Extra-legal abortion and post-abortion care knowledge, attitudes, and practices among obstetrician-gynecologist clinicians and medical residents in San José, Costa Rica: a qualitative study.

BACKGROUND: Induced abortion in Costa Rica is illegal in all cases except to save the life of the pregnant person. Despite severe restrictions to legal abortion, individuals in Costa Rica still induce abortions outside of the formal healthcare system. These individuals and those with spontaneous abortions, also known as miscarriages, occasionally need medical care for complications. In Costa Rica, an estimated 41% of unintended pregnancies end in abortion, yet there is very little published literature exploring the perspectives of healthcare providers on abortion in Costa Rica. METHODS: We interviewed ten obstetrician-gynecologist clinicians and five obstetrician-gynecologist medical residents in San José, Costa Rica about their beliefs and practices related to extra-legal abortion and post-abortion care (PAC) using a Spanish language in-depth semi-structured interview guide. After transcription and translation into English, analysis team pairs used a combination of deductive and inductive coding to identify themes and sub-themes within the data. RESULTS: Obstetrician-gynecologist clinicians and medical residents were aware of the presence of extra-legal abortion, and particularly, medication abortion, in their communities, but less familiar with dosing for induction. They expressed the desire to provide non-judgmental care and support their patients through extra-legal abortion and PAC journeys. Study participants were most familiar with providing care to individuals with spontaneous abortions. When discussing PAC, they often spoke about a policy of reporting individuals who seek PAC following an extra-legal abortion, without commenting on whether or not they followed the guidance. CONCLUSIONS: This study contributes to a gap in research about the knowledge, attitudes, and practices of Costa Rican obstetrician-gynecologist clinicians and medical residents around extra-legal abortion and PAC. The results reveal an opportunity to train these healthcare providers as harm reduction experts, who are able to accurately counsel individuals who are seeking abortion services outside of the healthcare system, and to provide training to improve care for individuals needing PAC.

Sustained impact of community-based interventions on contraceptive use among married adolescent girls in rural Niger: Results from a cluster randomized controlled trial.

OBJECTIVE: To evaluate the sustained impact of community-based family planning (FP) interventions on current modern contraceptive and long-acting reversible contraceptive (LARC) use among married adolescent girls in rural Niger. METHODS: We used a cluster randomized controlled trial design following married adolescent girls and their husbands over 3 years. Villages were randomized to one of four arms: household visits, small group discussions, combined intervention, or control. For 1.5 years, couples were exposed to one intervention activity per month and 1.5 years after implementation ended, we used a multi-level mixed effects logistic regression model to evaluate changes in key FP outcomes. RESULTS: We analyzed survey data from 404 married adolescent girls with data at baseline and endline. Small group discussions (+35.6%; adjusted odds ratio [aOR] 7.94, P < 0.001) and the combined intervention (+17.9%: aOR 4.53, P = 0.005) led to statistically significant increases in the odds of using modern contraceptives at endline compared with the control. The combined intervention (+14.2%; aOR 7.98, P < 0.001) and home visits (+12.6%; aOR 8.09, P < 0.001) led to statistically significant increases in odds of using LARC methods at endline compared with the control. Increase in LARC use was driven by implant use across all intervention groups. CONCLUSION: This study contributes to the empirical evidence base on the sustained impact of community-based interventions on increases in FP use among married adolescent girls in low- and middle-income countries.

Refugee and Internally Displaced Women's Abortion Knowledge, Attitudes and Practices: Addressing the Lack of Research in Low- and Middle-Income Countries.

Induced abortion is common: In 2017, an estimated 56% of all unintended pregnancies worldwide ended in abortion. Despite the frequency with which women terminate pregnancies, however, 135 countries impose restrictions on induced abortion beyond gestational age limits, which lead some women to seek unsafe abortion. The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating an unwanted pregnancy carried out by individuals who lack the requisite training and skills, in a setting that does not meet minimum medical standards, or both. An estimated 25 million unsafe abortions occur annually-nearly all (97%) in low- and middle-income countries (LMICs), where abortion is more likely to be heavily restricted. Unsafe abortion results in 22,800-31,000 maternal deaths each year. Furthermore, in developing regions, nearly seven of every 1,000 women are treated in a health facility for abortion complications. The legalization and derestriction of abortion are necessary steps in reducing maternal morbidity and mortality from unsafe abortion, but there are additional obstacles to services that must also be addressed.

Integrated Family Planning and Routine Child Immunization Services in Benin: A Process Evaluation.

INTRODUCTION: Integration of routine infant immunization and family planning services (FP/EPI) seeks to create opportunities for increased uptake of postpartum contraception. This evaluation assessed the implementation of a combined service provision model and experiences of postpartum women seeking services at integrated FP/EPI facilities in Benin. METHODS: We used a mixed qualitative methods design to conduct a process evaluation of services at eight facilities supported by CARE's HIN NOU VIVO! PROJECT: We facilitated focus group discussions with 56 postpartum women who attended integrated sessions, divided into family planning users and non-users. Using grounded theory methodology, we explored women's experiences with the integrated services. We conducted 159 patient flow analyses and evaluated fidelity to the integration model. RESULTS: Focus group participants responded positively to FP group education sessions during integrated FP/EPI days, but found the referral process confusing. Contraceptive use was motivated mainly by a desire for birth spacing, whereas fear of side effects and lack of spousal engagement were cited as reasons for contraceptive non-use. In four out of eight facilities, staffing shortages prevented FP group education sessions and referrals. DISCUSSION: Integrated FP/EPI services are feasible and accepted by postpartum women, but require consistent implementation across facilities. To achieve service integration goals, projects need to ensure availability of trained staff, supportive supervision, clear referral processes, and activities addressing the role of spouses and other stakeholders in reproductive health decisions.

Comparison of Women from Georgia and Contiguous States Who Obtained Abortions in Georgia, 1994-2016.

OBJECTIVES: To determine trends for Georgia and contiguous state residents seeking abortions in Georgia between 1994 and 2016. METHODS: We analyzed aggregate vital statistics data, collected in Georgia, on Georgia residents (n = 675,995) and contiguous state residents (Alabama, Florida, North Carolina, South Carolina, Tennessee) (n = 76,232) obtaining abortion and delivery services in Georgia between 1994 and 2016. We examined demographic, pregnancy, and abortion characteristics using counts, ratios, and χ2 tests of proportion. RESULTS: Of the data analyzed, 10.1% of all abortions were for contiguous state residents. The number of abortions in Georgia for contiguous state residents increased 35.3% from 1994 to 2016 (from n = 3115 to n = 4216) while it decreased for Georgia residents by 11.1% (from n = 32,934 to n = 29,264). Contiguous state residents exhibited a higher abortion ratio (1115) compared to Georgia women (224). These populations exhibited statistically significant differences across all variables and time points. Both populations demonstrated similar trends in ethnicity, race, education, marital status, and age. However, contiguous state residents were more likely to obtain an abortion at ≥ 20 weeks gestational age (13.8%) and obtained a lower proportion of suction curettage abortions (60.0%) and a higher proportion of dilation and evacuation procedures (31.9%). They were also less likely to be primigravid. CONCLUSIONS FOR PRACTICE: Women from neighboring states seek abortions in Georgia later in gestation and may therefore lack affordable, safe, early abortion care in their home states. Understanding trends in travel for abortion can allow providers and policymakers to better respond to the needs of patients.