Telehealth for Addressing Sexual and Reproductive Health and Rights Needs During the COVID-19 Pandemic and Beyond: A Hybrid Telemedicine-Community Accompaniment Model for Abortion and Contraception Services in Pakistan.

The COVID-19 pandemic led overburdened health care systems to deprioritize essential sexual and reproductive healthcare, including abortion and contraception care, while accelerating shifts in healthcare delivery to digital technologies. However, in many countries, including Pakistan, inequalities in access to digital technologies remain, presenting an opportunity for interventions that both increase access to deprioritized sexual and reproductive health and rights (SRHR) services and overcome the digital divide in delivering digital solutions to those in need of SRHR services. In June 2020, Ipas Pakistan partnered with Sehat Kahani (SK), a local health care NGO and telehealth service, and an existing network of Lady Health Workers (LHWs) to launch a novel hybrid telemedicine-community accompaniment pilot. The model linked women via LHWs with mobile devices to online providers for telemedicine consultations for SRH, including abortion services, contraception, and other gynecological consultations. In June 2020, we trained 98 LHWs and 22 telehealth doctors. Between June 2020 and March 2021, a total of 176 women were referred by LHWs for telehealth consultations. Among women who received abortion services, nearly all (90%) reported complete uterine evacuation. No serious adverse events were reported. Overall satisfaction was high; 81% reported being satisfied, and 86% said it is likely they would recommend the telehealth service to others. Data show that the provision of SRHR services via a telehealth-accompaniment model can be successfully implemented in Pakistan. Outcome data show high satisfaction and good clinical outcomes for women accessing care through this model. However, more data are needed to understand the full potential of this model. Barriers to digital health models, such as poor or inconsistent internet access, remain in places like Pakistan, especially in rural settings. This approach has its limitations but should be considered as an option in settings with similarly established community health networks and inequitable access to digital health.

"We don't want problems": reasons for denial of legal abortion based on conscientious objection in Mexico and Bolivia.

BACKGROUND: The misuse of conscientious objection (CO) is a significant barrier to legal abortion access in many countries, especially in Latin America. We examine the reasons for denial of legal abortion services in Mexico and Bolivia and identify ways to mitigate the misuse of CO. METHODS: We conducted 34 in-depth interviews and 12 focus group discussions in two states in Mexico and four departments in Bolivia. Results were coded and categorized using a thematic analysis approach. RESULTS: Denial of abortion services based on CO is widespread in health facilities in Mexico and Bolivia and is primarily employed for reasons other than moral, religious, or ethical considerations. The main reasons for denial of services based on CO is lack of knowledge about abortion-related laws and fear of legal problems in abortion service provision. Conversely, the main reason to provide services is to comply with relevant laws. Denying services under the guise of CO negatively impacts pregnant people and health care teams, including fewer safe abortion options and increased workload and stigma, respectively. Most respondents cited training and education on abortion law as the foremost way to mitigate the negative impacts of the misuse of CO. CONCLUSIONS: For many health personnel, knowing, understanding, and following the law is reason enough to provide abortion services. Individuals who object due to lack of knowledge about laws and fear of legal problems represent a key population that can be sensitized and equipped with the necessary information and resources to provide legal abortion services.

RESUMEN: ANTECEDENTES: El mal uso de la objeción de conciencia (OC) es una barrera importante para el acceso al aborto aún cuando es legal, en muchos países, especialmente en países en América Latina. Examinamos los motivos de la negación de servicios de aborto legal en México y Bolivia e identificamos formas de mitigar el uso indebido de la OC. MéTODOS: Realizamos 34 entrevistas a profundidad y 12 discusiones en grupo focal en dos estados en México y cuatro departamentos en Bolivia. Los resultados fueron codificados y categorizados utilizando un enfoque de análisis temático. RESULTADOS: La negación de servicios de aborto basados ​​en la OC está muy extendida en los establecimientos de salud en México y Bolivia y se emplea principalmente por razones distintas a las consideraciones morales, religiosas o éticas. Las principales razones para la negación de servicios basados ​​en la OC son la falta de conocimiento sobre las leyes relacionadas con el aborto y el temor a problemas legales en la prestación de servicios de aborto. Por el contrario, la razón principal para proporcionar servicios es cumplir con las leyes pertinentes. Negar servicios bajo la apariencia de OC impacta negativamente a las personas embarazadas y a los equipos de atención médica, incluidas menos opciones de aborto seguro y mayor carga de trabajo y estigma, respectivamente. La mayoría de los encuestados mencionaron la capacitación y educación sobre la ley del aborto como la principal forma de mitigar los impactos negativos del uso indebido de la OC. CONCLUSIONES: Para parte del personal de salud, conocer, comprender y cumplir la ley es motivo suficiente para proporcionar servicios de aborto. Las personas que se oponen debido a la falta de conocimiento sobre las leyes y el miedo a los problemas legales representan una población clave que puede ser sensibilizada y equipada con la información y los recursos necesarios para proporcionar servicios de aborto legal.

Factors Associated with Support for Adolescent Access to Contraception Among Mexican Catholic Parents.

We used a nationally representative survey of 2186 Mexican Catholic parents to assess two outcomes: support for adolescent access to modern contraception and whether adolescents unaccompanied by an adult should have access to contraceptive methods. A majority (85%) of Mexican Catholic parents support adolescent access to modern contraceptive methods, but there was less support (28%) for access to contraception unaccompanied. Further, our results show strong support (92%) for sex education in schools. Parents who believe that good Catholics can use contraception had higher odds of support for adolescent access and unaccompanied access to modern contraception. Mexican Catholic parents support adolescent access to modern contraception, but support for unaccompanied access to contraception is lower. This may reflect an interest in being involved, and not necessarily opposition to contraceptive use. Measures of Catholicism that focus on behaviors may better explain opinions about adolescent access to contraception.

Regulating Conscientious Objection to Legal Abortion in Argentina: Taking into Consideration Its Uses and Consequences.

Claims of conscientious objection (CO) have expanded in the health care field, particularly in relation to abortion services. In practice, CO is being used in ways beyond those originally imagined by liberalism, creating a number of barriers to abortion access. In Argentina, current CO regulation is lacking and insufficient. This issue was especially evident in the country's 2018 legislative debate on abortion law reform, during which CO took center stage. This paper presents a mixed-method study conducted in Argentina on the uses of CO in health facilities providing legal abortion services, with the goal of proposing specific regulatory language to address CO based not only on legal standards but also on empirical findings regarding CO in everyday reproductive health services. The research includes a review of literature and comparative law, a survey answered by 269 health professionals, and 11 in-depth interviews with stakeholders. The results from our survey and interviews indicate that Argentine health professionals who use CO to deny abortion are motivated by a combination of political, social, and personal factors, including a fear of stigmatization and potential legal issues. Furthermore, we find that the preeminent consequences of CO are delays in abortion services and conflicts within the health care team. The findings of this research allowed us to propose specific regulatory recommendations on CO, including limits and obligations, and suggestions for government and health system leaders.

Capturing compassion: A survey of Mexican Catholics assessing abortion support by reason for abortion and degree of Catholicism.

OBJECTIVE: No standard exists to measure religiosity in abortion studies. We test whether religiosity is associated with support for abortion among Mexican Catholics and whether different measures of degree of Catholicism alter the relationship. STUDY DESIGN: We conducted a nationally representative cross-sectional study using survey data from 2669 self-identified Mexican Catholics (response rate 85%). Our three outcomes were 1) overall support for legal abortion and support for abortion under exceptions, grouped as having 2) traditionally high agreement (rape, life) and 3) low agreement (on demand, socioeconomic). We used logistic regression controlling for sociodemographic covariates to test the association of four measures of Catholicism with our outcomes. RESULTS: The majority of Mexican Catholics support abortion in some circumstances. (90% at least one high agreement exception and 40% at least one low agreement exception). The only measure of degree of Catholicism significantly associated with all our outcomes was belief that a person who helps someone who aborts can be a good Catholic. Those who agreed (versus not) had higher odds of support for abortion for both high agreement (aOR 3.6 [95% CI: 1.7-7.9]) and low agreement (aOR 1.9 [95% CI: 1.3-2.7]) exceptions. Respondents who believe a woman who aborts does not need to confess (aOR 2.1 [95% CI: 1.5-2.8]) or needs to confess to God (aOR 1.4 [95% CI: 1.04-1.8]) versus a priest had higher odds of agreement with at least one low agreement exception. CONCLUSION: Opinion toward abortion among Mexican Catholics is diverse. More nuanced measures of Catholicism are valuable in assessing support for abortion, especially exceptions with low support. IMPLICATIONS: The main reasons women need abortion are precisely those with low support among Mexican Catholics. Focusing on nuanced measures of Catholicism can help us identify areas for shared values and frame messaging to meet the diversity of Catholic opinion. Catholicism is not an unsurmountable barrier to liberalization of abortion law.

Access to abortion under the heath exception: a comparative analysis in three countries.

BACKGROUND: Despite Britain, Colombia, and some Mexican states sharing a health exception within their abortion laws, access to abortion under the health exception varies widely. This study examines factors that result in heterogeneous application of similar health exception laws and consequences for access to legal abortion. Our research adds to previous literature by comparing implementation of similar abortion laws across countries to identify strategies for full implementation of the health exception. METHODS: We conducted a cross-country comparative descriptive study synthesizing data from document and literature review, official abortion statistics, and interviews with key informants. We gathered information on the use and interpretation of the health exception in the three countries from peer-reviewed literature, court documents, and grey literature. We next extracted public and private abortion statistics to understand the application of the law in each setting. We used a matrix to synthesize information and identify key factors in the use of the law. We conducted in-depth interviews with doctors and experts familiar with the health exception laws in each country and analyzed the qualitative data based on the previously identified factors. RESULTS: The health exception is used broadly in Britain, somewhat in Colombia, and very rarely in Mexican states. We identified five factors as particularly salient to application of the health exception in each setting: 1) comprehensiveness of the law including explicit mention of mental health, 2) a strong public health sector that funds abortion, 3) knowledge of and attitudes toward the health exception law, including guidelines for physicians in providing abortion, 4) dissemination of information about the health exception law, and 5) a history of court cases that protect women and clarify the health exception law. CONCLUSIONS: The health exception is a valuable tool for expanding access to legal abortion. Differences in the use of the health exception as an indication for legal abortion result in wide access for women in Britain to nearly no access in Mexican states. Our findings highlight the difference between theoretical and real access to legal abortion. The interpretation and application of the health exception law are pivotal to expanding real access to abortion.

Access to Contraception in the Context of Zika: Health System Challenges and Responses.

Women in areas of the Americas with endemic Aedes mosquito populations are at risk for exposure to Zika virus, which can cause fetal brain abnormalities and associated congenital microcephaly. Individual health care providers may encounter health system barriers to providing evidence-based care. We focus on Mexico and the state of Texas to highlight the role of health system factors in contraceptive access in the context of Zika and highlight efforts in Puerto Rico as an example of initiatives to improve access to contraception. In Mexico, states with the highest unmet need for contraception are low-lying coastal states. The government recently announced an investment to combat Zika but made no mention of family planning initiatives to assist women in preventing pregnancy. In Texas, the Department of State Health Services has issued recommendations to help women and men avoid mosquito bites; the issue of whether women should plan or avoid pregnancy is not addressed. Puerto Rico has the largest number of confirmed cases of Zika virus in the U.S. states and territories. Recently, the Centers for Disease Control and Prevention Foundation launched the Zika Contraception Access Network, which provides contraceptives at no cost to participating clinics in Puerto Rico. The Zika virus highlights weaknesses in health systems that make it difficult for women to use contraception if they want to delay births. Women across the globe, with or without Zika virus, need access to contraception to prevent unintended pregnancy, and health care providers require functioning health systems that offer support to ensure access is a reality.