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IntroductionUnsafe abortion past the first trimester disproportionately accounts for the majority of global abortion-related morbidity and mortality; research that documents the safety, feasibility and acceptability of existing models for providing information and support to women who self-manage outside of formal clinic settings is needed.MethodsThis study is a retrospective analysis of anonymised electronic client records from callers to a safe abortion hotline in Indonesia. Between July 2012 and October 2016, a total of 96 women contacted the hotline for information on medication abortion beyond 12 weeks' gestation and are included in this study. Descriptive statistics were calculated regarding pregnancy termination status, client experience with warning signs of potential complications, and medical care seeking and treatment.ResultsNinety-six women with pregnancies beyond the first trimester called the hotline for information on medication abortion; 91 women received counselling support from the hotline. Eighty-three women (91.2%) successfully terminated their pregnancies using medication and did not seek medical care. Five women exhibited warning signs of potential complications and sought medical care; one woman sought care after a failed abortion. Two women were lost to follow-up and the outcomes of their pregnancies are unknown.ConclusionsEvidence from our analysis suggests that a model of remote provision of support for abortions later in pregnancy by non-medically trained, skilled abortion counsellors could be a safe alternative for women in need of abortions beyond 12 weeks' gestation in a legally restrictive context. Further examination and documentation of the model is warranted.

Abortion in Zimbabwe is allowed to preserve the physical health of the woman, or in cases of rape, incest, or fetal impairment. Access even under these conditions is difficult and rare. We aimed to understand knowledge of the abortion law and attitudes towards abortion amongst health care providers' and abortion experts in Zimbabwe as these can hinder access to safe legal abortion. In 2016, we conducted a Health Facility Survey (HFS) (n=227) among health care providers' knowledgeable about abortion services in their facility in a census of facilities offering Post Abortion Care (PAC), and a Health Professionals Survey (HPS) among 118 abortion experts. Twenty-five percent of providers and 47% of experts knew all four reasons under which abortion is legal in Zimbabwe. Amongst providers and experts, 31% and 50% respectively were misinformed about one or more legal criteria. Most providers and experts were in support of expanding the legal provision of abortion to cases when the woman's mental health is at risk (65% and 79%, respectively) and if the woman is mentally incapacitated (66% amongst all). Seventy-one percent of experts recommend liberalizing the abortion law in order to reduce unsafe abortions. There is incomplete and sometimes inaccurate knowledge on the legal provisions for performing abortions in Zimbabwe amongst both health care providers and abortion experts. Incomplete knowledge of the law may be further reducing abortion access, highlighting the urgent need for educating health care providers on the legal status of abortion.

Objective Given Iran’s recent shift towards pronatalist population policies, concerns have arisen regarding the potential increase in abortion rates. This review study examines the trends of (medical), intentional (illegal), and spontaneous abortions in Iran over the past two decades, as well as the factors that have contributed to these trends. Methods This paper reviewed research articles published between 2005 and 2022 on abortion in Iran. The study employed the PRISMA checklist for systematic reviews. Articles were searched from international (Google Scholar, PubMed, Science Direct, and Web of Science) and national databases (Magiran, Medlib, SID). Once the eligibility criteria were applied, 42 records were included from the initial 349 records. Results Abortion is influenced by a variety of socioeconomic and cultural factors and the availability of family planning services. Factors that contribute to unintended pregnancy include attitudes toward abortion, knowledge about reproductive health, access to reproductive health services, and fertility desires, among others. In addition to health and medical factors, consanguineous marriage plays an important role in spontaneous and therapeutic abortion. A higher number of illegal abortions were reported by women from more privileged socioeconomic classes. In comparison, a higher number of medical and spontaneous abortions were reported by women from less privileged socioeconomic classes. Conclusion Iranian policymakers are concerned about the declining fertility rate and have turned to pronatalist policies. From a demographic standpoint, this seems to be a reasonable approach. However, the new population policies, particularly, the Family Protection and Young Population Law, along with creating limitations in access to reproductive health services and prenatal screening tests as well as stricter abortion law could potentially lead to an increase in various types of abortions and their associated consequences.

Background Access to safe abortion is legally restricted in Liberia, forcing women to resolve unintended pregnancies through unsafe methods, leading to severe illnesses and deaths. Liberia’s Government has committed to addressing abortion-related maternal mortalities by availing comprehensive post-abortion care. However, limited information exists on the capacity of health facilities to provide quality abortion-related care. This paper assesses the extent to which health facilities in Liberia are capable of delivering safe abortion and post-abortion care services. Methods Data for this analysis are drawn from a signal function survey conducted across 48 public facilities in Liberia from September to November 2021. The signal function survey captures several safe abortion and post-abortion care-related services, including staff training, equipment, commodities, and supplies. Data were collected from health providers knowledgeable about abortion-related care, such as safe abortion and post-abortion care, across sampled health facilities using a structured questionnaire. Data analysis involved summarizing proportions of clinics, health centers, and hospitals with the capacity to provide either basic and/or comprehensive safe abortion and post-abortion care. Results Out of the 48 facilities, 65% and 28% were classified as capable of providing basic and comprehensive post-abortion care (PAC) services, respectively. Fewer facilities (27%) could provide basic safe abortion care (SAC) and comprehensive SAC (16%). Differences by facility level were statistically significant for comprehensive PAC. The PAC signal functions fulfilled by the fewest facilities included referral capacity, blood transfusion, and surgical or laparotomy capacity. Conclusion The study highlights the limitations to providing basic SAC and PAC among our sample of public health facilities in Liberia and the poor capacity of these health facilities to provide comprehensive PAC and SAC services in particular. Full implementation of the 2019 National Comprehensive Abortion Care Guidelines could strengthen critical SAC and PAC services by ensuring adequate resources and training of the healthcare workforce.

Background Despite Nepal’s progressive legal framework permitting abortion, young women continue to face barriers in accessing safe abortion services (SAS), leading to preventable maternal mortality and morbidity. This study aimed to identify the key obstacles to SAS access among young women in the Makwanpur district of Nepal. Methods A convergent mixed-methods study was conducted in 2018. The quantitative component involved a cross-sectional survey of 447 female students aged 18–34, using a structured questionnaire to assess knowledge, stigma (via the Stigmatizing Attitudes, Beliefs, and Actions Scale - SABAS), and access to SAS. Multivariable logistic regression identified factors associated with low access. The qualitative component included six in-depth interviews with post-abortive women (PAWs), four with abortion service providers (ASPs), and three focus group discussions (FGDs) with 26 young community women. Data were analyzed thematically and integrated to provide a comprehensive understanding. Results Quantitatively, only 54.14% of respondents had high access to SAS. Key factors associated with low access included high abortion stigma (AOR: 2.97, 95% CI: 1.06–8.35), no internet use (AOR: 1.99, 95% CI: 1.02–3.86), and no contact with Female Community Health Volunteers (FCHVs) (AOR: 2.20, 95% CI: 1.21–4.31). While 70.69% knew abortion was legal, knowledge of specific legal conditions and free services was limited (47%). Qualitatively, seven key barriers emerged: [ 1 ] critical knowledge gaps about legality and service availability; [ 2 ] financial constraints, particularly for transportation; [ 3 ] pervasive abortion stigma and discrimination, especially against unmarried women; [ 4 ] geographical inaccessibility in rural areas; [ 5 ] marital status discrimination; [ 6 ] concerns about service quality and confidentiality; and [ 7 ] a lack of trained providers and resources, particularly for manual vacuum aspiration (MVA). Conclusion A complex interplay of informational, social, financial, and structural barriers impedes young women’s access to safe abortion in Nepal. Interventions must be multi-faceted, including targeted awareness campaigns (leveraging media and FCHVs), stigma reduction programs, expansion of services in rural areas, and strengthening of healthcare provider training and resources to ensure equitable access to safe abortion for all young women.

Background Unsafe abortion is a significant cause of maternal deaths worldwide. Most of these abortions are induced. Sub-Saharan Africa accounted for approximately 70% of global maternal deaths. In legalized context, implementation strategies ensure the access to safe abortion services. Several studies carried out in Europe, North America, and Asia, highlight strategies of implementation of access to safe abortion care and its outcomes. The objective of this review was to explore current knowledge on readiness and outcomes of implementation of safe abortion care policy in Africa. Methods We conducted a systematic scoping review using the Joanna Briggs Institute (JBI) approach to synthesize findings. We searched in PubMed, Scopus, and ProQuest Central databases. The inclusion criteria were articles published from January 2004 to the present, conducted in African countries, reporting readiness and outcomes of implementation of safe abortion care policy, and using quantitative, qualitative or both methodologies. Data were extracted and assessed concurrently by two researchers. Results In total, 639 articles were identified from databases. Of these, only 9 articles met the inclusion criteria and were included in the review (7 qualitative and 2 mixed methods). These studies focused on implementation of safe abortion care policies with variations in the legal status of abortion across countries, from total to partial or no legality. The readiness of implementation was based necessarily on providers training, on communication through development of guidelines and protocols, on sensitization of stakeholders during training sessions, workshops or informational campaigns and on the leadership shown by the health system managers. The outcomes of implementation such as acceptability, adoption, appropriateness, feasibility, fidelity, penetration and sustainability depended on good readiness for implementation. No study clearly has carried out a cost analysis of the implementation process. Conclusion Available evidence show that implementation of abortion policies implementation needs structured and coordinated readiness for effective and sustainable results. The involvement of all stakeholders is important for the successful implementation of safe abortion care services. Therefore, in Africa, advocacy efforts are needed for more commitment to standardized implementation strategies for access to safe abortion care with legalized abortion laws.

Background Ethiopia has one of the highest maternal mortality ratios in the world (420 per 100,000 live births in 2013), and unsafe abortion continues to be one of the major causes. To reduce deaths and disabilities from unsafe abortion, Ethiopia liberalized its abortion law in 2005 to allow safe abortion under certain conditions. This study aimed to measure how availability and utilization of safe abortion services has changed in the last decade in Ethiopia. Methods This paper draws on results from nationally representative health facility studies conducted in Ethiopia in 2008 and 2014. The data come from three sources at two points in time: 1) interviews with 335 health providers in 2008 and 822 health care providers in 2014, 2) review of facility logbooks, and 3) prospective data on 3092 women in 2008 and 5604 women in 2014 seeking treatment for abortion complications or induced abortion over a one month period. The Safe Abortion Care Model was used as a framework of analysis. Results There has been a rapid expansion of health facilities eligible to provide legal abortion services in Ethiopia since 2008. Between 2008 and 2014, the number of facilities reporting basic and comprehensive signal functions for abortion care increased. In 2014, access to basic abortion care services exceeded the recommended level of available facilities providing the service, increasing from 25 to 117%, with more than half of regions meeting the recommended level. Comprehensive abortion services increased from 20% of the recommended level in 2008 to 38% in 2014. Smaller regions and city administrations achieved or exceeded the recommended level of comprehensive service facilities, yet larger regions fall short. Between 2008 and 2014, the use of appropriate technology for conducting first and second trimester abortion and the provision of post abortion family planning has increased at the same time that abortion-related obstetric complications have decreased. Conclusion Ten years after the change in abortion law, service availability and quality has increased, but access to lifesaving comprehensive care still falls short of recommended levels.

Second-trimester medical abortion (STMA) accounts for 20–40% of abortions in Ethiopia and is associated with risks including uterine rupture, hemorrhage, infection, incomplete abortion, and prolonged hospitalization. This multicenter prospective study included 617 women undergoing STMA in three referral hospitals in the Amhara region from January to October 2024. Induction-to-expulsion time and associated factors were analyzed using Cox proportional hazard modeling. Median fetal and placental expulsion times were 10 and 10.5 hours, respectively, with an 81.2% complete expulsion rate. Prolonged expulsion was associated with higher gestational age, wider misoprostol dosing intervals, and younger maternal age. Reported complications included vaginal bleeding (34.8%), pain (44%), diarrhea (24.1%), vomiting (24%), fever (11.5%), infection (2.4%), incomplete abortion (19.8%), cervical tear (0.49%), and uterine rupture (0.16%). optimizing misoprostol regimens, improving pain management, strengthening follow-up, and ensuring surgical readiness are essential to enhance STMA safety and effectiveness. L'avortement médicamenteux au deuxième trimestre (AMT) représente 20 à 40 % des avortements en Éthiopie et est associé à des risques tels que la rupture utérine, l'hémorragie, l'infection, l'avortement incomplet et l'hospitalisation prolongée. Cette étude prospective multicentrique a inclus 617 femmes ayant subi un AMT dans trois hôpitaux de référence de la région d'Amhara, de janvier à octobre 2024. Le délai entre le déclenchement et l'expulsion et les facteurs associés ont été analysés à l'aide d'un modèle à risques proportionnels de Cox. Les durées médianes d'expulsion fœtale et placentaire étaient respectivement de 10 et 10,5 heures, avec un taux d'expulsion complète de 81,2 %. Une expulsion prolongée était associée à un âge gestationnel plus élevé, à des intervalles plus espacés entre les prises de misoprostol et à un âge maternel plus jeune. Les complications signalées comprenaient des saignements vaginaux (34,8 %), des douleurs (44 %), des diarrhées (24,1 %), des vomissements (24 %), de la fièvre (11,5 %), une infection (2,4 %), un avortement incomplet (19,8 %), une déchirure cervicale (0,49 %) et une rupture utérine (0,16 %). L'optimisation des schémas posologiques à base de misoprostol, l'amélioration de la prise en charge de la douleur, le renforcement du suivi et la préparation chirurgicale sont essentiels pour améliorer la sécurité et l'efficacité de l'avortement médicamenteux.

Current strong evidence supports that making abortion legal, safe, and accessible significantly reduces unsafe abortion-related maternal morbidity and mortality. We conducted a decade-long (2009 – 2019) trend-analysis study of safe abortion care and post-abortion care services in relation to introduction of a new abortion clinic at St. Paul’s Hospital in Ethiopia. There were 9491 total abortions (6449 post-abortion care cases and 3042 safe abortion cases) during the study period (between September 2009 to August 2019). Following the opening of a model abortion clinic, access to safe abortion care significantly increased, and post-abortion care abortion service dominance was replaced by safe abortion care. Before the introduction of the clinic in 2016, only 1 in 3 abortions were safe abortions, the rest being post-abortion care cases. During the years 2017-2018 and 2018-2019, safe abortion care increased to 6 in 10 and 7 in 10 of all comprehensive abortion care provided, respectively. This “They come when you build it” effect on the trends of safe abortion - a paradigm shift of post-abortion care into safe abortion care - can be implemented in other Sub-Saharan settings. Des données probantes solides confirment actuellement que la légalisation, la sécurité et l'accessibilité de l'avortement réduisent significativement la morbidité et la mortalité maternelles liées aux avortements à risque. Nous avons mené une analyse des tendances sur une décennie (2009-2019) concernant les soins d'avortement médicalisé et les services de soins post-avortement, en lien avec l'ouverture d'une nouvelle clinique d'avortement à l'hôpital St. Paul en Éthiopie. Au total, 9 491 avortements ont été pratiqués (6 449 cas de soins post-avortement et 3 042 cas d'avortement médicalisé) durant la période d'étude (de septembre 2009 à août 2019). Suite à l'ouverture d'une clinique d'avortement modèle, l'accès aux soins d'avortement médicalisé a considérablement augmenté, et la prédominance des services de soins post-avortement a été remplacée par des soins d'avortement médicalisé. Avant l'ouverture de la clinique en 2016, seul un avortement sur trois était un avortement médicalisé, le reste étant des cas de soins post-avortement. Au cours des années 2017-2018 et 2018-2019, les soins d'avortement médicalisé ont augmenté, atteignant respectivement 6 sur 10 et 7 sur 10 de l'ensemble des soins d'avortement complets dispensés. Cet effet « Ils interviennent quand vous le construisez » sur les tendances en matière d'avortement médicalisé – un changement de paradigme des soins post-avortement vers des soins d'avortement médicalisé – peut être mis en œuvre dans d'autres contextes d'Afrique subsaharienne.

Background Ghana is one of few countries in sub-Saharan Africa with relatively liberal abortion laws, but little is known about the availability and quality of abortion services nationally. The aim of this study was to describe the availability and capacity of health facilities to deliver essential PAC and SAC services in Ghana. Methods We utilized data from a nationally representative survey of Ghanaian health facilities capable of providing post-abortion care (PAC) and/or safe abortion care (SAC) ( n  = 539). We included 326 facilities that reported providing PAC (57%) or SAC (19%) in the preceding year. We utilized a signal functions approach to evaluate the infrastructural capacity of facilities to provide high quality basic and comprehensive care. We conducted descriptive analysis to estimate the proportion of primary and referral facilities with capacity to provide SAC and PAC and the proportion of SAC and PAC that took place in facilities with greater capacity, and fractional regression to explore factors associated with higher structural capacity for provision. Results Less than 20% of PAC and/or SAC providing facilities met all signal function criteria for basic or comprehensive PAC or for comprehensive SAC. Higher PAC caseloads and staff trained in vacuum aspiration was associated with higher capacity to provide PAC in primary and referral facilities, and private/faith-based ownership and rural location was associated with higher capacity to provide PAC in referral facilities. Primary facilities with a rural location were associated with lower basic SAC capacity. Discussion Overall very few public facilities have the infrastructural capacity to deliver all the signal functions for comprehensive abortion care in Ghana. There is potential to scale-up the delivery of safe abortion care by facilitating service provision all health facilities currently providing postabortion care. Conclusions SAC provision is much lower than PAC provision overall, yet there are persistent gaps in capacity to deliver basic PAC at primary facilities. These results highlight a need for the Ghana Ministry of Health to improve the infrastructural capability of health facilities to provide comprehensive abortion care.