Journal Articles
and Other Publications

6 April 2016 

Microcephaly in northeastern Brazil: a review of 16 208 births between 2012 and 2015

Juliana Sousa Soares de Araújo, Cláudio Teixeira Regis, Renata Grigório Silva Gomes, et al
Bulletin of the World Health Organization E-pub: 4 February 2016
A recent outbreak of microcephaly has been reported from Northeast Brazil. Neither its aetiology, nor its clinical significance has yet been fully established. A complication from an intrauterine infection with the Zika virus (ZIKV) is, thus far, the most explored hypothesis. In Paraíba, one of the nine States within the epicentre of the epidemic, 21 medical centres collaborate, via telemedicine since 2012, in a paediatric cardiology network. The Network’s database currently stores information on more than 100,000 neonates. To support the microcephaly research, from December 1st to 31st, 2015, the Network ran a task force and rescued the head circumference (OFC) from 16,208 neonates. A much higher than expected incidence of microcephaly was observed, varying from 2% to 8% according to the utilized classification criteria. These findings raise questions about the condition’s diagnosis and its notification. An observed presentation’s seasonality might reflect that of infections carried on by the Aedis aegypti vector. However, the temporal fluctuation was documented since late 2012, before the allegedly entry of the ZIKV in Brazil, in mid-2014. Further questions are raised on both the epidemiological surveillance of the Aedis aegypti infections, as well as on different aetiological possibilities for the outbreak. At this stage, follow-up studies in the children diagnosed with microcephaly are mandatory prior to concluding what problem we are facing; how it came about and which consequences it may, or not, bring to the Brazilian population in years to come.


Scientists announce they have worked out the structure of the Zika virus
Devika Serohi, et al.
Science 31 March 2016 DOI:

Two individual case reports in Lancet

Acute myelitis due to Zika virus infection   

Guillain-Barré syndrome associated with Zika virus infection
Lancet 2016;387(10026);
1347-1482,e24 Week of 2–8 April 2016
Tags: Brazil, Zika virus, microcephaly
Incidence of induced abortion and post-abortion care in Tanzania

Sarah C Keogh, Godfather Kimaro, Projestine Muganyizi, Jesse Philbin, Amos Kahwa, Esther Ngadaya, Akinrinola Bankole
PLoS ONE, 11 September 2015

This is the first nationally representative study of the incidence of abortion and the provision of post-abortion care in Tanzania. It was conducted by researchers at the US-based Guttmacher Institute and Tanzania’s National Institute for Medical Research and Muhimbili University of Health and Allied Sciences. It found that an estimated 405,000 abortions were performed in the country in 2013, the vast majority of which were clandestine, unsafe procedures under an abortion law that is both highly restrictive and ambiguous. 

The research surveyed health facilities and health professionals and reviewed population and fertility data. It estimated that 66,600 women received post-abortion care in health facilities for complications of unsafe abortions in 2013. However, almost 100,000 other women who experienced complications did not receive the medical attention they needed. 

“Recognizing that unsafe abortion is a leading cause of maternal death, the Tanzanian government has expanded the availability of post-abortion care over the past decade, but significant gaps still exist and most women do not receive the care they need,” said Sarah C Keogh. “This study identifies many of those gaps and will inform strategies to ensure that every Tanzanian woman who needs it can access life-saving post-abortion care.”  

The researchers recommend strengthening efforts to ensure universal access to post-abortion care, which is currently unevenly available, including by training mid-level providers and adequately supplying health facilities with the necessary drugs and equipment. They also emphasise the importance of including the provision of contraceptive services as a routine part of post-abortion care. Finally, they recommend that the ambiguity in Tanzania’s abortion law be clarified.

Tags: Tanzania, unsafe abortion, post-abortion care, abortion incidence
“These things are dangerous”: Understanding induced abortion trajectories in urban Zambia


Ernestina Coast, Susan F Murray
Social Science & Medicine 2016;153 (March):201–209 (open access)

“Access to comprehensive reproductive health
services, including safe abortion services within
the law, is recognized as a basic human right,
protected by a range of international human rights treaties
and laws.” First Lady of Zambia, Dr. Christine Kaseba,
2013, Ipas documentary.

Zambia has among the most liberal abortion laws in sub-Saharan Africa; however, this alone does not guarantee access to safe abortion, and 30% of maternal mortality is attributable to unsafe procedures. Too little is known about the pathways women take to reach abortion services, or what informs care-seeking behaviours, barriers and delays. In-depth qualitative interviews were conducted in 2013 with 112 women who accessed abortion-related care in a Lusaka tertiary government hospital at some point in their pathway. The sample included women seeking safe abortion and also those receiving hospital care following unsafe abortion.
They identified a typology of three care-seeking trajectories that ended in the use of hospital services: 1) clinical abortion induced in hospital (63.4%); clinical abortion initiated elsewhere, with post-abortion care in hospital (16.1%); and non-clinical abortion initiated elsewhere, with post-abortion care in hospital (20.5%). Framework analyses of 70 transcripts showed that trajectories to a termination of an unwanted pregnancy can be complex and iterative (Figure 1). Individuals may navigate private and public formal health care systems and consult unqualified providers, often trying multiple strategies. We found four major influences on which trajectory a woman followed, as well as the complexity and timing of her trajectory: i) the advice of trusted others, ii) perceptions of risk, iii) delays in care-seeking and receipt of services, and iv) economic cost. Even though abortion is legal in Zambia, girls and women still take significant risks to terminate unwanted pregnancies. Levels of awareness about the legality of abortion and its provision remain low even in urban Zambia, especially among adolescents. Unofficial payments required by some providers can be a major barrier to safe care. Timely access to safe abortion services depends on chance rather than informed exercise of entitlement.

Figure 1
The recruitment strategy yielded a heterogeneous sample, from a 15-year-old schoolgirl who had never used contraception, to a 23-year-old unmarried university student who did not want pregnancy to interrupt her studies, to a 42-year-old married mother of 6 children reporting contraceptive failure and an inability to support another child.
In this typology a clinical abortion included medical abortion alone, medical abortion plus manual vacuum aspiration or manual vacuum aspiration alone. A non-clinical abortion involved insertion of a foreign object, herbal medicine, and all other abortifacients used by respondents to try to terminate a pregnancy.
• Despite legal provision in Zambia, not all urban women access abortions safely.
• Unofficial payments requested by some providers cause delay and deter use.
• Self-administered medical abortion may now be a widespread strategy.
• Accessible information about how to obtain safe abortion is needed in Zambia.
Tags: Zambia, unsafe abortion, abortion methods, care-seeking pathways 
What makes a likely abortion provider? Evidence from a nationwide survey of final-year students at Ghana’s public midwifery training colleges
Sarah D Rominski, Jody Lori, Emmanuel Nakua, Veronica Dzomeku, Cheryl A Moyer
Contraception 2016;93(3):226–232

Nursing and Midwifery Training College, Kumasi, Ghana

Even in countries where the abortion law is technically liberal, the full application of the law has been delayed due to resistance on the part of providers to offer services. Ghana has a liberal law, allowing abortions for a wide range of indications. The current study sought to investigate factors associated with midwifery students’ reported likelihood to provide abortion services. Final-year students at 15 public midwifery training colleges participated in a computer-based survey. Demographic and attitudinal variables were tested against the outcome variable, likely to provide comprehensive abortion care (CAC) services, and those variables found to have a significant association in bivariate analysis were entered into a multivariate model. Marginal effects were assessed after the final logistic regression was conducted.
A total of 853 out of 929 eligible students enrolled in the 15 public midwifery schools took the survey,  response rate 91.8%. The mean age of the participants was 25 years, ranging from 18 to 49. The majority of the participants were in a relationship but not married. Most of the participants did not have any children. Each school contributed between 2.5% and 11.3% of participants. Most participants had received classroom education in MVA, but many fewer had received either simulation or supervised clinical practice in the procedure.
A majority of the participants reported being either very likely (n= 420, 49.24%) or somewhat likely (n= 179, 21%) to provide CAC services once they have graduated from midwifery school. For those who reported not being likely, the main reasons were personal beliefs and religious beliefs. A large majority (97.3%, n= 830) of the participants believe unsafe abortion to be a problem in Ghana, and 68.7% (n= 586) believe that Ghanaian women are able to access safe abortion services when they need them. A majority of the participants (73.3%, n= 625) agree that it is a good thing that Ghanaian women are able to access legal abortions, and 78.2% (n= 667) think that women should not use abortion as a form of birth control. Almost one fifth of the sample has experienced an unplanned pregnancy (19.9%, n= 170), while 41% (n= 503) have experienced a pregnancy scare, defined as a time when they thought they might be pregnant but it turned out they were not.
In multivariate regression analysis, the factors significantly associated with reported likeliness to provide CAC services were having had an unplanned pregnancy, currently using contraception, feeling adequately prepared, agreeing it is a good thing women can get a legal abortion and having been exposed to multiple forms of education around surgical abortion. Ensuring that midwives-in-training are well trained in abortion services, as well as encouraging empathy in these students, may increase the number of providers of safe abortion care in Ghana.
Tags: Ghana, mid-level abortion providers, midwives, training
Contraceptive failure rates in the developing world: an analysis of Demographic and Health Survey data in 43 countries
Chelsea Polis, Sarah EK Bradley, Akinrinola Bankole, Tsuyoshi Onda, Trevor N Croft, Susheela Singh
In the most comprehensive study to date of contraceptive failure rates in the developing world, researchers found that overall, failure rates are lowest for users of longer-acting contraceptive methods (IUDs, implants or injectables), intermediate for users of shorter-acting methods (oral contraceptive pills or male condoms) and highest for users of traditional methods (withdrawal or calendar rhythm). The report expands on previous research on failure rates by contraceptive method. “Of the 74 million unintended pregnancies each year in the developing world, a significant proportion - 30% - are due to contraceptive failure among women using traditional or modern methods,” lead author Chelsea Polis said. 

The data cover 17 countries in Africa, 16 in Asia, two in Eastern Europe and eight in Latin America and the Caribbean. The study estimated the contraceptive prevalence and the method mix for each country and the seven sub-regions in the analysis. It found that while the Northern Africa/Western Asia sub-region has relatively high contraceptive prevalence, a significant proportion of users rely on less effective traditional methods. By contrast, in Western Africa, contraceptive prevalence is relatively low, but the majority of users rely on modern methods. 

The study found that women younger than 25 generally have higher contraceptive failure rates than their older counterparts for all contraceptive methods except the implant, for which the failure rate did not vary by age. The authors call for expanded availability of youth-friendly counselling and services and recommend that service providers make available a wide range of contraceptive methods, comprehensive counselling and clear information about risks and benefits, including possible side effects, of each method.
Tags: global south, contraceptive methods, failure rates
General Comment on the Right to Sexual and Reproductive Health
by Katy Mayall, Center for Reproductive Rights

UN CESCR meeting Feb 2016

The Committee on Economic, Social and Cultural Rights (CESCR) recently adopted a
General Comment on the Right to Sexual and Reproductive Health, the first to focus exclusively on sexual and reproductive health and indicative of the great strides our movement has made in building out the international human rights framework to fully recognize reproductive rights as fundamental human rights. In particular, the general comment:
  • Largely frames individual autonomy and decision-making as being central to sexual and reproductive health. 
  • Speaks broadly about the need for safe abortion care and the elimination of restrictive abortion laws, without narrowly limiting this to specific circumstances, such as where pregnancy poses a risk to the woman's life or health or in cases of rape or incest. This follows the trend we have seen in the Committee on the Rights of the Child and, to a lesser extent, the CEDAW Committee.
  • Includes strong standards on conscientious objection, calling for states permitting conscientious objection to require referral to a provider capable and willing to provide the services, in addition to excluding the invocation of conscientious objection in urgent or emergency situations.
  • Condemns a broad range of procedural barriers, including mandatory waiting periods, biased counselling, and third-party authorization (parental, spousal and judicial).
  • Reinforces/strengthens the obligations of donor states as well as non-state actors, such as health care providers and health insurance and pharmaceutical companies
It is worth noting that there are some areas where the general comment could have been strengthened. For example, a number of the elements of the core obligations are quite vague, which in turn will undermine the ability to hold states accountable for these specific obligations. Further, although there is some strong content on sexual orientation and gender identity and expression, overall the general comment would have been significantly strengthened through a greater emphasis on this aspect of sexual and reproductive health. Lastly, the language on criminalization of abortion is a bit contradictory; although the general comment repeatedly recognizes the need for states to reform laws criminalizing abortion, it only explicitly frames the application of the criminal law to women who undergo abortions as a violation of the right to sexual and reproductive health - falling short of calling for the full decriminalization of abortion. 
Tags: UN Committee on Economic, Social and Cultural Rights, general comment, law and policy


Seminar: How can a state control swallowing? Medical abortion and the law

23 March 2016
Statutory reform is needed in UK abortion law because of serious tensions in how it can be interpreted, according to University of Kent Prof Sally Sheldon, and because it no longer makes sense in the context of modern medical practice. Her research was presented at a London seminar, where
she presented her
findings based on the fact that use of medical abortion pills, which accounts for over half of all legal terminations reported in Britain today, should lead to a revolution in abortion provision.
In both Northern Ireland and the Republic of Ireland, on the other hand, the regulation of abortion is highly restrictive, and the widespread use of abortion pills is one reason for the reduction in the numbers travelling at great emotional and financial cost to have a legal abortion in England.

Article: British abortion law: speaking from the past to govern the future
Sally Sheldon
The Modern Law Review 2016;79(2):283–316 DOI: 10.1111/1468-2230.12180
This paper analyses the poor alignment of the aging statutory framework and modern understandings
of medical best practice in the context of abortion services. With a particular focus
on medical abortion, it assesses the significant challenges that the gulf between the two poses
for clinicians, service providers, regulators and the courts. Law is said to be at its most effective
where there is a shared regulatory community that accepts and endorses the values that underpin
it. It is suggested that the example of abortion law provides a marked example of what
happens when legal norms once justified by broadly shared moral understandings, concerns for
patient safety and requirements of best practice are now either unsupported by or, indeed, sit in opposition to such concerns.
Tags: Great Britain, Northern Ireland, Ireland, medical abortion, law and policy

International Planned Parenthood Federation
Comment parler de l'avortement: guide pour l'élaboration de messages basés sur les droits

C'est le version français de la guide en anglais: How to talk about abortion: a guide to rights-based messaging.
Ce guide est conçu pour aider les organisations à réviser leurs supports de communication contenant des messages sur l’avortement. Il contient des informations de base sur l’avortement et sur les questions s’y rapportant, ainsi que des listes de contrôle pour réviser et améliorer les messages relatifs à l’avortement. Ce guide peut également être utilisé pour éclairer l’élaboration de nouveaux supports contenant des messages relatifs à l’avortement.
Tags: rights-based messaging
Editor: Marge Berer

Copyright © 2016 International Campaign for Women's Right to Safe Abortion, All rights reserved.