Blair G. Darney


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    Objective: The safety of abortion is well established, yet quality abortion care must reflect domains beyond safety. We document quality of care definitions, conceptual frameworks, and measures used in the literature and agency practices to inform ongoing efforts to develop quality metrics for abortion.
    Methods: We reviewed the abortion and contraception literature, the broader health services and quality in healthcare literature, and agency definitions and tools for quality measurement. We identified seminal definitions and frameworks as well as criteria for quality measures. Results: Health care quality is the degree to which services produce desired health outcomes and rely on best available evidence. Key frameworks from the Institute of Medicine (IOM) and World Health Organization (WHO) articulate domains of quality, focused on whether health care is effective, efficient, accessible, acceptable/patient-centered, equitable, and safe. Quality is further classified as technical (appropriate care) and interpersonal (interaction with provider). Evidence exists to guide clinical practice in abortion. However, assessment of the quality of clinical practice remains unstandardized, and very little evidence exists documenting client perceptions of both technical and interpersonal quality. Satisfaction, a common quality measure, is limited: women are nearly universally satisfied when they receive needed care, and global satisfaction does not tell us where or how to intervene to improve quality. A wide variety of measures and indicators have been used in the literature and by implementing agencies, but little evidence exists to link these measures with health or behavioral outcomes.
    Conclusions: Quality abortion care includes, but is not limited to, safety. We lack both common terminology and measures to assess abortion services across diverse health system settings, especially in low- and middle-income countries. Such measures would allow us to build evidence about the effectiveness, efficiency, accessibility, patient-centered-ness, equity, and safety of abortion services, and ultimately to improve abortion care for women across the globe.

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    Objective: There is little consensus about whether commonly used measures of Catholicism lend much to our understanding of abortion support.

    We tested whether degree of Catholicism was associated with support for abortion among Mexican Catholics and if different measures of Catholicism alter the relationship. Methods: We used data from 2,669 Mexican Catholics. Respondents were asked a question about support for legal abortion, as well as support for abortion under 10 exceptions, which we grouped into 2 categories: exceptions with traditionally majority (high) agreement and less than majority (low) agreement based on previous literature. Our independent variable was degree of Catholicism, measured in 4 ways: attendance at mass, degree of Catholicism, perception of a good Catholic, and confession after abortion. We ran multivariable logistic regression for our three outcomes, and separate models for each measure of Catholicism. Results: Perception of being a good Catholic was the only Catholicism measure that was significantly associated with all outcomes (legal abortion, high, and low agreement), controlling for covariates. Attendance at mass and self-identified Catholicism did not lend much beyond inclusion criteria. Respondents who believe a woman who helps someone who aborts can continue being a good Catholic had higher odds of support for abortion under high and low agreement exceptions. Respondents who believe a woman who aborts can confess to God or has no need to confess had higher odds of support for at least one low agreement exception. Conclusion: More nuanced measures of Catholicism that go beyond Catholicism as an identity are valuable in assessing support for abortion, especially exceptions with traditionally low support, which are the reasons most women need abortion.

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    Disparities in access to first trimester legal abortion in the public sector in Mexico City: Who presents past the gestational age limit?

    Blair G. Darney1 ,2, Biani Saavedra-Avendano1, Patricio Sanhueza4, Raffaela Schiavon3
    1National Institute of Public Health, Cuernavaca, Morelos, Mexico, 2Oregon Health & Science University, Portland, OR, USA, 3International Pregnancy Advisory Services, Mexico City, Mexico, 4Mexico City Ministry of Health, Mexico City, Mexico

    Objective: First trimester abortion was decriminalised in Mexico City in 2007; laws in Mexico’s other 31 states remain restrictive. Women who present for care past 12 weeks are not able to receive services. The objective of this study was to identify factors associated with presenting for public abortion services past the gestational limit.
    Methods: We conducted a retrospective cohort study using clinical data from the public abortion programme in 2011 and 2012. Our primary outcome was receipt of abortion services. We compared characteristics of women who did not receive abortion services with those who received either medical or aspiration abortion. We used multivariable logistic regression to identify associations between client characteristics and our primary outcome, controlling for socio-demographic and clinical confounders.  
    Results: Our sample included 22,945 women, 73.1% of whom had a medical, and 18.3% an aspiration abortion; 8.6% of the sample (n=1935) did not receive abortion services due to presenting past the gestational age limit. Adolescents (aged <18) made up 14.2% of the total sample and 32.7% of women came from outside Mexico City. In multivariable analyses women who travelled from the nearby State of Mexico (aOR=0.89; 95%CI=0.79–0.98) or from another state (aOR=0.83; 95%CI=0.67-0.99) both had lower odds of receiving services, compared with women living in Mexico City. Adolescents had lower odds of receiving services compared with adults (aOR=0.67; 95%CI=0.58-0.77). Women with basic educational levels (aOR=0.71 and 0.72 for primary and secondary versus high school or higher), or who had not experienced a previous pregnancy (aOR=0.79; 95%CI=0.69-0.90) had lower odds of receiving services.
    Conclusions: Factors associated with delay in seeking abortion services in Mexico City’s public abortion programme include distance travelled, younger age, nulliparity and low education level. Our results can be used to support efforts to promote earlier recognition of pregnancy and timely assistance to access services.