Postabortion and safe abortion care coverage, capacity, and caseloads during the global gag rule policy period in Ethiopia and Uganda.

BACKGROUND: Abortion-related complications contribute to preventable maternal mortality, accounting for 9.8% of maternal deaths globally, and 15.6% in sub-Saharan Africa. High-quality postabortion care (PAC) can mitigate the negative health outcomes associated with unsafe abortion. While the expanded Global Gag Rule policy did not prohibit the provision of PAC, other research has suggested that over-implementation of the policy has resulted in impacts on these services. The purpose of this study was to assess health facilities' capacity to provide PAC services in Uganda and PAC and safe abortion care (SAC) in Ethiopia during the time in which the policy was in effect. METHODS: We collected abortion care data between 2018 and 2020 from public health facilities in Ethiopia (N = 282) and Uganda (N = 223). We adapted a signal functions approach to create composite indicators of health facilities' capacity to provide basic and comprehensive PAC and SAC and present descriptive statistics documenting the state of service provision both before and after the GGR went into effect. We also investigate trends in caseloads over the time-period. RESULTS: In both countries, service coverage was high and improved over time, but facilities' capacity to provide basic PAC services was low in Uganda (17.8% in 2019) and Ethiopia (15.0% in 2020). The number of PAC cases increased by 15.5% over time in Uganda and decreased by 7% in Ethiopia. Basic SAC capacity increased substantially in Ethiopia from 66.7 to 82.8% overall, due in part to an increase in the provision of medication abortion, and the number of safe abortions increased in Ethiopia by 9.7%. CONCLUSIONS: The findings from this analysis suggest that public health systems in both Ethiopia and Uganda were able to maintain essential PAC/SAC services during the GGR period. In Ethiopia, there were improvements in the availability of safe abortion services and an overall improvement in the safety of abortion during this time-period. Despite loss of partnerships and potential disruptions in referral chains, lower-level facilities were able to expand their capacity to provide PAC services. However, PAC caseloads increased in Uganda which could indicate that, as hypothesized, abortion became more stigmatized, less accessible and less safe.

Sexual and Reproductive Health Literacy, Misoprostol Knowledge and Use of Medication Abortion in Lagos State, Nigeria: A Mixed Methods Study.

Little is known about the link between health literacy and women's ability to safely and successfully use misoprostol to self-induce an abortion. While abortion is only allowed to save a woman's life in Nigeria, misoprostol is widely available from drug sellers. We interviewed 394 women in 2018 in Lagos State, Nigeria, who induced abortion using misoprostol obtained from a drug seller to determine their sexual and reproductive health literacy (SRHL) and misoprostol knowledge levels; and how these were associated with ending the pregnancy successfully or seeking care for (perceived) complications. Our results show that women's misoprostol knowledge (measured both quantitatively and qualitatively) was low, but that almost all women were nevertheless able to use the drug effectively and safely. Higher SRHL was associated with being more likely to end the pregnancy successfully and also seeking postabortion health care. Our study is the first to examine this association and adds to the scarce literature examining the relationship between health literacy and self-use of misoprostol to induce abortions in restrictive settings.

Lived experiences and drivers of induced abortion among women in central Uganda.

Although unsafe abortions are preventable, they are one of the leading causes of maternal mortality and morbidity. Despite the serious potential health consequences, there is limited published information about drivers and challenges of obtaining abortions in restrictive settings such as Uganda. This limits efforts to improve programing for preventing unsafe abortion and providing comprehensive post abortion care. This study sought to understand the drivers and explain the lived abortion experiences among women from central Uganda, in an effort to promote greater access to safe reproductive healthcare services, and reduce unsafe abortions. This qualitative study included 40 purposely selected women who self-reported an abortion, living in Kampala and greater Rakai district, Uganda. They were part of a larger survey using respondent driven sampling, where seed participants were recruited from selected facilities offering post-abortion care, or through social referrals. Data were collected from May to September 2021 through in-depth interviews. Audio data were transcribed, managed using Atlas.ti 9, and analyzed thematically. The findings show that the underlying drivers stemmed from partners who were unsupportive, denied responsibility, or had raped/defiled women. Career and education decisions, stigma and fear to disappoint family also contributed. Women had feelings of confusion, neglect, betrayal, or shame after conception. Abortion and post-abortion experiences were mixed with physical and emotional pain including stigma, even when the conditions for safe abortion in the guidelines were satisfied. Although most women sought care from health facilities judged to provide safe and quality care, there was barely any counselling in these venues. Confidantes and health providers informed the choice of abortion methods, although the cost ultimately mattered most. The mental health of women whose partners are unsupportive or who conceive unintendedly need consideration. Abortion provided psychological relief from more complicated consequences of having an unplanned birth for women.

Quality of information offered to women by drug sellers providing medical abortion in Nigeria: Evidence from providers and their clients.

Background: Evidence confirmed that the demand for medical abortion (MA) increased significantly during the COVID-19 outbreak in many developing countries including Nigeria. In an abortion-restrictive setting like Nigeria, local pharmacies, and proprietary patent medicine vendors (PPMVs) continue to play a major role in the provision of MA including misoprostol. There is the need to understand these providers' knowledge about the use of misoprostol for abortion and the quality of information they provide to their clients. This analysis is focused on assessing the quality of care provided by both drug seller types, from drug sellers' and women's perspectives. Methodology: This study utilized primary data collected from drug sellers (pharmacists and PPMVs) and women across 6 Local Government Areas in Lagos State, Nigeria. The core sample included 126 drug sellers who had sold abortion-inducing drugs and 386 women who procured abortion-inducing drugs from the drug sellers during the time of the study. We calculate quality-of-care indices for the care women received from drug sellers, drawing on WHO guidelines for medication abortion provision. The index based on information from the sellers had two domains-technical competency and information provided to clients, while the index from the women's perspectives includes an additional domain, client experience. Results: Results show that the majority of drug sellers in the sample, 56% (n = 70), were pharmacists. However, far more than half of women 60% (n = 233) had visited PPMVs. Overall, the total quality score amongst all drug sellers (mean 0.48, SD0.15) was higher than the total score calculated based on women's responses (mean 0.39, SD 0.21). Using our quality-of-care index, pharmacies and PPMVs seem to have similar technical competency (mean score of 0.23, SD 0.13 in both groups (range 0-1), whilst PPMV's performed better on the information provided to client domain (mean score of 0.79, SD 0.17 compared with pharmacies 0.69, SD 0.25). Based on women's reports, PPMVs scored better on both quality of care domains (technical competency and information provided to clients) compared with pharmacies. Program/Policy Implication: In resource-constrained settings such as Nigeria, particularly in the context of health emergencies like COVID-19, there is the need to continue to strengthen and engage PPMVs' capacity and skills in dispensing and administration of MA drugs as a harm reduction strategy. Also, there is the need to target frontline providers in pharmacies for training and skill upscale in MA provision.

Availability, practices and acceptance of postabortion contraceptive services in health facilities: A study in six states of India.

OBJECTIVE: To assess the availability of and practices around postabortion contraceptive services in health facilities, and document women's acceptance of postabortion contraception in six Indian states. STUDY DESIGN: We conducted a survey of 4001 public and private health facilities that provide abortion-related care in six Indian states. In this analysis, we assess the availability and range of contraceptive methods offered, the protocols and practices around postabortion contraceptive counseling, the extent to which facilities require women to adopt contraception, and contraceptive uptake among women. RESULTS: Although some contraceptive methods and information were available at a majority of facilities (75-97%), the range of methods was lacking and the information provided to women varied considerably by state. 8-26% of facilities required women seeking induced abortions to accept a modern contraceptive method. Only half to two-thirds of postabortion patients adopted a modern method. CONCLUSION: The limited number of methods offered in facilities suggests that some women may not obtain the method they desire, or get information about the full range of methods that should be available. While contraceptive uptake should be voluntary, the requirement imposed by some facilities for women to adopt a modern contraceptive method in order to obtain an abortion must be addressed. IMPLICATIONS: Some 15.6 million Indian women had an induced abortion in 2015. Understanding the provision of postabortion contraceptive services in health facilities, including counseling, is necessary to inform policies and practices to better enable women and couples to make informed decisions to prevent future unintended pregnancies.

Incidence of treatment for postabortion complications in India, 2015.

Abortion has been legal under broad criteria in India since 1971. However, access to legal abortion services remains poor. In the past decade, medication abortion (MA) has become widely available in India and use of this method outside of health facilities accounts for over 70% of all abortions. Morbidity from unsafe abortion remains an important health issue. The informal providers who are the primary source of MA may have poor knowledge of the method and may offer inadequate or inaccurate advice on use of the method. Misuse of the method can result in women seeking treatment for true complications as well as during the normal processes of MA. An estimated 5% of all abortions are done using highly unsafe methods and performed by unskilled providers, also contributing to abortion morbidity. This paper provides new representative abortion-related morbidity measures at the national and subnational levels from a large-scale 2015 study of six Indian states-Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh. The outcomes include the number and treatment rates of women with complications resulting from induced abortion and the type of complications. The total number of women treated for abortion complications at the national level is 5.2 million, and the rate is 15.7 per 1000 women of reproductive age per year. In all six study states, a high proportion of all women receiving postabortion care were admitted with incomplete abortion from use of MA-ranging from 33% in Tamil Nadu to 65% in Assam. The paper fills an important gap by providing new evidence that can inform policy-makers and health planners at all levels and lead to improvements in the provision of postabortion care and legal abortion services-improvements that would greatly reduce abortion-related morbidity and its costs to Indian women, their families and the healthcare system.

An Application of the Confidante Method to Estimate Induced Abortion Incidence in Java, Indonesia.

CONTEXT: Induced abortion is legally restricted and highly stigmatized in Indonesia, and is thus extremely difficult to measure. Indirect methods leveraging women's social networks, such as the Confidante Method, have shown promise in estimating hidden behaviors, including abortion, in similar settings. METHODS: A community-based survey was conducted among 8,696 women aged 15-49 in Java, Indonesia, in November 2018-January 2019. Data were collected via in-person interviews with respondents about their own abortions and those of up to three of their closest confidantes. One-year induced abortion incidence rates per 1,000 women were estimated using a direct-report approach and the Confidante Method. RESULTS: The direct-report abortion rate was 3.4 per 1,000 women in 2018, compared with the Confidante Method rate of 11.3 per 1,000. Among the confidantes of women who reported an abortion in the past five years, the abortion rate was 42.0 per 1,000. Half of the women reported that they had no confidantes with whom they shared private information. Among women reporting an abortion and at least one confidante, 58% had disclosed their abortion to their confidante, indicating that substantial transmission bias was present. CONCLUSIONS: The Confidante Method relies on several assumptions that did not hold in this study. Although the method performed better than the direct-report approach, it underestimated the incidence of abortion in Java. More research is needed to understand how abortion-related information is shared within social networks and to assess the appropriateness of applying the Confidante Method to estimate abortion in a given context.

RESUMEN Contexto: El aborto inducido está restringido legalmente y sumamente estigmatizado en Indonesia y, por lo tanto, es extremadamente difícil de medir. Los métodos indirectos que aprovechan las redes sociales de mujeres, como el método basado en confidentes, han demostrado ser promisorios para estimar comportamientos que se ocultan, incluido el aborto, en entornos similares. Métodos: Entre noviembre de 2018 y enero de 2019, se llevó a cabo una encuesta basada en la comunidad entre 8,696 mujeres en edades de 15 a 49 años en Java, Indonesia. Se recolectaron datos a través de entrevistas presenciales con personas sobre sus propios abortos y los de hasta tres de sus confidentes más cercanas. Se estimaron tasas anuales de incidencia de aborto inducido por 1,000 mujeres mediante el uso del enfoque de informe directo y del método basado en confidentes. Resultados: La tasa de aborto por informe directo fue de 3.4 por 1,000 mujeres en 2018, en comparación con la tasa del método basado en confidentes de 11.3 por 1,000. Entre las personas confidentes de mujeres que reportaron haber tenido un aborto en los últimos cinco años, la tasa de aborto fue de 42.0 por 1,000. La mitad de las mujeres reportaron que no tenían confidentes con quienes compartir su información privada. Entre las mujeres que reportaron haber tenido un aborto y tener al menos una persona confidente, el 58% habían revelado su aborto a su confidente, lo que indica que hubo un importante sesgo de transmisión. Conclusiones: El método basado en confidentes depende de varias suposiciones que no fueron aplicables en este estudio. Aunque el método funcionó mejor que el enfoque de informe directo, subestimó la incidencia del aborto en Java. Es necesario realizar más investigación para comprender la forma en que la información relacionada con el aborto se comparte dentro de las redes sociales, así como para determinar qué tan apropiado es aplicar el método basado en confidentes para estimar la incidencia del aborto en un contexto determinado.

RÉSUMÉ Contexte: L'avortement provoqué est limité par la loi et fait l'objet d'une forte stigmatisation en Indonésie. Il est par conséquent extrêmement difficile d'en mesurer l'incidence. Les méthodes indirectes tirant parti des réseaux sociaux des femmes, comme celle de la « confidente ¼, se sont révélées prometteuses dans l'estimation de comportements cachés, notamment l'avortement, dans des contextes comparables. Méthodes: Une enquête communautaire a été menée auprès de 8 696 femmes âgées de 15 à 49 ans à Java (Indonésie) entre novembre 2018 et janvier 2019. Les données ont été collectées dans le cadre d'entretiens personnels avec les répondantes, concernant leurs propres avortements et ceux d'un maximum de trois de leurs confidentes les plus proches. Les taux d'incidence de l'avortement provoqué d'une année pour 1 000 femmes ont été estimés selon une approche de déclaration directe et par la méthode de la confidente. Résultats: Le taux d'avortement estimé par déclaration directe s'est avéré de 3,4 pour 1 000 femmes en 2018, par rapport à 11,3 pour 1 000 selon la méthode de la confidente. Parmi les confidentes des femmes ayant déclaré un avortement durant les cinq dernières années, le taux s'élevait à 42,0 pour 1 000. La moitié des femmes ont déclaré ne pas avoir de confidentes avec lesquelles elles partageaient une information privée. Parmi les femmes déclarant un avortement et au moins une confidente, 58% avaient divulgué leur avortement à leur confidente, indiquant un biais de transmission considérable. Conclusions: La méthode de la confidente repose sur plusieurs hypothèses non confirmées dans cette étude. Bien qu'ayant produit de meilleurs résultats que l'approche par déclaration directe, elle sous-estime l'incidence de l'avortement à Java. Il convient d'approfondir la recherche pour comprendre les modalités du partage de l'information relative à l'avortement au sein des réseaux sociaux et pour évaluer la pertinence du recours à la méthode de la confidente pour estimer l'incidence de l'avortement dans un contexte donné.

Estimating the Incidence of Induced Abortion in Java, Indonesia, 2018.

CONTEXT: In Indonesia, maternal mortality is high and abortion is restricted. Reliable information on induced abortion is needed; however, the difficulty of measuring abortion in settings where it is legally restricted and highly stigmatized calls for innovation in approaches to measuring abortion incidence. METHODS: The data were from three original surveys conducted in Java among health facilities, knowledgeable informants and women aged 15-49, fielded in April 2018-January 2019. Two methods were used to estimate the one-year induced abortion incidence rate in Java: the standard Abortion Incidence Complications Method (AICM) and a modified AICM. Each method was evaluated on the basis of data quality, and what is known about sexual and reproductive health indicators related to abortion rates, to determine which performed best in measuring abortion incidence in Java. RESULTS: Estimates of complications resulting from induced abortion from knowledgeable informants and the women differed substantially. The modified AICM produced an estimate of 42.5 abortions per 1,000 women aged 15-49, while the standard AICM estimate was lower (25.8 per 1,000). A comparison of the distribution of abortion methods used revealed that knowledgeable informants believed abortion was less safe than indicated by women's reports of their own experiences. Therefore, the standard AICM likely underestimates abortion. CONCLUSIONS: The modified AICM performed better than the standard AICM and indicates that abortion is common in Java. Increased access to contraceptives and high-quality postabortion care is needed. Future research should investigate the safety of abortion, especially with respect to self-managed abortion.

RESUMEN Contexto: La mortalidad materna en Indonesia es alta y el aborto está restringido. Se necesita información confiable sobre el aborto inducido; sin embargo, la dificultad de medir el aborto en entornos donde está restringido legalmente y es fuertemente estigmatizado, requiere esfuerzos de innovación en los enfoques para medir la incidencia del aborto. Métodos: Los datos se obtuvieron de tres encuestas originales realizadas en Java entre instituciones de salud, informantes conocedores del tema y mujeres en edades de 15 a 49 años y que fueron aplicadas entre abril de 2018 y enero de 2019. Se usaron dos métodos para estimar la tasa de incidencia de aborto inducido en un año en Java: el método estándar de estimación de aborto por complicaciones (AICM, por sus siglas en inglés) y el AICM modificado. Cada método se evaluó con base en la calidad de los datos y en lo que se sabe sobre indicadores de salud sexual y reproductiva relacionados con las tasas de aborto, para determinar cuál método se desempeñó mejor en la medición de la incidencia de aborto en Java. Resultados: Las estimaciones de complicaciones derivadas del aborto inducido según informantes conocedores del tema y según las mujeres, difirieron sustancialmente. El AICM modificado produjo una estimación de 42.5 abortos por 1,000 mujeres en edades de 15 a 49 años, mientras que la estimación del AICM estándar fue más baja (25.8 por 1,000). Una comparación de la distribución de los métodos de aborto usados reveló que los informantes conocedores creían que el aborto era menos seguro que lo indicado en los informes de las mujeres basados en sus propias experiencias. Por lo tanto, es probable que el método AICM estándar subestime la incidencia del aborto. Conclusiones: El método AICM modificado funcionó mejor que el AICM estándar e indica que el aborto es una práctica común en Java. Son necesarios un mayor acceso a los anticonceptivos y a una atención postaborto de alta calidad. Las futuras investigaciones deben investigar la seguridad del aborto, especialmente en relación con el aborto autoadministrado.

RÉSUMÉ Contexte: En Indonésie, la mortalité maternelle est élevée et l'avortement est limité par la loi. Il existe un besoin d'information fiable concernant l'avortement provoqué. La difficulté de mesurer l'avortement dans les contextes où il est strictement limité et fortement stigmatisé demande cependant des approches innovantes. Méthodes: Les données proviennent de trois enquêtes initiales menées à Java auprès de structures de santé, de sources bien informées et de femmes âgées de 15 à 49 ans, entre avril 2018 et janvier 2019. Le taux d'incidence de l'avortement provoqué à l'échelle d'une année à Java a été estimé selon deux méthodes: la méthode AICM standard d'évaluation de l'incidence de l'avortement en fonction des complications traitées et une méthode AICM modifiée. Chaque méthode a été évaluée en fonction de la qualité des données et de l'information connue sur les indicateurs de santé sexuelle et reproductive relatifs aux taux d'avortement, afin de déterminer celle qui avait le mieux mesuré l'incidence de l'avortement à Java. Résultats: Les estimations des complications résultant de l'avortement provoqué obtenues des sources informées et des femmes consultées se sont avérées nettement différentes. La méthode AICM modifiée a produit une estimation de 42,5 avortements pour 1 000 femmes âgées de 15 à 49 ans, tandis que la méthode AICM standard produisait une estimation inférieure (25,8 pour 1 000). En comparant la distribution des méthodes d'avortement pratiquées, on a constaté que les sources informées estimaient l'avortement moins sùr que ne l'indiquaient les déclarations des femmes concernant leur propre expérience. Il est dès lors probable que la méthode AICM standard sous-estime l'avortement. Conclusions: La méthode AICM modifiée, plus efficace que la méthode standard, fait état d'une pratique courante de l'avortement à Java. Un meilleur accès à la contraception et à des soins après avortement de qualité est nécessaire. La recherche future devrait se pencher sur la sécurité de l'avortement, en ce qui concerne en particulier les interventions autogérées.

Women's self-reported experiences using misoprostol obtained from drug sellers: a prospective cohort study in Lagos State, Nigeria.

OBJECTIVES: This study aimed to assess the safety and effectiveness of self-managed misoprostol abortions obtained outside of the formal health system in Lagos State, Nigeria. DESIGN: This was a prospective cohort study among women using misoprostol-containing medications purchased from drug sellers. Three telephone-administered surveys were conducted over 1 month. SETTING: Data were collected in 2018 in six local government areas in Lagos State. PARTICIPANTS: Drug sellers attempted to recruit all women who purchased misoprostol-containing medication. To remain in the study, participants had to be female and aged 18-49, and had to have purchased the medication for the purpose of abortion. Of 501 women initially recruited, 446 were eligible for the full study, and 394 completed all three surveys. PRIMARY AND SECONDARY OUTCOME MEASURES: Using self-reported measures, we assessed the quality of information provided by drug sellers; the prevalence of potential complications; and the proportion with completed abortions. RESULTS: Although drug sellers provided inadequate information about the pills, 94% of the sample reported a complete abortion without surgical intervention about 1 month after taking the medication. Assuming a conservative scenario where all individuals lost to follow-up had failed terminations, the completion rate dropped to 87%. While 86 women reported physical symptoms suggestive of complications, only six of them reported wanting or needing health facility care and four subsequently obtained care. CONCLUSIONS: Drug sellers are an important source of medical abortion in this setting. Despite the limitations of self-report, many women appear to have effectively self-administered misoprostol. Additional research is needed to expand the evidence on the safety and effectiveness of self-use of misoprostol for abortion in restrictive settings, and to inform approaches that support the health and well-being of people who use this method of abortion.

Provision of medical methods of abortion in facilities in India in 2015: A six state comparison.

Medical methods of abortion, MMA, has been legal in India since 2002. Guidelines stipulate that it should be administered by a provider or acquired via prescription. 1.2 million women having abortions in India use MMA acquired from health facilities [Singh, S., Shekhar, C., Acharya, R., Moore, A. M., Stillman, M., Pradhan, M. R., … Browne, A. (2018). The incidence of abortion and unintended pregnancy in India, 2015. The Lancet Global Health, 6(1), e111-e120. doi: 10.1016/S2214-109X(17)30453-9 ]. We undertook a study of abortion in Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh in 2015 to better understand under what conditions and how MMA is being administered in facilities. The majority of facilities that provide MMA are in the private sector and located in urban areas. Most facilities offer MMA both at the facility and as a prescription, although some facilities only offer MMA as a prescription. A high proportion of facilities report that women typically take the medication at home. (Re)training providers in MMA protocols and counselling, increasing the number of facilities offering MMA, and stocking of the drugs would help improve women's access to MMA and the information they need to be able to use this method safely. Key Messages: In the six states in our sample, Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu and Uttar Pradesh, 8% of abortions in 2015 were done using medical methods of abortion (MMA) acquired from health facilities. The majority of facilities that provide MMA in the six states are in the private sector and are located in urban areas. Health facilities in Madhya Pradesh and Tamil Nadu are comparatively better in their provision of MMA with Assam, Bihar, Gujarat and Uttar Pradesh demonstrating poorer provision of MMA. There are many opportunities for improvement in the practices of MMA provision through improved training of providers, accessibility to the medications and better support of women using MMA.

Challenges to implementing national comprehensive sexuality education curricula in low- and middle-income countries: Case studies of Ghana, Kenya, Peru and Guatemala.

School-based comprehensive sexuality education (CSE) can help adolescents achieve their full potential and realize their sexual and reproductive health and rights. This is particularly pressing in low- and middle-income countries (LMICs), where high rates of unintended pregnancy and STIs among adolescents can limit countries' ability to capitalize on the demographic dividend. While many LMICs have developed CSE curricula, their full implementation is often hindered by challenges around program planning and roll-out at the national and local level. A better understanding of these barriers, and similarities and differences across countries, can help devise strategies to improve implementation; yet few studies have examined these barriers. This paper analyzes the challenges to the implementation of national CSE curricula in four LMICs: Ghana, Kenya, Peru and Guatemala. It presents qualitative findings from in-depth interviews with central and local government officials, civil society representatives, and community level stakeholders ranging from religious leaders to youth representatives. Qualitative findings are complemented by quantitative results from surveys of principals, teachers who teach CSE topics, and students aged 15-17 in a representative sample of 60-80 secondary schools distributed across three regions in each country, for a total of around 3000 students per country. Challenges encountered were strikingly similar across countries. Program planning-related challenges included insufficient and piecemeal funding for CSE; lack of coordination of the various efforts by central and local government, NGOs and development partners; and inadequate systems for monitoring and evaluating teachers and students on CSE. Curriculum implementation-related challenges included inadequate weight given to CSE when integrated into other subjects, insufficient adaptation of the curriculum to local contexts, and limited stakeholder participation in curriculum development. While challenges were similar across countries, the strategies used to overcome them were different, and offer useful lessons to improve implementation for these and other low- and middle-income countries facing similar challenges.

The incidence of abortion and unintended pregnancy in India, 2015.

BACKGROUND: Reliable information on the incidence of induced abortion in India is lacking. Official statistics and national surveys provide incomplete coverage. Since the early 2000s, medication abortion has become increasingly available, improving the way women obtain abortions. The aim of this study was to estimate the national incidence of abortion and unintended pregnancy for 2015. METHODS: National abortion incidence was estimated through three separate components: abortions (medication and surgical) in facilities (including private sector, public sector, and non-governmental organisations [NGOs]); medication abortions outside facilities; and abortions outside of facilities and with methods other than medication abortion. Facility-based abortions were estimated from the 2015 Health Facilities Survey of 4001 public and private health facilities in six Indian states (Assam, Bihar, Gujarat, Madhya Pradesh, Tamil Nadu, and Uttar Pradesh) and from NGO clinic data. National medication abortion drug sales and distribution data were obtained from IMS Health and six principal NGOs (DKT International, Marie Stopes International, Population Services International, World Health Partners, Parivar Seva Santha, and Janani). We estimated the total number of abortions that are not medication abortions and are not obtained in a health facility setting through an indirect technique based on findings from community-based study findings in two states in 2009, with adjustments to account for the rapid increase in use of medication abortion since 2009. The total number of women of reproductive age and livebirth data were obtained from UN population data, and the proportion of births from unplanned pregnancies and data on contraceptive use and need were obtained from the 2015-16 National Family Health Survey-4. FINDINGS: We estimate that 15·6 million abortions (14·1 million-17·3 million) occurred in India in 2015. The abortion rate was 47·0 abortions (42·2-52·1) per 1000 women aged 15-49 years. 3·4 million abortions (22%) were obtained in health facilities, 11·5 million (73%) abortions were medication abortions done outside of health facilities, and 0·8 million (5%) abortions were done outside of health facilities using methods other than medication abortion. Overall, 12·7 million (81%) abortions were medication abortions, 2·2 million (14%) abortions were surgical, and 0·8 million (5%) abortions were done through other methods that were probably unsafe. We estimated 48·1 million pregnancies, a rate of 144·7 pregnancies per 1000 women aged 15-49 years, and a rate of 70·1 unintended pregnancies per 1000 women aged 15-49 years. Abortions accounted for one third of all pregnancies, and nearly half of pregnancies were unintended. INTERPRETATION: Health facilities can have a greater role in abortion service provision and provide quality care, including post-abortion contraception. Interventions are needed to expand access to abortion services through better equipping existing facilities, ensuring adequate and continuous supplies of medication abortion drugs, and by increasing the number of trained providers. In view of how many women rely on self-administration of medication abortion drugs, interventions are needed to provide women with accurate information on these drugs and follow-up care when needed. Research is needed to test interventions that improve knowledge and practice in providing medication abortion, and the Indian Government at the national and state level needs to prioritise improving policies and practice to increase access to comprehensive abortion care and quality contraceptive services that prevent unintended pregnancy. FUNDING: Government of UK Department for International Development (until 2015), the David and Lucile Packard Foundation, the John D. and Catherine T. MacArthur Foundation, and the Ford Foundation.