduct a pre-post analysis to investigate the overall changes in family planning service provision before and after the policy came into effect in Ethiopia. Our pre-post analyses revealed post-GGR reductions in the proportions of facilities reporting family planning provision through community health volunteers (-5.6, 95% CI [-10.2, -1.0]), mobile outreach visits (-13.1, 95% CI [-17.8, -8.4]), and family planning and postabortion care service integration (-4.8, 95% CI: [-9.1, -0.5]), as well as a 6.1 percentage points increase in contraceptive stock-outs over the past three months (95% CI [-0.6, 12.8]). We further investigate the impacts of the GGR on facilities exposed to noncompliant organizations that did not sign the policy and lost U.S. funding. We do not find any significant additional impacts on facilities in regions more exposed to noncompliant organizations. Overall, while the GGR was slow to fully impact NGOs in Ethiopia, it ultimately resulted in negative impacts on family planning service provision.

An Assessment of Third-Party Reporting of Close Ties to Measure Sensitive Behaviors: The Confidante Method to Measure Abortion Incidence in Ethiopia and Uganda.

Indirect estimation techniques are important tools for measuring sensitive and stigmatized behaviors. This includes third-party reporting methods, which have become increasingly common in the field of abortion measurement, where direct survey approaches notoriously lead to underreporting. This paper provides the first in-depth assessment of one of the most widely used of these techniques in the field of abortion measurement: the confidante method. We outline six key assumptions behind the confidante method and describe how violations of these assumptions can bias resulting estimates. Using data from modules added to the performance monitoring for action surveys in Uganda and Ethiopia in 2018, we compute one-year abortion incidence estimates using the confidante method. We also perform a validation check, using the method to estimate intrauterine device /implant use. Our results revealed implementation problems in both settings. Several of the method's foundational assumptions were violated, and efforts to adjust for these violations either failed or only partially addressed the resulting bias. Our validation check also failed, resulting in a gross overestimate of intrauterine device/implant use. These results have implications more broadly for the potential biases that can be introduced in using third-party reporting of close ties to measure other sensitive or stigmatized behaviors.

Health system capacity for post-abortion care in Java, Indonesia: a signal functions analysis.

BACKGROUND: The quality of obstetric care has been identified as a contributing factor in Indonesia's persistently high level of maternal mortality, and the country's restrictive abortion laws merit special attention to the quality of post-abortion care (PAC). Due to unique health policies and guidelines, in Indonesia, uterine evacuation for PAC is typically administered only by Ob/Gyns practicing in hospitals. METHODS: Using data from a survey of 657 hospitals and emergency obstetric-registered public health centers in Java, Indonesia's most populous island, we applied a signal functions analysis to measure the health system's capacity to offer PAC. We then used this framework to simulate the potential impact of the following hypothetical reforms on PAC capacity: allowing first-trimester uterine evacuation for PAC to take place at the primary care level, and allowing provision by clinicians other than Ob/Gyns. Finally, we calculated the proportion of PAC patients treated using four different uterine evacuation procedures. RESULTS: Forty-six percent of hospitals in Java have the full set of services needed to provide PAC, and PAC capacity is concentrated at the highest-level referral hospitals: 86% of referral hospitals have the full set of services, staffing, and equipment compared to 53% of maternity hospitals and 34% of local hospitals. No health centers are adequately staffed or authorized to offer basic PAC services under Indonesia's current guidelines. PAC capacity at all levels of the health system increases substantially in hypothetical scenarios under which authorization to perform first-trimester uterine evacuation for PAC is expanded to midwives and general physicians practicing in health centers. In 2018, 88% percent of PAC patients were treated using dilation and curettage (D&C). CONCLUSIONS: Offering first-trimester uterine evacuation for PAC in PONEDs and allowing clinicians other than Ob/Gyns to perform this procedure would greatly improve the capacity of Java's health system to serve PAC patients. Increasing the use of vacuum aspiration and misoprostol for PAC-related uterine evacuation would lower the burden of treatment for patients and facilitate the task-shifting efforts needed to expand access to this life-saving service.

An Application of the Confidante Method to Estimate Induced Abortion Incidence in Java, Indonesia.

CONTEXT: Induced abortion is legally restricted and highly stigmatized in Indonesia, and is thus extremely difficult to measure. Indirect methods leveraging women's social networks, such as the Confidante Method, have shown promise in estimating hidden behaviors, including abortion, in similar settings. METHODS: A community-based survey was conducted among 8,696 women aged 15-49 in Java, Indonesia, in November 2018-January 2019. Data were collected via in-person interviews with respondents about their own abortions and those of up to three of their closest confidantes. One-year induced abortion incidence rates per 1,000 women were estimated using a direct-report approach and the Confidante Method. RESULTS: The direct-report abortion rate was 3.4 per 1,000 women in 2018, compared with the Confidante Method rate of 11.3 per 1,000. Among the confidantes of women who reported an abortion in the past five years, the abortion rate was 42.0 per 1,000. Half of the women reported that they had no confidantes with whom they shared private information. Among women reporting an abortion and at least one confidante, 58% had disclosed their abortion to their confidante, indicating that substantial transmission bias was present. CONCLUSIONS: The Confidante Method relies on several assumptions that did not hold in this study. Although the method performed better than the direct-report approach, it underestimated the incidence of abortion in Java. More research is needed to understand how abortion-related information is shared within social networks and to assess the appropriateness of applying the Confidante Method to estimate abortion in a given context.

RESUMEN Contexto: El aborto inducido está restringido legalmente y sumamente estigmatizado en Indonesia y, por lo tanto, es extremadamente difícil de medir. Los métodos indirectos que aprovechan las redes sociales de mujeres, como el método basado en confidentes, han demostrado ser promisorios para estimar comportamientos que se ocultan, incluido el aborto, en entornos similares. Métodos: Entre noviembre de 2018 y enero de 2019, se llevó a cabo una encuesta basada en la comunidad entre 8,696 mujeres en edades de 15 a 49 años en Java, Indonesia. Se recolectaron datos a través de entrevistas presenciales con personas sobre sus propios abortos y los de hasta tres de sus confidentes más cercanas. Se estimaron tasas anuales de incidencia de aborto inducido por 1,000 mujeres mediante el uso del enfoque de informe directo y del método basado en confidentes. Resultados: La tasa de aborto por informe directo fue de 3.4 por 1,000 mujeres en 2018, en comparación con la tasa del método basado en confidentes de 11.3 por 1,000. Entre las personas confidentes de mujeres que reportaron haber tenido un aborto en los últimos cinco años, la tasa de aborto fue de 42.0 por 1,000. La mitad de las mujeres reportaron que no tenían confidentes con quienes compartir su información privada. Entre las mujeres que reportaron haber tenido un aborto y tener al menos una persona confidente, el 58% habían revelado su aborto a su confidente, lo que indica que hubo un importante sesgo de transmisión. Conclusiones: El método basado en confidentes depende de varias suposiciones que no fueron aplicables en este estudio. Aunque el método funcionó mejor que el enfoque de informe directo, subestimó la incidencia del aborto en Java. Es necesario realizar más investigación para comprender la forma en que la información relacionada con el aborto se comparte dentro de las redes sociales, así como para determinar qué tan apropiado es aplicar el método basado en confidentes para estimar la incidencia del aborto en un contexto determinado.

RÉSUMÉ Contexte: L'avortement provoqué est limité par la loi et fait l'objet d'une forte stigmatisation en Indonésie. Il est par conséquent extrêmement difficile d'en mesurer l'incidence. Les méthodes indirectes tirant parti des réseaux sociaux des femmes, comme celle de la « confidente ¼, se sont révélées prometteuses dans l'estimation de comportements cachés, notamment l'avortement, dans des contextes comparables. Méthodes: Une enquête communautaire a été menée auprès de 8 696 femmes âgées de 15 à 49 ans à Java (Indonésie) entre novembre 2018 et janvier 2019. Les données ont été collectées dans le cadre d'entretiens personnels avec les répondantes, concernant leurs propres avortements et ceux d'un maximum de trois de leurs confidentes les plus proches. Les taux d'incidence de l'avortement provoqué d'une année pour 1 000 femmes ont été estimés selon une approche de déclaration directe et par la méthode de la confidente. Résultats: Le taux d'avortement estimé par déclaration directe s'est avéré de 3,4 pour 1 000 femmes en 2018, par rapport à 11,3 pour 1 000 selon la méthode de la confidente. Parmi les confidentes des femmes ayant déclaré un avortement durant les cinq dernières années, le taux s'élevait à 42,0 pour 1 000. La moitié des femmes ont déclaré ne pas avoir de confidentes avec lesquelles elles partageaient une information privée. Parmi les femmes déclarant un avortement et au moins une confidente, 58% avaient divulgué leur avortement à leur confidente, indiquant un biais de transmission considérable. Conclusions: La méthode de la confidente repose sur plusieurs hypothèses non confirmées dans cette étude. Bien qu'ayant produit de meilleurs résultats que l'approche par déclaration directe, elle sous-estime l'incidence de l'avortement à Java. Il convient d'approfondir la recherche pour comprendre les modalités du partage de l'information relative à l'avortement au sein des réseaux sociaux et pour évaluer la pertinence du recours à la méthode de la confidente pour estimer l'incidence de l'avortement dans un contexte donné.

Estimating the Incidence of Induced Abortion in Java, Indonesia, 2018.

CONTEXT: In Indonesia, maternal mortality is high and abortion is restricted. Reliable information on induced abortion is needed; however, the difficulty of measuring abortion in settings where it is legally restricted and highly stigmatized calls for innovation in approaches to measuring abortion incidence. METHODS: The data were from three original surveys conducted in Java among health facilities, knowledgeable informants and women aged 15-49, fielded in April 2018-January 2019. Two methods were used to estimate the one-year induced abortion incidence rate in Java: the standard Abortion Incidence Complications Method (AICM) and a modified AICM. Each method was evaluated on the basis of data quality, and what is known about sexual and reproductive health indicators related to abortion rates, to determine which performed best in measuring abortion incidence in Java. RESULTS: Estimates of complications resulting from induced abortion from knowledgeable informants and the women differed substantially. The modified AICM produced an estimate of 42.5 abortions per 1,000 women aged 15-49, while the standard AICM estimate was lower (25.8 per 1,000). A comparison of the distribution of abortion methods used revealed that knowledgeable informants believed abortion was less safe than indicated by women's reports of their own experiences. Therefore, the standard AICM likely underestimates abortion. CONCLUSIONS: The modified AICM performed better than the standard AICM and indicates that abortion is common in Java. Increased access to contraceptives and high-quality postabortion care is needed. Future research should investigate the safety of abortion, especially with respect to self-managed abortion.

RESUMEN Contexto: La mortalidad materna en Indonesia es alta y el aborto está restringido. Se necesita información confiable sobre el aborto inducido; sin embargo, la dificultad de medir el aborto en entornos donde está restringido legalmente y es fuertemente estigmatizado, requiere esfuerzos de innovación en los enfoques para medir la incidencia del aborto. Métodos: Los datos se obtuvieron de tres encuestas originales realizadas en Java entre instituciones de salud, informantes conocedores del tema y mujeres en edades de 15 a 49 años y que fueron aplicadas entre abril de 2018 y enero de 2019. Se usaron dos métodos para estimar la tasa de incidencia de aborto inducido en un año en Java: el método estándar de estimación de aborto por complicaciones (AICM, por sus siglas en inglés) y el AICM modificado. Cada método se evaluó con base en la calidad de los datos y en lo que se sabe sobre indicadores de salud sexual y reproductiva relacionados con las tasas de aborto, para determinar cuál método se desempeñó mejor en la medición de la incidencia de aborto en Java. Resultados: Las estimaciones de complicaciones derivadas del aborto inducido según informantes conocedores del tema y según las mujeres, difirieron sustancialmente. El AICM modificado produjo una estimación de 42.5 abortos por 1,000 mujeres en edades de 15 a 49 años, mientras que la estimación del AICM estándar fue más baja (25.8 por 1,000). Una comparación de la distribución de los métodos de aborto usados reveló que los informantes conocedores creían que el aborto era menos seguro que lo indicado en los informes de las mujeres basados en sus propias experiencias. Por lo tanto, es probable que el método AICM estándar subestime la incidencia del aborto. Conclusiones: El método AICM modificado funcionó mejor que el AICM estándar e indica que el aborto es una práctica común en Java. Son necesarios un mayor acceso a los anticonceptivos y a una atención postaborto de alta calidad. Las futuras investigaciones deben investigar la seguridad del aborto, especialmente en relación con el aborto autoadministrado.

RÉSUMÉ Contexte: En Indonésie, la mortalité maternelle est élevée et l'avortement est limité par la loi. Il existe un besoin d'information fiable concernant l'avortement provoqué. La difficulté de mesurer l'avortement dans les contextes où il est strictement limité et fortement stigmatisé demande cependant des approches innovantes. Méthodes: Les données proviennent de trois enquêtes initiales menées à Java auprès de structures de santé, de sources bien informées et de femmes âgées de 15 à 49 ans, entre avril 2018 et janvier 2019. Le taux d'incidence de l'avortement provoqué à l'échelle d'une année à Java a été estimé selon deux méthodes: la méthode AICM standard d'évaluation de l'incidence de l'avortement en fonction des complications traitées et une méthode AICM modifiée. Chaque méthode a été évaluée en fonction de la qualité des données et de l'information connue sur les indicateurs de santé sexuelle et reproductive relatifs aux taux d'avortement, afin de déterminer celle qui avait le mieux mesuré l'incidence de l'avortement à Java. Résultats: Les estimations des complications résultant de l'avortement provoqué obtenues des sources informées et des femmes consultées se sont avérées nettement différentes. La méthode AICM modifiée a produit une estimation de 42,5 avortements pour 1 000 femmes âgées de 15 à 49 ans, tandis que la méthode AICM standard produisait une estimation inférieure (25,8 pour 1 000). En comparant la distribution des méthodes d'avortement pratiquées, on a constaté que les sources informées estimaient l'avortement moins sùr que ne l'indiquaient les déclarations des femmes concernant leur propre expérience. Il est dès lors probable que la méthode AICM standard sous-estime l'avortement. Conclusions: La méthode AICM modifiée, plus efficace que la méthode standard, fait état d'une pratique courante de l'avortement à Java. Un meilleur accès à la contraception et à des soins après avortement de qualité est nécessaire. La recherche future devrait se pencher sur la sécurité de l'avortement, en ce qui concerne en particulier les interventions autogérées.

Investigating the early impact of the Trump Administration's Global Gag Rule on sexual and reproductive health service delivery in Uganda.

BACKGROUND: The Global Gag Rule (GGR), reinstated by President Trump in January 2017, makes non-U.S. non-governmental organizations ineligible for U.S. foreign assistance if they provide access to or information about abortion. While evidence suggests previous iterations of the GGR negatively impacted sexual and reproductive health outcomes, no studies have quantitatively assessed the impacts of the Trump administration's GGR. METHODS: We constructed a panel dataset of facilities (76% public) using 2017/2018 Performance Monitoring and Accountability 2020 service delivery point (SDP) surveys in Uganda. Based on information from stakeholder meetings, we classified districts as more or less exposed to the GGR; 45% (N = 34) of study districts were classified as "more exposed", which corresponded to 145 "more exposed" and 142 "less exposed" health facilities in our sample. We assessed changes in provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, engagement with community health workers (CHWs), service integration, and quality of care from 2017 (pre-GGR) to 2018 (post-GGR). Multivariable regression models were estimated, and difference-in-differences impact estimators were determined by calculating predicted probabilities from interaction terms for exposure and survey round. FINDINGS: We observed no immediate impact of the GGR on the provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, service integration, or quality of care. We did observe a significant impact of the policy on the average number of CHWs, with "more exposed" facilities engaging 3.8 fewer CHWs post-GGR (95% CI:-7.31,-0.32). CONCLUSIONS: The reduction in CHWs could reduce contraceptive use and increase unintended pregnancies in Uganda. The lack of other significant findings may not be surprising given the short post-GGR observation window. Rapid organizational responses and stopgap funding from foreign governments may have mitigated any immediate impacts on service delivery in the short term. The true impact may not be felt for many years, as stopgap funding potentially ebbs and service providers adapt to new funding environments.

Evaluating the relationship between binge drinking rates and a replicable measure of U.S. state alcohol policy environments.

Excessive alcohol consumption contributes significantly to premature mortality, injuries and morbidity, and a range of U.S. state policies have been shown to reduce these behaviors. Monitoring state alcohol policy environments is essential, but methodologically challenging given that new laws may be passed (or repealed) each year, resulting in considerable variation across states. Existing measures have not been made public or have only a single year available. We develop a new replicable measure, the state alcohol policy score, for each state and year 2004-2009, that captures the essential features of a state's evidence-based alcohol policies. We evaluate its similarity to two existing alcohol policy measures and validate it by replicating findings from a previous study that used one of those measures to assess its relationship with several binge drinking outcomes. Estimates of the association between one-year lagged state alcohol policy scores and state binge drinking outcomes, obtained from the 2005-2010 Behavioral Risk Factor Surveillance System surveys (n = 440,951, 2010), were produced using Generalized Linear Models that controlled for state and individual-level co-variates, with fixed effects for year and region. We find a 10-percentage point increase in the state alcohol policy score was associated with a 9% lower odds of binge drinking (aOR = 0.91, 95% CI 0.89, 0.92; N = 1,992,086), a result consistent for men, women and for most age and race subgroups. We find that gender gaps in binge drinking behaviors narrowed in states with higher state alcohol policy scores. These results were nearly identical to those found in other studies using different scores obtained with the aid of expert opinions. We conclude that the score developed here is a valid measure that can be readily updated for monitoring and evaluating the variation and impact of state alcohol policies and make available our state scores for the years of the study.

Presence of Counterfeit Marlboro Gold Packs in Licensed Retail Stores in New York City: Evidence From Test Purchases.

BACKGROUND: There are no independent studies measuring the availability of premium brand counterfeit cigarettes in New York City from licensed retailers. METHODS: We forensically analyzed the cigarette packaging of Marlboro Gold (n = 1021) purchased from licensed tobacco retailers in New York City, using ultraviolet irradiation and light microscopy to determine whether they were counterfeit. RESULTS: We find that while only 0.5% (n = 5) of our sample exhibits at least one characteristic synonymous with counterfeit packaging, none of our packs can be conclusively classified as counterfeit. CONCLUSIONS: We do not find any counterfeit Marlboro Gold packs purchased at full price from licensed cigarette retailers throughout New York City. Future research using test purchases should include other venues (eg, street and online) and specifically ask for discounts to ascertain the overall presence of counterfeit cigarettes. IMPLICATIONS: This is the first study to independently measure the availability of counterfeit cigarette packs purchased at full price from licensed retailers in New York City. We find that none of the Marlboro Gold packs purchased from licensed cigarette retailers are counterfeit.

Improving Hepatitis C Identification: Technology Alone Is Not the Answer.

An estimated 3 to 5 million Americans are chronically infected with hepatitis C virus (HCV), and approximately 75% of those persons were born between 1945 and 1965 (the so-called baby boomer generation). Because of the largely asymptomatic nature of HCV, up to 50% of those infected are unaware of their disease. Risk-based testing has been largely ineffective. Based on prevalence data, the Centers for Disease Control and Prevention and other organizations recommend a onetime HCV antibody test for all baby boomers. However, uptake of this recommendation requires significant changes in clinical practice for already busy primary care clinicians. We studied the effectiveness of a quality improvement initiative based on continuous audit and feedback combined with education for improving testing in alignment with guidelines; the control group was a cohort of clinicians whose only reminder was an institution-wide electronic health record prompt. Our data show improved testing rates among all clinician groups, but more significant improvement occurred among providers who received continuous feedback about their clinical performance coupled with education.

The Relationship Between Social Support, HIV Serostatus, and Perceived Likelihood of Being HIV Positive Among Self-Settled Female, Foreign Migrants in Cape Town, South Africa.

Female cross-border migrants experience elevated risks for HIV, and migrants in South Africa may face additional risks due to the country's underlying HIV prevalence. These risks may be mitigated by the receipt of social support. A behavioral risk-factor survey was administered using respondent-driven sampling. Multivariable regression models assessed the relationships between social support and two HIV outcomes: HIV serostatus and perceived HIV status. Low social support was not significantly associated with HIV status (aOR = 1.03, 95 % CI 0.43-2.46), but was significantly related to a perception of being HIV positive (aPR = 1.36, 95 % CI 1.04-1.78). Age, marital status, and education level were significantly associated with HIV serostatus. Illegal border-crossing, length of time in South Africa, anal sex, and transactional sex were significantly associated with aperception of being HIV positive. Future research should investigate how HIV risks and the receipt of social support change throughout the migration process.

HIV Prevalence and Risk Factors Among Male Foreign Migrants in Cape Town, South Africa.

While migration has been shown to be a risk factor for HIV, variation in HIV prevalence by subgroups of migrants needs further exploration. This paper documents the HIV prevalence and key characteristics among male foreign migrants in Cape Town, South Africa and the effectiveness of respondent-driven sampling (RDS) to recruit this population. Participants in this cross-sectional study completed a behavioral risk-factor questionnaire and provided a dried blood sample for HIV analysis. Overall HIV prevalence was estimated to be 8.7 % (CI 5.4-11.8) but varied dramatically by country of origin. After adjusting for country of origin, HIV sero-positivity was positively associated with older age (p = 0.001), completing high school (p = 0.025), not having enough money for food (p = 0.036), alcohol use (p = 0.049), and engaging in transactional sex (p = 0.022). RDS was successful in recruiting foreign migrant men. A better understanding of the timing of HIV acquisition is needed to design targeted interventions for migrant men.

Engaging Caregivers in School-Based Obesity Prevention Initiatives in a Predominantly Latino Immigrant Community: A Qualitative Analysis.

OBJECTIVES: To explore caregiver perceptions of, and barriers and facilitators to, their involvement in school-based obesity prevention programs in underserved Latino immigrant communities. METHODS: Focus groups discussions were conducted with caregivers (n = 42) at 7 elementary schools with an academic partnership-based obesity prevention program. Thematic analysis was used to identify key findings in the data. RESULTS: Caregivers described their role as (1) learners of new and often complex health information using their children as primary messengers and (2) champions within their homes in which healthier choices are assimilated. Barriers to involvement included lack of time, financial pressures, unhealthy family practices, and concern that attempts to engage peers would be perceived as intrusive. Facilitators included assurance that stigmatizing health issues would be addressed with sensitivity. CONCLUSIONS AND IMPLICATIONS: Caregiver involvement in obesity prevention may be fostered by transmitting information through children, addressing cultural barriers, and avoiding potentially stigmatizing approaches to delivering health messages.