The COVID-19 pandemic has swept across the world, altering nearly every facet of contemporary life and causing behavioral and socioeconomic changes that seemed unthinkable a few months ago. The increased risks for human health include not just the dangers posed by the virus itself, but also the upheaval to the broader health care and societal landscapes, which has threatened access to critical sexual and reproductive health services. In this viewpoint, we describe how the pandemic has already posed challenges to reproductive autonomy in both the United States and globally, and then offer insights on how it may do so in the future. We conclude with a call not only to resist a rollback of access to reproductive health care during this pandemic, but to center a broad conception of reproductive autonomy in sexual and reproductive health research, policies and programs moving forward.
CONTEXTLittle is known about the pathways mediating the relationship between education and health. It is widely assumed that formal schooling leads to awareness of health risks (e.g., STIs) and, in turn, to adoption of preventive behavior (e.g., condom use); however, evidence supporting this mechanism has been limited.METHODSSurvey data were collected in 2010 from a sample of 247 adults aged 30-62 living in an isolated Andean district of Peru; these individuals had widely varying exposure to schooling, and their community had recently experienced elevated risks of STIs. Structural equation modeling was used to estimate the degree to which schooling is associated with cognitive resources, STI awareness and sexual health knowledge, and how these jointly are associated with ever-use of condoms.RESULTSThirty-two percent of respondents reported ever-use of condoms. One additional year of schooling was associated with a 2.7-percentage-point increase in the probability of condom use, after adjustment for covariates. The pathway between education and condom use was mediated by cognitive executive functioning (CEF) skills (0.26 standard deviations), STI awareness (0.09) and sexual health knowledge (0.10); CEF skills were associated with condom use both directly and indirectly, through STI awareness and sexual health knowledge, and accounted for two-thirds of the education-condom use gradient.CONCLUSIONSThe relationship between education and STI prevention may be more complex than is often assumed and is mediated by CEF skills, STI awareness and sexual health knowledge. Studies should examine whether STI prevention interventions are more effective if they enhance cognitive skills used to translate information into protective behaviors.
CONTEXTFew studies have explored clinicians' roles in the abortion experience in Ghana. Examining how clinicians understand conscientious objection to abortion-the right to refuse to provide legal abortion on the basis of moral or personal beliefs-may provide insight that could help manage the practice.METHODSEight in-depth interviews and four focus group discussions were conducted with 14 doctors and 20 midwives in health facilities in Ghana's Eastern and Volta Regions in May 2018. The semi-structured interview guides covered such topics as clinicians' understanding of conscientious objection, how it is practiced and the consequences of conscientious objection for providers and clients. The data were analyzed using thematic analysis.RESULTSMost clinicians did not understand the term "conscientious objection," and midwives had more knowledge on the subject than doctors. The main reasons for conscientious objection were antiabortion religious and cultural beliefs. Clinicians who objected referred clients to willing providers, counseled them to continue the pregnancies or inadvertently encouraged unsafe abortions. The negative consequences of conscientious objection to abortion for clients were complications and death from unsafe abortions; the consequences for providers included high patient volume and stigma for nonobjectors, leading some to claim objection to avoid these.CONCLUSIONSThe findings highlight the need for further research on the consequences of conscientious objection, including stigma leading to refusals. Such research may ultimately help to restrict clinicians' misuse of the right to object and improve women's reproductive health care in Ghana.
CONTEXT:A growing body of evidence indicates that nonclinical health care facility staff provide support beyond their traditional roles, particularly in low- and middle-income countries. It is important to examine the role of health facility cleaners in Kenya-from their perspective-to better understand their actual and perceived responsibilities in maternity care.METHODS:In-depth, face-to-face interviews using a semistructured guide were conducted with 14 cleaners working at three public health facilities in Nairobi and Kiambu Counties, Kenya, in August and September 2016. Results were coded and categorized using a thematic content analysis approach.RESULTS:Cleaners reported performing a range of services beyond typical maintenance responsibilities, including providing emotional, informational and instrumental support to maternity patients. They described feeling disrespected when patients were untidy or experienced bleeding; however, such examples revealed cleaners' need to better understand labor and childbirth processes. Cleaners also indicated a desire for training on interpersonal skills to improve their interactions with patients.CONCLUSION:Cleaners' direct involvement in maternity patients' care is an alarming symptom of overburdened health facilities, insufficient staffing and inadequate training. This key yet overlooked cadre of health care staff deserves appropriate support and further research to understand and alleviate health system shortcomings, and to improve the quality of maternity health care provision.
CONTEXT Providers' and women's characteristics are associated with postpartum copper IUD (PPIUD) outcomes, but the relationship between providers' level of experience and PPIUD expulsion and discontinuation has not been established. METHODS Data on 1,232 women and 118 providers who took part in a randomized trial of a PPIUD counselling and provision intervention in Nepal between 2015 and 2017 were used to identify associations between providers' and women's characteristics and PPIUD outcomes. Multinomial logistic regression models were used to estimate PPIUD expulsion and discontinuation risks at two years after insertion. RESULTS Thirteen percent of women had had partial or complete expulsions and 29% had discontinued PPIUD use by two years. Having a provider who had done at least 10 previous insertions was associated with lower risk of expulsion rather than continuation (relative risk ratio, 0.5) relative to having a less-experienced provider. Women had a higher risk of both expulsion and discontinuation relative to continuation if they were younger than 21 rather than aged 26-30 (2.4 and 1.7, respectively) or if they belonged to the Dalit rather than Brahmin caste (2.2 and 1.9, respectively). Women whose husbands did not live at home also had elevated discontinuation risks. CONCLUSION The findings highlight the need for increased training and supervision of providers during their first 10 PPIUD insertions. Counselling on risk of expulsion may especially benefit younger and Dalit women, and should include partners and other family members to avoid any stigma surrounding PPIUD use by women whose partner is away from home for a prolonged period.
CONTEXT Women's concerns about contraceptive-induced menstrual changes can lead to method discontinuation and nonuse, contributing to unmet need for contraception. Research on women's perceptions of amenorrhea related to longer acting methods and in low-income countries is limited. METHODS Data were from nationally representative household surveys and focus group discussions with women of reproductive age conducted in Burkina Faso and Uganda in 2016-2017. Bivariate cross-tabulations and multivariate logistic regression analyses were used to examine sociodemographic and reproductive characteristics associated with women's attitudes about contraceptive-induced amenorrhea (n=2,673 for Burkina Faso and 2,281 for Uganda); menstrual health determinants were also examined for Burkina Faso. Qualitative data from focus group discussions were analyzed to understand reasons behind women's attitudes and how they influence contraceptive decision making. RESULTS Sixty-five percent of women in Burkina Faso and 40% in Uganda reported they would choose a method that caused amenorrhea during use. In Burkina Faso, the predicted probability of accepting amenorrhea was higher for women aged 15-19 (compared with older women), living in rural areas, married and cohabiting (compared with never married), currently using a contraceptive method (compared with never users) and from Mossi households (compared with Gourmantché); menstrual health practices were not associated with amenorrhea acceptability. In Uganda, the least wealthy women had the highest predicted probability of accepting amenorrhea (51%). Qualitative analysis revealed a variety of reasons for women's attitudes about amenorrhea and differences by country, but the relationship between these attitudes and contraceptive decision making was similar across countries. CONCLUSIONS Addressing misconceptions about contraception and menstruation may result in more informed method decision making.
CONTEXT In Mexico, first-trimester abortion is legal in Mexico City and is available in the public and private sectors. Understanding subsequent contraceptive uptake and method mix among first-trimester abortion clients relative to that of women who deliver a live birth at a health facility could help identify where improvements in care following an obstetric event can be made across the health system. METHODS This article uses a retrospective cohort study to compare uptake of contraception prior to discharge between abortion clients in Mexico City's public abortion program and postpartum women from urban settings. The two data sources were clinical records of 45,233 abortion clients in Mexico City and information from a population-based survey of 1,289 urban women on their immediate postpartum contraceptive adoption. The primary outcome investigated was receipt of any reversible modern contraceptive method; secondary outcomes were level of method effectiveness and method type. Logistic regression and calculated multivariable probabilities were used to control for the effects of sociodemographic factors across the two data sources. RESULTS The adjusted probability of uptake of any reversible modern method of contraception was higher among abortion clients than among postpartum women (67% vs. 48%). However, among all women who had received a contraceptive method, abortion clients had a lower adjusted probability of having received a long-acting reversible contraceptive than did postpartum women (49% vs. 82%) and a higher probability of having received a moderately effective method (38% vs. 13%). The adjusted probability of implant uptake was higher among abortion clients than among postpartum women (9% vs. 3%), while the adjusted probability of IUD uptake was lower (38% vs. 78%). CONCLUSIONS Women receiving abortions in Mexico City's public abortion program were more likely than urban postpartum women to receive a reversible modern contraceptive method before leaving the facility. Women should be offered the full range of contraceptive methods after any obstetric event, to help them prevent unintended pregnancy and avoid short interpregnancy intervals.
COVID-19 has compromised and disrupted sexual and reproductive health (SRH) across multiple dimensions: individual-level access, health systems functioning, and at the policy and governance levels. Disruptions to supply chains, lockdown measures and travel restrictions, and overburdened health systems have particularly affected abortion access and service provision. The pandemic, rather than causing new issues, has heightened and exposed existing fractures and fissures within abortion access and provision. In this viewpoint, we draw on the concept of "structural violence" to make visible the contributing causes of these ruptures and their inequitable impact among different groups.
Induced abortion is common: In 2017, an estimated 56% of all unintended pregnancies worldwide ended in abortion. Despite the frequency with which women terminate pregnancies, however, 135 countries impose restrictions on induced abortion beyond gestational age limits, which lead some women to seek unsafe abortion. The World Health Organization (WHO) defines unsafe abortion as a procedure for terminating an unwanted pregnancy carried out by individuals who lack the requisite training and skills, in a setting that does not meet minimum medical standards, or both. An estimated 25 million unsafe abortions occur annually-nearly all (97%) in low- and middle-income countries (LMICs), where abortion is more likely to be heavily restricted. Unsafe abortion results in 22,800-31,000 maternal deaths each year. Furthermore, in developing regions, nearly seven of every 1,000 women are treated in a health facility for abortion complications. The legalization and derestriction of abortion are necessary steps in reducing maternal morbidity and mortality from unsafe abortion, but there are additional obstacles to services that must also be addressed.
Following the World Health Organization's (WHO) definition of self-care, abortion self-care is the ability of pregnant individuals to manage their unwanted pregnancies with or without the support of health care providers-particularly, in the early weeks of pregnancy (up to 12 weeks' gestation). The advent of medication abortion (MA) has made this possible, as early self-managed MA at home is a safe, acceptable and cost-effective method of pregnancy termination. The drugs currently available for MA are mifepristone and misoprostol, as well as the two packaged together (also known as the combipack), which is more efficacious than misoprostol alone in evacuating the uterus and is considered the first-line medication for MA. Regardless of the legality of abortion where they live, women worldwide are using these medications to self-manage pregnancy termination inside or outside clinical settings-in conjunction with telemedicine services, peer-led support groups, hotlines and online information sources-which has contributed significantly to reducing maternal mortality and morbidity from unsafe procedures.
The need for comprehensive sexual and reproductive health (SRH) care can be especially acute during humanitarian crises, as women and girls are at increased vulnerability of experiencing sexual violence, unintended pregnancy and pregnancy-related complications. However, in such settings, the chaos of displacement and basic survival may supplant the importance of SRH care, and individuals may also have diminished access to safe services. Abortion and abortion-related care may be particularly limited in humanitarian contexts because of a number of barriers beyond the lack of infrastructure, supplies and trained staff: For example, abortion care practitioners in emergency settings may perceive or face legal complications or loss of funding due to their provision of abortion services, insititutions and governments may lack timely data on and underestimate the true volume of abortion demand among refugees, and providers may hold a perception that providing abortion care in crisis settings may be too difficult to attempt.
CONTEXT:Telemedicine clients wishing to confirm a successful medication abortion outside of a clinic setting are commonly instructed to use high-sensitivity urine pregnancy tests, which can take up to four weeks to yield accurate results. Multilevel urine pregnancy tests (MLPTs), which provide accurate results in one week, are a promising alternative, but their use has not been evaluated within telemedicine services.METHODS:From November 2017 to May 2018, 165 eligible and consenting pregnant people who contacted safe2choose-an organization providing telemedicine abortion services internationally-for medication abortion were enrolled in a pilot study and mailed a package containing medication abortion drugs, two MLPTs and instructions. Data on 118 participants who completed a web-based evaluation survey two weeks after the package was sent were analyzed to examine participant experiences and satisfaction with the service.RESULTS:Responding participants were from 11 countries, including Mexico, the Philippines and Singapore. Ninety-three percent used both MLPTs, and 91% of those who used both tests used them at the correct time intervals. Among the 95% of participants whose MLPT results indicated that their pregnancy hormone levels decreased from before to after medication abortion, 86% correctly interpreted the results to mean that they were no longer pregnant. Satisfaction was high, with all indicating that the supplied information was helpful; more than nine out of 10 noted that they would want to use the MLPTs again.CONCLUSIONS:Incorporating MLPTs into telemedicine abortion services is feasible and associated with high client satisfaction. Enabling people to manage their own abortion follow-up care could greatly improve their overall abortion experience.
CONTEXT Evidence shows that laws that restrict abortion do not eliminate its practice, but instead result in women having clandestine abortions, which are likely to be unsafe. It is important to periodically assess changes in the legal status of abortion around the world. METHODS The criteria for legal abortion as of 2019 for 199 countries and territories were used to distribute them along a continuum of six mutually exclusive categories, from prohibited to permitted without restriction as to reason. The three most common additional legal grounds that fall outside of this continuum-rape, incest and fetal anomaly-were also quantified. Patterns by region and per capita gross national income were examined. Changes resulting from law reform and judicial decisions since 2008 were assessed, as were changes in policies and guidelines that affect access. RESULTS Legality correlated positively with income: The proportions of countries in the two most-liberal categories rose uniformly with gross national income. From 2008 to 2019,27 countries expanded the number of legal grounds for abortion; of those, 21 advanced to another legality category, and six added at least one of the most common additional legal grounds. Reform resulted from a range of strategies, generally involving multiple stakeholders and calls for compliance with international human rights norms. CONCLUSIONS The global trend toward liberalization continued over the past decade; however, even greater progress is needed to guarantee all women's right to legal abortion and to ensure adequate access to safe services in all countries.
CONTEXT:In 2017, Chile reformed its abortion law to allow the procedure under limited circumstances. Exploring the views of Chilean medical and midwifery faculty regarding abortion and the use of conscientious objection (CO) at the time of reform can inform how these topics are being taught to the country's future health care providers.METHODS:Between March and September 2017, 30 medical and midwifery school faculty from universities in Santiago, Chile were interviewed; 20 of the faculty taught at secular universities and 10 taught at religiously affiliated universities. Faculty perspectives on CO and abortion, the scope of CO, and teaching about CO and abortion were analyzed using a grounded theory approach.RESULTS:Most faculty at secular and religiously affiliated universities supported the rights of clinicians to refuse to provide abortion care. Secular-university faculty generally thought that CO should be limited to specific providers and rejected the idea of institutional CO, whereas religious-university faculty strongly supported the use of CO by a broad range of providers and at the institutional level. Only secular-university faculty endorsed the idea that CO should be regulated so that it does not hinder access to abortion care.CONCLUSIONS:The broader support for CO in abortion among religious-university faculty raises concerns about whether students are being taught their ethical responsibility to put the needs of their patients above their own. Future research should monitor whether Chile's CO regulations and practices are guaranteeing people's access to abortion care.
CONTEXT: The Democratic Republic of the Congo (DRC) decriminalized abortion under certain circumstances in 2018 through the Maputo Protocol. However, little is known about the readiness of the country's health facilities to provide comprehensive abortion care. METHODS: Data on 1,380 health facilities from the 2017-2018 DRC Service Provision Assessment (SPA) inventory survey were used to assess readiness to provide abortion care in four domains: termination of pregnancy, basic treatment of postabortion complications, comprehensive treatment of postabortion complications and postabortion contraceptive care. Analyses used a modified application of the emergency obstetric care signal function approach; criteria for readiness were based on World Health Organization guidelines. RESULTS: Thirty-one percent of DRC facilities met the criteria for readiness to provide abortions.The proportion of facilities classified as ready was higher among urban facilities than rural ones (50% vs. 26%), and among hospitals than health centers or reference health centers (72% vs. 25% and 45%, respectively). Few facilities were ready to provide either basic or comprehensive treatment of postabortion complications (4% and 1%); readiness to provide these services was greatest among hospitals (14% and 11%). Only a third of facilities displayed readiness to provide postabortion contraceptive care. Inadequate supplies of medication (e.g., misoprostol, antibiotics, contraceptives) and equipment were the greatest barrier to readiness. CONCLUSIONS: Most DRC facilities were not ready to provide comprehensive abortion care. Improving supplies of vital health commodities will improve readiness, and has the potential to reduce the prevalence of unplanned pregnancies and future demand for abortions.
CONTEXT:Abortion is particularly difficult to measure, especially in legally restrictive settings such as Pakistan. The List Experiment-a technique for measuring sensitive health behaviors indirectly-may minimize respondents' underreporting of abortion due to stigma or legal restrictions, but has not been previously applied to estimate abortion prevalence in Pakistan.METHODS:A sample of 4,159 married women of reproductive age were recruited from two communities of Karachi in 2018. Participants completed a survey that included a double list experiment to measure lifetime abortion prevalence, as well as direct questions about abortion and other background characteristics. Data were used to calculate direct and indirect estimates of abortion prevalence for the overall sample and by sociodemographic characteristics, as well as to test for a design effect. Regression analyses were conducted to examine associations between characteristics and abortion reporting from direct questioning and the list experiment.RESULTS:The estimate of abortion prevalence from the list experiment was 16%; the estimate from the direct question was 8%. No evidence of a design effect was found. Abortion reporting was associated with most selected characteristics in the regression model for direct questioning, but with few in the list experiment models.CONCLUSIONS:That the estimate of abortion prevalence in Karachi generated from the list experiment was twice that generated from direct questioning suggests that the indirect method reduced underreporting, and may have utility to estimate abortion in similar settings and to improve the accuracy of data collecting for other sensitive health topics.
CONTEXT Hygienic use of absorbent products during menstruation is a challenge for young women in India, especially among the underprivileged, who lack knowledge and access to resources. Reuse of menstrual absorbents can be unhygienic and result in adverse health and other outcomes. METHODS Data from the 2015-2016 National Family Health Survey-4 for 233,606 menstruating women aged 15-24 were used to examine levels and correlates of exclusive use of disposable absorbents during menstruation. Bivariate and logistic regression analyses were conducted to identify disparities in exclusive use by such characteristics as caste, mass media exposure and interaction with health workers. RESULTS Exclusive use of disposable absorbents was low among young women overall (37%), and varied substantially by caste and other characteristics. Compared with women from general castes, those from scheduled castes, scheduled tribes and other backward classes had reduced odds of exclusive disposable absorbent use (odds ratios, 0.8-0.9). Disposable absorbent use was negatively associated with lower levels of education and household wealth, and rural residence. Compared with women who reported daily media exposure, those exposed less frequently had reduced odds of disposable absorbent use (0.7-0.9). Among those who recently met with a health worker, odds of use were lower if menstrual hygiene had not been discussed (0.9). CONCLUSIONS Promoting awareness of proper menstrual hygiene-through education, media campaigns and discussion with reproductive health workers-and targeted interventions to disseminate and subsidize the purchase of disposable sanitary napkins should be pursued to address health disparities.
CONTEXT:Improving women's empowerment is pivotal to public health and development programs; however, inconsistent definitions and lack of cross-cultural measures compromise monitoring efforts.METHODS:Data collected in 2017-2018 in Ethiopia, Uganda and two sites in Nigeria were used to develop a cross-cultural index of women's and girls' empowerment in sexual and reproductive health (WGE-SRH). Item development was grounded in qualitative interviews, and informed by a conceptual framework that included domains of existence of choice and exercise of choice related to sex, contraceptive use and pregnancy. Items were pilot tested among 1,229 women aged 15-49 across sites. Psychometric properties were explored to identify crosssite constructs, and logistic regression was used to assess the construct validity of each dimension.RESULTS:Analyses identified subscales for sexual existence of choice (Cronbach's alphas, 0.71-0.79) and contraceptive existence of choice (0.56-0.78). A pregnancy existence of choice subscale emerged for only two sites (0.61-0.80). Internal reliability of the exercise of choice subscales varied. Construct validity analyses found that for some sites, high scores on the sexual and contraceptive existence of choice subscales were associated with elevated odds of volitional sex and contraceptive use, respectively. Combining the existence of choice and exercise of choice summary scores for sex strengthened associations with volitional sex.CONCLUSIONS:The cross-cultural WGE-SRH index can be used to assess existence of choice related to contraception and volitional sex. Further work is needed to improve measures of SRH exercise of choice, and investigate the index's multidimensionality and associations with SRH outcomes.
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.
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. International
