The Shift From Criminalization to Legalization of Abortion in Argentina.

This Viewpoint discusses passage and implementation of Law 27.610, which legalized abortion in Argentina under certain circumstances, and examines the ongoing clinical issues and legal challenges to the law.

Key drivers of fertility levels and differentials in India, at the national, state and population subgroup levels, 2015-2016: An application of Bongaarts' proximate determinants model.

OBJECTIVES: The transition to small family size is at an advanced phase in India, with a national TFR of 2.2 in 2015-16. This paper examines the roles of four key determinants of fertility-marriage, contraception, abortion and postpartum infecundability-for India, all 29 states and population subgroups. METHODS: Data from the most recent available national survey, the National Family Health Survey, conducted in 2015-16, were used. The Bongaarts proximate determinants model was used to quantify the roles of the four key factors that largely determine fertility. Methodological contributions of this analysis are: adaptations of the model to the Indian context; measurement of the role of abortion; and provision of estimates for sub-groups nationally and by state: age, education, residence, wealth status and caste. RESULTS: Nationally, marriage is the most important determinant of the reduction in fertility from the biological maximum, contributing 36%, followed by contraception and abortion, contributing 24% and 23% respectively, and post-partum infecundability contributed 16%. This national pattern of contributions characterizes most states and subgroups. Abortion makes a larger contribution than contraception among young women and better educated women. Findings suggest that sterility and infertility play a greater than average role in Southern states; marriage practices in some Northeastern states; and male migration for less-educated women. The absence of stronger relationships between the key proximate fertility determinants and geography or socio-economic status suggests that as family size declined, the role of these determinants is increasingly homogenous. CONCLUSIONS: Findings argue for improvements across all states and subgroups, in provision of contraceptive care and safe abortion services, given the importance of these mechanisms for implementing fertility preferences. In-depth studies are needed to identify policy and program needs that depend on the barriers and vulnerabilities that exist in specific areas and population groups.

Trends of Selective Fetal Reduction and Selective Termination in Multiple Pregnancy, in England and Wales: a Cross-Sectional Study.

Selective abortion was shown to be increasingly common in England and Wales over a 9-year period, occurring most frequently as twin to singleton reductions in the 1st trimester. We analysed the trends in selective abortion (SA) in multiple pregnancies in England and Wales between 2009 and 2018. This is a cross-sectional study looking at 1143 women with multiple pregnancies in England and Wales undergoing SA. There were a total of 1143 cases of SA between 2009 and 2018 in England and Wales, representing 0.07% of total abortions. There has been a steady increase in cases, from 90 in 2009 to 131 in 2018, with 82.3% justified under ground E of The Abortion Act 1967. The majority of SAs were carried out at 13-19 weeks gestation, and intracardiac injection of potassium chloride was the most prevalent method (75%). Twin to singleton reductions accounted for 59%, the most common form of SAs. Over half of all cases (59%) were performed in women aged 30-39 years, and 84% of all women were of White ethnicity. SA has been an option available for couples diagnosed with multiple pregnancy, especially when there are discordant anomalies. Although SA may decrease multiple pregnancy-related complications, preventative methods must be championed.

Association of Travel Distance to Nearest Abortion Facility With Rates of Abortion.

Importance: Travel distance to abortion services varies widely in the US. Some evidence shows travel distance affects use of abortion care, but there is no national analysis of how abortion rate changes with travel distance. Objective: To examine the association between travel distance to the nearest abortion care facility and the abortion rate and to model the effect of reduced travel distance. Design, Setting, and Participants: This cross-sectional geographic analysis used 2015 data on abortions by county of residence from 1948 counties in 27 states. Abortion rates were modeled using a spatial Poisson model adjusted for age, race/ethnicity, marital status, educational attainment, household poverty, nativity, and state abortion policies. Abortion rates for 3107 counties in the 48 contiguous states that were home to 62.5 million female residents of reproductive age (15-44 years) and changes under travel distance scenarios, including integration into primary care (<30 miles) and availability of telemedicine care (<5 miles), were estimated. Data were collected from April 2018 to October 2019 and analyzed from December 2019 to July 2020. Exposures: Median travel distance by car to the nearest abortion facility. Main Outcomes and Measures: US county abortion rate per 1000 female residents of reproductive age. Results: Among the 1948 counties included in the analysis, greater travel distances were associated with lower abortion rates in a dose-response manner. Compared with a median travel distance of less than 5 miles (median rate, 21.1 [range, 1.2-63.6] per 1000 female residents of reproductive age), distances of 5 to 15 miles (median rate, 12.2 [range, 0.5-23.4] per 1000 female residents of reproductive age; adjusted coefficient, -0.05 [95% CI, -0.07 to -0.03]) and 120 miles or more (median rate, 3.9 [range, 0-12.9] per 1000 female residents of reproductive age; coefficient, -0.73 [95% CI, -0.80 to -0.65]) were associated with lower rates. In a model of 3107 counties with 62.5 million female residents of reproductive age, 696 760 abortions were estimated (mean rate, 11.1 [range, 1.0-45.5] per 1000 female residents of reproductive age). If abortion were integrated into primary care, an additional 18 190 abortions (mean rate, 11.4 [range, 1.1-45.5] per 1000 female residents of reproductive age) were estimated. If telemedicine were widely available, an additional 70 920 abortions were estimated (mean rate, 12.3 [range, 1.4-45.5] per 1000 female residents of reproductive age). Conclusions and Relevance: These findings suggest that greater travel distances to abortion services are associated with lower abortion rates. The results indicate which geographic areas have insufficient access to abortion care. Modeling suggests that integrating abortion into primary care or making medication abortion care available by telemedicine may decrease unmet need.

From Embryotomy to Cesarean: Changes in Obstetric Operatory Techniques in Nineteenth- and Twentieth-Century Urban Brazil.

This article traces the historical processes by which Brazil became a world leader in cesarean sections. It demonstrates that physicians changed their position toward and use of different obstetric surgeries, in particular embryotomies and cesarean sections, over the course of the nineteenth and twentieth centuries. The authors demonstrate that Catholic obstetricians, building upon both advancements in cesarean section techniques and new civil legislation that gave some personhood to fetuses, began arguing that fetal life was on par with its maternal counterpart in the early twentieth century, a shift that had a lasting impact on obstetric practice for decades to come. In the second half of the twentieth century, cesarean sections proliferated in clinical practice, but abortions remained illegal. Most importantly, women remained patients to be worked on rather than active participants in their reproductive lives.

Greasing the wheels: The impact of COVID-19 on US physician attitudes and practices regarding medication abortion.

OBJECTIVE: To explore US provider perspectives about self-sourced medication abortion and how their attitudes and clinic practices changed in the context of the COVID-19 pandemic. STUDY DESIGN: We conducted a multi-method study of survey and interview data. We performed 40 baseline interviews and surveys in spring 2019 and 36 follow-up surveys and ten interviews one year later. We compared pre- and post-Likert scale responses of provider views on the importance of different aspects of standard medication abortion assessment and evaluation (e.g., related to ultrasounds and blood-typing). We performed content analysis of the follow-up interviews using deductive-inductive analysis. RESULTS: Survey results revealed that clinics substantially changed their medication abortion protocols in response to COVID-19, with more than half increasing their gestational age limits and introducing telemedicine for follow-up of a medication abortion. Interview analysis suggested that physicians were more supportive of self-sourced medication abortion in response to changing clinic protocols that decreased in-clinic assessment and evaluation for medication abortion, and as a result of physicians' altered assessments of risk in the context of COVID-19. Having evidence already in place that supported these practice changes made the implementation of new protocols more efficient, while working in a state with restrictive abortion policies thwarted the flexibility of clinics to adapt to changes in standards of care. CONCLUSION: This exploratory study reveals that the COVID-19 pandemic has altered clinical assessment of risk and has shifted practice towards a less medicalized model. Further work to facilitate person-centered abortion information and care can build on initial modifications in response to the pandemic. IMPLICATIONS: COVID-19 has shifted clinician perception of risk and has catalyzed a change in clinical protocols for medication abortion. However, state laws and policies that regulate medication abortion limit physician ability to respond to changes in risk assessment.

Changes to medication abortion clinical practices in response to the COVID-19 pandemic.

OBJECTIVES: To document medication abortion clinical practice changes adopted by providers in response to the COVID-19 pandemic. STUDY DESIGN: Longitudinal descriptive study, comprised of three online surveys conducted between April to December, 2020. We recruited sites from email lists of national abortion and family planning organizations. RESULTS: Seventy-four sites opted to participate. We analyzed 55/74 sites (74%) that provided medication abortion and completed all three surveys. The total number of abortion encounters reported by the sites remained consistent throughout the study period, though medication abortion encounters increased while first-trimester aspiration abortion encounters decreased. In response to the COVID-19 pandemic, sites reduced the number of in-person visits associated with medication abortion and confirmation of successful termination. In February 2020, considered prepandemic, 39/55 sites (71%) required 2 or more patient visits for a medication abortion. By April 2020, 19/55 sites (35%) reported reducing the total number of in-person visits associated with a medication abortion. As of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits. CONCLUSIONS: Sites quickly adopted protocols incorporating practices that are well-supported in the literature, including forgoing Rh-testing and pre-abortion ultrasound in some circumstances and relying on patient report of symptoms or home pregnancy tests to confirm successful completion of medication abortion. Importantly, these practices reduce face-to-face interactions and the opportunity for virus transmission. Sustaining these changes even after the public health crisis is over may increase patient access to abortion, and these impacts should be evaluated in future research. IMPLICATIONS STATEMENT: Medication abortion serves a critical function in maintaining access to abortion when there are limitations to in-person clinic visits. Sites throughout the country successfully and quickly adopted protocols that reduced visits associated with the abortion, reducing in-person screenings, relying on telehealth, and implementing remote follow-up.

Experiences of women seeking post-abortion care services in a Regional Hospital in Ghana.

INTRODUCTION: Abortions remain one of the highest contributors to maternal deaths in Ghana. In 2003, a policy on post-abortion care was introduced to help reduce abortion-related mortality and morbidity. However, depending on the method of pregnancy termination; women encounter varying experiences. This study examines the experiences of women seeking post-abortion care services in a Regional Hospital in Ghana. MATERIALS AND METHODS: In-depth interview technique was used to collect data from 20 purposively selected post-abortion care clients at the Volta Regional Hospital. Data were analysed manually using a qualitative content analysis technique. RESULTS: The study found that medical abortion was the main method of pregnancy termination used by women who participated in the study to induce abortion. Spontaneous abortion, however, was attributed mainly to engaging in activities that required the use of excessive energy and travelling on bad roads by pregnant women. The study also revealed that, women do not seek early post-abortion care services due to stigma and poverty. CONCLUSIONS: We found that severity of pain from complications, stigma and financial constraints were factors that influenced women's decision to seek post-abortion care services. Our findings also suggest that women who experienced spontaneous abortion mainly received financial and emotional support from partners and other family members. To encourage women to seek early post-abortion care services, the Ministry of Health and the Ghana Health Service should take pragmatic steps to educate women on the dangers associated with delay in seeking post-abortion care services and the factors that expose women to spontaneous abortions.

The future of abortion is now: Mifepristone by mail and in-clinic abortion access in the United States.

The COVID-19 pandemic disrupted health care delivery in all aspects of medicine, including abortion care. For 6 months, the mifepristone Risk Evaluation and Mitigation Strategy (REMS) was temporarily blocked, allowing for the remote provision of medication abortion. Remote medication abortion may become a dominant model of care in the future, either through the formal health system or through self-sourced, self-managed abortion. Clinics already face pressure from falling abortion rates and excessive regulation and with a transition to remote abortion, may not be able to sustain services. Although remote medication abortion improves access for many, those who need or want in-clinic care such as people later in pregnancy, people for whom abortion at home is not safe or feasible, or people who are not eligible for medication abortion, will need comprehensive support to access safe and appropriate care. To understand how we may adapt to remote abortion without leaving people behind, we can look outside of the U.S. to become familiar with emerging and alternative models of abortion care.

Trends in missing females at birth in India from 1981 to 2016: analyses of 2·1 million birth histories in nationally representative surveys.

BACKGROUND: Half of the world's missing female births occur in India, due to sex-selective abortion. It is unknown whether selective abortion of female fetuses has changed in recent years across different birth orders. We sought to document the trends in missing female births, particularly among second and third children, at national and state levels. METHODS: We examined birth histories from five nationally representative household surveys (National Family Health Surveys 1-4 and District Level Household Survey 2) to compute the conditional sex ratio (defined as the number of girls born per 1000 boys depending on previous birth sex) in India during 1981-2016. We estimated decadal variation in conditional sex ratio for 1987-96, 1997-2006, and 2007-16, and quantified trends in the numbers of missing female births for the states constituting >95% of India's population, as well as in 5-year intervals for each survey round. We used multivariate logistic regression to calculate the odds ratio of a second (or third) girl depending on the sex of the earlier child (or children), adjusting for education, wealth, religion, caste, and place of residence. FINDINGS: We assessed 2·1 million birth histories across the five surveys. Applying the conditional sex ratios from the surveys to national births, we found that 13·5 million female births were missing during the three decades of observation (1987-2016), on the basis of a natural sex ratio of 950 girls per 1000 boys. Missing female births increased from 3·5 million in 1987-96 to 5·5 million in 2007-16. Contrasting the conditional sex ratio from the first decade of observation (1987-96) to the last (2007-16) showed worsening for the whole of India and almost all states, among both birth orders. Punjab, Haryana, Gujarat, and Rajasthan had the most skewed sex ratios, comprising nearly a third of the national totals of missing second-born and third-born females at birth. From about 1986, the conditional sex ratio for second-order or third-order births after an earlier daughter or daughters diverged notably from that after an earlier son or sons. From 1981 to 2016, the sex ratio for second-born children after an earlier daughter decreased from 930 (99% CI 869-990) to 885 (859-912), and that for third-born children after two earlier daughters decreased from 968 (866-1069) to 788 (746-830). The probability of missing girls was mostly determined by earlier daughters, even after considering wealth quintile and education levels. The conditional sex ratio among the richest and most educated mothers was most distorted compared with lower wealth and education groups, and generally decreased with time, until a modest improvement in 2007-16. INTERPRETATION: In contrast to the substantial improvements in female child mortality in India, missing female births, driven by selective abortion of female fetuses, continues to increase across the states. Inclusion of a question on sex composition of births in the forthcoming census would provide local information on sex-selective abortion in each village and urban area of the country. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.

The Abortion Web Ecosystem: Cross-Sectional Analysis of Trustworthiness and Bias.

BACKGROUND: People use the internet as a primary source for learning about medical procedures and their associated safety profiles and risks. Although abortion is one of the most common procedures worldwide among women in their reproductive years, it is controversial and highly politicized. Substantial scientific evidence demonstrates that abortion is safe and does not increase a woman's future risk for depressive disorders or infertility. The extent to which information found on the internet reflects these medical facts in a trustworthy and unbiased manner is not known. OBJECTIVE: The purpose of this study was to collate and describe the trustworthiness and political slant or bias of web-based information about abortion safety and risks of depression and infertility following abortion. METHODS: We performed a cross-sectional study of internet websites using 3 search topics: (1) is abortion safe?, (2) does abortion cause depression?, and (3) does abortion cause infertility? We used the Google Adwords tool to identify the search terms most associated with those topics and Google's search engine to generate databases of websites related to each topic. We then classified and rated each website in terms of content slant (pro-choice, neutral, anti-choice), clarity of slant (obvious, in-between, or difficult/can't tell), trustworthiness (rating scale of 1-5, 5=most trustworthy), type (forum, feature, scholarly article, resource page, news article, blog, or video), and top-level domain (.com, .net, .org, .edu, .gov, or international domain). We compared website characteristics by search topic (safety, depression, or infertility) using bivariate tests. We summarized trustworthiness using the median and IQR, and we used box-and-whisker plots to visually compare trustworthiness by slant and domain type. RESULTS: Our search methods yielded a total of 111, 120, and 85 unique sites for safety, depression, and infertility, respectively. Of all the sites (n=316), 57.3% (181/316) were neutral, 35.4% (112/316) were anti-choice, and 7.3% (23/316) were pro-choice. The median trustworthiness score was 2.7 (IQR 1.7-3.7), which did not differ significantly across topics (P=.409). Anti-choice sites were less trustworthy (median score 1.3, IQR 1.0-1.7) than neutral (median score 3.3, IQR 2.7-4.0) and pro-choice (median score 3.7, IQR 3.3-4.3) sites. Anti-choice sites were also more likely to have slant clarity that was "difficult to tell" (41/112, 36.6%) compared with neutral (25/181, 13.8%) or pro-choice (4/23, 17.4%; P<.001) sites. A negative search term used for the topic of safety (eg, "risks") produced sites with lower trustworthiness scores than search terms with the word "safety" (median score 1.7 versus 3.7, respectively; P<.001). CONCLUSIONS: People seeking information about the safety and potential risks of abortion are likely to encounter a substantial amount of untrustworthy and slanted/biased abortion information. Anti-choice sites are prevalent, often difficult to identify as anti-choice, and less trustworthy than neutral or pro-choice sites. Web searches may lead the public to believe abortion is riskier than it is.

Trends in and predictors of pregnancy termination among 15-24 year-old women in Nigeria: a multi-level analysis of demographic and health surveys 2003-2018.

BACKGROUND: Three-quarters of pregnancy terminations in Africa are carried out in unsafe conditions. Unsafe abortion is the leading cause of maternal mortality among 15-24 year-old women in Sub-Saharan Africa. Greater understanding of the wider determinants of pregnancy termination in 15-24 year-olds could inform the design and development of interventions to mitigate the harm. Previous research has described the trends in and factors associated with termination of pregnancy for women of reproductive age in Nigeria. However, the wider determinants of pregnancy termination have not been ascertained, and data for all women have been aggregated which may obscure differences by age groups. Therefore, we examined the trends in and individual and contextual-level predictors of pregnancy termination among 15-24 year-old women in Nigeria. METHODS: We analysed data from the 2003, 2008, 2013 and 2018 Nigerian Demographic and Health Surveys (NDHS) comprising 45,793 women aged 15-24 years. Trends in pregnancy termination across the four survey datasets were examined using bivariate analysis. Individual and contextual predictors of pregnancy termination were analysed using a three-level binary logistic regression analysis and are reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: Trends in pregnancy termination declined from 5.8% in 2003 to 4.2% in 2013 then reversed to 4.9% in 2018. The declining trend was greater for 15-24 year-old women with higher socioeconomic status. Around 17% of the total variation in pregnancy termination was attributable to community factors, and 7% to state-level factors. Of all contextual variables considered, only contraceptive prevalence (proxy for reproductive health service access by young women) at community level was significant. Living in communities with higher contraceptive prevalence increased odds of termination compared with communities with lower contraceptive prevalence (aOR = 4.2; 95% CI 2.7-6.6). At the individual-level, sexual activity before age 15 increased odds of termination (aOR = 2.3; 95% CI 1.9-2.8) compared with women who initiated sexual activity at age 18 years or older, and married women had increased odds compared with never married women (aOR = 3.0; 95% CI 2.5-3.7). CONCLUSION: Our findings highlight the importance of disaggregating data for women across the reproductive lifecourse, and indicates where tailored interventions could be targeted to address factors associated with pregnancy termination among young women in Nigeria.

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

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

Trends and predictors of changes in modern contraceptive use among women aged 15-49 years in Tanzania from 2004-2016: Evidence from Tanzania Demographic and Health Surveys.

INTRODUCTION: Modern contraceptive use provides opportunities for women and couples to achieve optimal child spacing, achieve desired family size and reduce unsafe abortions. Despite these facts, modern contraceptive prevalence rate (mCPR) in Tanzania remains as low as 32%. This study aimed to determine trends and factors associated with changes in modern contraceptive use among women of reproductive age in Tanzania from 2004-2016. METHODOLOGY: This was a cross-sectional study utilizing data from Tanzania Demographic and Health Surveys of 2004-2005, 2010 and 2015-2016. Data analysis was performed using Stata version 14. Analysis considered the complex survey design through application of weights, clustering and strata. Multivariable Poisson decomposition analysis was used to assess factors associated with changes in modern contraceptive use. Results were presented in the form of decomposition coefficients and percentages. RESULTS: Modern contraceptive use increased from 23.0% in 2004 to 34.3% in 2016. Differences in women's characteristics contributed 12.5% of the increase in mCPR. These characteristics include partner's education levels, recent sexual activity and being visited by a family planning worker. The difference in coefficients contributed 87.5% increase in mCPR. The most increase in modern contraceptive use was attributed to rural population (44.1%) and women who experienced a termination of pregnancy (7.1%). CONCLUSION: Modern contraceptive use has steadily increased in Tanzania. Health policies and interventions need to target sexually active women, rural residents as well as less educated women and men to maintain and further accelerate the trends in mCPR. Interventions focusing on women who experienced a termination of pregnancy may also serve as an entry point to promote use of modern contraceptive methods.