Health system reform and safe abortion: A case study of Mongolia

Abstract

Unsafe abortion serves as a marker of global inequity as it is concentrated in the developing world where the poorest and most vulnerable women live. While liberalisation of abortion law is essential to the reduction of unsafe abortion, a number of challenges exist beyond this important step. This paper investigates how popular health system reforms consonant with neoliberal agendas can challenge access to safe abortion. We use Mongolia, a country that has liberalised abortion law, yet, limited access to safe abortion, as a case study. Mongolia embraced market reforms in 1990 and subsequently reformed its health system. We document how common reforms in the areas of finance and regulation can compromise the safety of abortions as they foster challenges that include inconsistencies in service delivery that further foment health inequities, adoption of reproductive health programmes that are incompatible with the local sociocultural context, unregulated growth of the private sector and poor enforcement of standards and technical guidelines for safe abortion. We then discuss how this case study suggests the conversations that reproductive health policy-makers must have with those engineering health sector reform to ensure access to safe abortion in a liberalised environment.     

Parents' views of community care for children with motor disabilities

Summary In this study we have ascertained the views of 40 parents of 4-year-old children with motor disabilities, on the health and education services, social service and the availability of respite care. The children with moderate or severe motor disability who were born in 1985, were identified from the Oxford Regional Register of Early Childhood Impairment.
Thirty-three (83%) completed a questionnaire taken to the home by the health visitor. Although most parents had access to a range of services, lack of information in the early years, fragmentation of services and limited choices were identified as problems. Parents regarded the breadth of care provided by the pre-school teacher counsellor and the nursery school as very useful, whereas the health service and social services were perceived as less appropriate.
This small study suggests that for some families, the objectives of community care as identified in the Griffiths Report (Griffiths 1988) and reiterated in the Children Act (1989) are not yet being met.     

Estimating the lifetime incidence of induced abortion and understanding abortion practices in a Northeastern Tanzania community through a household survey

ObjectivesAll Tanzanian abortion estimates rely on health facility data that do not take into account completely the incidence of abortion. This papers aims to estimate the lifetime incidence of induced abortion in Arusha, Tanzania via direct and double list-experiment methods using community data and evaluate outcomes and behaviors of women who had an abortion.MethodsFrom January to May 2018, a face-to-face interview survey was conducted on a representative sample of sexually active women (n = 3658) living in Arusha, Tanzania. Participants were selected in a three-stage random process and questions were asked about reproductive history, contraceptive use, and health seeking behaviors. A direct question and double list-experiment was used to estimate lifetime incidence of abortion.ResultsLifetime abortion incidence was 3% using the direct question compared to 7.7% using the double list-experiment method. However, post-estimation tests revealed a key study design violation thus invalidating list the experiment estimate. We find that 45% of women received their abortion outside the formal health care system, the most frequent method used was manyono pill (traditional medicine), and only 50% of women who experienced abortion complications sought treatment.ConclusionsWe provide another example of the performance of list experiment in measuring abortion incidence. Nearly half of reported abortions took place outside of the formal health system highlighting the substantial underestimation while using facility data to measure abortion. Seeking health care for potential complications was low despite post-abortion care services being free and legal in Tanzania.ImplicationsUsing administrative data to estimate lifetime incidence of abortion is inaccurate as we found half of our sample received abortions outside a health facility. Women should be encouraged to seek post-abortion care, when needed.     

Restricted access to abortion in the Republic of Ireland and Northern Ireland: exploring abortion tourism and barriers to legal reform

Access to abortion remains a controversial issue worldwide. In Ireland, both north and south, legal restrictions have resulted in thousands of women travelling to England and Wales and further afield to obtain abortions in the last decade alone, while others purchase the ‘abortion pill’ from Internet sources. This paper considers the socio-legal context in both jurisdictions, the data on those travelling to access abortion and the barriers to legal reform. It argues that moral conservatism in Ireland, north and south, has contributed to the restricted access to abortion, impacting on the experience of thousands of women, resulting in these individuals becoming ‘abortion tourists’.     

Cancer prevention in the community: a survey of community residents

Lifestyle exposures account for the greatest proportion of risk factors for cancer, yet these exposures have proven most difficult to alter. Despite intensive intervention efforts, many behaviour change programs are ill suited to the community. This research was undertaken to increase our understanding of prevention activities of interest to a sample of residents in two Ontario communities. 248 (62.3%) adult residents responded to a semi-structured self-administered questionnaire including open-ended questions on health issues, exposures and prevention activities of interest. While some of the beliefs expressed by respondents might have been anticipated (e.g., cigarette smoking and family history increase risk of cancer), others were not (e.g., only between 40 and 75% of respondents thought a high fat diet increased risk). Furthermore, many of those with personal health concerns expressed an interest in prevention. This process is proposed as a first step in launching more appropriate and sustainable community-based health promotion programs for cancer prevention.     

对医疗卫生体制改革的思考及建议

医疗卫生体制改革是一个非常复杂的世界性难题。本文结合医疗卫生行业存在的突出性问题，并就实现当前医疗卫生体制改革目标和任务，提出医疗卫生体制改革的前提、保障、人手、重点等建议，保证其改革的科学性、整体性和可行性。     

Medical abortion practices: a survey of National Abortion Federation members in the United States

Background

Little is known about clinical implementation of medical abortion in the United States following approval of mifepristone as an abortifacient by the Food and Drug Administration (FDA) in 2000. We collected information regarding medical abortion practices of National Abortion Federation (NAF) members for the year 2001.

Methods

Questionnaires were mailed to 337 active US NAF member facilities.

Results

A total of 258 facilities responded (77%); 252 nonhospital facilities were included in the analysis. Most of these facilities (87%) offered medical abortion in 2001, providing an estimated 28,400 medical abortions, approximately 52% of medical abortions in the US that year. Over 75% began offering mifepristone/misoprostol abortions within 5 months of the start of mifepristone distribution. Almost all (99%) reported using mifepristone/misoprostol regimens, with most offering one or more evidence-based alternative regimens (83%); a few (4%) used the FDA-approved regimen.

Conclusion

After FDA approval of mifepristone, NAF member facilities rapidly adopted evidence-based mifepristone/misoprostol regimens.     

长治市国际安全社区居民伤害流行病学调查

摘要:目的　了解国际安全社区潞安集团社区居民伤害发生情况,为创建国际安全社区提供决策支持。方法　采用随机抽样的方法,在国际安全社区潞安集团王庄社区八个居民点抽取到1148 户共3247名常住居民,对其2010年1月1日-2011年12月31日期间的伤害发生情况及相关因素进行回顾性调查,主要内容有性别、出生年月、文化程度、身高、体重、经济收入、伤害原因、受伤时间及发生地点、受伤时正在进行活动、伤害部位和性质。建立Epidata3.1数据库,数据统计分析用SPSS18.0进行。结果　社区居民伤害发生率为3.60%,95%置信区间为2.96%～4.27%;标化发生率为3.73%。伤害发生率随年龄增长而增高（伤害发生率1～14 岁组为4.12%,15～34 岁组为1.92%,35～54 岁组为3.55%,55 岁及以上年龄组为6.51%）;文化程度越高伤害发生率越低（大专及以上2.24%,高中/中专2.28%,初中为4.52%,小学及以下为5.58%）;家务和离退休人员伤害发生率高,分别为4.67%和6.23%,成人伤害与体重指数有关。前3位伤害类型为跌倒/ 坠落、切割穿刺伤和其他伤。发生地点以家庭住所、居民小区为多。受伤部位多为上下肢体,约15%伤害需住院治疗。结论　创建安全社区应全方位地开展伤害干预工作,重点干预文化程度低、年龄大,家庭主妇和离退休人员;重点干预场所应该为家庭住所、居民小区;减少因跌倒、切割穿刺伤发生,关注交通伤害的发生趋势。     

Community views on health sector reform and their participation in health priority setting: case of Lushoto and Muheza districts, Tanzania

BACKGROUND: Community participation (CP) is a key concept under 'primary health care' programmes and 'Health Sector Reform' (HSR) in many countries. However, international literature with current empirical evidence on CP in health priority setting and HSR in Tanzania is scanty. OBJECTIVES: To explore and describe community views on HSR and their participation in setting health priorities. METHODS: A multistage sampling of wards and villages was done, involving group discussions with members of households, Village Development Committees (VDCs) and Ward Development Committees (WDCs). RESULTS: Respondents at village and ward levels in both districts related HSR with a cost sharing system at public health facilities. Views on the advantages or disadvantages of HSR were mixed, most of the residents pointing out that user charges burden the poor, there is a shortage of drugs at peripheral health facilities, the performance of government health service staff and village health workers does not satisfy community needs, health insurance is promoted more than people actually benefit, VDC and WDC poorly function as compared to local community-participatory priority-setting structures. CONCLUSION: HSR may not meet the desired health needs unless more efforts are made to enhance the performance of the existing HSR structures and community knowledge and enhance trust and participation in the health sector programmes at all levels.     

南宁市15岁及以上社区居民吸烟现状调查

目的:了解南宁市15岁及以上社区居民的吸烟现状及控烟态度,为相关部门制定有效的社区控烟措施,形成"有效的控烟局面"提供参考依据。方法:在2010年10月-2010年12月间,采用随机抽样入户一对一问卷调查方式,调查南宁市15岁及以上社区居民821人,其中有805份问卷记录合格用于分析。调查采用中国公共卫生控烟能力建设项目组统一设计的调查问卷。结果:南宁市15岁及以上社区居民吸烟率为29.81%,现在吸烟率为26.96%,其中男性吸烟率和现在吸烟率(50.56%和46.52%)明显高于女性吸烟率和现在吸烟率(4.17%和2.78%);35岁～64岁的人群现在吸烟率较高;不同民族现在吸烟率差异无统计学意义;不同文化程度的人群现在吸烟率差异有统计学意义,随着文化程度的升高,现在吸烟率有降低的趋势;从事技术工作的人群现在吸烟率最高;去年一年人均收入在3万-不足4万组和5万及以上组的人群现在吸烟率明显高于其他组。人群被动吸烟率为41.24%;家庭吸烟率达66.69%,只有22.11%的家庭家中禁止吸烟;78.14%的调查对象所居住的社区从未开展过任何关于控烟的活动;70.81%的人赞成社区公共场所禁烟;61.99%的人认为政府出台相关政策才是社区禁烟最有效可行的方式。结论:南宁市15岁及以上社区居民吸烟与被动吸烟率近年有所升高,家庭吸烟率较高,社区控烟宣传力度明显不足,但社区控烟有较强大的群众支持力量;应以社区为载体,以家庭为单位,以政府为后盾,加强相关的健康教育及行为干预,推动社区公共场所的禁烟立法。     

Early abortion services in the United States: a provider survey

The objective of this study was to describe the availability of early surgical and medical abortion among members of the National Abortion Federation (NAF) and to identify factors affecting the integration of early abortion services into current services. Telephone interviews were conducted with staff at 113 Planned Parenthood affiliates and independent abortion providers between February and April 2000, prior to FDA approval of mifepristone. Early abortion services were available at 59% of sites, and establishing services was less difficult than or about what was anticipated. Sites generally found it easier to begin offering early surgical abortion than early medical abortion. Physician participation was found to be critical to implementing early services. At sites where some but not all providers offered early abortion, variations in service availability resulted. Given the option of reconsidering early services, virtually all sites would make the same decision again. These data suggest that developing mentoring relationships between experienced early abortion providers/sites and those not offering early services, and training physicians and other staff, are likely to be effective approaches to expanding service availability.     

First-trimester surgical abortion practices: a survey of National Abortion Federation members

Background

Designated providers in specialized clinics perform the majority of approximately 1.1 million first-trimester abortions carried out in the United States each year. Our objective was to assess the first-trimester surgical abortion practices of National Abortion Federation (NAF) members.

Study Design

We mailed questionnaires to NAF administrators and providers at their 364 active-member facilities in 2002.

Results

Two hundred eighty-nine (79%) facilities responded; we received administrative questionnaires from 273 facilities and 293 individual clinicians. NAF facilities provided at least 325,000 first-trimester surgical abortions in the United States in 2001. The majority of providers are obstetrician-gynecologists (63%), male (62%) and at least 50 years old (64%). Half of clinicians (49%) selectively utilize manual vacuum aspiration. Almost half (47%) routinely use a metal curette to verify procedure completion; these providers are more likely to be over 50 years of age or to have 20 years or more of abortion experience. Other practices are more uniform, including routine tissue examination (93%), postoperative antibiotics (88%) and contraceptive provision (oral contraceptives, 99%; depot medroxyprogesterone acetate, 79%).

Conclusions

Most perioperative practices for first-trimester abortions are similar among these respondents, in accord with evidence-based guidelines. The aging of skilled practitioners raises concerns about the future availability of surgical abortion.     

Second-trimester surgical abortion practices: a survey of National Abortion Federation members

Background

The objective of this analysis was to assess the second-trimester surgical abortion practices of National Abortion Federation (NAF) members in North America and Australia.

Study Design

In 2002, questionnaires were mailed to 364 active member clinics of NAF for completion by their clinic administrators and individual providers.

Results

Two hundred eighty-nine (79%) clinics responded. Most NAF clinics (72%) offer second-trimester abortion services. The majority of second-trimester providers are obstetrician/gynecologists (63%), male (62%) and at least 50 years old (63%). We describe second-trimester surgical abortion practices in terms of patient eligibility, cervical ripening, ultrasound use, anesthesia and postoperative care.

Conclusions

Surgical techniques and postoperative practices for second-trimester abortions are similar among these respondents, suggesting that NAF's efforts to promulgate best practices using evidence-based guidelines are succeeding. The aging of skilled practitioners raises concerns about the future availability of second-trimester abortion.     

Attitudes of obstetrics and gynecology residents toward abortion participation: a Philadelphia area survey

OBJECTIVE: The objective of this study was to evaluate the willingness of Philadelphia obstetrics and gynecology residents to participate in three abortion procedures for various fetal conditions. METHODS: Anonymous questionnaires were distributed to 310 residents from 18 programs. The survey asked the residents whether they would participate in first trimester dilatation and evacuation (D&E), second trimester prostaglandin induction or second trimester D&E for the following conditions: lethal fetal anomaly, nonlethal anomaly with certain long-term functional consequences, possible long-term functional consequences, little or no long-term functional consequences and elective abortion of a normal fetus. RESULTS: Of the 148 respondents, the percentage of residents who would participate in a second trimester D&E for each fetal condition was significantly lower than that for a first trimester D&E (p < or = .001). Additionally, for each abortion procedure, the participation rates consistently fell for lesser degrees of fetal severity. Participation was significantly associated with preferences regarding abortion legislation and personal abortion stance. CONCLUSION: Resident attitudes regarding abortion participation were related to severity of the fetal condition, gestational age and procedure type.     

The impact of community mental health reform on service users: a cohort study

British mental health services have undergone considerable reform in recent years. This paper reports a study designed to assess the impact of these changes on service users. The functioning of 100 randomly selected users of community mental health services in a North Wales town was assessed before the advent of two significant service changes – the establishment of a local Community Mental Health Team (CMHT) and the introduction of the main community care reforms in April 1993. Repeat assessments of sample members were made on three further occasions over the following 27 months, with a 9-month interval between each. Comparison of baseline and follow-up data suggested that services were appropriately targeted on users with a severe and enduring mental illness and that the functioning of this client group was successfully maintained over the study period. However, the establishment of a CMHT was associated with a temporary fall in social functioning, quality of life and satisfaction with services and there was no evidence to conclude that organizational reforms had led to an improvement in user outcomes in the medium term. Future mental health reorganization should be based on the evidence of research which includes an assessment of the impact of reforms on service users.