Grady Arnott

To be, or not to be, referred: A qualitative study of women from Burma's access to legal abortion care in Thailand

Background Reproductive health outcomes among women from Burma who live along the Thailand-Burma border demonstrate an unmet need for access to safe abortion services. In 2014, a multi-national team launched a collaborative three-year initiative to expand a program that refers eligible women for safe and legal abortion care to government Thai hospitals in Tak province, Thailand. Methods Over a six-month period we conducted 14 in-depth open-ended interviews with women from Burma who were referred through the program or denied a wanted abortion after being deemed ineligible for referral by staff at the participating clinic. We analyzed the interviews for content and themes using both deductive and inductive techniques. Results Women’s experiences accessing legal abortion care were positive and facilitated by appropriate options counseling, logistical support, and financial coverage. Five of the ineligible women we interviewed used traditional methods accessed on both sides of the border to self-induce an abortion and/or visited an untrained and unregulated provider. Discussion Our findings highlight the need to redouble efforts to expand access to safe and legal abortion care for women from Burma residing in northern Thailand. Ensuring that women who are denied a safe and legal abortion receive harm reduction interventions and resources is critical.

Community-based distribution of misoprostol for early abortion: evaluation of a program along the Thailand–Burma border

BACKGROUND Although abortion is legal in Thailand for a number of indications, women from Burma residing in Thailand are rarely able to access safe services. We evaluated the outcomes of a community-based distribution program that provides migrant, refugee, and cross-border women from Burma with evidence-based information about and access to misoprostol for early pregnancy termination. METHODS After determination of eligibility based on self-report and counseling, trained Network members instructed women to vaginally administer two 800-mcg doses of misoprostol 24 h apart and a third dose one week later, if needed. We systematically reviewed data from monitoring logbooks recorded over a three-year period to examine pregnancy outcomes. We also conducted in-depth open-ended interviews with the three leaders of the two Networks to understand better their perceptions and experiences as providers and counselors. We analyzed logbook data using descriptive statistics and interviews for content and themes using both deductive and inductive techniques. RESULTS From January 2012 through December 2014, 918 women received early abortion care using misoprostol through the community-based distribution program. Of these, 885 women (96.4%) were not pregnant at follow-up, 29 were pregnant at follow-up (3.2%), and four women were lost to follow-up (0.4%). Our interviews revealed that providers are motivated to participate due to concerns surrounding unsafe abortion in the community and frame their work as a public health intervention. CONCLUSIONS The documented outcomes from this initiative may be valuable for those working to reduce harm from unsafe abortion in other legally restricted, low-resource, and/or conflict-affected settings. IMPLICATIONS Our findings demonstrate that community-based distribution of misoprostol can be a safe and effective strategy for increasing access to safe abortion, even in a legally restricted, low-resource setting. Determining if similar strategies can be successfully employed in other contexts appears warranted.

No exceptions: documenting the abortion experiences of US Peace Corps volunteers

Since 1979, US federal appropriations bills have prohibited the use of federal funds from covering abortion care for Peace Corps volunteers. There are no exceptions; unlike other groups that receive health care through US federal funding streams, including Medicaid recipients, federal employees, and women in federal prisons, abortion care is not covered for volunteers even in cases of life endangerment, rape, or incest. We interviewed 433 returned Peace Corps volunteers to document opinions of, perceptions about, and experiences with obtaining abortion care. Our results regarding the abortion experiences of Peace Corps volunteers, especially those who were raped, bear witness to a profound inequity and show that the time has come to lift the “no exceptions” funding ban on abortion coverage.

“Without this program, women can lose their lives”: migrant women’s experiences with the Safe Abortion Referral Programme in Chiang Mai, Thailand

Abstract For displaced and migrant women in northern Thailand, access to health care is often limited, unwanted pregnancy is common, and unsafe abortion is a major contributor to maternal death and disability. Based on a pilot project and situational analysis research, in 2015 a multinational team introduced the Safe Abortion Referral Programme (SARP) in Chiang Mai, Thailand, to reduce the socio-linguistic, economic, documentation, and transportation barriers women from Burma face in accessing safe and legal abortion care in Thailand. Our qualitative study documented the experiences of women with unwanted pregnancies who accessed the SARP in order to inform programme improvement and expansion. We conducted 22 in-depth, in-person interviews and analysed them for content and themes using deductive and inductive techniques. Women were overwhelmingly positive about their experiences using the SARP. They reported lack of costs, friendly programme staff, accompaniment to and interpretation at the providing facility, and safety of services as key features. Financial and legal circumstances shaped access to the programme and women learned about the SARP through word-of-mouth and community workshops. After accessing the SARP and receiving support, women became community advocates for reproductive health. Efforts to expand the programme and raise awareness in migrant communities appear warranted. Our findings suggest that referral programmes for safe and legal abortion can be successful in settings with large displaced and migrant populations. Identifying ways to work within legal constraints to expand access to safe services has the potential to reduce harm from unsafe abortion even in humanitarian settings.

“It is just like having a period with back pain”: exploring women’s experiences with community-based distribution of misoprostol for early abortion on the Thailand–Burma border

INTRODUCTION The lack of economic development and longstanding conflict in Burma have led to mass population displacement. Unintended pregnancy and unsafe abortion are common and contribute to maternal death and disability. In 2011, stakeholders operating along the Thailand-Burma border established a community-based distribution program of misoprostol for early abortion, with the aim of providing safe and free abortion care in this low-resource and legally restricted setting. METHODS We conducted 16 in-depth, in-person interviews with women from Burma residing on both sides of the border who accessed misoprostol through the community-based distribution initiative. We analyzed interviews for content and themes using deductive and inductive methods. RESULTS Overall, women felt positively about their abortion experiences and the initiative. Previous abortion experiences and the recommendations of others shaped womens access. All participants, including those who remained pregnant after taking the misoprostol, would recommend the initiative to others. CONCLUSION Community-based distribution of misoprostol is an effective and culturally appropriate method of improving safe abortion care on the Thailand-Burma border. Supporting efforts to expand the harm reduction program to more communities and provide regular reproductive health and safe abortion trainings appears warranted. IMPLICATIONS In recent years, a number of organizations have launched programs dedicated to misoprostol-alone for early abortion. However, few have documented the experiences and perspectives of women. Our findings indicate providing misoprostol through lay provision in a legally restricted context is not only safe and effective but also culturally resonant.

Assessing abortion coverage in nurse practitioner programs in Canada: a national survey of program directors

OBJECTIVES Although nurse practitioners (NPs) play a critical role in the delivery of reproductive health services in Canada, there is a paucity of published information regarding the reproductive health education provided in their training programs. Our study aimed to understand better the didactic and curricular coverage of abortion in Canadian NP programs. STUDY DESIGN In 2014, we conducted a 3-contact, bilingual (English-French) mailed survey to assess the coverage of, time dedicated to and barriers to inclusion of 17 different areas of reproductive health, including abortion. We also asked respondents to speculate on whether or not mifepristone would be incorporated into the curriculum if approved by Health Canada for early abortion. We analyzed our results with descriptive statistics and used inductive techniques to analyze the open-ended questions for content and themes. RESULTS Sixteen of 23 (70%) program directors or their designees returned our survey. In general, abortion-related topics received less coverage than contraception, ectopic pregnancy management and miscarriage management. Fifty-six percent of respondents reported that their program did not offer information about first-trimester abortion procedures and/or post-abortion care in the didactic curriculum. Respondents expressed interest in incorporating mifepristone/misoprostol into NP education and training. CONCLUSION Reproductive health issues receive uneven and often inadequate curricular coverage in Canadian NP programs. Identifying avenues to expand education and training on abortion appears warranted. Embarking on curricular reform efforts is especially important given the upcoming introduction of mifepristone into the Canadian health system for early abortion. IMPLICATIONS Our findings draw attention to the need to integrate abortion-related content into NP education and training programs. The approval of Mifegymiso® may provide a window of opportunity to engage in curriculum reform efforts across the health professions in Canada.