Increasing access to abortion : perspectives on provider availability from different settings

Background: Unsafe abortion is estimated to cause around 23000 maternal deaths yearly, most of those deaths are preventable by proper use of contraception and access to safe abortion. Barriers to access to safe abortion include legal frameworks, infrastructure and shortage of eligible and trained providers. Lack of knowledge, stigma and cultural aspects influence women’s abortion-seeking behavior.

Aim: The overall aim of this thesis is to study factors that influence access to comprehensive abortion care focusing on increasing provider availability in different settings.

Materials, methods and results: Study I. A cross sectional survey including 1996 medical students found that disallowing attitudes and misconceptions were common. Very few had any clinical practice in abortion care. It is important to improve medical education and clinical training in abortion care services to influence medical student’s attitudes and ensure their future abortion provision. Study II. In-depth interviews were conducted with 23 medical students using a topic guide. Thematic analysis with an inductive approach was used to analyze data. Participants described a fear to provide abortion in their future practice, and their understanding of the law was limited. They also had limited clinical experience and were influenced by societal tradition and norm. Improved medical education including clinical practice is needed to increase the possibility that today’s medical students will become tomorrow’s abortion providers. Study III. A cost-effectiveness analysis was conducted alongside a randomized controlled equivalence trial to determine the cost-effectiveness of nurse-midwife provision of medical abortion compared with physicians. Average direct costs were EUR 45 for the nurse-midwife group and EUR 58 for the physician group. Increased effectiveness of the intervention gave an ICER at EUR -831 for direct costs and of EUR-1769 for total costs per avoided surgical intervention. Study IV. A systematic review was undertaken assess the effectiveness, safety and acceptability of non-physician provision of early medical abortion care including medical treatment for incomplete abortion. Electronic databases were searched using a search strategy based on PICOs. Six publications were included. Medical abortion by non-physicians using misoprostol regimens is equally effective as treatment by physicians. Acceptability among women, measured as overall satisfaction, is similar between groups. Quality of evidence range from low to moderate.

Conclusion: Provider availability is an important component for abortion access. It is important to focus on curricula for medical students and include abortion care to reduce stigma and ensure future provider availability. Midlevel provision of medical abortion is costeffective, effective and acceptable to women. Thus task-shifting is a way to increase access to safe abortion. In order to truly improve access to safe abortion care, increased knowledge is needed among providers and women.

List of scientific papers

I. Medical Student's attitudes and Perceptions on Abortion: a cross-sectional survey among medical interns in Maharastra, India. Sjöström S, Essén B, Sydén F, Gemzell-Danielsson K, Klingberg Allvin M. Contraception. 2014, 90, 42-46.
https://doi.org/10.1016/j.contraception.2014.02.005

II. Medical students are afraid to include abortion in their future practices: in-depth interviews in Maharastra, India. Sjöstström S., Essén B., Gemzell-Danielsson K., Klingberg-Allvin M. BMC Medical Education. 2016, 16:8.
https://doi.org/10.1186/s12909-016-0532-5

III. Medical abortion provided by nurse-midwifes or physicians in a high resource setting: a cost-effectiveness analysis. Sjöström S., Kopp-Kallner H., Simeonova E., Madestam A., Gemzell-Danielsson K. PLoS ONE. 2016 11(6): e0158645.
https://doi.org/10.1371/journal.pone.0158645

IV. Effectiveness, safety and acceptability of non-physician provision of first trimester medical abortion: a systematic review. Sjöström S., Dragoman M., Fønhus M.S., Ganatra B., Gemzell-Danielsson K. [Manuscript]