The Shift From Criminalization to Legalization of Abortion in Argentina

This Viewpoint discusses passage and implementation of Law 27.610, which legalized abortion in Argentina under certain circumstances, and examines the ongoing clinical issues and legal challenges to the law.

Key drivers of fertility levels and differentials in India, at the national, state and population subgroup levels, 2015-2016: An application of Bongaarts' proximate determinants model

OBJECTIVES

The transition to small family size is at an advanced phase in India, with a national TFR of 2.2 in 2015-16. This paper examines the roles of four key determinants of fertility-marriage, contraception, abortion and postpartum infecundability-for India, all 29 states and population subgroups.

METHODS

Data from the most recent available national survey, the National Family Health Survey, conducted in 2015-16, were used. The Bongaarts proximate determinants model was used to quantify the roles of the four key factors that largely determine fertility. Methodological contributions of this analysis are: adaptations of the model to the Indian context; measurement of the role of abortion; and provision of estimates for sub-groups nationally and by state: age, education, residence, wealth status and caste.

RESULTS

Nationally, marriage is the most important determinant of the reduction in fertility from the biological maximum, contributing 36%, followed by contraception and abortion, contributing 24% and 23% respectively, and post-partum infecundability contributed 16%. This national pattern of contributions characterizes most states and subgroups. Abortion makes a larger contribution than contraception among young women and better educated women. Findings suggest that sterility and infertility play a greater than average role in Southern states; marriage practices in some Northeastern states; and male migration for less-educated women. The absence of stronger relationships between the key proximate fertility determinants and geography or socio-economic status suggests that as family size declined, the role of these determinants is increasingly homogenous.

CONCLUSIONS

Findings argue for improvements across all states and subgroups, in provision of contraceptive care and safe abortion services, given the importance of these mechanisms for implementing fertility preferences. In-depth studies are needed to identify policy and program needs that depend on the barriers and vulnerabilities that exist in specific areas and population groups.

Association of Travel Distance to Nearest Abortion Facility With Rates of Abortion

IMPORTANCE

Travel distance to abortion services varies widely in the US. Some evidence shows travel distance affects use of abortion care, but there is no national analysis of how abortion rate changes with travel distance.

OBJECTIVE

To examine the association between travel distance to the nearest abortion care facility and the abortion rate and to model the effect of reduced travel distance.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional geographic analysis used 2015 data on abortions by county of residence from 1948 counties in 27 states. Abortion rates were modeled using a spatial Poisson model adjusted for age, race/ethnicity, marital status, educational attainment, household poverty, nativity, and state abortion policies. Abortion rates for 3107 counties in the 48 contiguous states that were home to 62.5 million female residents of reproductive age (15-44 years) and changes under travel distance scenarios, including integration into primary care (<30 miles) and availability of telemedicine care (<5 miles), were estimated. Data were collected from April 2018 to October 2019 and analyzed from December 2019 to July 2020.

EXPOSURES

Median travel distance by car to the nearest abortion facility.

MAIN OUTCOMES AND MEASURES

US county abortion rate per 1000 female residents of reproductive age.

RESULTS

Among the 1948 counties included in the analysis, greater travel distances were associated with lower abortion rates in a dose-response manner. Compared with a median travel distance of less than 5 miles (median rate, 21.1 [range, 1.2-63.6] per 1000 female residents of reproductive age), distances of 5 to 15 miles (median rate, 12.2 [range, 0.5-23.4] per 1000 female residents of reproductive age; adjusted coefficient, -0.05 [95% CI, -0.07 to -0.03]) and 120 miles or more (median rate, 3.9 [range, 0-12.9] per 1000 female residents of reproductive age; coefficient, -0.73 [95% CI, -0.80 to -0.65]) were associated with lower rates. In a model of 3107 counties with 62.5 million female residents of reproductive age, 696 760 abortions were estimated (mean rate, 11.1 [range, 1.0-45.5] per 1000 female residents of reproductive age). If abortion were integrated into primary care, an additional 18 190 abortions (mean rate, 11.4 [range, 1.1-45.5] per 1000 female residents of reproductive age) were estimated. If telemedicine were widely available, an additional 70 920 abortions were estimated (mean rate, 12.3 [range, 1.4-45.5] per 1000 female residents of reproductive age).

CONCLUSIONS AND RELEVANCE

These findings suggest that greater travel distances to abortion services are associated with lower abortion rates. The results indicate which geographic areas have insufficient access to abortion care. Modeling suggests that integrating abortion into primary care or making medication abortion care available by telemedicine may decrease unmet need.

Changes to medication abortion clinical practices in response to the COVID-19 pandemic

OBJECTIVES

To document medication abortion clinical practice changes adopted by providers in response to the COVID-19 pandemic.

STUDY DESIGN

Longitudinal descriptive study, comprised of three online surveys conducted between April to December, 2020. We recruited sites from email lists of national abortion and family planning organizations.

RESULTS

Seventy-four sites opted to participate. We analyzed 55/74 sites (74%) that provided medication abortion and completed all three surveys. The total number of abortion encounters reported by the sites remained consistent throughout the study period, though medication abortion encounters increased while first-trimester aspiration abortion encounters decreased. In response to the COVID-19 pandemic, sites reduced the number of in-person visits associated with medication abortion and confirmation of successful termination. In February 2020, considered prepandemic, 39/55 sites (71%) required 2 or more patient visits for a medication abortion. By April 2020, 19/55 sites (35%) reported reducing the total number of in-person visits associated with a medication abortion. As of October 2020, 37 sites indicated newly adopting a practice of offering medication abortion follow-up with no in-person visits.

CONCLUSIONS

Sites quickly adopted protocols incorporating practices that are well-supported in the literature, including forgoing Rh-testing and pre-abortion ultrasound in some circumstances and relying on patient report of symptoms or home pregnancy tests to confirm successful completion of medication abortion. Importantly, these practices reduce face-to-face interactions and the opportunity for virus transmission. Sustaining these changes even after the public health crisis is over may increase patient access to abortion, and these impacts should be evaluated in future research.

IMPLICATIONS STATEMENT

Medication abortion serves a critical function in maintaining access to abortion when there are limitations to in-person clinic visits. Sites throughout the country successfully and quickly adopted protocols that reduced visits associated with the abortion, reducing in-person screenings, relying on telehealth, and implementing remote follow-up.

Experiences of women seeking post-abortion care services in a Regional Hospital in Ghana

Introduction

Abortions remain one of the highest contributors to maternal deaths in Ghana. In 2003, a policy on post-abortion care was introduced to help reduce abortion-related mortality and morbidity. However, depending on the method of pregnancy termination; women encounter varying experiences. This study examines the experiences of women seeking post-abortion care services in a Regional Hospital in Ghana.

Materials and methods

In-depth interview technique was used to collect data from 20 purposively selected post-abortion care clients at the Volta Regional Hospital. Data were analysed manually using a qualitative content analysis technique.

Results

The study found that medical abortion was the main method of pregnancy termination used by women who participated in the study to induce abortion. Spontaneous abortion, however, was attributed mainly to engaging in activities that required the use of excessive energy and travelling on bad roads by pregnant women. The study also revealed that, women do not seek early post-abortion care services due to stigma and poverty.

Conclusions

We found that severity of pain from complications, stigma and financial constraints were factors that influenced women’s decision to seek post-abortion care services. Our findings also suggest that women who experienced spontaneous abortion mainly received financial and emotional support from partners and other family members. To encourage women to seek early post-abortion care services, the Ministry of Health and the Ghana Health Service should take pragmatic steps to educate women on the dangers associated with delay in seeking post-abortion care services and the factors that expose women to spontaneous abortions.

From Embryotomy to Cesarean: Changes in Obstetric Operatory Techniques in Nineteenth- and Twentieth-Century Urban Brazil

This article traces the historical processes by which Brazil became a world leader in cesarean sections. It demonstrates that physicians changed their position toward and use of different obstetric surgeries, in particular embryotomies and cesarean sections, over the course of the nineteenth and twentieth centuries. The authors demonstrate that Catholic obstetricians, building upon both advancements in cesarean section techniques and new civil legislation that gave some personhood to fetuses, began arguing that fetal life was on par with its maternal counterpart in the early twentieth century, a shift that had a lasting impact on obstetric practice for decades to come. In the second half of the twentieth century, cesarean sections proliferated in clinical practice, but abortions remained illegal. Most importantly, women remained patients to be worked on rather than active participants in their reproductive lives.

Simultaneous compared to interval administration of mifepristone and misoprostol for medical abortion up to 10+0 weeks' gestation: a systematic review with meta-analyses

BACKGROUND

Medical abortion with mifepristone and misoprostol usually involves an interval of 36-48 hours between administering these drugs; however, it is possible that the clinical efficacy at early gestations may be maintained when the drugs are taken simultaneously. The objective of this systematic review was to determine the safety and effectiveness of simultaneous compared with interval administration of mifepristone and misoprostol for abortion up to 10⁺⁰ weeks' gestation.

METHODS

We searched Embase Classic, Embase; Ovid MEDLINE(R) including Daily, and Epub Ahead-of-Print, In-Process & Other Non-Indexed Citations; and Cochrane Library on 11 December 2019. We included randomised controlled trials (RCTs), published in English from 1985, comparing simultaneous to interval administration of mifepristone and misoprostol for early abortion. Risk of bias was assessed using the Cochrane Collaboration checklist for RCTs. Meta-analysis of risk ratios (RRs) using the Mantel-Haenszel method were performed. The quality of the evidence was assessed using GRADE.

RESULTS

Meta-analyses of three RCTs (n=1280) showed no differences in 'ongoing pregnancy' (RR 1.78, 95% CI 0.38 to 8.36), 'haemorrhage requiring transfusion or ≥500 mL blood loss' (RR 0.11, 95% CI 0.01 to 2.03) and 'incomplete abortion with the need for surgical intervention' (RR 1.30, 95% CI 0.76 to 2.25) between the interventions. Individual study results showed no difference in patient satisfaction, or 'need for repeat misoprostol', although 'time to onset of bleeding or cramping' was longer after simultaneous than interval administration. The quality of evidence was very low to moderate.

CONCLUSION

The published data support the use of simultaneous mifepristone and misoprostol for medical abortion up to 9⁺⁰ weeks in women who prefer this method of administration.

What does informal access to misoprostol in Colombia look like? A mystery client methodology in Bogotá and the Coffee Axis

INTRODUCTION

In 2006, abortion was decriminalised in Colombia under certain circumstances. Yet, women avail themselves of ways to terminate pregnancy outside of the formal health system. This study explored how drug sellers engage with women who attempt to purchase misoprostol from them.

METHODS

A mapping exercise was undertaken to list small-chain and independent drug stores in two regions in Colombia. A sample (n=558) of drug stores was selected from this list and visited by mystery clients between November and December 2017. Mystery clients sought to obtain a medication to bring back a delayed period, and described the experience, the information obtained and the medications proffered in exit interviews.

RESULTS

Misoprostol was offered for purchase in 15% of the visits; in half of visits, only information about misoprostol was shared, while no information about misoprostol was provided on the remaining visits. Over half of sellers who refused to sell any medication provided referrals, most commonly to an abortion provider. Among visits which included discussion of misoprostol, two out of five sellers provided dosage instructions with most recommending the minimum adequate dosage. Mystery clients received little information on the physical effects to expect with the use of misoprostol and possible complications.

CONCLUSIONS

As misoprostol is being obtained from some drug sellers without a prescription, capacitating this cadre with at least a minimum of standardised information on dosage, routes of administration and expected effects and outcomes have the potential to improve reproductive health outcomes for women who choose to terminate pregnancies this way in Colombia.

Trends and predictors of changes in modern contraceptive use among women aged 15-49 years in Tanzania from 2004-2016: Evidence from Tanzania Demographic and Health Surveys

Introduction

Modern contraceptive use provides opportunities for women and couples to achieve optimal child spacing, achieve desired family size and reduce unsafe abortions. Despite these facts, modern contraceptive prevalence rate (mCPR) in Tanzania remains as low as 32%. This study aimed to determine trends and factors associated with changes in modern contraceptive use among women of reproductive age in Tanzania from 2004–2016.

Methodology

This was a cross-sectional study utilizing data from Tanzania Demographic and Health Surveys of 2004–2005, 2010 and 2015–2016. Data analysis was performed using Stata version 14. Analysis considered the complex survey design through application of weights, clustering and strata. Multivariable Poisson decomposition analysis was used to assess factors associated with changes in modern contraceptive use. Results were presented in the form of decomposition coefficients and percentages.

Results

Modern contraceptive use increased from 23.0% in 2004 to 34.3% in 2016. Differences in women’s characteristics contributed 12.5% of the increase in mCPR. These characteristics include partner’s education levels, recent sexual activity and being visited by a family planning worker. The difference in coefficients contributed 87.5% increase in mCPR. The most increase in modern contraceptive use was attributed to rural population (44.1%) and women who experienced a termination of pregnancy (7.1%).

Conclusion

Modern contraceptive use has steadily increased in Tanzania. Health policies and interventions need to target sexually active women, rural residents as well as less educated women and men to maintain and further accelerate the trends in mCPR. Interventions focusing on women who experienced a termination of pregnancy may also serve as an entry point to promote use of modern contraceptive methods.

Induced abortion incidence and safety in Côte d'Ivoire

Background

In Côte d’Ivoire, induced abortion is legally restricted unless a pregnancy threatens a woman’s life. Yet the limited available evidence suggests abortion is common and that unsafe abortion is contributing to the country’s high maternal mortality. Our study aimed to estimate the one-year incidence of induced abortion in Côte d’Ivoire using both direct and indirect methodologies, determine the safety of reported abortions, and identify the women most likely to experience a recent induced abortion or an unsafe abortion.

Methods

In 2018, we conducted a nationally representative, population-based survey of women age 15 to 49 in Côte d’Ivoire. Women reported their own abortion experiences and those of their closest female confidante. We estimated the one-year incidence of induced abortion, and the safety of the abortions women experienced. Using bivariate and multivariate regression, we separately assessed sociodemographic characteristics associated with having had a recent abortion or an unsafe abortion.

Results

Overall, 2,738 women participated in the survey, approximately two-thirds of whom reported on the abortion experiences of their closest female friend. Based on respondent data, the one-year incidence of induced abortion was 27.9 (95% CI 18.6–37.1) per 1,000 women of reproductive age, while the confidante incidence was higher at 40.7 (95% CI 33.3–48.1) per 1,000. Among respondents, 62.4% of abortions were most unsafe, while 78.5% of confidante abortions were most unsafe. Adolescents, less educated women, and the poorest women had the most unsafe abortions.

Conclusion

This study provides the first national estimates of induced abortion incidence and safety in Côte d’Ivoire, using a population-based approach to explore social determinants of abortion and unsafe abortion. Consistent with other research, our results suggest that legal restrictions on abortion in Côte d’Ivoire are not preventing women from having abortions, but rather pushing women to use unsafe, potentially dangerous abortion methods. Efforts to reduce the harms of unsafe abortion are urgently needed.

USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy

BACKGROUND

The Mexico City Policy, first announced by US President Ronald Reagan and since lifted and reinstated by presidents along partisan lines, prohibits US foreign assistance to any organisation that performs or provides counselling on abortion. Many organisations affected by this policy are also providers of modern contraception. If the policy reduces these organisations' ability to supply modern contraceptives, it could have the unintended consequence of increasing abortion rates.

METHODS

We empirically examined patterns of modern contraception use, pregnancies, and abortion among women in 26 countries in sub-Saharan Africa in response to the reinstatement and subsequent repeal of the Mexico City Policy across three presidential administrations (William Clinton, George W Bush, and Barack Obama). We combine individual-level data on pregnancies and abortions from 743 691 women, country-year data on modern contraception use, and annual data on development assistance for family planning and reproductive health in a difference-in-difference framework to examine relative changes in use of modern contraception, pregnancy, and abortion in response to the policy.

FINDINGS

We found that when the Mexico City Policy was in effect (2001-08), abortion rates rose among women in countries highly exposed to the policy by 4·8 abortions per 10 000 woman-years (95% CI 1·5 to 8·1, p=0·0041) relative to women in low-exposure countries and relative to periods when the policy was rescinded in 1995-2000 and 2009-14, a rise of approximately 40%. We found a symmetric reduction in use of modern contraception by 3·15 percentage points (relative decrease of 13·5%; 95% CI -4·9 to -1·4; p=0·0006) and increase in pregnancies by 3·2 percentage points (relative increase of 12%; 95% CI 1·6 to 4·8; p<0·0001) while the policy was enacted.

INTERPRETATION

Our findings suggest that curbing US assistance to family planning organisations, especially those that consider abortion as a method of family planning, increases abortion prevalence in sub-Saharan African countries most affected by the policy.

FUNDING

The William and Flora Hewlett Foundation, the Doris Duke Charitable Foundation, the David and Lucile Packard Foundation, and the Stanford Earth Dean's Fellowship.

Risk factors for voluntary interruption of pregnancy and possible preventive public health actions

Introduction

Voluntary interruption of pregnancy (VIP) is one of the most frequent healthcare procedures in the world and a Public Health concern in many countries, especially after liberalization of the abortion laws. The study has been carried out to identify the factors that still influence a fraction of female population towards abortion in the absence of fetal malformations.

Methods

We conducted a cross-sectional study in the period 2012-2016. The survey was carried out on all VIPs performed at the Gynecology and Obstetrics Unit of the University Hospital “G. Martino” in Messina, Italy.

Results

The analyzed sample consisted of 1131 women, aged between 16 and 50 years. Only 4% of VIPs was due to a diagnosis of fetal malformation. In relation to the presence or absence of fetal malformations as the possible reason for VIP, the sample was split up into two groups and the socio-demographic characteristics were considered. VIPs in the absence of malformations were significantly more frequent in younger women with a lower educational level, in unmarried and unemployed women and in women who already had children. These results were confirmed to Pearson test that indicated that all these variables were related to VIP in the absence of malformations.

Conclusions

Based on our results, it is crucial to further prevent requests for VIPs through information and sex education programs for adolescents in schools and consultants, and responsible procreation promotion programs.

Ectopic pregnancy incidence in the Republic of Korea in 2009-2015: A population-based cross-sectional study

We estimated the incidence of ectopic pregnancy (EP) and the success rate of expectant management of EP in South Korea. We analyzed data from 2009 to 2015 using the Health Insurance Review and Assessment Service National Inpatient Sample (HIRA-NIS) database. EP was identified by diagnostic codes, and strict EP was identified by both diagnostic codes and treatment codes. From 2009 to 2015, 369,701 cases of EP, abortion, or delivery were extracted from a total of 4,476,495 women. Of the total pregnancies, 8,556 cases were EPs. The incidence of EP was 34.1 ± 0.7 per 1,000 pregnancies and the incidence of strict EP was 17.3 ± 0.3 per 1,000 pregnancies. Among women aged 25-44 years, age was associated with a higher incidence of EP (odds ratio [OR]: 1.13; 95% confidence interval [CI]: 1.06, 1.19; P < 0.01). The incidence rates of EP (OR: 0.99; 95% CI: 0.97, 1.01; P = 0.51) did not significantly differ by year. The incidence of EP in Korea was 17.3 ± 0.3 per 1,000 pregnancies, and almost did not change over 7 years. About 50% of EPs were treated without surgery or methotrexate. This study provides an important reference for the treatment of EP.

Reported contraceptive use in the month of becoming pregnant among U.S. abortion patients in 2000 and 2014

OBJECTIVES

The objective was to determine whether types of contraceptive methods used by abortion patients in the month they became pregnant changed between 2000 and 2014.

STUDY DESIGN

We used secondary data from the 2000 (n=10,015) and 2014 (8177) Abortion Patient Surveys. Patients were asked which contraceptive methods they had last used and when they had stopped or if they were still using them. The main outcome variable was type of contraceptive method used in the month the pregnancy began. We used bivariate logistic regressions to assess changes in the demographic and contraceptive use profiles of abortion patients.

RESULTS

In both years, slightly more than half of patients reported that they had used a contraceptive method in the month they became pregnant, though the decline from 54% in 2000 to 51% in 2014 was statistically significant (p=.011). The methods most commonly reported to have been used in the month the pregnancy began were condoms (28% and 24% in 2000 and 2014, p<.001) followed by the pill (14% and 13%, p=.12). There was a statistically significant increase in the proportion of abortion patients who reported using long-acting reversible methods in the month they got pregnant (0.1% in 2000 vs. 1% in 2014, p<.001), and the estimated number of abortions attributed to these users was greater in 2014 than in 2000 (9500 vs. 1800).

CONCLUSIONS

Contraceptive use patterns of abortion patients were similar in both time periods, and changes in method use mirrored changes in contraceptive use among the larger population of women.

IMPLICATIONS

Postabortion contraception counseling has the potential to help nonusers find methods that meet their preferences and to help women better use their current methods.

ESHRE Capri Workshop Group. Induced abortion

Abortion is common. Data on abortion rates are inexact but can be used to explore trends. Globally, the estimated rate in the period 2010-2014 was 35 abortions per 1000 women (aged 15-44 years), five points less than the rate of 40 for the period 1990-1994. Abortion laws vary around the world but are generally more restrictive in developing countries. Restrictive laws do not necessarily deter women from seeking abortion but often lead to unsafe practice with significant mortality and morbidity. While a legal framework for abortion is a prerequisite for availability, many laws, which are not evidence based, restrict availability and delay access. Abortion should be available in the interests of public health and any legal framework should be as permissive as possible in order to promote access. In the absence of legal access, harm reduction strategies are needed to reduce abortion-related mortality and morbidity. Abortion can be performed surgically (in the first trimester, by manual or electric vacuum aspiration) or with medication: both are safe and effective. Cervical priming facilitates surgery and reduces the risk of incomplete abortion. Diagnosis of incomplete abortion should be made on clinical grounds, not by ultrasound. Septic abortion is a common cause of maternal death almost always following unsafe abortion and thus largely preventable. While routine follow-up after abortion is unnecessary, all women should be offered a contraceptive method immediately after the abortion. This, together with improved education and other interventions, may succeed in reducing unintended pregnancy.

Does the Use of Unreliable Contraceptive Methods Increase the Number of Abortions? Results from a National Survey of Women in the United States

In this study the authors assessed the association between the types contraceptive use (unreliable or traditional methods vs. modern methods) and number of abortions among a nationally representative sample of abortion patients in the United States from the Abortion Patients Survey 2008. Unadjusted and adjusted prevalence ratios were calculated to determine the association between unreliable contraceptive methods and number of abortions. Results from the unadjusted and adjusted prevalence ratios revealed that women who used modern methods of contraception were more likely to have had previous abortions compared to women who did not use contraceptives and those who used traditional methods of contraception. Implications for practice, policy, and the role of social workers are discussed.

Trends in Abortion Incidence and Availability in North Carolina, 1980-2013

OBJECTIVES

Abortion incidence has declined nationally during the last decade. In recent years, many states, including North Carolina, have passed legislation related to the provision of abortion services. Despite the changing political environment, there is no comprehensive analysis on past and current trends related to unintended pregnancy and abortion in North Carolina.

METHODS

This study is a secondary analysis of vital registration data made publicly available by the North Carolina State Center for Health Statistics. Birth and induced abortion records were obtained for the years 1980 to 2013. We describe abortion incidence and demographic characteristics of women obtaining abortions over time.

RESULTS

The number of North Carolina abortions declined 36% between 1980 and 2013. The abortion ratio declined from 26/100 pregnancies (live births and abortions) in 1980 to just 14/100 in 2013. These ratios, however, vary across demographic subgroups. In 2013, the abortion ratio was more than 2 times greater for non-Hispanic black women than non-Hispanic white women (22 and 9, respectively). Among non-Hispanic black and Hispanic women, the abortion ratio is greater among women with a previous pregnancy as compared with women in their first pregnancy. For non-Hispanic white women, the abortion ratios are similar for first and higher-order pregnancies.

CONCLUSIONS

Trends in North Carolina are similar to national trends; however, detailed analyses by race/ethnicity, age, and parity demonstrate important distinctions among abortion patients over time in the state. We discuss these trends in relation to policy changes and increased access to effective contraceptives.

[The standard mid-pregnancy anomaly scan in the Netherlands: what is its effect?]

- The mid-pregnancy anomaly scan was introduced into the Netherlands in 2007. The scan is performed at 18- 21 weeks of pregnancy.- The detection rate of open spina bifida is 94%.- In the Netherlands, 60% of all congenital heart defects are diagnosed prenatally compared with 35-40% in other countries. There is a strong relationship between the severity of the heart defect and the detection rate, as more than 95% of all univentricular heart defects are detected.- The detection rate of isolated cleft lip and cleft palate has increased from 32% to 87%.- The absolute number of abortions has not increased since the implementation of the anomaly scan. However, perinatal morbidity and mortality have decreased.- To further increase the quality of the screening programme, prenatal and postnatal congenital defect registries should be linked and studies into the effect of intensive training of sonographists with modern teaching methods should be performed.

Incidence of Induced Abortion in Uganda, 2013: New Estimates Since 2003

BACKGROUND

In Uganda, abortion is permitted only when the life of a woman is in danger. This restriction compels the perpetuation of the practice in secrecy and often under unsafe conditions. In 2003, 294,000 induced abortions were estimated to occur each year in Uganda. Since then, no other research on abortion incidence has been conducted in the country.

METHODS

Data from 418 health facilities were used to estimate the number and rate of induced abortion in 2013. An indirect estimation methodology was used to calculate the annual incidence of induced abortions ─ nationally and by major regions. The use of a comparable methodology in an earlier study permits assessment of trends between 2003 and 2013.

RESULTS

In 2013, an estimated 128,682 women were treated for abortion complications and an estimated 314,304 induced abortions occurred, both slightly up from 110,000 and 294,000 in 2003, respectively. The national abortion rate was 39 abortions per 1,000 women aged 15-49, down from 51 in 2003. Regional variation in abortion rates is very large, from as high as an estimated 77 per 1,000 women 15-49 in Kampala region, to as low as 18 per 1,000 women in Western region. The overall pregnancy rate also declined from 326 to 288; however the proportion of pregnancies that were unintended increased slightly, from 49% to 52%.

CONCLUSION

Unsafe abortion remains a major problem confronting Ugandan women. Although the overall pregnancy rate and the abortion rate declined in the past decade, the majority of pregnancies to Ugandan women are still unintended. These findings reflect the increase in the use of modern contraception but also suggest that a large proportion of women are still having difficulty practicing contraception effectively. Improved access to contraceptive services and abortion-related care are still needed.

The Effects of Islam and Traditional Practices on Women’s Health and Reproduction

The aim of this study was to investigate the effects of Islam as a religion and culture on Turkish women’s health. The study included 138 household members residing in the territory of three primary health care centers in Turkey: Güzelbahçe, Fahrettin Altay and Esentepe. Data were collected by means of a questionnaire prepared by a multidisciplinary team that included specialists from the departments of public health, psychiatric nursing and sociology. We found that the women’s health behavior changed from traditional to rational as education levels increased, and that religious and traditional attitudes and behaviors were predominant in the countryside, especially practices related to pregnancy, delivery, the postpartum period, induced abortion and family planning. One of the most important prerequisites for the improvement of women’s health is that nurses should know the religious practices and culture of the society for which they provide care, so that their efforts to protect and improve women’s health will be effective.

[Contraception and abortion: an update in 2015]

Family doctors can play an important role in preventing unplanned pregnancies. This article addresses the different contraceptives methods available in Switzerland, which are classified in 2 groups and recommends using the GATHER approach (Greet, Ask, Tell, Help, Explain, Return) to promote compliance. LARC (long acting reversible contraceptives) can be recommended to any woman who needs a reliable birth control method. These contraceptives require minimum effort for high efficiency. Further explanation regarding the use of an emergency contraception must be provided when short action contraceptives are chosen. Switzerland's abortion rate is one of the lowest in the world. Medical abortion tends to be more and more prominent. Under certain circumstances, it can be self-administered at home.

[Bioethics is dead. Long live medical ethics!]

The purpose of this paper is to show a paradigmatic crisis in academic bioethics. Since an important part of bioethicists began to relativize the ethical prohibition of killing an innocent human being, one way or another they began to ally with the death industry: the business of abortion, and then that of euthanasia. The thesis of this paper is that by crossing that Rubicon bioethics has been corrupted and has lost its connection to the ethical, political and legal discourse. One can only hope that it will revive from its ashes if it retakes the ″taboo″ of the sacredness of human life, something for which medical ethics could provide invaluable help, because it still keeps the notion that ″a doctor should not kill″, although in an excessively ″discreet″ and somehow ″ashamed″ way. However, conscientious doctors know more about ethics than most bioethicists.

Reproductive health of adolescents in Russia: statistics, problems and prospects of improvement

At the beginning of the 21st century we still face the problem of reproductive health of women, children and adolescents in Russia. Final overcoming of the "Russian Cross" primarily relates to preventing further decline of women in reproductive age and children aged 0-17 years.The following medico-social determinants of women's reproductive health are considered: family prosperity, somatic growth and sexual maturation, chronic extragenital diseases, sexual and reproductive behavior, environmental wellbeing of territory and gynecological care organization. Analysis of gynecological morbidity of Russian girls and adolescents at the beginning of this century spots an upward trend. The results of our anonymous questionnaire survey of socially adapted students among 3327 girls of 13-19 years testify that 59.9% of respondents in this age cohort do not practice daily genitalia toilet. According to our population-based studies, 24.0% of women have first pregnancy at the juvenile age followed by labor in 18.4% of young women, abortion in 81.6%. Menstrual disorders represent the most common symptoms and strong indications of reproductive health problems related, inter alia, to progesterone deficiency which can lead to serious consequences (infertility, miscarriage, breast disease). The choice of medication for the menstrual disorders treatment should consider instruction indications, the lack of limitations and contraindications, need for contraception, concomitant diseases and states, proved efficacy of the medication. Prospects of solving reproductive and demographic problems in the twenty-first century are largely beyond the control of clinicians being aggravated by unresolved environmental and social problems.

Characteristics of Abortion Care Seekers in Western Nigeria

BACKGROUND

Induced abortion remains a major challenge in Nigeria and indeed the developing world because of its contribution to maternal morbidity and mortality. In Nigeria, abortion law is restrictive, and therefore abortion is provided clandestinely. Information on characteristics of abortion care seekers is available but requires updating. Hence, the need to carry out this study in order to suggest effective and proper intervention strategies to combat the problem of unwanted pregnancy and unsafe abortion.

STUDY DESIGN

This was a prospective hospital-based study. Data collection was done by making use of a pretested standardized questionnaire.

RESULTS

About two-fifths (42.8%) of the respondents were between the ages of 15 and 24 years, of which the adolescents between the ages of 15 and 19 years constituted 11.7%. Slightly less than half (48.4%) of the respondents were unmarried, while married women constituted 51%. Students were the single highest group (32.4%), closely followed by trading, which was the predominant economic activity (32.3%). Respondents terminated their pregnancies mainly because they were unmarried, students or did not desire to have children. Most of the respondents (43.4%) obtained abortion service from health facility they had used previously as a family clinic, while 38.6% of the women were introduced to providers by friends. Average contraceptive prevalence among the abortion care seekers was 29.9%.

CONCLUSION

Abortion needs cut across all reproductive age groups. Reproductive health services including sexuality education and contraception should be provided for women while major governmental policy changes should be made to make abortion care accessible and safe.

Abortion incidence and service availability in the United States, 2011

CONTEXT

Following a long-term decline, abortion incidence stabilized between 2005 and 2008. Given the proliferation of state-level abortion restrictions, it is critical to assess abortion incidence and access to services since that time.

METHODS

In 2012-2013, all facilities known or expected to have provided abortion services in 2010 and 2011 were surveyed. Data on the number of abortions were combined with population data to estimate national and state-level abortion rates. Incidence of abortions was assessed by provider type and caseload. Information on state abortion regulations implemented between 2008 and 2011 was collected, and possible relationships with abortion rates and provider numbers were considered.

RESULTS

In 2011, an estimated 1.1 million abortions were performed in the United States; the abortion rate was 16.9 per 1,000 women aged 15-44, representing a drop of 13% since 2008. The number of abortion providers declined 4%; the number of clinics dropped 1%. In 2011, 89% of counties had no clinics, and 38% of women of reproductive age lived in those counties. Early medication abortions accounted for a greater proportion of nonhospital abortions in 2011 (23%) than in 2008 (17%). Of the 106 new abortion restrictions implemented during the study period, few or none appeared to be related to state-level patterns in abortion rates or number of providers.

CONCLUSIONS

The national abortion rate has resumed its decline, and no evidence was found that the overall drop in abortion incidence was related to the decrease in providers or to restrictions implemented between 2008 and 2011.

Of paradox and plausibility: the dynamic of change in medical law

This article develops a model of change in medical law. Drawing on systems theory, it argues that medical law participates in a dynamic of 'deparadoxification' and 'reparadoxification' whereby the underlying contingency of the law is variously concealed through plausible argumentation, or revealed by critical challenge. Medical law is, thus, thoroughly rhetorical. An examination of the development of the law on abortion and on the sterilization of incompetent adults shows that plausibility is achieved through the deployment of substantive common sense and formal stylistic devices. It is undermined where these elements are shown to be arbitrary and constructed. In conclusion, it is argued that the politics of medical law are constituted by this antagonistic process of establishing and challenging provisionally stable normative regimes.

What happens the morning after? The costs and benefits of expanding access to emergency contraception

Emergency contraception (EC) can prevent pregnancy after sex, but only if taken within 72 hours of intercourse. Over the past 15 years, access to EC has been expanded at both the state and federal level. This paper studies the impact of those policies. We find that expanded access to EC has had no statistically significant effect on birth or abortion rates. Expansions of access, however, have changed the venue in which the drug is obtained, shifting its provision from hospital emergency departments to pharmacies. We find evidence that this shift may have led to a decrease in reports of sexual assault.

A disability critique of the new prenatal test for Down syndrome

This article presents evidence that the availability of a new noninvasive test for Down syndrome (known as "MaterniT21") could result in increased uptake of prenatal testing for Down syndrome and an increase in selective abortions of affected fetuses. I argue that people with Down syndrome and those sympathetic to them have reason to object to these developments because bias against cognitive disability is an influence on decisions to test and terminate for Down syndrome, and social practices motivated by bias are objectionable. The article addresses many of the challenges to the disability critique formulated by its detractors. I discuss whether the disability critique is the same as the "expressivist" objection to prenatal testing, the nature of the harm experienced by people with Down syndrome, and the link between prenatal testing and this harm.

[Phenomenon of induced abortion carried out by adolescents in Europe and Italy between 1980 and 2010]

AIM

We have performed an examination of databases and websites of statistical documentation available on the Internet to identify sources of information related to the phenomenon of induced abortion carried out by adolescents, to its trend over time and in different geographical areas, in order to verify changes versus analogies.

METHODS

The study was a collection of statistical data, describing the trend of induced abortions carried by teenagers, published by the open access resources on the Internet. The phenomenon was observed on two different units of analysis, women under the age of 20 versus 18 years, placed in space-time dimensions consisted of geographical areas of different sizes, Europe, Italy, Northern Italy, and Lombardy on the period 1980-2010. Sources showing information on the collection and processing of disseminated data were preferred.

RESULTS

During the examined period the data show the increase of voluntary terminations of pregnancy among adolescents in several European countries. In Northern Italy and Lombardy abortion rates were higher than in the national area. Changes in the characteristics presented by the samples emerged, consisting in the decrease of women in their late teens versus the increase of those in mean adolescence and the growth of women with foreign citizenship.

CONCLUSION

The use of statistical resources through the Internet has offered information to assist in identification of target populations on which to address intervention strategies for prevention. Useful to services in the choice of actions to combat the phenomenon of abortion and for the development of the skills required to teenagers from current demographic trends. In particular from abasement of age of first sexual intercourse, postponement of marriage and of first child to always higher age, the increase in migration flows.

The Groningen Protocol for newborn euthanasia; which way did the slippery slope tilt?

In The Netherlands, neonatal euthanasia has become a legal option and the Groningen Protocol contains an approach to identify situations in which neonatal euthanasia might be appropriate. In the 5 years following the publication of the protocol, neither the prediction that this would be the first step on a slippery slope, nor the prediction of complete transparency and legal control became true. Instead, we experienced a transformation of the healthcare system after antenatal screening policy became a part of antenatal care. This resulted in increased terminations of pregnancy and less euthanasia.

Changes in association between previous therapeutic abortion and preterm birth in Scotland, 1980 to 2008: a historical cohort study

BACKGROUND

Numerous studies have demonstrated that therapeutic termination of pregnancy (abortion) is associated with an increased risk of subsequent preterm birth. However, the literature is inconsistent, and methods of abortion have changed dramatically over the last 30 years. We hypothesized that the association between previous abortion and the risk of preterm first birth changed in Scotland between 1 January 1980 and 31 December 2008.

METHODS AND FINDINGS

We studied linked Scottish national databases of births and perinatal deaths. We analysed the risk of preterm birth in relation to the number of previous abortions in 732,719 first births (≥24 wk), adjusting for maternal characteristics. The risk (adjusted odds ratio [95% CI]) of preterm birth was modelled using logistic regression, and associations were expressed for a one-unit increase in the number of previous abortions. Previous abortion was associated with an increased risk of preterm birth (1.12 [1.09-1.16]). When analysed by year of delivery, the association was strongest in 1980-1983 (1.32 [1.21-1.43]), progressively declined between 1984 and 1999, and was no longer apparent in 2000-2003 (0.98 [0.91-1.05]) or 2004-2008 (1.02 [0.95-1.09]). A statistical test for interaction between previous abortion and year was highly statistically significant (p<0.001). Analysis of data for abortions among nulliparous women in Scotland 1992-2008 demonstrated that the proportion that were surgical without use of cervical pre-treatment decreased from 31% to 0.4%, and that the proportion of medical abortions increased from 18% to 68%.

CONCLUSIONS

Previous abortion was a risk factor for spontaneous preterm birth in Scotland in the 1980s and 1990s, but the association progressively weakened and disappeared altogether by 2000. These changes were paralleled by increasing use of medical abortion and cervical pre-treatment prior to surgical abortion. Although it is plausible that the two trends were related, we could not test this directly as the data on the method of prior abortions were not linked to individuals in the cohort. However, we speculate that modernising abortion methods may be an effective long-term strategy to reduce global rates of preterm birth.

Divergent trends in abortion and birth control practices in belarus, Russia and Ukraine

Context

The last decade witnessed growing differences in abortion dynamics in Belarus, Russia, and Ukraine despite demographic, social, and historical similarities of these nations. This paper investigates changes in birth control practices in the three countries and searches for an explanation of the diverging trends in abortion.

Methods

Official abortion and contraceptive use statistics, provided by national statistical agencies, were analysed. Respective laws and other legal documents were examined and compared between the three countries. To disclose inter-country differences in prevalence of the modern methods of contraception and its association with major demographic and social factors, an analysis of data from national sample surveys was performed, including binary logistic regression.

Results

The growing gap in abortion rate in Belarus, Russia, and Ukraine is a genuine phenomenon, not a statistical artefact. The examination of abortion and prevalence of contraception based on official statistics and three national sample surveys did not reveal any unambiguous factors that could explain differences in abortion dynamics in Belarus, Russia, and Ukraine. However, it is very likely that the cause of the inter-country discrepancies lies in contraceptive behavior itself, in adequacies of contraceptive knowledge and practices. Additionally, large differences in government policies, which are very important in shaping contraceptive practices of the population, were detected.

Conclusion

Since the end of the 1990s, the Russian government switched to archaic ideology in the area of reproductive health and family planning and neglects evidence-based arguments. Such an extreme turn in the governmental position is not observed in Belarus or Ukraine. This is an important factor contributing to the slowdown in the decrease of abortion rates in Russia.

Induced abortion: incidence and trends worldwide from 1995 to 2008

BACKGROUND

Data of abortion incidence and trends are needed to monitor progress toward improvement of maternal health and access to family planning. To date, estimates of safe and unsafe abortion worldwide have only been made for 1995 and 2003.

METHODS

We used the standard WHO definition of unsafe abortions. Safe abortion estimates were based largely on official statistics and nationally representative surveys. Unsafe abortion estimates were based primarily on information from published studies, hospital records, and surveys of women. We used additional sources and systematic approaches to make corrections and projections as needed where data were misreported, incomplete, or from earlier years. We assessed trends in abortion incidence using rates developed for 1995, 2003, and 2008 with the same methodology. We used linear regression models to explore the association of the legal status of abortion with the abortion rate across subregions of the world in 2008.

FINDINGS

The global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15-44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. The average annual percent change in the rate was nearly 2·4% between 1995 and 2003 and 0·3% between 2003 and 2008. Worldwide, 49% of abortions were unsafe in 2008, compared to 44% in 1995. About one in five pregnancies ended in abortion in 2008. The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05).

INTERPRETATION

The substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals.

FUNDING

UK Department for International Development, Dutch Ministry of Foreign Affairs, and John D and Catherine T MacArthur Foundation.

Why is the teen birth rate in the United States so high and why does it matter?

Teens in the United States are far more likely to give birth than in any other industrialized country in the world. U.S. teens are two and a half times as likely to give birth as compared to teens in Canada, around four times as likely as teens in Germany or Norway, and almost 10 times as likely as teens in Switzerland. Among more developed countries, Russia has the next highest teen birth rate after the United States, but an American teenage girl is still around 25 percent more likely to give birth than her counterpart in Russia. Moreover, these statistics incorporate the almost 40 percent fall in the teen birth rate that the United States has experienced over the past two decades. Differences across U.S. states are quite dramatic as well. A teenage girl in Mississippi is four times more likely to give birth than a teenage girl in New Hampshire--and 15 times more likely to give birth as a teen compared to a teenage girl in Switzerland. This paper has two overarching goals: understanding why the teen birth rate is so high in the United States and understanding why it matters. Thus, we begin by examining multiple sources of data to put current rates of teen childbearing into the perspective of cross-country comparisons and recent historical context. We examine teen birth rates alongside pregnancy, abortion, and "shotgun" marriage rates as well as the antecedent behaviors of sexual activity and contraceptive use. We seek insights as to why the rate of teen childbearing is so unusually high in the United States as a whole, and in some U.S. states in particular. We argue that explanations that economists have tended to study are unable to account for any sizable share of the variation in teen childbearing rates across place. We describe some recent empirical work demonstrating that variation in income inequality across U.S. states and developed countries can explain a sizable share of the geographic variation in teen childbearing. To the extent that income inequality is associated with a lack of economic opportunity and heightened social marginalization for those at the bottom of the distribution, this empirical finding is potentially consistent with the ideas that other social scientists have been promoting for decades but which have been largely untested with large data sets and standard econometric methods. Our reading of the totality of evidence leads us to conclude that being on a low economic trajectory in life leads many teenage girls to have children while they are young and unmarried and that poor outcomes seen later in life (relative to teens who do not have children) are simply the continuation of the original low economic trajectory. That is, teen childbearing is explained by the low economic trajectory but is not an additional cause of later difficulties in life. Surprisingly, teen birth itself does not appear to have much direct economic consequence. Moreover, no silver bullet such as expanding access to contraception or abstinence education will solve this particular social problem. Our view is that teen childbearing is so high in the United States because of underlying social and economic problems. It reflects a decision among a set of girls to "drop-out" of the economic mainstream; they choose non-marital motherhood at a young age instead of investing in their own economic progress because they feel they have little chance of advancement. This thesis suggests that to address teen childbearing in America will require addressing some difficult social problems: in particular, the perceived and actual lack of economic opportunity among those at the bottom of the economic ladder.