Self-reported Follow-up Care Needs Can be Met in Both Facility and Self-managed Abortion: Evidence from Low- and Middle-income Countries

Objective: To understand in-facility follow-up care-seeking behavior among both people who self-managed medication abortions (SMA) and those who obtained facility-managed care in six countries and to explore factors that contribute to meeting individual’s self-reported care needs that are core to person-centered care. Study Design: We conducted a qualitative thematic analysis of 67 in-depth interviews conducted with facility or SMA seekers. We first classified individuals as having their care needs met or not, and whether they sought follow-up care. We then identified predisposing, enabling, or need factors that contributed to having care needs met or not. Results: A total of n=67 participants were included in this analysis from six countries. The majority of participants (n=59, 88%) had their care needs met and half (n=33, 49%) sought follow-up care in a facility. Most participants, both at facilities and through SMA, reported their needs were met. Having support from family or accompaniment groups (activists who provide abortion guidance outside of clinical settings), knowing what to expect, and living close to a facility were key enabling factors that allowed individuals to have their care needs met via a facility follow-up visit or to feel confident completing their abortion at home. Inhibiting factors including health system challenges; stigma from providers; legal risk; unsupportive family; and uncertainty prevented some from having their care needs met. Conclusion: Medication abortion follow-up care needs can be met both in and outside of health facilities. Attention towards supporting enabling factors to meet client needs is essential to person-centered abortion care provision

Supporting Self-managed Abortion Care in “practice not premise”: Provider Perspectives, Roles, and Referral Pathways in India

Objective: Describe provider perspectives and roles in self-managed abortion (SMA) in India and identify referral pathways to facility- and self-managed abortion care. Methods: We conducted a qualitative study of 33 semi-structured interviews with a range of providers (medical, community health, and pharmacy) in India. We conducted a thematic analysis and identified referral pathways including the type of provider, the abortion care modality (in-facility or SMA), and the reason. Results: Referrals to facility-managed abortion care were common. Providers\u27 perception of SMA safety coupled with­ liability concerns resulted in discouraging clients from seeking SMA. Nonetheless, participants acknowledged three areas where providers played a role in SMA: providing information, dispensing medication, and providing support. SMA referrals pathways occurred bidirectionally between pharmacy workers and local providers. Some community health workers provided referrals to pharmacies, but more often only provided information and support. Conclusion: Despite provider concerns, support and referrals for SMA do occur in India. Understanding the dynamics of provider perspectives, roles, and referral pathways can inform improvements to comprehensive reproductive health policies and programs in order to promote client-centered abortion care—including SMA—and address provider concerns. There is a need for synergies between the formal health sector and SMA support networks. Keywords: Abortion, self-managed abortion, pharmacy, referrals, quality of car

Traveling for Abortion Services in Mexico 2016-2019: Community-Level Contexts of Mexico City Public Abortion Clients

Objective: To describe the community context of women who travel to access Mexico City’s public sector abortion program and identify factors associated with traveling from small towns and rural settings. Methods: We used data from the Interrupción Legal de Embarazo (ILE) program (2016-2019) and identified all abortion clients who traveled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to compare ILE clients’ individual characteristics with municipality averages and characterize municipalities on several measures of vulnerability. We also compared municipalities that sent ILE clients and those that did not. We used logistic regression to identify factors associated with traveling to access ILE services from smaller (fewer than 100,000 inhabitants versus more populated municipalities. Results: Our sample included 21,629 ILE clients who traveled to Mexico City from 491 municipalities and 31 states across Mexico; the majority traveled from the wealthiest (81.9%), and most populated (over 100,000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom 3 quintiles. Clients with a high school or university education (versus less) and those from a municipality with a high adolescent fertility rate had higher odds of traveling from a smaller (versus more populous) municipality (OR 1.2; 95% CI 1.02-1.41 and OR 4.7; 95% CI 3.93-5.65, respectively)

Travelling for Abortion Services in Mexico 2016–2019: Community-Level Contexts of Mexico City Public Abortion Clients

Objective: To describe the community context of women who travel to access Mexico City’s public sector abortion programme and identify factors associated with travelling from highly marginalised settings. Methods: We used data from the Interrupción Legal de Embarazo (ILE) programme (2016–2019) and identified all abortion clients who travelled from outside Mexico City. We merged in contextual information at the municipality level and used descriptive statistics to describe ILE clients’ individual characteristics and municipalities on several measures of vulnerability. We also compared municipalities that ILE clients travelled from with those where no one travelled from. We used logistic regression to identify factors associated with travelling to access ILE services from highly marginalised versus less marginalised municipalities. Results: Our sample included 21 629 ILE clients who travelled to Mexico City from 491 municipalities within all 31 states outside Mexico City. The majority of clients travelled from the least marginalised (81.9%) and most populated (over 100 000 inhabitants; 91.3%) municipalities. Most (91.2%) ILE clients came from municipalities with adolescent fertility rates in the bottom three quintiles. Clients with a primary or secondary education (vs high school or more) and those from a municipality with a high adolescent fertility rate (top two quintiles) had higher odds of travelling from a highly marginalised (vs less) municipality (adjusted odds ratio (aOR) 1.46, 95% CI 1.35 to 1.58 and aOR 1.89, 95% CI 1.68 to 2.12, respectively). Conclusion: ILE clients travel from geographically and socioeconomically diverse communities. There is an unmet need for legal abortion across Mexico

Client-reported quality of in-facility medication abortion compared with pharmacy-based self-managed abortion in Bangladesh

Objective: We used the newly developed Abortion Care Quality (ACQ) Tool to compare client-reported quality of medication abortion care by modality (facility-based versus pharmacy-based self-managed abortion (SMA)) in Bangladesh. Study Design: We used the abortion client ACQTool exit and 30-day follow-up surveys and bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by service modality. We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client socio-demographic characteristics. Results: Of 550 abortion clients, 146 (26.5%) received a facility-based medication abortion and 404 (73.5%) had a pharmacy-based SMA. Clients reported higher quality in facilities for five indicators; higher in pharmacies for two indicators; the remaining 11 indicators were not different by modality. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (aOR = 3.55; 95% CI 2.27-5.58) but lower odds of reporting high information provision (aOR = 0.14; 95% CI 0.09-0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse even occurred (aOR = 0.45; 95% CI 0.23-0.82). Conclusions: In Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable