The quality of abortion services in Turkey

Effects of implementing a postabortion care strategy in Kinshasa referral hospitals, Democratic Republic of the Congo

Objectives

To evaluate the effects of the implementation of a postabortion care (PAC) strategy in Kinshasa referral hospitals, this study analyzed the quality of postabortion care services, including postabortion contraception, and the duration of hospitalization.

Methodology

We estimated the effects of the PAC strategy using a quasi-experimental study by evaluating the outcomes of 334 patients with the diagnosis of a complication of induced abortion admitted to 10 hospitals in which the PAC strategy was implemented compared to the same outcomes in 314 patients with the same diagnosis admitted to 10 control facilities from 01/01/2016 to 12/31/2018. In response to government policy, the PAC strategy included the treatment of abortion complications with recommended uterine evacuation technology, the family planning counseling and service provision, linkages with other reproductive health services, including STI evaluation and HIV counseling and/or referral for testing, and partnerships between providers and communities. The information was collected using a questionnaire and stored using open data kit software. We supplemented this information with data abstracted from patient records, facility registries of gynecological obstetrical emergencies, and family planning registries. We analyzed data and developed regression models using STATA15. Thus, we compared changes in use of specific treatments and duration of hospitalization using a "difference-in-differences" analysis.

Results

The implementation of PAC strategy in Kinshasa referral hospitals has resulted in the utilization of WHO recommended uterine evacuation method MVA (29.3% more in the experimental structures, p = 0.025), a significant decline in sharp-curettage (19.3% less, p = 0.132), and a decline in the duration of hospitalization of patients admitted for PAC (1 day less, p = 0.020). We did not observe any change in the use of PAC services, mortality, and the provision of post abortion contraception.

Conclusion

Despite significant improvement in the management of PAC, the uptake in WHO approved technology—namely MVA, and the duration of hospitalization, these outcomes while a significant improvement for DRC, indicate that additional quality improvement strategies for management of PAC and risk-mitigating strategies to reduce barriers to care are required.

How Do Pronatalist Policies Impact Women’s Access to Safe Abortion Services in Turkey?

A pronatalist discourse and anti-abortion rhetoric used by prominent politicians in Turkey, prior to and following the proposed ban of abortion in 2012, have resulted in reports of women facing difficulty accessing safe abortion services (SAS), risking the resurgence of unsafe abortions. We conducted a qualitative study to identify the impact of the ongoing pronatalist discourse on women’s access to SAS, using semi-structured interviews with 19 experts (16 female, 3 male) in reproductive health, including academics, doctors, midwives, and health authorities. Participants from 4 cities (Ankara, Istanbul, Izmir, and Manisa) were identified through a combined snowball and purposive sampling technique. The findings show that the pronatalist discourse has directly and indirectly inhibited access to SAS. Women’s and health professionals’ perception of abortion services has been tainted by rhetoric; provision of SAS in the public sector is slowly ceasing; and health reform-related organizational changes have diminished access to family planning services and contraceptive methods. Provision of SAS in the private sector continues but is only accessible for women with sufficient financial means. Preventing women’s access to SAS risks a rise in unwanted pregnancies and—consequently—in the number of women who may seek dangerous alternatives, including unsafe, life-threatening abortions.

Morbidity and mortality due to unsafe abortion in Pakistan

OBJECTIVES

To determine the frequency of women who had undergone an unsafe abortion and attended a tertiary care hospital in Pakistan with complications.

METHODS

Patients with a history of termination at a gestational age of less than or equal to 22 weeks were included in the study.

RESULTS

Of 230 women who met the inclusion criteria, 50 (21.7%) patients had undergone an unsafe abortion and attended the hospital with associated complications. Unintended pregnancy was the reason for the abortion in 82% of women (n=41). Eighteen (36%) underwent terminations performed by doctors, 18 (36%) by Lady Health Visitors (n=18), 10 (20%) by an untrained birth attendant (Dai), and 4 (8.0%) by nurses. Dilatation and evacuation procedures were performed in 28 (56.0%) women, while a Laminaria tent prior to evacuation was used in 18 (36.0%). Major complications included uterine perforation and gastrointestinal injury, observed in 27 (54.0%) women. Hemorrhage was observed in 13 (26.0%) women with retained products of conception after incomplete abortion. Six (12.0%) women died.

CONCLUSION

Healthcare providers performed the majority of terminations. To prevent maternal mortality, improved skills through refresher courses and workshops on safer methods are needed.

The evaluation of family planning services given in Erzurum mother–child health and family planning centerin Eastern Turkey

OBJECTIVES

This study was done on women who attended to Mother-Child Health and Family Planning (MCH-FP) center asking for FP services or materials. Data were collected about their opinion of the services and about the performance of the service itself.

METHODS

This is a descriptive and cross-sectional study composed of 235 women.

RESULTS

In Family Planning, counseling was done by midwifes in 67.3%, by nurses in 26.6%, and only 4.5% by doctors. Proper hygienic conditions were confirmed by 89% of the women, about the equipment the percentage was 91%. Privacy was taken care of properly in 95.5% of the cases. The quality of service with regard to waiting was expressed as not waiting at all in 22.6%, and 76.6% found free seats while waiting. The cleanliness of the waiting hall was appreciated by 97.4%. In general 95.7% of the attendants appreciated the kindliness of the staff.

CONCLUSIONS

This study reveals that the performances of the MCH-FP service are well appreciated by the public.

The predictors of retained products of conception following first-trimester pregnancy termination with manual vacuum aspiration

OBJECTIVE

To identify the risk factors associated with retained products of conception (RPC) following first-trimester pregnancy termination with manual vacuum aspiration (MVA).

METHODS

We analyzed 1623 patients who underwent MVA during the first 9 weeks of their pregnancies in SSK Aegean Obstetrics and Gynecology Teaching Hospital Department of Family Planning in between February 2001 and January 2004.

RESULTS

A total of 81 patients (5%) had RPC after MVA. We found that RPC after MVA were significantly associated with patient's age (P = 0.026), body mass index (BMI) (P = 0.017), and week of gestation applied MVA (P = 0.012); but not associated with parity (P = 0.063), history of previous MVA (P = 0.845), and history of previous miscarriage (P = 0.918).

CONCLUSION

Our study suggests that the frequency of RPC after MVA has been affected by current pregnancy-related factors such as patient age, BMI, and gestational age rather than the prior obstetric history of the patients.

Study Supports the Introduction of Early Medical Abortion in Turkey

In Turkey, there is an unmet need for induced abortion services provided by the public health services, especially in rural and semi-urban areas. The objective of this clinical study was to show that early medical abortion could be introduced safely in Turkey to improve women's access to services. In the study, women aged 18-49 up to 56 days of pregnancy were offered a choice between medical abortion with 200 mg mifepristone followed by 400 mcg oral misoprostol and MVA with local anaesthesia. 209 chose medical and 149 surgical abortion. Data from an additional 112 women were collected to obtain a similar number of surgical abortion cases. Women's preference for and satisfaction with the chosen method, side effects and complications up to the 14-day follow-up visit were recorded. 75% of women who chose medical abortion opted for home use of misoprostol. Pain with medical abortion on average lasted 3.6 +/- 3.0 days and with surgical abortion 3.7 +/- 2.9 days. 90% of women who had medical abortion said they would prefer it again compared to 70% of those having surgical abortion. There were 1.4% ongoing pregnancies in the medical abortion group and none in the surgical group. Provider training and familiarity with medical abortion are crucial. The high incomplete abortion rate indicates that the dose and regimen of misoprostol should be reconsidered. The findings support the introduction of early medical abortion in Turkey.

Postcoital contraception in Turkey

OBJECTIVES

The purpose of this article is to determine the knowledge status of women concerning postcoital contraception when they turn to curettage in order to terminate an undesired pregnancy.

METHODS

This defining study has been carried out at a maternity hospital in Izmir on pregnant women admitted for curettage. We interviewed 150 pregnant cases using an improbability sampling method.

RESULTS

We discovered that 48.7% of women had avoided pregnancy before curettage by withdrawal before ejaculation. When we investigated the method used after uncontrolled coitus, 27.3% of cases reported vaginal douche while 12.7% indicated curettage. After having an unprotected coitus or failure in contraceptive methods 99.3% of the women indicated they would report to health institutes to utilize postcoital methods if they were familiar with them.

CONCLUSIONS

Postcoital contraception may be a solution for undesired pregnancies.

The effectiveness of preabortion contraception counseling

OBJECTIVE

To demonstrate the impact of preabortion counseling followed by immediate postabortal provision of the chosen method on postabortion contraceptive use.

METHODS

Three hundred and forty-two women undergoing voluntary termination of pregnancy at less than 10 weeks gestation were enrolled at the Woman and Child Health Training and Research Clinic, Medical School of Istanbul. Clinic visits and telephone surveys were performed to measure contraceptive use at 6 months following abortion.

RESULT

Two hundred and thirty-six women either visited the clinic or responded to the telephone survey. Eighty percent of the respondents reported use of a modern contraceptive as compared to less than 40% prevalence found in the national survey.

CONCLUSION

Preabortion counseling combined with immediate postabortal provision of contraceptives may significantly increase contraceptive use at 6 months postprocedure.

International developments in abortion law from 1988 to 1998

OBJECTIVES

In 2 successive decades since 1967, legal accommodation of abortion has grown in many countries. The objective of this study was to assess whether liberalizing trends have been maintained in the last decade and whether increased protection of women's human rights has influenced legal reform.

METHODS

A worldwide review was conducted of legislation and judicial rulings affecting abortion, and legal reforms were measured against governmental commitments made under international human rights treaties and at United Nations conferences.

RESULTS

Since 1987, 26 jurisdictions have extended grounds for lawful abortion, and 4 countries have restricted grounds. Additional limits on access to legal abortion services include restrictions on funding of services, mandatory counseling and reflection delay requirements, third-party authorizations, and blockades of abortion clinics.

CONCLUSIONS

Progressive liberalization has moved abortion laws from a focus on punishment toward concern with women's health and welfare and with their human rights. However, widespread maternal mortality and morbidity show that reform must be accompanied by accessible abortion services and improved contraceptive care and information.