Caitlin Gerdts

Impact of Clinic Closures on Women Obtaining Abortion Services After Implementation of a Restrictive Law in Texas

OBJECTIVES To evaluate the additional burdens experienced by Texas abortion patients whose nearest in-state clinic was one of more than half of facilities providing abortion that had closed after the introduction of House Bill 2 in 2013. METHODS In mid-2014, we surveyed Texas-resident women seeking abortions in 10 Texas facilities (n = 398), including both Planned Parenthood-affiliated clinics and independent providers that performed more than 1500 abortions in 2013 and provided procedures up to a gestational age of at least 14 weeks from last menstrual period. We compared indicators of burden for women whose nearest clinic in 2013 closed and those whose nearest clinic remained open. RESULTS For women whose nearest clinic closed (38%), the mean one-way distance traveled was 85 miles, compared with 22 miles for women whose nearest clinic remained open (P ≤ .001). After adjustment, more women whose nearest clinic closed traveled more than 50 miles (44% vs 10%), had out-of-pocket expenses greater than

Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model

100 (32% vs 20%), had a frustrated demand for medication abortion (37% vs 22%), and reported that it was somewhat or very hard to get to the clinic (36% vs 18%; P < .05). CONCLUSIONS Clinic closures after House Bill 2 resulted in significant burdens for women able to obtain care.

Measuring Unsafe Abortion-Related Mortality: A Systematic Review of the Existing Methods

Summary Background Global estimates of unsafe abortions have been produced for 1995, 2003, and 2008. However, reconceptualisation of the framework and methods for estimating abortion safety is needed owing to the increased availability of simple methods for safe abortion (eg, medical abortion), the increasingly widespread use of misoprostol outside formal health systems in contexts where abortion is legally restricted, and the need to account for the multiple factors that affect abortion safety. Methods We used all available empirical data on abortion methods, providers, and settings, and factors affecting safety as covariates within a Bayesian hierarchical model to estimate the global, regional, and subregional distributions of abortion by safety categories. We used a three-tiered categorisation based on the WHO definition of unsafe abortion and WHO guidelines on safe abortion to categorise abortions as safe or unsafe and to further divide unsafe abortions into two categories of less safe and least safe. Findings Of the 55· 7 million abortions that occurred worldwide each year between 2010–14, we estimated that 30·6 million (54·9%, 90% uncertainty interval 49·9–59·4) were safe, 17·1 million (30·7%, 25·5–35·6) were less safe, and 8·0 million (14·4%, 11·5–18·1) were least safe. Thus, 25·1 million (45·1%, 40·6–50·1) abortions each year between 2010 and 2014 were unsafe, with 24·3 million (97%) of these in developing countries. The proportion of unsafe abortions was significantly higher in developing countries than developed countries (49·5% vs 12·5%). When grouped by the legal status of abortion, the proportion of unsafe abortions was significantly higher in countries with highly restrictive abortion laws than in those with less restrictive laws. Interpretation Increased efforts are needed, especially in developing countries, to ensure access to safe abortion. The paucity of empirical data is a limitation of these findings. Improved in-country data for health services and innovative research to address these gaps are needed to improve future estimates. Funding UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction; David and Lucile Packard Foundation; UK Aid from the UK Government; Dutch Ministry of Foreign Affairs; Norwegian Agency for Development Cooperation.

Women's experiences seeking abortion care shortly after the closure of clinics due to a restrictive law in Texas

Background The WHO estimates that 13% of maternal mortality is due to unsafe abortion, but challenges with measurement and data quality persist. To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists. Study Design To be included in this study, articles had to meet the following criteria: (1) published between September 1st, 2000-December 1st, 2011; (2) utilized data from a country where abortion is “considered unsafe”; (3) specified and enumerated causes of maternal death including “abortion”; (4) enumerated ≥100 maternal deaths; (5) a quantitative research study; (6) published in a peer-reviewed journal. Results 7,438 articles were initially identified. Thirty-six studies were ultimately included. Overall, studies rated “Very Good” found the highest estimates of abortion related mortality (median 16%, range 1–27.4%). Studies rated “Very Poor” found the lowest overall proportion of abortion related deaths (median: 2%, range 1.3–9.4%). Conclusions Improvements in the quality of data collection would facilitate better understanding global abortion-related mortality. Until improved data exist, better reporting of study procedures and standardization of the definition of abortion and abortion-related mortality should be encouraged.

Measurement of postpartum blood loss.

OBJECTIVE In 2013, Texas passed legislation restricting abortion services. Almost half of the states clinics had closed by April 2014, and there was a 13% decline in abortions in the 6 months after the first portions of the law went into effect, compared to the same period 1 year prior. We aimed to describe womens experiences seeking abortion care shortly after clinics closed and document pregnancy outcomes of women affected by these closures. STUDY DESIGN Between November 2013 and November 2014, we recruited women who sought abortion care at Texas clinics that were no longer providing services. Some participants had appointments scheduled at clinics that stopped offering care when the law went into effect; others called seeking care at clinics that had closed. Texas resident women seeking abortion in Albuquerque, New Mexico, were also recruited. RESULTS We conducted 23 in-depth interviews and performed a thematic analysis. As a result of clinic closures, women experienced confusion about where to go for abortion services, and most reported increased cost and travel time to obtain care. Having to travel farther for care also compromised their privacy. Eight women were delayed more than 1 week, two did not receive care until they were more than 12 weeks pregnant and two did not obtain their desired abortion at all. Five women considered self-inducing the abortion, but none attempted this. CONCLUSIONS The clinic closures resulted in multiple barriers to care, leading to delayed abortion care for some and preventing others from having the abortion they wanted. IMPLICATIONS The restrictions on abortion facilities that resulted in the closure of clinics in Texas created significant burdens on women that prevented them from having desired abortions. These laws may also adversely affect public health by moving women who would have had abortions in the first trimester to having second-trimester procedures.

Side Effects, Physical Health Consequences, and Mortality Associated with Abortion and Birth after an Unwanted Pregnancy

Better accuracy is only the first step towards improving outcomes

'This Is Real Misery': Experiences of Women Denied Legal Abortion in Tunisia.

INTRODUCTION The safety of abortion in the United States has been documented extensively. In the context of unwanted pregnancy, however, there are few data comparing the health consequences of having an abortion versus carrying an unwanted pregnancy to term. METHODS We examine and compare the self-reported physical health consequences after birth and abortion among participants of the Turnaway Study, which recruited women seeking abortions at 30 clinics across the United States. We also investigate and report maternal mortality among all women enrolled in the study. RESULTS In our study sample, women who gave birth reported potentially life-threatening complications, such as eclampsia and postpartum hemorrhage, whereas those having abortions did not. Women who gave birth reported the need to limit physical activity for a period of time three times longer than that reported by women who received abortions. Among all women enrolled in the Turnaway Study, one maternal death was identified-one woman who had been denied an abortion died from a condition that confers a higher risk of death among pregnant women. CONCLUSION These results reinforce the existing data on the safety of induced abortion when compared with childbirth, and highlight the risk of serious morbidity and mortality associated with childbirth after unwanted pregnancy.

Measuring abortion-related mortality: challenges and opportunities

Barriers to accessing legal abortion services in Tunisia are increasing, despite a liberal abortion law, and women are often denied wanted legal abortion services. In this paper, we seek to explore the reasons for abortion denial and whether these reasons had a legal or medical basis. We also identify barriers women faced in accessing abortion and make recommendations for improved access to quality abortion care. We recruited women immediately after they had been turned away from legal abortion services at two facilities in Tunis, Tunisia. Thirteen women consented to participate in qualitative interviews two months after they were turned away from the facility. Women were denied abortion care on the day they were recruited due to three main reasons: gestational age, health conditions, and logistical barriers. Nine women ultimately terminated their pregnancies at another facility, and four women carried to term. None of the women attempted illegal abortion services or self-induction. Further research is needed in order to assess abortion denial from the perspective of providers and medical staff.

Reducing under-reporting of stigmatized health events using the List Experiment: results from a randomized, population-based study of abortion in Liberia

Two recent efforts to quantify the causes of maternal deaths on a global scale generated divergent estimates of abortion-related mortality. Such discrepancies in estimates of abortion-related mortality present an important opportunity to explore unique challenges and opportunities associated with the generation and interpretation of abortion-related mortality estimates. While innovations in primary data collection and estimation methodologies are much needed, at the very least, studies that seek to measure maternal deaths due to abortion should endeavor to improve transparency, acknowledge limitations of data, and contextualize results. As we move towards sustainable development goals beyond 2015, the need for valid and reliable estimates of abortion-related mortality has never been more pressing. The post-MDG development agenda that aims to improve global health, reduce health inequities, and increase accountability, requires new and novel approaches be tested to improve measurement and estimation of abortion-related mortality, as well as incidence, safety and morbidity.

Conscientious objection to abortion provision: Why context matters

BACKGROUND Direct measurement of sensitive health events is often limited by high levels of under-reporting due to stigma and concerns about privacy. Abortion in particular is notoriously difficult to measure. This study implements a novel method to estimate the cumulative lifetime incidence of induced abortion in Liberia. METHODS In a randomly selected sample of 3219 women ages 15–49 years in June 2013 in Liberia, we implemented the ‘Double List Experiment’. To measure abortion incidence, each woman was read two lists: (A) a list of non-sensitive items and (B) a list of correlated non-sensitive items with abortion added. The sensitive item, abortion, was randomly added to either List A or List B for each respondent. The respondent reported a simple count of the options on each list that she had experienced, without indicating which options. Difference in means calculations between the average counts for each list were then averaged to provide an estimate of the population proportion that has had an abortion. RESULTS The list experiment estimates that 32% [95% confidence interval (CI): 0.29-0.34) of respondents surveyed had ever had an abortion (26% of women in urban areas, and 36% of women in rural areas, P-value for difference < 0.001), with a 95% response rate. CONCLUSIONS The list experiment generated an estimate five times greater than the only previous representative estimate of abortion in Liberia, indicating the potential utility of this method to reduce under-reporting in the measurement of abortion. The method could be widely applied to measure other stigmatized health topics, including sexual behaviours, sexual assault or domestic violence.