Journal Articles and Reports
18 May 2016 


Myths and misinformation: an analysis of text messages sent to a sexual and reproductive health Q&A service in Nigeria
Ann K Blanc, Kimberly Glazer, Uju Ofomata-Aderemi, Fadekemi Akinfaderin-Agarau

Studies in Family Planning 2016;47(1):39–53
MyQuestion is a platform that allows young people to ask SRH questions via text message. Trained counselors provide responses using a database of answers to frequently asked questions or customized replies. We analyze the content of more than 300,000 text messages received by the service since 2007 to address three questions: which health topics are most frequently submitted; what kinds of questions are asked about these topics; and what language is used to convey the questions? We found a substantial unmet need for basic SRH information, with users’ questions communicated in ways that convey considerable confusion, misinformation, and urgency. The analysis can be used to improve similar Q&A services and to improve the provision of SRH services for young people more generally.
Among the almost 50 million young people aged 10–24 in Nigeria,… more than one in three 18-year-old women has already had a child or is pregnant. Approximately 1.6 million Nigerian women aged 15–24, more than three quarters of whom are married, are estimated to have an unmet need for contraception. Less than 8% of married women in this age group are using contraception, compared to 63% of sexually active unmarried women. The country is characterized by large variations in adolescent sexual and reproductive health…
The potential contribution of mobile phone-based platforms for reaching young people with sexual and reproductive health information and services is not yet well understood. Some innovative applications have been tested in recent years in sub-Saharan Africa and elsewhere, and the World Health Organization is pilot testing the Adolescent/Youth Reproductive Mobile Access and Delivery Initiative for Love and Life Outcomes (ARMADILLO), an on-demand system that allows young people to request and receive SRH information through an SMS platform, with future plans to evaluate its impact. In this article, we describe one such application underway in Nigeria…
Approximately 12,000–15,000 questions are received on the platform each month, with the majority received via text. [Questions about pregnancy were the 5th most frequent.] The average response time for questions received via text is 2–3 hours, although telecommunication network problems occasionally cause delays… When highly sensitive questions are asked (e.g. from a person who says she has had an unsafe abortion), the user is sent a short message asking her to call the hotline immediately for more detailed counseling…
…Many users ask about products for pregnancy prevention or termination. Texts cite “the pill to prevent pregnancy” or mention specific products by name. Data frequently show requests for information on “which pill” or the “correct pill” and where to get it. Numerous submissions ask whether it is possible to prevent pregnancy after sexual intercourse and seek pills to “remove pregnancy” either immediately or in the early weeks or months after having unprotected sex (“Plz want is d name of d pill …to kill d sperm ejaculated in my vagina so as not to get pregnant?”)…
…There is a desire for information on abortion procedures and access to the “drugs for abortion.” Texts include references to both medical and surgical abortion (“What is the name(s) of the pill a pregenate woman will take when she does not want the child”; “What is the name of the medicine for abortion?”; “what is the full meaning of D&C when doing an abortion”; “what is d&c use for abortion”), but indicate substantial ignorance and misconceptions about certain methods and how they can be obtained (“How many types of abortion do we have?”; “Is flushing out sperm immediately after sex abortion?”; “Is there a particular drug 4 abortion”). The importance of privacy in a context where abortion is highly stigmatized is evident (“What are the drugs use in abortion? pls reply no matter how embarrassing the question may be”; “Pls a friend of mine is pregnant and she does not want anybody to know she wants an abortion what should she do”; “How can one abort an unwanted pregnancy without going to a hospital ”)…

Tags: Nigeria, young people, abortion information, text messaging

The red umbrella is used around the world as a symbol
of sex worker solidarity and struggle for their rights.

Why we need to bridge the gap between sex workers’ movements and abortion rights activism

Kristin Francoeur, Surabhi Srivastava 

In plain speak, Tarshi, India, 5 April 2016
…Barriers to sex workers’ reproductive freedom – including means and access to prevent pregnancy, options to terminate pregnancy, and the choice and resources to raise children – haven’t been thoroughly explored because sexual and reproductive health and rights have been applied in a limited fashion to sex workers. It is telling that the majority of studies concerning FSWs in the Global South address their sexual health but narrowly, focusing on prevention and treatment of HIV/AIDS… Most outreach to sex workers does not seriously consider their sexual autonomy or reproductive lives, part of an implicit marginalising of FSWs even among activists, leading them to classify FSWs as a separate category at arm’s length from “other” women.
…[B]arriers to accessing safe and legal abortion are sometimes intensified for FSWs because of their marginalised position in society. However, research indicates that because of the relatively high frequency of unplanned pregnancies FSWs face, they may differ from other abortion seekers with regard to their own attitudes toward termination of pregnancy, and how information, resources, and support related to abortion circulate within sex worker communities. Sex workers in Uganda report that because of the nature of their work, abortion information is readily available within their communities, in which women are an active support network for each other with regard to unplanned pregnancies and other issues. In Kolkata, Ghosh asserts that having an abortion is such a common occurrence among FSWs that it doesn’t carry the same “inhibition” as it does for women in a “family setting”.
At the same time, it would be a mistake to assume that there’s a homogeneous narrative around FSWs’ lived experiences of abortion. In Laos, for instance – where both sex work and abortion are illegal – a more complicated ethical stance of FSWs emerges, challenging the idea that sex workers lack an ethical and/or emotional response to abortion and are merely annoyed by it as a work-related hazard. Though many interviewees had experienced abortion before or after entering sex work, about 70% thought that abortion should remain illegal in Laos, should not be culturally accepted, and that women who terminated pregnancies were immoral. Yet, 70% also strongly agreed that abortion is the best option they have when facing unintended pregnancy. Instead of positioning FSWs as a separate category, the authors of this study show that, of course, sex workers’ sense of morality is affected by broader social mores, even as they might intentionally or implicitly subvert norms by participating in a marginalised form of work.

Tags: India, sex workers, abortion access

WOMEN from Northern Ireland and the Irish
Republic had almost 25,000 abortions in England
and Wales over the last five years – an average
of close to 100 terminations every week.

Ireland: When the Church Is State 

Ailbhe Smyth

Conscience, Catholics for Choice, 25 April 2016
“The Irish Church’s failures have caused its people to choose secularism over faith.” This was the dramatic headline on the May 25, 2015 edition of the Catholic Herald (UK) after the same-sex marriage referendum victory.
Although the large majority of people in Ireland continue to define themselves as Catholic, it is a very different kind of Catholicism from the traditional form that held us enslaved for so long. It is more individualistic, more independent, more rational… Irish people are no longer prepared to follow the diktat of the church in socio-sexual matters. While Ireland may in some respects still be “culturally Catholic,” that culture is increasingly and manifestly tempered by a sophisticated and cosmo­politan perspective…
Nonetheless, we still have a major struggle in front of us: to obtain the right to safe, legal and, ideally, free abortion in Ireland. Wresting women’s freedom, autonomy and bodily integrity from the hands of patriarchal power  ̶  and none more patriarchal than the Catholic hier­archy  ̶  is an urgent and still daunting task. Abortion has always been the most diffi­cult issue: It is the unmentionable, the most stigmatized, the most profoundly silenced. Political leadership is still very weak and inconsistent on women’s issues, and the large majority of politicians haven’t the courage to tackle the issue of abortion…

Tags: Ireland, Catholic church, secularism
Abortion stigma: a systematic review
Franz Hanschmidt, Katja Linde, Anja Hilbert, Steffi  G Riedel-Heller, Anette Kersting

Perspectives on Sexual and Reproductive Health 2016:48(4)
Abstract: Although stigma has been identified as a potential risk factor for the well-being of women who have had abortions, little attention has been paid to the study of abortion-related stigma. A systematic search of the databases Medline, PsycArticles, PsycInfo, PubMed and Web of Science was conducted; the search terms were “(abortion OR pregnancy termination) AND stigma.” Articles were eligible for inclusion if the main research question addressed experiences of individuals subjected to abortion stigma, public attitudes that stigmatize women who have had abortions or interventions aimed at managing abortion stigma. To provide a comprehensive overview of this issue, any study published by February 2015 was considered, restricted to English- and German-language studies.
Seven quantitative and seven qualitative studies were eligible for inclusion. All but two dated from 2009 or later; the earliest was from 1984. Studies were based mainly on US samples; some included participants from Ghana, Great Britain, Mexico, Nigeria, Pakistan, Peru and Zambia. The majority of studies showed that women who have had abortions experience fear of social judgment, self-judgment and a need for secrecy. Secrecy was associated with increased psychological distress and social isolation. Some studies found stigmatizing attitudes in the public. Stigma appeared to be salient in abortion providers’ lives. Evidence of interventions to reduce abortion stigma was scarce. Most studies had limitations regarding generalizability and validity.
Conclusion:  More research, using validated measures, is needed to enhance understanding of abortion stigma and thereby reduce its impact on affected individuals.
Tags: abortion stigma, systematic review
The culture of illegal abortion in South Africa
Rebecca Hodes

Journal of Southern African Studies 2016;42(1):79–93
Abstract: Abortion is a common medical experience, globally and in South Africa. Worldwide, approximately one in five pregnancies ends in abortion. But many societies understand abortion as a moral transgression, even if its benefits to public health are sanctioned legally. South Africa’s abortion culture reveals this paradox: abortion is often publicly condemned – by political authorities, healthcare workers, patients and their families – but privately sanctioned. The apartheid state sought to control the sexual behaviour of its subjects, and passed laws to regulate reproduction. These laws were defied en masse, by patients, doctors and clandestine providers. This article explores the apartheid state’s failure to police abortion, arguing that post-apartheid abortion culture has powerful continuities with the past. Abortion was legalised in 1996, during South Africa’s transition to democracy. While the Choice on Termination of Pregnancy Act has reduced mortality and morbidity resulting from unsafe abortion, illegal abortion remains popular. Unsafe abortion is notoriously difficult to quantify. In South Africa, high rates of maternal morbidity and mortality, including from uterine sepsis, point to the persistence of unsafe, illegal abortion. Women continue to terminate unwanted pregnancies as they always have: away from the glare of public censure, in the shadows of the reproductive arena.

Tags: South Africa, abortion stigma

Community health care client in rural Ecuador
Photo: PP Global/Mark Tuschman

In combating abortion stigma, finding the most responsible and effective tools
JoAnn DiLernia, Planned Parenthood Global

Making inroads, 16 April 2016
For more than 45 years, Planned Parenthood Global (PP Global) has been working to expand access to safe and legal abortion services, especially where access to providers is most needed. A big part of that work is combating abortion stigma… We take a multi-pronged approach:
The World Health Organization has recommended that abortion be provided at the lowest level of care. PP Global agrees and designed a protocol for misoprostol for first trimester abortion administered by low level health care workers, called Community Based Access to Misoprostol (CBAM). Our trainings and training materials aim to support the delivery of services to women where they are most needed, and access to an abortion provider is limited.
Secondly, we have been working with the University of Michigan to implement Provider Share Workshops (PSWs) with providers in the Latin American countries we work in to help reduce their internalized and felt stigma. These workshops have been used to strengthen PP Global’s Abortion Provider Support Network. And third, we are beginning to use research to bolster our efforts against stigma through CBAM. Implemented in 2013 by a local partner, we identified a shift in women’s opinions regarding abortion and decided to explore this further. We designed a mixed-method study aimed to compare the prevalence of abortion stigma in three communities based on their access to a provider. This study consisted of community based surveys and in-depth interviews with providers and their clients. We hypothesized that the presence and length of time a community-based abortion provider was in the community would influence and ultimately reduce the existing levels of abortion stigma.
Because abortion is highly stigmatized, it is infrequently discussed in the communities where we work. For example, we feared that conducting research could cause harm to our study respondents by exposing both abortion providers and women seeking abortions. Exposure could put our respondents at risk of being ostracized from the community, shamed, ridiculed, and potentially exposed to legal consequences. We had to ask ourselves what was more important: scientific rigor or the privacy of study respondents. After further examination we ultimately decided that the protection of our providers’ and clients’ privacy was more important than the rigor of the study. In order to respect the privacy of our study group and also gather important evidence on stigma, we decided to use the PP Global staff who already worked with the providers as interviewers; and in turn had the providers interview their own patients.
In a three-day workshop, PP Global staff and a representative from Ibis Reproductive Health trained providers on how to conduct in-depth interviews... In all, we conducted seven provider interviews and 30 client interviews. Following data collection, we conducted a semi-structured debrief with the providers to learn more about their overall experience and gather complementary insight that was not captured via the client interview recordings. The debrief served as an opportunity to identify lessons learned and brainstorm ideas with the providers about future research and interventions.
All in all, this methodology seemed to be a success. The reaction of providers was overwhelming. They were excited about the process of being involved in a research study, and reported that the clients were excited and happy to help the providers who helped them. The providers also mentioned that the women were also extremely grateful to the providers and presented their story as a testimony. …We gained a safe space for clients and providers alike to talk about and discuss their experience with abortion and abortion stigma. To us, this has proved to be one of the biggest successes of this project.

Tags: Latin America, abortion stigma, qualitative survey, training for providers

Click here for English, Spanish and French versions
"Abortion stigma around the globe”: a qualitative synthesis

Making inroads, 31 March 2016
After a review of literature and available resources, we discovered a lack of analysis of qualitative research. Through the production of this resource, we hoped to paint a picture of how stigma appears in different geographic regions, and across the different levels of the ecological model. We specifically examined peer-reviewed articles that addressed abortion stigma (in the title, abstract or subject heading), employed qualitative methods, and reported thematic findings on abortion stigma. We found that stigma, not surprisingly, is socially constructed, culturally and socially embedded and is influenced by social and cultural mores. Without cultural norm transformation, stigma continues to manifest in multiple ways, across a variety of contexts.

Tags: abortion stigma, literature review

Inform yourself about abortion: it's safe, legal and free in Mexico City

Constructing a validated scale to measure community-level abortion stigma in Mexico

Annik M Sorhaindo, Tahilin S Karver, Jonathan G Karver, Sandra G Garcia

Contraception 2016;93(5):421–431
Abstract: We developed a scale to measure abortion stigma at the community level, examine its prevalence and explore factors associated with abortion stigma in a nationally representative sample. Following intensive qualitative work to identify dimensions of the stigma construct, we developed a comprehensive list of statements that were cognitively tested and reduced to 33 to form a scale. We piloted the scale in a nationally and sub-regionally representative household public opinion survey administered to 5600 Mexican residents… Abortion stigma prevents women from accessing safe abortion services. Measuring community-level abortion stigma is key to documenting its pervasiveness, testing interventions aimed at reducing it and understanding associated factors. This scale may be useful in countries similar to Mexico to support policymakers, practitioners and advocates in upholding women's reproductive rights.
Editor's note: This is a very complicated research article, but the list of statements expressing abortion stigma that people were asked to respond to are extremely useful.

Tags: Mexico, abortion stigma, prevalence, measurement

Lancet, 11 May 2016

Abortion incidence between 1990 and 2014: global, regional, and sub-regional levels and trends
Gilda Sedgh, Jonathan Bearak, Susheela Singh, Akinrinola Bankole, et al.

Lancet, 11 May 2016
Abstract: We estimate sub-regional, regional, and global levels and trends in abortion incidence for 1990 to 2014, and abortion rates in subgroups of women. We use the results to estimate the proportion of pregnancies that end in abortion and examine whether abortion rates vary in countries grouped by the legal status of abortion… We estimated that 35 abortions (90% uncertainty interval [UI] 33 to 44) occurred annually per 1,000 women aged 15–44 years worldwide in 2010–14, which was 5 points less than 40 (39–48) in 1990–94 (90% UI for decline −11 to 0). Because of population growth, the annual number of abortions worldwide increased by 5·9 million (90% UI −1·3 to 15·4), from 50·4 million in 1990–94 (48·6 to 59·9) to 56·3 million (52·4 to 70·0) in 2010–14. In the developed world, the abortion rate declined 19 points (−26 to −14), from 46 (41 to 59) to 27 (24 to 37). In the developing world, we found a non-significant 2 point decline (90% UI −9 to 4) in the rate from 39 (37 to 47) to 37 (34 to 46). Some 25% (90% UI 23 to 29) of pregnancies ended in abortion in 2010–14. Globally, 73% (90% UI 59 to 82) of abortions were obtained by married women in 2010–14 compared with 27% (18 to 41) obtained by unmarried women. We did not observe an association between the abortion rates for 2010–14 and the grounds under which abortion is legally allowed.
Interpretation: Abortion rates have declined significantly since 1990 in the developed world but not in the developing world. Ensuring access to sexual and reproductive health care could help millions of women avoid unintended pregnancies and ensure access to safe abortion.

Tags: abortion incidence, abortion rates by region, estimates, trends


Measuring unsafe abortion-related mortality: a systematic review of the existing methods
Caitlin Gerdts, Divya Vohra, Jennifer Ahern

PLoS ONE 2013;8(1): e53346
Abstract: To our knowledge, no systematic assessment of the validity of studies reporting estimates of abortion-related mortality exists. Articles in this study had to be published between 1 Sept 2000 and 1 Dec 2011; utilized data from a country where abortion is considered unsafe; specified and enumerated causes of maternal death, including "abortion"; enumerated maternal deaths; were quantitative research; and were published in a peer-reviewed journal. Of 7,438 articles identified, 36 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 of 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.

Tags: abortion mortality estimates, systematic assessment
Identifying indicators for quality abortion care: a systematic literature review
Amanda Dennis, Kelly Blanchard, Tshego Bessenaar
Journal of Family Planning & Reproductive Health Care, 12 May 2016
A systematic review was conducted of 13 peer-reviewed articles and eight reports focused on indicators of quality abortion care. A total of 75 indicators of quality abortion were identified; these indicators address a variety of issues including policy, health systems, trained-provider availability, women's decision making, and morbidity and mortality. There is little agreement about indicators for measuring quality abortion care; more work is needed to ensure efforts to assess quality are informed and coordinated.

Tags: quality of care, indicators

Randomized trial assessing home use of two pregnancy tests for determining early medical abortion outcomes at 3, 7 and 14 days after mifepristone
Jennifer Blum, Wendy R Sheldon, Nguyen Thi Nhu Ngoc, Beverly Winikoff, et al.

Contraception, 8 April 2016
Abstract: To evaluate the accuracy, feasibility and acceptability of two urine pregnancy tests in assessing abortion outcomes at three time points after mifepristone administration. This randomized trial enrolled women seeking early medical abortion at two hospitals in Vietnam. Investigators randomly allocated participants to at-home administration of a multilevel urine pregnancy test (MLPT) or a high sensitivity urine pregnancy test (HSPT) to assess their abortion outcomes. A baseline test was administered on the same day as mifepristone. Participants performed and interpreted results of pregnancy tests taken 3, 7 and 14 days after mifepristone. Ultrasound exam determined continuing pregnancy.
Results and conclusions: Six hundred women enrolled, and 300 received each test. 97.4% (584) had follow-up, of whom 13 women had continuing pregnancies. At all three time points, the sensitivity and negative predictive values for both tests were 100.0%. Most women found their assigned tests easy to use and would prefer future home follow-up with a pregnancy test. The MLPT enables women to assess their abortion outcomes more reliably than with HSPT. With MLPT, women can know their outcomes as early as 3 days after mifepristone.
Implications: Medical abortion service delivery with an MLPT to obtain a baseline (pre-abortion) human chorionic gonadotropin (hCG) estimate and a second follow-up MLPT 1 to 2 weeks later can establish whether there has been a drop in hCG, signifying absence of a continuing pregnancy. Used this way, MLPTs can enable women to assess their abortion status outside of a clinic setting and without serum hCG testing and/or ultrasound.

Tags: medical abortion, post-abortion pregnancy test, home use

Zika: The Film
Prevention of potential sexual transmission of Zika virus

WHO Interim Guidance, WHO/ZIKV/MOC/16.1, 18 February 2016

The primary transmission route of Zika virus is via the Aedes mosquito. However, sexual transmission of Zika virus may also be possible, with limited evidence recorded in a few cases. This is of concern due to an association between Zika virus infection and potential complications, including microcephaly and Guillain-Barré syndrome. The current evidence base on Zika virus remains extremely limited. This guidance will be reviewed and the recommendations updated as new evidence emerges.
  • All patients (male and female) with Zika virus infection and their sexual partners (particularly pregnant women) should receive information about the potential risks of sexual transmission of Zika virus, contraceptive measures and safer sexual practices1, and should be provided with condoms when feasible. Women who have had unprotected sex and do not wish to become pregnant because of concern with infection with Zika virus should also have ready access to emergency contraceptive services and counselling.
  • Sexual partners of pregnant women, living in or returning from areas where local transmission of Zika virus is known to occur, should use safer sexual practices or abstinence from sexual activity for the duration of the pregnancy.
  • Men and women living in areas where local transmission of Zika virus is known to occur should consider adopting safer sexual practices or abstaining from sexual activity.
  • Men and women returning from where local transmission of Zika virus is known to occur should adopt safer sexual practices or consider abstinence for at least four weeks after return.
  • Independently of considerations regarding Zika virus, WHO always recommends the use of safer sexual practices including correct and consistent use of condoms to prevent HIV, other sexually transmitted infections and unwanted pregnancies. 
WHO does not recommend routine semen testing to detect Zika virus.

Tags: Zika virus, WHO, interim guidance, sexual transmission, safer sex practices

Correction to Zika Virus Update re Brazil policy, 4 May 2016 (
Sonia Correa, Sexuality Policy Watch
In this sombre scenario, since January, the  Ministry of Social Development has been  announcing that it would grant access to a social security benefit known as the BCP (in the value of one monthly minimum wage: US$ 300) for all mothers of babies affected by Zika related congenital syndrome. However, since then, the only concrete measure that has been adopted was the transfer of additional resources to states to accelerate the diagnostics of Zika infections and related effects. The extension of the BCP, however, remains a  crucial component of a proper state response to the crisis. ANIS has called  for this measure  in the appeal it is preparing for the Brazilian Supreme Court in relation to the Zika crisis and its effects on women’s lives, health and reproductive rights. The core argument of the ANIS appeal is that the State failed its constitutional mandate to protect women’s health, well-being and rights and that the responsibility for the drastic effects of the crisis (including taking to term pregnancies of gravely impaired children) cannot fall on the shoulders of women.
Editor: Marge Berer

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