Landscape assessment of the availability of medical abortion medicines in India.

BACKGROUND: Medical abortion with mifepristone and misoprostol can be provided up to 63 days' gestation in India. This accounts for 67.5 percent of all abortions in the country. We conducted an assessment to determine the availability of medical abortion medicines, specifically the combi-pack, in India. METHODS: We applied the World Health Organization landscape assessment protocol at the national level. The assessment protocol included a five-step adaptation of an existing availability framework, including online data collection, desk review, country-level key informant interviews, and an analysis to identify barriers and opportunities to improve medical abortion availability. The assessment was conducted between August and March 2021. RESULTS: Medicines for medical abortion are included in the national essential drug list and available with prescription in India. The assessment identified 42 combi-pack products developed by 35 manufacturers. The quality of medical abortion medicines is regulated by national authorities; but as health is devolved to states, there are significant inter-state variations. This is seen across financing, procurement, manufacturing, and monitoring mechanisms for quality assurance of medical abortion medicines prior to distribution. There is a need to strengthen supply chain systems, ensure consistent availability of trained providers and build community awareness on use of medical abortion medicines for early abortions, at the time of the assessment. CONCLUSION: Opportunities to improve availability and quality of medical abortion medicines exist. For example, uniform implementation of regulatory standards, greater emphasis on quality-assurance during manufacturing, and standardizing of procurement and supply chain systems across states. Regular in-service training of providers on medical abortion is required. Finally, innovations in evidence dissemination and community engagement about the recently amended abortion law are needed.

Medical abortion is popular in India and benefits from a liberal legal context. It is important to understand the availability of quality abortion medicines in the country. Using the World Health Organization country assessment protocol and availability framework for medical abortion medicines we examined the availability of these medicines from supply to demand. We used this information to identify opportunities for increasing availability of quality-assured medical abortion medicines. We found that the context for medical abortion varies across states. Strengthening procurement and supply chain management, with a greater emphasis on quality-assurance and regulation of manufacturing should be instituted at the state-level. Training is also needed to increase provider knowledge of the latest national guidelines and laws to ensure respectful and person-centered services. Finally, the public should be informed about medical abortion as a safe and effective choice, especially for early abortions.

Strengthening regional commitment to ensuring access to medical abortion medicines in WHO's South-East Asia region: report of a participatory assessment and workshop.

BACKGROUND: In 2019, the World Health Organization identified improving access to safe abortion as an important priority toward improving sexual and reproductive health and rights and achieving Sustainable Development Goals. One strategy for addressing this priority is strengthening access to medicines for medical abortion. All 11 countries in the South-East Asia Region have some indications for legal abortion and permit post-abortion care. Therefore, strengthening access to medical abortion medicines is a reasonable strategy for improving access to safe abortion for the Region. METHODOLOGY: We applied an adapted version of an existing World Health Organization landscape assessment protocol for the availability of medical abortion medicines at the country-level in the South-East Asia Region. We collected publicly available data on the existence of national health laws, policies, and standard treatment guidelines; inclusion of medical abortion medicines in the national essential medicines list; and marketing authorization status for medical abortion medicines for each country and verified by Ministries of health. The findings were once more presented, discussed and recommendations were formulated during regional technical consultation workshop. Each country teams participated in the process, and subsequently, the suggestions were validated by representatives from Ministries of Health.. RESULTS: Few countries in the Region currently have national policies and guidelines for comprehensive safe abortion. However, either mifepristone-misoprostol in combination or misoprostol alone (for other indications) is included in national essential medicines lists in all countries except Indonesia and Sri Lanka. Few countries earmark specific public funds for procuring and distributing medical abortion commodities. In countries where abortion is legal, the private sector and NGOs support access to medical abortion information and medicines. Several countries only allow registered medical practitioners or specialists to administer medical abortion. CONCLUSION: Following this rapid participatory assessment and technical consultation workshop, the World Health Organization South-East Asia Regional Technical Advisory and Sexual and Reproductive Health and Rights technical committee recommended priority actions for policy and advocacy, service delivery, and monitoring and evaluation, and indicated areas for support.

Identifying and prioritizing evidence needs in self-care interventions for sexual and reproductive health.

Background: Self-care as an extension of health care systems can increase access to care. The development of programs and generation of evidence to support self-care in sexual and reproductive health (SRH) is a relatively nascent field. We undertook a study to identify and prioritize evidence gaps for SRH self-care. Methods: We used the CHNRI methodology and administered two online surveys to stakeholders affiliated with major self-care networks. The first survey was used to identify evidence gaps, and the second to prioritize them using predetermined criteria. Results: We received 51 responses to the first survey and 36 responses to the second. Many evidence gaps focused on awareness of and demand for self-care options and best mechanisms for supporting users of self-care with information, counseling and linkages to care. Conclusion: A priority area of work ahead should be determining which aspects of the learning agenda reflect gaps in evidence and which reflect a need to effectively synthesize and disseminate existing evidence.

Creativity, serendipity, and collaboration: Cross-cutting features of successful task-sharing in comprehensive safe abortion care.

Limited capacity to deliver comprehensive safe abortion care and shortages in trained healthcare providers contribute to a lack of access to safe services. The World Health Organization published guidelines and recommendations on expanding health worker roles through task-sharing as one way to address disparities. A multicountry case study was conducted in six diverse contexts (Bangladesh, Colombia, Ghana, Mexico City in Mexico, Sweden, and Tunisia) to determine the cross-cutting strategies that enabled inclusion of a broader range of healthcare workers in comprehensive safe abortion care. Five strategies emerged: leveraging of favorable contexts, policies, and guidelines; use of evidence for advocacy; building upon existing task-sharing; mitigation of negative responses to abortion and task-sharing; and collaboration across sectors. The findings suggest that there are potential opportunities for stakeholders to employ these strategies in many contexts to broaden health worker roles in comprehensive safe abortion care.

Implementation considerations when expanding health worker roles to include safe abortion care: a five-country case study synthesis.

BACKGROUND: Allowing a broader range of trained health workers to deliver services can be an important way of improving access to safe abortion care. However, the expansion of health worker roles may be challenging to implement. This study aimed to explore factors influencing the implementation of role expansion strategies for non-physician providers to include the delivery of abortion care. METHODS: We conducted a multi-country case study synthesis in Bangladesh, Ethiopia, Nepal, South Africa and Uruguay, where the roles of non-physician providers have been formally expanded to include the provision of abortion care. We searched for documentation from each country related to non-physician providers, abortion care services and role expansion through general internet searches, Google Scholar and PubMed, and gathered feedback from 12 key informants. We carried out a thematic analysis of the data, drawing on categories from the SURE Framework of factors affecting the implementation of policy options. RESULTS: Several factors appeared to affect the successful implementation of including non-physician providers to provide abortion care services. These included health workers' knowledge about abortion legislation and services; and health workers' willingness to provide abortion care. Health workers' willingness appeared to be influenced by their personal views about abortion, the method of abortion and stage of pregnancy and their perceptions of their professional roles. While managers' and co-workers' attitudes towards the use of non-physician providers varied, the synthesis suggests that female clients focused less on the type of health worker and more on factors such as trust, privacy, cost, and closeness to home. Health systems factors also played a role, including workloads and incentives, training, supervision and support, supplies, referral systems, and monitoring and evaluation. Strategies used, with varying success, to address some of these issues in the study countries included values clarification workshops, health worker rotation, access to emotional support for health workers, the incorporation of abortion care services into pre-service curricula, and in-service training strategies. CONCLUSIONS: To increase the likelihood of success for role expansion strategies in the area of safe abortion, programme planners must consider how to ensure motivation, support and reasonable working conditions for affected health workers.

Being targeted: Young women's experience of being identified for a teenage pregnancy prevention programme.

Research on the unintended consequences of targeting 'high-risk' young people for health interventions is limited. Using qualitative data from an evaluation of the Teens & Toddlers Pregnancy Prevention programme, we explored how young women experienced being identified as at risk for teenage pregnancy to understand the processes via which unintended consequences may occur. Schools' lack of transparency regarding the targeting strategy and criteria led to feelings of confusion and mistrust among some young women. Black and minority ethnic young women perceived that the assessment of their risk was based on stereotyping. Others felt their outgoing character was misinterpreted as signifying risk. To manage these imposed labels, stigma and reputational risks, young women responded to being targeted by adopting strategies, such as distancing, silence and refusal. To limit harmful consequences, programmes could involve prospective participants in determining their need for intervention or introduce programmes for young people at all levels of risk.

Exploring intergenerational changes in perceptions of gender roles and sexuality among Indigenous women in Oaxaca.

The south of Mexico has traditionally faced disproportionate social, health and economic disadvantage relative to the rest of the country, due in part to lower levels of economic and human development, and barriers faced by Indigenous populations. The state of Oaxaca, in particular, has one of the highest proportions of Indigenous people and consistently displays high rates of maternal mortality, sexually transmitted infections and teenage pregnancy. This study examines how social values and norms surrounding sexuality have changed between two generations of women living in Indigenous communities in Oaxaca. We conducted semi-structured in-depth interviews with 19 women from two generational cohorts in 12 communities. Comparison views of these two cohorts suggest that cultural gender norms continue to govern how women express and experience their sexuality. In particular, feelings of shame and fear permeate the expression of sexuality, virginity continues be a determinant of a woman's worth and motherhood remains the key attribute to womanhood. Evidence points to a transformation of norms, and access to information and services related to sexual health is increasing. Nonetheless, there is still a need for culturally appropriate sex education programmes focused on female empowerment, increased access to sexual health services, and a reduction in the stigma surrounding women's expressions of sexuality.

Constructing a validated scale to measure community-level abortion stigma in Mexico.

OBJECTIVE: In Mexico, abortion stigma in the general population is largely unexplored. We developed a scale to measure abortion stigma at the community level, examine its prevalence and explore factors associated with abortion stigma in a nationally representative sample. STUDY DESIGN: Following intensive qualitative work to identify dimensions of the stigma construct, we developed a comprehensive list of statements that were cognitively tested and reduced to 33 to form a scale. We piloted the scale in a nationally and subregionally representative household public opinion survey administered to 5600 Mexican residents. RESULTS: Factor analysis tested the internal consistency and reliability of five previously hypothesized dimensions of abortion stigma: secrecy, religion, autonomy, discrimination and guilt/shame. Under the assumption that these dimensions were independent, confirmatory factor analysis indicated that each of these dimensions functioned as independent subscales. However, to test this assumption, we conducted exploratory factor analysis that revealed a strong codependence between discrimination, guilt/shame and religion statements, resulting in a 23-item four-factor model of abortion stigma and the elimination of the guilt/shame dimension. Both methods revealed a full scale and subscales with Cronbach's alphas between 0.80 and 0.90. Regression analyses suggested that older, less educated individuals living in the north of Mexico report higher levels of stigma, especially related to discrimination and religion. CONCLUSIONS: This community-level abortion stigma scale is the first to be developed and tested in Mexico. This tool may be used in Mexico and other similar country settings to document the prevalence of community-level abortion stigma, identify associated factors and test interventions aimed at reducing abortion stigma. IMPLICATIONS: Abortion stigma prevents women from accessing safe abortion services. Measuring community-level abortion stigma is key to documenting its pervasiveness, testing interventions aimed at reducing it and understanding associated factors. This scale may be useful in countries similar to Mexico to support policymakers, practitioners and advocates in upholding women's reproductive rights.

Qualitative evidence on abortion stigma from Mexico City and five states in Mexico.

Social manifestations of abortion stigma depend upon cultural, legal, and religious context. Abortion stigma in Mexico is under-researched. This study explored the sources, experiences, and consequences of stigma from the perspectives of women who had had an abortion, male partners, and members of the general population in different regional and legal contexts. We explored abortion stigma in Mexico City where abortion is legal in the first trimester and five states-Chihuahua, Chiapas, Jalisco, Oaxaca, and Yucatán-where abortion remains restricted. In each state, we conducted three focus groups-men ages 24-40 years (n = 36), women 25-40 years (n = 37), and young women ages 18-24 years (n = 27)-and four in-depth face-to-face interviews in total; two with women (n = 12) and two with the male partners of women who had had an abortion (n = 12). For 4 of the 12 women, this was their second abortion. This exploratory study suggests that abortion stigma was influenced by norms that placed a high value on motherhood and a conservative Catholic discourse. Some participants in this study described abortion as an "indelible mark" on a woman's identity and "divine punishment" as a consequence. Perspectives encountered in Mexico City often differed from the conservative postures in the states.

Pilot multimethod trial of a school-ethos intervention to reduce substance use: building hypotheses about upstream pathways to prevention.

PURPOSE: Interventions to improve school ethos can reduce substance use but "upstream" causal pathways relating to implementation and school-level changes are uncertain. We use qualitative and quantitative data from a pilot trial to build hypotheses regarding these. METHODS: The Healthy School Ethos intervention involved two schools being provided with facilitation, training, and funding to plan and implement actions (some mandatory and some locally determined) to improve school ethos over one year. The evaluation involved a pilot-trial with two intervention and two comparison schools; semi-structured interviews with facilitators, staff, and students; and baseline and follow-up surveys with students aged 11 to 12 years. RESULTS: Student accounts linked participation in planning or delivering intervention activities with improved self-regard and relationships with staff and other students. Some activities such as re-writing school rules involved broad participation. Students in receipt of actions such as peer-mediation or motivational sessions reported benefits such as improved safety and relationships. Some student accounts linked improved self-regard and relationships with increased engagement and aspirations, and reduced substance use. At 9-month follow-up, students in intervention schools reported less hurting and teasing of others and feeling unsafe at school. Other outcomes suggested intervention benefits but were not significant. CONCLUSIONS: School-ethos interventions may reduce substance use through upstream pathways involving the aforementioned factors. Future phase-III trials should quantitatively model the extent to which these mediate intervention effects.