HD-Background Selector

Zambia has one of the most liberal abortion laws in sub-Saharan Africa. However, rates of unsafe abortion remain high with negative health and economic consequences. Little is known about the economic burden on women of abortion care-seeking in low income countries. The majority of studies focus on direct costs (e.g. hospital fees). This article estimates the individual-level economic burden of safe and unsafe abortion care-seeking in Zambia, incorporating all indirect and direct costs. It uses data collected in 2013 from a tertiary hospital in Lusaka, (n = 112) with women who had an abortion. Three treatment routes are identified: (1) safe abortion at the hospital, (2) unsafe clandestine medical abortion initiated elsewhere with post-abortion care at the hospital and (3) unsafe abortion initiated elsewhere with post-abortion care at the hospital. Based on these three typologies, we use descriptive analysis and linear regression to estimate the costs for women of seeking safe and unsafe abortion and to establish whether the burden of abortion care-seeking costs is equally distributed across the sample. Around 39% of women had an unsafe abortion, incurring substantial economic costs before seeking post-abortion care. Adolescents and poorer women are more likely to use unsafe abortion. Unsafe abortion requiring post-abortion care costs women 27% more than a safe abortion. When accounting for uncertainty this figure increases dramatically. For safe and unsafe abortions, unofficial provider payments represent a major cost to women. This study demonstrates that despite a liberal legislation, Zambia still needs better dissemination of the law to women and providers and resources to ensure abortion service access. The policy implications of this study include: the role of pharmacists and mid-level providers in the provision of medical abortion services; increased access to contraception, especially for adolescents; and elimination of demands for unofficial provider payments

The Providers Share Workshop (PSW) is a facilitated workshop that gives abortion care workers an opportunity to reflect on the rewards and burdens of their work. We report on the workshop's impact on professional burnout.

Unsafe abortion is a significant but preventable cause of global maternal mortality and morbidity. Zambia has among the most liberal abortion laws in sub-Saharan Africa, however this alone does not guarantee access to safe abortion, and 30% of maternal mortality is attributable to unsafe procedures. Too little is known about the pathways women take to reach abortion services in such resource-poor settings, or what informs care-seeking behaviours, barriers and delays. In-depth qualitative interviews were conducted in 2013 with 112 women who accessed abortion-related care in a Lusaka tertiary government hospital at some point in their pathway. The sample included women seeking safe abortion and also those receiving hospital care following unsafe abortion. We identified a typology of three care-seeking trajectories that ended in the use of hospital services: clinical abortion induced in hospital; clinical abortion initiated elsewhere, with post-abortion care in hospital; and non-clinical abortion initiated elsewhere, with post-abortion care in hospital. Framework analyses of 70 transcripts showed that trajectories to a termination of an unwanted pregnancy can be complex and iterative. Individuals may navigate private and public formal healthcare systems and consult unqualified providers, often trying multiple strategies. We found four major influences on which trajectory a woman followed, as well as the complexity and timing of her trajectory: i) the advice of trusted others ii) perceptions of risk iii) delays in care-seeking and receipt of services and iv) economic cost. Even though abortion is legal in Zambia, girls and women still take significant risks to terminate unwanted pregnancies. Levels of awareness about the legality of abortion and its provision remain low even in urban Zambia, especially among adolescents. Unofficial payments required by some providers can be a major barrier to safe care. Timely access to safe abortion services depends on chance rather than informed exercise of entitlement.

While studies on unsafe abortion practices and abortion-related deaths among young women with low socio-economic status are reported in Sub-Saharan Africa, scanty information exists on young educated women, especially university students. This study explores the perceptions of female undergraduate students concerning unplanned premarital and unwanted pregnancy, and the implications on abortion practices. The study is based on data from a mixed-method study involving a survey of 420 female students in two universities in Southwestern Nigeria, in-depth interviews and focus group discussions. The results showed that most participants consider unplanned pregnancy to have negative consequences on educational goal attainment as well as physical and emotional wellbeing. Parenting style, social stigma attached to premarital pregnancy and fears about the socio-economic consequences of raising a baby and dropping out of school are reasons female university students would strife to avoid pregnancy. There are dreadful underlying cultural and socioeconomic consequences of premarital unplanned pregnancy as reported by majority of the students. Individual choices about what to do about an unplanned pregnancy could be greatly influenced by these socio-cultural factors.

"Background: Pain is often cited as one of the worst features of medical abortion. Further, inadequate pain management may motivate some women to seek unnecessary clinical care. There is a need to identify effective methods for pain control in this setting. Methods/Design: We propose a randomized, placebo-controlled trial. 576 participants (288 nulliparous; 288 parous) from study sites in Nepal, South Africa and Vietnam will be randomly allocated to one of three treatments: (1) ibuprofen 400 mg PO and metoclopramide 10 mg PO; (2) tramadol 50 mg PO and a placebo; or (3) two placebo pills, to be taken immediately before misoprostol and repeated once four hours later. All women will be provided with supplementary analgesia for use as needed during the medical abortion. We hypothesize that women receiving prophylactic analgesia will report lower maximal pain scores in the first 8 h following misoprostol administration compared to women receiving placebos for medical abortion through 63 days’ gestation. Our primary objective is to determine whether prophylactic administration of ibuprofen and metoclopramide or tramadol provides superior pain relief compared to analgesia administration after pain begins, measured during the first eight hours after misoprostol administration. Secondary objectives include identifying covariates associated with higher reported pain scores; determining any impact of the study medicines on medical abortion success; and, qualitatively exploring women’s physical experiences of medical abortion, especially related to pain, and how can they be improved. Data sources include medical records, participant symptom diaries and interview data obtained on the day of enrollment, during the medical abortion, and at follow-up. Participants will be contacted via telephone on day 3 and return for follow-up will occur approximately 14 days after mifepristone, concluding study participation. A subset of 42 women will also be invited to undergo in-depth qualitative interviews following study completion. Discussion: Although pain is one of the most common side effects encountered with medical abortion, little is known about optimal pain management for this process. This multi-arm trial design offers an efficient approach to evaluating two prophylactic pain management regimens compared to use of pain medication as needed."

"OBJECTIVES: Provision of objective, evidence-based counselling in the context of induced abortion services is considered global good practise. However, there is limited understanding over the counselling needs of women accessing abortion services, particularly in sub-Saharan Africa. This study aimed to explore the content and quality of pre-abortion counselling amongst women accessing an abortion service in South Africa as well as client experience of the counselling process. Perceptions of nurse counsellors were also sought. STUDY DESIGN: This was a mixed methods study conducted at a Choice of Termination of Pregnancy clinic based at a district level hospital in KwaZulu-Natal, South Africa. Sixty women requesting an abortion were interviewed via a semi-structured questionnaire. In-depth interviews were conducted with four nurses who provided pre-abortion counselling at the clinic. Interviews were coded for emergent themes and categories. RESULTS: Clinic nurses had widely variable counselling training and experience, ranging from less than 2 months to 8 years, but all clients reported that they had been treated with respect at their counselling session. The group-based counselling format and biomedical and health promotion content did not accommodate clients' differential counselling needs, which included requests for support from women experiencing intimate partner violence (IPV). There was limited provider awareness of client's additional counselling needs. CONCLUSION: Abortion counselling services should be tailored to clients' differential counselling needs. Group-based counselling followed by optional one-on-one counselling sessions is one possible strategy to address unmet client need in South Africa. Provision of abortion provider training in IPV is recommended as well as establishment of referral pathways for women experiencing IPV. IMPLICATIONS: Paying attention to the differential counselling needs of women seeking an abortion should be a key component to the provision of abortion services. In this way, abortion services can provide a gateway to additional support for women living in violent relationships and/or other adverse social circumstances."

A systematic review was conducted of 13 peer-reviewed articles and eight reports focused on indicators of quality abortion care. A total of 75 indicators of quality abortion were identified; these indicators address a variety of issues including policy, health systems, trained-provider availability, women's decision making, and morbidity and mortality. There is little agreement about indicators for measuring quality abortion care; more work is needed to ensure efforts to assess quality are informed and coordinated.

BACKGROUND: Unsafe abortions are a serious public health problem and a major human rights Issue. In low-income countries, where restrictive abortion laws are common, safe abortion care is not always available to women in need. Health care providers have an important role in the provision of abortion services. However, the shortage of health care providers in low-income countries is critical and exacerbated by the unwillingness of some health care providers to provide abortion services. The aim of this study was to identify, summarise and synthesis/Dissertation available research addressing health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. METHODS: A systematic literature search of three databases was conducted in November 2014, as well as a manual search of reference lists. The selection criteria included quantitative and qualitative research studies written in English, regardless of the year of publication, exploring health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia. The quality of all articles that met the inclusion criteria was assessed. The studies were critically appraised, and thematic analysis was used to synthesis/Dissertatione the data. RESULTS: Thirty-six studies, published during 1977 and 2014, including data from 15 different countries, met the inclusion criteria. Nine key themes were identified as influencing the health care providers' attitudes towards induced abortions: 1) human rights, 2) gender, 3) religion, 4) access, 5) unpreparedness, 6) quality of life, 7) ambivalence 8) quality of care and 9) stigma and victimisation. CONCLUSION: Health care providers in sub-Saharan Africa and Southeast Asia have moral-, social- and gender-based reservations about induced abortion. These reservations influence attitudes towards induced abortions and subsequently affect the relationship between the health care provider and the pregnant woman who wishes to have an abortion. A values clarification exercise among abortion care providers is needed.

BACKGROUND: This study explored the reasons for variation in hospital maternal mortality ratio (MMR) between studies from sub-Saharan Africa. METHODS: A systematic review was conducted to identify hospital-based studies which reported the prevalence of maternal mortality. An overall MMR from all the hospital-based studies was calculated using a metaanalysis. Potential sources of heterogeneity in the MMR between studies were identified using metaregression techniques. RESULTS: We identified 4243 studies, of which 64 were eligible for inclusion in the metaanalysis. The pooled hospital MMR for sub-Saharan Africa was 957 per 100 000 live births, although there was strong evidence for between-study heterogeneity. Regional estimates varied from 294 per 100 000 live births in Southern Africa to 1338 in Western Africa. Overall, throughout the region, the percentage of skilled birth attendance and type of hospital accounted for 44% of the total variation of the hospital MMR between studies. CONCLUSIONS: This paper highlights the need to improve the organisation of health systems and the quality of care that is being offered in health facilities to pregnant women in Africa; and emphasizes the importance of increasing the percentage of skilled birth attendance in the region. In order to achieve the Millennium development goal (MDG) and reduce maternal mortality in the region, particularly in Western Africa, new and stronger approaches are needed.

Although pregnancy termination is restricted by law in Tanzania, it is widely practiced and almost always unsafe, and contributes to the country's high maternal morbidity and mortality. Yet the majority of abortion-related deaths are preventable, as are the unintended pregnancies associated with abortion. Better access to contraceptives, more comprehensive post-abortion care and greater availability of safe abortion services within the current legal framework are critical to achieving the Millennium Development Goal 5 of reducing maternal mortality and ensuring universal access to reproductive health care by 2015.

"BACKGROUND: Unsafe abortion imposes heavy burdens on both individuals and society, particularly in low-income countries, many of which have restrictive abortion laws. Providing family planning counseling and services to women following an abortion has emerged as a key strategy to address this issue. STUDY DESIGN: This systematic review gathered, appraised and synthesized recent research evidence on the effects of post-abortion family planning counseling and services on women in low-income countries. RESULTS: Of the 2965 potentially relevant records that were identified and screened, 15 studies satisfied the inclusion criteria. None provided evidence on the effectiveness of post-abortion family planning counseling and services on maternal morbidity and mortality. One controlled study found that, compared to the group of non-beneficiaries, women who received post-abortion family planning counseling and services had significantly fewer unplanned pregnancies and fewer repeat abortions during the 12-month follow-up period. All 15 studies examined contraception-related outcomes. In the seven studies which used a comparative design, there was greater acceptance and/or use of modern contraceptives in women who had received post-abortion family planning counseling and services relative to the no-program group. CONCLUSIONS: The current evidence on the use of post-abortion family planning counseling and services in low-income countries to address the problem of unsafe abortion is inconclusive. Nevertheless, the increase in acceptance and/or use of contraceptives is encouraging and has the potential to be further explored. Adequate funding to support robust research in this area of reproductive health is urgently needed."

OBJECTIVE: Training midlevel providers (MLPs) to conduct surgical abortions and manage medical abortions has been proposed as a way to increase women's access to safe abortion. This paper reviews the evidence that compares the effectiveness and safety of abortion procedures administered by MLPs versus doctors. METHODS: A systematic search was conducted of published trials and comparison studies assessing the effectiveness and/or safety of abortion provided by MLPs compared to doctors. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, and Popline were searched. The primary outcomes of interest were: (1) incomplete or failed abortion; and (2) measures of safety (adverse events and complications) of abortion procedures administered by MLPs and doctors. Odds ratios (ORs) and their 95% confidence intervals (CIs) were calculated for each study. Data were synthesized in a narrative fashion. FINDINGS: Five studies were included in this review (n = 8539 women), comprising two randomized controlled trials (RCTs) (n = 3821) and three prospective cohort studies (n = 4718). In total, 4198 women underwent a procedure administered by an MLP, and 4341 women underwent a physician-administered procedure. Studies took place in the US, Nepal, South Africa, Vietnam, and India. Four studies used surgical abortion with maximum gestational ages ranging from 10 to 16+ weeks, while a medical abortion study had gestational ages up to 9 weeks. In RCTs, the effect estimates for incomplete or failed abortion for procedures performed by MLPs compared with doctors were OR = 2.00 (95% CI 0.85-4.68) for surgical abortion, and OR = 0.69 (95% CI 0.34-1.37) for medical abortion. Complications were rare among both provider types (1.2%-3.1%; OR = 1.80, 95% CI 0.83-3.90 for surgical abortions), and no deaths were reported. CONCLUSION: There were no statistical differences in incomplete abortion and complications for first trimester surgical and medical abortion up to 9 weeks performed by MLPs compared with physicians. Further studies are required to establish more precise effect estimates.

A combination of stigma, ignorance of reformist laws and health care facilities that offer abortion services being 'unidentifiable' mean that 43% of designated facilities today fail to provide first-trimester pregnancy termination services. This emerged at a Dialogue on Safe Abortions, attended by many of the country's top experts on the subject and held at a Cape Town hotel last month. Dr Eddie Mhlanga, Cluster Manager of Maternal, Child and Women's Health in the national health department, said it was 'very sad' that 3 years after the Choice on Termination of Pregnancy (CTOP) Act was liberally amended, only 57% of designated TOP facilities (including Marie Stopes private clinics) were actually functional.

Executive Summary: This study examined how pregnancy prevention and management services (specifically, the provision of emergency contraception, pregnancy testing and counselling, and termination or referral for termination of pregnancy services) feature within post-rape care (PRC) services in sub-Saharan Africa. Guidance provided by the World Health Organisation was used as a benchmark for examining these issues. The study drew on a range of sources via a desk review, as well as on information provided through key informant interviews.Several key messages emerge from the study’s overall findings: 1. National PRC guidelines consistently identify pregnancy prevention as an essential element of sexual assault management and all include provisions on emergency contraception for eligible survivors. Nonetheless, the study reveals a disconnect between PRC guidelines and guidelines for reproductive health/family planning, with the latter less likely to address the specific needs of rape survivors although many contain general provisions on emergency contraception. 2. Pregnancy management and safe abortion for survivors do not feature prominently in national sexual violence guidelines in the region, with only a few exceptions. Existing provisions for pregnancy management and abortion also tend to lack detailed guidance or country-specific information that would facilitate access to these services.

This report provides an assessment of the current status of PAC services in Rwanda. While some PAC services are available, the practices are not adequate to provide quality care in postabortion management for the majority of clients. To address this gap, it is necessary to provide support for improved quality of PAC services and to ensure that supplies are available and ready for emergencies.The subject of postabortion care itself is still a taboo for many providers, who may not make a distinction between inducing abortion and performing postabortion care for abortion complications. This confusion caused some providers to decline to participate in this assessment, despite the research team’s efforts to sensitize providers to this distinction.

The Community Abortion Morbidity Study was an exploratory qualitative study examining community perceptions of abortion morbidity experience among residents of Kampala and Mbarara districts in 2003. The data came from eight focus group discussions with women aged 18-60, 82 in-depth interviews with women aged 18-60 and men aged 20-50, and 33 indepth interviews with health care providers (HCPs). This report presents evidence on reasons for the occurrence of unwanted pregnancy, abortion practice, health problems women experience as a result of stopping a pregnancy, actions women take to obtain treatment, the barriers they face in obtaining treatment, and the social and economic consequences of abortion.

Each minute of every day, nearly 40 women undergo dangerous, unsafe abortions. These unsafe abortions are often performed by unskilled providers or under unhygienic condition or both. Estimates based on figures for 2000 indicate that 19 million unsafe abortions take place each year and an estimated 681000 women die as consequences of unsafe abortion, and almost all occur in developing countries. In Nigeria, as is also the case in most developing countries, unsafe abortion has assumed a serious public health problem, and induced unsafe abortion has been established as an important contributor to maternal morbidity and mortality. In Nigeria, induced abortion is a criminal offence both for the seeker and the provider. The penalty is 14 and 7 years jail sentences, respectively, for the provider and client. These penalties notwithstanding, induced unsafe abortions are still performed on a daily basis both by skilled and unskilled personnel. There are approximately 610 000 abortions performed in Nigeria annually with an abortion rate of 25.4 per 1000; of these, 60% are thought to be unsafe. In Nigeria, unsafe abortion contributes up to 20% of maternal mortality, and those women that survive are faced with complications such as sepsis, vesicovaginal fistula, anaemia, ruptured uterus (sometimes ending in hysterectomy), amongst others.

"PURPOSE: Abortion rates are likely the most inaccurate of all demographic data in countries where abortions are illegal. In areas where abortion is legal in most circumstances, it is possible to record the numbers of abortions being performed. In areas where abortion is illegal or highly restricted, there are high levels of underreporting of abortion due to fear, stigma, and shame. In addition, health care workers often do not report providing abortion services due to the legal and moral implications. Induced abortion is a key component of reproductive health; high rates of unsafe abortion contribute to maternal mortality and morbidity worldwide. In addition, high rates of induced abortion are often strongly associated with an absence of modern contraception use. Because of these challenges to researching the actual rates of induced abortions which take place in countries with restrictive abortion laws, numerous methods have been developed to estimate the rates of induced abortion in these areas. One of the newest estimation methods is the Westoff Regression Approach which was developed by Charles Westoff in 2008. This method was developed based on the strong negative correlation between contractive prevalence rates and induced abortion rates in counties with relatively high levels of abortion reporting. The regression formula was based on observations from 18 countries in Eastern Europe and Central Asia. The model was later adapted for use in other geographic regions. The formula used for this analysis was based on an adaptation of the regression model found to closely reflect the actual levels of induced abortion in Nigeria. The purpose of this analysis was to estimate the annual rates of induced abortion in the Savanes region of northern Togo represented in available data from 1998 Togo Demographic and Health Survey using an adapted Westoff Regression Approach; all abortion in Togo was illegal in 1998. METHODS: Data from the most recent Demographic and Health Survey (1998) available for Togo were used to estimate the rates of induced abortion in the Savanes region. The data were gathered from the “Women’s Questionnaire” of the Demographic and Health Survey completed by 1679 women aged 15-49 years living in the Savanes region. The regression equation used is as follows: total abortion rate = 2.94-0.033(modern contraceptive prevalence rate of ever-married women)-0.252(total fertility rate)+0.091(mean years of education). The annual abortion rates were calculated by the following characteristics: geography, religion, ethnicity, and socioeconomic status. The annual abortion rates were calculated from the total abortion rates. Stata statistical software was used to calculate the age-specific fertility and total fertility rates. SPSS statistical software was used to calculate the modern contraceptive prevalence rates and mean years of education. Excel was used to calculate the total abortion rates and annual abortion rates. RESULTS: The model estimated the overall annual abortion rate in the Savanes region was 39.12 abortions per 1,000 ever-married women. It was 66.84 per 1,000 ever-married women in the urban areas and 32.99 per 1,000 ever-married women in the rural areas. Dividing the women by religion showed that Muslim women had the highest estimated annual abortion rate at 53.65 per 1,000 ever-married women and women who practiced traditional religions had the lowest rate at 30.77 per 1,000 ever-married women. Dividing the women by ethnicity found that women with a Togolese ethnicity other than Gourma, the predominant ethnicity in the region, had the highest annual abortion rate at 71.06 per 1,000 ever-married women. Women who were a non-Togolese ethnicity had the lowest rate at 35.98 per 1,000 ever-married women. Dividing women by socioeconomic status using the proxy indicator of radio ownership found that women who owned a radio (high socioeconomic status) had an estimated annual abortion rate of 48.10 per 1,000 ever-married women compared to women who did not own a radio (low socioeconomic status) who had an estimated annual abortion rate of 32.00 per 1,000 ever-married women. CONCLUSIONS: The regression model estimates of the annual abortion rates in the Savanes region of Togo were similar to the estimates done by the Guttmacher Institute for Africa in 1995 and the West African region in 2008 which were 33 and 28 per 1,000 ever-married women aged 15-44 respectively. This shows that the estimates found using the Westoff Regression Approach are likely within a probable range of the actual rates of induced abortion which took place in the Savanes region of Togo in the late 1990s. There are a number of limitations of using the Westoff Regression Approach to estimate annual abortion rates. The model is based on the assumption of a strong negative association between modern contraceptive prevalence rates and the number of lifetime abortions per woman and the total fertility rates, but this assumption is mostly based on data from developed countries. In addition, greater use of traditional family planning methods, which is present in Togo, are connected with higher rates of abortion. Other limitations include a lack of a ‘gold standard’ to evaluate these estimates of annual abortion rates and the inability to calculate annual abortion rates by parity, educational attainment, age, or contraception use due to these variables being used in the model. In addition, most methods of estimating annual abortion rates overestimate the actual abortion rates in countries where modern contraceptive use is low and total fertility rates are high, as they are in Togo. While these limitations exist around the use of the Westoff Regression Approach for estimating rates of induced abortion in Togo, because of the extremely limited data which exists on actual rates of induced abortion in this area these estimations provide some insight into the state of induced abortion in the Savanes region of Togo at the turn of the 21st century. "

This article provides the first ever review of literature analysing the health policy processes of low and middle income countries (LMICs). Based on a systematic search of published literature using two leading international databases, the article maps the terrain of work published between 1994 and 2007, in terms of policy topics, lines of inquiry and geographical base, as well as critically evaluating its strengths and weaknesses. The overall objective of the review is to provide a platform for the further development of this field of work. From an initial set of several thousand articles, only 391 were identified as relevant to the focus of inquiry. Of these, 164 were selected for detailed review because they present empirical analyses of health policy change processes within LMIC settings. Examination of these articles clearly shows that LMIC health policy analysis is still in its infancy. There are only small numbers of such analyses, whilst the diversity of policy areas, topics and analytical Issues that have been addressed across a large number of country settings results in a limited depth of coverage within this body of work. In addition, the majority of articles are largely descriptive in nature, limiting understanding of policy change processes within or across countries. Nonetheless, the broad features of experience that can be identified from these articles clearly confirm the importance of integrating concern for politics, process and power into the study of health policy. By generating understanding of the factors influencing the experience and results of policy change, such analysis can inform action to strengthen future policy development and implementation. This article, finally, outlines five key actions needed to strengthen the field of health policy analysis within LMICs, including capacity development and efforts to generate systematic and coherent bodies of work underpinned by both the intent to undertake rigorous analytical work and concern to support policy change.

AIM: Under the Millennium Development Goal of improving maternal health (MDG 5), the global community aims to reduce maternal mortality ratio (MMR) by three quarters. Unsafe abortion is a significant, but preventable cause of maternal mortality. In Eastern Africa for every 100,000 live births it is estimated that 160 women die from causes related to unsafe abortion –accounting for almost 30% of all maternal mortality. Zambia’s MMR is 440, of which a significant proportion is likely to be due to unsafe abortions, although there are no nationally representative data available. In spite of the existence of a Termination of Pregnancy Act (1972), women face logistical, financial, social, and legal obstacles to access safe abortion services in Zambia. Therefore more attention towards implementation of interventions that direct resources to the prevention of unsafe abortions is needed. In this paper we present an economic argument for policy makers to consider. We compare the cost of safe abortion and post abortion care for the Zambian health system. Our evidence shows that post abortion care can be at least 3 to 5 times more expensive compared to safe abortions.                                              OBJECTIVE: To estimate the per-case and annual costs of termination of pregnancy (TOP) and post abortion care (PAC) for the Zambian health system.                               METHODS: We collected data on cost of drugs, materials and personnel time from the University Teaching Hospital (UTH) in Lusaka. We estimated the per-case and annual costs of providing TOP and PAC services at UTH and projected these costs to provide estimates for Zambia. Due to unavailability of the actual number of PAC and TOP cases in Zambia, we used estimates from previous studies and from other similar countries, and complemented it with sensitivity analysis to provide a range of costs.                          KEY TINDINGS: We found that per-case and annual costs of PAC can be at least 3 to 5 times more expensive compared to TOP. Costs of medications and supplies accounted for the bulk of these costs.
AIM: Under the Millennium Development Goal of improving maternal health (MDG 5), the global community aims to reduce maternal mortality ratio (MMR) by three quarters. Unsafe abortion is a significant, but preventable cause of maternal mortality. In Eastern Africa for every 100,000 live births it is estimated that 160 women die from causes related to unsafe abortion –accounting for almost 30% of all maternal mortality. Zambia’s MMR is 440, of which a significant proportion is likely to be due to unsafe abortions, although there are no nationally representative data available. In spite of the existence of a Termination of Pregnancy Act (1972), women face logistical, financial, social, and legal obstacles to access safe abortion services in Zambia. Therefore more attention towards implementation of interventions that direct resources to the prevention of unsafe abortions is needed. In this paper we present an economic argument for policy makers to consider. We compare the cost of safe abortion and post abortion care for the Zambian health system. Our evidence shows that post abortion care can be at least 3 to 5 times more expensive compared to safe abortions.                                              OBJECTIVE: To estimate the per-case and annual costs of termination of pregnancy (TOP) and post abortion care (PAC) for the Zambian health system.                               METHODS: We collected data on cost of drugs, materials and personnel time from the University Teaching Hospital (UTH) in Lusaka. We estimated the per-case and annual costs of providing TOP and PAC services at UTH and projected these costs to provide estimates for Zambia. Due to unavailability of the actual number of PAC and TOP cases in Zambia, we used estimates from previous studies and from other similar countries, and complemented it with sensitivity analysis to provide a range of costs.                          KEY TINDINGS: We found that per-case and annual costs of PAC can be at least 3 to 5 times more expensive compared to TOP. Costs of medications and supplies accounted for the bulk of these costs.

Misoprostol is a drug widely used in the provision of medication abortion. While misoprostol is sold in many developing countries, legal restrictions on abortion, particularly in sub-Saharan Africa, limit its registration for this indication. Studies in Latin America have explored pharmacy sales of misoprostol for abortion, but there is limited data from African countries. We surveyed 179 pharmacy employees from 150 pharmacies in seven regions of Tanzania in April 2012 to determine stock availability and knowledge and attitudes regarding misoprostol sales. One-third (32%) of pharmacies had misoprostol in stock at the time of the survey. The most common reason mentioned for ordering misoprostol was demand from individual customers, while those pharmacies who did not order reported that they feared the drug would be misused. One-third of respondents (32%) spontaneously mentioned abortion as an indication for which misoprostol could be used; however, less than 10% could give an appropriate dose. Half of respondents reported ever dispensing misoprostol, with 19% of those citing abortion was the most common reason for which women purchase the drug. In addition, reported prescription requirement was high. In legally restrictive settings, misoprostol sold by pharmacies is likely used for medication abortion. However, correct dose information is limited, increasing the probability of women experiencing incomplete abortions. Future research should include simulated sales encounters, including mystery shoppers, to validate the extent to which and for what indications pharmacies in countries with legal restrictions on abortion sell misoprostol to consumers.

Zimbabwe's maternal mortality ratio (MMR) of 960 is currently 50% higher than the average MMR in sub-Saharan Africa. The Zimbabwe Ministry of Health and Child Welfare (ZMoHCW) is committed to strengthening its health system by creating access to misoprostol, a uterotonic drug that can be used to manage postpartum hemorrhage (PPH) as well as to treat incomplete abortion and miscarriage. As PPH and unsafe abortion are two of the top five causes of maternal mortality in Zimbabwe, the ZMoHCW has formed a multi-pronged strategy for introducing misoprostol into the Zimbabwean health system. The strategy consists of: 1) policy change (e.g., introducing misoprostol on the Essential Drugs List of Zimbabwe as well as into the country's post-abortion Care Guidelines); 2) conducting operations research testing the feasibility of introducing misoprostol at all facility levels; and 3) working to revise the registration of a misoprostol product in the country to include obstetric indications. Despite the challenges of operating within an under-resourced health system, preliminary data from the operations research demonstrates that misoprostol is already being successfully used to manage PPH and treat incomplete abortion and miscarriage at all facility levels. The introduction of misoprostol to address two of the primary causes of maternal deaths has been identified by the ZMoHCW as a global best practice for scaling up facility-based maternal health services in low-income countries and a replicable model for strengthening health systems globally.

"BACKGROUND: A septic abortion refers to any abortion (spontaneous or induced) complicated by upper genital tract infection including endometritis or parametritis. The mainstay of treatment of septic abortion is antibiotic therapy alone or in combination with evacuation of retained products of conception. Regimens including broad-spectrum antibiotics are routinely recommended for treatment. However, there is no consensus on the most effective antibiotics alone or in combination to treat septic abortion. This review aimed to bridge this gap in knowledge to inform policy and practice. OBJECTIVES: To review the effectiveness of various individual antibiotics or antibiotic regimens in the treatment of septic abortion. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and POPLINE using the following keywords: 'Abortion', 'septic abortion', 'Antibiotics', 'Infected abortion', 'post-abortion infection'. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov for ongoing trials on 19 April, 2016. SELECTION CRITERIA: We considered for inclusion randomised controlled trials (RCTs) and non-RCTs that compared antibiotic(s) to another antibiotic(s), irrespective of route of administration, dosage, and duration as well as studies comparing antibiotics alone with antibiotics in combination with other interventions such as dilation and curettage (D&C). DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from included trials. We resolved disagreements through consultation with a third author. One review author entered extracted data into Review Manager 5.3, and a second review author cross-checked the entry for accuracy. MAIN RESULTS: We included 3 small RCTs involving 233 women that were conducted over 3 decades ago. Clindamycin did not differ significantly from penicillin plus chloramphenicol in reducing fever in all women (mean difference (MD) -12.30, 95% confidence interval (CI) -25.12 to 0.52; women = 77; studies = 1). The evidence for this was of moderate quality. ""Response to treatment was evaluated by the patient's 'fever index' expressed in degree-hour and defined as the total quantity of fever under the daily temperature curve with 99°F (37.2°C) as the baseline"". There was no difference in duration of hospitalisation between clindamycin and penicillin plus chloramphenicol. The mean duration of hospital stay for women in each group was 5 days (MD 0.00, 95% CI -0.54 to 0.54; women = 77; studies = 1).One study evaluated the effect of penicillin plus chloramphenicol versus cephalothin plus kanamycin before and after D&C. Response to therapy was evaluated by ""the time from start of antibiotics until fever lysis and time from D&C until patients become afebrile"". Low-quality evidence suggested that the effect of penicillin plus chloramphenicol on fever did not differ from that of cephalothin plus kanamycin (MD -2.30, 95% CI -17.31 to 12.71; women = 56; studies = 1). There was no significant difference between penicillin plus chloramphenicol versus cephalothin plus kanamycin when D&C was performed during antibiotic therapy (MD -1.00, 95% CI -13.84 to 11.84; women = 56; studies = 1). The quality of evidence was low. A study with unclear risk of bias showed that the time for fever resolution (MD -5.03, 95% CI -5.77 to -4.29; women = 100; studies = 1) as well as time for resolution of leukocytosis (MD -4.88, 95% CI -5.98 to -3.78; women = 100; studies = 1) was significantly lower with tetracycline plus enzymes compared with intravenous penicillin G. Treatment failure and adverse events occurred infrequently, and the difference between groups was not statistically significant. AUTHORS' CONCLUSIONS: We found no strong evidence that intravenous clindamycin alone was better than penicillin plus chloramphenicol for treating women with septic abortion. Similarly, available evidence did not suggest that penicillin plus chloramphenicol was better than cephalothin plus kanamycin for the treatment of women with septic abortion. Tetracyline enzyme antibiotic appeared to be more effective than intravenous penicillin G in reducing the time to fever defervescence, but this evidence was provided by only one study at low risk of bias. There is a need for high-quality RCTs providing reliable evidence for treatments of septic abortion with antibiotics that are currently in use. The three included studies were carried out over 30 years ago. There is also a need to include institutions in low-resource settings, such as sub-Saharan Africa, Latin America and the Caribbean, and South Asia, with a high burden of abortion and health systems challenges."

The Government of Ghana has taken important steps to mitigate the impact of unsafe abortion. However, the expected decline in maternal deaths is yet to be realized. This literature review aims to present findings from empirical research directly related to abortion provision in Ghana and identify gaps for future research. A total of four (4) databases were searched with the keywords "Ghana and abortion" and hand review of reference lists was conducted. All abstracts were reviewed. The final include sample was 39 articles. Abortion-related complications represent a large component of admissions to gynecological wards in hospitals in Ghana as well as a large contributor to maternal mortality. Almost half of the included studies were hospital-based, mainly chart reviews. This review has identified gaps in the literature including: interviewing women who have sought unsafe abortions and with healthcare providers who may act as gatekeepers to women wishing to access safe abortion services.

The complications of unsafe, illegal abortions are a significant cause of maternal mortality in Botswana. The stigma attached to abortion leads some women to seek clandestine procedures, or alternatively, to carry the fetus to term and abandon the infant at birth. I conducted research into perceptions of abortion in urban Botswana in order to understand the social and cultural obstacles to women's reproductive autonomy, focusing particularly on attitudes to terminating a pregnancy. I carried out 21 interviews with female and male urban adult Batswana. This article constitutes a review of the abortion Issue in Botswana based on my research. Restrictive laws must eventually be abolished to allow women access to safe, timely abortions. My findings however, suggest that socio-cultural factors, Not punitive laws, present the greatest barriers to women seeking to terminate an unwanted pregnancy. These factors must be addressed so that effective local solutions to unsafe abortion can be generated.

BACKGROUND: The weight of evidence suggests that women who freely choose to terminate a pregnancy are unlikely to experience significant mental health risks, however some studies have documented psychological distress in the form of posttraumatic stress disorder and depression in the aftermath of termination. Choice of anaesthetic has been suggested as a determinant of outcome. This study compared the effects of local anaesthesia and intravenous sedation, administered for elective surgical termination, on outcomes of pain, cortisol, and psychological distress. METHODS: 155 women were recruited from a private abortion clinic and state hospital (mean age: 25.4 +/- 6.1 years) and assessed on various symptom domains, using both clinician-administered interviews and self-report measures just prior to termination, immediately post-procedure, and at 1 month and 3 months post-procedure. Morning salivary cortisol assays were collected prior to anaesthesia and termination. RESULTS: The group who received local anaesthetic demonstrated higher baseline cortisol levels (mean = 4.7 vs 0.2), more dissociative symptoms immediately post-termination (mean = 14.7 vs 7.3), and higher levels of pain before (mean = 4.9 vs 3.0) and during the procedure (mean = 8.0 vs 4.4). However, in the longer-term (1 and 3 months), there were No significant differences in pain, psychological outcomes (PTSD, depression, self-esteem, state anxiety), or disability between the groups. More than 65% of the variance in PTSD symptoms at 3 months could be explained by baseline PTSD symptom severity and disability, and post-termination dissociative symptoms. Of interest was the finding that pre-procedural cortisol levels were positively correlated with PTSD symptoms at both 1 and 3 months. CONCLUSION: High rates of PTSD characterise women who have undergone surgical abortions (almost one fifth of the sample meet criteria for PTSD), with women who receive local anaesthetic experiencing more severe acute reactions. The choice of anesthetic, however, does Not appear to impact on longer-term psychiatric outcomes or functional status.

Unsafe abortion continues to be a major contributor to maternal mortality and morbidity around the world. This article examines the role of pharmacists in expanding women's access to safe medical abortion in Latin America, Africa, and Asia. Available research shows that although pharmacists and pharmacy workers often sell abortion medications to women, accurate information about how to use the medications safely and effectively is rarely offered. No publication covered effective interventions by pharmacists to expand access to medical abortion, but lessons can be learned from successful interventions with other reproductive health services. To better serve women, increasing awareness and improving training for pharmacists and pharmacy workers about unsafe abortion - and medications that can safely induce abortion - are needed.

BACKGROUND: Abortions performed by persons lacking the requisite skills or in environments lacking minimal medical standards or both are considered unsafe. It is estimated that over 20 million unsafe abortions are performed annually and about 70 000 women die globally as a result, with the majority occurring in the developing world. This study aims to determine the sociodemographic factors involved in complicated unsafe abortions. SUBJECT and METHODS: The study is a four-year retrospective evaluation of all cases of complicated unsafe abortions managed at the Niger Delta University Teaching Hospital, Okolobiri, Bayelsa state, Nigeria between January 1, 2007 and December 31,2010. RESULTS: The incidence of unsafe complicated abortions over the study period was 4.10% of total deliveries and contributed 14.0% of gynaecological admissions: 34.92% occurred in adolescents less than 20 years of age, of which the majority (55.55%) were secondary school students. There were 55.45% of patients who were nulliparae, 60.32% were unemployed and 69.80% were unmarried. A total of 87.30% had never used any form of contraceptive. Abortion mortality rate was 256/100 000 deliveries and the case fatality was 4.76%. It constituted 30.0% of all gynaecological deaths and 17.64% of maternal deaths during the study period. The commonest cause of death was septicaemia (66.66%). CONCLUSIONS: Unfavourable sociodemographic factors are major determinants of the high incidence of unsafe abortion in the Niger Delta despite strict abortion laws. Concrete measures must be put in place to address these, as unsafe abortion and its complications are a major cause of maternal morbidity and mortality in the environment.

This paper examines the ethics of childcare in Yoruba culture in the contexts of autism and abortion. The traditional Yoruba moral principles of ibikojuibi (equality of humans at birth) and ajowapo (solidarity) have been theoretically developed to establish the personhood of autistic children and provide a justification for not aborting foetuses with autism. Despite these justifications, this paper argues that there is a need for contextual rethinking, which would allow for: (i) prenatal genetic testing, as well as abortion of foetuses with a high risk of the autism mutation, and (ii) early clinical diagnosis and treatment of autistic children in contemporary Yoruba society.

The number of maternal deaths due to unsafe abortions has fallen worldwide since the early 1990s. However, the situation in sub-Saharan Africa (SSA) remains a source of great concern for multiple reasons: abortion rates have not fallen, clandestine abortions are common and often deadly, and post-abortion care (PAC) for women experiencing problems from spontaneous or induced abortion remains deficient. Abortion remains largely outlawed nearly everywhere, which pushes the practice into a dangerous and shadowy underground market. This confluence of factors leads to high rates of preventable abortion-related morbidity and mortality.

OBJECTIVES: Abortion in Nigeria is permitted only to save a woman's life. Most abortions in that country take place under unsafe conditions and constitute a major source of maternal morbidity and mortality. We present a case of multiple visceral injuries complicating an induced abortion. CASE: A 28-year-old multiparous woman at 12 weeks' gestation had an induced abortion by dilatation and curettage in a private clinic. The procedure was complicated by uterine perforation and bowel injury, with protrusion of gangrenous loops of bowel from the vagina. At laparotomy the uterus was repaired, and a bowel resection with re-anastomosis was performed. The patient's recovery was uneventful. CONCLUSIONS: Increasing the uptake of contraception, training healthcare providers in safe methods of induced abortion, and liberalising abortion laws can reduce abortion-related morbidity and mortality in Nigeria.

Termination of pregnancy (TOP) for health or other reasons is an emotive and contentious issue, steeped in the context of a political, moral and religious climate. For most women, the decision to have a TOP is not easy, regardless of the reason. While early literature supported the notion that that there is little in the way of negative sequelae following TOP, more recent long-term studies have suggested that negative sequelae may be more common than was previously thought. Risk factors for the development of negative sequelae include the attitude projected by those providing the procedure (negative attitudes of providers tend to promote emotional sequelae in women undergoing TOP), previous psychological/psychiatric history (associated with higher rates of post-traumatic stress disorder (PTSD) and depression following TOP), and low income (with women from low-income groups having higher admission rates for depression and PTSD after TOP.

For women in Africa, access to modern methods of contraception, safe abortion, and other aspects of reproductive health care is, quite simply, a matter of life and death, as well as a basic human right. In my medical career and my work in international women's health over the past 42 years, mostly in Africa, I have personally witnessed or heard from colleagues many tragic stories of women dying painful deaths that were wholly preventable through known technologies for the provision of safe abortion care. To remedy this injustice, healthcare professionals, members of the global community, and women's leaders everywhere must undertake a concerted effort to accelerate movement from rhetoric to action. Lofty conference declarations are no longer enough.

It is ten years this month since the Choice on Termination of Pregnancy (CTOP) Act of 1996 was enacted. The passing of this Act was in keeping with the South African Constitution and represented a major breakthrough for women's reproductive rights. The Act allows for abortion on request to be performed at a designated health facility. This may be performed by a doctor or, during the first trimester, by a registered midwife who has completed the prescribed training course. In the second trimester, abortions may be performed by doctors up to 20 weeks' gestational age. This applies if the pregnancy endangers a woman's physical or mental health, if there is a risk of fetal abnormality, in the case of rape or incest, or if the continued pregnancy could adversely affect a woman's socio-economic situation. The Act has increased women's legal access to safe abortion services, leading to a dramatic decline in morbidity and mortality associated with unsafe abortions. However, numerous barriers continue to limit service access. One indicator of this is that almost a quarter of abortions are performed after 12 weeks of pregnancy. In addition, there is evidence that some women continue to have abortions outside of designated facilities.

Using results from the ethnographic literature and two qualitative studies on people’s representations of different means of birth control (abstinence, contraception, abortion) in two populations in Burkina Faso (one rural and one urban), we designed a multi-dimensional quantitative scale to measure individuals’ attitudes towards varied means of birth control. We applied it in two representative surveys in rural and urban Burkina Faso. Relating individuals’ attitudes towards birth control to their socio-demographic characteristics and to their attitudes towards other life dimensions, and applying N. Elias’ theory of the civilization process, we seek to explain why abortion is less tolerated, while more widely practiced, in the city than in the villages.

Restrictions on safe abortion remain a danger to women's health in industrialised countries, but strike hardest in developing countries. Legal bans on abortion exist in virtually all African countries, where they contribute to 4.2 million unsafe abortions yearly, and to 12% of maternal deaths.Conscientious objection by health professionals can hinder safe abortion even where policies are liberal. We anonymously surveyed attitudes of medical students and physicians towards abortion in Cameroon-a sub-Saharan country where a population of 16 million is served by 1500 physicians practising mostly in public hospitals without universal insurance coverage. Our sample consisted of physicians attending the 2002 Cameroon National Medical Conference (n=300), and medical students at the Yaounde Medical School (n=400). The methods are reported elsewhere.

To the Editor: The Choice on Termination of Pregnancy Act appears to have had a very marked impact on abortion-related mortality. This conclusion can be drawn by comparing the number of abortion-related deaths found in the Confidential Enquiries into Maternal Deaths (Department of Health 1999 and 2003)2,3 and the 2000 national incomplete-abortion survey with the estimates of pre-legislative reform mortality found in the 1994 national incomplete-abortion survey. The latter survey estimated that there were 425 (78 - 736) deaths each year in public facilities from unsafe abortion. When the survey was repeated in 2000, no deaths were detected in the 3-week data collection period in any study hospital. We could conclude that a significant decline in mortality had occurred but it was not possible to estimate the annual number of deaths accurately. The Confidential Enquiries, however, provide complete ascertainment of hospital deaths and so no estimation is needed. In the 1998 Confidential Enquiry,2 32 abortion-related maternal deaths (5.7% of the total) were found. The Second Report (1999 - 2001)3 found 40 abortion-related deaths per year. Comparison of the 1994 research estimate and the 1998 - 2001 mortality data (averaged) suggests that there has been a 91.1% reduction in deaths from unsafe abortion, with a possible range of 51.3 - 94.8% depending on the position of the true figure in 1994 within the confidence intervals of the estimate. This reduction in mortality after abortion legalisation is even greater than that reported in other countries, such as Romania, and shows that this legislation has been extremely successful in advancing women's health and rights.

Background: Postabortion care (PAC), is a package of services provided to women who have had an incomplete spontaneous or induced abortion. Knowing the users and non-users of PAC and reasons for use and none-use is important. Objective: The study aimed at identifying PAC service users and non-users and reasons for using or not using the PAC services. Methods: A total of 103 users and six non-users of PAC services were interviewed. Results: Most of the PAC users were young, not formally employed, single and educated to secondary or primary education. Information sharing about one’s health status; support from partner, relative or parents; privacy and absence of queues availability of PAC services and availability of transport enhanced utilization. Inability to pay for PAC services, fear of healthcare providers, fear of being arrested and avoiding stigma hampered utilization. Conclusion. Reducing abortion stigma and making PAC services affordable may increase its use. Key words: Postabortion care, utilization, abortion complications, non-user, Tanzania

"Safe abortion is a necessary prerequisite of the human rights to health and gender nondiscrimination, yet half of abortions globally are still unsafe—contributing to 13% of maternal mortality. In South Africa, abortion was legalized after Apartheid in 1996, but today an estimated 58% of abortions remain unsafe there and researchers have observed resurgence in abortion-related deaths since 2002. Preliminary evidence suggests Black African women of lower socioeconomic position, particularly those living with HIV, are at disproportionate risk of unsafe abortion-related complications and death. Poor access to safe services is often cited as the major barrier to safe abortion. While most researchers have attributed such limited access to abortion stigma, it remains unclear how prevalent negative abortion attitudes are in South Africa today, how those might have changed over time, or whether differences exist by race or socioeconomic position. The current study analyzes abortion attitudes collected in a nationally representative sample from the South African Social Attitudes Survey in 2013. First, the study investigates how prevalent negative abortion attitudes are in South Africa today. Then binary logistic regression models of negative abortion attitudes are used to calculate odds ratios for race, educational attainment, and household income. Binary logistic regression models are also estimated stratified by race and education level. Results suggest an important role of secondary and post-secondary education in addressing abortion stigma. Significant differences in abortion attitudes are noted by province but not by race. "

This article reports a clinical case study of “Grace”, a black Zimbabwean woman with post-abortion syndrome (PAS), a form of post-traumatic stress disorder precipitated by aborting an unwanted pregnancy. She was treated by a middle class white South African trainee Clinical Psychologist. The case narrative documents the assessment and the course of treatment which was guided by ongoing case formulation based on current evidence-based models. Factors that made her vulnerable to developing PTSD included active suppression of the memory of the event and lack of social support. An understanding of these factors was used to guide an effective intervention. In spite of the differences in culture and background between client and therapist, there was considerable commonality in their experience as young women and students who each had to balance personal and occupational priorities. The narrative also highlights the commonalities of Grace's experiences with those reported in the literature on post-abortion syndrome, which is mostly from the U. S. A. and Europe.

Restrictive abortion laws are, perhaps correctly, blamed for the high mortality and morbidity associated with unsafe abortion in low-income countries. Induced abortion is illegal in Nigeria, except for strict medical indications certified by at least 2 doctors. Legalization could enable women with unwanted pregnancies to procure safe induced abortions from health facilities; however, abortions performed by caregivers in private health facilities may not be entirely safe—consistent with clinical experience and previous studies from Nigeria in which physicians at private hospitals were implicated by patients in a significant proportion of complicated induced abortions.