Effects of Carrying an Unwanted Pregnancy to Term on Women's Existing Children

Predictors of contraceptive discontinuation in Rwanda: evidence from demographic and health survey 2019-2020

BACKGROUND

Despite advancements, Rwanda continues to face challenges regarding contraceptive discontinuation. The 2019-2020 Rwanda Demographic and Health Survey (DHS) reported a 30% discontinuation rate among women within the first year of use. This study analyses predictors of discontinuation using this DHS data, with the goal of strengthening Rwanda's family planning programs.

METHODS

Data from the 2019-20 Rwanda DHS (14,634 women aged 15-49) was examined. A two-stage sampling design informed the survey. Life table methods and Cox proportional hazard models were used to analyze discontinuation rates, median usage duration across contraceptive methods, and the influence of demographic and other factors.

RESULTS

Results indicated a progressive rise in contraceptive discontinuation over different period: 16.69% at 6 months, 29.29% at 12 months, and 47.21% at 24 months. Pills and male condoms showed higher discontinuation probabilities early on. While injectables and LAM initially showed lower discontinuation, rates rose significantly by the 24th month. Health concerns and side effects were the primary reasons cited for discontinuation. The Cox proportional hazards analysis revealed significant factors influencing discontinuation: contraceptive method, desire for pregnancy, husband's disapproval, access/availability, and the desire for a more effective method.

CONCLUSION

This study highlights substantial contraceptive discontinuation rates in Rwanda, particularly for pills and injectables. Method type, health concerns, side effects, and method failure were associated with discontinuation. Interventions should focus on improving contraceptive continuation and investigating alternative methods with lower discontinuation tendencies.

"Shouldn't Nobody Make a Woman do What they Don't Want to do with their Body": Black Women's Reactions to the Supreme Court's Overturn of Roe v. Wade

Black women, particularly those with low-income, are projected to be the most negatively impacted group following the Supreme Court's overturn of Roe v Wade. It is expected that the rate of increase in live births, as well as the rate of maternal mortality, will be steepest for Black women due to high rates of unmet needs for contraception, unintended pregnancies, poverty, barriers to legal abortion access, and systemic racism. Previous research has shown that the legalization of abortion in 1973 significantly improved educational and employment outcomes for Black women, in particular. The current study seeks to assess the perceptions of predominantly under-resourced Black women following the overturning of Roe v Wade. Eighteen Black women participated in one of five focus groups during the summer of 2022 and shared their reactions to the Supreme Court ruling. Using grounded theory, researchers generated the following themes: sexism via forced births, economic implications, and dangers of banned abortions. Based on participants' concerns resulting from the Roe v Wade overturn, policy implications are provided for improving the following systems: safety net, child welfare, and infant and perinatal mental health care.

Reproductive Justice as a Framework for Abortion Care

This article presents an in-depth analysis of abortion access and rights within the Reproductive Justice framework, underscoring the health, social, and economic consequences of limited access. It emphasizes the critical role of abortion as essential, safe health care and highlights the complexities surrounding abortion decisions and the barriers faced by poor and historically marginalized populations. Amid the escalating access restrictions, the article concludes with a call to action for obstetricians and gynecologists and our allied health care providers to recognize, support, and advocate for safe, legal, and affordable abortion services as fundamental to health care equity and human rights.

Emotional, informational, and decision-making support needs among people seeking abortion in the US: perspectives from All-Options Talkline callers

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.

"Have you ever wanted or needed an abortion you did not get?" Data from a 2022 nationally representative online survey in the United States

OBJECTIVE

Describe the prevalence of considering, wanting, and not obtaining a wanted abortion among a nationally representative sample of 15-44 year olds in the United States who had ever been pregnant.

STUDY DESIGN

We analyzed data from ever-pregnant respondents (unweighted n = 1789) from a larger online survey about contraceptive access using the nationally representative AmeriSpeak panel. Among those not obtaining wanted abortions, weighted frequencies for sociodemographic characteristics and reasons for not getting the abortion are presented.

RESULTS

Nearly 6% of the full sample reported having wanted an abortion they did not obtain. In open-ended responses, respondents most frequently reported individual reasons (43.8%) for not getting an abortion (e.g., changing their mind; personal opposition) and financial, logistical, or informational barriers (24.7%) likely related to policy. A quarter (24.1%) of the sample reported a past abortion. Among those who reported no past abortions, about one-fifth had considered abortion in the past, and 6.8% had wanted or needed one. Among those reporting no prior abortions who had considered abortion, only a third (34.3%) also report ever wanting or needing one.

CONCLUSIONS

This study begins to quantify the experience, even before the Supreme Court's 2022 decision in Dobbs v. Jackson Women's Health Organization, of being unable to obtain a wanted abortion. Additionally, findings suggest that people in a national sample will answer questions about whether and why they did not obtain a wanted abortion.

IMPLICATIONS

This study provides the first known national estimates of lifetime history of not getting a wanted abortion. Survey questions can be used for future research. Prospective and ongoing measurement of the inability to get a wanted abortion could be one part of documenting the effects of Dobbs on abortion access.

The patient/physician relationship in a post-Roe world: a neonatologist viewpoint

The Supreme Court ruling in Dobbs v. Jackson Women's Health Organization has far-reaching implications that go beyond the practice of obstetrics and gynecology. The ruling and subsequent laws and bills impact many specialties and have implications for healthcare as a whole. The rapidly changing medicolegal landscape has significant bearings on and implications for the fields of neonatology and pediatrics. These rulings have an impact on the patient-physician relationship and a shared decision-making approach to care. Furthermore, there are significant sequelae of forced birth and resuscitation. This review provides a clinically relevant update of the current medicolegal landscape and applications to the practice of neonatology.

The Dobbs v Jackson Women's Health Organization Supreme Court Decision-Concerns, Challenges, and Consequences for Health Care

This Viewpoint discusses potential consequences that the US Supreme Court ruling in Dobbs v Jackson Women’s Health Organization may have for patient outcomes, public health, training and legal challenges for health care professionals, and the patient-practitioner relationship.

Spatial variations and multilevel mixed effect analysis on determinants factors of modern contraceptive utilization among reproductive age women in Ethiopia; proven by Ethiopian mini demographic health survey 2019

INTRODUCTION

Globally, in 2019, there are 1.9 billion women of reproductive age (15-49), of which 1.1 billion have a need for family planning. Of these, 842 million use contraceptives, and 270 million still have an unmet need for contraception. Ethiopia is a low-income country with inadequate access to family planning (FP), especially in the developing regions. The Ethiopian government was striving to increase the number of health facility in order to provide quality maternal care and services. Increasing the modern contraceptive prevalence rate is one of the goals of the government to reduce maternal and child mortality and morbidity.

METHODS

Secondary data analysis was conducted using data from mini-EDHS of 2019 demographic and health Survey datasets. The study comprised a total of 8885 reproductive-age women. Spatial variations and multilevel mixed effect analysis on determinants factors of modern contraceptive use among reproductive age women in Ethiopia; evidenced by mini-EDHS 2019. Finally, the percentage and odd ratio, its 95% confidence intervals, and the result of spatial analysis were reported.

RESULT

This study includes a total weighted sample of 8885 reproductive-age women from the 2019 mini-Ethiopian demographic and health survey. The prevalence of modern contraceptive use was 25.5% in Ethiopia. living in urban area [AOR = 2.13; 95% CI = (1.75, 2.61); P = 0.000], being married [AOR = 1.42; 95% CI = (1.19, 1.70); P = 0.000] were found positively associated with contraceptive use. In contrast to this, attending primary education [AOR = 0.91; 95% CI = (0.74, 1.12); P = 0.000]., being Muslim [AOR = 0.25; 95% CI = (0.22, 0.29); P = 0.000], being poorest [AOR = 0.54; 95% CI = (0.45, 0.66); P = 0.000] were found negatively associated with contraceptive use.

CONCLUSION

In this study Individual and community level factors were associated with modern contraceptive use and also there were spatial variations in modern contraceptive use across the region among reproductive-age women. Empowering women to have better educational status, improving the wealth index, promoting marriage, creating awareness among rural residences women and promoting education about modern contraceptives through religiously acceptable persons, and promoting modern contraceptive use in developing regions were the key factors to improve modern contraceptive use among reproductive age women in Ethiopia.

The Importance of the International Community in Protecting the Right to Abortion: The Cases of Malta and of the US Supreme Court

According to the World Health Organization (WHO), abortion is often necessary and is not a criminalizable medical act. Unfortunately, despite the global trend in recent years tending towards liberalization of abortion as a fundamental right of women in certain circumstances, it is still not guaranteed in all countries of the world in the same way. Moreover, the abortion debate is often characterized by unscientific opinions based on political and/or religious ideologies. Recently, a European episode has rekindled the debate on abortion: in Malta, a tourist was unable to have an abortion, with consequent risks, even serious ones, on her health. In addition, even in the United States a Supreme Court ruling created a considerable stir: the Roe v. Wade (1973) ruling that had legalized abortion at the federal level was revoked. After the ruling of the Supreme Court, each state of the USA can decide for itself whether and how to legalize abortion. These recent international developments are particularly worrying and make even more evident the need for abortion to be protected at an international level as an inalienable and fundamental human right, and therefore not to be limited.

The far-reaching impact of abortion bans: reproductive care and beyond

On 24 June 2022, the US Supreme Court overturned Roe v. Wade, a 49-year-old precedent that provided federal constitutional protection for abortions up to the point of foetal viability, returning jurisdiction to the individual states. Restrictions that came into effect automatically in several states, and are anticipated in others, will severely limit access to abortions in approximately half of the US. Even though every state allows for exceptions to the abortion bans, in some instances these exceptions can be used to preserve the health of a pregnant patient, while in other instances, only to preserve their life. The vague and confusing nature of the abortion ban exceptions threatens to compromise the standard of care for patients with pregnancy complications that are distinct from abortions, such as nonviable pregnancies, miscarriages, and ectopic pregnancies. Additionally, we envision challenges for the treatment of women with certain autoimmune conditions, pregnant cancer patients, and patients contemplating preimplantation genetic diagnosis as part of assisted reproductive technologies. The abortion ban exceptions will impact and interfere with the medical care of pregnant and non-pregnant patient populations alike and are poised to create a medical and public health crisis unlike any other one from the recent past.

Non-barrier contraceptive use patterns among Latina adolescents attending California reproductive health centers: A longitudinal study

OBJECTIVES

To describe use of non-barrier contraceptives over a 9-month period, consistency in method use, and identify factors associated with method nonuse, switching, and consistency among Latina adolescents attending California sexual and reproductive health (SRH) centers.

STUDY DESIGN

We conducted a cohort study using data self-reported at baseline, and 3- and 9-months post-baseline. The analysis included 1162 sexually active adolescents aged 18 to 19 who self-identified as female and Latina, indicated that they were not currently pregnant or trying to become pregnant, and who attended California SRH centers between June 2016 and June 2020. We used binomial generalized multivariable linear models with a log link to assess the likelihood of nonbarrier method consistency, switching, and non-use.

RESULTS

At baseline, 453 of 1162 (39%) of respondents were using short-acting methods (pill, patch, ring, or injection), 113 of 1162 (9.7%) were using long-acting methods (implants or intrauterine devices [IUDs]), and 596 of 1162 (51.3%) reported using neither short- nor long-acting methods. Over a 9-month period, 22/33 (66.7%) of those using IUDs consistently used the method, which was a statistically greater frequency of consistency than individuals who selected other nonbarrier methods (270/530 [50.9%], aRR: 1.40; 95% CI: 1.11, 1.77). Implant users had rates of method consistency similar to users of other nonbarrier methods (aRR: 1.11; 95% CI: 0.89, 1.38). Factors independently associated with method consistency included being older, having never been pregnant, having greater perceived risk of pregnancy, and greater contraceptive knowledge.

CONCLUSION

Sexually active Latina adolescents attending California SRH centers who were not trying to become pregnant maintained consistent contraceptive use more frequently when using an IUD. Using a patient-centered approach, contraceptive counseling for Latina adolescents can describe the combined efficacy and contraceptive stability offered by IUDs should patients desire it.

IMPLICATIONS

This study addressees gaps in knowledge about U.S. Latina adolescents' contraceptive use patterns. We demonstrate that IUD users, and not implant users, appear more likely to consistently use their method than those using non-LARC methods. Patient-centered contraceptive counseling for Latina adolescents can describe the greater contraceptive stability that IUDs may offer.

Trauma of abortion restrictions and forced pregnancy: urgent implications for acute care surgeons

In the aftermath of the Supreme Court's Dobbs vs. Jackson Women's Health decision, acute care surgeons face an increased likelihood of seeing patients with complications from both self-managed abortions and forced pregnancy in underserved areas of reproductive and maternity care throughout the USA. Acute care surgeons have an ethical and legal duty to provide care to these patients, especially in obstetrics and gynecology deserts, which already exist in much of the country and are likely to be exacerbated by legislation banning abortion. Structural inequities lead to an over-representation of poor individuals and people of color among patients seeking abortion care, and it is imperative to make central the fact that people of color who can become pregnant will be disproportionately affected by this legislation in every respect. Acute care surgeons must take action to become aware of and trained to treat both the direct clinical complications and the extragestational consequences of reproductive injustice, while also using their collective voices to reaffirm the right to abortion as essential healthcare in the USA.

Denial of legal abortion in Nepal

INTRODUCTION

In Nepal, abortion is legal on request through 12 weeks of pregnancy and up to 28 weeks for health and other reasons. Abortion is available at public facilities at no cost and by trained private providers. Yet, over half of abortions are provided outside this legal system. We sought to investigate the extent to which patients are denied an abortion at clinics legally able to provide services and factors associated with presenting late for care, being denied, and receiving an abortion after being denied.

METHODS

We used data from a prospective longitudinal study with 1835 women aged 15-45. Between April 2019 and December 2020, we recruited 1,835 women seeking abortions at 22 sites across Nepal, including those seeking care at any gestational age (n = 537) and then only those seeking care at or after 10 weeks of gestation or do not know their gestational age (n = 1,298). We conducted interviewer-led surveys with these women at the time they were seeking abortion service (n = 1,835), at six weeks after abortion-seeking (n = 1523) and six-month intervals for three years. Using descriptive and multivariable logistic regression models, we examined factors associated with presenting for abortion before versus after 10 weeks gestation, with receiving versus being denied an abortion, and with continuing the pregnancy after being denied care. We also described reasons for the denial of care and how and where participants sought abortion care subsequent to being denied. Mixed-effects models was used to accounting clustering effect at the facility level.

RESULTS

Among those recruited when eligibility included seeking abortion at any gestational age, four in ten women sought abortion care beyond 10 weeks or did not know their gestation and just over one in ten was denied care. Of the full sample, 73% were at or beyond 10 weeks gestation, 44% were denied care, and 60% of those denied continued to seek care after denial. Nearly three-quarters of those denied care were legally eligible for abortion, based on their gestation and pre-existing conditions. Women with lower socioeconomic status, including those who were younger, less educated, and less wealthy, were more likely to present later for abortion, more likely to be turned away, and more likely to continue the pregnancy after denial of care.

CONCLUSION

Denial of legal abortion care in Nepal is common, particularly among those with fewer resources. The majority of those denied in the sample should have been able to obtain care according to Nepal's abortion law. Abortion denial could have significant potential implications for the health and well-being of women and their families in Nepal.

"I was afraid they will be judging me and even deny me the service": Experiences of denial and dissuasion during abortion care in Ethiopia

INTRODUCTION

Disrespect 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 DESIGN

We 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.

RESULTS

Participants 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.

CONCLUSIONS

Participants 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.

COVID-19 impacts on abortion care-seeking experiences in the Washington, DC, Maryland, and Virginia regions of the United States

CONTEXT

Many people wanted to avoid or delay childbearing during the COVID-19 pandemic. This study sought to examine the extent COVID-19 influenced abortion care-seeking in a region that did not enact policy restricting abortion due to the pandemic, has high service availability, and few abortion-restrictive policies.

METHODOLOGY

We conducted telephone surveys with adults (n=72) requesting abortion appointments between September 2020 and March 2021 at five clinics in Washington, DC, Maryland, and Virginia. We used χ² tests to compare sociodemographic, reproductive history, service delivery characteristics, and pandemic-related life changes by whether COVID-19 influenced abortion care-seeking.

RESULTS

Most respondents (93%) had an abortion at the time of the survey, 4% were awaiting their scheduled appointment, and 3% did not have an appointment scheduled. Nearly 40% of people reported COVID-19 influenced their decision to have an abortion. These individuals were significantly more likely to report "not financially prepared" (44% vs. 16%) as a reason for termination compared to people reporting no influence of COVID-19. They were also more likely to have lost or changed their health insurance due to pandemic-related employment changes (15% vs. 2%), report substantial money difficulties due to COVID-19 (59% vs. 33%), and report that paying for their abortion was "very difficult" (25% vs. 2%).

CONCLUSION

COVID-19 influenced many people to have an abortion, particularly those financially disadvantaged by the pandemic. Expansion of Medicaid abortion coverage in Washington, DC and Virginia could reduce financial barriers to care and help people to better meet their reproductive needs amid future crises.

Options Counseling for the Pregnant Adolescent Patient

Although teenage pregnancy rates have decreased over the past 30 years, many adolescents become pregnant every year. It is important for pediatricians to have the ability and the resources to make a timely pregnancy diagnosis in their adolescent patients and provide them with nonjudgmental counseling that includes the full range of pregnancy options. Counseling includes an unbiased discussion of the adolescent's options to continue or terminate the pregnancy, supporting the adolescent in the decision-making process, and referring the adolescent to appropriate resources and services. It is important for pediatricians to be familiar with laws and policies impacting access to abortion care, especially for minor adolescents, as well as laws that seek to limit health care professionals' provision of unbiased pregnancy options counseling and referrals, either for abortion care or continuation of pregnancy in accordance with the adolescent's choice. Pediatricians who choose not to provide such discussions should promptly refer pregnant adolescent patients to a health care professional who will offer developmentally appropriate pregnancy options counseling that includes the full range of pregnancy options. Pediatricians should be aware of and oppose policies that restrict their ability to provide pregnant adolescents with unbiased counseling that includes the full range of pregnancy options. This approach to pregnancy options counseling has not changed since the original 1989 American Academy of Pediatrics statement on this issue.

Beyond Abortion: The Consequences of Overturning Roe

The upcoming U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization has the potential to eliminate or severely restrict access to legal abortion care in the United States. We address the impact that the decision could have on abortion access and its consequences beyond abortion care. We posit that an abortion ban would, in effect, mean that anyone who becomes pregnant, including those who continue a pregnancy and give birth to healthy newborns and those with pregnancy complications or adverse pregnancy outcomes will become newly vulnerable to legal surveillance, civil detentions, forced interventions, and criminal prosecution. The harms imposed by banning or severely restricting abortion access will disproportionately affect persons of color and perpetuate structural racism. We caution that focusing on Roe as a decision that only protects ending a pregnancy ignores the protection that the decision also affords people who want to continue their pregnancies. It overlooks the ways in which overturning Roe will curtail fundamental rights for all those who become pregnant and will undermine their status as full persons meriting Constitutional protections. Such a singular focus inevitably obscures the common ground that people across the ideological spectrum might inhabit to ensure the safety, health, humanity, and rights of all people who experience pregnancy.

Potential Impact of Telemedicine for Medication Abortion Policy and Programming Changes on Abortion Accessibility in the United States

Objectives. To quantify the impact of telemedicine for medication abortion (TMAB) expansion or ban removal on abortion accessibility. Methods. We included 1091 facilities from the 2018 Advancing New Standards in Reproductive Health facility database and Planned Parenthood Web site, among which 241 did not offer abortion as sites for TMAB expansion. Accessibility was defined as the proportion of reproductive-aged women living within a 30-, 60-, or 90-minute drive time from an abortion-providing facility. We calculated accessibility differences between 3 scenarios: (1) facilities offering abortion in 2018 (reference), (2) the reference scenario in addition to all facilities in states without TMAB bans (TMAB expansion), and (3) all facilities (TMAB ban removal). We also stratified by state and urban-rural status. Results. In 2018, 65%, 81%, and 89% of women lived within a 30-, 60-, or 90-minute drive time from an abortion-providing facility, respectively. Expansion and ban removal expanded abortion accessibility relative to the current accessibility scenario (range: 1.25-5.66 percentage points). Women in rural blocks experienced greater increases in accessibility than those in urban blocks. Conclusions. TMAB program and policy changes could expand abortion accessibility to an additional 3.5 million reproductive-aged women. Public Health Implications. Our findings can inform where to invest resources to improve abortion accessibility. (Am J Public Health. 2022;112(8):1202-1211. https://doi.org/10.2105/AJPH.2022.306876).

Undue burdens created by the Texas Abortion Law for vulnerable pregnant women

The new Texas abortion law requires the physician to determine whether a fetal heartbeat is present and prohibits abortion after a heartbeat has been documented. An exception is allowed when a "medical emergency necessitated the abortion." These and other provisions of the statute are to be enforced through "civil actions" brought by private citizens. This article identifies 3 populations of vulnerable women who will experience undue burdens created by the Texas abortion law. We begin with an account of the concept of undue burden in the jurisprudence of abortion, as expressed in the 1992 US Supreme Court case, Planned Parenthood v. Casey of Southeastern Pennsylvania. We then provide an evidence-based account of the predictable, undue burdens for 3 populations of vulnerable women: pregnant women with decreased freedom of movement; pregnant minors; and pregnant women with major mental disorders and cognitive disabilities. The Texas law creates an undue burden on these 3 populations of vulnerable women by reducing or even eliminating access to abortion services outside of Texas. The Texas law also creates an undue burden by preventably increasing the risks of morbidity, including loss of fertility, and mortality for these 3 populations of vulnerable women. For these women, it is indisputable that the Texas law will create undue burdens and is therefore not compatible with the jurisprudence of abortion as set forth in Planned Parenthood v. Casey because a "significant number of women will likely be prevented from obtaining an abortion." Federal courts should therefore strike down this law.

Factors associated with modern contraceptive demands satisfied among currently married/in-union women of reproductive age in Ethiopia: a multilevel analysis of the 2016 Demographic and Health Survey

OBJECTIVES

Regardless of the local and international initiatives, excluding exempting services, demand satisfied for contraceptives remains low in Ethiopia. This circumstance is supposed to be attributed to different level factors; however, most were not well addressed in the previous studies. Therefore, this study aimed at assessing the magnitude and individual, household and community-level factors associated with demand satisfied for modern contraceptive (DSFMC) methods among married/in-union women of reproductive age.

DESIGN

Cross-sectional study.

SETTING

A community-based study across the country.

PARTICIPANTS

Randomly selected 9126 married/in-union women had participated using a structured questionnaire.

OUTCOME

DSFMC methods among married/in-union women of reproductive age.

RESULTS

DSFMC methods in Ethiopia was 39.5% (95% CI 38.5% to 40.5%). Women aged 35-49 years (adjusted OR (AOR): 0.43, 95% CI 0.32 to 0.58), Muslim religion (AOR: 0.58, 95% CI0.43 to 0.78), husband lived elsewhere (AOR: 0.42, 95% CI 0.29 to 0.60), joint decision making to use (AOR: 1.30, 95% CI 1.04 to 1.62), good knowledge (AOR: 1.57, 95% CI 1.32 to 1.86) and wealth status of poorer (AOR: 1.56, 95% CI 1.17 to 2.06), middle (AOR: 1.77, 95% CI 1.33 to 2.35), richer (AOR: 1.96, 95% CI 1.49 to 2.59), and richest (AOR: 1.49, 95% CI 1.05 to 2.08), pastoralist regions (AOR: 0.28, 95% CI 0.18 to 0.42), and agrarian regions (AOR: 1.72, 95% CI 1.21 to 2.44) and rural residency (AOR: 0.56, 95% CI 0.37 to 0.82) were factors significantly associated.

CONCLUSIONS

Women's age, religion, the current living place of husbands and women's knowledge were individual-level factors. Household wealth status and mutual decision making to use were household-level factors. Region and residency were households and community-level factors associated with DSFMCs. Increasing the accessibility of modern contraceptive methods to women in rural areas and pastoralist regions, those living separately, engaging religious leaders and men in the programme, would increase their satisfying demand.

Prenatal care utilization in pregnant women who consider but do not have abortions

Background

Over half of all pregnancies in the United States are unintended, and 18% result in termination of pregnancy (TOP). Some women seek TOP, but ultimately continue their pregnancy. Data are limited about their utilization of prenatal care and their perinatal outcomes. Our primary outcome was to investigate differences in guideline-based prenatal care utilization in women who consider but do not have an abortion.

Methods

Retrospective cohort study of patients having obstetrical dating ultrasound (US) from 2011–2018 at a single academic medical center that offers TOP. Contemplators completed US with intention of TOP but instead continued the pregnancy to live birth. A 2:1 group of non-contemplators completed US and continued to live birth. A prenatal care utilization scoring system was used to compare groups. Secondary outcomes investigated differences in adverse pregnancy outcomes and postpartum care.

Results

There were 94 contemplators and 183 non-contemplators. Inadequate prenatal care utilization initially was more common in contemplators than non-contemplators (62.8% vs 85.8%, p < 0.01) but was not significant after adjustment (aOR 1.0, 95% CI 0.40 – 2.56). There were no differences in adverse obstetric or neonatal outcomes. Contemplators were significantly more likely to have a postpartum contraceptive method (PPCM) upon hospital discharge (aOR 4.8, 95% CI 1.16 – 20.0) and significantly more likely to use a highly-effective PPCM (aOR 6.4, 95% CI 2.34 – 17.4).

Conclusions

Reversal of intention for TOP is not associated with differences in prenatal care utilization, but is associated with increased uptake of postpartum contraceptive method.

Global Gender Inequality, Older Women, and the Call for Change in the United States

Gender inequality that persists through much of their lives, from birth through adulthood, impacts women and their quality of life in their later years. With some variation this holds true in every nation in the global community. In older adults, the most apparent indication of gender inequality-and a linchpin-is the disproportionate impoverishment of older women compared to older men. We take stock of global policy directions toward equality for girls and women, focusing specifically on derived avenues for furthering and protecting the economic well-being of older women in the United States, cognizant that these directions can rebound with implications for nations worldwide.

Travelling for abortion services in Mexico 2016-2019: community-level contexts of Mexico City public abortion clients

OBJECTIVE

To describe the community context of women who travel to access Mexico City's public sector abortion programme and identify factors associated with travelling from highly marginalised settings.

METHODS

We used data from the Interrupción Legal de Embarazo (ILE) programme (2016-2019) and identified all abortion clients who travelled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to describe ILE clients' individual characteristics and municipalities on several measures of vulnerability. We also compared municipalities that ILE clients travelled from with those where no one travelled from. We used logistic regression to identify factors associated with travelling to access ILE services from highly marginalised versus less marginalised municipalities.

RESULTS

Our sample included 21 629 ILE clients who travelled to Mexico City from 491 municipalities within all 31 states outside Mexico City. The majority of clients travelled from the least marginalised (81.9%) and most populated (over 100 000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom three quintiles. Clients with a primary or secondary education (vs high school or more) and those from a municipality with a high adolescent fertility rate (top two quintiles) had higher odds of travelling from a highly marginalised (vs less) municipality (adjusted odds ratio (aOR) 1.46, 95% CI 1.35 to 1.58 and aOR 1.89, 95% CI 1.68 to 2.12, respectively).

CONCLUSION

ILE clients travel from geographically and socioeconomically diverse communities. There is an unmet need for legal abortion across Mexico.

Permeability of abortion care in the Netherlands: a qualitative analysis of women's experiences, health professional perspectives, and the internet resource of Women on Web

Despite a relatively permissive abortion law, women in the Netherlands encounter difficulties in accessing abortion care. Little is known about their experiences. This study explores women's experiences with (online) abortion services and relevant health professionals' experiences delivering care, with the goal of identifying key barriers encountered by abortion-seekers in the Netherlands. An exploratory qualitative research design with a constructivist approach and an abbreviated grounded theory method was used. Interviews with 20 women who had had an abortion and 14 health professionals who provide abortion care, and 200 emails of women seeking abortion care through the non-governmental organisation Women on Web, were coded inductively and deductively (using the Candidacy Framework) thereby generating themes. Abortion-seekers faced barriers including: (i) burden of taboo, (ii) vulnerability (emotional, financial, and social), (iii) health professional evaluation and (iv) disempowerment and distress. The overarching theme was women's lack of autonomy in access to abortion care. The key barriers to abortion access in the Netherlands are the institutionalisation of taboo in abortion law and care, complex candidacy regulations, lack of permeability for certain marginalised groups, and women's inability to speak openly about abortion. To increase the permeability of abortion care, and thereby women's autonomy, legislators and policy-makers must trust women to make their own reproductive decisions and avoid actions that stigmatise abortion and hinder access to care, while actively developing systemic support for vulnerable groups.

Prevalence and factors associated with unplanned pregnancy in a Brazilian capital in the Northeast

Abstract Objectives: to analyze the prevalence and factors associated with unplanned pregnancy in a Brazilian capital in the Northeast. Methods: a cross-sectional study nested to a hospital birth cohort with a probable sample of 5,110 puerperal women. Associated factors were analyzed using a hierarchical theoretical model in three levels: distal (women’s socioeconomic and demographic characteristics), intermediate (reproductive characteristics, maternal habits and BMI), and proximal level (partner's characteristics). Multivariate Poisson regression analysis was performed. Results: the prevalence of unplanned pregnancy was 68.1% (CI95%=66.8-69.4). Multivariate analysis showed association with black skin color/race (PR=1.03; CI95%=1.01- 1.07), mother's age group up to 19 years old (PR=1.09; CI95%=1.06-1.12) and 20 to 24 years old (PR=1.04; CI95%=1.01-1.07), not living with partner (PR=1.09; CI95%=1.07- 1.11), highest number of people in the household: 5 people (PR= 1.10; CI95%=1.08-1.13) and 3 to 4 (PR=1.08; CI95%=1.05-1.10), number of ≥4 children (PR=1.09; CI95%=1.06- 1.13) and 2 or 3 children (PR=1.03; CI95%=1.02-1.05), alcohol consumption (PR=1.03; CI95%=1.01-1.05), malnourished pre-pregnancy BMI (PR=1.03; CI95%=1.01-1.06) and partner’s low schooling (5 to 8 years) (PR=1.03; CI95%=1.01-1.07). Prior abortion was inversely associated with planned pregnancy (PR=0.95; CI95%=0.93-0.97). Conclusions: the prevalence of unplanned pregnancy was high and was associated with socioeconomic and demographic characteristics that reflect on the combination of the complex inequalities that impact women and their partners

Emotions over five years after denial of abortion in the United States: Contextualizing the effects of abortion denial on women's health and lives

BACKGROUND

The Turnaway Study was the first to follow women denied abortions because of state law or facility policy over five years. The study has found negative effects on women's socioeconomic status, physical health, and on their children's wellbeing. However, women did not suffer lasting mental health consequences, prompting questions about the effects of denial on women's emotions.

METHODS

In this mixed methods study, we used quantitative and qualitative interview data from the Turnaway Study to offer insight into these findings. We surveyed 161 women who were denied abortions at 30 facilities across the United States between 2008 and 2010 one week after the abortion denial and semiannually over five years. Mixed-effects regression analyses examined emotions about having been denied the abortion over time. To contextualize the quantitative findings, we draw on in-depth qualitative interviews with 15 participants, conducted in 2014-2015, for their accounts of their emotions and feelings over time.

RESULTS

Survey participants reported both negative and positive emotions about the abortion denial one week after. Emotions became significantly less negative and more positive over their pregnancy and after childbirth. In multivariable models, lower social support, more difficulty deciding to seek abortion, and placing the baby for adoption were associated with reporting more negative emotions. Interviews revealed how, for some, belief in antiabortion narratives contributed to initial positive emotions. Subsequent positive life events and bonding with the child also led to positive retrospective evaluations of the denial.

CONCLUSIONS

Findings of emergent positive emotions about having been denied an abortion suggest that individuals are able to cope emotionally with an abortion denial, although evidence that policies leading to abortion denial cause significant health and socioeconomic harms remains.

Fertility intentions and recent births among US abortion patients

OBJECTIVE

To examine fertility intentions among abortion patients and the potential of abortion for avoiding short birth intervals.

STUDY DESIGN

We used national data from a sample of more than 8000 individuals obtaining abortions in the United States in 2014. We created a measure of fertility intentions based on prior births and responses to an item asking about future childbearing expectations. We identify respondents who reported having a birth in the last 12 months as at risk of a short birth interval. We used simple logistic regression to assess for differences in these measures according to key demographic variables.

RESULTS

Most commonly, 39% of patients intended to have (more) children, with similar proportions wanting to delay a first birth (20%) or postpone a second or higher order birth (19%). Some 31% of abortion patients had completed childbearing; they had one or more prior births and did not want to have any more children. Similar proportions of respondents were not sure if they wanted to have children (16%) or did not want to have any children (15%). Among abortion patients who had children, 14% had had a birth in the prior year. We estimate that as many as 77,800 short birth intervals were averted in 2014 because individuals had access to abortion.

CONCLUSIONS

These findings support the view that abortion allows individuals to plan and space their births according to their reproductive life plans and intentions.

IMPLICATIONS

Access to abortion may help thousands of individuals in the United States avoid short birth intervals, potentially leading to improvements in maternal and child health.

Abortion as a Catastrophic Health Expenditure in the United States

PURPOSE

Abortion is a critical reproductive health service that is difficult for many in the United States to afford owing to policies aimed at restricting insurance coverage of this basic health service. This article assesses whether the resulting high out-of-pocket cost for abortion could be considered a catastrophic health expenditure, and explores potential policies that could prevent households from experiencing financial hardship or impoverishment.

METHODS

We assessed if the average costs of a first and second trimester abortion procedure in 2016 were catastrophic health expenditures by applying a 40% threshold to the monthly nonsubsistence income of households earning their state's median income in all 50 states and Washington, DC.

RESULTS

The out-of-pocket cost for a first trimester abortion procedure would have been catastrophic for households earning their state's median monthly income in 39 states. In nine of these states, the average cost was between 100% and 199% of a household's nonsubsistence income, and in another nine states, this cost was at least double a household's nonsubsistence income. The out-of-pocket cost of a second trimester abortion would have been catastrophic for households earning their state's median monthly income in all 50 states and Washington, DC.

CONCLUSIONS

In a majority of states, the out-of-pocket cost of an abortion is financially catastrophic for households earning no more than their state's median monthly income. The United States should implement policies to create or improve health care safety nets to guarantee abortion care for all individuals, regardless of their income or insurance status.

"We keep quiet": exploring the context of pregnancy intention in a low-resource community in Ecuador

Unintended pregnancies are both a consequence and a cause of socioeconomic inequality. Family planning prevents unintended pregnancy and reduces health disparities. The purpose of this study is to describe the structural, social, economic context of pregnancy intention in a peri-urban, diverse, low-resource community in Ecuador. A qualitative descriptive methodology was used. Semi-structured individual interviews were performed with 19 female participants of reproductive age. Interviews were professionally transcribed in Spanish, translated into English, and analysed in MAXQDA using content analysis. The majority of pregnancies were reported as unintended and four themes emerged to describe the context. (1) Women's autonomy is limited by men, (2) Women keep quiet, (3) Systems failed women, and (4) Building resilience. Health systems, gender-based violence, limited education and financial means, and policies yet to be enforced served as barriers to both empowerment and family planning. In spite of this, many women were able to transition into safety, and prevent or delay pregnancy with new partners. Ecuador has made significant economic gains in the past two decades, but these findings suggest that inequality persists in some regions of Ecuador. The women in this study report needing to feel safe, productive and valued to plan their families. Public health professionals need to involve multi-sectors in solutions to reduce health disparities and address determinants of maternal/child health including gender-based violence, economic and systemic limitations. DOI:10.1080/26410397.2019.1686198

Factors associated with induced abortion in Nepal: data from a nationally representative population-based cross-sectional survey

Background

Despite the legalization of abortion services in 2002, unsafe abortion (abortion services conducted by persons lacking necessary skill or in substandard settings or both) continues to be a public health concern in Nepal. There is a lack of national research exploring the characteristics of women who choose to have an abortion. This study assessed abortion in Nepal and its correlates using data from a nationally representative population-based cross-sectional survey.

Methods

We employed data from the Nepal Demographic and Health Survey 2016. Sample selection was based on stratified two-stage cluster sampling in rural areas and three-stage sampling in urban areas. The primary outcome is report of induced abortion in the 5 years preceding the survey, as recorded in the pregnancy history. All values were weighted by sample weights to provide population-level estimates. Bivariate and multivariate logistic regressions were performed using STATA 14 considering cluster sampling design.

Results

A total of 12,862 women of reproductive age (15–49 years) were interviewed. Overall, 4% (95% CI: 3.41–4.29) reported an abortion within the last 5 years (and less than 1% had had more than one abortion during that time). A higher proportion of women aged 20–34 years (5.7%), women with primary education (5.1%), women aware of abortion legalization (5.5%), and women in the richest wealth quintile (5.4%) had an abortion in the past 5 years. Compared to women aged < 20 years, women aged 20–34 years had higher odds (AOR: 5.54; 95% CI: 2.87–10.72) of having had an abortion in the past 5 years. Women with three or more living children had greater odds (AOR: 2.24; 95% CI: 1.51–3.31) of having had an abortion than women with no living children. The odds of having an abortion in the past 5 years increased with each wealth quintile, with the richest wealth quintile having almost three-fold greater odds of having had an abortion. No significant association was observed between having an abortion and the ecological zone and place of residence.

Conclusion

This nationally representative study shows that abortion is associated with women’s age, knowledge of abortion legality, wealth status, number of living children, and caste/ethnicity. Targeted interventions to young women, those in the poorest wealth quintile, women from Terai caste groups, and those who reside in Province 2 would be instrumental to address disproportional access to abortion services. Overall, strengthening contraceptive provision and abortion education programs would be cornerstone to improving the health of women and girls in Nepal.