Country-specific estimates of unintended pregnancy and abortion incidence: a global comparative analysis of levels in 2015-2019

Neonatal mortality and contraceptive utilization following abortion restriction in the Dominican Republic: A difference-in-differences analysis

In 2009, the Dominican Republic's Constitutional Assembly banned abortion under all circumstances, including cases of rape and/or situations in which the mother's health is at risk. Abortion policies have the potential to influence access to reproductive and neonatal health services, health outcomes, and health equity. In this study, we utilized a difference-in-differences approach to evaluate the association between the 2009 abortion reform in the Dominican Republic and neonatal mortality and modern contraceptive utilization. We harmonized data from Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) between 1999 and 2019 to assemble a panel of 792,165 live births across 17 countries for analyses of neonatal mortality and 417,110 women ages 15-49 across 8 countries for analyses of modern contraceptive use. We compared outcome trajectories in the Dominican Republic to a group of control countries that did not change their abortion policies during the study period and are assumed to represent the counterfactual. Fixed effects for country and year were included to control for unobserved time-invariant confounders that varied across countries and temporal trends that were shared across countries, respectively. We also assessed for heterogeneity by household wealth, rural residency, and educational attainment through a stratified analysis. Over the study period, the rate of neonatal mortality was 27.0 per 1,000 live births and there were 39 per 100 women reporting use of modern contraceptives. Abortion restriction was associated with an additional 6.3 (95 % CI = 2.1, 10.5) neonatal deaths per 1,000 live births and a 9.6 (95 % CI = 4.2, 15.0) percentage-point decrease in modern contraceptive use. Estimates were robust to adjustment for individual, household, and country-level characteristics. However, there is possibility of residual confounding by unmeasured time-varying confounders, such as concomitant policy changes or interventions. Further research into how restrictive abortion policies compound racial, ethnic, and socioeconomic inequities is needed.

How have unintended pregnancies and contraceptive use among adolescent girls and young women changed in Uganda? Evidence from the 2014 and 2019 PMA national surveys

Unintended pregnancies among adolescent girls and young women (AGYW), and any pregnancy among adolescent girls are still a challenge, especially in Sub-Saharan Africa and Uganda. We assess prevalence of unintended pregnancy in Uganda, associated factors and contraceptive use following unintended pregnancy among adolescent girls and young women in 2014 and 2019 in Uganda. Data are from the 2014 and 2019 performance monitoring for action (PMA) surveys. There were 1,479 AGYW reporting ever/ or current pregnancy in the two surveys, 780 in 2014 and 699 in 2019. Data included socio-demographics and pregnancy intendedness. Descriptive analyses were conducted stratified by adolescent girls and young women and compared between surveys. The percent of unintended pregnancies was determined as the number of AGYW reporting unintended pregnancy divided by eligible participants. A weighted comparison of the prevalence of unintended pregnancies was made between the surveys, and statistical significance determined at a 5% type-1 error rate. All analyses were conducted with Stata version15 using svy surveyset methodology accounting for complex survey design. Relative to 2014, the 2019 survey showed a significant reduction in percent of AGYW reporting ever pregnant or given birth, 60% to 49%, p = 0.007; a decline in unintended pregnancy among adolescent girls, 52% to 42%, p = 0.049, and among young women with secondary education, 36% to 13%, p = 0.001. Conversely, the 2019 survey showed significant increase in contraception among those ever pregnant, 26% to 40%, p < 0.001; higher in young women (30% to 47%, p = 0.001) compared to adolescent girls (16% to 25%, p = 0.005). The commonest contraceptive methods were short-acting at both surveys, while the long-acting methods significantly increased among young women (20% to 35%, p = 0.003). The decline in unintended pregnancies was consistent with increased use of contraceptive methods. Although we observed a significant decline in unintended pregnancy among adolescent girls, the proportion reporting unintended pregnancy remains high.

The War on Drugs is a war on women: Louisiana's Abortion Law

This commentary explores the criminalization of abortion in Louisiana by arguing that it mirrors the punitive policies of the War on Drugs. We critically analyze the reclassification of abortion-inducing drugs like Mifepristone and Misoprostol as controlled substances to demonstrate how these laws disproportionately impact women, particularly those who are poor and Black and Brown. Drawing on parallels to the racial caste system perpetuated by the War on Drugs, we argue that these policies are less about public health and more about social control, with severe implications for reproductive autonomy and justice. By linking the scheduling of Mifepristone and Misoprostol to the War on Drugs, we show how abortion criminalization and abortion medication criminalization extend the arm of the American legal system to police and punish Black and Brown bodies and communities. We conclude by calling for a reevaluation of these legal frameworks to prevent further marginalization and harm.

A qualitative study of abortion decision-making trajectories among pregnant women at their first antenatal care visit in Kampala, Uganda

Background

In Uganda, only about half of women who want to avoid pregnancy are using modern contraceptives, leading to high numbers of unintended pregnancies and elevated maternal and neonatal morbidity and mortality. In this study, we aimed to learn more about women's abortion decision-making before continuing to carry a pregnancy.

Methods

We utilised a qualitative study design and interviewed 31 purposively selected single and partnered pregnant women aged ≥18 years at their first antenatal care visit at Kawempe National Referral Hospital in Kampala, Uganda. We conducted the interviews in Luganda or English, transcribed them, and then translated them into English, as needed, for analysis. We analysed the data using thematic analysis. Deductive codes were based on social networks, social support, and health behaviour theories, and inductive codes were derived from interview transcripts.

Results

Almost half of the study participants (n = 13) considered an induced abortion before deciding to continue carrying their pregnancy. The most commonly stated reasons they considered abortion included anticipated interruptions to work and education, exhaustion related to child-rearing, and lack of social support. Other participants (n = 9) reported not considering abortion due to anticipated social support for their pregnancy, concerns about abortion-related morbidity and mortality, late confirmation of pregnancy, and religious beliefs. No participants discussed Uganda's restrictive abortion policies as a reason not to consider abortion.

Conclusions

Our results point to opportunities for continued reproductive health education and improved access to reproductive health services to allow pregnant women to meet their reproductive needs, seek out family planning, antenatal care, and safe abortion services when desired, and create support networks for pregnant women.

Utilization of antenatal care among immigrant women in Norway: a nationwide register-based cohort study

BACKGROUND

International research suggests that immigrants face poorer access to antenatal care, but comprehensive nationwide studies identifying variations across immigrant groups are lacking. Using national registries like the Medical Birth Registry, we compared antenatal care utilization among immigrant women by country/region of origin to Norwegian women.

METHODS

We included 348,547 singleton births between 2012-2018 by women aged ≥ 16 years registered with ≥ 1 antenatal consultation in primary care, including 79,671 (22.9%) births by immigrant women. We calculated odds ratios (OR) and 95% confidence intervals (CI) using both crude and adjusted logistic regression models, assessing the likelihood of immigrant women having fewer consultations than recommended by national guidelines compared to Norwegian women per trimester. Estimates were adjusted for relevant sociodemographic variables.

RESULTS

Large country-specific differences in estimates were noted across all trimesters. In the crude models, Eritrean (OR 3.01 [95%CI: 2.76-3.28]), Somali (OR 2.63 [95%CI: 2.48-2.79]) and Ethiopian (OR 1.90 [95%CI: 1.67-2.16]) women, and women from other Sub-Saharan countries (OR 1.92 [95%CI: 1.77-2.08]), had the highest odds of initiating antenatal care later than the first trimester. In later trimesters, care utilization by immigrants and Norwegian women were more similar, except for lower utilization among Somali women. Sociodemographic variables explained much of the observed differences.

CONCLUSION

Late initiation and substandard utilization of antenatal care among certain immigrant groups exists in Norway. Timely access to antenatal care is important for maternal and child health. Efforts should be initiated to facilitate earlier initiation of antenatal care, particularly among Eritrean, Somali, Ethiopian and other Sub-Saharan women.

Unintended pregnancy and gender inequality worldwide: an ecological analysis

Unintended pregnancy compromises many women's and girls' ability to pursue the lives that they want. The conditional unintended pregnancy rate (CUPR) is a measure of unintended pregnancy among women who wish to avoid getting pregnant. Using the CUPR, we explore the relationship between gender inequality and unintended pregnancy across 132 countries. We used gender inequality indicators from the UNDP Human Development Report and estimates of the incidence of unintended pregnancy published by the Guttmacher Institute and WHO. We regressed the CUPR on several measures of gender inequality using least squares with a percentile bootstrap to account for sampling error and the additional uncertainty in the model-based unintended pregnancy estimates. We find that unintended pregnancy is positively correlated with multiple composite measures of gender inequality, even after controlling for countries' levels of economic development. Of the components of gender inequality, gender disparities in educational attainment were most strongly correlated with unintended pregnancy in multivariable regressions. We also find that female educational attainment is a stronger predictor of the CUPR than male educational attainment. Analyses with the standard unintended pregnancy rate, a measure that does not take into account differences across settings in the proportion of women who wish to avoid getting pregnant, obscured the strength of the observed relationships. Further exploration of the factors underlying this relationship can inform policies to improve the quality of women's lives.

Knowledge, attitudes, and practices regarding contraception amongst community pharmacy staff: a cross-sectional study in Nigeria

Introduction

Lack of access to effective contraception methods can lead to an increased prevalence of unintended pregnancies, as well as possible deleterious health consequences. Community pharmacies represent the most accessible gateway for population medicines' and healthcare needs. Regarding contraceptives, they have also been identified as a platform for the provision of additional services, such as complementary counselling. This study aimed at assessing the knowledge, attitudes, and practices of community pharmacy staff towards contraception.

Methods

A cross-sectional study was undertaken in the Federal Capital Territory, Nigeria. Data were collected from 315 community pharmacy staff using self-administered questionnaires. The participants' knowledge and attitude scores were categorised using Bloom's cut-off point. Analyses were undertaken using Statistical Package for Social Sciences. The data were analysed using frequency distribution, chi-square, and linear regression at a 5% level of significance.

Results

Male participants in the study (165/315, 52.4%) were slightly higher than the female respondents (150/315, 47.6%), and about two-thirds of the study cohort were pharmacists (200/315, 63.5%). The majority of the participants (183/315, 58.1%) had poor knowledge of contraceptive use. A quarter of them (81/315, 25.7%) reported moderate attitudes. Almost all the participants (279/298, 93.6%) indicated recommending contraceptives for married adults, and a significant proportion of them (136/292, 45.5%) were opposed to recommending contraceptives for unmarried adolescents. Study respondents' professional role was also identified as a significant influence on their knowledge of contraceptives and contraception (p < 0.001).

Conclusion

Findings from this study revealed poor knowledge and negative attitudes of community pharmacy staff towards contraception. Government and relevant stakeholders can build on these novel findings to reform pertinent contextual policies and practices. This can significantly improve access to contraceptives amongst the populace, and consequently reduce unintended pregnancies alongside possible health and societal implications.

Evaluation of immediate and sustained effects of transitioning quality long-acting reversible contraceptives (LARCs) services to public sector health facilities in Ghana: a pre-post intervention study

BACKGROUND

Long-acting reversible contraceptives (LARCs) are highly effective at preventing pregnancy and demonstrate favorable client satisfaction. However, limited knowledge, misconceptions, and concerns about side effects hinder LARC adoption. Marie Stopes International-Ghana collaborated with Ghana Health Service to implement a 5 year multifaceted intervention to transition quality LARC services from an outreach approach to being available in public sector health facilities. This study evaluates if the intervention resulted in immediate or sustained improvements in the provision of quality LARC services in the public sector.

METHODS

Using a pre-post intervention design, facility structural quality, providers' training, practice, and knowledge on the provision of LARCs, and clients' perceived service quality were assessed in 8 Ghanaian regions. Analyses compared endline and baseline data, categorized into two groups based on the program phase: Recent Intervention facilities and GHS Support facilities. Facility records on a 3 month volume of LARC provision were compared between the last quarters of 2019 and 2022. Multivariate logistic regressions of any increase in the volume of LARC provision were conducted with associated endline facility and provider characteristics summarized at the facility level.

RESULTS

Significant increases were found in the provision of IUD services among Recent Intervention facilities (CHPS facilities: T0 13%, T2 50%, p < 0.001; HC/Hospitals: T0 23%, T2 53%, p < 0.001), while almost all providers offered implant services across facility types and intervention phases. The proportion of providers ever been trained to insert LARCs increased. Immediate and sustained effects were found on knowledge of LARC provision. Although facilities had significant increases in usual IUD availability among those in Recent Intervention (CHPS: T0 13.0%, T2 50.0%, p < 0.001), availability of IUD decreased to pre-intervention level upon transition to GHS Support. Controlling for other factors, facilities which had transitioned to GHS support were far less likely than those in the Recent Intervention phase to have an increase in the volume of LARC provision.

CONCLUSIONS

This 5 year collaboration between MSI-Ghana and the Ghana Health Service increased the capacity of providers at 210 GHS facilities to provide high-quality LARC services. Future programs to improve LARC provision in the public sector may also consider including sustainable interventions to strengthen logistical management systems and targeting barriers to LARC access in the community. Increasing access to and use of modern contraception reduces unintended pregnancies and unsafe abortions, thereby decreasing maternal morbidity and mortality. Despite long-acting reversible contraceptives (LARCs) are highly effective at pregnancy prevention and favored by clients, utilization in many low- and middle-income countries has been low. In Ghana, less than half of women who want to delay, space, or limit childbearing use a modern contraceptive method. As the public sector is the predominant source of family planning services, improving the quality and provision of LARC services in the public sector has the most potential to increase women's access to LARCs. Marie Stopes International-Ghana collaborated with Ghana Health Service to implement a 5-year program to transition the provision of quality LARC services from its mobile clinic outreach model to public sector health facilities through a phased approach. We studied the immediate and longer-term effects on the provision and utilization of quality LARC services in the public sector. We collected three rounds of data from intervention facilities, associated providers, and clients. We found increased providers providing IUD services, trained in LARC provision, and increased and sustained knowledge needed for quality LARC services provision. Despite improvement, after the intervention ended, IUD availability at the facility decreased. Facilities that completed the intervention for at least several months were less likely to maintain the increased level of LARC provision than those still in the intervention or recently concluded. These findings underline the need for additional efforts to strengthen logistical management systems to ensure consistent provision of quality LARC services.

Knowledge, Attitudes, and Practices Toward Contraceptive Methods Among Female Undergraduate Students of Chiang Mai University, Thailand: A Cross-Sectional Survey

Background

Unintended pregnancies are associated with unsafe abortions and maternal deaths. Undergraduates are at risk of unexpected pregnancy due to changes in their lives. Adequate knowledge and attitudes toward contraceptive uses are essential to help prevent pregnancy.

Objective

To assess sex activity, knowledge, attitudes, and practices of contraception methods among female undergraduates at Chiang Mai University, Thailand.

Methods

Self-administered anonymous questionnaires were answered by female undergraduate students via an online platform. The questionnaire consisted of four parts (sociodemographic and contraception use, knowledge of contraceptive methods, attitudes, and sources of information.).

Results

A total of 475 women responded to the questionnaire. Of them, 29.2% had sex experience, with significantly lower prevalence among the students in health sciences faculties, when compared with those of nonhealth sciences (20.6% vs. 40.2%; p-value <0.001). The mean ± standard deviation scores of knowledge of contraceptive methods was 12.84 ± 4.59 (range, 0-24), indicating a medium level. There were only 15.1% of participants who were categorized as a high level, while many participants (86.9%) had a positive attitude toward contraceptive methods. Most participants gained contraceptive knowledge from online content from the internet and social media.

Conclusion

Nearly 30% of the female university students had sex experience, lower than that in most previous studies, with significantly lower prevalence in the group of health sciences faculties. Most female university students had a positive attitude toward contraception uses; however, their knowledge about contraception was relatively limited. Finally, most contraceptive methods used were relatively less effective and theoretically at risk for unintended pregnancy.

Exploring Potential Biomarkers in Recurrent Pregnancy Loss: A Literature Review of Omics Studies to Molecular Mechanisms

Recurrent pregnancy loss (RPL) is characterized by the occurrence of three or more consecutive spontaneous pregnancy losses before 20-24 weeks of gestation. Despite significant progress in the investigation of the biological pathways associated with unexplained RPL, the precise molecular mechanisms remain elusive. Recent advances in multi-omics approaches have identified numerous biomarkers that offer potential avenues for understanding the underlying complexities of RPL. The aim of this comprehensive literature review was to investigate the functional roles of these candidate markers and explore the possible key mechanisms that may contribute to RPL. We also aimed to elucidate the functional networks predicted by omics analyses, which hold promise for providing invaluable insights into novel diagnostic and therapeutic strategies for women experiencing RPL. Furthermore, this review expands on clinical implications and possible applications, highlighting those currently moving towards clinical use and ongoing studies developing in this direction.

Barriers to healthcare access among female youths in Mozambique: a mixed-effects and spatial analysis using DHS 2022/23 data

BACKGROUND

Access to healthcare involves timely and affordable service availability. Barriers, such as economic and geographic factors, particularly affect low- and middle-income countries. This study analyzes the spatial distribution and socio-economic determinants of healthcare access barriers among female youths in Mozambique to inform targeted interventions.

METHODS

Data from the Mozambique Demographic and Health Survey (DHS) 2022/23 on maternal and child health was analyzed. Using a stratified two-stage sampling design, 619 enumeration areas were selected, including 5,743 female youths aged 15-24. Barriers were assessed based on finances, distance, permission, and safety, with independent variables like age, education, wealth index, marital status, and community factors. Analyses included multilevel logistic regression and spatial methods (Global Moran's I, SaTScan) using Stata 17 and ArcGIS 10.7 to identify barriers and clusters.

RESULTS

This study found that 49.10% (95% CI: 47.81%, 50.39%) of female youths reported barriers to healthcare access, primarily due to financial difficulties (40.69%) and distance (38.16%). Youths aged 20-24 were 15% lower odds of facing barriers (AOR = 0.85, 95% CI: 0.73, 0.99). Those with no formal education were 2.18 times more likely to face barriers (AOR = 2.18, 95% CI: 1.22, 3.88). Youths from poor and middle-wealth households were 1.9 times (AOR = 1.9, 95% CI: 1.44, 2.49) and 1.51 times (AOR = 1.51, 95% CI: 1.19, 1.92) more likely to face barriers, respectively. Married youths had a 1.22 times higher likelihood of facing barriers (AOR = 1.22, 95% CI: 1.03, 1.44), and rural residents were three times more likely to experience challenges compared to urban residents (AOR = 3.00, 95% CI: 2.24, 4.01). Spatial analysis revealed regional disparities, with hotspots in Southern Manica and Northern Zambezia.

CONCLUSIONS

Female youths in Mozambique face significant barriers to healthcare access, mainly due to financial constraints and distance, with regional concentrations in Southern Manica, Southern Niassa, and Northern Zambezia. Key determinants include age, education, marital status, rural residency, and economic status. Targeted interventions should address these disparities by enhancing economic opportunities, promoting education, and improving transportation infrastructure. Policymakers must prioritize strategies to advance gender equity and health outcomes for female youths in Mozambique.

Abortion and unintended pregnancy in Pakistan: new evidence for 2023 and trends over the past decade

BACKGROUND

Despite induced abortion being highly legally restricted in Pakistan, studies in 2002 and 2012 showed that many women rely on abortion when faced with an unintended pregnancy. Following the 2012 study, concerted efforts were made to improve contraceptive services and to strengthen postabortion care. The availability and use of misoprostol also expanded in the past decade. Our primary objective was to provide new evidence on the rates of unintended pregnancy, induced abortion and postabortion care in 2023 and to assess trends in these outcomes since 2012.

METHODS

This is a cross-sectional study based on a Health Professional Survey, and a nationally representative Health Facilities Survey, conducted in 2023. A widely applied methodology is used to estimate rates of abortion and unintended pregnancy. Data sources and methods are comparable across the 2012 and 2023 studies.

RESULTS

In 2023, an estimated six million unintended pregnancies occurred and 64% of them or 3.8 (95% CI 2.2 to 6.4) million resulted in induced abortions. This corresponds to an annual unintended pregnancy rate of 100 and an induced abortion rate of 66 (95% CI 38 to 111) per 1000 women aged 15-49. There was no significant change in the unintended pregnancy rate, but the abortion rate increased by 25% between 2012 and 2023. In 2023, 697 913 women were treated for postabortion complications, corresponding to an annual rate of 12.1 (95% CI 6.4 to 16.5) per 1000 women ages 15-49. This treatment rate declined by 16% between 2012 and 2023.

CONCLUSIONS

The unintended pregnancy rate has remained stable in the past decade. However, Pakistani women are increasingly relying on abortion to resolve unintended pregnancy. The treatment rate of postabortion complications has declined, owing largely to widespread access to misoprostol. This transformation of the abortion landscape calls for concerted efforts to increase contraceptive use and strengthen postabortion care.

Optimizing Diabetes-in-Pregnancy Outcomes Requires a Care Continuum

This study aimed to assess the strengths, limitations, opportunities, and threats presented by diabetes-in-pregnancy. We review the improvements in maternal and fetal mortality since the advent of insulin therapy, evaluate current health challenges, and identify opportunities for preventing increased mortality due to diabetes-in-pregnancy. Prior to 1922, women with type 1 diabetes mellitus (T1DM) of childbearing age were discouraged from becoming pregnant as the maternal and fetal/neonatal mortality rates were extremely high. Starvation-level dietary restriction was the only "treatment," with limited success in managing the disease. The discovery of insulin coupled with careful clinical management presented the possibility of successful pregnancies for women with T1dm. Over the course of the next half-century, maternal survival increased from 54 to 97%. However, the gains made in reducing adverse outcomes of diabetes in pregnancy are eroding due to modern challenges. The global obesity epidemic has led to an increase in type 2 and gestational diabetes mellitus (DM). T1DM also is on the rise. Together, the rise in the prevalence of pregestational diabetes has increased the risks for adverse outcomes. Here we review the ongoing challenges as well as opportunities for research to improve outcomes. We suggest that overweight, obesity, and diabetes management must be coupled with preconception counseling and education and must include, in addition to, Ob/Gyns, primary care, nutrition, weight management, and other experts to ensure that those at risk of pregnancy complications due to diabetes have the best possible outcomes. KEY POINTS: · Diabetes in pregnancy is affecting more people.. · The obesity epidemic is fueling an increase in pregestational diabetes.. · Research is needed to reduce inequities in diabetes in pregnancy outcomes.. · Blood glucose control should start prior to pregnancy..

Development of three-layer microneedle system for controlled and sustained release of Levonorgestrel: A pioneering approach to long-term contraceptive delivery

The increasing prevalence of unintended pregnancies, a persistent issue affecting public health and hindering progress towards the Sustainable Development Goals (SDGs), highlights the critical need for innovative contraceptive approaches. While current methods, including hormonal contraceptives such as levonorgestrel (LNG), offer potential solutions, challenges like limited access and inconsistent use persist. This study introduces a new approach with the development of a three-layer microneedle (TIMN) containing LNG designed to provide extended contraceptive efficacy. The TIMN was formulated with varying concentrations of polyvinylpyrrolidone (PVP) and polycaprolactone (PCL) in the first layer, resulting in microneedles approximately 700 µm in height. In this study, TIMN demonstrated superior mechanical strength with less than 10% reduction in needle height under compression. The formulations maintained a surface pH within the skin's normal range, ensuring safety and compatibility, while water vapor transmission (WVT) values indicated good stability under high humidity. Moisture absorption ability (MAA) testing showed low water absorption, suggesting suitability for extended use. In vitro release studies revealed that TIMN released 28.34% of LNG after 24 h and up to 97.34% over 14 days, demonstrating controlled and sustained release. Ex vivo studies confirmed TIMN's longer-lasting LNG availability compared to the control, and in vivo pharmacokinetic studies showed that TIMN maintained therapeutic LNG levels for up to 14 days, outperforming oral LNG suspension. Biocompatibility tests, including HET-CAM and hemolysis assays, confirmed TIMN's safety, with no significant irritation or toxicity. Histopathological analysis further supported the absence of adverse reactions. The TIMN formulation, exhibits promising properties for long-term drug delivery, including mechanical strength, stability, controlled release, and biocompatibility, making it a viable candidate for improved contraceptive therapy.

Predictors of Fetal Attachment, Anxiety, Stress, and Worry in Unintended Pregnancies in the Primary Care Center in Southern Iran

Background

Despite the prevalence of unintended pregnancies, little is known about the connections between psychosocial and sociodemographic characteristics. This study explored the predictors of fetal attachment, worry, anxiety, and stress in unintended pregnancies.

Materials and Methods

This descriptive, cross-sectional study was conducted on 229 father and mother pairs from two primary healthcare centers in Fars province in southern Iran. Data were collected in a face-to-face survey using the Parents Fetal Attachment Scale, Spielberger State-Trait Anxiety Inventory (STAI), Cambridge Worry Scale (CWS), Perceived Stress Scale (PSS), and Parental Worry Scale. The participants were selected using the two-stage random cluster sampling method from November 2022 to February 2023. Data were analyzed in SPSS software using binary logistic and multiple linear regression tests.

Results

According to the findings, education level and previous parenting experience were found to have a statistically significant effect on the attachment levels of mothers (F4,224 = 5.14; p < 0.05). However, there was no statistically significant difference between the perceived stress of mothers and fathers (p > 0.05). Previous parenting experience significantly affected mothers' anxiety (odd ratio: 3.20; p < 0.05). The age variable had a significant relationship with the mothers' perceived stress (p < 0.05).

Conclusions

According to the results, unwanted pregnancy had a significant relationship with fetal attachment, anxiety, stress, and worry. It is recommended that to enhance the mental health of couples who have experienced unintended pregnancy, a platform should be provided for the development of their psychosocial environment.

Approaches to a crisis in early pregnancy: an explorative qualitative study of medical students and doctors in training in Ireland, using a story completion model

A crisis in early pregnancy can be due to an unplanned pregnancy or a suspected abnormality. Pregnant people have the right to unbiased and comprehensive advice of all options from healthcare providers. Using story completion models (SCM), the aim of this qualitative study was to explore the attitudes of medical students and doctors in training towards crisis pregnancy, specifically two scenarios: early unplanned pregnancy and fatal fetal abnormality (anencephaly). Participants were invited from medical students attending University College Dublin (UCD) and trainees in Obstetrics and Gynaecology at the Royal College of Physicians of Ireland (RCPI) from July to December 2022. SCM involves giving the consenting participant an introduction to a hypothetical situation that acts as the beginning of a story and asking them to complete it. Stories were compiled and analysed using thematic analysis. Research Ethics Committee approval was given by both UCD and the RCPI. The standards for reporting qualitative research guidelines were followed. Eight doctors in training and six medical students consented to participate in the study; all but two medical students completed both stories to the required word count, giving 25 stories for analysis. For both situations, stories described a variety of approaches, all of which were based on the person's, or couple's, wishes, from continuing in pregnancy to deciding to end the pregnancy. SCM allowed detailed analysis of potentially sensitive subjects such as pregnancy options. This study showed that participating medical students and doctors in training recognise that pregnant people have the right to all choices in crisis pregnancy.

Pregnancy planning in women with epilepsy: A single center observational study with focus on epilepsy type

PURPOSE

To explore various aspects of pregnancy planning in women with epilepsy and to identify factors needing particular attention in the counselling of these patients with focus on epilepsy type.

METHODS

285 pregnancies in 192 women were collected from the EURAP registry in Trondheim, Norway. Medical records were reviewed to validate diagnoses and types of epilepsy according to revised ILAE classifications.

RESULTS

Ten women proved to have non-epileptic conditions, leaving 274 pregnancies in 182 patients for inclusion. In 40 %, the epilepsy was focal, in 45 % generalized, including 18 % with JME. In 14 %, the epilepsy type was unknown. Pregnancies were planned in 64 %; 16 % were unintended and 20 % undetermined. Unintended pregnancies occurred in 15 % with focal and in 17 % with generalized epilepsy and in only 10 % of the JME subgroup. Planned pregnancy was associated with both preconception folic acid intake (p < 0.001) and breastfeeding ≥6 months (p = 0.011). Epilepsy of unknown type had the lowest rates of intended pregnancy and folic acid use.

CONCLUSION

We found no difference in pregnancy planning between focal and generalized epilepsy. Intended pregnancy was strongly associated with both folic acid and breastfeeding. The JME subgroup did not perform worse but rather above average regarding family planning and breastfeeding. The lowest proportion of folic acid intake was found in epilepsy of unknown type in which seizure control is common, and patients may receive less attention from the specialist health service. Appropriate counselling regarding pregnancy should reach out to all fertile women regardless of epilepsy type and seizure control.

Socio-ecological influences on access to abortion care in Costa Rica: a qualitative analysis of key perspectives from clinical and policy stakeholders

Costa Rica prohibits abortion except under narrow circumstances to save the pregnant person's life. The country boasts historically strong support for social policy and human rights, while also presenting a complex and restrictive abortion access landscape. From September 2021 to March 2022, we conducted 23 interviews with obstetrician-gynecologist (OB/GYN) physicians, OB/GYN medical residents, and policy stakeholders to explore the socio-ecological influences on abortion access in Costa Rica. We sampled clinicians and policy stakeholders from the Universidad de Ciencias Médicas listserv through snowball sampling and conducted semi-structured in-depth interviews in Spanish. We identified limited access to comprehensive sexual health education, lack of support from interpersonal networks, inadequate provider knowledge and training, financial and migratory status, and both provider and community stigma as substantial barriers to abortion access. This study addresses a gap in published research around the social determinants of abortion in Costa Rica and sheds light on the attitudes and opinions of the medical and policy stakeholder communities about abortion access. The results highlight the need for expanded access to comprehensive sexual health education, abortion-related training for healthcare providers, and increased programming efforts, such as funding, outreach, and implementation, to ensure comprehensive reproductive health services are available and accessible, especially for vulnerable populations in Costa Rica.

Effect of pregnancy intention on completion of maternity continuum of care in Sub-Saharan Africa: systematic review and meta-analysis

BACKGROUND

The maternity continuum of care is a strategy to provide timely and quality maternal and child healthcare through preconception, pregnancy, childbirth, postnatal, and the early childhood periods. The maternity continuum of care effectively reduces global maternal and neonatal deaths. However, several factors are reported to cause low completion of the maternity continuum of care in sub-Saharan Africa. There has been substantial debate in the literature as to whether pregnancy intention influences the completion of the maternity continuum of care. Although several studies have been conducted to determine the influence of pregnancy intention on the completion of the maternity continuum of care, findings are inconsistent and have not been systematically reviewed. Therefore, this review aims to determine the effect of pregnancy intention on the completion of the maternity continuum of care in sub-Saharan African countries.

METHODS

A systematic search of articles was performed from MEDLINE Complete, CINAHL Complete, PsycINFO, EMBASE, Maternity & Infant Care, Global Health, Scopus, and Web of Science. The identified articles were imported into Covidence and independently screened by two researchers for abstract and title, and then full-text. The quality of the studies was evaluated using the Newcastle-Ottawa Scale. The Cochran's Q test and I2 were used for assessing the potential heterogeneity of the studies. Publication bias was assessed using Egger's regression test and inspection of a funnel plot. A fixed-effects meta-analysis model was used to compute the effect of pregnancy intention on the completion of the maternity continuum of care.

RESULTS

Ten studies involving 343,932 participants were included in the final analysis. The pooled estimate of the meta-analysis found that women with intended pregnancy had 2.12 times higher odds of completing the maternity continuum of care (pooled odds ratio: 2.12, 95% CI: 1.33, 3.36) as compared to women with unintended pregnancy.

CONCLUSION

Intended pregnancy has a statistically significant positive effect on completing the maternity continuum of care. Policymakers and healthcare providers need to implement strategies to encourage women to plan their pregnancies through the strengthening of pre-conception care and contraceptive counselling to prevent unintended pregnancies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023409134.

Supporting contraceptive self-care and reproductive empowerment with a digital health game in Barbados: Development and Pre-implementation study for What's My Method?

Effective contraceptive education is essential to reducing unwanted pregnancy, increasing uptake of modern contraceptive methods, and thoughtfully planning desired births. New World Health Organization (WHO) and family planning organization guidelines recommend situating contraceptive education and counseling within a broader context of self-care that emphasizes individual agency and reproductive empowerment. Digital health interventions, and games for health specifically, have been validated as effective and scalable tools for self-guided and interactive health education, especially among younger tech-savvy individuals. Barbados currently supplements provider-based contraceptive counseling with analog materials (pamphlets and posters) and informational videos that play on a screen in the waiting room. As part of an implementation framework, this study seeks to conduct a formative evaluation of the What's My Method? (WMM) game intervention as a tool to support contraceptive counseling and increase reproductive empowerment among childbearing persons in Barbados. We test-deployed the WMM game in Bridgetown, Barbados, conducting playtests and unstructured discussions with prototypes of the WMM game among three groups of stakeholders (youth contraception ambassadors: n=8; healthcare providers: n=7; and nursing students: n=27) to determine acceptability of the intervention, efficacy of the game as a learning tool, and willingness to adopt the tool in their healthcare context. Feedback on acceptability of the game was largely positive. Detailed constructive comments informed modifications and improvements to the game. The questionnaire used to assess contraceptive knowledge gain did not prove effective. Results indicate that the WMM game is well-received and accepted by the healthcare professionals who would be deploying it. This pilot testing has informed the design of the modified WMM for a randomized controlled trial (RCT) to test the deployment of the game in a healthcare setting.

Unplanned births and their effects on maternal Health: Findings from the Constances Cohort

Unplanned births remain relatively common, even in regions with high contraceptive prevalence and accessible abortion services, such as contemporary France. Previous studies have shown that unplanned births can have numerous negative consequences for the well-being of mothers and children, including poorer maternal health behaviors, delayed and insufficient prenatal care, and depression during or immediately after pregnancy. However, these studies do not provide conclusive evidence on whether the observed outcomes are a consequence of unplanned births or of the conditions in which they likely occur. Furthermore, scant attention has been given to other dimensions of maternal well-being, such as physical health. This study uses longitudinal data from the French Constances Cohort and applies fixed-effects event study models to examine how women's self-rated general health and risk of depressive symptoms are affected in the years following an unplanned birth. Results show that women who had an unplanned birth reported a sudden, significant drop in their general health in the year following the birth, particularly among the youngest, while health outcomes following planned births showed a gradual, slight decrease over the time-period considered. The risk of depressive symptoms increased similarly after birth for both unplanned and planned births. This study contributes to the literature by using a longitudinally constructed measure of unplanned births based on pre-birth fertility intentions, rather than commonly used retrospective measures prone to ex post rationalization. It also distinguishes between unwanted and mistimed births while further examining their consequences on medium-term maternal health.

Examining subjective well-being during pregnancy and its association with pregnancy intendedness among women in Nigeria: A population-based cross-sectional multilevel study

In this study, we examined the patterns of subjective well-being (SWB) measures among pregnant women and quantified the extent to which pregnancy intendedness is associated with low SWB measures during pregnancy. We analyzed data from the 2021 Nigeria Multiple Indicator Cluster Survey comprising 3,491 pregnant women. The associations between pregnancy intention and low SWB measures (unhappiness, low life satisfaction [LS] and diminished optimism) were determined by fitting series of multilevel logistic regression models with random intercepts. Among pregnant women in our sample 20%, 37.5% and 9.6%, reported being unhappy, experiencing low LS and having diminished optimism, respectively. However, we found no significant association between pregnancy intention and being unhappy (mistimed: adjusted odds ratio [aOR] = 1.19, 95% CI = 0.88-1.60; unwanted: aOR = 1.16, 95% CI = 0.71-1.91), experiencing low LS (mistimed: aOR = 1.07, 95% CI = 0.83-1.37; unwanted: aOR = 1.06, 95% CI = 0.69-1.65) and having diminished optimism (mistimed: aOR = 1.22, 95% CI = 0.82-1.82; unwanted: aOR = 1.07, 95% CI = 0.56-2.04). Findings from the study suggest that pregnant women in Nigeria who reported having either a mistimed or unwanted pregnancy were just as likely to report being unhappy, experience low LS and have diminished optimism as women whose pregnancy was intended.

Spatial heterogeneity in unintended pregnancy and its determinants in India

BACKGROUND

Understanding the geographic variation of unintended pregnancy is crucial for informing tailored policies and programs to improve maternal and child health outcomes. Although spatial analyses of unintended pregnancy have been conducted in several developing countries, such research is lacking in India. This study addresses this gap by investigating the geographic distribution and determinants of unintended pregnancy in India.

METHODS

We analysed data from the National Family Health Survey-5 encompassing 232,920 pregnancies occurring between 2014 and 2021 in India. We conducted a spatial analysis to investigate the distribution of unintended pregnancies at both state and district levels using choropleth maps. To assess spatial autocorrelation, Global Moran's I statistic was employed. Cluster and outlier analysis techniques were then utilized to identify significant clusters of unintended pregnancies across India. Furthermore, we employed Spatial Lag Model (SLM) and Spatial Error Model (SEM) to investigate the factors influencing the occurrence of unintended pregnancies within districts.

RESULTS

The national rate of unintended pregnancy in India is approximately 9.1%, but this rate varies significantly between different states and districts of India. The rate exceeded 10% in the states situated in the northern plain such as Haryana, Delhi, Uttar Pradesh, Bihar, and West Bengal, as well as in the Himalayan states of Himachal Pradesh, Uttarakhand, Sikkim, and Arunachal Pradesh. Moreover, within these states, numerous districts reported rates exceeding 15%. The results of Global Moran's I indicated a statistically significant geographical clustering of unintended pregnancy rates at the district level, with a coefficient of 0.47 (p < 0.01). Cluster and outlier analysis further identified three major high-high clusters, predominantly located in the districts of Arunachal Pradesh, northern West Bengal, Bihar, western Uttar Pradesh, Haryana, Delhi, alongside a few smaller clusters in Odisha, Madhya Pradesh, Uttarakhand, and Himachal Pradesh. This geographic clustering of unintended pregnancy may be attributed to factors such as unmet needs for family planning, preferences for smaller family sizes, or the desire for male children. Results from the SEM underscored that parity and use of modern contraceptive were statistically significant predictors of unintended pregnancy at the district level.

CONCLUSION

Our analysis of comprehensive, nationally representative data from NFHS-5 in India reveals significant geographical disparities in unintended pregnancies, evident at both state and district levels. These findings underscore the critical importance of targeted policy interventions, particularly in geographical hotspots, to effectively reduce unintended pregnancy rates and can contribute significantly to improving reproductive health outcomes across the country.

Pattern of contraceptive use among reproductive-aged women with disabilities in Bangladesh: Evidence from multiple indicator cluster survey 2019

BACKGROUND

Contraception is crucial for reproductive-aged women with disabilities, empowering them to manage reproductive choices and enhancing overall health, autonomy, and well-being.

OBJECTIVE

The objective of this study was to examine the usage patterns of contraceptive methods among reproductive-aged women with disabilities in Bangladesh.

METHODS

We analyzed data from 47,465 reproductive-aged women from the 2019 Bangladesh Multiple Indicator Cluster Survey. Outcome variables included contraceptive usage patterns, grouped into any contraceptive methods, any modern contraceptive methods, and any traditional contraceptive methods. The primary explanatory variable considered was disabilities level (women with no disabilities, women with moderate disabilities, and women with severe disabilities), along with types of disabilities. A multilevel mixed-effects logistic regression model was used to assess associations between outcomes and explanatory variables while accounting for confounding.

RESULTS

The prevalence of any contraceptive methods use was 66.4 %, declining to 54 % among women with severe disabilities. The odd of modern contraception use was 31 % lower (aOR, 0.69, 95 % CI, 0.65-0.73) among women with moderate disabilities and 47 % lower (aOR, 0.53, 95 % CI, 0.47-0.60) among those with severe disabilities, compared to women with no disabilities. Within the individual domains of disabilities, those with vision, walking, cognitive, and self-care-related disabilities reported lower odds of modern contraception uptake than those with no disabilities.

CONCLUSIONS

The study highlights that women with disabilities use contraceptives less often, increasing vulnerability to unintended and short interval pregnancies and unsafe abortion. Strengthening family planning and prioritizing women with disabilities for modern contraceptives are vital.

Long-term effects of unintended pregnancy on children: Findings from the Dutch prospective birth-cohort Amsterdam born children and their development study

Several studies investigated short-term risks of children born from unintended pregnancies, however evidence about long-term risks is lacking. We aimed to examine whether children born from unintended pregnancies experience psychosocial problems up into adolescence. This study is based on the longitudinal birth cohort study 'Amsterdam Born Children and their Development' (n = 7784). Unintended pregnancy was measured as a multidimensional construct, based on self-reports on the extent of pregnancy mistiming ('This pregnancy happened too soon'), unwantedness ('I did not want to be pregnant (anymore)') and unhappiness ('I am happy to be pregnant'; recoded). Further, children's psychosocial problems were measured with the Strengths and Difficulties Questionnaire, at 5-6, 11-12 and 15-16 years old. Multiple over-time associations between unintended pregnancy and children's psychosocial problems were analysed using Structural Equation Modelling, while controlling for confounders. Results showed that pregnancy mistiming was a significant predictor of internalizing (β = 0.10, p < 0.001) and externalizing problems (β = 0.07, p = 0.006) and unwanted pregnancy of internalizing problems (β = 0.13, p < 0.001) at 5-6 years. These associations were substantially mediated by maternal mental health and poorer maternal bonding. Associations were no longer present at 11-12 and 15-16 years. Thus, we conclude that children born from unintended pregnancies experience more psychosocial problems at 5-6 years, but no longer at 11-12 and 15-16 years. Unintended pregnancies often coincide with maternal mental health problems and socioeconomic factors. Most importantly, the associations between unintended pregnancy and children's psychosocial problems are influenced by maternal mental health and poorer bonding. Therefore it is important to improve maternal mental health and bonding for the benefit of both mother and child, rather than on the isolated effect of unintended pregnancy per se.

Knowledge gaps related to HIV and condom use for preventing pregnancy: a cross-sectional study among migrants in Sweden

BACKGROUND

Information and knowledge of sexual and reproductive health and rights (SRHR) plays a crucial role in promoting safe sexual practices among young migrants. We aimed to assess the sociodemographic factors of migrants associated with knowledge of condoms and the prevention, treatment, and transmission of HIV to highlight the need for SRHR information, including comprehensive sexual health education.

METHODS

A cross-sectional survey was conducted (2018-2019) among migrants at Swedish language schools and high schools across Sweden. The survey included questions about knowledge of condom use for preventing pregnancy and HIV treatment and transmission. Descriptive statistics were calculated, and multivariable logistic regression analyses were performed to assess the responses to the knowledge questions and sociodemographic characteristics.

RESULTS

Out of 3430 respondents (median age: 35, interquartile range: 20), approximately 39% were unaware that condoms can prevent unplanned pregnancies. Only 58% of the respondents knew that condoms reduce the risk of contracting HIV. About 77% were unaware of HIV treatment, and 52% reported not knowing that a woman with HIV could transmit the virus to her baby during pregnancy or breastfeeding. Incorrect knowledge about condom use to prevent unwanted pregnancy was associated with several factors: younger age (15-19 years) adjusted odds ratio (aOR) 1.35; 95% confidence interval (CI), 1.02-1.79); female respondents (aOR: 1.68; 95% CI 1.36-2.07); lack of previous sexual health education (aOR: 2.57; 95% CI 2.11-3.13); low level of education (aOR: 1.30; 95% CI 1.04-1.61). Originating from the Americas, European, or sub-Saharan African regions was associated with a 34-42% decreased likelihood of incorrect knowledge that condoms can reduce the risk of HIV infection compared to respondents from the Middle East and North Africa (MENA). More than half (64%) of respondents reported needing more SRHR information.

CONCLUSIONS

We found significant knowledge gaps on HIV and condom use for preventing pregnancy among migrants in Sweden. Comprehensive sexual health education in language schools, along with information to newly arrived migrants from diverse regional backgrounds and targeted sexual health services to younger individuals, women, and those who lack sexual health education, are needed to address these information gaps and provide crucial SRHR education and information.

Association between Abortion and All-Cause and Cause-Specific Premature Mortality: A Prospective Cohort Study from the UK Biobank

Background: Concerns have been raised about the increasing prevalence of both spontaneous and induced abortions worldwide, yet their effect on premature mortality remains poorly understood. We aimed to examine the associations between abortion and all-cause and cause-specific premature mortality, and the potential effect modification by maternal characteristics. Methods: Women aged 39 to 71 years at baseline (2006 to 2010) with prior pregnancies were derived from the UK Biobank and categorized as no abortion history, spontaneous abortion alone, induced abortion alone, and both spontaneous and induced abortions. All-cause and cause-specific mortality were ascertained through linkage to death certificate data, with premature death defined as occurring before the age of 70. Results: Of the 225,049 ever gravid women, 43,418 (19.3%) reported spontaneous abortion alone, 27,135 (12.1%) reported induced abortion alone, and 10,448 (4.6%) reported both spontaneous and induced abortions. During a median of 14.4 years of follow-up, 5,353 deaths were recorded, including 3,314 cancer-related and 1,444 cardiovascular deaths. Compared with no abortion history, spontaneous abortion alone was associated with an increased risk of all-cause premature mortality (adjusted hazard ratio [aHR] 1.10, 95% confidence interval [CI] 1.02 to 1.17), and induced abortion alone was associated with increased risks of all-cause (aHR 1.12, 95% CI 1.04 to 1.22) and cardiovascular mortality (aHR 1.27, 95% CI 1.09 to 1.48). The aHRs for all-cause and cardiovascular mortality were higher for recurrent abortions, whether spontaneous or induced (P trend < 0.05). The increased risk of all-cause mortality associated with induced abortion was higher in women with hypertensive disorders of pregnancy than in those without (40% vs. 9%, P interaction = 0.045). Conclusions: Either spontaneous or induced abortion alone was associated with an increased risk of premature mortality, with induced abortion alone particularly linked to cardiovascular death. Future studies are encouraged to explore the underlying mechanisms.

Scoping review of qualitative studies on family planning in Uganda

Family planning (FP) is an essential component of public health programs and significantly impacts maternal and child health outcomes. In Uganda, there is a need for a comprehensive review of the existing literature on FP to inform future research and programmatic efforts. This scoping review aims to identify factors shaping the use of FP in Uganda. We conducted a systematic search of eight scholarly databases, for qualitative studies on FP in Uganda. We screened the titles and abstracts of identified articles published between 2002-2023 and assessed their eligibility based on predefined criteria. We extracted data from the 71 eligible studies and synthesized the findings using thematic analysis and the Ecological Systems Theory (EST) individual, interpersonal, community, institutional, and policy-level determinants. Findings reveal the interplay of factors at different socio-ecological levels influencing family planning decisions. At the individual level, the most common determinants related to the EST were knowledge and attitudes of FP. Interpersonal dynamics, including partner communication and social support networks, played pivotal roles. Community-level factors, such as cultural norms and accessibility of services, significantly influenced family planning practices. Institutional and policy-level factors, particularly a healthcare system's quality and policies, also shaped use. Other themes included the intersection of HIV/AIDS on FP practice and Ugandan views of comprehensive abortion care. This scoping review underscores the intricate socio-ecological fabric shaping FP in Uganda. The findings highlight the need for targeted interventions to increase knowledge and awareness of FP, improve access to services, and address social and cultural norms that discourage contraceptive use. Policymakers and program implementers should also consider gender dynamics and power imbalances in FP programs to ensure they are equitable and effective.

Do women with a previous unintended birth subsequently experience missed opportunities for postpartum family planning counseling? A multilevel mixed effects analysis

Client-provider communication about family planning (FP) remains an important strategy for preventing unintended pregnancy. Yet, the literature lacks empirical studies examining whether and how women's intendedness of a recent pregnancy may impact subsequent receipt of FP counseling. We investigated whether the intendedness of a recent pregnancy is associated with subsequent missed opportunities (MOs) for FP counseling, taking into account compositional and contextual factors. We performed a secondary analysis using pooled data from the 2016, 2017 and 2018 Performance Monitoring and Accountability 2020 cross-sectional surveys conducted in Nigeria, adjusting for complex design effects. Weighted multilevel logistic regression modeling was used to examine the relationships between pregnancy intention and MOs, overall and at the health facility, using two-level random intercept models. In the analytic sample of women within 24 months postpartum (N = 6479), nearly 60% experienced MOs for FP counseling overall and even 45% of those who visited a health facility visit in the past 12 months (N = 4194) experienced MOs. In the multivariable models adjusted for individual-/household- and community-level factors, women whose recent birth was either mistimed or unwanted were just as likely to have MOs for FP counseling as their counterparts whose pregnancy was intended (p > 0.05). Factors independently associated with a MOs include individual/household level factors such as level of education, exposure to FP media, household wealth index and contextual-level variables (geographic region). While evidence that pregnancy intendedness is associated with MOs for FP counseling remains inconclusive, efforts to mitigate these MOs requires prioritizing women's prior pregnancy intentions as well as equipping healthcare providers with the capacity need to provide high-quality client-centered FP counseling, particularly for women whose recent birth was unintended.

Landscape assessment of the availability of medical abortion medicines in India

BACKGROUND

Medical abortion with mifepristone and misoprostol can be provided up to 63 days' gestation in India. This accounts for 67.5 percent of all abortions in the country. We conducted an assessment to determine the availability of medical abortion medicines, specifically the combi-pack, in India.

METHODS

We applied the World Health Organization landscape assessment protocol at the national level. The assessment protocol included a five-step adaptation of an existing availability framework, including online data collection, desk review, country-level key informant interviews, and an analysis to identify barriers and opportunities to improve medical abortion availability. The assessment was conducted between August and March 2021.

RESULTS

Medicines for medical abortion are included in the national essential drug list and available with prescription in India. The assessment identified 42 combi-pack products developed by 35 manufacturers. The quality of medical abortion medicines is regulated by national authorities; but as health is devolved to states, there are significant inter-state variations. This is seen across financing, procurement, manufacturing, and monitoring mechanisms for quality assurance of medical abortion medicines prior to distribution. There is a need to strengthen supply chain systems, ensure consistent availability of trained providers and build community awareness on use of medical abortion medicines for early abortions, at the time of the assessment.

CONCLUSION

Opportunities to improve availability and quality of medical abortion medicines exist. For example, uniform implementation of regulatory standards, greater emphasis on quality-assurance during manufacturing, and standardizing of procurement and supply chain systems across states. Regular in-service training of providers on medical abortion is required. Finally, innovations in evidence dissemination and community engagement about the recently amended abortion law are needed.

Challenges to epilepsy management in Rwandan women living with epilepsy

BACKGROUND AND PURPOSE

In Rwanda, epilepsy prevalence ranges between 29‰ and 49‰. Many women living with epilepsy (WwE) are of childbearing age. Epilepsy characteristics and management, contraception, pregnancy, puerperium and stigma in WwE presenting at the neurology clinic of Ndera, Rwanda, were investigated.

METHODS

This prospective cross-sectional study investigated demographics, epilepsy characteristics, treatment, contraception, folic acid use, pregnancy, puerperium and stigma in WwE aged ≥18 years. Subgroups were analysed by status of any pregnancy and time of epilepsy diagnosis relative to pregnancy, with significant differences expected.

RESULTS

During December 2020 and January 2021, a hundred WwE were enrolled (range 18-67 years). Fifty-two women had never been pregnant, 39 women had epilepsy onset before pregnancy and nine were diagnosed after pregnancy. No significant differences in age, marital status or occupation were observed. Contraception was used by 27%, of whom 50% were taking enzyme-inducing anti-epileptic medication. Valproate was used by 46% of WwE of reproductive age. Thirty-nine women with epilepsy onset before pregnancy reported 91 pregnancies, with 14% spontaneous abortions. None used folic acid before conception, and 59% only during pregnancy. Five of 78 newborns were preterm. No offspring had major congenital malformations. Nearly 25% of WwE were not compliant with their anti-epileptic medication schedule during pregnancy or breastfeeding. Internalized stigma was observed in more than 60%. Up to 25% had been discriminated against at school or work.

CONCLUSION

A comprehensive strategy considering the reproductive health and societal challenges of WwE is needed to drive optimal epilepsy management, reproductive health outcomes and societal inclusion.

The impact of early death on birth counts in the United States, 1950 to 2019

In a previous issue of PNAS Nexus, Bor et al. quantified the number of "missing Americans"-the deaths that would have been averted if the United States had experienced the mortality conditions of other wealthy nations. In 2019 alone, their estimates indicate that more than 100,000 individuals in reproductive ages (15-49 years) would have survived. The concept of the "missing Americans" is a valuable one, but here we argue that it is incomplete because it does not include children that would have been born to those who died an early death. We examine 3 indicators to assess the strength of the mortality-fertility nexus at the population level, showing that mortality more negatively affects birth counts in the United States than in other wealthy nations. Using the mortality conditions in other wealthy nations as a reference, we estimate that between 2010 and 2019 alone, approximately 200,000 children were not born in the United States due to the premature death of their potential mothers. Our findings highlight that improving morbidity and mortality among people of reproductive age-without compromising their reproductive autonomy-is critical in the United States.

PROTOCOL: Abortion and mental health outcomes: A systematic review and meta-analysis

This is a protocol for a systematic review and meta-analysis of research on mental health outcomes of abortion. Does abortion increase the risk of adverse mental health outcomes? That is the central question for this review. Our review aims to inform policy and practice by locating, critically appraising, and synthesizing empirical evidence on associations between abortion and subsequent mental health outcomes. Given the controversies surrounding this topic and the complex social, political, legal, and ideological contexts in which research and reviews on abortion are conducted, it is especially important to conduct this systematic review and meta-analysis with comprehensive, rigorous, unbiased, and transparent methods. We will include a variety of study designs to enhance understanding of studies' methodological strengths and weaknesses and to identify potential explanations for conflicting results. We will follow open science principles, providing access to our methods, measures, and results, and making data available for re-analysis.

Using the behaviour change wheel to examine facilitators and barriers to assertive contraception-use conversations for Indonesian women

Contraception-use communication between sexual partners is important to reduce unwanted pregnancies and protect sexual and reproductive health. There is a dearth of research focused on developing countries where sexual and reproductive health conversations are often considered taboo. Using the Behaviour Change Wheel, this qualitative study examines the facilitators and barriers to having assertive contraception-use conversations with a male partner for Indonesian women and then identifies behaviour change techniques as potential intervention strategies. Semi-structured interviews were conducted with ten Indonesian women aged 18 to 29 years who had been sexually active and were currently in a committed dating relationship with a male partner. Using thematic analysis, 13 themes were identified. Facilitators of assertive contraception-use communication include knowledge about sexual and reproductive health and contraception, communication skills, closeness of the relationship with one's partner, other people's experiences of sex and contraception, and social media norms concerning the open discussion of sex and contraception. Fear of initiating the conversation about contraception was a barrier. Partner's attitude towards having contraception-use conversations and the taboos surrounding contraception in Indonesian culture acted as both facilitators and barriers. Suggested strategies to promote contraception-use communication include using social media to break the stigma surrounding sexual and reproductive health matters, normalising assertive conversations about contraceptive use with sexual partners, empowering women to be more assertive about their preferences for contraception, and teaching strategies to promote assertive contraception-use communication among young women and men in Indonesia.

Respectful Abortion Care initiative: How a large-scale virtual training for providers in India increased knowledge of the new 2021 Medical Termination of Pregnancy Act

BACKGROUND

In a historic move to ensure comprehensive abortion care, India amended the 1971 Medical Termination of Pregnancy (MTP) Act in 2021, creating an unprecedented opportunity for accelerating safe, respectful, and rights-based abortion services. The Federation of Obstetric and Gynecological Societies of India (FOGSI), together with World Health Organization (WHO) India and the Ministry of Health and Family Welfare, set up a flagship initiative "Respectful Abortion Care" (RAC) to provide training to obstetricians and gynecologists on the new Act, and also address their values and biases.

METHODS

Virtual training sessions were organized during the COVID-19 pandemic to disseminate the amendments made under the MTP Act and address provider values and biases. The primary focus was on private providers as they account for more than half of all abortion services in India (52.9%). The RAC modules were systematically designed and delivered by 690 Master Trainers, trained by FOGSI and WHO.

RESULTS

A total of 9051 FOGSI members (22%, with 50% from private clinics) completed the RAC trainings. Pretests and post-tests were conducted for impact assessment. Significant improvement was seen on knowledge of criteria for termination of pregnancy for significant birth defects (52%-83%). The post-training survey showed a high level of commitment to promote RAC: >95% were strongly motivated to perform or assist in abortion; 89% reported that the WHO value clarification exercises were helpful in facilitating open discussions on sensitive topics in a comfortable manner; 96% expressed a strong commitment to addressing the issue of respect and confidentiality in abortion care.

CONCLUSION

RAC was a unique initiative around the MTP Act amendment 2021 in India, which demonstrated that collaboration and leadership by professional associations can help motivate providers and lead to improved knowledge and commitment from public and private sector providers.

The science of uncertainty guides fetal-neonatal neurology principles and practice: diagnostic-prognostic opportunities and challenges

Fetal-neonatal neurologists (FNNs) consider diagnostic, therapeutic, and prognostic decisions strengthened by interdisciplinary collaborations. Bio-social perspectives of the woman's health influence evaluations of maternal-placental-fetal (MPF) triad, neonate, and child. A dual cognitive process integrates "fast thinking-slow thinking" to reach shared decisions that minimize bias and maintain trust. Assessing the science of uncertainty with uncertainties in science improves diagnostic choices across the developmental-aging continuum. Three case vignettes highlight challenges that illustrate this approach. The first maternal-fetal dyad involved a woman who had been recommended to terminate her pregnancy based on an incorrect diagnosis of an encephalocele. A meningocele was subsequently identified when she sought a second opinion with normal outcome for her child. The second vignette involved two pregnancies during which fetal cardiac rhabdomyoma was identified, suggesting tuberous sclerosis complex (TSC). One woman sought an out-of-state termination without confirmation using fetal brain MRI or postmortem examination. The second woman requested pregnancy care with postnatal evaluations. Her adult child experiences challenges associated with TSC sequelae. The third vignette involved a prenatal diagnosis of an open neural tube defect with arthrogryposis multiplex congenita. The family requested prenatal surgical closure of the defect at another institution at their personal expense despite receiving a grave prognosis. The subsequent Management of Myelomeningocele Study (MOMS) would not have recommended this procedure. Their adult child requires medical care for global developmental delay, intractable epilepsy, and autism. These three evaluations involved uncertainties requiring shared clinical decisions among all stakeholders. Falsely negative or misleading positive interpretation of results reduced chances for optimal outcomes. FNN diagnostic skills require an understanding of dynamic gene-environment interactions affecting reproductive followed by pregnancy exposomes that influence the MPF triad health with fetal neuroplasticity consequences. Toxic stressor interplay can impair the neural exposome, expressed as anomalous and/or destructive fetal brain lesions. Functional improvements or permanent sequelae may be expressed across the lifespan. Equitable and compassionate healthcare for women and families require shared decisions that preserve pregnancy health, guided by person-specific racial-ethnic, religious, and bio-social perspectives. Applying developmental origins theory to neurologic principles and practice supports a brain health capital strategy for all persons across each generation.

Avortement au Maroc et virage au drame : femmes et professionnels de santé en parlent ! Une étude transversale mixte à Agadir

RésuméLes avortements à risque constituent une problématique majeure de santé publique, responsable de la mortalité et de la morbidité maternelles et absorbant les ressources des systèmes de santé publique à l'échelle mondiale. Malgré l'ampleur très probable du problème de l'avortement non sécurisé au Maroc, peu de données sont accessibles sur cette question. Cette recherche vise à analyser la situation de l'avortement du point de vue des femmes et des professionnels de santé dans la préfecture d'Agadir Idaoutanane au Sud du Maroc. Nous avons conduit une étude transversale mixte. De janvier à septembre 2018, 266 femmes ont été recrutées pour répondre à un questionnaire, et 45 entretiens avec les femmes et les professionnels de la santé impliqués dans la santé sexuelle et reproductive (SSR) ont été menés. Nous avons procédé à une analyse descriptive des données quantitatives et à une analyse de contenu thématique des données recueillies par les entretiens individuels. Les résultats de l'étude révèlent que les avortements sont la conjugaison de plusieurs facteurs multidimensionnels. Le manque d'informations en SSR et l'échec de la contraception sont les facteurs majeurs de grossesses non désirées. L'avortement provoqué est un sujet tabou, fortement stigmatisant, portant à l'image sociale de la personne. L'accessibilité aux services d'avortement est marquée de grandes disparités et de trajectoires différentes. Cette étude apporte une contribution à l'analyse du phénomène de l'avortement au Maroc et appelle à une action politique urgente sur plusieurs niveaux: l'accès aux programmes d'éducation sexuelle et à la contraception appropriée, l'élargissement des indications d'avortement préconisées dans le projet de loi, la mise en place des stratégies de lutte contre la stigmatisation de l'avortement par les professionnels de santé et l'accès à des soins post-avortement de haute qualité.

A scoping review of qualitative studies on sexual and reproductive health and rights in Uganda: Exploring factors at multiple levels

BACKGROUND

Uganda is burdened by high unintended and teen pregnancies, high sexually transmitted infections, and harm caused by unsafe abortion.

OBJECTIVES

Explore factors influencing sexual and reproductive health and rights (SRHR) in Uganda by synthesizing evidence from qualitative studies using a scoping review.

ELIGIBILITY CRITERIA

Original qualitative peer-reviewed research studies published between 2002 and 2023 in any language exploring factors influencing SRHR in Uganda.

SOURCES OF EVIDENCE

Eight databases searched using qualitative/mixed methods search filters and no language limits.

CHARTING METHODS

Information extracted included author, article title, publication year, study aims, participant description, data collection type, sample size, main findings, factors at the individual, interpersonal, community, and policy levels, implications for SRHR in Uganda, and study limitations. Quality of the selected articles was assessed using the Critical Appraisal Skills Programme tool.

RESULTS

One hundred seventy-three studies met inclusion criteria. At the individual level, knowledge and attitudes toward SRHR, risky sexual behavior, and access to maternal SRHR services were identified as critical factors influencing health outcomes. Interpersonal factors included communication with sexual partners and relationships with family, school, and community members. Healthcare organization factors included adolescent access to education, SRHR services, and HIV prevention. Cultural and social factors included gendered norms and male involvement in SRHR. Policy-level factors included the importance of aligning policy and practice.

CONCLUSIONS

Multiple factors at individual, interpersonal, community, healthcare, cultural, and policy levels were found to influence SRHR in Uganda. The findings suggest that interventions targeting multiple levels of the socio-ecological system may be necessary to improve SRHR outcomes. This review highlights the need for a holistic approach that considers the broader socio-ecological context. Reducing identified gaps in the literature, particularly between policy and practice related to SRHR, is urgently needed in Uganda. We hope this review will inform the development of policies and interventions to improve SRHR outcomes.

Pregnancy termination and determinant factors among women of reproductive age in Kenya, evidence from Kenyan Demographic and Health Survey 2022: Multilevel analysis

BACKGROUND

Pregnancy termination is one of the common causes of maternal mortality, particularly in developing countries, and remains a global public health concern despite the efforts made to enhance maternal healthcare services. Maternal mortality is still the highest in sub-Saharan Africa, including Kenya, due to pregnancy termination.

OBJECTIVES

This study aimed to investigate the current burden of pregnancy termination and its determinants among reproductive-age women in Kenya.

DESIGN

A cross-sectional study design with multilevel analysis.

METHODS

The total weighted samples of 19,530 women of reproductive age were included in this study. The data were taken from the Kenyan Demographic and Health Survey 2022. A multilevel multivariable logistic regression model was used to identify the determinant factors of pregnancy termination. In the multivariable multilevel analysis, the adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to declare significant determinants of pregnancy termination among women of reproductive age.

RESULTS

The overall prevalence of pregnancy termination among women of reproductive age in Kenya was 14.19%. The determinant factors associated with pregnancy termination were the age of the women; as age increased, the risk of pregnancy termination increased, 25-29 years (AOR = 2.23; 95 CI (1.08-4.60)), 30-34 years (AOR = 2.98; 95% CI (1.43-6.18)), 35-39 years (AOR = 3.24; 95% CI (1.55-6.76)), 40-44 years (AOR = 4.57; 95% CI (2.16-9.68)), 45- 49 years (AOR = 5.16; 95% CI (2.33-9.98)); marital status: married (AOR = 5.63; 95% CI (3.08-10.29)), ever married (AOR = 5.05; 95% CI (2.74-9.33)); wealth index: richest (AOR = 1.32; 95% CI (1.05-1.63)); employment status: employed (AOR = 1.23; 95% CI (1.09-1.38)); preceding birth interval: greater than 24 months (AOR = 1.21; 95% CI (1.06-1.38)); urban residence (AOR = 1.25; 95% CI (1.06-1.46)); and Islamic followers (AOR = 1.64; 95% CI (1.31-2.06)).

CONCLUSION

Pregnancy termination among women of reproductive age in Kenya has become an important public health concern. Policymakers and other stakeholders should focus on maternal healthcare service programs to prevent the termination of pregnancy. The determinant factors are an important input to developing strategies to improve the accessibility of maternal healthcare services in the country.

Pregnancy Desirability and Motivational Readiness for Postpartum Contraceptive Use: Findings from Population-Based Surveys in Eight Sub-Saharan African Countries

This study examined the associations between pregnancy intention and motivational readiness for postpartum contraceptive use. Data for this cross-sectional analysis were derived from nationally representative surveys of the Performance Monitoring and Accountability 2020 (PMA2020) project conducted in eight sub-Saharan African countries. Participants included 9488 nonpregnant women of reproductive age (15-49 years) who had given birth in the last 2 years. Weighted multinomial logistic regression analyses were performed to estimate the odds ratios (OR) and their corresponding 95% confidence intervals (CIs) of the associations of motivational readiness for contraceptive adoption categorized as precontemplation, contemplation, and post-action with pregnancy intention. After adjusting for confounding factors, the findings revealed that women in Côte d'Ivoire and Nigeria who had mistimed pregnancies had significantly higher odds of being in the contemplation vs. precontemplation stage compared to those who had intended pregnancies. Similarly, women who had unwanted pregnancies in Ethiopia were also more likely to be in the contemplation stage. Furthermore, significant differences were observed for women in Burkina Faso, Côte d'Ivoire, and Nigeria regarding the association between mistimed pregnancies and being in the post-action stage. For women who had unwanted pregnancies, this association was significant only in Nigeria. Additionally, the odds of being in the contemplation stage, compared to the post-action stage, for women who had unwanted pregnancies were significantly higher in Ethiopia and Nigeria. These results indicate that recent unintended pregnancies in specific sub-Saharan African countries may motivate women to take action to prevent future unintended pregnancies. The findings underscore the importance of tailored and context-specific approaches in family-planning programs based on the stage of motivational readiness.

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

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

The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries

Previous studies have found high levels of unintended pregnancy among female sex workers (FSW), but less attention has been paid to their abortion practices and outcomes. This study is the first to investigate abortion-related mortality among FSW across eight countries: Angola, Brazil, Democratic Republic of Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa. The Community Knowledge Approach (CKA) was used to survey a convenience sample of FSW (n = 1280). Participants reported on the deaths of peer FSW in their social networks during group meetings convened by non-governmental organisations (n = 165 groups, conducted across 24 cities in 2019). Details on any peer FSW deaths in the preceding five years were recorded. The circumstances of abortion-related deaths are reported here. Of the 1320 maternal deaths reported, 750 (56.8%) were due to unsafe abortion. The number of abortion-related deaths reported was highest in DRC (304 deaths reported by 270 participants), Kenya (188 deaths reported by 175 participants), and Nigeria (216 deaths reported by 312 participants). Among the abortion-related deaths, mean gestational age was 4.6 months and 75% occurred outside hospital. Unsafe abortion methods varied by country, but consumption of traditional or unknown medicines was most common (37.9% and 29.9%, respectively). The 750 abortion-related deaths led to 1207 children being left motherless. The CKA successfully recorded a stigmatised practice among a marginalised population, identifying very high levels of abortion-related mortality. Urgent action is now needed to deliver comprehensive sexual and reproductive healthcare to this vulnerable population, including contraption, safe abortion, and post-abortion care.

Patient Perspectives on Contraceptive use in North India: A Case for Increased Contraceptive Counseling by Providers

Background

Given the underutilization of contraception in India, this study was undertaken to gauge cisgender female clients' knowledge of, attitudes toward, and barriers to contraceptive usage in North India.

Methodology

The present study was done at a tertiary care Institute in North India, where 209 structured interviews were conducted with cisgender female patients attending the outpatient department. One-way chi-square tests for independence, Kruskal-Wallis test, and Wilcoxon test were applied to quantitative data. Themes from qualitative questions were coded and analyzed.

Results

Differences in awareness among contraceptives were found to be highly statistically significant (H (9) = 1022.3, p < 2.2 e-16). Friends or colleagues comprised the predominant information source for most contraceptive methods. Participants' contraceptive usage was low, with 27.27% stating no prior use and 47.47% indicating occasional use (X2 (3, N = 198) = 66.121, p < 2.89 e-14). Lack of perceived need, concern for side effects, fear and desire for children were top reasons for non-use of contraceptive methods. Majority of the participants (79.45%) expressed comfort speaking with their spouse about contraception, 47.18% with a medical provider, 32.82% with friends, 15.38% with family, 2.05% with a health educator, and 3.59% with no one. Participants indicated little prior contraceptive counseling experience.

Conclusion

Our study shows differential levels of awareness, usage, and barriers on contraceptive methods among participants. Results also suggest the importance of spouses and friends in clients' contraceptive decision-making process and their limited counseling experience with health care providers.

Do Indian women know about and use the emergency contraceptive pill? An analysis of nationally representative data from 2005-06 and 2019-21

The emergency contraceptive pill (ECP) is a post-coital contraceptive method that prevents unintended pregnancy and is useful in specific circumstances. This study examined the awareness and use of the ECP in India, as there is scarce evidence in this area to guide policy development. This study used data from the 2005-06 (n = 124 385) and 2019-21 (n = 724 115) rounds of the National Family Health Survey of India. Bivariate analysis and multivariate logistic regression were applied to explore how demographic characteristics including age, education (none, primary, secondary, higher), wealth quintile, place of residence (urban, rural), marital status, parity, desire for children, whether current pregnancy was wanted, whether the women had had an abortion in the past 5 years, and whether current use of contraceptive methods affected the likelihood of knowledge and use of ECP. In the past 15 years, knowledge of ECP has increased by 37 percentage points but still remains relatively low at 48%. Less than 1% of the sample (0.55%) used ECP. Women aged 30-34 years, from wealthier and more educated backgrounds, living in urban areas, and currently using condoms had a higher likelihood of using ECP in comparison with women from age group 15-19 years, those from the poorest backgrounds, those with no education, those living in rural areas and those not using any contraceptive method, respectively. In comparison to married women, never-married women exhibited a higher awareness of ECP but lower use. More efforts must be made to improve awareness of the ECP, especially among adolescents, those with less education, poorer women and those in rural areas. The government is taking steps to improve access to ECP, and India's female community health workers, the ASHAs, could be further supported to enhance awareness of ECP.

Health workers' experience of providing second-trimester abortion care in Ethiopia: a qualitative study

BACKGROUND

Second-trimester abortions are less common than abortions in the first trimester, yet they disproportionately account for a higher burden of abortion-related mortality and morbidity worldwide. Health workers play a crucial role in granting or denying access to these services, yet little is known about their experiences. Ethiopia has been successful in reducing mortality due to unsafe abortion over the past decade, but access to second trimester abortion remains a challenge. The aim of this study is to better understand this issue by exploring the experiences of second-trimester abortion providers working in Addis Ababa, Ethiopia.

METHODS

A qualitative study with 13 in-depth semi-structured interviews with 16 health workers directly involved in providing second-trimester abortions, this included obstetrician and gynaecologist specialists and residents, general practitioners, nurses, and midwives. Data was collected at four public hospitals and one non-governmental clinic in Addis Ababa, Ethiopia and analysed using Malterud's text-condensation method.

RESULTS

The providers recognized the critical need for second-trimester abortion services and were motivated by their empathy towards women who often sought care late due to marginalisation and poverty making it difficult to access abortion before the second trimester. However, service provision was challenging according to the providers, and barriers like lack of access to essential drugs and equipment, few providers willing to conduct abortions late in pregnancy and unclear guidelines were commonly experienced. This led to highly demanding working conditions. The providers experienced ethical dilemmas pertaining to the possible viability of the fetus and women desperately requesting the service after the legal limit.

CONCLUSIONS

Second-trimester abortion providers faced severe barriers and ethical dilemmas pushing their moral threshold and medical risk-taking in efforts to deliver second-trimester abortions to vulnerable women in need of the service. Effort is needed to minimize health system barriers and improve guidelines and support for second-trimester abortion providers in order to increase access and quality of second-trimester abortion services in Ethiopia. The barriers forcing women into second trimester abortions also need to be addressed.

Associations between unintended fatherhood and paternal mental health problems: A systematic review and meta-analysis

BACKGROUND

Unintended pregnancies are linked to adverse parental mental health, yet little attention has been given to this relationship in fathers specifically. We aimed to meta-analyse associations between unintended pregnancies and mental health problems in fathers with children aged ≤36 months.

METHODS

We conducted keyword searches of Medline, CINAHL, Academic Search Complete, PsycInfo and Embase to February 2, 2022, and hand searched included reference lists.

RESULTS

Of 2826 records identified, 23 studies (N = 8085 fathers), reporting 29 effects, were eligible for meta-analysis. Included studies assessed depression, anxiety, stress, parenting stress, post-traumatic stress disorder (PTSD), alcohol misuse and psychological distress. Pooled estimates, from random effects meta-analyses, for all mental health outcomes (k = 29; OR = 2.28) and depression only (k = 19; OR = 2.36), showed that the odds of reporting mental health difficulties were >2-fold higher in men reporting unintended births compared with those reporting intended births. However, there was no evidence of association with anxiety (k = 2) or stress (k = 2). Overall, mental health problems were greater in low-income countries. No differences were found across parity, timepoint of mental health assessment, or instruments used to measure mental health symptoms.

LIMITATIONS

Analyses were limited by the use of retrospective assessment of pregnancy intention, and heterogeneity of measures used. Further, assessment of fathers' mental health was restricted to the first year postpartum. This review was limited to English language studies.

CONCLUSIONS

Unintended pregnancies present an identifiable risk for postpartum mental health problems in fathers.

Abortion incidence and safety in Niger in 2021: Findings from a nationally representative cross-sectional survey of reproductive-aged women using direct and indirect measurement approaches

Niger is a country in which legal restrictions and a dearth of research has long limited our understanding of the extent and safety of induced abortion. The current study is the first national study of induced abortion in Niger. It uses direct (self-report) and indirect (best friend method) to provide nationally representative estimates of induced abortion incidence and safety and evaluates the performance of the indirect measurement approach. We used cross-sectional, representative survey data on women aged 15-49 in Niger collected between January and May 2022; final sample included 3,696 women. The survey included questions on respondents' and their closest female friends' experience with abortion, including methods and sources used. We calculated one-year abortion incidence and the proportion of abortions involving non-recommended methods and/or sources to determine safety separately for respondents and friends, overall and by background characteristics. The fully adjusted one-year friend abortion rate was 6.7 abortions per 1,000 women in 2021, which was substantially higher than the corresponding respondent rate of 0.4 per 1,000 women. Confidence intervals were wide, but friend estimates suggest higher abortion rates among women in their 20s, those with secondary or higher education, and those with no children. Nearly all abortions were unsafe (97% respondents, 100% friends), involving non-recommended methods and/or sources. While abortion numbers were small, unsafe abortion appeared more common among older women, married women, those with children, and those residing in rural areas. Our findings indicate that, despite legal restrictions, some women undergo abortions in Niger at great risk to their physical safety. Ensuring adequate access to quality voluntary family planning services to prevent unintended pregnancy and postabortion care to treat complications is essential to reducing the risk of unsafe abortion in the country.

Extra-legal abortion and post-abortion care knowledge, attitudes, and practices among obstetrician-gynecologist clinicians and medical residents in San José, Costa Rica: a qualitative study

BACKGROUND

Induced abortion in Costa Rica is illegal in all cases except to save the life of the pregnant person. Despite severe restrictions to legal abortion, individuals in Costa Rica still induce abortions outside of the formal healthcare system. These individuals and those with spontaneous abortions, also known as miscarriages, occasionally need medical care for complications. In Costa Rica, an estimated 41% of unintended pregnancies end in abortion, yet there is very little published literature exploring the perspectives of healthcare providers on abortion in Costa Rica.

METHODS

We interviewed ten obstetrician-gynecologist clinicians and five obstetrician-gynecologist medical residents in San José, Costa Rica about their beliefs and practices related to extra-legal abortion and post-abortion care (PAC) using a Spanish language in-depth semi-structured interview guide. After transcription and translation into English, analysis team pairs used a combination of deductive and inductive coding to identify themes and sub-themes within the data.

RESULTS

Obstetrician-gynecologist clinicians and medical residents were aware of the presence of extra-legal abortion, and particularly, medication abortion, in their communities, but less familiar with dosing for induction. They expressed the desire to provide non-judgmental care and support their patients through extra-legal abortion and PAC journeys. Study participants were most familiar with providing care to individuals with spontaneous abortions. When discussing PAC, they often spoke about a policy of reporting individuals who seek PAC following an extra-legal abortion, without commenting on whether or not they followed the guidance.

CONCLUSIONS

This study contributes to a gap in research about the knowledge, attitudes, and practices of Costa Rican obstetrician-gynecologist clinicians and medical residents around extra-legal abortion and PAC. The results reveal an opportunity to train these healthcare providers as harm reduction experts, who are able to accurately counsel individuals who are seeking abortion services outside of the healthcare system, and to provide training to improve care for individuals needing PAC.

Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys

Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda.

Interactions of the male contraceptive target EPPIN with semenogelin-1 and small organic ligands

Novel male contraceptives will promote gender equality in sharing contraceptive responsibility. The sperm-associated protein epididymal protease inhibitor (EPPIN) is a promising target for non-hormonal male contraception. EPPIN interacts with the semen coagulum protein semenogelin-1 (SEMG1) on the sperm surface, leading to transient inhibition of sperm motility after ejaculation. Small organic molecules targeting EPPIN's SEMG1-binding are under development as male contraceptives. Here, we combined computational approaches to uncover key aspects underlying EPPIN binding to SEMG1 and small organic ligands. We generated a human EPPIN model showing a typical arrangement of the WFDC (Whey-acid four disulfide core)-type and Kunitz-type domains, connected by a hinge region. Determining the EPPIN model's intrinsic motion by molecular dynamics simulations and normal mode analysis revealed a conformation, presenting a binding pocket that accommodates SEMG1Glu229-Gln247, EP055, and EP012. EPPIN's residues Phe63 and Lys68 (WFDC domain), Asp71 (hinge region), and Asn113, Asn114, and Asn115 (Kunitz domain) were identified as hot spots for SEMG1, EP055, and EP012 binding. Moreover, hydrophobic and hydrophilic residues in the WFDC and Kunitz domains allow plasma membrane anchoring, orienting the EPPIN binding pocket to the solvent. Targeting EPPIN's essential residues for its biomolecular interactions may improve the rational design of EPPIN ligands as spermiostatic compounds.