Denial of legal abortion in Nepal.

INTRODUCTION: In Nepal, abortion is legal on request through 12 weeks of pregnancy and up to 28 weeks for health and other reasons. Abortion is available at public facilities at no cost and by trained private providers. Yet, over half of abortions are provided outside this legal system. We sought to investigate the extent to which patients are denied an abortion at clinics legally able to provide services and factors associated with presenting late for care, being denied, and receiving an abortion after being denied. METHODS: We used data from a prospective longitudinal study with 1835 women aged 15-45. Between April 2019 and December 2020, we recruited 1,835 women seeking abortions at 22 sites across Nepal, including those seeking care at any gestational age (n = 537) and then only those seeking care at or after 10 weeks of gestation or do not know their gestational age (n = 1,298). We conducted interviewer-led surveys with these women at the time they were seeking abortion service (n = 1,835), at six weeks after abortion-seeking (n = 1523) and six-month intervals for three years. Using descriptive and multivariable logistic regression models, we examined factors associated with presenting for abortion before versus after 10 weeks gestation, with receiving versus being denied an abortion, and with continuing the pregnancy after being denied care. We also described reasons for the denial of care and how and where participants sought abortion care subsequent to being denied. Mixed-effects models was used to accounting clustering effect at the facility level. RESULTS: Among those recruited when eligibility included seeking abortion at any gestational age, four in ten women sought abortion care beyond 10 weeks or did not know their gestation and just over one in ten was denied care. Of the full sample, 73% were at or beyond 10 weeks gestation, 44% were denied care, and 60% of those denied continued to seek care after denial. Nearly three-quarters of those denied care were legally eligible for abortion, based on their gestation and pre-existing conditions. Women with lower socioeconomic status, including those who were younger, less educated, and less wealthy, were more likely to present later for abortion, more likely to be turned away, and more likely to continue the pregnancy after denial of care. CONCLUSION: Denial of legal abortion care in Nepal is common, particularly among those with fewer resources. The majority of those denied in the sample should have been able to obtain care according to Nepal's abortion law. Abortion denial could have significant potential implications for the health and well-being of women and their families in Nepal.

Trends In Self-Pay Charges And Insurance Acceptance For Abortion In The United States, 2017-20.

The Hyde Amendment prevents federal funds, including Medicaid, from covering abortion care, and many states have legal restrictions that prevent private insurance plans from covering abortion. As a result, most people pay for abortion out of pocket. We examined patient self-pay charges for three abortion types (medication abortion, first-trimester procedural abortion, and second-trimester abortion), as well as facilities' acceptance of health insurance, during the period 2017-20. We found that during this time, median patient charges increased for medication abortion (from $495 to $560) and first-trimester procedural abortion (from $475 to $575) but not second-trimester abortion (from $935 to $895). The proportion of facilities that accept insurance decreased over time (from 89 percent to 80 percent). We noted substantial regional variation, with the South having lower costs and lower insurance acceptance. Charges for first-trimester procedural abortions are increasing, and acceptance of health insurance is declining. According to the Federal Reserve, one-quarter of Americans could not pay for a $400 emergency expense solely with the money in their bank accounts-an amount lower than any abortion cost in 2020. Lifting Hyde restrictions and requiring public and private health insurance to cover this essential, time-sensitive health service without copays or deductibles would greatly reduce the financial burden of abortion.

Predictors of prior unsuccessful pharmacy abortion attempts among women presenting for abortion in government certified clinics in Nepal.

OBJECTIVE: Although abortion in Nepal is broadly legal and free of charge, many women seek abortion care outside the legal system, including from pharmacies. We evaluated the prevalence of, and factors associated with, prior unsuccessful abortion attempts among women presenting to 14 randomly-selected government approved abortion health facilities across Nepal. METHODS: Eligible participants were recruited in 2019 by trained research staff from certified abortion facilities. Participants (n = 1160) completed research staff-administered baseline surveys. We used multivariable mixed-effects logistic regression models to evaluate factors associated with having attempted pharmacy abortion prior to coming to the health facility. RESULTS: Almost one in seven (14%) women had tried to end their pregnancy before presenting to a participating clinic, often (9%) using medication obtained from a pharmacy. Women who lived farther from the clinic (aOR 1.28 per log hours travel time, 95% CI 1.10-1.49) and who reported financial difficulty in accessing the clinic (19% vs. 10%, aOR 2.10, 95% CI 1.20-3.70) had increased odds of having tried to access abortion through a pharmacy. CONCLUSION: Integrating pharmacies into the legal network of abortion providers may improve access to safe care, particularly for rural women with financial and practical travel limitations.

Abortion service availability during the COVID-19 pandemic: Results from a national census of abortion facilities in the U.S.

OBJECTIVE: This study assessed the impact of COVID-19 on abortion services in all 50 United States states and the District of Columbia. STUDY DESIGN: ANSIRH's Abortion Facility Database is a systematic collection of data on all publicly-advertising abortion facilities in the United States, updated annually through online searches and mystery shopper phone calls. Research staff updated the database in May-August 2020, assessing the number of facilities that closed, limited or stopped providing abortions, and provided telehealth options in summer 2020 due to COVID-19.  We describe these changes using frequencies and highlighting themes and examples from coded qualitative data. RESULTS: Located primarily in the South and Midwest, 24 of 751 facilities that were open in 2019 temporarily closed due to the pandemic, with 9 still closed by August 2020. Other facilities described suspending abortions, referring abortion patients to other facilities, or limiting services to medication abortion. While most facilities required in-person visits for reasons like state abortion restrictions, 22% (n = 150) offered phone or telehealth consultations, no-test visits, or medication abortion by mail to reduce or eliminate patient time in the clinic. Some facilities used creative strategies to reduce COVID-19 risk like allowing patients to wait for visits in their cars or offering drive-through medication pick-up. CONCLUSIONS: The COVID-19 pandemic caused several disruptions to abortion service availability, including closures. To reduce in-person visit time, some clinics shifted to offering medication abortion (versus procedural) or telehealth. While the pandemic and abortion restrictions increased barriers to abortion provision, facilities were resilient and adapted to provide safe care for their patients. IMPLICATIONS: Barriers to abortion access were exacerbated during the COVID-19 pandemic, particularly in areas of the country with more restrictive policies toward abortion. Telehealth care protocols offered by many abortion facilities provide an option to reduce or eliminate in-person visits.

Care for Incarcerated Pregnant People With Opioid Use Disorder: Equity and Justice Implications.

With the simultaneous rise in maternal opioid use disorder (OUD) and the incarceration of pregnant people in the United States, we must ensure that prisons and jails adequately address the health and well-being of incarcerated pregnant people with OUD. Despite long-established, clear, and evidence-based recommendations regarding the treatment of OUD during pregnancy, incarcerated pregnant people with OUD do not consistently receive medication treatment and are instead forced into opioid withdrawal. This inadequate care raises multiple concerns, including issues of justice and equity, considerations regarding the legal and ethical obligations of the provision of health care, and violations of the medical and legal rights of incarcerated people. We offer recommendations for improving care for this often-ignored group.