Can community health workers play a greater role in increasing access to medical abortion services? A qualitative study

Despite being legally available in India since 1971, barriers to safe and legal abortion remain, and unsafe and/or illegal abortion continues to be a problem. Community health workers have been involved in improving access to health information and care for maternal and child health in resource poor settings, but their role in facilitating accurate information about and access to safe abortion has been relatively unexplored. A qualitative study was conducted in Rajasthan, India to study acceptability, perspectives and preferences of women and community health workers, regarding the involvement of community health workers in medical abortion referrals.; In-depth interviews were conducted with 24 women seeking early medical abortion at legal abortion facilities or presenting at these facilities for a follow-up assessment after medical abortion. Ten community health workers who were trained to assess eligibility for early medical abortion and/or to assess whether women needed a follow-up visit after early medical abortion were also interviewed. The transcripts were coded using ATLAS-ti 7 (version 7.1.4) in the local language and reports were generated for all the codes, emerging themes were identified and the findings were analysed.; Community health workers (CHWs) were willing to play a role in assessing eligibility for medical abortion and in identifying women who are in need of follow-up care after early medical abortion, when provided with appropriate training, regular supplies and job aids. Women however had apprehensions about contacting CHWs in relation to abortions. Important barriers that prevented women from seeking information and assistance from community health workers were fear of breach of confidentiality and a perception that they would be pressurised to undergo sterilisation.; Our findings support a potential for greater role of CHWs in making safe abortion information and services accessible to women, while highlighting the need to address women's concerns about approaching CHWs in case of unwanted pregnancy. Further intervention research would be needed to shed light on the effectiveness of role of CHWs in facilitating access to safe abortion and to outline specific components in a programme setting.; Not applicable

Pregnancies, abortions, and pregnancy intentions: a protocol for modeling and reporting global, regional and country estimates

Background Estimates of pregnancies, abortions and pregnancy intentions can help assess how effectively women and couples are able to fulfil their childbearing aspirations. Abortion incidence estimates are also a necessary foundation for research on the safety of abortions performed and the consequences of unsafe abortion. Furthermore, periodic estimates of these indicators are needed to help inform policy and programmes. Methods We will develop a Bayesian hierarchical times series model which estimates levels and trends in pregnancy rates, abortion rates, and percentages of pregnancies and births unintended for each five-year period between 1990 and 2019. The model will be informed by data on abortion incidence and the percentage of births or pregnancies that were unintended. We will develop a data classification process to be applied to all available data. Model-based estimates and associated uncertainty will take account of data sparsity and quality. Our proposed approach will advance previous work in two key ways. First, we will estimate pregnancy and abortion rates simultaneously, and model the propensity to abort an unintended pregnancy, as opposed to modeling abortion rates directly as in prior work. Secondly, we will produce estimates that are reproducible at the country level by publishing the data inputs, data classification processes and source code. Discussion This protocol will form the basis for updated global, regional and national estimates of intended and unintended pregnancy rates, abortion rates, and the percent of unintended pregnancies ending in abortion, from 1990 to 2019

Formation of partnerships among young women and men in Pune district, Maharashtra

Young people in India face traditional age- and sex-stratified norms that espouse gender double standards. Premarital partnerships are taboo and anecdotal evidence suggests that in many settings in India, the hint of a romantic relationship or even social interaction between young girls and boys is sufficient to damage a family\u27s reputation and/or result in accelerated arranged marriage, particularly for the girl. While there is a prevailing perception at the community level that in these circumstances, premarital partnerships are rare, there is a small body of literature that suggests that such partnerships are indeed formed and sexual relations experienced, among, typically, fewer than 10 percent of young women and 15–30 percent of young men. At the same time, little is known about the lives of young people and the contexts in which they form romantic, marital, and other partnerships. This report describes the situation of young unmarried and married women and men aged 15–24 in rural and urban slum settings in India, namely Pune district, Maharashtra

The magnitude and severity of abortion-related morbidity in settings with limited access to abortion services:a systematic review and meta-regression

Introduction: Defining and accurately measuring abortion-related morbidity is important for understanding the spectrum of risk associated with unsafe abortion and for assessing the impact of changes in abortion-related policy and practices. This systematic review aims to estimate the magnitude and severity of complications associated with abortion in areas where access to abortion is limited, with a particular focus on potentially life-threatening complications. Methods: A previous systematic review covering the literature up to 2010 was updated with studies identified through a systematic search of Medline, Embase, Popline and two WHO regional databases until July 2016. Studies from settings where access to abortion is limited were included if they quantified the percentage of abortion-related hospital admissions that had any of the following complications: mortality, a near-miss event, haemorrhage, sepsis, injury and anaemia. We calculated summary measures of the percentage of abortion-related hospital admissions with each complication by conducting meta-analysis and explored whether these have changed over time. Results: Based on data collected between 1988 and 2014 from 70 studies from 28 countries, we estimate that at least 9% of abortion-related hospital admissions have a near-miss event and approximately 1.5% ends in a death. Haemorrhage was the most common complication reported; the pooled percentage of abortion-related hospital admissions with severe haemorrhage was 23%, with around 9% having near-miss haemorrhage reported. There was strong evidence for between-study heterogeneity across most outcomes. Conclusions: In spite of the challenges on how near miss morbidity has been defined and measured in the included studies, our results suggest that a substantial percentage of abortion-related hospital admissions have potentially life-threatening complications. Estimates that are more reliable will only be obtained with increased use of standard definitions such as the WHO near-miss criteria and/or better reporting of clinical criteria applied in studies

WHO Multi-Country Survey on Abortion-related Morbidity and Mortality in Health Facilities: study protocol

Introduction: According to the WHO, abortion accounts for about 8% (4.7–13.2) of maternal mortality worldwide. In 2010, the WHO Multi-Country Survey (MCS) on Maternal and Newborn Health collected data on over 300 000 women who were admitted in health facilities to receive pregnancy-related care. Abortion data were partially captured by centring on severe maternal outcomes (ie, near-miss or maternal deaths). Building on the experiences of the prior MCS as well as current WHO reproductive health projects, we are undertaking a multi-country survey to better capture the burden and severity of abortion-related complications and management among women presenting to the health facilities. Methods and analysis: This is a large cross-sectional study with prospective data collection. It will be implemented in health facilities in 30 countries across the WHO regions of Africa, Americas, Eastern Mediterranean, Europe, South East Asia and Western Pacific. Countries and facilities will be identified through a multistage sampling methodology. Data collection will be at both the facility and individual levels, involving review of medical records and exit surveys with eligible women using audio computer-assisted self-interview. All women presenting to the health facilities with signs and symptoms of abortion complications will comprise the study population. Online data entry and management will be performed on a web-based data management system. Analysis will include prevalence of abortion-related complications and descriptive frequencies of procedural/non-procedural management and experience of care. Ethics and dissemination: Ethical issues of the consent process are addressed. Dissemination plans will involve the participating facilities and communities to further strengthen abortion-related research capacity within the MCS on Abortion (MCS-A) countries. Furthermore, dissemination of results will be an iterative process at both the facility and national level to potentially propagate positive changes to abortion-related policies and practices

Abortion metrics: a scoping review of abortion measures and indicators.

Consensus is lacking on the most appropriate indicators to document progress in safe abortion at programmatic and country level. We conducted a scoping review to provide an extensive summary of abortion indicators used over 10 years (2008-2018) to inform the debate on how progress in the provision and access to abortion care can be best captured. Documents were identified in PubMed and Popline and supplemented by materials identified on major non-governmental organisation websites. We screened 1999 abstracts and seven additional relevant documents. Ultimately, we extracted information on 792 indicators from 142 documents. Using a conceptual framework developed inductively, we grouped indicators into seven domains (social and policy context, abortion access and availability, abortion prevalence and incidence, abortion care, abortion outcomes, abortion impact and characteristics of women) and 40 subdomains. Indicators of access and availability and of the provision of abortion care were the most common. Indicators of outcomes were fewer and focused on physical health, with few measures of psychological well-being and no measures of quality of life or functioning. Similarly, there were few indicators attempting to measure the context, including beliefs and social attitudes at the population level. Most indicators used special studies either in facilities or at population level. The list of indicators (in online supplemental appendix) is an extensive resource for the design of monitoring and evaluation plans of abortion programmes. The large number indicators, many specific to one source only and with similar concepts measured in a multitude of ways, suggest the need for standardisation

Accuracy of assessment of eligibility for early medical abortion by community health workers in Ethiopia, India and South Africa

Objective To assess the accuracy of assessment of eligibility for early medical abortion by community health workers using a simple checklist toolkit. Design Diagnostic accuracy study. Setting Ethiopia, India and South Africa. METHODS: Two hundred seventeen women in Ethiopia, 258 in India and 236 in South Africa were enrolled into the study. A checklist toolkit to determine eligibility for early medical abortion was validated by comparing results of clinician and community health worker assessment of eligibility using the checklist toolkit with the reference standard exam. RESULTS: Accuracy was over 90% and the negative likelihood ratio <0.1 at all three sites when used by clinician assessors. Positive likelihood ratios were 4.3 in Ethiopia, 5.8 in India and 6.3 in South Africa. When used by community health workers the overall accuracy of the toolkit was 92% in Ethiopia, 80% in India and 77% in South Africa negative likelihood ratios were 0.08 in Ethiopia, 0.25 in India and 0.22 in South Africa and positive likelihood ratios were 5.9 in Ethiopia and 2.0 in India and South Africa. CONCLUSION: The checklist toolkit, as used by clinicians, was excellent at ruling out participants who were not eligible, and moderately effective at ruling in participants who were eligible for medical abortion. Results were promising when used by community health workers particularly in Ethiopia where they had more prior experience with use of diagnostic aids and longer professional training. The checklist toolkit assessments resulted in some participants being wrongly assessed as eligible for medical abortion which is an area of concern. Further research is needed to streamline the components of the tool, explore optimal duration and content of training for community health workers, and test feasibility and acceptability

A prospective study of complications from comprehensive abortion care services in Nepal

<p>Abstract</p> <p>Background</p> <p>In March 2002, Nepal's Parliament approved legislation to permit abortion on request up to 12 weeks of pregnancy. Between 2004 and 2007, 176 comprehensive abortion care (CAC) service sites were established in Nepal, leading to a rise in safe, legal abortions. Though monitoring systems have been developed, reporting of complications has not always been complete or accurate. The purpose of this study was to report the frequency and type of abortion complications arising from CAC procedures in different types of facilities in Nepal.</p> <p>Methods</p> <p>A total of 7,386 CAC clients from a sample of facilities across Nepal were enrolled over a three-month period in 2008. Data collection included an initial health questionnaire at the time of abortion care and a follow-up questionnaire assessing complications, administered two weeks after the abortion procedure. A total of 7,007 women (95%) were successfully followed up. Complication rates were assessed overall and by facility type. Multivariable logistic regression was used to assess the association between experiencing a complication and client demographic and facility characteristics.</p> <p>Results</p> <p>Among the 7,007 clients who were successfully followed, only 1.87% (n = 131) experienced signs and symptoms of complications at the two-week follow up, the most common being retained products of conception (1.37%), suspected sepsis (0.39%), offensive discharge (0.51%) and moderate bleeding (0.26%). Women receiving care at non-governmental organization (NGO) facilities were less likely to experience complications than women at government facilities, adjusting for individual and facility characteristics (AOR = 0.18; 95% CI: 0.08-0.40). Compared to women receiving CAC at 4-5 weeks gestation, women at 10-12 weeks gestation were more likely to experience complications, adjusting for individual and facility characteristics (AOR = 4.21; 95% CI: 1.38-12.82).</p> <p>Conclusions</p> <p>The abortion complication rate in Nepali CAC facilities is low and similar to other settings; however, significant differences in complication rates were observed by facility type and gestational age. Interventions such as supportive supervision to improve providers' uterine evacuation skills and investment in equipment for infection control may lower complication rates in government facilities. In addition, there should be increased focus on early pregnancy detection and access to CAC services early in pregnancy in order to prevent complications.</p

Maternal and perinatal health research priorities beyond 2015 : an international survey and prioritization exercise

Background: Maternal mortality has declined by nearly half since 1990, but over a quarter million women still die every year of causes related to pregnancy and childbirth. Maternal-health related targets are falling short of the 2015 Millennium Development Goals and a post-2015 Development Agenda is emerging. In connection with this, setting global research priorities for the next decade is now required. Methods. We adapted the methods of the Child Health and Nutrition Research Initiative (CHNRI) to identify and set global research priorities for maternal and perinatal health for the period 2015 to 2025. Priority research questions were received from various international stakeholders constituting a large reference group, and consolidated into a final list of research questions by a technical working group. Questions on this list were then scored by the reference working group according to five independent and equally weighted criteria. Normalized research priority scores (NRPS) were calculated, and research priority questions were ranked accordingly. Results: A list of 190 priority research questions for improving maternal and perinatal health was scored by 140 stakeholders. Most priority research questions (89%) were concerned with the evaluation of implementation and delivery of existing interventions, with research subthemes frequently concerned with training and/or awareness interventions (11%), and access to interventions and/or services (14%). Twenty-one questions (11%) involved the discovery of new interventions or technologies. Conclusions: Key research priorities in maternal and perinatal health were identified. The resulting ranked list of research questions provides a valuable resource for health research investors, researchers and other stakeholders. We are hopeful that this exercise will inform the post-2015 Development Agenda and assist donors, research-policy decision makers and researchers to invest in research that will ultimately make the most significant difference in the lives of mothers and babies.</p