Social accountability as a strategy to promote sexual and reproductive health entitlements for stigmatized issues and populations.

Social accountability is often put forward as a strategy to promote health rights, but we lack a programmatic evidence base on if, when, and how social accountability strategies can be used to promote access to quality Sexual and Reproductive Health (SRH) care for stigmatized populations and/or stigmatized issues. In this Commentary, we discuss the potential advantages and disadvantages of social accountability strategies in promoting the availability of a full range of SRH services for excluded and historically oppressed populations. We accomplish this by describing four programs that sought to promote access to quality SRH care for stigmatized populations and/or stigmatized services. Program implementers faced similar challenges, including stigma and harmful gender norms among providers and communities, and lack of clear guidance, authority, and knowledge of Sexual and Reproductive Health and Rights (SRHR) entitlements at local level. To overcome these challenges, the programs employed several strategies, including linking their strategies to legal accountability, budgetary expenditures, or other institutionalized processes; taking steps to ensure inclusion, including through consultation with excluded or stigmatized groups throughout the program design and implementation process; specific outreach and support to integrating marginalized groups into program activities; and the creation of separate spaces to ensure confidentiality and safety. The program experiences described here suggest some general principles for ensuring that social accountability efforts are inclusive both in terms of populations and issues addressed. Further empirical research can test and further flesh out these principles, and deepen our understanding of context.

Human rights-based accountability for sexual and reproductive health and rights in humanitarian settings: Findings from a pilot study in northern Uganda.

Ensuring accountability for the realization of sexual and reproductive health and rights is a human rights obligation and central tenet of strategies to improve health systems and outcomes in humanitarian settings. This pilot study explored the feasibility and acceptability of deploying human rights strategies, specifically through a participatory community-led complaints mechanism, to hold humanitarian health systems to account for the sexual and reproductive health and rights of refugee and host community women and girls in northern Uganda. Over a fifteen-month period we conducted a multi-methods exploratory study with refugee and host community rights-holders and duty-bearers using longitudinal in-depth interviews, focus groups, and secondary data document review. Deductive and inductive coding techniques were used to analyze data iteratively for content and themes. 107 sexual and reproductive health and rights related complaints and feedback were collected through the community complaints mechanism. Complaints concerned experiences of disrespect and abuse by health care workers; lack of adolescent access to sexual and reproductive health services and information; sexual and gender-based violence; and lack of access to acceptable and quality health goods and services. Participants reported an increased understanding and claiming of human rights through the intervention, acceptability of rights-based accountability strategies among humanitarian health system actors, and improved access to remedies when sexual and reproductive health rights are not respected. Findings demonstrate integrating rights-based social accountability mechanisms at the level of humanitarian response as a promising approach for strengthening and holding humanitarian health systems accountable for the sexual and reproductive health and rights of women and girls affected by humanitarian situations.

"It is just like having a period with back pain": exploring women's experiences with community-based distribution of misoprostol for early abortion on the Thailand-Burma border.

INTRODUCTION: The lack of economic development and longstanding conflict in Burma have led to mass population displacement. Unintended pregnancy and unsafe abortion are common and contribute to maternal death and disability. In 2011, stakeholders operating along the Thailand-Burma border established a community-based distribution program of misoprostol for early abortion, with the aim of providing safe and free abortion care in this low-resource and legally restricted setting. METHODS: We conducted 16 in-depth, in-person interviews with women from Burma residing on both sides of the border who accessed misoprostol through the community-based distribution initiative. We analyzed interviews for content and themes using deductive and inductive methods. RESULTS: Overall, women felt positively about their abortion experiences and the initiative. Previous abortion experiences and the recommendations of others shaped women's access. All participants, including those who remained pregnant after taking the misoprostol, would recommend the initiative to others. CONCLUSION: Community-based distribution of misoprostol is an effective and culturally appropriate method of improving safe abortion care on the Thailand-Burma border. Supporting efforts to expand the harm reduction program to more communities and provide regular reproductive health and safe abortion trainings appears warranted. IMPLICATIONS: In recent years, a number of organizations have launched programs dedicated to misoprostol-alone for early abortion. However, few have documented the experiences and perspectives of women. Our findings indicate providing misoprostol through lay provision in a legally restricted context is not only safe and effective but also culturally resonant.

"Without this program, women can lose their lives": migrant women's experiences with the Safe Abortion Referral Programme in Chiang Mai, Thailand.

For displaced and migrant women in northern Thailand, access to health care is often limited, unwanted pregnancy is common, and unsafe abortion is a major contributor to maternal death and disability. Based on a pilot project and situational analysis research, in 2015 a multinational team introduced the Safe Abortion Referral Programme (SARP) in Chiang Mai, Thailand, to reduce the socio-linguistic, economic, documentation, and transportation barriers women from Burma face in accessing safe and legal abortion care in Thailand. Our qualitative study documented the experiences of women with unwanted pregnancies who accessed the SARP in order to inform programme improvement and expansion. We conducted 22 in-depth, in-person interviews and analysed them for content and themes using deductive and inductive techniques. Women were overwhelmingly positive about their experiences using the SARP. They reported lack of costs, friendly programme staff, accompaniment to and interpretation at the providing facility, and safety of services as key features. Financial and legal circumstances shaped access to the programme and women learned about the SARP through word-of-mouth and community workshops. After accessing the SARP and receiving support, women became community advocates for reproductive health. Efforts to expand the programme and raise awareness in migrant communities appear warranted. Our findings suggest that referral programmes for safe and legal abortion can be successful in settings with large displaced and migrant populations. Identifying ways to work within legal constraints to expand access to safe services has the potential to reduce harm from unsafe abortion even in humanitarian settings.

To be, or not to be, referred: A qualitative study of women from Burma's access to legal abortion care in Thailand.

BACKGROUND: Reproductive health outcomes among women from Burma who live along the Thailand-Burma border demonstrate an unmet need for access to safe abortion services. In 2014, a multi-national team launched a collaborative three-year initiative to expand a program that refers eligible women for safe and legal abortion care to government Thai hospitals in Tak province, Thailand. METHODS: Over a six-month period we conducted 14 in-depth open-ended interviews with women from Burma who were referred through the program or denied a wanted abortion after being deemed ineligible for referral by staff at the participating clinic. We analyzed the interviews for content and themes using both deductive and inductive techniques. RESULTS: Women's experiences accessing legal abortion care were positive and facilitated by appropriate options counseling, logistical support, and financial coverage. Five of the ineligible women we interviewed used traditional methods accessed on both sides of the border to self-induce an abortion and/or visited an untrained and unregulated provider. DISCUSSION: Our findings highlight the need to redouble efforts to expand access to safe and legal abortion care for women from Burma residing in northern Thailand. Ensuring that women who are denied a safe and legal abortion receive harm reduction interventions and resources is critical.

Community-based distribution of misoprostol for early abortion: evaluation of a program along the Thailand-Burma border.

BACKGROUND: Although abortion is legal in Thailand for a number of indications, women from Burma residing in Thailand are rarely able to access safe services. We evaluated the outcomes of a community-based distribution program that provides migrant, refugee, and cross-border women from Burma with evidence-based information about and access to misoprostol for early pregnancy termination. METHODS: After determination of eligibility based on self-report and counseling, trained Network members instructed women to vaginally administer two 800-mcg doses of misoprostol 24 h apart and a third dose one week later, if needed. We systematically reviewed data from monitoring logbooks recorded over a three-year period to examine pregnancy outcomes. We also conducted in-depth open-ended interviews with the three leaders of the two Networks to understand better their perceptions and experiences as providers and counselors. We analyzed logbook data using descriptive statistics and interviews for content and themes using both deductive and inductive techniques. RESULTS: From January 2012 through December 2014, 918 women received early abortion care using misoprostol through the community-based distribution program. Of these, 885 women (96.4%) were not pregnant at follow-up, 29 were pregnant at follow-up (3.2%), and four women were lost to follow-up (0.4%). Our interviews revealed that providers are motivated to participate due to concerns surrounding unsafe abortion in the community and frame their work as a public health intervention. CONCLUSIONS: The documented outcomes from this initiative may be valuable for those working to reduce harm from unsafe abortion in other legally restricted, low-resource, and/or conflict-affected settings. IMPLICATIONS: Our findings demonstrate that community-based distribution of misoprostol can be a safe and effective strategy for increasing access to safe abortion, even in a legally restricted, low-resource setting. Determining if similar strategies can be successfully employed in other contexts appears warranted.

Exploring Legal Restrictions, Regulatory Reform, and Geographic Disparities in Abortion Access in Thailand.

Despite decades of advocacy among Thai governmental and nongovernmental actors to remove abortion from the country's 1957 Criminal Code, this medically necessary service remains significantly legally restricted. In 2005, in the most recent regulatory reform to date, the Thai Medical Council established regulatory measures to allow a degree of physician interpretation within the confines of the existing law. Drawing on findings from a review of institutional policies and legislative materials, key informant interviews, and informal discussions with health service providers, government representatives, and nonprofit stakeholders, this article explores how legal reforms and health policies have shaped the abortion landscape in Thailand and influenced geographic disparities in availability and accessibility. Notwithstanding a strong medical community and the recent introduction of mifepristone for medication abortion (also known as medical abortion), the narrow interpretation of the regulatory criteria by physicians further entrenches these disparities. This article examines the causes of subnational disparities, focusing on the northern provinces and the western periphery of Thailand, and explores strategies to improve access to abortion in this legally restricted setting.

Assessing abortion coverage in nurse practitioner programs in Canada: a national survey of program directors.

OBJECTIVES: Although nurse practitioners (NPs) play a critical role in the delivery of reproductive health services in Canada, there is a paucity of published information regarding the reproductive health education provided in their training programs. Our study aimed to understand better the didactic and curricular coverage of abortion in Canadian NP programs. STUDY DESIGN: In 2014, we conducted a 3-contact, bilingual (English-French) mailed survey to assess the coverage of, time dedicated to and barriers to inclusion of 17 different areas of reproductive health, including abortion. We also asked respondents to speculate on whether or not mifepristone would be incorporated into the curriculum if approved by Health Canada for early abortion. We analyzed our results with descriptive statistics and used inductive techniques to analyze the open-ended questions for content and themes. RESULTS: Sixteen of 23 (70%) program directors or their designees returned our survey. In general, abortion-related topics received less coverage than contraception, ectopic pregnancy management and miscarriage management. Fifty-six percent of respondents reported that their program did not offer information about first-trimester abortion procedures and/or post-abortion care in the didactic curriculum. Respondents expressed interest in incorporating mifepristone/misoprostol into NP education and training. CONCLUSION: Reproductive health issues receive uneven and often inadequate curricular coverage in Canadian NP programs. Identifying avenues to expand education and training on abortion appears warranted. Embarking on curricular reform efforts is especially important given the upcoming introduction of mifepristone into the Canadian health system for early abortion. IMPLICATIONS: Our findings draw attention to the need to integrate abortion-related content into NP education and training programs. The approval of Mifegymiso® may provide a window of opportunity to engage in curriculum reform efforts across the health professions in Canada.

No Exceptions: Documenting the Abortion Experiences of US Peace Corps Volunteers.

Since 1979, US federal appropriations bills have prohibited the use of federal funds from covering abortion care for Peace Corps volunteers. There are no exceptions; unlike other groups that receive health care through US federal funding streams, including Medicaid recipients, federal employees, and women in federal prisons, abortion care is not covered for volunteers even in cases of life endangerment, rape, or incest. We interviewed 433 returned Peace Corps volunteers to document opinions of, perceptions about, and experiences with obtaining abortion care. Our results regarding the abortion experiences of Peace Corps volunteers, especially those who were raped, bear witness to a profound inequity and show that the time has come to lift the "no exceptions" funding ban on abortion coverage.