Barriers and delays in access to abortion care: a cross-sectional study of people traveling to obtain care in England and the Netherlands from European countries where abortion is legal on broad grounds.

INTRODUCTION: This study characterized the extent to which (1) financial barriers and (2) abortion care-seeking within a person's country of residence were associated with delays in abortion access among those travelling to England and the Netherlands for abortion care from European countries where abortion is legal on broad grounds in the first trimester but where access past the first trimester is limited to specific circumstances. METHODOLOGY: We drew on cross-sectional survey data collected at five abortion clinics in England and the Netherlands from 2017 to 2019 (n = 164). We assessed the relationship between difficulty paying for the abortion/travel, acute financial insecurity, and in-country care seeking on delays to abortion using multivariable discrete-time hazards models. RESULTS: Participants who reported facing both difficulty paying for the abortion procedure and/or travel and difficulty covering basic living costs in the last month reported longer delays in accessing care than those who had no financial difficulty (adjusted hazard odds ratio: 0.39 95% CI 0.21-0.74). This group delayed paying other expenses (39%) or sold something of value (13%) to fund their abortion, resulting in ~ 60% of those with financial difficulty reporting it took them over a week to raise the funds needed for their abortion. Having contacted or visited an abortion provider in the country of residence was associated with delays in presenting abroad for an abortion. DISCUSSION: These findings point to inequities in access to timely abortion care based on socioeconomic status. Legal time limits on abortion may intersect with individuals' interactions with the health care system to delay care.

This paper explores delays in accessing abortion care associated with financial and medical system barriers. We focus on residents of countries in Europe where abortion is available on broad grounds in the first trimester seeking abortion care outside of their country of residence. This study demonstrates an association between difficulty covering abortion costs for people facing financial insecurity and in-country care seeking and delays in accessing abortion abroad. Policy barriers, medical system barriers, as well as financial barriers may interact to delay access to care for people in European countries with broad grounds for abortion access in the first trimester but restrictions thereafter, especially for people later in pregnancy.

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.

Self-managed medication abortion trajectories: results from a prospective observational study in Argentina, Nigeria and Southeast Asia.

OBJECTIVES: Time is a crucial factor in abortion-seeking because options for care change with pregnancy duration, and most people prefer to access abortion care early in pregnancy. We aimed to collect data on the timing of steps in accompanied self-managed abortion-seeking experiences in legally restrictive settings. METHODS: In this prospective, observational, cohort study we recruited callers from three abortion accompaniment groups in Argentina, Nigeria and a country in Southeast Asia. Participants completed a baseline survey before starting a self-managed medication abortion (SMA) and two follow-up surveys (approximately 1 and 3 weeks after taking medication). Primary outcomes of interest included: (1) time from abortion decision to contacting the hotline, (2) time from contacting the hotline to obtaining pills and (3) time from obtaining pills to taking the first dose. We explored relationships between participant characteristics and each of these outcomes and evaluated differences in overall abortion time using survival analyses. RESULTS: Between July 31, 2019 and October 01, 2020 we enrolled 1352 eligible callers; 1148 provided data for this analysis. After deciding to have an abortion, participants took 12.2 days on average (95% CI: 11.6, 12.9) to start medications for abortion. On average, participants at later pregnancy durations progressed through the SMA process more quickly (<4 weeks: 20.9 days, 4 weeks: 11 days, 5-6 weeks: 10.1 days, 7-9 weeks, 10.4 days, 10+ weeks: 9.1 days; p<0.001). CONCLUSIONS: Overall, participants accessed accompaniment group support and started abortion regimens quickly and at relatively early pregnancy durations. SMA with accompaniment provided a time-efficient route for obtaining abortions.

Medication Abortion Safety and Effectiveness With Misoprostol Alone.

Importance: Misoprostol-alone regimens for abortion may be more effective than previously thought. Objective: To estimate the effectiveness of medication abortion with misoprostol alone among individuals self-managing their abortion. Design, Setting, and Participants: For this prospective observational cohort study of callers to safe abortion hotlines and accompaniment groups in Argentina, Nigeria, and Southeast Asia, participants were recruited between July 31, 2019, and October 1, 2020, prior to starting their medication abortion. Eligible participants were 13 years or older, had no contraindications to medication abortion, and were not currently bleeding. Participants completed a baseline and 2 follow-up surveys. The analysis was restricted to participants who reported using misoprostol alone and was performed between January 6, 2022 and September 8, 2023. Exposure: Self-managed medication abortion using misoprostol alone. Main Outcomes and Measures: The primary outcome was effectiveness, defined as participant self-report of complete abortion without procedural intervention, measured at 1 week and 3 weeks after taking misoprostol. Secondary outcomes included method safety, measured by self-report of experiencing warning signs (eg, heavy bleeding, pain, fever, discharge) indicative of a potential complication and by medical treatment (eg, blood transfusion, intravenous fluids, overnight hospital stay) indicative of a potential adverse event. Additional outcomes included length of bleeding and cramping, time to expulsion, and experience of adverse effects. Results: Among 1352 enrolled participants, 637 used misoprostol-alone regimens for abortion and were included in the analysis (591 [92.8%] from Nigeria, 45 [7.1%] from Southeast Asia, and 1 [0.2%] from Argentina; 384 [60.2%] aged 20-29 years; 317 [49.8%] with pregnancy durations <7 weeks and 205 [32.2%] with pregnancy durations between 7 and <9 weeks). At last follow-up after taking medication (median, 22 days; IQR, 21-26 days), 625 participants (98.1%; 95% CI, 96.7%-98.9%) had a complete abortion without procedural intervention. Potential adverse events were reported by 6 participants (0.9%; 95% CI, 0.4%-2.1%). Most participants experienced bleeding for less than 1 week (median, 4 days; IQR, 3-6 days) and expelled their pregnancy within 24 hours of starting the abortion process (median, 12 hours; IQR, 9-15 hours). Common side effects included nausea (335 participants [52.6%]), fever (232 [36.4%]), and diarrhea (181 [28.4%]). Conclusions and Relevance: The findings suggest that misoprostol alone is a highly effective method of pregnancy termination. Future research should explore strategies to maximize the effectiveness of misoprostol alone in clinical and nonclinical settings.

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.

Effectiveness of Self-Managed Medication Abortion Between 9 and 16 Weeks of Gestation.

OBJECTIVE: To evaluate abortion completion after self-managed medication abortion in pregnancies at or beyond 9 weeks of gestation. METHODS: We conducted a prospective observational cohort study in which we recruited callers to three abortion-accompaniment groups in Argentina, Nigeria, and Southeast Asia who were initiating a self-managed medication abortion. Participants completed a baseline survey over the phone before taking pills and then two follow-up phone surveys 1 and 3 weeks after taking pills. The primary outcome was abortion completion; secondary outcomes included physical experiences and health care seeking and treatment. RESULTS: Between 2019 and 2020, we enrolled 1,352 participants, 19.5% (264/1,352) of whom self-managed a medication abortion at 9 or more weeks of gestation: 75.0% (198/264) at 9-11 weeks, 19.3% (51/264) at 12-14 weeks, and 5.7% (15/264) at 15-22 weeks. Participants were aged 26 years on average (SD 5.6 years); 56.4% (149/264) used the combined regimen (mifepristone+misoprostol), and 43.6% (115/264) used misoprostol only. At the last follow-up, 89.4% (236/264) had a complete abortion without procedural intervention, 5.3% (14/264) had a complete abortion with manual vacuum aspiration or dilation and curettage procedure, 4.9% (13/264) had an incomplete abortion, and 0.4% (1/264) participants did not report an abortion outcome. Some participants (23.5%, 62/264) sought health care during or after the self-managed medication abortion, most commonly to confirm completion (15.9%, 42/264); 9.1% (24/264) needed further medical intervention (procedural evacuation, antibiotics, additional misoprostol, intravenous fluids, blood transfusion, or overnight stay in the facility). Those who were 12 or more weeks pregnant were more likely to seek care at a clinic or hospital than those who were 9-11 weeks pregnant (adjusted relative risk 1.62, 95% CI 1.3-2.1). CONCLUSION: People who self-managed an abortion with medication between 9 and 16 weeks of gestation had high levels of abortion completion and accessed health care to confirm completion or to treat potential complications. CLINICALTRIALREGISTRATION: ISRCTN, ISRCTN95769543.

Characterizing two models for abortion care in Argentina pre-Law 27.610: 2016-2019.

OBJECTIVE: Explore the use of two abortion care models in Argentina over the period 2016-2019: pro-rights private medical service providers and abortion accompaniment (via self-management and via health institutions); and compare the profile of who accesses these models and when. METHODS: We used data from accompaniment collectives in the Socorristas en Red and private service providers. We estimated annual abortion rates via these service models and compared the profile of the populations by type of service and gestational age (2019) using descriptive statistics and chi-square tests. RESULTS: In 2016, 37 people per 100,000 women of reproductive age obtained accompanied self-managed abortions, and the number increased to 111 per 100,000 in 2019, a threefold increase. The rate of abortions via care providers was 18 per 100,000 in 2016 and 33 in 2019. Higher proportions of those who obtained abortion via care providers were 30 years or older. A higher proportion of those accompanied were 19 years or younger; 11% of those who obtained accompanied self-managed abortions were more than 12 weeks gestation compared with 7% among those who had accompanied abortions via health institutions and 0.2% among those who had abortions with private providers. A higher proportion of those who accessed accompanied abortions after 12 weeks gestation had lower educational levels, did not work or have social security coverage, had more past pregnancies, and attempted to terminate their pregnancies prior to contacting the Socorristas compared to those who had accompanied abortions at 12 weeks or earlier. CONCLUSIONS: In Argentina, prior to Law 27.610 models of care guaranteed access to safe abortion. It is important to continue making visible and legitimizing these models of care so that all those who decide to have an abortion, whether inside or outside health institutions, have safe and positive experiences.

Step by Step in Argentina: Putting Abortion Rights into Practice.

In December of 2020, the Argentine Congress legalized abortion through 14 weeks, vastly increasing access to abortion care in the country. The law's passage followed years of advocacy for abortion rights in Argentina - including mass public and civil society mobilization, vocal support from an established pool of abortion providers who offered abortion services under specific legal exceptions prior to the new law, and the growth of community groups such as the Socorristas en Red who provide support for people to self-manage abortions. Aided by ample political will, the number of health facilities offering services increased substantially after the law was passed, and the public visibility around the law has helped assure people seeking abortion that it is their right. Proyecto mirar is an initiative focused on both gathering and using qualitative and quantitative data to inform stakeholders about the progress and obstacles of the law's implementation. In this review, we present an overall summary of the first two years of implementation of the abortion law in Argentina based on proyecto mirar data and contextualized through the historical processes that have contributed to the law's passage and application. While we see increases in abortion services and improved public perception around abortion rights, inequities in access and quality of care persist throughout the country. Specifically, providers in some regions are well trained, while others create obstacles to access, and in some regions health services provide high quality abortion care whereas others provide substandard care. To be sure, the implementation of public policies does not happen overnight; it requires government support and backing to tackle obstacles and solve implementation problems. Our findings suggest that when new abortion laws are passed, they must be supported by civil society and government leaders to ensure that associated policies are well crafted and monitored to ensure successful implementation.

Respondent-Driven Sampling for Estimation of the Cumulative Lifetime Incidence of Abortion in Soweto, Johannesburg, South Africa: A Methodological Assessment.

Respondent-driven sampling (RDS) is a potential strategy for addressing challenges in accurate estimation of abortion incidence, but it relies on often untested assumptions. We conducted an RDS study to estimate the cumulative lifetime incidence of abortion in Soweto, Johannesburg, South Africa (April-December 2018), to evaluate whether RDS assumptions were met, and to compare RDS estimates of incidence with estimates adjusted for employment and age based on census data. A total of 849 participants were recruited from 11 seed participants between April and December 2018. The assumption that individuals can identify target population members and the assumption of approximation of sampling with replacement was met. There were minor violations of the assumptions of seed independence from the final sample and reciprocity of ties. Assumptions of accurate degree reporting and random recruitment were not met. Failure to meet assumptions yielded a study sample with different employment characteristics than those of the target population; this could not be resolved by standard RDS methods. The RDS estimate of cumulative lifetime abortion incidence was 12.1% (95% confidence interval: 9.8, 14.3), and the employment-adjusted estimate was 16.9% (95% confidence interval: 12.8, 22.1). We caution researchers in using RDS for representative estimates of abortion incidence. Use of postsurvey weights to adjust for differences in characteristics between the sample and the target population may yield more representative results.

Travel for later abortion in the USA: lived experiences, structural contributors and abortion fund support.

As abortion restrictions expand in the USA, pregnant people will continue to experience delays and be forced to travel for abortion. The study aims to describe later abortion travel experiences, understand structural factors influencing travel, and identify strategies to improve travel. This qualitative phenomenological study analyses data from 19 interviews with people who travelled at least 25 miles for abortion after the first trimester. Framework analysis used a structural violence lens. More than two-thirds of participants travelled interstate, and half received abortion fund support. Key considerations of travel include logistics, challenges during the journey, and physical and emotional recovery during and after travel. Restrictive laws, financial insecurity and anti-abortion infrastructure are forms of structural violence that created challenges and delays. Reliance on abortion funds facilitated access but also entailed uncertainty. Better resourced abortion funds could organise travel in advance, facilitate the travel of accompanying escorts, and tailor emotional support to reduce stress for those travelling. Clinical and practical support systems must be prepared to support people travelling for abortion, as later abortion and forced travel is increasing since the constitutional right to abortion in the USA was overturned. Findings can inform interventions to support the increasing number of people travelling for abortion.

"The first difficulty is time": The impact of gestational age limits on reproductive health and justice in the context of cross-border travel for abortion care in Europe.

Drawing on qualitative and quantitative data collected during a 5-year multi-disciplinary European research project, in this article we show how restrictions on access to legal abortion, and particularly gestational age (GA) limits at the end of the first trimester of pregnancy, negatively affect women and pregnant people living in European countries where abortion is legal on request or on broad grounds. First, we examine why most European legislations establish GA limits, and illustrate how abortion is framed in national laws and in the current national and international legal and political debates on abortion rights. We then show, based on research data we collected during our 5-year project and contextualized with existing data and statistics, how these restrictions force thousands of people to travel across borders from European countries where abortion is legal, delaying access to care, and increasing pregnant people's health risks. Finally, we explore, from an anthropological perspective, how pregnant people who travel across borders for abortion care conceptualize abortion access, and the relationship between the right to abortion care and the GA restrictions that limit this right. Our study participants criticize the time restrictions established by the laws in their countries of residence as failing to meet pregnant people's needs, highlight the crucial importance of easy, timely access to abortion care even beyond the first trimester of pregnancy, and suggest a more relational approach to the right to access safe, legal abortion. Abortion travel is also a matter of reproductive justice because access to care depends on specific resources including finances, information, support, citizenship status, and social networks. Our work contributes to scholarly and public debates about reproductive governance and justice, by shifting the locus of attention to GA limits and its impact on women and pregnant people, particularly in geopolotical settings where abortion laws are deemed liberal.

French women's experiences and opinions with in-country versus cross-border abortion travel: a mixed-methods paper.

OBJECTIVES: This is the first study contrasting the experience of women residing in France and travelling for abortion services inside and outside their country of residence. We compare travel reasons and costs as well as our study participants' opinions of abortion legislation. The article documents legal and procedural barriers related to accessing local and timely abortions and provides policy recommendations to broaden care options. METHODS: The study is based on a mixed-methods research design. Quantitative data were descriptively analysed using Stata and drawn from 100 surveys with in-country abortion seekers collected from 3 Parisian hospitals, and 57 surveys with French residents seeking abortion care in the Netherlands (42), Spain (10) and the UK (5). Qualitative data were thematically analysed using ATLAS.ti and drawn from 36 interviews with French residents (23 in-country abortion seekers and 13 cross-border abortion travellers). FINDINGS: Gestational age (GA) limits were the key reason for cross-border travel, while lack of close-by, timely and good quality abortion care was the main driver for in-country abortion travel. Unlike in-country travellers, cross-border abortion seekers faced significant financial costs and burdens related to such travel. Partners, family members and service providers offered important support structures to both cross-border and in-country travellers. CONCLUSIONS: Legal time limits appeared to be the key driver for abortion-related travel of French residents. Having passed or being at risk of exceeding the GA limit caused women to travel outside their country or department of residence for abortion care.

Accounting for Misclassification and Selection Bias in Estimating Effectiveness of Self-managed Medication Abortion.

BACKGROUND: Studies on the effectiveness of self-managed medication abortion may suffer from misclassification and selection bias due to self-reported outcomes and loss of follow-up. Monte Carlo sensitivity analysis can estimate self-managed abortion effectiveness accounting for these potential biases. METHODS: We conducted a Monte Carlo sensitivity analysis based on data from the Studying Accompaniment model Feasibility and Effectiveness Study (the SAFE Study), to generate bias-adjusted estimates of the effectiveness of self-managed abortion with accompaniment group support. Between July 2019 and April 2020, we enrolled a total of 1051 callers who contacted accompaniment groups in Argentina and Nigeria for self-managed abortion information; 961 took abortion medications and completed at least one follow-up. Using these data, we calculated measures of effectiveness adjusted for ineligibility, misclassification, and selection bias across 50,000 simulations with bias parameters drawn from pre-specified Beta distributions in R. RESULTS: After accounting for the potential influence of various sources of bias, bias-adjusted estimates of effectiveness were similar to observed estimates, conditional on chosen bias parameters: 92.68% (95% simulation interval: 87.80%, 95.74%) for mifepristone in combination with misoprostol (versus 93.7% in the observed data) and 98.47% (95% simulation interval: 96.79%, 99.39%) for misoprostol alone (versus 99.3% in the observed data). CONCLUSIONS: After adjustment for multiple potential sources of bias, estimates of self-managed medication abortion effectiveness remain high. Monte Carlo sensitivity analysis may be useful in studies measuring an epidemiologic proportion (i.e., effectiveness, prevalence, cumulative incidence) while accounting for possible selection or misclassification bias.

'To be vigilant to leave no trace': secrecy, invisibility and abortion travel from the Republic of Ireland.

Until 2018, abortion in the Republic of Ireland was banned in almost all circumstances under one of the most restrictive legal regimes in Europe. The main solution for Irish women and pregnant people seeking abortion services had been to pursue care abroad, typically in clinics in England. In this paper we focus on the hardships of waiting for abortion care experienced by Irish residents leading up to their travel for appointments in England in 2017 and 2018. Based on in-depth interviews with 53 Irish women collected at three British Pregnancy Advisory Services (BPAS) clinics in England we analyse women's experiences as they navigated an 'environment of secrecy' in Ireland. This included making specific secrecy efforts when navigating travel arrangements, conversations, movement, health records, and the travel itself. Despite the expansion of abortion access in Ireland in 2018, the need to travel abroad continues for many women. We argue that the continued need for secrecy when women have to travel abroad for care perpetuates this important phenomenon's invisibility. This argument also applies to other countries where abortion access is restricted, and women are forced to travel for care. We also caution against the presumption that all Irish residents are able to travel internationally for healthcare.

Characterizing two models for abortion care in Argentina pre-Law 27.610: 2016-2019 / Utilización de dos modelos en la atención al aborto en Argentina pre-Ley 27.610: 2016-2019

ABSTRACT OBJECTIVE Explore the use of two abortion care models in Argentina over the period 2016-2019: pro-rights private medical service providers and abortion accompaniment (via self-management and via health institutions); and compare the profile of who accesses these models and when. METHODS We used data from accompaniment collectives in the Socorristas en Red and private service providers. We estimated annual abortion rates via these service models and compared the profile of the populations by type of service and gestational age (2019) using descriptive statistics and chi-square tests. RESULTS In 2016, 37 people per 100,000 women of reproductive age obtained accompanied self-managed abortions, and the number increased to 111 per 100,000 in 2019, a threefold increase. The rate of abortions via care providers was 18 per 100,000 in 2016 and 33 in 2019. Higher proportions of those who obtained abortion via care providers were 30 years or older. A higher proportion of those accompanied were 19 years or younger; 11% of those who obtained accompanied self-managed abortions were more than 12 weeks gestation compared with 7% among those who had accompanied abortions via health institutions and 0.2% among those who had abortions with private providers. A higher proportion of those who accessed accompanied abortions after 12 weeks gestation had lower educational levels, did not work or have social security coverage, had more past pregnancies, and attempted to terminate their pregnancies prior to contacting the Socorristas compared to those who had accompanied abortions at 12 weeks or earlier. CONCLUSIONS In Argentina, prior to Law 27.610 models of care guaranteed access to safe abortion. It is important to continue making visible and legitimizing these models of care so that all those who decide to have an abortion, whether inside or outside health institutions, have safe and positive experiences.

RESUMEN OBJETIVO Explorar la utilización de dos modelos para la atención al aborto en Argentina en el período 2016-2019: abortos con proveedores de servicios médicos privados proderechos y abortos acompañados (vía autogestión y vía instituciones de salud); y comparar el perfil de quiénes acceden a estos modelos y cuándo. MÉTODOS Utilizamos datos de sistematizaciones de colectivas de acompañamiento en Socorristas en Red y de proveedores de servicios privados. Estimamos tasas anuales de abortos mediante estos servicios y comparamos el perfil de las poblaciones por tipo de servicio y edad gestacional (2019) utilizando estadísticas descriptivas y prueba chi-cuadrado. RESULTADOS En el 2016, 37 personas por cada 100,000 mujeres en edad reproductiva obtuvieron abortos acompañados vía autogestión, aumentando a 111 por 100,000 en 2019, es decir, se triplicó. La tasa de abortos con proveedores fue de 18 por 100,000 en 2016 y de 33 en 2019. Mayor proporción de quienes acudieron con proveedores tenía 30 años o más y mayor proporción de personas acompañadas tenía 19 años o menos; el 11% de quienes obtuvieron abortos acompañados vía autogestión tenía más de 12 semanas de gestación en comparación con el 7% entre quienes tuvieron abortos acompañados vía instituciones de salud y el 0.2% entre quienes abortaron con proveedores. Una mayor proporción de quienes accedieron a abortos acompañados después de 12 semanas de gestación tenía menor nivel educativo, no trabajaban ni tenían cobertura de obra social, y habían tenido más embarazos e intentado interrumpir su embarazo comparando con quienes abortaron acompañadas a las 12 semanas o antes. CONCLUSIONES En Argentina existen modelos de atención que han garantizado el acceso a abortos seguros desde antes de la Ley 27.610. Es importante continuar visibilizando y legitimando estos modelos para que todas las personas que deciden abortar, dentro o fuera de instituciones de salud, tengan experiencias seguras y positivas.

Incidence of and Experiences with Abortion Attempts in Soweto, South Africa: Respondent-Driven Sampling Study.

BACKGROUND: Estimation of abortion incidence, particularly in settings where most abortions occur outside of health facility settings, is critical for understanding information gaps and service delivery needs in different settings. However, the existing methods for measuring out-of-facility abortion incidence are plagued with methodological challenges. Respondent-driven sampling (RDS) may offer a methodological improvement in the estimation of abortion incidence. OBJECTIVE: In this study, we tested the feasibility of using RDS to recruit participants into a study about abortion and estimated the proportion of people who ever attempted abortion as well as 1-year and 5-year incidence of abortion (both in-facility and out-of-facility settings) among women of reproductive age in Soweto, South Africa. METHODS: Participants were eligible if they identified as a woman; were aged between 15 and 49 years; spoke English, Tswana, isiZulu, Sotho, or Xhosa; and lived in Soweto. Working with community partners, we identified 11 seeds who were provided with coupons to refer eligible peers to the study. Upon arrival at the study site, the recruits completed an interviewer-administered questionnaire that solicited information about demographic characteristics, social network composition, health behaviors, sexual history, pregnancy history, and experience with abortion; recruits also received 3 recruitment coupons. Recruitment was tracked using coupon numbering. We used the RDS-II estimator to estimate the population proportions of demographic characteristics and our primary outcome, the proportion of people who ever attempted abortion. RESULTS: Between April 4, 2018, and December 17, 2018, 849 eligible participants were recruited into the study. The estimated proportion of people who ever attempted abortion was 12.1% (95% CI 9.7%-14.4%). A total of 7.1% (95% CI 5.4%-8.9%) reported a facility-based abortion, and 4.4% (95% CI 3.0%-5.8%) reported an out-of-facility abortion. CONCLUSIONS: The estimated proportion of people who ever attempted abortion of 12% (102/849) in our study likely represents a substantial underestimation of the actual proportion of abortion attempts among this study population-representing a failure of the RDS method to generate more reliable estimates of abortion incidence in our study. We caution against the use of RDS to measure the incidence of abortion because of persistent concerns with underreporting but consider potential alternative applications of RDS with respect to the study of abortion.

Inter-departmental abortion travels in metropolitan France: A mixed-methods analysis of women's experiences, access, and barriers to abortion care.

In Europe, there is a dearth of studies on abortion-related mobilities within countries where abortion is legal. In France, 18% of women seek abortion care outside their department of residence care. Most of these flows take place within Île-de-France region. This paper aims at providing novel insights into the motives and experiences of women traveling within France and particularly within the Île-de-France region for abortion care. It draws upon official abortion statistics as well as quantitative and qualitative data collected in three Parisian hospitals during a five-year European research project on barriers to legal abortion and abortion travel. Despite governmental efforts to facilitate access to abortions over the past decades, our findings show that various barriers exist for why women do not find services in their department of residence (lack of services or access to preferred methods, quality of care, long waiting times). However, most of our study participants report coming to Paris as a convenience and use commuting as a strategy to overcome obstacles in receiving abortion care.