Changes in Morbidity and Abortion Care in Ethiopia After Legal Reform: National Results from 2008 and 2014.
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ABSTRACT: In Ethiopia, liberalization of the abortion law in 2005 led to changes in abortion services. It is important to examine how levels and types of abortion care-i.e., legal abortion and treatment of abortion complications-changed over time.Between December 2013 and May 2014, data were collected on symptoms, procedures and treatment from 5,604 women who sought abortion care at a sample of 439 public and private health facilities; the sample did not include lower-level private facilities-some of which provide abortion care-to maintain comparability with the sample from a 2008 study. These data were combined with monitoring data from 105,806 women treated in 74 nongovernmental organization facilities in 2013. Descriptive analyses were conducted and annual estimates were calculated to compare the numbers and types of abortion care services provided in 2008 and 2014.The estimated annual number of women seeking a legal abortion in the types of facilities sampled increased from 158,000 in 2008 to 220,000 in 2014, and the estimated number presenting for postabortion care increased from 58,000 to 125,000. The proportion of abortion care provided in the public sector increased from 36% to 56% nationally. The proportion of women presenting for postabortion care who had severe complications rose from 7% to 11%, the share of all abortion procedures accounted for by medical abortion increased from 0% to 36%, and the proportion of abortion care provided by midlevel health workers increased from 48% to 83%. Most women received postabortion contraception.Ethiopia has made substantial progress in expanding comprehensive abortion care; however, eradication of morbidity from unsafe abortion has not yet been achieved.
Project description:In 2005, Ethiopia's parliament amended the penal code to expand the circumstances in which abortion is legal. Although the country has expanded access to abortion and postabortion care, the last estimates of abortion incidence date from 2008.Data were collected in 2014 from a nationally representative sample of 822 facilities that provide abortion or postabortion care, and from 82 key informants knowledgeable about abortion services in Ethiopia. The Abortion Incidence Complications Methodology and the Prospective Morbidity Methodology were used to estimate the incidence of abortion in Ethiopia and assess trends since 2008.An estimated 620,300 induced abortions were performed in Ethiopia in 2014. The annual abortion rate was 28 per 1,000 women aged 15-49, an increase from 22 per 1,000 in 2008, and was highest in urban regions (Addis Ababa, Dire Dawa and Harari). Between 2008 and 2014, the proportion of abortions occurring in facilities rose from 27% to 53%, and the number of such abortions increased substantially; nonetheless, an estimated 294,100 abortions occurred outside of health facilities in 2014. The number of women receiving treatment for complications from induced abortion nearly doubled between 2008 and 2014, from 52,600 to 103,600. Thirty-eight percent of pregnancies were unintended in 2014, a slight decline from 42% in 2008.Although the increases in the number of women obtaining legal abortions and postabortion care are consistent with improvements in women's access to health care, a substantial number of abortions continue to occur outside of health facilities, a reality that must be addressed.
Project description:BackgroundIn August 2017, Chile lifted its complete ban on abortion by permitting abortion in three limited circumstances: 1) to save a woman's life, 2) lethal fetal anomaly, and 3) rape. The new law allows regulated use of conscientious objection (CO) in abortion care, including allowing institutions to register as objectors. This study assesses medical and midwifery students' support for CO, following legal reform.MethodsFrom October 2017 to May 2018, we surveyed medical and midwifery students from seven universities located in Santiago, Chile. Universities included 4 secular (2 public and 2 private) and 3 private religiously-affiliated universities; all offering medical degrees with a specialization in obstetrics and gynecology (ob-gyn) and five offering midwifery degrees. We used generalized estimating equations (GEE) to identify characteristics associated with student support for CO, intentions to use CO to refuse to care for someone seeking abortion, and support for CO at the institutional level.Results333 of the 413 eligible students who opened the survey, completed the questions on conscientious objection; 26% were seeking medical degrees with an ob-gyn specialty, 25% were seeking midwifery degrees, and 49% were seeking medical degrees and had not yet decided their specialty. While nearly all endorse requirements for conscientious objecting clinicians to inform (92%) and refer (91%) abortion-seeking patients, a minority (18%) would personally use conscientious objection to avoid caring for a patient seeking abortion (12% secular and 39% religious university students). About half of religious-university students (52%) and one-fifth of secular-university (20%) students support objections at the institutional level.ConclusionsMost students support the regulated use of CO which preserves patients' access to abortion care. Religious-university student views on the use of conscientious objection in abortion care are discordant with those of their institutions which currently support institutional-level objections.
Project description:Argentina's 2021 abortion law grants the right to abortion on-request up to 14 weeks' gestation, as well as continuing to allow abortion after 14 weeks on specific grounds. The early years after law reform provide a unique opportunity to assess progress and identify barriers, to both inform program improvements and guide other countries undergoing reform. This study assesses the first two years of law implementation. We surveyed a purposive sample of 45 key informants about implementation successes and barriers. In addition, we surveyed 223 public health facilities (selected through stratified systematic random sampling) in three provinces: Buenos Aires, Chaco and La Rioja. We collected information on abortion services, resources, personnel, training, and obstacles to provision. We present weighted results on characteristics of abortion provision by facilities, representative of each province, complemented by key informant perspectives. Two years into law reform, abortions under 14 weeks were offered in a large number of facilities at all levels, while later abortions were offered mainly in hospitals. Facilities adhered to protocols, had adequate supplies, and kept comprehensive records. Over 90% of abortions were performed using misoprostol, with MVA accounting for most of the remainder. Major barriers to provision included insufficient personnel, exacerbated by high levels of conscientious objection (over 60% of hospitals had at least 2 objecting doctors), and inadequate training in methods other than misoprostol, particularly among health centers. Argentina has made impressive advances in the short time since law reform. Implementation could be improved by increasing personnel (through incentives, task-shifting, and enforcement of conscientious objection regulations), strengthening training on different abortion techniques, and expanding public information campaigns about abortion rights and services available. In the face of diminished support for abortion under the new government, measures to strengthen abortion services and reduce stigma are critical, if reproductive rights are to be upheld.
Project description:IntroductionIn Nepal, abortion is legal on request through 12 weeks of pregnancy and up to 28 weeks for health and other reasons. Abortion is available at public facilities at no cost and by trained private providers. Yet, over half of abortions are provided outside this legal system. We sought to investigate the extent to which patients are denied an abortion at clinics legally able to provide services and factors associated with presenting late for care, being denied, and receiving an abortion after being denied.MethodsWe used data from a prospective longitudinal study with 1835 women aged 15-45. Between April 2019 and December 2020, we recruited 1,835 women seeking abortions at 22 sites across Nepal, including those seeking care at any gestational age (n = 537) and then only those seeking care at or after 10 weeks of gestation or do not know their gestational age (n = 1,298). We conducted interviewer-led surveys with these women at the time they were seeking abortion service (n = 1,835), at six weeks after abortion-seeking (n = 1523) and six-month intervals for three years. Using descriptive and multivariable logistic regression models, we examined factors associated with presenting for abortion before versus after 10 weeks gestation, with receiving versus being denied an abortion, and with continuing the pregnancy after being denied care. We also described reasons for the denial of care and how and where participants sought abortion care subsequent to being denied. Mixed-effects models was used to accounting clustering effect at the facility level.ResultsAmong those recruited when eligibility included seeking abortion at any gestational age, four in ten women sought abortion care beyond 10 weeks or did not know their gestation and just over one in ten was denied care. Of the full sample, 73% were at or beyond 10 weeks gestation, 44% were denied care, and 60% of those denied continued to seek care after denial. Nearly three-quarters of those denied care were legally eligible for abortion, based on their gestation and pre-existing conditions. Women with lower socioeconomic status, including those who were younger, less educated, and less wealthy, were more likely to present later for abortion, more likely to be turned away, and more likely to continue the pregnancy after denial of care.ConclusionDenial of legal abortion care in Nepal is common, particularly among those with fewer resources. The majority of those denied in the sample should have been able to obtain care according to Nepal's abortion law. Abortion denial could have significant potential implications for the health and well-being of women and their families in Nepal.
Project description:ObjectiveTo assess the availability of an institutional-level respectful maternity care (RMC) index, its components, and associated factors.MethodsA cross-sectional study design was applied to a 2016 census of 3804 health facilities in Ethiopia. The availability of an institutional-level RMC index was computed as the availability of all nine items identified as important aspects of institutional-level RMC during childbirth. Logistic regression analysis was used to identify factors associated with availability of the index.ResultsThree components of the institutional-level RMC index were identified: "RMC policy," "RMC experience," and "facility for provision of RMC." Overall, 28% of facilities (hospitals, 29.9%; health centers, 27.8%) reported availability of the institutional-level RMC index. Facility location urbanization (urban region), percentage of maternal and newborn health workers trained in basic emergency obstetric and newborn care, and availability of maternity waiting homes in health facilities were positively associated with availability of the institutional-level RMC index.ConclusionOnly one in three facilities reported availability of the institutional-level RMC index. The Ethiopian government should consider strengthening support mechanisms in different administrative regions (urban, pastoralist, and agrarian), implementing the provision training for health workers that incorporates RMC components, and increasing the availability of maternity waiting homes.
Project description:Background: Chronic obstructive pulmonary disease (COPD) remains a leading cause of disability and death in the United States. The "COPD in the United States" project gathered data about the impact of COPD to highlight variability across states and provide a single point of access to data for state decision makers, the public health community and advocates. This report provides a summary of COPD-related morbidity and mortality in the United States and individual states during 2014-2015 (some metrics contain data from other years). Methods: We used data from multiple sources ( the Behavioral Risk Factor Surveillance System [BRFSS], the Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research online database, the CDC's chronic disease indicators data, Centers from Medicare and Medicaid Services Chronic Conditions Data Warehouse, Medical Expenditures Panel Survey and the American Association of Cardiovascular and Pulmonary Rehabilitation Pulmonary Rehabilitation Directory) to estimate 10 national and state-specific COPD metrics (prevalence, hospitalizations and emergency department visits, 30-day hospital readmissions, mortality, vaccinations, smoking prevalence, per capita medical cost, and the number of COPD patients per a pulmonary rehabilitation program) and to calculate average score across the 10 metrics. Additionally, we used BRFSS data to calculate the prevalence of common comorbid diseases among people who also report having a diagnosis of COPD. Results: During 2014-2015, 5.9% of adults (more than 15.9 million) reported having been told by their health care professional that they had COPD. The age-adjusted prevalence ranged from 3.7% for Puerto Rico and Hawaii, to 12% for West Virginia. The average score, 1 being best and 5 being worst, of the overall COPD burden based on the 10 key metrics ranged from 1.5 for Puerto Rico and Utah to 4.6 for West Virginia. Conclusion: The level of COPD morbidity and mortality is severe throughout the United States. There is considerable variability in COPD metrics by state. These differences may be useful in identifying and addressing policy gaps in the public health approach to COPD and in implementing the COPD National Action Plan.
Project description:Lesbian, gay, and bisexual (LGB) individuals have higher prevalence of lifetime suicide ideation and attempt than their heterosexual peers, but less is known about differences in suicide acceptability (i.e., believing suicide is a viable answer to a problem). The purpose of this study was to examine if LGB adults had greater suicide acceptability than heterosexual adults. A total of 4 items in the General Social Surveys from 2008 to 2014 assessed whether a nationally representative sample of U.S. adult respondents (n = 5,037) thought it acceptable for individuals to kill themselves if one: goes bankrupt, dishonors their family, is tired of living, or has an incurable disease. Multiple logistic regression analyses were used to assess the association of sexual orientation with suicide acceptability items after adjusting for confounding factors. Compared with heterosexuals, lesbians/gays had higher odds of reporting suicide acceptability if one goes bankrupt (OR = 1.92; 95% CI: 1.06, 3.46), dishonors family (OR = 1.83; 95% CI: 1.01, 3.28), or is tired of living (OR = 2.25; 95% CI: 1.30, 3.90). Bisexual and heterosexual groups were largely similar across the 4 suicide acceptability items. No sexual orientation differences were observed for reporting acceptability of suicide in the instance of an incurable disease. Post hoc analyses revealed significant interactions between sex and sexual orientation, such that differences in suicide acceptability seemed to be driven by sexual minority women rather than by sexual minority men. Suicide acceptability differs by sexual orientation, and community-level interventions around changing norms about suicide may be a prevention strategy for sexual minority individuals.
Project description:BackgroundFamily planning (FP) is part of Ethiopia's essential health service package. However, integrating FP into other health care services is a relatively new concept. Integrated service can minimize missed opportunities and allow health workers to provide FP services and Reproductive, Maternal, Newborn, Child, Adolescent, and Nutrition (RMNCAH-N) services simultaneously. Thus, the objective of this study was to assess the levels of FP integration into maternal and child health (MCH) services at primary health care service delivery units in Ethiopia.MethodsThis was a facility-based cross-sectional study conducted from July to October 2022. We conducted a nationally representative survey of primary health care (PHC) facilities selected from seven regions and two-city administrations in Ethiopia to assess the current level of FP integration across four service delivery units (antenatal care unit, postnatal care unit, post-abortion care unit, and immunization unit) of the facilities. We collected data from selected health facilities through interview with health facility managers, healthcare providers in the selected service units, clients seeking health services, and extraction of data from facility records. We employed descriptive analysis, and categorized the degree of FP integration according to the FP information and services provided in the selected service delivery units.ResultsThis national FP integration survey included 122 health facilities (39 primary hospitals, 42 health centers, and 41 health posts) from seven regions and two city administrations. The study found a huge discrepancy regarding FP counselling given at ANC, PNC, PAC, and immunization service delivery units as reported by health care providers and clients. The proportion of PNC and immunization clients who received FP counselling was higher at health post compared to hospitals and health centers. Moreover, the proportion of PAC clients who received FP information was higher in primary hospitals compared to health centers.ConclusionData from facility records and provider interviews showed significant FP integration within ANC, PNC, and immunization units of PHC facilities. However, client exit interviews indicated low FP counselling integration. Facility records revealed few PNC and PAC clients received contraceptives in the past year. The study found high FP counselling and provision of at least one short- or long-acting contraceptive at PNC and PAC units. No facility offered contraceptives at immunization units, indicating missed FP integration opportunities.