"We mostly focus on preventing pregnancy, we don't really focus on preventing HIV ": Young people's perceptions and priorities when preventing unplanned pregnancy and HIV.

In South Africa, the high rate of human immunodeficiency virus (HIV) infection among young people and unplanned pregnancies remains a concern. Using a qualitative approach, this study aimed to explore how young people between 18 and 24 years old perceive the risk of unplanned pregnancy and HIV, and how they give priority to and act to prevent both concerns. Fifty-four young people were recruited from three provinces in South Africa: KwaZulu-Natal, Eastern Cape, and Gauteng. Data collection took place between May and June in 2016. All data collection was carried out in person using a standardised discussion guide and a semi-structured interview guide in English. We conducted eight focus group discussions with young people and three in-depth interviews with young people who had become parents in their teens. We utilised thematic analysis grounded in a social constructionist framework to assess patterns and associations in the data. Respondents reported unplanned pregnancy and HIV as prevalent among their peers, but prioritised both concerns differently. Preventing pregnancy was a greater priority and threat than HIV. Respondents were less concerned about being infected with HIV which was perceived as invisible and not a death sentence because of the efficacy and ease of use of treatment. HIV was considered comparatively more manageable and less burdensome than other chronic illnesses and unplanned pregnancy. Our study suggests unplanned pregnancy and HIV prevention interventions should prioritise responding to young people's primary desire to control their fertility, but also encourage them to have holistic sexual and reproductive health goals that include HIV prevention. Our findings suggest a pressing need for biomedical therapies that offer combined HIV and pregnancy prevention for young people. Future programmes need to be agile and innovative in addressing young people's tendency to prioritise HIV and pregnancy differently, and they need to revive the sense of urgency to prevent HIV.

Client-reported quality of facility-managed medication abortion compared with pharmacy-sourced self-managed abortion in Bangladesh.

OBJECTIVE: We used the newly developed Abortion Care Quality Tool (ACQTool) to compare client-reported quality of medication abortion care by source (facility-managed vs pharmacy-sourced self-managed abortion (SMA)) in Bangladesh. METHODS: We leveraged exit and 30-day follow-up surveys collected to develop and validate the ACQTool collected at nongovernmental organisation (NGO)-supported or -operated facilities in the public and private sector and pharmacies from three districts in Bangladesh. We used bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by source (facility vs pharmacy). We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client sociodemographic characteristics. RESULTS: Of 550 abortion clients, 146 (26.5%) received a facility-managed medication abortion and 404 (73.5%) had a pharmacy-sourced SMA. Clients reported higher quality in facilities for five indicators, and higher in pharmacies for two indicators; the remaining 11 indicators were not different by source. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (adjusted odds ratio (aOR) 3.55; 95% CI 2.27 to 5.58) but lower odds of reporting high information provision (aOR 0.14; 95% CI 0.09 to 0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse event occurred (aOR 0.45; 95% CI 0.23 to 0.82). CONCLUSIONS: In Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable.

Developing and validating an abortion care quality metric for facility and out-of-facility settings: an observational cohort study in Bangladesh, Ethiopia, and Nigeria.

Background: Despite progress in assuring provision of safe abortion, substantial disparities remain in quality of abortion care around the world. However, no consistent, valid, reliable method exists to routinely measure quality in abortion care across facility and out-of-facility settings, impeding learning and improvement. To address this need, the Abortion Service Quality Initiative developed the first global standard for measuring quality of abortion care in low-income and middle-income countries. Methods: This prospective cohort study was conducted in Bangladesh, Ethiopia, and Nigeria in 2020-2022. Participants included sites and providers offering abortion care, including health facilities, pharmacies, proprietary and patent medicine vendors (PPMVs), and hotlines, and clients aged 15-49 receiving abortion care from a selected site. 111 structure and process indicators were tested, which originated from a review of existing abortion quality indicators and from qualitative research to develop additional client-centred quality indicators. The indicators were tested against 12 clinical and client experience outcomes at the site-level (such as abortion-related deaths) and client-level (such as whether the client would recommend the service to a friend) that were expected to result from the abortion quality indicators. Indicators were selected for the final metric based on predictive validity assessed using Bayesian models to test associations between indicators and outcomes, content validity, and performance. Findings: We included 1915 abortion clients recruited from 131 sites offering abortion care across the three countries. Among the 111 indicators tested, 44 were associated with outcomes in Bayesian analyses and an additional 8 were recommended for inclusion by the study's Resource Group for face validity. These 52 indicators were evaluated on content validity, predictive validity, and performance, and 29 validated indicators were included in the final abortion care quality metric. The 29 validated indicators were feasibility tested among 53 clients and 24 providers from 9 facility sites in Ethiopia and 57 clients and 6 PPMVs from 9 PPMV sites in Nigeria. The median time required to complete each survey instrument indicated feasibility: 10 min to complete the client exit survey, 16 min to complete the provider survey, and 11 min to complete the site checklist. Overall, the indicators performed well. However, all providers in the feasibility test failed two indicators of provider knowledge to competently complete the abortion procedure, and these indicators were subsequently revised to improve performance. Interpretation: This study provides 29 validated abortion care quality indicators to assess quality in facility, pharmacy, and hotline settings in low-income and middle-income countries. Future research should validate the Abortion Care Quality (ACQ) Tool in additional abortion care settings, such as telemedicine, online medication abortion (MA) sellers, and traditional abortion providers, and in other geographical and legal settings. Funding: The David and Lucile Packard Foundation and the Children's Investment Fund Foundation.

Quality of care from the perspective of people obtaining abortion: a qualitative study in four countries.

OBJECTIVE: This qualitative study aimed to identify person-centred domains that would contribute to the definition and measurement of abortion quality of care based on the perceptions, experiences and priorities of people seeking abortion. METHODS: We conducted interviews with people seeking abortion aged 15-41 who obtained care in Argentina, Bangladesh, Ethiopia or Nigeria. Participants were recruited from hospitals, clinics, pharmacies, call centres and accompaniment models. We conducted thematic analysis and quantified key domains of quality identified by the participants. RESULTS: We identified six themes that contributed to high-quality abortion care from the clients' perspective, with particular focus on interpersonal dynamics. These themes emerged as participants described their abortion experience, reflected on their interactions with providers and defined good and bad care. The six themes included (1) kindness and respect, (2) information exchange, (3) emotional support, (4) attentive care throughout the process, (5) privacy and confidentiality and (6) prepared for and able to cope with pain. CONCLUSIONS: People seeking abortion across multiple country contexts and among various care models have confirmed the importance of interpersonal care in quality. These findings provide guidance on six priority areas which could be used to sharpen the definition of abortion quality, improve measurement, and design interventions to improve quality.

Emotional, informational, and decision-making support needs among people seeking abortion in the US: perspectives from All-Options Talkline callers.

People seeking abortion may need or want emotional or informational support before, during, and after their abortion. Feeling supported and affirmed contributes to perceptions of quality care. The All-Options Talkline offers free, telephone-based, peer counselling to callers anywhere in the United States. This study aimed to explore the types of support received through the Talkline and the ways it supplemented other forms of support received by people who obtained an abortion. Between May 2021 and February 2022, we conducted 30 interviews via telephone or Zoom with callers recruited through the Talkline. We coded the interviews and conducted thematic analysis, focusing on themes related to gaps of support from family, friends, and healthcare professionals, as well as types of support received through the Talkline. We identified four key motivations for calling the Talkline, including the need for (1) decision-making support and validation, (2) a neutral perspective, (3) emotional support to discuss negative or complex feelings, and (4) information about the abortion process. Participants indicated that interactions with family, friends, and healthcare professionals ranged from unsupportive and negative, to substantially supportive. Access to the Talkline was particularly useful prior to clinical interactions and in the weeks or months after an abortion. We found that the All-Options Talkline provided person-centred, remote support for callers, filling gaps or supplementing support from one's community or healthcare professionals. Abortion support from non-medically trained support people contributes to high-quality abortion care, especially in a time of increasing abortion restrictions and use of remote abortion services.

Applying a One Health lens to understanding the impact of climate and environmental change on healthcare-associated infections.

The pace and trajectory of global and local environmental changes are jeopardizing our health in numerous ways, among them exacerbating the risk of disease emergence and spread in both the community and the healthcare setting via healthcare-associated infections (HAIs). Factors such as climate change, widespread land alteration, and biodiversity loss underlie changing human-animal-environment interactions that drive disease vectors, pathogen spillover, and cross-species transmission of zoonoses. Climate change-associated extreme weather events also threaten critical healthcare infrastructure, infection prevention and control (IPC) efforts, and treatment continuity, adding to stress to strained systems and creating new areas of vulnerability. These dynamics increase the likelihood of developing antimicrobial resistance (AMR), vulnerability to HAIs, and high-consequence hospital-based disease transmission. Using a One Health approach to both human and animal health systems, we can become climate smart by re-examining impacts on and relationships with the environment. We can then work collaboratively to reduce and respond to the growing threat and burden of infectious diseases.

Challenges accessing contraceptive care and interest in over-the-counter oral contraceptive pill use among Black, Indigenous, and people of color: An online cross-sectional survey.

OBJECTIVE: To examine challenges accessing contraception in the past year and their association with interest in using an over the counter (OTC) oral contraceptive pill (OCP) among Black, Indigenous, and people of color (BIPOC) in the United States. STUDY DESIGN: From May 2021 to March 2022, a collaborative research team conducted a cross-sectional online survey using convenience sampling to recruit people who identify as Asian American, Native Hawaiian, or Pacific Islander, Black or African American, Indigenous, or Latina/Latinx and used or wanted to use a contraceptive method in the past year. Respondents were recruited through reproductive justice and community-based organizations. RESULTS: Among 727 respondents, 45% reported experiencing at least one challenge accessing contraception in the past year of which 37% reported a logistical challenge, and 20% reported an interpersonal challenge. Sixty-seven percent of respondents said they were likely to use an OTC OCP. Respondents who reported experiencing at least one challenge accessing contraception in the past year were more likely to say they would use an OTC OCP. Fifty-seven percent of respondents who were not using a contraceptive method in the past year reported they were likely to use an OTC OCP. CONCLUSION: Among people in this study, interest in an OTC OCP is high, particularly among those who have faced challenges accessing contraception, and among those who are not currently using a contraceptive method. IMPLICATIONS: Availability of an OCP OTC has the potential to address challenges accessing contraceptive care among BIPOC in the United States, who are often impacted by structural inequities and racism. Findings from this study can inform future OTC implementation strategies to ensure OTC access addresses logistical and interpersonal challenges.

Comparing preference for and use of medication abortion in Texas after policy changes in 2014 and 2018.

OBJECTIVES: Assess preferences for and use of medication abortion in Texas after implementation of two policy changes: a 2013 state law restricting medication abortion and the FDA label change for mifepristone in 2016 nullifying some of this restriction. STUDY DESIGN: We analyzed surveys conducted in 2014 and 2018 with abortion patients at 10 Texas abortion facilities. We calculated the percentage of all respondents with an initial preference for medication abortion by survey year, and the type of abortion obtained or planned to obtain among those who were at <10 weeks of gestation. We used multivariable-adjusted mixed-effects Poisson regression models to assess factors associated with medication abortion preference and actual/planned use. RESULTS: Overall, 156 (41%) of 376 respondents in 2014 and 247 (55%) of 448 respondents in 2018 reported initial preference for medication abortion (Prevalence ratio [PR]: 1.28; 95% CI 1.03-1.59). Among those who were <10 weeks of gestation and initially preferred medication abortion, 39 of 124 (31%) obtained or were planning to obtain the method in 2014, compared with 188 of 223 (84%) in 2018 (PR: 2.65; 95% CI: 1.69-4.15). After multivariable adjustment, respondents who initially preferred medication abortion and were 7 to 9 weeks of gestation at the time of their ultrasonography (vs <7 weeks) were less likely to obtain or plan to obtain the method (PR: 0.69; 95% CI: 0.57-0.84). CONCLUSIONS: Abortion patients were more likely to prefer and obtain or plan to obtain their preferred medication abortion after legal restrictions in Texas were nullified. IMPLICATIONS: State policies can affect people's ability to obtain their preferred abortion method. Efforts to provide both abortion options whenever possible, and inform people where each can be obtained, remains an important component of person-centered care despite increasing state abortion restrictions and bans following the reversal of Roe v Wade.

"I was afraid they will be judging me and even deny me the service": Experiences of denial and dissuasion during abortion care in Ethiopia.

Introduction: Disrespect and abuse are components of poor quality abortion care. This analysis aimed to understand negative experiences of care from perspectives of abortion clients in public and private facilities in Ethiopia. Study Design: We conducted 23 in-depth interviews with people who obtained abortion care in Addis Ababa, Ethiopia as well as Aksum and Mekele in Tigray State, Ethiopia. The interviews were coded using a priori and emergent codes and we conducted thematic analysis to understand negative interactions with providers from participant's perspectives. Results: Participants experienced denial of abortion services along their pathway to care and attempts by providers to dissuade them prior to providing an abortion. Underlying both the denial and the dissuasion were reports of disrespect and condemnation from providers. Participants described how providers doubted or forced them to justify their reasons for having an abortion, stigmatized them for seeking multiple abortions or later abortions, and ascribed misinformation about abortion safety. Despite reports of denial, dissuasion, and disrespect, abortion clients generally felt that providers had their best interest at heart and were grateful for having access to an abortion. Conclusions: Participants in Ethiopia experienced providers as gatekeepers to legal abortion services, facing disrespect and judgment at facilities where they sought care. Interventions aimed at increasing awareness of abortion laws such that clients understand their rights and values clarification interventions for providers could help reduce barriers to accessing care and improve the quality of abortion services.

The influence of feminist abortion accompaniment on emotions related to abortion: A longitudinal observational study in Mexico.

Emotions can reflect how individuals internalize identities, social roles, and broader power structures, including abortion stigma. Abortion accompaniment, in the form of logistical, informational, and emotional support offered by individuals and organizations, takes a person-centered, feminist, and rights-based approach. We tested the extent to which abortion accompaniment may decrease negative and increase positive feelings an individual holds related to their abortion. Using observational longitudinal data collected between January 2017 and mid-2018, we compared negative and positive emotional responses to a personal abortion experience one month and six months following the abortion to emotions immediately prior to the abortion ("baseline"), among women travelling from outside of Mexico City to abortion clinics in Mexico City with and without support of the accompaniment organization, Fondo MARIA. We used doubly robust longitudinal mixed effects models with inverse probability weighting methods. At baseline, accompanied and unaccompanied participants experienced an average of 4.9 and 4.4 negative emotions out of eight respectively (i.e., anguish, nervousness, scared, anxious, sadness, guilt, anger, shame) and 1.7 and 1.9 positive emotions of out 4 respectively (happiness, calmness, decidedness, and relief). From our model results, women accompanied (n = 77) had larger decreases in negative feelings (p < .05) and larger increases in positive feelings (p < .01) toward their abortion compared to those who were not accompanied (n = 119) at six months. These changes led the majority of accompanied respondents to have primarily positive feelings about their abortion by endline. Abortion accompaniment through Fondo MARIA in Mexico City was associated with a larger decrease in negative feelings, particularly those related to stigma, and a larger increase in positive feelings six months after abortion. Accompaniment's focus on person-centered support, self-determination, and autonomy may enable people seeking abortion to view their decision as one that is valid and legitimate, and resist the predominant stigmatizing narratives framing abortion as something that is transgressive.

Toward a Standard Measure of Abortion Service Quality-A Stakeholder First Approach.

Measurement of the quality of abortion services is essential to service improvement. Currently, its measurement is not standardized, and some of the tools which exist are very long, and may deter use. To address this issue, this study describes a process used to create a new, more concise measure of abortion care quality, which was done with the end users in mind. Using a collaborative approach and engaging numerous stakeholders, we developed an approach to defining and selecting a set of indicators, to be tested against abortion outcomes of interest. Indicators were solicited from 12 abortion service provision entities, cataloged, and grouped within a theoretical framework. A resource group of over 40 participants was engaged through surveys, webinars, and one in-person meeting to provide input in prioritizing the indicators. We began with a list of over 1,000 measures, and engaged stakeholders to reduce the list to 72 indicators for testing. These indicators were supplemented with an additional 39 indicators drawn from qualitative research with clients, in order to ensure the client perspective is well represented. The selected indicators can be applied in pharmacies, facilities, or with hotlines, and for clients of surgical or medical abortion services in all countries. To ensure that the final suggested measures are most impactful for service providers, indicators will be tested against outcomes from 2,000 abortion clients in three countries. Those indicators which are well correlated with outcomes will be prioritized.

Perspectives on high-quality interpersonal care among people obtaining abortions in Argentina.

INTRODUCTION: Little is known about how people who have abortions describe high-quality interpersonal care in Argentina. This qualitative study aimed to understand preferences and priorities in their interactions with providers. STUDY DESIGN: We conducted 24 in-depth interviews with people who obtained abortions at a comprehensive reproductive health clinic or with support from a feminist accompaniment group in Buenos Aires and Neuquén, Argentina. We iteratively coded transcripts using a thematic analysis approach based on interpersonal domains present in current quality of care frameworks. RESULTS: Participants described high-quality abortion care as feeling acompañamiento and contención from their providers - terms that imply receiving kind, caring, compassionate and emotionally supportive care throughout their abortion. They described four key elements of interpersonal interactions: attentive communication from providers and accompaniers, clear and understandable information provision, non-judgmental support, and individualized options for pain management. CONCLUSIONS: People obtaining abortions in Argentina consistently identified receiving compassionate and supportive care throughout an abortion as a key aspect of care. The findings have implications for incorporating people's perspectives in the development of care guidelines, training of providers, and monitoring and improving of services. This is particularly important as the government of Argentina prepares to expand legal access to abortion.

Little is known about how people who have abortions perceive the quality of the care they receive and what aspects of interpersonal interactions with providers matter to them. This qualitative study aimed to understand preferences of  people who had abortions at both a reproductive health clinic and with an accompaniment group in Argentina. We interviewed 24 people who obtained abortion care in Buenos Aires and Neuquén, Argentina. We asked them about their preferences for and experiences of abortion care. Then we analyzed the interviews, specifically assessing aspects of interpersonal care based on quality of care frameworks from the literature. Participants described high-quality abortion care as feeling acompañamiento and contención from their providers­terms that imply receiving kind, caring, compassionate and emotionally supportive care throughout their abortions. They described four key elements of interpersonal interactions: attentive communication from providers and accompaniers, clear and understandable information provision, non-judgmental support, and individualized options for pain management. In conclusion, people obtaining abortions in two distinct models of care in Argentina consistently identified receiving compassionate and supportive care throughout an abortion as a key aspect of care. The findings have implications for incorporating people's perspectives in the development of care guidelines, training of providers, and monitoring and improving of services. This is particularly important as the government of Argentina prepares to expand legal access to abortion.

"I just have to hope that this abortion should go well": Perceptions, fears, and experiences of abortion clients in Nigeria.

This qualitative study aimed to examine how abortion clients in Nigeria perceive abortion and explore the role their beliefs and fears play in their care-seeking experiences and interactions with providers. Abortion is severely legally restricted in Nigeria but remains common. We conducted in-depth interviews with 25 people who obtained abortion services through three distinct models of care. We coded interview transcripts and conducted thematic analysis. Clients perceived negative attitudes toward abortion in their communities, though clients' own beliefs were more nuanced. Clients recounted a range of fears, and nearly all mentioned worrying that they might die as a result of their abortion. Despite their concerns, clients relied on social networks and word-of-mouth recommendations to identify providers they perceived as trustworthy and safe. Kind and non-judgmental treatment, clear instructions, open communication, and reassurance of privacy and confidentiality by providers alleviated client fears and helped clients feel supported throughout their abortion process. Within restrictive contexts, the mobilization of information networks, provision of high-quality care through innovative models, and personalization of care to individual needs can assuage fears and contribute to reducing stigma and increasing access to safe abortion services.

Exploring Experiences Responding to the Individual Level Abortion Stigma Scale: Methodological Considerations From In-depth Interviews.

Background: The Individual-Level Abortion Stigma (ILAS) scale is a tool to measure multiple dimensions of stigma among people who have abortions. Despite use of the scale globally, little is known about participant experiences completing the scale. We assessed reactions to and experiences with the scale among women who obtained abortions in Mexico, exploring how the items made them feel about themselves and their abortion. Methods: We conducted 10 in-depth interviews with women approximately 6 months after their abortion. We explored experiences answering the ILAS overall as well as each sub-scale (self-judgement; worries about judgement; isolation; community condemnation). We used thematic analysis to examine overall experiences with the ILAS and framework analysis to summarize responses by sub-scale. Results: Many respondents reported positive experiences responding to the scale or said it served a therapeutic purpose. Other participants said the scale caused strong or mixed emotions or generated doubts. Women generally described mixed and negative reactions to the "worries about judgement" and "community condemnation" sub-scales, and more neutral or positive reactions to the "isolation" and "self judgement" sub-scales. Nearly all respondents hypothesized that completing the ILAS at the time of their abortion would be more difficult than responding months after their abortion. Conclusions: People can experience both positive and negative effects when responding to abortion stigma scales. Use of the scales may cause discomfort and introduce concepts that further perpetuate stigma. This study highlights the importance of carefully considering when it is appropriate to implement the scale and exploring safeguards for participants.

Abortion quality of care from the client perspective: a qualitative study in India and Kenya.

Quality healthcare is a key part of people's right to health and dignity, yet access to high-quality care can be limited by legal, social and economic contexts. There is limited consensus on what domains constitute quality in abortion care and the opinions of people seeking abortion have little representation in current abortion quality measures. In this qualitative study, we conducted 45 interviews with abortion clients in Mumbai, India, and in Eldoret and Thika, Kenya, to assess experiences with abortion care, definitions of quality and priorities for high-quality abortion care. Among the many aspects of care that mattered to clients, the client-provider relationships emerged as essential. Clients prioritized being treated with kindness, respect and dignity; receiving information and counselling that was personalized to their individual situation and reassurance and support from their provider throughout the entire abortion process, including follow-up after the abortion. Many clients also noted the importance of skilled providers and appropriate care. There were similarities across the two country contexts, yet there were some differences in how clients defined high-quality care; therefore, specific political and cultural influences must be considered when implementing measurement and improving person-centred quality of care. These domains, particularly interpersonal interactions, should be prioritized in India and Kenya when health systems, facilities and providers design person-centred measures for quality in abortion care.

Perspectives on self-managed abortion among providers in hospitals along the Texas-Mexico border.

BACKGROUND: Following self-managed abortion (SMA), or a pregnancy termination attempt outside of the formal health system, some patients may seek care in an emergency department. Information about provider experiences treating these patients in hospital settings on the Texas-Mexico border is lacking. METHODS: The study team conducted semi-structured interviews with physicians, advanced practice clinicians, and nurses who had experience with patients presenting with early pregnancy complications in emergency and/or labor and delivery departments in five hospitals near the Texas-Mexico border. Interview questions focused on respondents' roles at the hospital, knowledge of abortion services and laws, perspectives on SMA trends, experiences treating patients presenting after SMA, and potential gaps in training related to abortion. Researchers conducted interviews in person between October 2017 and January 2018, and analyzed transcripts using a thematic analysis approach. RESULTS: Most of the 54 participants interviewed said that the care provided to SMA patients was, and should be, the same as for patients presenting after miscarriage. The majority had treated a patient they suspected or confirmed had attempted SMA; typically, these cases required only expectant management and confirmation of pregnancy termination, or treatment for incomplete abortion. In rare cases, further clinical intervention was required. Many providers lacked clinical and legal knowledge about abortion, including local resources available. CONCLUSIONS: Treatment provided to SMA patients is similar to that provided to patients presenting after early pregnancy loss. Lack of provider knowledge about abortion and SMA, despite their involvement with SMA patients, highlights a need for improved training.

Border-state abortions increased for Texas residents after House Bill 2.

OBJECTIVES: To assess changes in Texas-resident border-state abortions, medication abortions, and abortions ≥22 weeks from last menstrual period (LMP) before and after implementation of House Bill 2 (HB2) in November 2013 and before and after the US Supreme Court's decision regarding HB2 in June 2016. STUDY DESIGN: We conducted an interrupted time series analysis using 2012-2017 data on Texas-resident abortions in Arkansas, Louisiana, Oklahoma, and New Mexico. Data on procedure type and gestational age were available only for abortions in New Mexico. RESULTS: Border states reported 762 Texas-resident abortions in 2012, 1,673 in 2014, and 1,475 in 2017. Texas-resident abortions in all border states nearly doubled following HB2's implementation (incidence rate ratio [IRR]=1.92, 95% CI: 1.67-2.20). Border-state abortions then decreased by 19% after the 2016 US Supreme Court decision, compared to the period prior to the decision and after HB2's implementation (IRR=0.81, 95% CI: 0.73-0.91). From 2012 to 2014, the proportion of Texas-resident abortions in New Mexico that were medication abortion increased from 5% to 20% (p < 0.001) and the proportion that were ≥22 weeks from LMP decreased from 40% to 23% (p < p<0.001). Texas vital statistics undercounted annual out-of-state abortions, reporting only 13%-73% of abortions reported by border-state clinics during the study period. CONCLUSIONS: HB2 was associated with increases in border-state abortions for Texas residents, including in the number of those ≥22 weeks from LMP. Border-state abortions declined after the Supreme Court ruled HB2 unconstitutional yet remained higher than pre-HB2 levels. IMPLICATIONS STATEMENT: Abortion restrictions that severely curtail access may result in increases in travel out of state for care. Documenting out-of-state abortions is important for evaluating broader policy impacts and to prepare for future service disruptions. Texas residents may have more limited options for care if border states enact restrictive abortion laws.

Factors influencing abortion decisions, delays, and experiences with abortion accompaniment in Mexico among women living outside Mexico City: results from a cross-sectional study.

Access to abortion throughout much of Mexico has been restricted. Fondo Maria is an abortion accompaniment fund that provides informational, logistical, financial, and emotional support to people seeking abortion care in Mexico. This cross-sectional study examines the factors that influenced decision-making and contributed to delays in accessing care and explores experiences with Fondo Maria's support among women living outside Mexico City (CDMX). We describe and compare the experiences of women across the sample (n = 103) who were either supported by Fondo Maria to travel to CDMX to obtain an abortion (n = 60), or self-managed a medical abortion in their home state (n = 43). Data were collected between January 2017 and July 2018. Seventy-seven percent of participants reported that it was difficult to access abortion care in their home state and 34% of participants indicated they were delayed in accessing care, primarily due to a lack of financial support. The majority of participants (58%) who travelled to CDMX for their abortion did so because it seemed safer. The money/cost of the trip was the most commonly cited reason (33%) why participants who self-managed stayed in their home state. Eighty-seven percent of participants said Fondo Maria's services met or exceeded their expectations. Our data suggest that people seeking abortion and living outside CDMX face multiple and overlapping barriers that can delay care-seeking and influence decision-making. Abortion accompaniment networks, such as Fondo Maria, offer a well-received model of support for people seeking abortion in restrictive states across Mexico.

"It's not a seven-headed beast": abortion experience among women that received support from helplines for medication abortion in restrictive settings.

There are a growing number of abortion helplines where counselors provide person-centered medication abortion services in legally restrictive settings. Few researchers have explored the perceptions and experiences of the people who obtain support from these helplines. Between April and August 2017, we conducted 30 interviews with women who had a medication abortion with support from helpline counselors in Poland, Brazil, or Nigeria. Before seeking care with the helpline, women often heard negative stories about abortion and faced enacted stigma from the formal healthcare sector, or chose not to seek services from their doctors due to fear of stigmatizing treatment. Conversely, during their care with the helpline counselors, women received clear information in a timely manner, and were treated with kindness, compassion, respect, and without judgment. Many women gained knowledge and understanding of medication abortion, and some gained a sense of community among those who experienced abortion. Helpline models can provide high-quality, person-centered abortion care to people seeking abortions in legally restrictive contexts. Evidence from these service-delivery models could help improve service within the formal healthcare systems and expand access to high-quality, safe abortion by redefining what it means to provide care.

Addressing Abortion Provider Stigma: A Pilot Implementation of the Providers Share Workshop in Sub-Saharan Africa and Latin America.

CONTEXT: In much of Sub-Saharan Africa and Latin America, abortion is legally restricted, and abortion providers experience stigma and legal jeopardy. The Providers Share Workshop group intervention has been shown to reduce provider stigma in the United States, but has not been evaluated in other settings. METHODS: In 2014-2015, the Providers Share Workshop was adapted and piloted among 59 abortion caregivers from three Sub-Saharan African countries and 93 caregivers from seven Latin American countries. Survey data collected before, directly following and six months after each workshop measured stigma, attitudes, and legal safety and advocacy engagement, using original items and adapted scales. Univariate analyses and baseline pairwise correlations were used to measure changes in outcomes over time, and between demographic characteristics and outcomes. Mixed-effects linear regressions and multivariable models controlling for demographics were used to assess changes in outcomes over time. RESULTS: Six months after workshop participation, total abortion stigma had decreased among caregivers in Sub-Saharan Africa and in Latin America (beta coefficients, -0.2 and -0.4, respectively). Unfavorable attitudes had decreased in Africa (-0.2) but not in Latin America, where attitudes were favorable to start; emotional exhaustion and depersonalization also had decreased in Africa (-2.9 and -1.2), and legal safety had increased (0.8). Increased total abortion stigma was negatively associated with legal safety, in both Africa and Latin America (-1.9 and -0.6), and with legal advocacy in Africa (-1.5). CONCLUSIONS: The Providers Share Workshop is a promising intervention to support the abortion care workforce in Sub-Saharan African and Latin American settings.

RESUMEN Contexto: En gran parte del África subsahariana y América Latina, el aborto está legalmente restringido y los proveedores de servicios de aborto experimentan estigma y riesgo legal. Se ha demostrado que la intervención grupal del Taller de Proveedores para Compartir Experiencias reduce el estigma del proveedor en los Estados Unidos, pero no se ha evaluado en otros entornos. Métodos: Entre 2014 y 2015, el Taller de Proveedores para Compartir Experiencias fue adaptado y puesto a prueba entre 59 proveedores de servicios de aborto de tres países del África subsahariana y 93 proveedores de servicios de siete países latinoamericanos. Los datos de la encuesta recopilados antes, inmediatamente después y seis meses después de cada taller, mediante el uso de elementos originales y escalas adaptadas, midieron el estigma, las actitudes y la seguridad jurídica, así como el compromiso con la defensa y promoción del aborto. Se utilizaron análisis univariados y correlaciones de referencia por pares para medir los cambios en los resultados a través del tiempo y entre la demografía y los resultados. Se utilizaron regresiones lineales de efectos mixtos y modelos multivariables que controlan las variables demográficas para evaluar los cambios en los resultados a través del tiempo. Resultados: Seis meses después de la participación en el taller, el estigma total del aborto había disminuido entre los proveedores en África y América Latina (coeficientes beta, ­0.2 y ­0.4, respectivamente). Las actitudes desfavorables habían disminuido en África (­0.2) pero no en América Latina, donde las actitudes eran favorables para el inicio; el desgste emocional y la despersonalización también habían disminuido en África (­2.9 y ­1.2, respectivamente) y la seguridad legal había aumentado (0.8). El aumento del estigma total del aborto se asoció negativamente con la seguridad jurídica, tanto en África como en América Latina (coeficientes beta, ­1.9 y ­0.6, respectivamente) y con la defensa jurídica en África (­1.5). Conclusiones: El Taller de Proveedores para Compartir Experiencias es una intervención prometedora para apoyar a la fuerza laboral de atención del aborto en entornos de África subsahariana y América Latina.

RÉSUMÉ Contexte: Dans une grande partie de l'Afrique subsaharienne et de l'Amérique latine, l'avortement est limité par la loi et ses prestataires sont en proie à la stigmatisation et au péril judiciaire. Comme l'indiquent les études, l'intervention du groupe Providers Share Workshop réduit cette stigmatisation aux États-Unis; elle n'a cependant pas été évaluée dans d'autres contextes. Méthodes: En 2014­2015, l'atelier Providers Share Workshop a été adapté et piloté auprès de 59 membres du personnel de soins de l'avortement de trois pays d'Afrique subsaharienne et 93 soignants de sept pays d'Amérique latine. Les données d'enquête collectées avant, directement après et six mois après chaque atelier ont mesuré la stigmatisation, les attitudes et l'engagement de sécurité et de défense juridique sur la base des questions originales et d'échelles adaptées. Les changements de résultats au fil du temps, et entre les caractéristiques démographiques et les résultats, ont été mesurés par analyses univariées et par corrélations par paires de référence. Des régressions linéaires à effets mixtes et des modèles multivariés tenant compte des caractéristiques démographiques ont servi à évaluer les changements de résultats au fil du temps. Résultats: Six mois après la participation à l'atelier, la stigmatisation totale de l'avortement s'était réduite parmi le personnel soignant d'Afrique et d'Amérique latine (coefficients bêta de ­0,2 et ­0,4, respectivement). Les attitudes défavorables étaient en baisse en Afrique (­0,2) mais pas en Amérique latine, où les attitudes étaient favorables dès le début; l'épuisement affectif et la dépersonnalisation étaient en baisse aussi en Afrique (­2,9 et ­1,2, respectivement), tandis que la sécurité juridique était en hausse (0,8). Une stigmatisation totale supérieure de l'avortement s'est révélée associée négativement avec la sécurité juridique, en Afrique aussi bien qu'en Amérique latine (coefficients bêta de ­1,9 et ­0,6, respectivement), et avec la défense juridique en Afrique (­1,5). Conclusions: L'atelier Providers Share Workshop est une intervention prometteuse de soutien du personnel de soins de l'avortement en Afrique subsaharienne et en Amérique latine.