Willingness to perform induced abortion and associated factors among graduating midwifery, medical, nursing, and public health officer students of University of Gondar, Northwest Ethiopia: institution based cross sectional study.

BACKGROUND: In developing countries, abortion is often unsafe and a significant cause of maternal morbidity and mortality accounting for about 8% (4.7-13.2%) of maternal mortality worldwide. Internationally, safe abortion services are recognized as reducing maternal mortality, and liberalized abortion laws are associated with reduced mortality resulting from unsafe abortion procedures. However, health care providers have moral, social and gender-based reservations that affects their willingness towards providing induced abortion services. The purpose of this study was to assess willingness to perform induced abortion and associated factors among graduating Midwifery, Medical, Nursing, and Public health officer students of University of Gondar. METHODS: Institution based cross sectional study was conducted from March 29 to May 30, 2019. All graduating students available during data collection period were considered as study population. Stratified simple random sampling technique was used to select 424 study participants. Pre tested, semi- structured, self-administered questionnaire was used to collect data. Data analysis was done using SPSS version 20. Ethical clearance was obtained from School of midwifery under the delegation of institutional review board of university of Gondar. RESULTS: Two hundred ninety students out of 424 students were willing to perform induced abortion for indications supported by Ethiopian abortion law, making a proportion of 68.4% (95%Cl: 64.2, 72.9). Sex (Being male (AOR = 4.89, 95%CI: 3.02, 7.89)), religion (being orthodox than protestant (AOR = 10.41, 95%CI: 3.02, 21.57)), being Muslim than protestant (AOR = 5.73, 95%CI: 1.37, 15.92)) and having once or less a week religious attendance (AOR = 2.00, 95% CI: 1.20, 3.34) were factors associated with willingness towards performing induced abortion. CONCLUSIONS: According to this study willingness of students towards providing induced abortion services was good. However female students, protestant followers and those students with more than once a week religious attendance should be encouraged to support women's access to induced abortion services by referring them to other health care professionals willing to provide induced abortion services.

How task-sharing in abortion care became the norm in Sweden: A case study of historic and current determinants and events.

We performed a country case study using thematic analysis of interviews and existing grey and published literature to identify facilitators and barriers to the implementation of midwife-provided abortion care in Sweden. Identified facilitating factors were: (1) the historical role and high status of Swedish midwives; (2) Swedish research and development of medical abortion that enabled an enlarged clinical role for midwives; (3) collaborations between individual clinicians and researchers within the professional associations, and the autonomy of clinical units to implement changes in clinical practice; (4) a historic precedent of changes in abortion policy occurring without prior official or legal sanction; (5) a context of liberal abortion laws, secularity, gender equality, public support for abortion, trust in public institutions; and (6) an increasing global interest in task-shifting to increase access and reduce costs. Identified barriers/risks were: (1) the lack of systems for monitoring and evaluation; and (2) a loss of physician competence in abortion care.

Accommodating conscientious objection in the midwifery workforce: a ratio-data analysis of midwives, birth and late abortions in 18 European countries in 2016.

BACKGROUND: In recent years, the role of a midwife has expanded to include the provision of abortion-related care. The laws on abortion in many European countries allow for those who hold a conscientious objection to participating to refrain from such participation. However, some writers have expressed concerns that this may have a detrimental effect on the workforce and limit women's access to the service. METHOD: The aim of this study was to provide a picture of the potential exposure midwives in Europe have to late abortions, an important factor in the integration of accommodation of conscientious objection to abortion by midwives into workload planning. We collected data from Ministries of Health or government statistical departments in 32 European countries on numbers of births, abortions, late abortions and midwives in 2016. We conducted a ratio-data analysis in those countries that met the inclusion criteria. RESULTS: Eighteen of the 32 countries provided full data; thus, our calculations are based on a total of 4 036 633 live births, 49 834 late abortions and a total of 132 071 midwives. The calculated ratios of live births to midwife, abortions to midwife and late abortions to midwife illustrate the wide variations between countries in relation to ratios of midwives to live births (15.22-53.99) and late abortions (0.17-1.47) CONCLUSIONS: This study provides the first comprehensive insight to ratios relating to birth and abortion, especially late abortion services, with regard to the midwifery workforce. It is essential to improve the reporting of abortion data and access to it within Europe to support evidence-informed decisions on optimising the contribution of the midwifery workforce especially within highly contentious fields such as abortion services. The study's findings suggest that there should be neither be any difficulty for those who are responsible for workload allocation nor compromises to a women's right to abortion services.

Providing quality abortion care: Findings from a study of six states in India.

OBJECTIVE: Although abortion has been legal in India since 1971, but very little research has been done so far on the issue of the quality of abortion services. To fill this gap, this paper examines whether the quality of abortion services provided in the country is in line with the WHO's recommendations. STUDY DESIGN: We analyse a cross-sectional health facilities survey conducted in six Indian states, representing different sociocultural and geographical regions, as part of a study done in 2015. MAIN OUTCOME MEASURES: Percentage of facilities offering different abortion methods, type of anaesthesia given, audio-visual privacy level, compliance with the law by obtaining woman's consent only, imposing the requirement of adopting a contraceptive method as a precondition to receive abortion. RESULTS: Except for the state of Madhya Pradesh, fewer than half of the facilities in the other states offer safe abortion services. Fewer than half of the facilities offer the WHO recommended manual vacuum aspiration method. Only 6-26% facilities across the states seek the woman's consent alone for providing abortion. About 8-26% facilities across the states also require that women adopt some method of contraception before receiving abortion. CONCLUSION: To provide comprehensive quality abortion care, India needs to expand the provider base by including doctors from the Ayurveda, Unani, Siddha, and Homeopathy streams as also nurses and auxiliary midwives after providing them necessary skills. Medical and nursing colleges and training institutions should expand their curriculum by offering an in-service short-term training on vacuum aspiration (VA) and medical methods of abortion.

The role of nurses and midwives in the provision of abortion care: A scoping review.

AIMS AND OBJECTIVES: To define the role and scope of the nurse and midwife within the global context of abortion. BACKGROUND: An estimated 56 million women seek abortions each year; nurses and midwives are commonly involved in their care (Singh et al., 2018, https://www.guttmacher.org/sites/default/files/report_pdf/abortion-worldwide-2017.pdf). As new models of abortion care emerge, there is a pressing need to develop a baseline understanding of the role and scope of nurses and midwives who care for women seeking abortions. DESIGN: The review design was Arksey and O'Malley's five-stage methodological framework. The review follows the PRISMA-ScR checklist. METHODS: MEDLINE, CINAHL, Scopus and ScienceDirect were used to identify original research, commentaries and reports, published between 2008-2019, from which we selected 74 publications reporting on the nursing or midwifery role in abortion care. RESULTS: Nurses and midwives provide abortion care in a variety of practice. Three themes emerged from the literature: the regulated role; providing psychosocial care; and the expanding scope of practice. CONCLUSIONS: The literature on nursing and midwifery practice in abortion care is broad. Abortion-related practices are potentially over-regulated. Appropriately trained nurses and midwives can provide abortions as safely as physicians. The preparation of nurses and midwives to provide abortion care requires further research. Also, healthcare organisations should explore person-centred models of abortion care. RELEVANCE TO CLINICAL PRACTICE: Abortion care is a common procedure performed across many healthcare settings. Nurses and midwives provide technical and psychosocial care to women who seek abortions. Governments and regulatory bodies could safely extend their scope of practice to increase women's access to safe abortions. Introduction of education programmes, as well as embedding practice in person-centred models of care, may improve outcomes for women seeking abortions.

Potential conflicts in midwifery practice regarding conscientious objection to abortions in Scotland.

BACKGROUND:: This study was developed as a result of a court case involving conflicts between midwives' professional practice and their faith when caring for women undergoing abortions in Scotland. RESEARCH QUESTIONS:: What are practising Roman Catholics' perspectives of potential conflicts between midwives' professional practice in Scotland with regard to involvement in abortions and their faith? How relevant is the 'conscience clause' to midwifery practice today? and What are participants' understandings of Canon 1398 in relation to midwifery practice? RESEARCH DESIGN:: The theoretical underpinning of this study was Gadamer's hermeneutic out of which the method developed by Fleming et al. involving a five-stage approach was utilised. PARTICIPANTS AND RESEARCH CONTEXT:: The research was conducted in the south of Scotland. A purposive sampling method was used. Eight participants who were practising Roman Catholics familiar with the subject of conscientious objection who were either midwives, lawyers (civil, canon or both) or priests contributed. ETHICAL CONSIDERATIONS:: The major ethical issues related to respect for autonomy, maintaining confidentiality and obtaining voluntary informed consent. Parish priests agreed to act as gatekeepers to prospective participants. All legal requirements were addressed regarding data collection and storage. Approval was given by the ethics committee of the university with which one of the researchers were associated. FINDINGS:: Three key themes provide an understanding of the situation in which midwives find themselves when considering the care for a woman admitted for an abortion: competing legal systems, competing views of conscience and limits of participation. CONCLUSION:: Clear guidelines for practice should be developed by a multi-professional and consumer group based on an update of the abortion law to reflect the change from a surgical to medical procedure. Clarification of Canon 1398 in relation to what is and is not participation in the procurement of abortion would be of benefit to midwives with a conscientious objection.

Freedom of conscience in Europe? An analysis of three cases of midwives with conscientious objection to abortion.

While abortion has been legal in most developed countries for many years, the topic remains controversial. A major area of controversy concerns women's rights vis-a-vis the rights of health professionals to opt out of providing the service on conscience grounds. Although scholars from various disciplines have addressed this issue in the literature, there is a lack of empirical research on the topic. This paper provides a documentary analysis of three examples of conscientious objection on religious grounds to performing abortion-related care by midwives in different Member States of the European Union, two of which have resulted in legal action. These examples show that as well as the laws of the respective countries and the European Union, professional and church law each played a part in the decisions made. However, support from both professional and religious sources was inconsistent both within and between the examples. The authors conclude that there is a need for clear guidelines at both local and pan-European level for health professionals and recommend a European-wide forum to develop and test them.

Updates to the US Food and Drug Administration Regulations for Mifepristone: Implications for Clinical Practice and Access to Abortion.

This article provides information on recent changes in the US Food and Drug Administration (FDA) labeling and safety regulations for mifepristone (Mifeprex). The revised label now permits midwives, advanced practice nurses, and physician assistants to order and prescribe mifepristone, eliminating the requirement for physician supervision. The updated label also extends eligibility for use from 49 to 70 days' gestation and decreases the number of required visits from 3 to 2. The recommended dose of mifepristone has been reduced, and the dosage, timing, and route of administration for misoprostol have also been changed to reflect current research. These changes have implications for clinical practice and may lead to expanded access for women in the United States.

Abortion providers, professional identity, and restrictive laws: A qualitative study.

Most studies on the impact of restrictive abortion laws have focused on patient-level outcomes. To better understand how such laws affect providers, we conducted a qualitative study of 27 abortion providers working under a restrictive law in North Carolina. Providers derived professional identity from their motivations, values, and experiences of pride related to abortion provision. The law affected their professional identities by perpetuating negative characterizations of their profession, requiring changes to patient care and communication, and creating conflicts between professional values and legal obligations. We conclude that a holistic understanding of the impact of abortion laws should include providers' perspectives.

[[Abortive Pollution in the Sacred Laws of Cyrene and Kos].] / Il Miaema Abortivo Nelle Leggi Sacre Di Cirene E Cos.

In the society of the ancient Greece sacred laws on the abortion are a typical example of a mixture between the temple wisdom tradition and the medical tugvr. The epigraphic discoveries made between the end of the nineteenth century and the beginning of the twentieth century in Cos and Cyrene offered meaningfid evidences of the cooperation between priests and physicians to evaluate each single case of abortion and impose the right atonement. This contribution aims at showing how firm the line of continuity between medicine as wisdom and medicine as T Xvn was in the ancient Greece, focusing on the hot topic of the abortion. The question will be analyzed from a multidisciplinary approach which includes history of language, history of medicine and history of religion as the nature of the topic and of the evidences reauires.

What makes a likely abortion provider? Evidence from a nationwide survey of final-year students at Ghana's public midwifery training colleges.

BACKGROUND: Even in countries where the abortion law is technically liberal, the full application of the law has been delayed due to resistance on the part of providers to offer services. Ghana has a liberal law, allowing abortions for a wide range of indications. The current study sought to investigate factors associated with midwifery students' reported likelihood to provide abortion services. METHODS: Final-year students at 15 public midwifery training colleges participated in a computer-based survey. Demographic and attitudinal variables were tested against the outcome variable, likely to provide comprehensive abortion care (CAC) services, and those variables found to have a significant association in bivariate analysis were entered into a multivariate model. Marginal effects were assessed after the final logistic regression was conducted. RESULTS: A total of 853 out of 929 eligible students enrolled in the 15 public midwifery schools took the survey, for a response rate of 91.8%. In multivariate regression analysis, the factors significantly associated with reported likeliness to provide CAC services were having had an unplanned pregnancy, currently using contraception, feeling adequately prepared, agreeing it is a good thing women can get a legal abortion and having been exposed to multiple forms of education around surgical abortion. DISCUSSION: Midwifery students at Ghana's public midwifery training colleges report that they are likely to provide CAC. Ensuring that midwives-in-training are well trained in abortion services, as well as encouraging empathy in these students, may increase the number of providers of safe abortion care in Ghana.

WHEN CONSCIENCE ISN'T CLEAR: GREATER GLASGOW HEALTH BOARD v DOOGAN AND ANOTHER [2014] UKSC 68.

The Supreme Court's judgment in Doogan is a judicial review of a decision by Greater Glasgow Health Board regarding the scope of the conscience-based exemption in section 4(1) of the Abortion Act 1967. The case progressed through the Outer and Inner Houses of the Court of Session in Edinburgh before final judgment was delivered in the Supreme Court by Baroness Hale on December 17 2014. The Supreme Court eschewed consideration of the human rights dimension of the case (which had featured in the Outer House decision) and approached its judgment as 'a pure question of statutory construction'. This commentary engages with the judgment on its own terms, assessing it as an exercise in statutory interpretation, and leaves it to others who may wish to do so to comment on the human rights aspects of the case.

"We can lose our life for the abortion": exploring the dynamics shaping abortion care in peri-urban Yangon, Myanmar.

OBJECTIVES: Induced abortion in Myanmar is severely legally restricted and permissible only to save a woman's life. As a result, unsafe abortion is common and contributes significantly to maternal mortality. Our overall study aimed to explore women's reproductive health needs in peri-urban Yangon, a dynamic series of townships on the periphery of the country's largest city characterized by poor infrastructure, slum settlements and a mobile, migrant population. In this paper, we focus specifically on the perceptions, opinions and experiences of both adult women and key informants with respect to induced abortion and postabortion care in peri-urban Yangon. STUDY DESIGN: In 2014, we conducted 18 key informant interviews with individuals working in reproductive health in peri-urban Yangon and seven focus group discussions with health service providers (n=2) and adult women (n=5). We analyzed these data for content and themes using a multiphased iterative approach. RESULTS: In peri-urban Yangon, unsafe abortion appears to be common and is largely provided by traditional birth attendants. Women use a range of mechanical, medication and traditional methods, often in combination. Postabortion care is available but misinformation and fear of harassment keep many women from accessing timely care. CONCLUSION: Efforts to reform the highly restrictive abortion law in Myanmar combined with implementation of harm reduction strategies have the potential to greatly improve a neglected area of women's health. Future research on the cost of unsafe abortion to the public sector could be instrumental in achieving legal and service delivery reform. IMPLICATIONS: Measures to increase access to safe, legal abortion care and reduce harm from unsafe abortion need to be expanded. Developing strategies to liberalize Myanmar's abortion law, raising awareness about misoprostol, training clinicians to provide woman-centered postabortion care and documenting the cost of unsafe abortion to the public sector appear warranted.

[Bioethics is dead. Long live medical ethics!]. / La Bioética ha Muerto. ¡Viva la Ética Médica!

The purpose of this paper is to show a paradigmatic crisis in academic bioethics. Since an important part of bioethicists began to relativize the ethical prohibition of killing an innocent human being, one way or another they began to ally with the death industry: the business of abortion, and then that of euthanasia. The thesis of this paper is that by crossing that Rubicon bioethics has been corrupted and has lost its connection to the ethical, political and legal discourse. One can only hope that it will revive from its ashes if it retakes the ″taboo″ of the sacredness of human life, something for which medical ethics could provide invaluable help, because it still keeps the notion that ″a doctor should not kill″, although in an excessively ″discreet″ and somehow ″ashamed″ way. However, conscientious doctors know more about ethics than most bioethicists.

Unsafe abortion requiring hospital admission in the Eastern Highlands of Papua New Guinea--a descriptive study of women's and health care workers' experiences.

BACKGROUND: In Papua New Guinea induced abortion is restricted under the Criminal Code Law. Unsafe abortions are known to be widely practiced and sepsis due to unsafe abortion is a leading cause of maternal mortality. METHODS: We undertook a six month, prospective, mixed methods study at the Eastern Highlands Provincial Hospital. Semi structured and in depth interviews were undertaken with women presenting following induced abortion. This paper describes the reasons why women resorted to unsafe abortion, the techniques used, decision to seek post abortion care and women's reflections post abortion. RESULTS: 28 women were admitted to hospital following an induced abortion. Reasons for inducing an abortion included: wanting to continue with studies, relationship problems and socio-cultural factors. Misoprostol was the most frequently used method to end the pregnancy. Physical and mechanical means, traditional herbs and spiritual beliefs were also reported. Women sought care post abortion due to excessive vaginal bleeding, and severe abdominal pain with some afraid they would die if they did not seek help. CONCLUSION: In the absence of contraceptive information and services to avoid, postpone or space pregnancies, women in this setting are resorting to unsafe means to end an unwanted pregnancy, putting their lives at risk. Women need access to safe, effective means of abortion.

Personal Beliefs and Professional Responsibilities: Ethiopian Midwives' Attitudes toward Providing Abortion Services after Legal Reform.

In 2005, Ethiopia liberalized its abortion law and subsequently authorized midwives to offer abortion services. Using a 2013 survey of 188 midwives and 12 interviews with third-year midwifery students, this cross-sectional research examines midwives' attitudes toward abortion to understand their decisions about service provision. Most midwives were willing to provide abortion services. This willingness was positively and significantly related to clinical experience with abortion, but negatively and significantly related to religiosity, belief that providers have the right to refuse to provide services, and care of patients from periurban as opposed to rural areas. No significant relationship was found with perceptions of abortion stigma, years of work as a midwife, or knowledge of the law. Interview data suggest complex dynamics underlying midwives' willingness to offer services, including conflicts between professional norms and religious beliefs. Findings can inform Ethiopia's efforts to reduce maternal mortality through task-shifting to midwives and can aid other countries that are confronting provider shortages and high levels of maternal mortality and morbidity, particularly due to unsafe abortion.

Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states.

OBJECTIVE: To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health. DESIGN: Population-based natural experiment. SETTING AND DATA SOURCES: Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011. MAIN OUTCOMES: Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR). INDEPENDENT VARIABLES: Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence. MAIN RESULTS: Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (ß-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (ß=-0.061 to -1.100), skilled attendance at birth (ß=-0.032 to -0.427), low birth weight (ß=0.149 to 2.166), all-abortion hospitalisation ratio (ß=-0.566 to -0.962), clean water (ß=-0.048 to -0.730), sanitation (ß=-0.052 to -0.758) and intimate-partner violence (ß=0.085 to 0.755). TFR showed an inverse association with MMR (ß=-14.329) and MMRAO (ß=-1.750) and a direct association with iAMR (ß=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates. CONCLUSIONS: Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.

Ethical and legal issues in cross-system practice in India: Past, present and future.

Recent changes in policies allowing practitioners of Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) to integrate into the mainstream of healthcare and also allowing practitioners of Ayurveda and Homoeopathy to perform medical termination of pregnancy (MTP) under the proposed amendment to the MTP bill have brought crosssystem practice into the limelight. We evaluate cross-system practice from its legal and ethical perspectives. Across judgments, the judiciary has held that cross-system practice is a form of medical negligence; however, it is permitted only in those states where the concerned governments have authorized it by a general or special order. Further, though a state government may authorize an alternative medicine doctor to prescribe allopathic medicines (or vice versa), it does not condone the prescription of wrong medicines or wrong diagnosis. Courts have also stated that prescribing allopathic medicines and misrepresenting these as traditional medicines is an unfair trade practice and not explaining the side-effects of a prescribed allopathic medicine amounts to medical negligence. Finally, the Supreme Court has cautioned that employing traditional medical practitioners who do not possess the required skill and competence to give allopathic treatment in hospitals and to let an emergency patient be treated by them is gross negligence. In the event of an unwanted outcome, the responsibility is completely on the hospital authorities. Therefore, there is an urgent need to abolish cross-system practice, invest in healthcare, and bring radical changes in health legislations to make right to healthcare a reality.