In response to mounting abortion restrictions and criminalization in the United States, more people are having medication abortions outside of clinical settings. Since 2021, Mexico-based accompaniment collectives have provided support for self-managed abortion in the U.S. Through a collaborative research-activist partnership with three accompaniment collectives, we conducted a qualitative study to understand the care-seeking journeys and abortion experiences of people who contacted Mexico-based accompaniment collectives. We completed 21 interviews including six in-depth interviews via Zoom and 15 asynchronous text interviews through secure phone messaging. Our thematic coding and analysis elucidated factors that contributed to seeking accompaniment support including restrictive laws, preference to avoid clinical care, and financial considerations. Participants described concerns about legal risks such as criminalization and surveillance, and fears around the abortion process. They often felt initial skepticism toward the accompaniment model of care, and many explained how they developed trust through referrals from trusted sources, successful receipt of the pills, and timely, person-centered communication with the accompaniment collective. Participants identified ways they felt prepared for the abortion process through information provision and emotional support, from both the accompaniment collectives and other sources. The Mexico-based accompaniment collectives offered acceptable, person-centered care especially when other options were financially or geographically inaccessible. Evidence-based information and support from these and other allied groups can increase safe, effective abortion care and contribute to reducing the risk of criminalization.

OBJECTIVE:This study aimed to describe practices for cervical preparation and induction of fetal demise among physicians providing dilation and evacuation (D&E) for abortion between 24- and 27-weeks' gestation in ambulatory settings in the US. STUDY DESIGN:Between June and September 2024, we recruited physicians from 14 ambulatory abortion facilities to complete an online survey. We conducted follow-up interviews with respondents as needed for clarification or additional information. We compared practices among providers using closed- and open-ended responses. RESULTS:Among 18 respondents working at 12 facilities, most provided care throughout the gestational range and reported few limitations for obstetrical conditions (e.g. history of Cesarean section or placenta previa). It was common to place osmotic dilators the day before the D&E, use adjunctive misoprostol on the day of the D&E, and induce fetal demise on the first day of 2- or 3-day procedures. Variations across practices included number of procedure days, use of adjunctive mifepristone, medications for induction of fetal demise, timing of misoprostol, and techniques to address inadequate dilation. We described pain management and patient comfort techniques, as well as factors that influenced individualized care plans. CONCLUSIONS:Later abortion providers report a wide range of practices and techniques which have been adapted from established second-trimester D&E practices to take care of patients with more advanced gestational durations. Physicians adjust their approach to accommodate the needs of the patient or clinical circumstances. IMPLICATIONS:Physicians who provide abortion care at or above 24 weeks' gestation play a key role in ensuring abortion access throughout pregnancy. Documenting the diversity of current practices and techniques will support training new clinicians and those who wish to expand the gestational limits of their practice.

Importance:With increasing abortion restrictions, more people self-manage their abortions with medications. Little is known about geographic and demographic characteristics of those self-managing abortions in the US, particularly after the Dobbs v Jackson Women's Health Organization decision. Objective:To describe requests for self-managed medication abortion support in the US through Mexico-based accompaniment collectives. Design, Setting, and Participants:This is a cross-sectional study of records from 2023 from 2 Mexico-based accompaniment collectives. Participants were people in the US requesting support from Mexico-based accompaniment collectives to self-manage an abortion. Exposures:State abortion policy context (complete abortion bans, 6-week and/or embryonic cardiac activity bans, 12- to 15-week bans, and abortion available past 15 weeks), sociodemographic characteristics (poverty, insurance status, and Spanish language), and driving distance from the nearest abortion facility. Main Outcomes and Measures:The primary outcomes were the sociodemographic characteristics of those requesting support from accompaniment collectives and the rate of requests to these collectives by zip code tabulation areas (ZCTAs). Demographic characteristics, pregnancy characteristics, and state policy context were described. Differences in request characteristics by state-level abortion policy category were tested using χ2 tests. Also, rates of requests per 100 000 female individuals aged 15 to 49 years within categories of ZCTA-level characteristics were estimated. Results:A total of 2850 requests were analyzed, with 700 requests (24.6%) from people aged 20 to 24 years, 995 (34.9%) from people aged 25 to 34 years, and 192 (6.7%) from people younger than 20 years. Pregnancy duration was 6 weeks or less for 1441 requests (50.6%), 7 to 9 weeks for 677 requests (23.8%), and 12 weeks or more for 160 requests (5.6%). In total, 2363 requests (82.9%) were from states with complete abortion bans. Requests with pregnancies at 12 weeks or more ranged from 98 (4.2%) in complete-ban states to 36 requests (14.8%) in states where abortion was available past 15 weeks (P < .001). Spanish was spoken with accompaniers by 65 requesters (38.0%) in states where abortion was available past 15 weeks and by 282 requesters (13.2%) in complete-ban states (P < .001). The mean ZCTA-level request rate was 2.44 (95% CI, 1.81-3.08) per 100 000 female individuals aged 15 to 49 years and increased with ZCTA-level poverty (from 0.35 [95% CI, 0.23-0.53] to 1.63 [95% CI, 1.14-2.34] requests per 100 000 female individuals aged 15 to 49 years) and Spanish-speaking population share (from 0.25 [95% CI, 0.12-0.54] to 1.56 [95% CI, 1.03-2.39] requests per 100 000 female individuals aged 15 to 49 years). ZCTAs more than 8 hours from an abortion facility in complete ban states had the highest request rate (7.85 [95% CI, 4.53-13.61] requests per 100 000 female individuals aged 15 to 49 years). Conclusions and Relevance:In this cross-sectional study of accompaniment network records, requests for Mexico-based accompaniment support were highest in states with abortion bans and in communities with elevated poverty, uninsurance, and Spanish-speaking populations, underscoring the role of accompaniment collectives in serving communities facing the greatest structural barriers to facility-based abortion care.

Use of preferred contraceptive methods is a measure of reproductive autonomy, yet barriers persist across the United States in accessing preferred methods of contraception, with disparities in access among communities of color. Using data from a 2021-2022 cross-sectional survey of 727 people aged 13-50 and living in the United States who identified as Asian American, Native Hawaiian, or Pacific Islander (29%); Black or African American (34%), Indigenous (13%), and Latina/Latinx (31%), we examined those who were not using their preferred contraceptive method(s), including the preferred method type and the reasons for not using this method(s). We ran an adjusted logistic regression to test the association between the quality of the last health care interaction related to contraception and the use of a non-preferred method. Thirty-seven percent of respondents preferred a contraceptive method they were not currently using. Among current contraceptive users, long-acting methods were preferred most often, while non-current contraceptive users desired long-acting and short-acting hormonal methods equally. Respondents most often cited concerns about side effects/health risks (65%) and financial/logistical reasons (42%) as the top reasons for not using their preferred method(s). Those who reported receiving higher quality care in a recent contraceptive visit were more likely to be using the method they wanted to be using. Use of a preferred contraceptive method may increase when receiving high-quality counselling and care. Strategies to improve access to preferred methods should address side effects and health concerns, as well as financial and logistical barriers among Black, Indigenous, and people of color.

BACKGROUND:Menstrual Regulation (MR) has been legal in Bangladesh since 1979 in an effort to reduce maternal mortality from unsafe abortion care. However, access to high-quality and patient-centered MR care remains a challenge. This analysis aimed to explore what clients know before going into care and the experience itself across a variety of service delivery sites where MR care is available.METHODS:We conducted 26 qualitative semi-structured interviews with MR clients who were recruited from three different service delivery sites in Dhaka, Bangladesh from January to March 2019. Interviews explored client expectations and beliefs about MR care, the experience of the care they received, and their perception of the quality of that care. We conducted a thematic content analysis using a priori and emergent codes.RESULTS:Clients overall lacked knowledge about MR care and held fears about the damage to their bodies after receiving care. Despite their fears, roughly half the clients held positive expectations about the care they would receive. Call center clients felt the most prepared by their provider about what to expect during their MR care. During counseling sessions, providers at in-facility locations reinforced the perception of risk of future fertility as a result of MR and commonly questioned clients on their need for MR services. Some even attempted to dissuade nulliparous women from getting the care. Clients received this type of questioning throughout their time at the facilities, not just from their medical providers. The majority of clients perceived their care as good and rationalized these comments from their providers as coming from a caring place. However, a handful of clients did report bad care and negative feelings about their interactions with providers and other clinical staff.CONCLUSION:Providers and clinical staff can play a key role in shaping the experience of clients accessing MR care. Training on accurate knowledge about the safety and effectiveness of MR, and the importance of client communication could help improve client knowledge and person-centered quality of MR care.

Systematic racism and oppression have contributed to the multifarious barriers encountered by Black, Indigenous, and people of color (BIPOC) seeking contraceptive counseling and care. Obtaining contraceptive services may be especially difficult for young BIPOC, who may encounter additional challenges due to their age.

Alrededor del mundo, las personas con capacidad de gestar recurren a métodos y proveedores de medicina tradicional para abortar; sin embargo pocos estudios exploran las perspectivas de proveedores tradicionales con relación al aborto. El objetivo de este estudio cualitativo es explorar las perspectivas y prácticas de proveedores tradicionales en el norte de Perú con relación al aborto. Se realizaron entrevistas a profundidad con 20 proveedores tradicionales en el Departamento de Piura (2018). Participantes reconocieron que las mujeres de su comunidad requieren servicios para regular su menstruación debido a retrasos o “retenciones”, y reconocieron que las causas de estas situaciones pueden incluir o no el embarazo. La mayoría señaló tratar el retraso menstrual, no obstante la mayoría negó practicar el aborto. El estudio evidencia el rol clave que proveedores de medicina tradicional juegan en la atención a la salud sexual y la salud reproductiva en sus comunidades, y reconoce sus perspectivas así como preocupaciones sobre el aborto. Es importante honrar y respetar la medicina tradicional al mismo tiempo que se desarrollan procesos para erradicar el estigma hacia el aborto.

In South Africa, the high rate of human immunodeficiency virus (HIV) infection among young people and unplanned pregnancies remains a concern. Using a qualitative approach, this study aimed to explore how young people between 18 and 24 years old perceive the risk of unplanned pregnancy and HIV, and how they give priority to and act to prevent both concerns. Fifty-four young people were recruited from three provinces in South Africa: KwaZulu-Natal, Eastern Cape, and Gauteng. Data collection took place between May and June in 2016. All data collection was carried out in person using a standardised discussion guide and a semi-structured interview guide in English. We conducted eight focus group discussions with young people and three in-depth interviews with young people who had become parents in their teens. We utilised thematic analysis grounded in a social constructionist framework to assess patterns and associations in the data. Respondents reported unplanned pregnancy and HIV as prevalent among their peers, but prioritised both concerns differently. Preventing pregnancy was a greater priority and threat than HIV. Respondents were less concerned about being infected with HIV which was perceived as invisible and not a death sentence because of the efficacy and ease of use of treatment. HIV was considered comparatively more manageable and less burdensome than other chronic illnesses and unplanned pregnancy. Our study suggests unplanned pregnancy and HIV prevention interventions should prioritise responding to young people's primary desire to control their fertility, but also encourage them to have holistic sexual and reproductive health goals that include HIV prevention. Our findings suggest a pressing need for biomedical therapies that offer combined HIV and pregnancy prevention for young people. Future programmes need to be agile and innovative in addressing young people's tendency to prioritise HIV and pregnancy differently, and they need revive the sense of urgency to prevent HIV.

Globally, people resort to traditional methods and healers for pregnancy termination; however, research focusing on traditional healers' perspectives about abortion are scarce. The objective of this qualitative study is to explore the perspectives and practices of traditional healers in Peru in relation to abortion. In-depth interviews were carried out with 20 traditional healers in the Piura Department in 2018. Participants recognized that women in their community seek menstrual regulation services given delayed menses or "retenciones" and acknowledged that pregnancy might or might not be the cause of menstrual delays. While most participants confirmed that they perform menstrual regulations, the majority denied practicing abortion services. This study shows the key role that traditional healers play in supporting their communities' sexual and reproductive health and acknowledges their perspectives and concerns in relation to abortion. It is essential that traditional medicine is respected and honored while developing strategies to eradicate abortion stigma.

ObjectiveWe used the newly developed Abortion Care Quality Tool (ACQTool) to compare client-reported quality of medication abortion care by source (facility-managed vs pharmacy-sourced self-managed abortion (SMA)) in Bangladesh.MethodsWe leveraged exit and 30-day follow-up surveys collected to develop and validate the ACQTool collected at nongovernmental organisation (NGO)-supported or -operated facilities in the public and private sector and pharmacies from three districts in Bangladesh. We used bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by source (facility vs pharmacy). We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client sociodemographic characteristics.ResultsOf 550 abortion clients, 146 (26.5%) received a facility-managed medication abortion and 404 (73.5%) had a pharmacy-sourced SMA. Clients reported higher quality in facilities for five indicators, and higher in pharmacies for two indicators; the remaining 11 indicators were not different by source. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (adjusted odds ratio (aOR) 3.55; 95% CI 2.27 to 5.58) but lower odds of reporting high information provision (aOR 0.14; 95% CI 0.09 to 0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse event occurred (aOR 0.45; 95% CI 0.23 to 0.82).ConclusionsIn Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable.

Objectives: Assess preferences for and use of medication abortion in Texas after implementation of two policy changes: a 2013 state law restricting medication abortion and the FDA label change for mifepris-tone in 2016 nullifying some of this restriction.Study design: We analyzed surveys conducted in 2014 and 2018 with abortion patients at 10 Texas abor-tion facilities. We calculated the percentage of all respondents with an initial preference for medication abortion by survey year, and the type of abortion obtained or planned to obtain among those who were at < 10 weeks of gestation. We used multivariable-adjusted mixed-effects Poisson regression models to assess factors associated with medication abortion preference and actual/planned use.Results: Overall, 156 (41%) of 376 respondents in 2014 and 247 (55%) of 448 respondents in 2018 reported initial preference for medication abortion (Prevalence ratio [PR]: 1.28; 95% CI 1.03 -1.59). Among those who were < 10 weeks of gestation and initially preferred medication abortion, 39 of 124 (31%) obtained or were planning to obtain the method in 2014, compared with 188 of 223 (84%) in 2018 (PR: 2.65; 95% CI: 1.69 -4.15). After multivariable adjustment, respondents who initially preferred medication abortion and were 7 to 9 weeks of gestation at the time of their ultrasonography (vs < 7 weeks) were less likely to obtain or plan to obtain the method (PR: 0.69; 95% CI: 0.57 -0.84). Conclusions: Abortion patients were more likely to prefer and obtain or plan to obtain their preferred medication abortion after legal restrictions in Texas were nullified.Implications: State policies can affect people's ability to obtain their preferred abortion method. Efforts to provide both abortion options whenever possible, and inform people where each can be obtained, remains an important component of person-centered care despite increasing state abortion restrictions and bans following the reversal of Roe v Wade .(c) 2022 Elsevier Inc. All rights reserved.

Objective This qualitative study aimed to identify person-centred domains that would contribute to the definition and measurement of abortion quality of care based on the perceptions, experiences and priorities of people seeking abortion.Methods We conducted interviews with people seeking abortion aged 15–41 who obtained care in Argentina, Bangladesh, Ethiopia or Nigeria. Participants were recruited from hospitals, clinics, pharmacies, call centres and accompaniment models. We conducted thematic analysis and quantified key domains of quality identified by the participants.Results We identified six themes that contributed to high-quality abortion care from the clients’ perspective, with particular focus on interpersonal dynamics. These themes emerged as participants described their abortion experience, reflected on their interactions with providers and defined good and bad care. The six themes included (1) kindness and respect, (2) information exchange, (3) emotional support, (4) attentive care throughout the process, (5) privacy and confidentiality and (6) prepared for and able to cope with pain.Conclusions People seeking abortion across multiple country contexts and among various care models have confirmed the importance of interpersonal care in quality. These findings provide guidance on six priority areas which could be used to sharpen the definition of abortion quality, improve measurement, and design interventions to improve quality.

Background Despite progress in assuring provision of safe abortion, substantial disparities remain in quality of abortion care around the world. However, no consistent, valid, reliable method exists to routinely measure quality in abortion care across facility and out-of-facility settings, impeding learning and improvement. To address this need, the Abortion Service Quality Initiative developed the first global standard for measuring quality of abortion care in low-income and middle-income countries. Methods This prospective cohort study was conducted in Bangladesh, Ethiopia, and Nigeria in 2020-2022. Partici-pants included sites and providers offering abortion care, including health facilities, pharmacies, proprietary and patent medicine vendors (PPMVs), and hotlines, and clients aged 15-49 receiving abortion care from a selected site. 111 structure and process indicators were tested, which originated from a review of existing abortion quality in-dicators and from qualitative research to develop additional client-centred quality indicators. The indicators were tested against 12 clinical and client experience outcomes at the site-level (such as abortion-related deaths) and client-level (such as whether the client would recommend the service to a friend) that were expected to result from the abortion quality indicators. Indicators were selected for the final metric based on predictive validity assessed using Bayesian models to test associations between indicators and outcomes, content validity, and performance. Findings We included 1915 abortion clients recruited from 131 sites offering abortion care across the three countries. Among the 111 indicators tested, 44 were associated with outcomes in Bayesian analyses and an additional 8 were recommended for inclusion by the study's Resource Group for face validity. These 52 indicators were evaluated on content validity, predictive validity, and performance, and 29 validated indicators were included in the final abortion care quality metric. The 29 validated indicators were feasibility tested among 53 clients and 24 providers from 9 facility sites in Ethiopia and 57 clients and 6 PPMVs from 9 PPMV sites in Nigeria. The median time required to complete each survey instrument indicated feasibility: 10 min to complete the client exit survey, 16 min to complete the provider survey, and 11 min to complete the site checklist. Overall, the indicators performed well. However, all providers in the feasibility test failed two indicators of provider knowledge to competently complete the abortion procedure, and these indicators were subsequently revised to improve performance. Interpretation This study provides 29 validated abortion care quality indicators to assess quality in facility, pharmacy, and hotline settings in low-income and middle-income countries. Future research should validate the Abortion Care Quality (ACQ) Tool in additional abortion care settings, such as telemedicine, online medication abortion (MA) sellers, and traditional abortion providers, and in other geographical and legal settings. Funding The David and Lucile Packard Foundation and the Children's Investment Fund Foundation. 2023;66: Published December https://doi.org/10. 1016/j.eclinm.2023. 102347 Copyright (c) 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Objectives Recent lawsuits have challenged FDA approval and the continued availability of the medication mifepristone for abortion care in the US. Whatever the outcome of these efforts, misoprostol will remain available for off-label prescribing, and misoprostol alone can safely and effectively be used for medication abortion. We sought to determine the viability of strategies to increase access to misoprostol through a legal analysis. Methods To assess the various strategies, we conducted a state-by-state analysis of legislation, regulation, and case law to identify states in which access to a misoprostol-only regimen can be substantially increased via nurse practitioners or pharmacists. We also analyzed whether changes in practice, regulations, or law could expand the cadre of nurses and pharmacists providing abortions. Results Several states allow non-physicians to provide medication abortions and do not restrict that care to a mifepristone-based protocol. Our analysis found 20 states that could be viable targets for this strategy, nine of which we labeled priority states due to their proximity to jurisdictions with the most severe restrictions on abortion. For four of those states — Illinois, Minnesota, Colorado, and New Mexico — we also identified specific actions that could increase the prescribing of misoprostol by nurse practitioners and pharmacists. Conclusions Expanding patient access to misoprostol is possible, immediately and without legislative action, through changes in practice. This strategy holds promise for increasing access even in states where abortion is already legally protected and can normalize abortion care within more primary healthcare settings. Recent lawsuits have challenged FDA approval and the continued availability of the medication mifepristone for abortion care in the US. Whatever the outcome of these efforts, misoprostol will remain available for off-label prescribing, and misoprostol alone can safely and effectively be used for medication abortion. We sought to determine the viability of strategies to increase access to misoprostol through a legal analysis. To assess the various strategies, we conducted a state-by-state analysis of legislation, regulation, and case law to identify states in which access to a misoprostol-only regimen can be substantially increased via nurse practitioners or pharmacists. We also analyzed whether changes in practice, regulations, or law could expand the cadre of nurses and pharmacists providing abortions. Several states allow non-physicians to provide medication abortions and do not restrict that care to a mifepristone-based protocol. Our analysis found 20 states that could be viable targets for this strategy, nine of which we labeled priority states due to their proximity to jurisdictions with the most severe restrictions on abortion. For four of those states — Illinois, Minnesota, Colorado, and New Mexico — we also identified specific actions that could increase the prescribing of misoprostol by nurse practitioners and pharmacists. Expanding patient access to misoprostol is possible, immediately and without legislative action, through changes in practice. This strategy holds promise for increasing access even in states where abortion is already legally protected and can normalize abortion care within more primary healthcare settings.

People seeking abortion may need or want emotional or informational support before, during, and after their abortion. Feeling supported and affirmed contributes to perceptions of quality care. The All-Options Talkline offers free, telephone-based, peer counselling to callers anywhere in the United States. This study aimed to explore the types of support received through the Talkline and the ways it supplemented other forms of support received by people who obtained an abortion. Between May 2021 and February 2022, we conducted 30 interviews via telephone or Zoom with callers recruited through the Talkline. We coded the interviews and conducted thematic analysis, focusing on themes related to gaps of support from family, friends, and healthcare professionals, as well as types of support received through the Talkline. We identified four key motivations for calling the Talkline, including the need for (1) decision-making support and validation, (2) a neutral perspective, (3) emotional support to discuss negative or complex feelings, and (4) information about the abortion process. Participants indicated that interactions with family, friends, and healthcare professionals ranged from unsupportive and negative, to substantially supportive. Access to the Talkline was particularly useful prior to clinical interactions and in the weeks or months after an abortion. We found that the All-Options Talkline provided person-centred, remote support for callers, filling gaps or supplementing support from one's community or healthcare professionals. Abortion support from non-medically trained support people contributes to high-quality abortion care, especially in a time of increasing abortion restrictions and use of remote abortion services.

OBJECTIVE:To examine challenges accessing contraception in the past year and their association with interest in using an over the counter (OTC) oral contraceptive pill (OCP) among Black, Indigenous, and people of color (BIPOC) in the United States. STUDY DESIGN:From May 2021 to March 2022, a collaborative research team conducted a cross-sectional online survey using convenience sampling to recruit people who identify as Asian American, Native Hawaiian, or Pacific Islander, Black or African American, Indigenous, or Latina/Latinx and used or wanted to use a contraceptive method in the past year. Respondents were recruited through reproductive justice and community-based organizations. RESULTS:Among 727 respondents, 45% reported experiencing at least one challenge accessing contraception in the past year of which 37% reported a logistical challenge, and 20% reported an interpersonal challenge. Sixty-seven percent of respondents said they were likely to use an OTC OCP. Respondents who reported experiencing at least one challenge accessing contraception in the past year were more likely to say they would use an OTC OCP. Fifty-seven percent of respondents who were not using a contraceptive method in the past year reported they were likely to use an OTC OCP. CONCLUSION:Among people in this study, interest in an OTC OCP is high, particularly among those who have faced challenges accessing contraception, and among those who are not currently using a contraceptive method. IMPLICATIONS:Availability of an OCP OTC has the potential to address challenges accessing contraceptive care among BIPOC in the United States, who are often impacted by structural inequities and racism. Findings from this study can inform future OTC implementation strategies to ensure OTC access addresses logistical and interpersonal challenges.

Measurement of the quality of abortion services is essential to service improvement. Currently, its measurement is not standardized, and some of the tools which exist are very long, and may deter use. To address this issue, this study describes a process used to create a new, more concise measure of abortion care quality, which was done with the end users in mind. Using a collaborative approach and engaging numerous stakeholders, we developed an approach to defining and selecting a set of indicators, to be tested against abortion outcomes of interest. Indicators were solicited from 12 abortion service provision entities, cataloged, and grouped within a theoretical framework. A resource group of over 40 participants was engaged through surveys, webinars, and one in-person meeting to provide input in prioritizing the indicators. We began with a list of over 1,000 measures, and engaged stakeholders to reduce the list to 72 indicators for testing. These indicators were supplemented with an additional 39 indicators drawn from qualitative research with clients, in order to ensure the client perspective is well represented. The selected indicators can be applied in pharmacies, facilities, or with hotlines, and for clients of surgical or medical abortion services in all countries. To ensure that the final suggested measures are most impactful for service providers, indicators will be tested against outcomes from 2,000 abortion clients in three countries. Those indicators which are well correlated with outcomes will be prioritized.

IntroductionDisrespect and abuse are components of poor quality abortion care. This analysis aimed to understand negative experiences of care from perspectives of abortion clients in public and private facilities in Ethiopia.Study DesignWe conducted 23 in-depth interviews with people who obtained abortion care in Addis Ababa, Ethiopia as well as Aksum and Mekele in Tigray State, Ethiopia. The interviews were coded using a priori and emergent codes and we conducted thematic analysis to understand negative interactions with providers from participant's perspectives.ResultsParticipants experienced denial of abortion services along their pathway to care and attempts by providers to dissuade them prior to providing an abortion. Underlying both the denial and the dissuasion were reports of disrespect and condemnation from providers. Participants described how providers doubted or forced them to justify their reasons for having an abortion, stigmatized them for seeking multiple abortions or later abortions, and ascribed misinformation about abortion safety. Despite reports of denial, dissuasion, and disrespect, abortion clients generally felt that providers had their best interest at heart and were grateful for having access to an abortion.ConclusionsParticipants in Ethiopia experienced providers as gatekeepers to legal abortion services, facing disrespect and judgment at facilities where they sought care. Interventions aimed at increasing awareness of abortion laws such that clients understand their rights and values clarification interventions for providers could help reduce barriers to accessing care and improve the quality of abortion services.

This qualitative study aimed to examine how abortion clients in Nigeria perceive abortion and explore the role their beliefs and fears play in their care-seeking experiences and interactions with providers. Abortion is severely legally restricted in Nigeria but remains common. We conducted in-depth interviews with 25 people who obtained abortion services through three distinct models of care. We coded interview transcripts and conducted thematic analysis. Clients perceived negative attitudes toward abortion in their communities, though clients' own beliefs were more nuanced. Clients recounted a range of fears, and nearly all mentioned worrying that they might die as a result of their abortion. Despite their concerns, clients relied on social networks and word-of-mouth recommendations to identify providers they perceived as trustworthy and safe. Kind and non-judgmental treatment, clear instructions, open communication, and reassurance of privacy and confidentiality by providers alleviated client fears and helped clients feel supported throughout their abortion process. Within restrictive contexts, the mobilization of information networks, provision of high-quality care through innovative models, and personalization of care to individual needs can assuage fears and contribute to reducing stigma and increasing access to safe abortion services.