Perils and possibilities of health exception laws: A narrative review.

Forty-seven of the 203 countries with abortion laws detailed by the Center for Reproductive Rights have a health exception (HE) clause, inconsistent in both wording and implementation, even within countries. This narrative review sought to determine the understanding and implementation of the legally permissible HE in different countries, or states, to provide clarification and guidance for strategies that will maximize permitted access to safe abortion within the law and avoid undue delays that harm the lives and health of women and their families. A multimethod approach was used. The literature search for countries with HE laws, including physical, mental, and social health, and exceptions for threat to life, rape, incest, and fetal anomaly, returned sparse results. The review of emblematic cases that had reached regional courts on the grounds of human rights violation for failure to obtain legal abortion under the country's HE clause included some examples qualifying on multiple grounds. We interviewed 15 physician advocates from 14 countries about use of the HE in their countries. Informants from Latin America interpreted the HE to refer to physical, psychological, and social health. HE laws are common but confusing, with significant opportunities to improve access through clarification and implementation. Where multiple grounds permit ending a pregnancy, the least onerous exception for the patient is the most ethical. Examples of progress in Colombia and Ghana demonstrate successful approaches to broader HE implementation.

The role of healthcare providers in expanding legal abortion: Qualitative insights from Argentina, Ireland, and South Korea.

Abortion laws are key in creating an enabling environment that facilitates the advancement of people's sexual and reproductive health and rights. Around 50 countries have liberalized their abortion laws in the last decades by adding new grounds allowing abortion. The road toward the expansion of legal abortion is a long, highly sensitive, and difficult process. The specific role of healthcare providers in influencing abortion law reforms has been scarcely studied. With the objective to better understand their (potential) roles, a qualitative study was conducted in 2021 focusing on three countries that had recently liberalized their abortion regulations: Argentina, South Korea, and Ireland. For each country, key informant interviews were conducted with actors in advocacy for legal change, the majority with healthcare providers. The study results indicate that healthcare providers can contribute to the expansion of legal abortion through their influence on public and legal debates. Healthcare providers were found to be scientifically credible and trustworthy. Their voice and argumentation counteracted anti-rights arguments and addressed information gaps, by providing specific clinical experiences and medical information. Healthcare providers amplified women's experiences through their testimonies and had entry points within governmental bodies, which facilitated their advocacy. These healthcare providers often functioned as individual operating obstetrician/gynecologists or general practitioners who were engaged in networks of health professionals or had previous advocacy experience. In a global context of social and political contention around abortion, extending the engagement of healthcare providers in law and policy deliberation on abortion appears to be useful. This requires recognizing the diversity of roles that healthcare providers can take up, creating a safe environment in which they can operate, equipping them with skills that go beyond the medical expert role and facilitating strategic partnerships that seek complementarity between multiple stakeholders, building on the uniqueness of each stakeholder's expertise.

Restrictive points of entry into abortion care in Ireland: a qualitative study of expectations and experiences with the service.

This article focuses on access to early medical abortion care under Section 12 of the Health (Regulation of Termination of Pregnancy) Act 2018, in Ireland and identifies existing barriers resulting from gaps in current policy design. The article draws primarily on qualitative interviews with 24 service users, 20 primary healthcare providers in the community and 27 key informants, including from grassroots groups that work with women from different migrant communities, to examine service users' experiences accessing early medical abortions on request up to 12 weeks gestation. The interviews were part of a wider mixed-methods study from 2020-2021 examining the barriers and facilitators to the implementation of abortion policy in Ireland. Our findings highlight care seekers' experiences with the GP-led service provision, including delays, facing non-providers, the mandatory three-day waiting period, and oversubscribed women's health and family planning clinics. Our findings also highlight the compounding challenges for migrants and additional barriers posed by the geographical distribution of the service and the 12-week gestational limit. Finally, it focuses on the remaining challenges for racialised and other marginalised groups. In order to provide a "thick description" of women's lives and the complexity of their experiences with abortion services in Ireland, we also present two narrative vignettes of service users, and their experiences with delays and navigating the healthcare system as migrants. To this effect, this article applies a reproductive justice framework to the results to highlight the compounding effects of these barriers on people located along multiple axes of social inequality.

Associations between contraceptive availability and rate of subsequent legal abortions in Colombia: A historical cohort analysis.

OBJECTIVE: To describe factors associated with subsequent abortions in Colombia and evaluate whether high-efficacy contraceptive availability (IUD) post-index abortion was associated with higher efficacy contraceptive initiation and fewer subsequent abortions within 2 years. METHODS: The study population comprised patients aged 15-44 years who underwent index abortion in 2017 at four clinics in Bogotá, Colombia. Using charts, we conducted a retrospective cohort study with 2-year follow-up (2017-2019) after the index abortion for outcomes of contraceptive initiation and subsequent abortion. We evaluated associations between demographic or clinical characteristics and outcomes using Pearson chi-square and multivariate logistic regression. RESULTS: Of 9175 patients with index abortion, 3409 (37.2%) initiated an intrauterine device (IUD) and 467 (5.1%) had a subsequent abortion within the study period (2017-2019). IUD availability (adjusted odds ratio [aOR], 1.64; 95% confidence interval [CI], 1.39-1.93) and insurance use (aOR, 5.03; 95% CI, 4.37-5.78) were associated with high-efficacy contraceptive initiation; medication abortion was inversely associated (aOR, 0.24; 95% CI, 0.22-0.27). Initiation of no (aOR, 4.94; 95% CI, 3.59-6.80) or moderate-efficacy (injection: aOR, 4.21 [95% CI, 3.14-5.62]; oral contraceptive pill: aOR, 4.60 [95% CI, 3.21-6.59]) methods were associated with subsequent abortion. CONCLUSION: Subsequent abortion is inversely associated with initiated postabortion contraceptive efficacy, which is modifiable on a systems level by improving access to effective postabortion contraception.

Abortion policy implementation in Ireland: successes and challenges in the establishment of hospital-based services.

Objective: To describe successes and highlight remaining challenges in the establishment of hospital-based abortion services after legal change in the Republic of Ireland. Methods: We conducted a mixed-methods study on the implementation of abortion policy in Ireland. In this manuscript, we present the results from a qualitative analysis of in-depth interviews conducted with hospital-based providers, service users, and key informants. We used Dedoose software to conduct a thematic analysis of the data. Results: We report findings from interviews with 28 obstetrician gynecologists, midwives, psychiatrists, anesthesiologists, and nurses; a subset of 7 service users who sought care in hospitals; and 27 key informants. In this analysis, we describe how key themes that pertain to information, capacity and power, facilitated and hindered the implementation of hospital-based abortion services. We found that individual champions are key to establishing the service, but their motivation is not always sufficient to integrate abortion into existing clinical services, and conscientious objection is a persistent barrier to expanding abortion services. The main challenges highlighted here are lack of abortion provision at some hospitals and limited access to surgical abortion at most hospitals due to provider-level, logistical, and infrastructure barriers. Conclusions: This study presents new information on how abortion policy is implemented on the ground in hospital settings. Its findings can inform public health officials and providers in Ireland and other countries wishing to establish abortion services.

Information flow as reproductive governance. Patient journey analysis of information barriers and facilitators to abortion care in the republic of Ireland.

Background: Information flow - information communication and transmission pathways and practices within healthcare systems - impacts patient journeys. Historically, regulating information flow was a key technology of reproductive governance in the Republic of Ireland. Pre-2018, law and the State sustained informational barriers to and through abortion care in Ireland. An expanded abortion service was implemented in January 2019. Method: Patient Journey Analysis (PJA) interrogates informational facilitators and barriers to/through post-2019 abortion care in Ireland. We focus on information flow at the interfaces between the 'public' sphere and 'point of entry', 'point of entry' and primary care, and primary and secondary care. Materials: The paper uses data from a mixed-method study. A tool for assessing online abortion service information (ASIAT), desktop research, and qualitative data from 108 in-depth interviews with providers, policy-makers, advocacy groups, and service users informed the analysis. Results: Abortion patient journeys vary. Information flow issues, e.g. communication of how to access services, referral systems, and information handover, act as barriers and facilitators. Barriers increase where movement from primary to secondary is needed. Applications: The article identifies good practice in information flow strategy, as well as areas for development. It illustrates the significance of information flow in accomplishing reproductive governance.

Abortion policy implementation in Ireland: Lessons from the community model of care.

BACKGROUND: In 2018, the right to lawful abortion in the Republic of Ireland significantly expanded, and service provision commenced on 1 January, 2019. Community provision of early medical abortion to 9 weeks plus 6 days gestation delivered by General Practitioners constitutes the backbone of the Irish abortion policy implementation. We conducted a study in 2020-2021 to examine the barriers and facilitators of the Irish abortion policy implementation. METHODS: We collected data using qualitative in-depth interviews (IDIs) which were conducted in-person or remotely. We coded and analysed interview transcripts following the grounded theory approach. RESULTS: We collected 108 IDIs in Ireland from May 2020 to March 2021. This article draws on 79 IDIs with three participant samples directly relevant to the community model of care: (a) 27 key informants involved in the abortion policy development and implementation representing government healthcare administration, medical professionals, and advocacy organisations, (b) 22 healthcare providers involved in abortion provision in community settings, and (c) 30 service users who sought abortion services in 2020. Facilitators of community-based abortion provision have been: a collaborative approach between the Irish government and the medical community to develop the model of care, and strong support systems for providers. The MyOptions helpline for service users is a successful national referral model. The main barriers to provision are the mandatory 3-day wait, unclear or slow referral pathways from primary to hospital care, barriers for migrants, and a shortage and incomplete geographic distribution of providers, especially in rural areas. CONCLUSIONS: We conclude that access to abortion care in Ireland has been greatly expanded since the policy implementation in 2019. The community delivery of care and the national helpline constitute key features of the Irish abortion policy implementation that could be duplicated in other contexts and countries. Several challenges to full abortion policy implementation remain.

Integrating self-managed medication abortion with medical care.

In this commentary, we distill key messages from a new framework for self-managed medication abortion developed by Global Doctors for Choice. Since Global Doctors for Choice supports doctors working in different contexts around the world, the document also highlights clinical concerns and advocacy opportunities for clinicians in both low- and high-resource settings, and in places with varying legal and administrative restrictions on abortion.

Attitudes and experiences with termination of pregnancy among Irish obstetrics & gynaecology trainees in the context of recent legal change: A survey study.

OBJECTIVE: This study examines Irish obstetrics and gynaecology trainees' experiences with and opinions of termination of pregnancy (ToP) after legal change. STUDY DESIGN: We invited obstetrics & gynaecology non-consultant hospital doctors (NCHDs) to participate in a web-based survey through a professional e-mail listserv. We conducted descriptive statistical analyses of responses using Stata SE Version 16. RESULTS: A total of 102/202 (50.5%) trainees responded to the survey. Of these, 61.8% believed that ToP should be allowed on request up to 12 weeks and in limited circumstances thereafter (in line with current law), and 19.6% believe ToP should be allowed on request even after 12 weeks. Knowledge about the abortion law was high (70.6% achieved a perfect knowledge score). Since the new law came into effect, 61.8% of trainees reported participation in abortion care, though only 25.5% had performed surgical procedures. More than 75% of respondents would like to receive more training in all clinical skills related to ToP. In the future, 67.6% of respondents would be willing to provide TOP in all circumstances allowed by law. CONCLUSION: Irish obstetrics & gynaecology NCHDs are generally supportive of the legislation. Few trainees have performed surgical abortions, and most would like to receive additional clinical training related to ToP.

Implementing and expanding safe abortion care: An international comparative case study of six countries.

We conducted a comparative case study-based investigation of health sector strategies that were useful in expanding or establishing new abortion services. We selected geographically diverse countries from across the human development index if they had implemented new abortion laws, or changed interpretations of existing laws or policies, within the past 15 years (Colombia, Ethiopia, Ghana, Portugal, South Africa, and Uruguay). Factors facilitating the expansion of services include use of a public health frame, situating abortion as one component of a comprehensive reproductive health package, and including country-based health and women's rights organizations, medical and other professional societies, and international agencies and nongovernment organizations in the design and rollout of services. Task sharing and the use of techniques that do not require much infrastructure, such as manual vacuum aspiration and medical abortion, are important for rapid establishment of services, especially in low-resource settings. Political will emerged as the key factor in establishing or expanding access to safe abortion services.

Implementing safe abortion in Ghana: "We must tell our story and tell it well".

In the first years of the new century, the Ministry of Health/Ghana Health Service determined to reduce abortion-associated morbidity and mortality by increasing access to safe care. This was accomplished by interpreting Ghana's restrictive law so that more women qualified for legal services; by framing this effort in public health terms; by bundling abortion together with contraception and postabortion care in a comprehensive package of services; and by training new cadres of health workers to provide manual vacuum aspiration and medical abortion. The Ministry of Health/Ghana Health Service convened medical and midwifery societies, nongovernmental organizations, and bilateral agencies to implement this plan, while retaining the leadership role. However, because of provider shortages, aggravated by conscientious objection, and because many still do not understand when abortion can be legally provided, some women still resort to unsafe care. Nonetheless, Ghana provides an example of the critical role of political will in redressing harms from unsafe abortion.

Conscientious objection to abortion provision: Why context matters.

Conscientious objection to abortion - a clinician's refusal to perform abortions because of moral or religious beliefs - is a limited right, intended to protect clinicians' convictions while maintaining abortion access. This paper argues that conscientious objection policies and debates around the world generally do not take into account the social, political, and economic pressures that profoundly influence clinicians who must decide whether to claim objector status. Lack of clarity about abortion policies, high workload, low pay, and stigma towards abortion providers can discourage abortion provision. As the only legal way to refuse to provide abortions that are permitted by law, conscientious objection can become a safety valve for clinicians under pressure and may be claimed by clinicians who do not have moral or religious objections. Social factors including stigma also shape how stakeholders and policy-makers approach conscientious objection. To appropriately limit the scope of conscientious objection and make protection of conscience more meaningful, more information is needed about how conscientious objection is practised. Additionally, abortion trainings should include information about conscientious objection and its limits, reproductive rights, and creating an enabling environment for abortion provision. Policy-makers and all stakeholders should also focus on creating an enabling environment and reducing stigma.

Prevalence of conscientious objection to legal abortion among clinicians in northern Ghana.

OBJECTIVE: To assess the prevalence of conscientious objection (CO), motivations, knowledge of Ghana's abortion law, attitudes, and behaviors toward abortion provision among medical providers in northern Ghana, and measures to regulate CO. METHODS: Between June and November 2015, the present cross-sectional survey-based descriptive study measured prevalence, knowledge, and attitudes about CO among 213 eligible health practitioners who were trained in abortion provision and working in hospital facilities in northern Ghana. Results were stratified by facility ownership and provider type. RESULTS: Approximately half (94/213, 44.1%) of trained providers reported that they were currently providing abortions. The overall prevalence of self-identified and hypothetical objection was 37.9% and 33.8%, respectively. Among 87 physicians, 37 (42.5%) and 39 (44.8%) were categorized as self-identified and hypothetical objectors, respectively. Among 126 midwives, nurses, and physician assistants, 43 (34.7%) and 33 (26.2%) were coded as self-identified and hypothetical objectors, respectively. A high proportion of providers reported familiarity with Ghana's abortion law and supported regulation of CO. CONCLUSION: CO based on moral and religious grounds is prevalent in northern Ghana. Providers indicated an acceptance of policies and guidelines that would regulate its application to reduce the burden that CO poses for women seeking abortion services.

Regulation of Conscientious Objection to Abortion: An International Comparative Multiple-Case Study.

Since abortion laws were liberalized in Western Europe, conscientious objection (CO) to abortion has become increasingly contentious. We investigated the efficacy and acceptability of laws and policies that permit CO and ensure access to legal abortion services. This is a comparative multiple-case study, which triangulates multiple data sources, including interviews with key stakeholders from all sides of the debate in England, Italy, Norway, and Portugal. While the laws in all four countries have similarities, we found that implementation varied. In this sample, the ingredients that appear necessary for a functional health system that guarantees access to abortion while still permitting CO include clarity about who can object and to which components of care; ready access by mandating referral or establishing direct entry; and assurance of a functioning abortion service through direct provision or by contracting services. Social attitudes toward both objection and abortion, and the prevalence of CO, additionally influence the degree to which CO policies are effectively implemented in these cases. England, Norway, and Portugal illustrate that it is possible to accommodate individuals who object to providing abortion, while still assuring that women have access to legal health care services.

Conscientious objection to abortion and reproductive healthcare: a review of recent literature and implications for adolescents.

PURPOSE OF REVIEW: Conscientious objection to reproductive healthcare (refusal to perform abortion, assisted reproductive technologies, prenatal diagnosis, contraception, including emergency contraception and sterilization, etc.) has become a widespread global phenomenon and constitutes a barrier to these services for many women. Adolescents are a particularly vulnerable group because some providers object to specific aspects of their reproductive healthcare because of their status as minors. RECENT FINDINGS: Recent peer-reviewed publications concerning conscientious objection address provider attitudes to abortion and emergency contraception, ethical arguments against conscientious objection, calls for clarification of the current laws regarding conscientious objection, legal case commentaries, and descriptions of the country-specific impact of policies in Russia and Italy. SUMMARY: Conscientious objection is understudied, complicated, and appears to constitute a barrier to care, especially for certain subgroups, although the degree to which conscientious objection has compromised sexual and reproductive healthcare for adolescents is unknown. Physicians are well positioned to support individual conscience while honoring their obligations to patients and to medical evidence.

Conscientious objection and refusal to provide reproductive healthcare: a White Paper examining prevalence, health consequences, and policy responses.

BACKGROUND: Global Doctors for Choice-a transnational network of physician advocates for reproductive health and rights-began exploring the phenomenon of conscience-based refusal of reproductive healthcare as a result of increasing reports of harms worldwide. The present White Paper examines the prevalence and impact of such refusal and reviews policy efforts to balance individual conscience, autonomy in reproductive decision making, safeguards for health, and professional medical integrity. OBJECTIVES AND SEARCH STRATEGY: The White Paper draws on medical, public health, legal, ethical, and social science literature published between 1998 and 2013 in English, French, German, Italian, Portuguese, and Spanish. Estimates of prevalence are difficult to obtain, as there is no consensus about criteria for refuser status and no standardized definition of the practice, and the studies have sampling and other methodologic limitations. The White Paper reviews these data and offers logical frameworks to represent the possible health and health system consequences of conscience-based refusal to provide abortion; assisted reproductive technologies; contraception; treatment in cases of maternal health risk and inevitable pregnancy loss; and prenatal diagnosis. It concludes by categorizing legal, regulatory, and other policy responses to the practice. CONCLUSIONS: Empirical evidence is essential for varied political actors as they respond with policies or regulations to the competing concerns at stake. Further research and training in diverse geopolitical settings are required. With dual commitments toward their own conscience and their obligations to patients' health and rights, providers and professional medical/public health societies must lead attempts to respond to conscience-based refusal and to safeguard reproductive health, medical integrity, and women's lives.