Online abortion drug sales in Indonesia: a quality of care assessment

by Ann M Moore, Jesse Philbin, Iwan Ariawan, Meiwita Budiharsana, Rachel Murro, Riznawaty Imma Aryanty, Akinrinola Bankole

Studies in Family Planning, 20 October 2020  (Open access) DOI: https://doi.org/10.1111/sifp.12138

This study sought to understand the experience of buying misoprostol online for pregnancy termination in Indonesia. We conducted a mystery client study August through October, 2019. Interactions were analyzed quantitatively and qualitatively, along with the contents of the packages. One hundred ten sellers were contacted, from whom mystery clients made 76 purchases and received 64 drug packages. Almost all sellers sold “packets” containing multiple drugs; 73 percent of packets contained misoprostol, and 47 percent contained at least 800 mcg of misoprostol. Thirty‐four packets contained insufficient drugs to complete an abortion. When compared to WHO standards, 87 percent of sellers imparted incomplete information about potential physical effects; no seller provided information about possible complications. Women buying misoprostol from informal online drugs sellers will be underprepared for understanding potential side effects and complications. Educational activities are needed to increase women’s access to information about safe use of misoprostol as a harm reduction strategy.



Induced abortion incidence and safety in Rajasthan, India: evidence that expansion of services is needed

by Danish Ahmad, Mridula Shankar, Anoop Khanna, Caroline Moreau, Suzanne Bell

Studies in Family Planning, 3 December 2020 (early view, not open access)

Despite induced abortion being broadly legal in India, up‐to‐date information on its frequency and safety is not readily available. Using direct and indirect methodological approaches, this study measures the one‐year incidence and safety of induced abortions among women in the state of Rajasthan [date of study not stated]. The analysis utilizes data from a population‐based survey of 5,832 reproductive aged women who reported on the abortion experiences of their closest female confidante in addition to themselves. We separately assess correlates of having a recent and most unsafe abortion using multivariable regression models. The confidante approach produced a one‐year abortion incidence estimate of 23 per 1,000 women, whereas the respondent estimate is 9.5 per 1,000 women. Based on the confidante estimate, approximately 441,000 abortions occurred in Rajasthan over a year. Overall, 25 and 29 percent of respondent and confidante reported abortions were classified as most unsafe. Results suggest that abortion remains an integral component of women’s fertility regulation, and that a liberal law alone is insufficient to guarantee access to safe abortion services. Existing policies on abortion in India need updating to permit task sharing in line with current recommendations to expand service delivery so that demand is met through provision of safe and accessible services.



The syndemic of Covid-19 and gender-based violence in humanitarian settings: leveraging lessons from Ebola in the Democratic Republic of Congo

by Lindsay Stark, Melissa Meinhart, Luissa Vahedi, Simone E Carter, Elisabeth Roesch, Isabel Scott Moncrieff, Philomene Mwanze Palaku, Flore Rossi, Catherine Poulton

BMJ Global Health, 18 November 2020;5:e004194. doi:10.1136/ bmjgh-2020-004194

– Efforts to situate gender-based violence (GBV) within the COVID-19 pandemic remain inadequate. Based on the knowledge that the public health crises of violence and infectious disease are intersecting, we use a syndemic perspective to examine their shared influence in humanitarian settings.

– When the humanitarian community exclusively prioritises the lives saved from infectious diseases, such as Ebola and COVID-19, the lives impacted by interrelated factors, such as GBV, can be overlooked.

– This narrative leverages learnings from the 2018–2020 Ebola outbreak in the Democratic Republic of the Congo (DRC) to inform and strengthen ongoing responses related to GBV and COVID-19 within humanitarian settings.

– For both Ebola and COVID-19, response efforts have overlooked the life-saving nature of GBV services. These services, including one-stop crisis centres and safe spaces, are vulnerable to cessation when health service providers attempt to prevent and control the spread of infectious disease without incorporating a gender-sensitive lens.

– A critical opportunity to integrate women within response planning is through local women’s organisations which are already embedded in local communities

SOURCE: RAISE/IAWG Literature Review, E-mail, 4 December 2020



Integrating sexual and reproductive health into health system strengthening in humanitarian settings: a planning workshop toolkit to transition from minimum to comprehensive services in the Demo

by Nguyen Toan Tran, Alison Greer, Brigitte Kini, Hassan Abdi, Kariman Rajeh, Hilde Cortier, Mohira Boboeva

Conflict and Health, 25 November 2020;14:Article 81  Open access

Background: Planning to transition from the Minimum Initial Service Package for Sexual and Reproductive Health (SRH) toward comprehensive SRH services has been a challenge in humanitarian settings. To bridge this gap, a workshop toolkit for SRH coordinators was designed to support effective planning. This article aims to describe the toolkit design, piloting, and final product.

Methods: Anchored in the Health System Building Blocks Framework of the World Health Organization, the design entailed two complementary and participatory strategies. First, a collaborative design phase with iterative feedback loops involved global partners with extensive operational experience in the initial toolkit conception. The second phase engaged stakeholders from three major humanitarian crises to participate in pilot workshops to contextualize, evaluate, validate, and improve the toolkit using qualitative interviews and end-of-workshop evaluations. The aim of this two-phase design process was to finalize a planning toolkit that can be utilized in and adapted to diverse humanitarian contexts, and efficiently and effectively meet its objectives. Pilots occurred in the Democratic Republic of Congo for the Kasai region crisis, Bangladesh for the Rohingya humanitarian response in Cox’s Bazar, and Yemen for selected Governorates.

Results: Results suggest that the toolkit enabled facilitators to foster a systematic, participatory, interactive, and inclusive planning process among participants over a two-day workshop. The approach was reportedly effective and time-efficient in producing a joint work plan. The main planning priorities cutting across settings included improving comprehensive SRH services in general, healthcare workforce strengthening, such as midwifery capacity development, increasing community mobilization and engagement, focusing on adolescent SRH, and enhancing maternal and newborn health services in terms of quality, coverage, and referral pathways. Recommendations for improvement included a dedicated and adequately anticipated pre-workshop preparation to gather relevant data, encouraging participants to undertake preliminary study to equalize knowledge to partake fully in the workshop, and enlisting participants from marginalized and underserved populations.

Conclusion: Collaborative design and piloting efforts resulted in a workshop toolkit that could support a systematic and efficient identification of priority activities and services related to comprehensive SRH. Such priorities could help meet the SRH needs of communities emerging from acute humanitarian situations while strengthening the overall health system.

SOURCE: RAISE/IAWG Literature Review, E-mail, 4 December 2020



Young women’s complex patterns of contraceptive use: findings from an Australian cohort study

by Melissa Harris, Jacqueline Coombe, Peta M Forder, Jayne C Lucke, Deborah Bateson, Deborah Loxton

Perspectives on Sexual and Reproductive Health, 17 November 2020  (Not open access)

DOI: https://doi.org/10.1363/psrh.12158

Context: Unintended pregnancy is common among young women. Understanding how such women use contraceptives – including method combinations – is essential to providing high‐quality contraceptive care.

Methods: Data were from a representative cohort of 2,965 Australian women aged 18–23 who participated in the 2012–2013 Contraceptive Use, Pregnancy Intention and Decisions baseline survey, had been heterosexually active in the previous six months, and were not pregnant or trying to conceive. Latent class analysis was employed to characterize women’s contraceptive choices; multinomial logistic regression was used to evaluate correlates of membership in the identified classes.

Results: The vast majority of women (96%) reported using one or more contraceptives, most commonly short‐acting hormonal methods (60%), barrier methods (38%), long‐acting contraceptives (16%) and withdrawal (15%). In total, 32 combinations were reported. Four latent classes of method use were identified: no contraception (4% of women); short‐acting hormonal methods with supplementation (59%, mostly the pill); high‐efficacy contraceptives with supplementation (15%, all long‐acting reversible contraceptive users); and low‐efficacy contraceptive combinations (21%); supplementation usually involved barrier methods or withdrawal. Class membership differed according to women’s characteristics; for example, women who had ever been pregnant were more likely than other women to be in the no‐contraception, high‐efficacy contraceptive or low‐efficacy contraceptive combination classes than in the short‐acting hormonal contraceptive class (odds ratios, 2.0‐3.0).

Conclusions: The complexity of women’s contraceptive choices and the associations between latent classes and such characteristics as pregnancy history highlight the need for individualized approaches to pregnancy prevention and contraceptive care.



Abortion clinics are rapidly closing; many won’t come back

Time, by Abigail Abrams, 2 December 2020

Excerpts from the article:

Dr Yashica Robinson is an optimist… As one of the last abortion providers in Alabama, a willingness to see the bright side is practically a job requirement. For much of the past year, Robinson, who is the medical director at the Huntsville-based Alabama Women’s Center for Reproductive Alternatives, and her staff have fought to overcome the challenges posed by Covid-19, while simultaneously battling a state effort to suspend all abortion services during the pandemic. “We will continue to be innovative and be creative and find ways that we will make this work,” she says, with characteristic resolve. But there’s one topic that clouds Robinson’s confident disposition: her clinic’s limping finances.

Most independent abortion clinics across the country are in a similar boat. Keeping clinic doors open during COVID-19 has required spending much more money—on on cleaning and personal protective equipment, and on hiring more staff to facilitate social distancing rules that also reduced the number of patients who could be seen. At at the same time, 11 states temporarily suspended abortion services this spring, amid the growing pandemic. While all of those orders were blocked by courts or expired, the temporary closures and legal battles were financially devastating for independent abortion clinics. Meanwhile, as layoffs have spiked and businesses have gone under, patients have been less able to pay for their care, putting clinics even more in the red….

….When independent abortion clinics do close because of these increasing obstacles, that can leave patients in some parts of the country with severely limited access to abortion and other health services. Five states have only one abortion clinic remaining, according to the Abortion Care Network report, and a number of others rely completely on a small number of independent abortion clinics. And while most abortions take place during the first trimester of pregnancy, when someone does need an abortion later on, independent clinics are more likely to provide those services. Independent clinics represent 66% of all clinics that provide abortions after 16 weeks, and after 22 weeks, independent clinics make up 81% of those providing care.

Once abortion clinics close, they rarely reopen. The startup costs and hurdles, including applying for credit, finding a space that will rent to an abortion clinic and complying with many state’s strict abortion laws, are particularly difficult for independent abortion clinics to overcome…. [continues]



Government stakeholders’ perspectives on the family planning environment in three Nigerian cities: qualitative findings from the Nigerian Urban Reproductive Health Initiative Sustainability Study

Global Health Action, 2020;13(1)

Background: The Nigerian government has made numerous commitments to expanding access to family planning services for its population yet has faced many challenges in implementing these commitments. Foreign donors provide support for expanding access to family planning in key populations.

Objective: This study examines the family planning environment after donor funding has ended, including how government stakeholders perceive family planning services and their role in providing them post-donor funding.

Methods: The NURHI Sustainability Study used qualitative data to evaluate the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI), which focused on increasing the use of modern contraceptive methods, particularly among the urban poor. This study presents results from in-depth interviews with 16 key government stakeholders, selected using purposive sampling methods, in three cities: Ilorin (where NURHI Phase 1 programming discontinued in 2015), Kaduna (where programming continued under NURHI Phase 2), and Jos (a comparison city). A thematic analysis was employed to identify key themes related to government stakeholders’ perspectives on the family planning environment and sustainability of NURHI programming.

Results: Respondents from all three cities highlighted local political leaders’ positive perceptions about family planning. All respondents were open to continued foreign donor support for family planning services while respondents in Kaduna and Jos emphasized the need for governments to lead efforts among all family planning actors. Stakeholders highlighted the benefits of a dedicated and implemented family planning budget line and encouraged continued state financial support. Respondents in Kaduna and Ilorin praised the positive influence of NURHI programming while those from Ilorin reflected on the need for future programs to gradually close-out their efforts to support sustainability.

Conclusions: As donors look to transition to government ownership of family planning efforts, it is important for family planning programs to understand and incorporate government stakeholders’ perspectives into their sustainability planning efforts.

From Background section: Nigeria’s population more than doubled in size from 1990 to 2019 and is expected to grow by 200 million from 2019 to 2050, an absolute growth in population numbers only exceeded by India. The Nigerian government faces many challenges in ensuring that such a large population is healthy and educated, highlighting the need for quality family planning (FP) services. In 2018, 10.5% of all women of reproductive age in Nigeria were using a modern contraceptive method. As part of their FP2020 commitment, the Nigerian government pledged in 2012 to achieve a modern contraceptive prevalence rate of 27% among all women of reproductive age by 2020. Projections indicate that Nigeria is not on track to meet this ambitious goal since the 2020 estimated prevalence is 14.8%.



Medical Abortion and Self-Managed Abortion: Frequently Asked Questions on Health and Human Rights

by Center for Reproductive Rights and Ipas, 2 December 2020

This publication answers the following questions:

  • What is medical abortion
  • How safe and effective is medical abortion?
  • How is medical abortion regulated?
  • What is self-managed abortion?
  • Is self-managed abortion safe?
  • Is self-managed abortion legal?
  • Why do people self-manage their abortions?
  • What does international human rights law say on abortion and on medical abortion?
  • What is the impact of COVID-19 on self-managed medical abortion?

The document also includes a set of recommendations to States and to United Nations treaty bodies that would improve access to services and respect, protect and fulfil human rights, and detailed endnotes.