Landscape assessment of the availability of medical abortion medicines in India.

BACKGROUND: Medical abortion with mifepristone and misoprostol can be provided up to 63 days' gestation in India. This accounts for 67.5 percent of all abortions in the country. We conducted an assessment to determine the availability of medical abortion medicines, specifically the combi-pack, in India. METHODS: We applied the World Health Organization landscape assessment protocol at the national level. The assessment protocol included a five-step adaptation of an existing availability framework, including online data collection, desk review, country-level key informant interviews, and an analysis to identify barriers and opportunities to improve medical abortion availability. The assessment was conducted between August and March 2021. RESULTS: Medicines for medical abortion are included in the national essential drug list and available with prescription in India. The assessment identified 42 combi-pack products developed by 35 manufacturers. The quality of medical abortion medicines is regulated by national authorities; but as health is devolved to states, there are significant inter-state variations. This is seen across financing, procurement, manufacturing, and monitoring mechanisms for quality assurance of medical abortion medicines prior to distribution. There is a need to strengthen supply chain systems, ensure consistent availability of trained providers and build community awareness on use of medical abortion medicines for early abortions, at the time of the assessment. CONCLUSION: Opportunities to improve availability and quality of medical abortion medicines exist. For example, uniform implementation of regulatory standards, greater emphasis on quality-assurance during manufacturing, and standardizing of procurement and supply chain systems across states. Regular in-service training of providers on medical abortion is required. Finally, innovations in evidence dissemination and community engagement about the recently amended abortion law are needed.

Medical abortion is popular in India and benefits from a liberal legal context. It is important to understand the availability of quality abortion medicines in the country. Using the World Health Organization country assessment protocol and availability framework for medical abortion medicines we examined the availability of these medicines from supply to demand. We used this information to identify opportunities for increasing availability of quality-assured medical abortion medicines. We found that the context for medical abortion varies across states. Strengthening procurement and supply chain management, with a greater emphasis on quality-assurance and regulation of manufacturing should be instituted at the state-level. Training is also needed to increase provider knowledge of the latest national guidelines and laws to ensure respectful and person-centered services. Finally, the public should be informed about medical abortion as a safe and effective choice, especially for early abortions.

Strengthening regional commitment to ensuring access to medical abortion medicines in WHO's South-East Asia region: report of a participatory assessment and workshop.

BACKGROUND: In 2019, the World Health Organization identified improving access to safe abortion as an important priority toward improving sexual and reproductive health and rights and achieving Sustainable Development Goals. One strategy for addressing this priority is strengthening access to medicines for medical abortion. All 11 countries in the South-East Asia Region have some indications for legal abortion and permit post-abortion care. Therefore, strengthening access to medical abortion medicines is a reasonable strategy for improving access to safe abortion for the Region. METHODOLOGY: We applied an adapted version of an existing World Health Organization landscape assessment protocol for the availability of medical abortion medicines at the country-level in the South-East Asia Region. We collected publicly available data on the existence of national health laws, policies, and standard treatment guidelines; inclusion of medical abortion medicines in the national essential medicines list; and marketing authorization status for medical abortion medicines for each country and verified by Ministries of health. The findings were once more presented, discussed and recommendations were formulated during regional technical consultation workshop. Each country teams participated in the process, and subsequently, the suggestions were validated by representatives from Ministries of Health.. RESULTS: Few countries in the Region currently have national policies and guidelines for comprehensive safe abortion. However, either mifepristone-misoprostol in combination or misoprostol alone (for other indications) is included in national essential medicines lists in all countries except Indonesia and Sri Lanka. Few countries earmark specific public funds for procuring and distributing medical abortion commodities. In countries where abortion is legal, the private sector and NGOs support access to medical abortion information and medicines. Several countries only allow registered medical practitioners or specialists to administer medical abortion. CONCLUSION: Following this rapid participatory assessment and technical consultation workshop, the World Health Organization South-East Asia Regional Technical Advisory and Sexual and Reproductive Health and Rights technical committee recommended priority actions for policy and advocacy, service delivery, and monitoring and evaluation, and indicated areas for support.

Description of the methodology for developing and validating the WHO's family planning and comprehensive abortion care competencies for the primary health care workforce.

A qualified health workforce is essential to receiving effective, timely, affordable, equitable and respectful family planning and comprehensive abortion care. However, in many countries, health workers lack the competencies required to deliver quality family planning and comprehensive abortion care services. Competency-based education and learning aims to train and assess competencies. The theory-supported approach focuses on outcomes, emphasizes the learner's ability to perform, promotes learner-centeredness and links the health needs of the population to the competencies required of health workers. In 2011, the World Health Organization published a guidance document, Sexual and reproductive health - Core competencies in primary care, defining the competencies that primary care providers need to safely deliver sexual and reproductive health services at the community level and included family planning and comprehensive abortion care. In this article, we describe the methodology and process undertaken in 2020, by the World Health Organization to produce the family planning and comprehensive abortion care competencies guidance, filling gaps identified in the previous guidance document. The World Health Organization's Family Planning and Comprehensive Abortion Care toolkit for the primary health care workforce was published in 2022 and defines the key competencies for health workers in primary health care providing quality family planning and comprehensive abortion care services, as well as support for developing programmes and curricula for education and lifelong learning. The Toolkit is useful for practitioners, managers/supervisors and employers, educators, regulatory bodies, and policymakers. It is an important advance toward strengthening family planning and comprehensive abortion care services in primary health care.

Adaptations to comprehensive abortion care during the COVID-19 pandemic: case studies of provision in Bolivia, Mali, Nepal, and the occupied Palestinian territory.

The COVID-19 pandemic impacted comprehensive abortion care provision. To maintain access to services while keeping individuals safe from infection, many organisations adapted their programmes. We conducted a programme evaluation to examine service adaptations implemented in Bolivia, Mali, Nepal, and the occupied Palestinian territory. Our programme evaluation used a case study approach to explore four programme adaptations through 14 group and individual interviews among 16 service providers, facility managers and representatives from supporting organisations. Data collection took place between October 2021 and January 2022. We identified adaptations to comprehensive abortion care services in relation to provision, health information systems and counselling, and referrals. Four overarching strategies emerged: (1) the use of digital technologies, (2) home and community outreach, (3) health worker optimisation, and (4) further consideration of groups in vulnerable situations. In Bolivia, the use of a messaging application increased access to confidential gender-based violence support and comprehensive abortion care. In Mali, the adoption of digital approaches created timely and complete data reporting and trained members of the community served as "interlocutors" between the communities and providers. In Nepal, an interim law expanded medical abortion provision to pharmacies, and home visits complemented facility-based services. In the occupied Palestinian territory, the use of a hotline and social media expanded access to quick and reliable information, counselling, referrals, and post-abortion care. Adaptations to comprehensive abortion care service delivery to mitigate disruptions to services during the COVID-19 pandemic may continue to benefit service quality of care, access to care, routine monitoring, as well as inclusivity and communication in the longer term.

Identifying and prioritizing evidence needs in self-care interventions for sexual and reproductive health.

Background: Self-care as an extension of health care systems can increase access to care. The development of programs and generation of evidence to support self-care in sexual and reproductive health (SRH) is a relatively nascent field. We undertook a study to identify and prioritize evidence gaps for SRH self-care. Methods: We used the CHNRI methodology and administered two online surveys to stakeholders affiliated with major self-care networks. The first survey was used to identify evidence gaps, and the second to prioritize them using predetermined criteria. Results: We received 51 responses to the first survey and 36 responses to the second. Many evidence gaps focused on awareness of and demand for self-care options and best mechanisms for supporting users of self-care with information, counseling and linkages to care. Conclusion: A priority area of work ahead should be determining which aspects of the learning agenda reflect gaps in evidence and which reflect a need to effectively synthesize and disseminate existing evidence.

Interventions to reduce stigma related to contraception and abortion: a scoping review.

OBJECTIVES: We conducted a scoping review to identify the types, volume and characteristics of available evidence and analyse the gaps in the knowledge base for evaluated interventions to reduce contraception and abortion stigma. DESIGN: We conducted a search of five electronic databases to identify articles published between January 2000 and January 2022, and explored the websites of relevant organisations and grey literature databases for unpublished and non-commercial reports. Articles were assessed for eligibility, and data were extracted. DATA SOURCES: We searched MEDLINE, PubMed, Embase, Web of Science and PsycINFO. ELIGIBILITY CRITERIA: Articles included were: (1) published between January 2000 and January 2022, (2) written in English, (3) reports of the evaluation of an intervention designed to reduce contraceptive and/or abortion stigma, (4) used any type of study design and (5) conducted in any country context. DATA EXTRACTION AND SYNTHESIS: Included studies were charted according to study location, study aim, study design, type of contraceptive method(s), study population, type of stigma, and intervention approach. RESULTS: Some 18 articles were included in the final analysis (11 quantitative, 6 qualitative and 1 mixed methods). Fourteen of the studies focused exclusively on abortion stigma, and two studies focused on contraception stigma only; while two studies considered both. A majority of the studies aimed to address intrapersonal stigma. We found no interventions designed to address stigma at the structural level. In terms of intervention approaches, seven were categorised as education/training/skills building, five as counselling/peer support, three as contact and three as media. CONCLUSION: There is a dearth of evaluations of interventions to reduce contraception and abortion stigma. Investment in implementation science is necessary to develop the evidence base and inform the development of effective interventions, and use existing stigma scales to evaluate effectiveness. This scoping review can serve as a precursor to systematic reviews assessing the effectiveness of approaches.

Why does abortion stigma matter? A scoping review and hybrid analysis of qualitative evidence illustrating the role of stigma in the quality of abortion care.

Abortion stigma shapes the environment in which abortion is delivered and received and can have important implications for quality in abortion care. However, this has not previously been clearly articulated and evidenced. We conducted a scoping review of existing qualitative evidence to characterize the relationship between abortion stigma and quality in abortion care. Using a systematic process, we located 50 qualitative studies to include in our analysis. We applied the interface of the WHO quality of care and abortion stigma frameworks to the qualitative evidence to capture manifestations of the interaction between abortion stigma and quality in abortion care in the existing literature. Four overarching themes linked to abortion stigma emerged: A) abortion as a sin and other religious views; B) regulation of abortion; C) judgement, labelling and marking; and D) shame, denial, and secrecy. We further characterized the emerging ways in which abortion stigma operates to inhibit quality in abortion care into seven manifestations of the relationship between abortion stigma and quality in abortion care: 1) poor treatment and the repercussions, 2) gatekeeping and obstruction of access, 3) avoiding disclosure, 4) arduous and unnecessary requirements, 5) poor infrastructure and lack of resources, 6) punishment and threats and 7) lack of a designated place for abortion services. This evidence complements the abortion stigma-adapted WHO quality of care framework suggested by the International Network for the Reduction of Abortion Discrimination and Stigma (inroads) by illustrating specifically how the postulated stigma-related barriers to quality abortion care occur in practice. Further research should assess these manifestations in the quantitative literature and contribute to the development of quality in abortion care indicators that include measures of abortion stigma, and the development of abortion stigma reduction interventions to improve quality in abortion care.

Scoping review of research on self-managed medication abortion in low-income and middle-income countries.

BACKGROUND: We undertook a scoping review of recent studies on self-managed medical abortion (MA) or abortion where some or all of the process is led independently by the person having the abortion, in low-income and middle-income countries (LMICs) to uncover evidence gaps and help stakeholders leverage existing evidence. METHODS: We searched five bibliographic databases for all articles published on MA between 2007 and July 2020 in LMICs. The search yielded 1294 articles. We identified 107 articles in which one or more of the three WHO-defined subtasks for MA was self-led outside of a clinic setting, and use of drugs that are part of safe, evidence-based regimens was related to the study exposure or outcome. We classified these studies by subject area, study design, country, legal context, gestational age and other categories. RESULTS: The 107 studies covered research in 44 countries, of which 18 have liberal abortion laws. Seventy- four articles reported on quantitative research methods, of which 14 were randomised controlled trials. Fifty-two studies focused on MA in the first trimester. Sixty-two focused on WHO subtask two (drug administration) and 32 focused on subtask three (assessing and managing abortion completion). We found little research on self-management of the entire MA process, innovative approaches to supporting self-managed MA or the needs of underserved populations. CONCLUSION: We recommend syntheses of evidence on safety and efficacy of self-managed MA and preferences of people undergoing self-managed MA. We also encourage new research on topics including self-management of the entire process, the needs and experiences of underserved populations and innovative approaches to supporting people undertaking self-managed MA. The time is opportune for amplifying and expanding evidence to inform programmes and policies on self-care.

Glancing at the past and course-setting for the future: lessons from the last decade of research on medication abortion in high-income countries.

OBJECTIVE: Although medication abortion has become more common in high-income countries, the procedure has not yet met early expectations for widening access to abortion. High-quality evidence can serve as a catalyst for changes in policy and practice. To direct research priorities, it is important to understand where quality evidence is concentrated and where gaps remain. High-income countries have developed a body of evidence that may have implications for the future of medication abortion. This literature review assesses the characteristics and quality of published studies on medication abortion conducted in the last 10 years in high-income countries and indicates future areas for research to advance policy and practice, and broaden access. STUDY DESIGN: A structured search for literature resulted in 207 included studies. A framework based upon the World Health Organization definition of sub-tasks for medication abortion was developed to categorize research by recognized stages of the medication abortion process. Using an iterative and inductive approach, additional sub-themes were created under each of these categories. Established quality assessment frameworks were drawn upon to gauge the internal and external validity of the included research. RESULTS: Studies in the US and the UK have dominated research on MA in high-income countries. The political and social contexts of these countries will have shaped of this body of research. The past decade of research has focused largely on clinical aspects of medication abortion. CONCLUSION: Researchers should consider refocusing energies toward testing service delivery approaches demonstrating promise and prioritizing research that has broader generalizability and relevance outside of narrow clinical contexts. Although medication abortion is more commonly available worldwide, it is not being used as often as people thought it would be, particularly in high income countries. In order to encourage changes in policy and practice that would allow greater use, we need good quality evidence. If we can understand where we do not have enough research and where we have good amounts of research, we can determine where to invest energies in further studies. Many high-income countries have produced research on medication abortion that could influence policy and practice in similarly resourced contexts. I conducted a literature review to be able to understand the type and quality of research on medication abortion conducted in high-income countries in the past 10 years. I conducted the review in an organized way to make sure that the papers reviewed discussed studies that I thought would be important for answering this question. The literature review found 207 papers. Each of these papers were reviewed and organized them by theme. I also used existing methods to determinine the quality of each study. Most of the research came from the US and the UK. Furthermore, most of the research conducted in the past 10 years was focused on clinical studies of medication abortion. In future studies, researchers should focus more on new ways of providing medication abortion to women that offers greater access. Also, the studies should be designed so that the results have meaning for a broader group of people or situations beyond where the study was done.

Creativity, serendipity, and collaboration: Cross-cutting features of successful task-sharing in comprehensive safe abortion care.

Limited capacity to deliver comprehensive safe abortion care and shortages in trained healthcare providers contribute to a lack of access to safe services. The World Health Organization published guidelines and recommendations on expanding health worker roles through task-sharing as one way to address disparities. A multicountry case study was conducted in six diverse contexts (Bangladesh, Colombia, Ghana, Mexico City in Mexico, Sweden, and Tunisia) to determine the cross-cutting strategies that enabled inclusion of a broader range of healthcare workers in comprehensive safe abortion care. Five strategies emerged: leveraging of favorable contexts, policies, and guidelines; use of evidence for advocacy; building upon existing task-sharing; mitigation of negative responses to abortion and task-sharing; and collaboration across sectors. The findings suggest that there are potential opportunities for stakeholders to employ these strategies in many contexts to broaden health worker roles in comprehensive safe abortion care.

WHO guidelines and the role of the physician in task sharing in safe abortion care.

Globally, many women undergo unsafe abortion, although abortion is extremely safe when done in accordance with recommended guidelines. Hence, many women suffer from abortion-related complications, and unsafe abortion remains a major cause of maternal mortality. The high percentage of unsafe abortion is attributed to the inability of women to access safe abortion services. A critical barrier to access is the lack of trained providers. To address this problem, task sharing and the expansion of health worker roles in abortion care have become a public health strategy to mitigate health worker shortages and reduce unsafe abortion. This chapter provides an overview of the WHO guidance on task sharing in safe abortion care, discusses the special role of physicians, and highlights the complexity of implementing task sharing by analyzing the findings from six country case studies.

Story Circles and abortion stigma in Mexico: a mixed-methods evaluation of a new intervention for reducing individual level abortion stigma.

This study presents the results of an evaluation of a Story Circles intervention to reduce individual level abortion stigma among women who have experienced abortion in Mexico. Using a mixed-methods approach, the study explored whether participation in the intervention reduced 18 women's experience of stigma one month after having participated. The study used the Individual Level Abortion Stigma Scale (ILAS Scale), qualitative interviews and focus groups to gain an understanding of women's experiences of the intervention and any changes in stigmatising feelings. Findings suggest that the Story Circles offered women a place to talk about their abortion in an affirmative and supportive environment, unlike the context of their daily lives where stigma generated silence and affected their well-being. Participants were able to build trust, share their experiences, create connections and transform their perception of their abortion from a negative experience to one that was empowering and life-affirming. This also led to other significant positive changes in their lives. The paper offers recommendations about programme and intervention design and implementation for practitioners working to reduce individual level stigma among women who have experienced abortion.

Implementation considerations when expanding health worker roles to include safe abortion care: a five-country case study synthesis.

BACKGROUND: Allowing a broader range of trained health workers to deliver services can be an important way of improving access to safe abortion care. However, the expansion of health worker roles may be challenging to implement. This study aimed to explore factors influencing the implementation of role expansion strategies for non-physician providers to include the delivery of abortion care. METHODS: We conducted a multi-country case study synthesis in Bangladesh, Ethiopia, Nepal, South Africa and Uruguay, where the roles of non-physician providers have been formally expanded to include the provision of abortion care. We searched for documentation from each country related to non-physician providers, abortion care services and role expansion through general internet searches, Google Scholar and PubMed, and gathered feedback from 12 key informants. We carried out a thematic analysis of the data, drawing on categories from the SURE Framework of factors affecting the implementation of policy options. RESULTS: Several factors appeared to affect the successful implementation of including non-physician providers to provide abortion care services. These included health workers' knowledge about abortion legislation and services; and health workers' willingness to provide abortion care. Health workers' willingness appeared to be influenced by their personal views about abortion, the method of abortion and stage of pregnancy and their perceptions of their professional roles. While managers' and co-workers' attitudes towards the use of non-physician providers varied, the synthesis suggests that female clients focused less on the type of health worker and more on factors such as trust, privacy, cost, and closeness to home. Health systems factors also played a role, including workloads and incentives, training, supervision and support, supplies, referral systems, and monitoring and evaluation. Strategies used, with varying success, to address some of these issues in the study countries included values clarification workshops, health worker rotation, access to emotional support for health workers, the incorporation of abortion care services into pre-service curricula, and in-service training strategies. CONCLUSIONS: To increase the likelihood of success for role expansion strategies in the area of safe abortion, programme planners must consider how to ensure motivation, support and reasonable working conditions for affected health workers.

A Qualitative Study of Participant Engagement With a Weight Loss Intervention.

BACKGROUND: Overweight and obesity are major public health problems and an increasing global challenge. In lieu of wider policy changes to tackle the obesogenic environment in which we presently reside, improving the design of individual-level weight loss interventions is important. AIM: To identify which aspects of the Camden Weight Loss randomized controlled trial weight loss intervention participants engaged with, with the aim of improving the design of future studies and maximizing retention. METHOD: A qualitative study comprising semistructured interviews ( n = 18) and a focus group ( n = 5) with intervention participants. RESULTS: Two important aspects of participant engagement with the intervention consistently emerged from interviews and focus group: the advisor-participant relationship and the program structure. Some materials used during the program sessions were important in supporting the intervention; however, others were not well received by participants. CONCLUSION: An individual-level weight loss intervention should be acceptable from the patient perspective in order to ensure participants are engaged with the program for as long as possible to maximize favorable results. Providing ongoing support in a long-term program with a trained empathetic advisor may be effective at engaging with people trying to lose weight in a weight loss intervention.

Being targeted: Young women's experience of being identified for a teenage pregnancy prevention programme.

Research on the unintended consequences of targeting 'high-risk' young people for health interventions is limited. Using qualitative data from an evaluation of the Teens & Toddlers Pregnancy Prevention programme, we explored how young women experienced being identified as at risk for teenage pregnancy to understand the processes via which unintended consequences may occur. Schools' lack of transparency regarding the targeting strategy and criteria led to feelings of confusion and mistrust among some young women. Black and minority ethnic young women perceived that the assessment of their risk was based on stereotyping. Others felt their outgoing character was misinterpreted as signifying risk. To manage these imposed labels, stigma and reputational risks, young women responded to being targeted by adopting strategies, such as distancing, silence and refusal. To limit harmful consequences, programmes could involve prospective participants in determining their need for intervention or introduce programmes for young people at all levels of risk.

Exploring intergenerational changes in perceptions of gender roles and sexuality among Indigenous women in Oaxaca.

The south of Mexico has traditionally faced disproportionate social, health and economic disadvantage relative to the rest of the country, due in part to lower levels of economic and human development, and barriers faced by Indigenous populations. The state of Oaxaca, in particular, has one of the highest proportions of Indigenous people and consistently displays high rates of maternal mortality, sexually transmitted infections and teenage pregnancy. This study examines how social values and norms surrounding sexuality have changed between two generations of women living in Indigenous communities in Oaxaca. We conducted semi-structured in-depth interviews with 19 women from two generational cohorts in 12 communities. Comparison views of these two cohorts suggest that cultural gender norms continue to govern how women express and experience their sexuality. In particular, feelings of shame and fear permeate the expression of sexuality, virginity continues be a determinant of a woman's worth and motherhood remains the key attribute to womanhood. Evidence points to a transformation of norms, and access to information and services related to sexual health is increasing. Nonetheless, there is still a need for culturally appropriate sex education programmes focused on female empowerment, increased access to sexual health services, and a reduction in the stigma surrounding women's expressions of sexuality.

Constructing a validated scale to measure community-level abortion stigma in Mexico.

OBJECTIVE: In Mexico, abortion stigma in the general population is largely unexplored. We developed a scale to measure abortion stigma at the community level, examine its prevalence and explore factors associated with abortion stigma in a nationally representative sample. STUDY DESIGN: Following intensive qualitative work to identify dimensions of the stigma construct, we developed a comprehensive list of statements that were cognitively tested and reduced to 33 to form a scale. We piloted the scale in a nationally and subregionally representative household public opinion survey administered to 5600 Mexican residents. RESULTS: Factor analysis tested the internal consistency and reliability of five previously hypothesized dimensions of abortion stigma: secrecy, religion, autonomy, discrimination and guilt/shame. Under the assumption that these dimensions were independent, confirmatory factor analysis indicated that each of these dimensions functioned as independent subscales. However, to test this assumption, we conducted exploratory factor analysis that revealed a strong codependence between discrimination, guilt/shame and religion statements, resulting in a 23-item four-factor model of abortion stigma and the elimination of the guilt/shame dimension. Both methods revealed a full scale and subscales with Cronbach's alphas between 0.80 and 0.90. Regression analyses suggested that older, less educated individuals living in the north of Mexico report higher levels of stigma, especially related to discrimination and religion. CONCLUSIONS: This community-level abortion stigma scale is the first to be developed and tested in Mexico. This tool may be used in Mexico and other similar country settings to document the prevalence of community-level abortion stigma, identify associated factors and test interventions aimed at reducing abortion stigma. IMPLICATIONS: Abortion stigma prevents women from accessing safe abortion services. Measuring community-level abortion stigma is key to documenting its pervasiveness, testing interventions aimed at reducing it and understanding associated factors. This scale may be useful in countries similar to Mexico to support policymakers, practitioners and advocates in upholding women's reproductive rights.