Socio-ecological influences on access to abortion care in Costa Rica: a qualitative analysis of key perspectives from clinical and policy stakeholders.

Costa Rica prohibits abortion except under narrow circumstances to save the pregnant person's life. The country boasts historically strong support for social policy and human rights, while also presenting a complex and restrictive abortion access landscape. From September 2021 to March 2022, we conducted 23 interviews with obstetrician-gynecologist (OB/GYN) physicians, OB/GYN medical residents, and policy stakeholders to explore the socio-ecological influences on abortion access in Costa Rica. We sampled clinicians and policy stakeholders from the Universidad de Ciencias Médicas listserv through snowball sampling and conducted semi-structured in-depth interviews in Spanish. We identified limited access to comprehensive sexual health education, lack of support from interpersonal networks, inadequate provider knowledge and training, financial and migratory status, and both provider and community stigma as substantial barriers to abortion access. This study addresses a gap in published research around the social determinants of abortion in Costa Rica and sheds light on the attitudes and opinions of the medical and policy stakeholder communities about abortion access. The results highlight the need for expanded access to comprehensive sexual health education, abortion-related training for healthcare providers, and increased programming efforts, such as funding, outreach, and implementation, to ensure comprehensive reproductive health services are available and accessible, especially for vulnerable populations in Costa Rica.

"Siempre me critican": barriers to reproductive health in Ocotal, Nicaragua / "Siempre me critican": barreras de acceso a la salud reproductiva en Ocotal, Nicaragua

OBJECTIVE: To identify perceived barriers to accessing reproductive health care according to the women of Ocotal, Nicaragua; describe their understanding of their reproductive rights; and document their opinions about Nicaragua's total ban on abortion. METHODS: From May to June 2014, three focus group discussions were held in Spanish with 17 women from two different neighborhoods (barrios) in the city of Ocotal, Nicaragua. A semi-structured discussion guide with open-ended questions was employed to elucidate local perspectives regarding the focus group discussions themes. RESULTS: Serious obstacles including 1) violence against women, 2) machismo, 3) criticism from others, and 4) lack of communication and education limit women's ability to make their own reproductive health decisions. Women had a pervasive lack of knowledge about reproductive rights and the international human rights documents that define them. In addition, due to religious and cultural ideologies, most women supported the country's total ban on abortion in most circumstances, with the possible exception of rape. CONCLUSIONS: Both men and women in Ocotal should be encouraged to participate in community-level programs designed to reduce the impact of the following obstacles to receiving reproductive health care: 1) violence against women and machismo; 2) insufficient, non-standardized sexual education and information about reproductive rights; and 3) poor communication within families and the community at large. Any future public health campaigns to address women's reproductive health needs in Ocotal should implement these types of programs, at the neighborhood level, to reduce stigma surrounding sexual health and activity.

OBJETIVO: Determinar cómo perciben las mujeres de Ocotal, Nicaragua, las barreras de acceso a la atención de salud reproductiva; describir sus conocimientos acerca de los derechos reproductivos; y consignar sus opiniones acerca de la prohibición total del aborto en Nicaragua. MÉTODOS: De mayo a junio del 2014, se establecieron tres grupos de discusión en español en los que participaron 17 mujeres de dos barrios diferentes de la ciudad de Ocotal. Se utilizó una guía de discusión semiestructurada que constaba de preguntas de respuesta libre para dilucidar las perspectivas locales con respecto a los temas del grupo de discusión. RESULTADOS: Los obstáculos graves, incluidos 1) la violencia contra la mujer, 2) el machismo, 3) las críticas por parte de otros, y 4) la falta de comunicación y formación, limitan la capacidad de las mujeres para tomar sus propias decisiones de salud reproductiva. Las mujeres mostraron una carencia generalizada de conocimientos acerca de sus derechos reproductivos y los documentos internacionales de derechos humanos que los definen. Además, como consecuencia de sus ideas religiosas y culturales, la mayor parte de las mujeres apoyaron la prohibición total del aborto en el país en la mayor parte de las circunstancias, con la posible excepción de la violación. CONCLUSIONES: Se debe alentar a los hombres y mujeres de Ocotal a participar en los programas comunitarios diseñados para reducir la repercusión de los siguientes obstáculos para obtener atención de salud reproductiva: 1) la violencia contra la mujer y el machismo; 2) la educación sexual no estandarizada y la información acerca de sus derechos reproductivos insuficientes; y 3) la comunicación deficiente dentro de las familias y en la comunidad en general. Con objeto de reducir el estigma en torno a la salud y la actividad sexuales, las futuras campañas de salud pública orientadas a tratar las necesidades de salud reproductiva de las mujeres de Ocotal deben llevar a cabo en los barrios estos tipos de programas.

"I have no choice": influences on contraceptive use and abortion among women in the Democratic Republic of the Congo

In 2015, the Democratic Republic of the Congo (DRC) recorded an estimated maternal mortality ratio of 693/100,000 live births. Strict abortion laws, high fertility rates, low contraceptive prevalence, and lack of emergency obstetric care all contribute to the high maternal mortality ratio. This study explored influences on contraceptive use and abortion in the DRC. Qualitative in-depth interviews were conducted with 32 women and 10 healthcare providers in four provinces. Participants were recruited at health centers and households in the study communities. Thematic analysis was used and identified that Congolese women's contraceptive decision-making was shaped by a range of external influences rather than their own independent decisions. Non-autonomous decisions and strict abortion laws influenced the methods used to abort a pregnancy, exposing risks of infection, complication, and fatality. These findings highlight that Congolese women's decisions about their fertility and family planning are constrained by policy and socio-cultural influences

Concordancia entre informacoes do SISPRENATAL e o recordatorio maternoem relacao à idade gestacional no momento do inicio do cuidado pre-natal / Agreement between SISPRENATAL and mother's recall for gestational age at prenatal care initiation

Comparou-se o início da atenção pré-natal durante o primeiro trimestre da gravidez (adequação do início do acompanhamento) a partir de entrevistas com as mulheres e a coleta de dados junto ao sistema de informações de saúde pré-natal (SISPRENATAL). Foram entrevistadas 238 mulheres que fizeram o pré-natal nas Unidades da Saúde da Família em Vespasiano, Minas Gerais. Informações sobre a idade gestacional e primeira visita pré natal foram coletadas. As entrevistas e a análise do SISPRENATAL indicaram que cerca de 30% das mulheres tiveram início de acompanhamento pré-natal inadequado. Entrevistas e os dados do SISPRENATAL tiveram um nível razoável de concordância pela análise de adequação da iniciação (Kappa=0,35; IC 95%: 0,22-0,48). A partir de modelos de regressão observou-se que a concordância foi mais provável quando as mulheres se recordavam dos procedimentos de acompanhamento ou quando não utilizaram o setor privado. O uso do setor privado (16,4%) foi associado a data mais tardia de inclusão da gestante no SISPRENATAL, quando comparado com as entrevistas. Em resumo, diferenças entre o recordatório materno e o SISPRENATAL foram associadas à não lembrança das informações por parte das mulheres entrevistadas e ao acompanhamento junto ao setor privado. Apesar dalimitação do viés de memória, o recordatório materno foi considerado mais fidedigno do que o SISPRENATAL na obtenção de dados sobre o início do acompanhamento da gestante na rede pública de saúde.

We compared the initiation of prenatal care during the first trimester of pregnancy (adequacy of initiation) between mother's recall and the prenatal health information system (SISPRENATAL). We asked 238 women that received prenatal care at Family Health Units in Vespasiano, Minas Gerais their gestational age at first prenatal visit. Both recall and SISPRENATAL indicated that 30% of women had inadequate initiation. There was fair agreement in the adequacy of initiation (Kappa=0.35, 95% CI: 0.22-0.48) between recall and SISPRENATAL. Through regression models, we found that agreement was more likely with mother's shorter recall period and non-use of the private sector. Use of the private sector (16.4%) was also correlated with a later date of initiation by SISPRENATAL than by mother's recall. In sum, differences in the adequacy of initiation between recall and SISPRENATAL were associated with longer recall periods and with use of the private sector. Despite the limitation of recall bias, mother's recall is preferable to SISPRENATAL for capturing the public use by the pregnant women.

Slowing the stork: Better health for women through family planning

Better Health for Women and Children through Family Planning. Population Council; 5-9 Oct. 1987

. World Health Organization

. International Planed Parenthood Federation

. UNICEF

. UNDP

. PNUD

. World Bank

. Banco Mundial