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“Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua

• Samantha M. Luffy 1 ,
• Dabney P. Evans   ORCID: orcid.org/0000-0002-2201-5655 1 &
• Roger W. Rochat 1  

BMC Women's Health volume  19 , Article number:  76 ( 2019 ) Cite this article

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Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua, from June to July 2014.

Case presentation

This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria’s experience.

Conclusions

Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria’s case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria’s experience demonstrates that an individual’s health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion.

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Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, however, the international community, States, and advocates have made great strides to advance our understanding of sexual and reproductive rights and how they can be protected at the national and international levels. The 1994 Cairo Declaration began this process by including sexual health under the umbrella of reproductive health and recognized the impact of violence on an individual’s sexual and reproductive health (SRH) decision-making. [ 1 ] One year later, the 1995 Beijing Platform for Action specifically addressed the issues of unintended pregnancy and abortion by emphasizing that improved family planning services should be the main method by which unintended pregnancies and unsafe abortions are prevented. [ 2 ]

A recent World Health Organization (WHO) report on the relationships between sexual health, human rights, and State’s laws sets the foundation for our contemporary understanding of these issues. The 2015 report describes sexual health as, “a state of physical, emotional, mental and social well-being in relation to sexuality.” [ 3 ] That state includes control over one’s fertility via access to health services such as abortion; it also includes the right to enjoy sexual experiences free from coercion, discrimination, and violence. [ 3 ] Whether experienced alone or in combination, rape, unintended pregnancy, and abortion are important SRH issues on which public health can and should intervene.

In the public health field, case studies provide a useful lens through which to examine individual women’s sexual and reproductive health experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; an in-depth analysis of these personal experiences can identify contextual risk factors and missed opportunities for public health rights-based  intervention. This type of analysis is especially cogent when legal policies and social factors, such as gender inequality, may influence one’s SRH decision-making process. On an individual level, bearing witness to women’s stories through in-depth interviews helps document their lived experience; surveying these experiences within the context of laws related to SRH provides important evidence for the impact of such policies on women’s well-being.

We present the case of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her complex experience of violence, unintended pregnancy, and unsafe abortion represent a series of contextual factors and missed opportunities for public health and human rights intervention. Ana Maria’s story, told through the use of a pseudonym, takes place in a city located in North Central Nicaragua – a country that presents unique challenges related to its citizens’ fulfillment of their sexual and reproductive health and rights.

Violence against women in Nicaragua

Along with 189 States, Nicaragua is a party to the United Nations (UN) Convention on the Elimination of All Forms of Discrimination against Women, which includes State obligations to protect and promote the health and well-being of Nicaraguan women. [ 4 ] As defined by human rights documents, the right to health includes access to health care services, as well as provisions for the underlying social determinants of health, such as personal experiences of structural violence. [ 5 ]

In the Nicaraguan context, political and sociocultural institutions support unequal power relations between genders. [ 6 ] Machismo is one such form of structural violence that perpetuates gender inequality and has been identified as a barrier to SRH promotion in Nicaragua. [ 7 , 8 ] The term ‘ machismo ’ is most commonly used to describe male behaviors that are sexist, hyper masculine, chauvinistic, or violent towards women. [ 9 ] These behaviors often legitimize the patriarchy, reinforce traditional gender roles, and are used to limit or control the actions of women, who are often perceived as inferior. [ 10 ]

The vast majority (89.7%) of Nicaraguan women have experienced some form of gender-based violence  during their lifetime, which poses a serious public health problem. The latest population-based Demographic and Health Survey showed that at least 50% of Nicaraguan women surveyed had experienced either verbal/psychological, physical, or sexual violenceduring their lifetime. An additional 29.3% of women reported having experienced both physical and sexual violence at least once, while another 10.4% reported having experienced all three types of violence. [ 11 ]

In 2012, Nicaragua joined a host of other Central and South American countries that have implemented laws to eliminate all forms of violence against women VAW, including rape and femicide. [ 12 ] Nicaragua’s federal law against VAW, Law 779, intends to eradicate such violence in both public and private spheres. [ 13 ] On paper, Law 779 guarantees women freedom from violence and discrimination, but it is unclear if the law is being adequately enforced; it has been reported that some women believe VAW has increased since the law’s implementation. [ 14 ]

Before Law 779, violent acts like rape, particularly of young women ages 15–24, were endemic in Nicaragua. Approximately two-thirds of rapes reported in Nicaragua between 1998 and 2008 were committed against girls under 17 years of age; most of these acts were committed by a known acquaintance. [ 15 ] Due to a lack of reporting and to culturally propagated stigma regarding rape, no reliable data suggest that Law 779 has been effective in reducing the incidence of rape in Nicaragua. For women who wish to terminate a pregnancy that resulted from rape, access to abortion services is vital, yet completely illegal. [ 16 ] In contrast, technical guidance from the WHO recommends that health systems include access to safe abortion services for women who experience unintended pregnancy or become pregnant as a result of rape. [ 17 ]

Family planning and unintended pregnancy in Nicaragua

Like violence, unintended pregnancies -- not only those that result from rape -- pose a widespread public health problem in Nicaragua. National data suggest that 65% of pregnancies among women ages 15–29 were unintended. [ 11 ] Oftentimes, unintended pregnancy results from a complex combination of social determinants of health including: low socioeconomic status (SES), low education level, lack of access to adequate reproductive health care, and restrictive reproductive rights laws. [ 18 , 19 , 20 ] Nicaraguan women of low SES with limited access to family planning services are at an increased risk of depression, violence, and unemployment due to an unintended pregnancy. [ 19 , 20 ]

The UN Committee on the Elimination of all forms of Discrimination Against Women (CEDAW) has expressed concern regarding the lack of comprehensive sexual education programs, as well as inadequate family planning services, and high rates of unintended pregnancy throughout Nicaragua. [ 21 ] Due to a lack of sexual education, Nicaraguan adolescents, if they use contraceptives like male condoms or oral contraceptive pills, often do so inconsistently or incorrectly. [ 22 ]

Deeply rooted cultural stigma surrounding unmarried women’s sexual behavior contributes to the harsh criticism of young women in Nicaragua that use a method of family planning or engage in sexual relationships outside of a committed union. [ 18 , 22 ] Also, young women who are not in a formal union may experience unplanned sex (consensual or nonconsensual) and are unlikely to be using contraception, which further increases the risk of unintended pregnancy. [ 22 ] These social and cultural factors, in conjunction with restrictive reproductive rights laws, may contribute to a high incidence of unintended pregnancy among young Nicaraguan women.

The total ban on abortion in Nicaragua

Compounding the economic, social, and emotional burden of unintended pregnancy on women’s lives is the current prohibition of abortion in Nicaragua. In 2006, the National Assembly unanimously passed a law to criminalize abortion, which had been legal in Nicaragua since the late 1800s. [ 20 ] Researchers often refer to this law as the “total ban” on abortion. [ 20 , 23 ] The total ban prohibits the termination of a pregnancy in all cases, including incest, rape, fetal anomaly, and danger to the life of the woman. Laws that prohibit medical procedures are, by definition, barriers to access; equitable access to safe medical services is a critical element of the right to health. [ 3 , 5 ] The UN Committee on Civil and Political Rights (CCPR) has also recognized the discriminatory and harmful nature of criminalizing medical procedures that only women undergo. [ 24 ]

Nicaragua is one of the few countries in the world to completely ban abortion in all circumstances. In States where illegal, abortion does not stop. Instead, women are forced to obtain abortions from unskilled providers in conditions that are often unsafe and unhygienic. [ 25 ] Unsafe abortions are among the main preventable causes of maternal morbidity and mortality worldwide and can be avoided through decriminalization of such services. [ 26 ]

The Nicaraguan ban includes serious legal penalties for women who obtain illegal abortions, as well as for the medical professionals who perform them, which can have profound negative effects on women’s health. [ 20 , 23 ] Women who need or want an abortion face not only the health risks that accompany an unsafe procedure, but additional criminal penalties. The total ban on abortion violates the human rights of both health care providers and women nationwide, as well as the confidentiality inherent in the patient-provider relationship. [ 20 ] It also results in a ‘chilling effect’ where health care providers are unwilling to provide both abortion and postabortion care (PAC) services for fear of prosecution. [ 20 ]

In response to the negative impacts of the total ban on maternal morbidity and mortality in Nicaragua, as well as detrimental effects on women’s physical, mental, and emotional health, CEDAW has recommended that the Nicaraguan government review the total ban and remove the punitive measures imposed on women who have abortions. [ 21 ] While the Nicaraguan government may not view abortion as a human right per se, women should not face morbidity or mortality as a result of illegal or unsafe abortion. [ 27 ]

Criminalizing abortion also increases stigma around this issue and significantly reduces people’s willingness to speak openly about abortion and related SRH services. Qualitative research conducted in Nicaragua suggests that women who have had unsafe abortions rarely discuss their experiences openly due to the illegal and highly stigmatized nature of such procedures. [ 18 ] Therefore, the overall aim of the study was to better understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua from June to July 2014. This private method of data collection allowed for the detailed exploration of each young woman’s personal experience with an unintended pregnancy, including the decision-making process she went through regarding how to respond to the pregnancy. Given the personal nature of this experience – including the criminalization and stigmatization of women who obtain abortions – IDIs allowed the participants to share intimate details and information that would be inappropriate or dangerous to share in a group setting. One case, presented here, emerged as salient for understanding the intersections of violence, unintended pregnancy, and abortion – and the missed opportunities for rights-based public health intervention.

Emory University’s Institutional Review Board ruled the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. Nevertheless, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. The first author reviewed the informed consent form in Spanish with each participant and then acquired each participant’s signature and verbal informed consent before the IDIs were conducted. The investigators developed a semi-structured interview guide with open-ended questions and piloted the guide twice to improve the cultural appropriateness of the script (Additional file 1 ). The investigators also collaborated with local partners to design and implement the research according to local cultural and social norms. Due to the contentious topics discussed in this study, these collaborators prefer to not be mentioned by name. Interviews were conducted in Spanish in a private location and audio taped to protect the participants’ privacy. Recordings were transcribed verbatim and transcripts were coded and analyzed using MAXQDA11 software (VERBI GmbH, Berlin, Germany).

Initially, participants were recruited for interviews through purposive sampling of individuals who had disclosed a personal experience with unintended pregnancy during focus group discussions (FGDs) conducted in a larger parent study. At the end of each interview, participants were asked to refer other young women they knew who may have experienced an unintended pregnancy to participate in an interview. This form of respondent-driven sampling created a network of participants with a wide variety of experiences with unintended pregnancy. Of the ten interviewees, two had experienced unintended pregnancy as a result of rape, though both used the phrase “ sexo no consensual ” or “nonconsensual sex” in lieu of “ violación, ” the Spanish word for rape. One of these women shared her personal experience receiving an unsafe abortion to terminate an unintended pregnancy that had resulted from rape. Her story, shared under the use of the pseudonym Ana Maria, is presented here in order to:

Illustrate the harmful impact of restrictive abortion laws on the health and well-being of women – especially those who do not have access to abortion in the case of rape; and

Exemplify the nexus of contextual risk factors that impact women’s SRH decision-making, such as conservative social norms and restrictive legal policies.

Through thorough analysis, we examine the impact of these contextual factors that impacted Ana Maria’s experience.

When she was 19, Ana Maria was raped by her godfather, a close friend of her family.

In an in-depth interview, Ana Maria described enduring incessant verbal harassment from her godfather – her elder brother’s best friend – in the months before the assault. He constantly called and texted her cell phone in order to interrogate her about platonic relationships with other men in town and to convince her to spend time alone with him. Even though he was married with children and she repeatedly dismissed his advances, he continued to engage in this form of psychological violence with his goddaughter. Ana Maria described eventually “giving in” and meeting him – not knowing that this encounter would result in her forcible rape.

The disclosure of Ana Maria’s rape during her interview was spontaneous and unexpected. Ana Maria was unwilling to disclose explicit details of the sexual assault. Instead, she stated multiple times that the sexual contact was nonconsensual and she did not want to have sex with him. When asked if she told anyone about this experience, she said no because she did not want others to judge her for what had happened.

Approximately a month of scared silence after she was raped, Ana Maria noticed that her period had not come. Nervous, she bought a pregnancy test from a local pharmacy. To her dismay, the test was positive. In order to confirm the pregnancy, she traveled alone to the nearby health center in her town to obtain a blood test. Again, the test was positive. She had never been pregnant before and she was terrified. In the midst of her fear, she shared the results with her rapist, her godfather.

His response: get an abortion. He did not want to lose his wife and children if they found out about the pregnancy.

Other than their illegal nature, Ana Maria knew nothing about abortions – where to get one, how it was done, what it felt like. She asked her neighbors to explain it to her. They said “it was worse than having a baby and [experiencing] childbirth.”

Though Ana Maria did not want to get the abortion, her godfather continued to pressure her to get the procedure saying, “Regardless, you must get the abortion… you are not the first woman to have ever had one.” Similar to the emotional violence before he raped her, he called and texted Ana Maria every day telling her to, “do it as fast as you can.” He forbade her from telling anyone about the pregnancy and Ana Maria didn’t feel like she had anyone to confide in about the situation. She worried about people judging her for getting pregnant outside of a committed relationship – even though she was raped. Ana Maria described this difficult time:

“When he started to pressure me [to get the abortion], I felt alone. I did not have enough trust in anyone to tell them [what had happened] because… if I had had enough trust in someone, I know that they would not have let me do it. If I had been given advice, they would have said, ‘No, do not do it,’ but I did not have anyone and I felt so depressed. What made it worse, I couldn’t sleep; I could not sleep [because I was] thinking of everything he had told me. At night, I would remember how it all started and I do not know what he did to find that money, but he gave me the money to get the abortion.”

Her godfather gave her 3000 Córdobas (approximately USD112 at the time) and put her on a public bus, alone. He had arranged for her to receive the abortion from an older woman that practiced “natural medicine” in a nearby city. When Ana Maria arrived at the woman’s home, she was instructed to remove her pants and underwear and lie on a bed. Ana Maria did not receive any medication before the woman inserted a “device like the one used for a Papanicolau… and then another device like an iron rod” into her vagina.

After describing these devices, Ana Maria made a jerking motion back and forth with her arm to imitate the movement the woman used to perform the abortion.

Once it was over, the woman gave Ana Maria an injection of an unknown substance and told her that she would pass a few blood clots over the next few days. That night, however, Ana Maria’s condition worsened; she became feverish, felt disoriented, and began to pass dark, fetid clots of blood. She described the pain she experienced throughout the ordeal:

“I felt so much pain when they took her out of me. I felt pain when the blood was leaving my body and when I had the fever. I felt a terrible pain that only I suffered. I am [a] different [person] now because of those pains.”

Ana Maria was too afraid to tell her family about the assault or the abortion because she was uncertain how they would react. She was even more terrified of the potential legal repercussions that she could face for violating the total ban on abortion. Within a few days of the abortion, though, Ana Maria’s brother heard rumors of his sister’s situation from neighbors “in the street” and confronted her about what had happened. At first, Ana Maria denied that she had had an abortion, but her brother continued to ask for the truth. Though she was nervous, Ana Maria eventually told her brother everything that had happened – from her godfather’s incessant verbal harassment, to the rape, to the unsafe abortion she was forced to get.

Afraid for his sister’s life, Ana Maria’s brother contacted a local nurse who discreetly provides postabortion care (PAC) to women experiencing complications from unsafe abortion and other obstetric emergencies. This nurse is locally known to be one of the few health care providers who provide PAC despite many other providers’ fear of prosecution under the total ban. The nurse recommended that Ana Maria come to the hospital immediately.

Ana Maria spent almost two weeks as an inpatient at the only hospital in the region. She had become septic as a result of what she described as a “perforated uterus,” a common complication from unsafe abortion. [ 28 ] Upon her initial examination, the nurse was afraid that her uterus could not be repaired because the infection was so severe. Fortunately, the medical team administered an ultrasound, removed infected blood clots, and completed uterine surgery to repair the damage from the unsafe abortion. At the request of the gynecologist taking care of her, Ana Maria received the one-month contraceptive hormonal injection before being discharged. At the time of the interview, Ana Maria had not received the next month’s injection because she “didn’t have any use for a man.”

As a result of this experience, Ana Maria reported feelings of depression, isolation, and recurring dreams about a little girl, which she described in this way:

“After I was discharged, I always dreamt of a little girl and that she was mine, standing in my doorway and when I awoke, I couldn’t find her. I looked for her in my bed but she wasn’t there. And this has tormented me because, it’s true: I am the girl that committed this error, but the little girl was not at fault. He pressured me so strongly to get the abortion, so I did.”

Ana Maria had the same recurring dream every night for more than two weeks and she continued to feel depressed weeks after leaving the hospital. One of the sources of her depression was the isolation she felt because there was no one with whom she could share this experience.

According to Ana Maria, she longs to have other people to talk to about her experience – particularly those who may have had similar experiences. She also expressed a desire to pursue a law degree so that she can have a career in local government.

Discussion and conclusions

Ana Maria’s case provides insight into the contextual factors effecting her ability to realize her sexual and reproductive health and rights in Nicaragua where restrictive legal policies and conservative cultural norms around sexuality abound. These contextual risk factors include social norms related to sexual health, laws targeting VAW, and the criminalization of abortion.

Social norms related to sexual health

The fundamental relationship between structural inequality and sexual and reproductive rights has been duly noted; gender inequality, in particular, must be addressed in order to fulfill sexual rights for women. [ 29 ] As in many cases in Nicaragua, the fact that Ana Maria’s first sexual experience was nonconsensual and was initiated by an older male and trusted family friend highlights the uneven power relations between men and women in Nicaraguan culture, which propagate high instances of VAW and sexual assault. In a patriarchal society where machismo and gender inequality run rampant, women’s sexuality is further constrained by the stigmatization of sexual health and a culture of violence that limits women’s autonomy. The compound stigma surrounding sexual health in general, and rape in particular, negatively impacted Ana Maria’s knowledge and ability to access mental health and SRH services, including emergency contraception and post-rape care, which may have assisted her immediately following her assault. Before her brother intervened, Ana Maria’s fear of judgment and legal repercussions also prevented her from seeking PAC, which was necessary to save her life.

Comprehensive sexual education is a primary way to challenge these social norms and widespread stigma surrounding sexuality and SRH services, such as contraception and PAC, at the population level. Such education might have mitigated Ana Maria’s experience of unintended pregnancy through the provision of advance knowledge of emergency contraception and medical options in the event of pregnancy. CEDAW has recognized this missed opportunity for public health intervention in Nicaragua, and recommends sexual education as a means of addressing stigma related to sexuality, decreasing unintended pregnancy, and increasing the acceptability and use of family planning services throughout the country. [ 21 ] Furthermore, the lack of adolescent-friendly sexual education and SRH services symbolizes a social reluctance to acknowledge the reality that young people have sex. [ 30 ] Such ignorance results in a lack of information on healthy relationships and human reproduction, as well as experiences of unintended pregnancy, early motherhood, and unsafe abortion. Exposure to this type of information may have improved Ana Maria’s ability to protect herself, mitigated the impact of Nicaragua’s pervasive misogyny on her decision making, and lessened the influence of her godfather’s coercion before her experiences of rape and unsafe abortion.

Individual and structural violence against women

Though we do not know explicit details of Ana Maria’s rape, the act of rape is inherently violent. The assault violated her right to enjoy sexual experiences free from coercion and violence. [ 3 ] To further constrain her sexual and reproductive rights, Ana Maria’s experience of rape resulted in an unintended pregnancy and an unsafe abortion that she was pressured into undergoing. Along with physical sequelae as a result of the procedure, she also expressed feelings of depression and isolation, which are common symptoms of post-traumatic stress disorder (PTSD). [ 31 ] These mental health consequences are forms of emotional violence that Ana Maria continued to experience long after the initial insult of physical violence. We can’t distinguish whether her mental health symptoms were a pre-existing condition or a result of the traumatic experience presented here. It is likely, however, that all parts of this experience impacted her mental and physical health. As reported elsewhere, perceived social criticism and a lack of social support are barriers to the fulfillment of sexual and reproductive health among young Nicaraguan women. [ 18 ] These contextual risk factors undoubtedly played a role in Ana Maria’s ability to navigate the circumstances surrounding her assault and its aftermath.

What legal recourse was feasibly available to Ana Maria for the crime of her sexual assault? To our knowledge, Ana Maria did not report the rape to authorities nor did her godfather ever face criminal charges for his actions. Yet Ana Maria’s own fear of prosecution for undergoing the unsafe abortion, as well as shame and fear of being stigmatized by others in her community, strongly influenced her decision not to report the rape -- even though Law 779 contains sanctions specific to those who commit rape.

In the event she had reported the crime, however, it is unclear if Law 779 would have provided justice. There are no data to suggest that Law 779 has led to an increase in the reporting or prosecution of rape at the national level. To the contrary, qualitative work in Nicaragua found a perceived increase in VAW following the passage of the law. [ 14 ] In Nicaragua, the inconsistent or ineffective enforcement of Law 779 is another factor worthy of consideration in cases like Ana Maria’s where individuals do not report such crimes. Documents like the UN Women Model Protocol have recently been released to improve the enforcement of laws like Law 779 in Latin American countries, presenting an opportunity for the effective operationalization of the law in Nicaragua. [ 32 ] If Law 779 is not adequately enforced, women like Ana Maria face the potential for re-victimization through the structural violence of impuity and continued exposure to VAW. To our knowledge, Ana Maria’s perpetrator faced no consequences for his perpetration of harassment, coercion and rape of Ana Maria. Moreover, in countries where abortion is criminalized, such as El Salvador, it is most often women who face criminal sanctions. [ 33 ] Indeed, it was Ana Maria herself who bore the physical and mental burden that resulted from her assault, unintended pregnancy, and unsafe abortion.

The criminalization of abortion

The criminalization of health services is a strategy that governments use to regulate people’s sexuality and sexual activity. [ 34 ] The criminalization of services such as abortion limits women’s ability to make autonomous decisions about their SRH. By definition, laws that restrict access to health services exclude people from receiving the information and services necessary to realize the highest level of SRH possible. [ 5 ] The criminalization of abortion puts the health and well-being of individuals and communities at risk. Beyond the individual level, complications from unsafe abortion often put unnecessary and immeasurable financial burdens on health systems that are already stretched [ 28 ].

Ana Maria did not have a choice when it came to her abortion; the man who raped her coerced her to undergo an unsafe and illegal procedure. The criminalization of abortion in Nicaragua put Ana Maria’s health at risk in two ways: first, it prevented her from obtaining a safe abortion and second, it limited her access to comprehensive sexual health information that could have helped her address her unintended pregnancy, through emergency contraception. After the unsafe abortion procedure, her access to PAC was likely constrained by her own fear of the possible legal repercussions of undergoing an abortion, and was compounded by her inability to trust that a health care provider would maintain patient confidentiality and provide adequate PAC.

In Nicaragua, the total ban on abortion directly contradicts strategic objectives outlined in the Beijing Declaration, which guarantees women’s rights to comprehensive SRH care, including family planning and PAC services. Though providing PAC is not considered illegal under the total ban, many Nicaraguan health care providers refuse to treat women who have had unsafe abortions, which results in a ‘chilling effect’; providers do not want to be accused of being complicit in providing abortions so they refuse to provide PAC services. The ‘chilling effect’ put Ana Maria at risk of morbidity or mortality as a result of the complications that resulted from her unsafe abortion.

Equally troubling is the use of criminal law against individuals like Ana Maria as well as health care professionals that provide PAC. By requiring health care providers to report to the police women who have had abortions, the total ban violates the privacy inherent in the patient-provider relationship. Health care providers are faced with a dual loyalty to both the State’s laws and the confidentiality of their patients, which makes it difficult for providers to fulfill their professional obligations. It also makes health care professionals complicit in a discriminatory practice, one where women face legal sanctions in ways that men do not. The criminalization of abortion in Nicaragua therefore resulted in the fear, stigma, discrimination, and negative health outcomes observed in Ana Maria’s case.

The contextual risk factors that contributed to Ana Maria’s experience of rape, unintended pregnancy, and unsafe abortion are as follows: sexual assault, impunity for violence, gender inequality, restrictive social norms around SRH, stigma resulting from unintended pregnancy and abortion, harmful health impacts from an unsafe abortion, and fear of prosecution due to the total ban. Her first sexual experience was forced and nonconsensual and preceded by months of harassment. Social norms made taboo any discussion of the harassment and sexual violence she experienced at the hands of her godfather; without social support, she was coerced into undergoing an unsafe abortion that resulted in serious mental and physical health sequelae. The illegal nature of abortion in Nicaragua placed Ana Maria at risk for social stigma as well as criminal prosecution. Her subsequent underutilization of family planning services at the time of the interview also placed Ana Maria at risk for an unintended pregnancy in the future; other long-term physical and mental health effects of her experience remain unknown.

The realization of one’s sexual and reproductive rights guarantees autonomous decision-making over one’s fertility and sexual experiences. However, Ana Maria’s story demonstrates that an individual’s SRH decisions are not made in isolation, free from the influence of social norms and national laws. Far too many women experience their sexuality in the context of individual and structural violence, such as VAW and gender inequality. This case highlights the contextual risk factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion; we must continue to critically investigate these factors to ensure that experiences like Ana Maria’s do not become further normalized in Nicaragua. Due to restrictive social norms around SRH, Ana Maria grew up experiencing stigma and taboo associated with sex, sexuality, contraceptive use and abortion. She also lacked access to information regarding SRH, healthy relationships, and how to respond to VAW before she was assaulted. After her assault, she did not have access to post-rape care, emergency contraception, safe abortion services, or mental health services to help her process this trauma. Shame and fear of stigma also prevented Ana Maria from reaching out for social support from family, friends, or the health or legal system. From the legal perspective, inadequate enforcement of VAW laws and the criminalization of abortion further exacerbated the trauma Ana Maria experienced.

It would require active engagement from the Nicaraguan government to address the contextual risk factors identified herein to protect their citizens’ right to health and prevent future experiences like Ana Maria’s. These efforts are particularly relevant given recent political unrest throughout Nicaragua including anti-government protests demanding the president’s resignation. [ 35 ] Nicaraguans’ right to health is at risk not only due to the widespread violence, but also because health care workers are being dismissed and persecuted nationwide. [ 36 ] Sexual and reproductive health researchers, advocates, and the public will continue to monitor Nicaragua’s response to the immediate demands and needs of its citizens -- including the demand that Nicaraguan women like Ana Maria are able to fully exercise their sexual and reproductive rights in times of both conflict and peace.

Availability of data and materials

Deidentified data are available upon reasonable request.

Abbreviations

Committee on Civil and Political Rights

Committee on the Elimination of all forms of Discrimination Against Women

In-Depth Interviews

Postabortion Care

Post-Traumatic Stress Disorder

Socioeconomic Status

Sexual and Reproductive Health

United Nations

Violence Against Women

World Health Organization

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Acknowledgements

The authors thank the research team and in-country collaborators from Proyecto Paz y Amistad, as well as the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund for financially supporting this project. We are also grateful to Ellen Chiang for her editorial support.

This study was funded with support from the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund. The funders did not play any direct role in the design of the study; the collection, analysis, and interpretation of data; or the writing of the manuscript.

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All authors contributed extensively to the work presented in this manuscript. SML, DPE, and RWR jointly designed the study. SML performed data collection and data analysis. SML and DPE wrote the manuscript with significant input from RWR. DPE and RWR also provided support and supervision throughout the study. All authors read and approved the final manuscript.

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Emory University’s Institutional Review Board found the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. The authors partnered with Proyecto Paz y Amistad, a local organization to design and implement this study. Proyecto Paz y Amistad deferred to the Emory University IRB’s determination. Nicaragua is notably absent from the US Department of Health and Human Services, International Compilation of Human Research Standards ( https://www.hhs.gov/ohrp/sites/default/files/2018-International-Compilation-of-Human-Research-Standards.pdf ). To our knowledge, there were no existing national level human subjects requirements or exemptions at the time of data collection.

Though the project was exempt from full review by Emory University’s Institutional Review Board, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. Verbal informed consent was acquired from all participants before the IDIs were conducted and each participant signed a waiver to participate.

Due to the sensitive nature of this work, individual partners at Proyeto Paz y Amistad have asked not be named publicly as authors on this work, although their partnership was instrumental in the implementation of this study.

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Luffy, S.M., Evans, D.P. & Rochat, R.W. “Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua. BMC Women's Health 19 , 76 (2019). https://doi.org/10.1186/s12905-019-0771-9

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Public Health in the Field: The Public Health Case for Abortion Rights

Annalies Winny

Lindsay Smith Rogers

This article is adapted from a special episode of the Public Health On Call Podcast called Public Health in the Field. You can hear the full episode here .

Please note: Throughout this article, the gendered terms “woman” and “women” are used as that’s how the CDC and other sources record related data. 

More coverage:

• Overturning Roe v. Wade and Public Health
• What We Know—and Don't Yet Know—About The Leaked Supreme Court Draft Opinion That Could Overturn Roe v. Wade

A single case before the Supreme Court will likely decide the future of Roe v. Wade.

In 2018, the Mississippi legislature passed and the governor signed House Bill 1510, known as the  Gestational Age Act , which bans abortions after 15 weeks. There are exceptions if the life of the fetus or parent is at risk—but not in cases of rape or incest. The law violated Roe v. Wade, a Supreme Court decision that protects the right to abortion prior to “viability” of the fetus, which is at around 24 weeks. The bill was quickly blocked by lower federal courts but now the law’s fate is up to the Supreme Court.

The outcome of this case— Dobbs v. Jackson Women’s Health Organization —has implications for abortion rights far beyond Mississippi: A decision that previability bans are not unconstitutional could upend longstanding protections established by Roe v. Wade, the 1973 landmark case that legalized abortion nationwide. 

The conversation about abortion rights in the U.S. is a noisy one involving politics, precedents, and personal beliefs. What often gets short shrift, however, is the public health reality that restricting access to abortion results in erosion of the health of women, especially low-income and women of color. This is why abortion is so much more than a legal battle. 

The Public Health Case for Abortion Rights

Many women who were denied wanted abortions had higher levels of household poverty, debt, evictions, and other economic hardships and instabilities, according to Joanne Rosen , JD , associate director of the  Johns Hopkins Center for Law and the Public’s Health .

The findings come from a 10-year study,  The Turnaway Study , which followed nearly 1,000 women who either had or were denied abortions and tracked their mental and physical health and financial impacts. 

“The study also found that women who were seeking but unable to obtain abortions endured higher levels of physical violence from the men who had fathered these children,” Rosen says. “And people who were turned away when seeking abortions endured more health problems than women who were able to obtain [them], as well as more serious health problems.

“That gives you a sense of the ways in which being unable to obtain abortions had really long lasting impacts on these peoples’ lives.”

A 2020 study in the  American Journal of Preventive Medicine found that women living in states with less restrictive reproductive health policies were less likely to give birth to low-weight babies. Other research  published in The Lancet found that restrictive abortion laws actually mean a higher rate of abortion-related maternal deaths.

Restrictive abortion laws affect more than just the health of individuals and families—they affect the economy, too. Research from The Lancet found that “ensuring women’s access to safe abortion services does lower medical costs for health systems.”  

The  Institute for Women’s Policy Research has a host of data around how reproductive health restrictions impact women’s earning potential, including an interactive map tool, Total Economic Losses Due to State-level Abortion Restrictions. In Mississippi , for example, the data indicate that an absence of abortion restrictions would translate to a 1.8% increase of Black women in the labor force, over 2% for Hispanic women, and a leap of more than 2.6% for women who identify as Asian-Pacific Islander. This same tool calculates that removing abortion restrictions would translate to an estimated $13.4 million in increased earnings at the state level for Black women alone. 

Abortion restrictions disproportionately affect people of color and those with low-incomes. According to  data from the CDC , Black women are five times more likely to have an abortion than white women, and Latinx women are two times as likely as whites. Seventy-five percent of people who have abortions are low-income or poor. 

Mississippi, Texas, and The Supreme Court   

On December 1, the Supreme Court will hear Dobbs v. Jackson Women’s Health Organization and Joanne Rosen thinks it’s unlikely the Court would agree to hear the case if they were just going to affirm the status quo. 

The case isn’t the only one on the docket, however. Texas’ Senate Bill 8, which bans abortion after six weeks of pregnancy, made headlines earlier this month and may impact SCOTUS’ ultimate decision on the Mississippi case. The high-profile law came before the Supreme Court in November 2021 and Rosen said the important thing to note is that the Court didn’t actually address whether the six-week ban is constitutional. Rather, they examined the unusual enforcement scheme of the law—where, when, and by whom the Texas law could be challenged.

Rosen says that the justices may compare the Texas law with the Mississippi law and, when considering a six-week abortion ban, a 15-week ban may seem less extreme. In this way, the Texas case could give the Court some cover to uphold Mississippi’s 15-week ban.

It’s likely to be months before an opinion is released; Rosen says the Court typically releases its decisions on high-stakes or controversial cases in June. And high stakes this is: for the future of abortion, for reproductive health rights, and for public health. 

Annalies Winny is an associate editor for  Global Health NOW . 

Alissa Zhu is a journalist and current  MSPH student at the Bloomberg School.

Lindsay Smith Rogers, MA, is the producer of the  Public Health On Call podcast and the associate director of content strategy for the Johns Hopkins Bloomberg School of Public Health.

RELATED CONTENT:

• Public Health Law Experts Discuss the Supreme Court Vacancy and Barrett Nomination

Public Health On Call

This article is adapted from a special episode of the  Public Health On Call Podcast  called Public Health in the Field.

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The public health case for abortion rights

Joanne rosen from the johns hopkins center for law and the public's health discusses dobbs v. jackson women's health organization, which heads to the supreme court dec. 1.

By Annalies Winny, Alissa Zhu, and Lindsay Smith Rogers

This article is adapted from a special episode of the Public Health On Call podcast called Public Health in the Field. Hear the full episode online .

Editor's note: The terms "woman" and "women" are used throughout this article because that is how the CDC and other sources record related data.

A potentially landmark battle is in play over abortion rights, and it's headed to the U.S. Supreme Court on Dec. 1.

In 2018, the Mississippi legislature passed and the governor signed House Bill 1510, known as the Gestational Age Act, which bans abortions after 15 weeks. There are exceptions if the life of the fetus or parent is at risk—but not in cases of rape or incest. The law violated Roe v. Wade, the 1973 Supreme Court decision that legalized abortion nationwide and protects the right to abortion prior to "viability" of the fetus, which is at around 24 weeks. House Bill 1510 was quickly blocked by lower federal courts but now the law's fate is up to the Supreme Court.

The outcome of this case—Dobbs v. Jackson Women's Health Organization—has implications for abortion rights far beyond Mississippi: A decision that previability bans are not unconstitutional could upend longstanding protections established by Roe v. Wade.

The conversation about abortion rights in the U.S. is a noisy one involving politics, precedents, and personal beliefs. What often gets short shrift, however, is the public health reality that restricting access to abortion frequently results in erosion of the health of women, especially low-income women and women of color. This is why abortion is so much more than a legal battle.

According to The Turnaway Study , a 10-year study that followed nearly 1,000 women who either had or were denied abortions, any women who were denied wanted abortions had higher levels of household poverty, debt, evictions, and other economic hardships and instabilities, says Joanne Rosen , associate director of the Johns Hopkins Center for Law and the Public's Health.

"The study also found that women who were seeking but unable to obtain abortions endured higher levels of physical violence from the men who had fathered these children," Rosen says. "And people who were turned away when seeking abortions endured more health problems than women who were able to obtain [them], as well as more serious health problems. That gives you a sense of the ways in which being unable to obtain abortions had really long lasting impacts on these peoples' lives."

A 2020 study in the American Journal of Preventive Medicine found that women living in states with less restrictive reproductive health policies were less likely to give birth to low-weight babies. Other research published in The Lancet found that restrictive abortion laws actually mean a higher rate of abortion-related maternal deaths.

Restrictive abortion laws affect more than just the health of individuals and families—they affect the economy, too. Research from The Lancet found that "ensuring women's access to safe abortion services does lower medical costs for health systems."

The Institute for Women's Policy Research has a host of data around how reproductive health restrictions impact women's earning potential, including an interactive map tool, Total Economic Losses Due to State-level Abortion Restrictions. In Mississippi, for example, the data indicate that removing restrictions to abortion would translate to a 1.8% increase of Black women in the labor force, over 2% for Hispanic women, and a leap of more than 2.6% for women who identify as Asian-Pacific Islander. This same tool calculates that removing restrictions on abortion access would translate to an estimated $13.4 million in increased earnings at the state level for Black women alone.

Abortion restrictions disproportionately affect people of color and those with low-incomes. According to data from the CDC, Black women are five times more likely to have an abortion than white women, and Latinx women are two times as likely as whites. Seventy-five percent of people who have abortions are low-income or poor.

Mississippi, Texas, and the Supreme Court

On Dec. 1, the Supreme Court will hear Dobbs v. Jackson Women's Health Organization and Rosen thinks it's unlikely the court would agree to hear the case if they were just going to affirm the status quo.

The case isn't the only one on the docket, however. Texas' Senate Bill 8, which bans abortion after six weeks of pregnancy, made headlines earlier this month and may impact the court's ultimate decision on the Mississippi case. The high-profile law came before the Supreme Court in November 2021 and Rosen said the important thing to note is that the justices didn't actually address whether the six-week ban is constitutional. Rather, they examined the unusual enforcement scheme of the law—where, when, and by whom the Texas law could be challenged.

Rosen says that the justices may compare the Texas law with the Mississippi law and, when considering a six-week abortion ban, a 15-week ban may seem less extreme. In this way, the Texas case could give the court some cover to uphold Mississippi's 15-week ban.

It's likely to be months before an opinion is released; Rosen says the court typically releases its decisions on high-stakes or controversial cases in June. And high stakes this is: for the future of abortion, for reproductive health rights, and for public health.

Posted in Health , Politics+Society

Tagged supreme court , reproductive health , abortion

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Addressing a Crisis in Abortion Access

A case study in advocacy.

Lynch, Beatrice BS; Mallow, Michaela MPH; Bodde, Katharine E. S. MEd, JD; Castaldi-Micca, Danielle BA; Yanow, Susan MSW; Nádas, Marisa MD, MPH

Albert Einstein College of Medicine, The Bronx, New York; NYC Health + Hospitals; the New York Civil Liberties Union; the National Institute for Reproductive Health, New York, New York; the Later Abortion Initiative, Ibis Reproductive Health, Cambridge, Massachusetts.

Corresponding author: Marisa Nádas, MD, MPH, NYC Health + Hospitals, Jacobi Medical Center, The Bronx, New York; email: [email protected] .

Financial Disclosure The authors did not report any potential conflicts of interest.

The authors acknowledge the continuous efforts of clinicians who provide abortion and their supporters in New York.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at https://links.lww.com/AOG/C746 .

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND) , where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

As restrictions on abortion increase nationwide, it is critical to ensure ongoing access to abortion care throughout pregnancy. People may seek abortions later in pregnancy as a result of financial or legal barriers that delay care or because of changing circumstances, such as the status of their partner, the health of other children, employment, or a new fetal diagnosis. New York State has been a beacon for abortion access since 1970. Yet, after Roe v Wade was decided, New York State abortion law was not in compliance with federal law, and risk-averse medical institutions hesitated to provide later abortions, forcing patients out of state for care. After years of advocacy, the Reproductive Health Act was passed in 2019. Clinicians and advocates collaborated to translate policy into expanded practice at NYC Health + Hospitals, the largest public health care system in the United States. NYC Health + Hospitals conducted an internal review, identified barriers to abortion care, and addressed these through improvements in public and internal communication, strengthening of procedural skills, and a better referral system. As a result, abortion services have become visible and the system’s capacity and gestational age limit have expanded. The example of NYC Health + Hospitals is an instructive model to ensure that abortion care is provided to the most vulnerable patients, including those who need care later in pregnancy. Given the ongoing threat to reproductive rights, this example of expanded access is particularly timely.

Health care systems can ensure that high-quality abortion care is available to all by identifying and removing barriers to services in collaboration with local advocates.

On December 1, 2021, the U.S. Supreme Court heard arguments in a Mississippi case, Dobbs v Jackson . 1 Experts who listened to the arguments and questions from the Justices agree that the current federal protections for abortion established by Roe v Wade (hereinafter “ Roe ”) 2 will be significantly weakened. Access will be particularly restricted for people who need abortions later in pregnancy. 3 In 2021 alone, there have been 108 abortion restrictions enacted in 19 states, the highest total in any year since the 1973 Roe decision, 4 most of which dramatically reduce the upper gestational age for abortion care.

Prohibiting abortion does not remove the need for abortion, but instead exacerbates the economic stratification between who can and cannot access care. 5 People need later abortions for many of the same reasons people need abortions earlier in pregnancy. Studies show that many of those who seek abortion care after 20 weeks of gestation wanted an earlier abortion but faced financial hurdles and legal barriers, including the need to travel for care. 6 For others, new information such as a fetal diagnosis may arise later in pregnancy. 7 And for others still, circumstances change and a wanted pregnancy becomes untenable, for example when a partner leaves or dies, a young child develops a serious illness, or someone in the family loses their job or health insurance. In all of these circumstances, the ability to access later care is essential and yet has constricted over the past decade. 8 It is anticipated that at least 22 states will quickly restrict abortion if the Supreme Court weakens federal protections, either following Texas’ example of banning abortion after an early point in pregnancy or falling in step with a currently enjoined Alabama law banning all abortions. These bans will result in people from these states traveling long distances to access services and will place a burden on clinicians who provide abortion in neighboring states, particularly for later abortion care. 9

It is critical that facilities expand their capacity to provide abortion care to those who will travel for care wherever possible. This article highlights the effort of the public health care system in New York City to expand access to later abortion care.

New York State has historically been considered a beacon for abortion access. New York State permitted abortion in 1970, 3 years before Roe . However, after Roe was decided in 1973, New York State law fell short of constitutional protections with respect to later care. The 1970 state law criminalized care after 24 weeks from the commencement of pregnancy unless a person’s life was at risk. 10 This meant that, even though Roe and subsequent cases protected care later in pregnancy when a pregnant person’s health or life is at risk or a fetus is not viable, risk-averse medical institutions in New York State were reluctant to provide later care in those instances. As a result, pregnant people and their families were forced to travel to distant states such as New Mexico and Colorado to seek later abortion care, far from the support of family, friends, and familiar physicians and at great financial cost, stress, and additional health risks. 11

Despite the legal challenges, over the past decades, advocates and health care professionals in New York City and New York State worked to expand access to care. This included interviewing health care professionals to better understand access points and needs, convening physician roundtables, and strengthening referral networks. Furthermore, attention was given to creating residency training initiatives, 12 seeking legal opinions from the New York State Attorney General to clarify health care professionals’ scope, and creating the first-in-the-nation direct municipal funding to individuals for abortion care. 13 However, access to later care did not improve, as evidenced in an informal New York City physician survey done by advocates in 2015, which revealed that hospitals were not providing care after 24 weeks of gestation, except for specific maternal or fetal indications, and only one ambulatory facility was providing care up to 26 weeks of gestation. Finally, after more than a decade of advocacy, in 2019, New York State passed the Reproductive Health Act. 14

The Reproductive Health Act made three principal changes to New York State’s abortion law. It 1) removed abortion from the criminal code; 2) clarified that advanced practice clinicians such as physician assistants, nurse practitioners, and licensed midwives may provide abortion care within their scope of practice; and 3) created protections that allow for abortion up to 24 weeks from the commencement of pregnancy and throughout pregnancy when the patient’s life or health is at risk or in cases of fetal nonviability. Advocates and clinicians have been working with the New York State Department of Health to create guidance interpreting the Reproductive Health Act’s parameters. The guidance was newly released on May 6, 2022 in the form of a letter from the Commissioner of Health, and it aligns with federal policy (eg, 45 CFR § 46.102) and the “ReVITALize: Gynecology Data Definitions” endorsed by the American College of Obstetricians and Gynecologists and numerous other respected national organizations, placing the “commencement of pregnancy” at implantation of a fertilized egg. 15 This will have a significant effect on clinical practice, placing “24 weeks from the commencement of pregnancy” at 27–28 weeks from the last menstrual period, as opposed to the previous interpretation of 26 weeks from the last menstrual period. Furthermore, this guidance aligns with the Supreme Court’s broad definition of health, 16 which supports individualized decision making between patient and health care team throughout pregnancy.

However, policy and legal changes do not automatically result in changes to medical practice. Determined New York City advocates worked closely with hospital and ambulatory clinicians who provide abortion to mobilize expanded services allowed under the Reproductive Health Act. One example of this successful collaboration is the expansion of abortion care within NYC Health + Hospitals.

CASE STUDY: NYC HEALTH + HOSPITALS

NYC Health + Hospitals is the largest public health care system in the United States, comprised of 11 hospitals (see Box 1), five long-term care facilities, a certified home health agency, and more than 100 community health centers. Its mission is to deliver high-quality comprehensive health care services to all with compassion, dignity, and respect. The health care system provides essential inpatient, outpatient, and home-based services to more than 1 million New Yorkers annually. NYC Health + Hospitals recognizes abortion as an essential and necessary component of comprehensive care, and abortion care is available at all of the hospitals; however, these services have expanded and contracted over the years, largely as a result of staffing changes, loss of institutional knowledge, competing priorities, and the evolving political landscape. Interpretations of New York State’s previous abortion law allowed for abortion care for any indication up to 26 weeks of gestation; yet, by 2019, when the Reproductive Health Act was passed, many staff were unaware of the existing legal parameters that regulated abortion, and few health care professionals had the clinical experience to provide care beyond 24 weeks of gestation, leaving a gap in care beyond that point. Furthermore, each hospital had its own organizational politics related to historical practices, unique patient communities, and current leadership views. However, NYC Health + Hospitals clinician–advocates identified strong supporters of reproductive rights at the systemwide leadership level and, with their endorsement, moved forward on expanding abortion access. Supported by policy advocates, these clinicians assessed existing barriers to care and created a strategic plan around communication, skill-building, and accessibility to expand abortion services to more fully align with the Reproductive Health Act.

NYC Health + Hospitals Acute Care Facilities

•  NYC Health + Hospitals/Jacobi
•  NYC Health + Hospitals/Lincoln
•  NYC Health + Hospitals/North Central Bronx
•  NYC Health + Hospitals/Coney Island
•  NYC Health + Hospitals/Kings County
•  NYC Health + Hospitals/Woodhull
•  NYC Health + Hospitals/Bellevue
•  NYC Health + Hospitals/Harlem
•  NYC Health + Hospitals/Metropolitan
•  NYC Health + Hospitals/Elmhurst
•  NYC Health + Hospitals/Queens

COMMUNICATION

The first critical barrier identified was a lack of knowledge among patients and physicians about the abortion care NYC Health + Hospitals provided. Patients often went elsewhere for abortion care. Owing to communication challenges within the vast health care system, there was also low clinician awareness about abortion services. To improve patient awareness, clinician–advocates worked with the hospital communications team to edit patient materials to provide clear and accessible information about abortion on all websites, social media, and printed materials. To target awareness on the provider side, clinician–advocates provide ongoing presentations to give real-time clarification to clinicians and staff regarding what the Reproductive Health Act means for patient care. Additionally, the systemwide policy on abortion later in pregnancy, which was first written in 2003, was revised by a working group comprised of family planning directors from several hospitals. It was updated to align with the Reproductive Health Act and then approved by hospital legal counsel. It is being circulated to physician and nursing leadership to bring people up to date on current New York State law.

ENHANCING PROCEDURAL SKILLS

NYC Health + Hospitals clinicians also identified gaps in procedural skills that needed to be filled to expand services. Training for later abortion care is limited by the small volume of cases, the narrow specialization of care, and the misinformation and stigma about these services that exists within the medical community. To build clinician skills and participation, two educational projects are underway. The first is the development and implementation of training for physicians on administering feticidal injections. Although inducing fetal death is part of the clinical process for abortions after 24 weeks of gestation in NYC Health + Hospitals, the injection procedure is not a standard part of obstetrics and gynecology residency or family planning fellowship training. Abortion services historically have relied on maternal–fetal medicine specialists to perform this procedure; however, this depends on these specialists being comfortable participating in later abortion care. Training physicians who provide abortion services in the injection procedure will reduce the reliance on outside specialists. The second project focuses on the expansion of surgical skills needed to provide later abortion care. To facilitate training, physicians have been credentialed at multiple sites, allowing practitioners who are the sole providers of later abortion care at their facilities to find support for skill expansion outside their home institutions. Building a cadre of trained clinicians who provide abortion services who are able to administer injections and perform abortions across the pregnancy spectrum will solidify access to later abortion care within the health care system.

ACCESSIBILITY

Abortion is a time-sensitive service that requires appropriate and timely referral. The clinician–advocate team identified several obstacles within the existing referral network. There was no effective communication pathway to support timely referrals, nor a central, identifiable referral pathway for external health care professionals. In addition, because care can be cost-prohibitive for patients, seamless connections to sources of financial support such as abortion funds are a critical part of the referral system, but they were absent. To improve accessibility, NYC Health + Hospitals created a new, nimble referral system that can reduce logistical barriers to care. This referral system was built by a team comprised of physicians, administrators, members of the electronic medical record team, and data analysts. This new system integrates a patient’s geographic preference and gestational age to ensure an appropriate and timely referral. The health care system is also liaising with abortion funds to facilitate financial support for patients who face financial barriers to care.

Additionally, NYC Health + Hospitals created a new position of “Client Navigator,” following a successful model that was created in Massachusetts. 17 The Client Navigator’s primary role will be to accompany patients who need logistic or financial support through their abortion care experience, linking them to necessary resources and ensuring timely access to care. The Client Navigator will also support health care professionals both inside and outside the public health care system who are seeking referrals for their patients. This position has been filled and onboarding is underway.

In the past 6 years, NYC Health + Hospitals has successfully made abortion services more visible to the public by citing them in public speeches, clearly explaining them on their website, and adding information about these services in patient materials. The health care system added two institutions to the list of hospitals providing abortions at more than 20 weeks of gestation and expanded systemwide capacity to provide abortion care up to 26 weeks of gestation. The number of clinicians who provide abortion care has grown with internal training and changes in hiring priorities, resulting in 10 new providers. Further, there is now a strong network of health care professionals across institutions involved in a systemwide Reproductive Health Working Group, which creates policies and cross-institutional support. This working group consists of family planning leaders from several institutions within the system and serves as a team of experts that sets medical standards for the system and liaises with individual institutions. The group has created systemwide guidance for medication abortion, later abortion, and long-acting reversible contraception. Each institution has expanded access in an individualized way depending on local politics. Future systemwide goals include expansion of abortion services to include the option of induction termination and expanding beyond 26 weeks of gestation. With this measurable progress, NYC Health + Hospitals is increasing access to abortion care for people in New York City who need this critical service.

Replication of this model in other hospital systems where allowed by law is urgent. Given the ongoing threat to abortion access stemming from the Supreme Court and state legislatures that continue to pass restrictions aiming to eliminate care, it will take a national movement of health care professionals to create sustainable abortion access. The internal advocacy by NYC Health + Hospitals clinicians, supported by state-based advocates who helped to clear legislative and regulatory barriers, is a clear example of how to provide and expand abortion care for the most vulnerable patients, including those in need of care later in pregnancy. To ensure that the right to abortion does not become a hollow promise, health care systems must evaluate and address barriers, review and expand policies, and build coalitions with local advocates, supportive lawmakers, and abortion funds so that high-quality abortion care is a reality for all our communities.

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Addressing a Crisis in Abortion Access: A Case Study in Advocacy

Affiliation.

• 1 Albert Einstein College of Medicine, The Bronx, New York; NYC Health + Hospitals; the New York Civil Liberties Union; the National Institute for Reproductive Health, New York, New York; the Later Abortion Initiative, Ibis Reproductive Health, Cambridge, Massachusetts.
• PMID: 35849467
• PMCID: PMC9205299
• DOI: 10.1097/AOG.0000000000004839

As restrictions on abortion increase nationwide, it is critical to ensure ongoing access to abortion care throughout pregnancy. People may seek abortions later in pregnancy as a result of financial or legal barriers that delay care or because of changing circumstances, such as the status of their partner, the health of other children, employment, or a new fetal diagnosis. New York State has been a beacon for abortion access since 1970. Yet, after Roe v Wade was decided, New York State abortion law was not in compliance with federal law, and risk-averse medical institutions hesitated to provide later abortions, forcing patients out of state for care. After years of advocacy, the Reproductive Health Act was passed in 2019. Clinicians and advocates collaborated to translate policy into expanded practice at NYC Health + Hospitals, the largest public health care system in the United States. NYC Health + Hospitals conducted an internal review, identified barriers to abortion care, and addressed these through improvements in public and internal communication, strengthening of procedural skills, and a better referral system. As a result, abortion services have become visible and the system's capacity and gestational age limit have expanded. The example of NYC Health + Hospitals is an instructive model to ensure that abortion care is provided to the most vulnerable patients, including those who need care later in pregnancy. Given the ongoing threat to reproductive rights, this example of expanded access is particularly timely.

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.

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Conflict of interest statement

Financial Disclosure The authors did not report any potential conflicts of interest.

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Study Examines The Lasting Effects Of Having — Or Being Denied — An Abortion

Terry Gross

In The Turnaway Study, Diana Greene Foster shares research conducted over 10 years with about 1,000 women who had or were denied abortions, tracking impacts on mental, physical and economic health.

Copyright © 2020 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

The Most Important Study in the Abortion Debate

Researchers rigorously tested the persistent notion that abortion wounds the women who seek it.

The demographer Diana Greene Foster was in Orlando last month, preparing for the end of Roe v. Wade , when Politico published a leaked draft of a majority Supreme Court opinion striking down the landmark ruling. The opinion, written by Justice Samuel Alito, would revoke the constitutional right to abortion and thus give states the ability to ban the medical procedure.

Foster, the director of the Bixby Population Sciences Research Unit at UC San Francisco, was at a meeting of abortion providers, seeking their help recruiting people for a new study . And she was racing against time. She wanted to look, she told me, “at the last person served in, say, Nebraska, compared to the first person turned away in Nebraska.” Nearly two dozen red and purple states are expected to enact stringent limits or even bans on abortion as soon as the Supreme Court strikes down Roe v. Wade , as it is poised to do. Foster intends to study women with unwanted pregnancies just before and just after the right to an abortion vanishes.

Read: When a right becomes a privilege

When Alito’s draft surfaced, Foster told me, “I was struck by how little it considered the people who would be affected. The experience of someone who’s pregnant when they do not want to be and what happens to their life is absolutely not considered in that document.” Foster’s earlier work provides detailed insight into what does happen. The landmark Turnaway Study , which she led, is a crystal ball into our post- Roe future and, I would argue, the single most important piece of academic research in American life at this moment.

The legal and political debate about abortion in recent decades has tended to focus more on the rights and experience of embryos and fetuses than the people who gestate them. And some commentators—including ones seated on the Supreme Court—have speculated that termination is not just a cruel convenience, but one that harms women too . Foster and her colleagues rigorously tested that notion. Their research demonstrates that, in general, abortion does not wound women physically, psychologically, or financially. Carrying an unwanted pregnancy to term does.

In a 2007 decision , Gonzales v. Carhart , the Supreme Court upheld a ban on one specific, uncommon abortion procedure. In his majority opinion , Justice Anthony Kennedy ventured a guess about abortion’s effect on women’s lives: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained,” he wrote. “Severe depression and loss of esteem can follow.”

Was that really true? Activists insisted so, but social scientists were not sure . Indeed, they were not sure about a lot of things when it came to the effect of the termination of a pregnancy on a person’s life. Many papers compared individuals who had an abortion with people who carried a pregnancy to term. The problem is that those are two different groups of people; to state the obvious, most people seeking an abortion are experiencing an unplanned pregnancy, while a majority of people carrying to term intended to get pregnant.

Foster and her co-authors figured out a way to isolate the impact of abortion itself. Nearly all states bar the procedure after a certain gestational age or after the point that a fetus is considered viable outside the womb . The researchers could compare people who were “turned away” by a provider because they were too far along with people who had an abortion at the same clinics. (They did not include people who ended a pregnancy for medical reasons.) The women who got an abortion would be similar, in terms of demographics and socioeconomics, to those who were turned away; what would separate the two groups was only that some women got to the clinic on time, and some didn’t.

In time, 30 abortion providers—ones that had the latest gestational limit of any clinic within 150 miles, meaning that a person could not easily access an abortion if they were turned away—agreed to work with the researchers. They recruited nearly 1,000 women to be interviewed every six months for five years. The findings were voluminous, resulting in 50 publications and counting. They were also clear. Kennedy’s speculation was wrong: Women, as a general point, do not regret having an abortion at all.

Researchers found, among other things, that women who were denied abortions were more likely to end up living in poverty. They had worse credit scores and, even years later, were more likely to not have enough money for the basics, such as food and gas. They were more likely to be unemployed. They were more likely to go through bankruptcy or eviction. “The two groups were economically the same when they sought an abortion,” Foster told me. “One became poorer.”

Read: The calamity of unwanted motherhood

In addition, those denied a termination were more likely to be with a partner who abused them. They were more likely to end up as a single parent. They had more trouble bonding with their infants, were less likely to agree with the statement “I feel happy when my child laughs or smiles,” and were more likely to say they “feel trapped as a mother.” They experienced more anxiety and had lower self-esteem, though those effects faded in time. They were half as likely to be in a “very good” romantic relationship at two years. They were less likely to have “aspirational” life plans.

Their bodies were different too. The ones denied an abortion were in worse health, experiencing more hypertension and chronic pain. None of the women who had an abortion died from it. This is unsurprising; other research shows that the procedure has extremely low complication rates , as well as no known negative health or fertility effects . Yet in the Turnaway sample, pregnancy ended up killing two of the women who wanted a termination and did not get one.

The Turnaway Study also showed that abortion is a choice that women often make in order to take care of their family. Most of the women seeking an abortion were already mothers. In the years after they terminated a pregnancy, their kids were better off; they were more likely to hit their developmental milestones and less likely to live in poverty. Moreover, many women who had an abortion went on to have more children. Those pregnancies were much more likely to be planned, and those kids had better outcomes too.

The interviews made clear that women, far from taking a casual view of abortion, took the decision seriously. Most reported using contraception when they got pregnant, and most of the people who sought an abortion after their state’s limit simply did not realize they were pregnant until it was too late. (Many women have irregular periods, do not experience morning sickness, and do not feel fetal movement until late in the second trimester.) The women gave nuanced, compelling reasons for wanting to end their pregnancies.

Afterward, nearly all said that termination had been the right decision. At five years, only 14 percent felt any sadness about having an abortion; two in three ended up having no or very few emotions about it at all. “Relief” was the most common feeling, and an abiding one.

From the May 2022 issue: The future of abortion in a post- Roe America

The policy impact of the Turnaway research has been significant, even though it was published during a period when states have been restricting abortion access. In 2018, the Iowa Supreme Court struck down a law requiring a 72-hour waiting period between when a person seeks and has an abortion, noting that “the vast majority of abortion patients do not regret the procedure, even years later, and instead feel relief and acceptance”—a Turnaway finding. That same finding was cited by members of Chile’s constitutional court  as they allowed for the decriminalization of abortion in certain circumstances.

Yet the research has not swayed many people who advocate for abortion bans, believing that life begins at conception and that the law must prioritize the needs of the fetus. Other activists have argued that Turnaway is methodologically flawed; some women approached in the clinic waiting room declined to participate, and not all participating women completed all interviews . “The women who anticipate and experience the most negative reactions to abortion are the least likely to want to participate in interviews,” the activist David Reardon argued in a 2018 article in a Catholic Medical Association journal.

Still, four dozen papers analyzing the Turnaway Study’s findings have been published in peer-reviewed journals; the research is “the gold standard,” Emily M. Johnston, an Urban Institute health-policy expert who wasn’t involved with the project, told me. In the trajectories of women who received an abortion and those who were denied one, “we can understand the impact of abortion on women’s lives,” Foster told me. “They don’t have to represent all women seeking abortion for the findings to be valid.” And her work has been buttressed by other surveys, showing that women fear the repercussions of unplanned pregnancies for good reason and do not tend to regret having a termination. “Among the women we spoke with, they did not regret either choice,” whether that was having an abortion or carrying to term, Johnston told me. “These women were thinking about their desires for themselves, but also were thinking very thoughtfully about what kind of life they could provide for a child.”

The Turnaway study , for Foster, underscored that nobody needs the government to decide whether they need an abortion. If and when America’s highest court overturns Roe , though, an estimated 34 million women of reproductive age will lose some or all access to the procedure in the state where they live. Some people will travel to an out-of-state clinic to terminate a pregnancy; some will get pills by mail to manage their abortions at home; some will “try and do things that are less safe,” as Foster put it. Many will carry to term: The Guttmacher Institute has estimated that there will be roughly 100,000 fewer legal abortions per year post- Roe . “The question now is who is able to circumvent the law, what that costs, and who suffers from these bans,” Foster told me. “The burden of this will be disproportionately put on people who are least able to support a pregnancy and to support a child.”

Ellen Gruber Garvey: I helped women get abortions in pre- Roe America

Foster said that there is a lot we still do not know about how the end of Roe might alter the course of people’s lives—the topic of her new research. “In the Turnaway Study, people were too late to get an abortion, but they didn’t have to feel like the police were going to knock on their door,” she told me. “Now, if you’re able to find an abortion somewhere and you have a complication, do you get health care? Do you seek health care out if you’re having a miscarriage, or are you too scared? If you’re going to travel across state lines, can you tell your mother or your boss what you’re doing?”

In addition, she said that she was uncertain about the role that abortion funds —local, on-the-ground organizations that help people find, travel to, and pay for terminations—might play. “We really don’t know who is calling these hotlines,” she said. “When people call, what support do they need? What is enough, and who falls through the cracks?” She added that many people are unaware that such services exist, and might have trouble accessing them.

People are resourceful when seeking a termination and resilient when denied an abortion, Foster told me. But looking into the post- Roe future, she predicted, “There’s going to be some widespread and scary consequences just from the fact that we’ve made this common health-care practice against the law.” Foster, to her dismay, is about to have a lot more research to do.

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Case Study – Abortion Rights and/or Wrongs

Print this case study here:  Case Study – Abortion Rights and-or Wrongs

Case Study: Abortion Rights and/or Wrongs

By Tarris Rosell, PhD, DMin

Kate is a 17 year old patient, unmarried and 8 weeks pregnant. She is a rather remarkable girl in that she lives independently while still a senior in a high school. She tells you that she was an adoptee given back to foster care, and then abused in that system. She is now an emancipated minor who works 30 hours per week at a service industry job while also earning a 4.0 GPA in school, ranking in the top 10% of her class. She is college-bound, with a full-ride scholarship for pre-med undergraduate studies at a prestigious university.

Kate has absolutely no family support, and the former boyfriend who is the father of her unborn child/fetus simply disappeared upon learning of the pregnancy. Your patient is scared, uninsured, and says she doesn’t want to be pregnant or a mom (“Perhaps someday, but not now!”). She rejects the adoption option, based on her own experience growing up, and requests abortion only, at this hospital where she has always received medical care.”

Questions for discussion

1. Your faith-based health care system rejects elective abortion option. What ought to be done for Kate? And by whom?

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• Volume 6, Issue 10
• Estimating the visibility rate of abortion: a case study of Kerman, Iran
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• Maryam Zamanian 1 ,
• Mohammad Reza Baneshi 1 ,
• AliAkbar Haghdoost 2 ,
• Farzaneh Zolala 2
• 1 Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences , Kerman , Iran
• 2 HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences , Kerman , Iran
• Correspondence to Dr Farzaneh Zolala; zolalafarzaneh{at}gmail.com

Objectives Abortion is a sensitive issue; many cultures disapprove of it, which leads to under-reporting. This study sought to estimate the rate of abortion visibility in the city of Kerman, Iran—that is, the percentage of acquaintances who knew about a particular abortion. For estimating the visibility rate, it is crucial to use the network scale-up method, which is a new, indirect method of estimating sensitive behaviours more accurately.

Materials and methods This cross-sectional study was conducted in Kerman, Iran using various methods to ensure the cooperation of clinicians and women. A total of 222 women who had had an abortion within the previous year (74 elective, 74 medical and 74 spontaneous abortions) were recruited. Participants were asked how many of their acquaintances were aware of their abortion. Abortion visibility was estimated by abortion type. 95% CIs were calculated by a bootstrap procedure. A zero-inflated negative binomial regression analysis was conducted to assess the variables related to visibility.

Results The visibility (95% CI) of elective, medical and spontaneous abortion was 8% (6% to 10%), 60% (54% to 66%) and 50% (43% to 57%), respectively. Women and consanguineal family were more likely to be aware of the abortion than men and affinal family. Non-family members had a low probability of knowing about the abortion, except in elective cases. Abortion type, marital status, sex of the acquaintance and closeness of the relationship were the most important determinants of abortion visibility in the final multifactorial model.

Conclusions This study shows the visibility rate to be low, but it does differ among social network members and by the type of abortion in question. This difference might be explained through social and cultural norms as well as stigma surrounding abortion. The low visibility rate might explain the low estimates of abortion rates found in other studies.

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This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2016-012761

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Strengths and limitations of this study

This is a rare study estimating abortion visibility in Iran—as well as in the rest of the world; the results could draw policy makers' attention to appropriate policies by providing a more realistic picture of abortion.

The most important challenge faced in this study was low participation from women who had abortions and reproductive health providers because of stigma and severe legal restrictions. As a result, we tried to encourage their participation using different strategies.

We were unable to assess other cases of abortion (eg, women who used traditional and herbal medicines, as well as cases performed by non-medical providers or the woman herself). The visibility of abortion in such cases may be different from the cases we considered.

Introduction

Self-reporting and direct methods of measuring health events are prone to high levels of under-reporting bias. This bias is much more common for behaviours that are sensitive or subject to social disapproval, occurring more often among women. 1 , 2 Abortion can be classified as a sensitive issue because of the high level of stigma related to it and legal restrictions in many communities. 3

Abortion can be divided into two overarching categories, spontaneous and induced, with the latter further divided into two types, medical and elective. 4 Medical abortion is performed in cases of fetal anomaly or to safeguard the mother's health, whereas elective abortion is performed at the request of the mother for other than therapeutic reasons. Elective abortion, which has also been called intentional, criminal or illegal abortion, garners greater stigma in many societies. 3 , 5 Stigma causes women to hide their experience of abortion from acquaintances and healthcare providers. 6 Even in communities where abortion is legal, a comparison of medical records and self-reported abortion rates shows a high discrepancy of ∼70%. 7 This rate may be much higher in societies where abortion is illegal, which results in under-reporting and unsafe abortions that can jeopardise the mother's life. 8

Iran—a Middle Eastern country governed by the Islamic state—culturally, religiously and legally prohibits elective abortion. Because of these conditions, many elective abortions are performed at home or under unsafe conditions, 9 which could lead to the mother's death or irreparable complications. 3 These abortions can never be registered if they are performed successfully, and, in cases of referral to a hospital for a critical complication endangering the mother's health, the mothers often report spontaneous abortion rather than elective. 9 In addition, a new population growth policy in Iran is encouraging families to have more children, as the Iranian population has declined in recent years. 10 This, in turn, could increase legal restrictions and ultimately lead to even more under-reporting of abortion. Last but not least, not all cases of spontaneous abortion are recorded in the registration system. 5

While the data derived from direct survey methods and from the registration system represent just the tip of the iceberg, an accurate estimate of abortion is necessary to inspire more effective planning and policymaking to reduce unsafe abortion and to improve maternal health. Such an estimate is also needed for purposes such as accurate estimation of pregnancy rates, levels of unintended pregnancy (UP) (UP itself includes two main categories: unwanted pregnancy and mistimed pregnancy) and contraceptive failure rate. 11

How can better estimates for sensitive issues be obtained? An effective alternative method to self-reporting and direct techniques is the network scale-up (NSU) method, an indirect technique. In this method, a representative sample of the general population is questioned about the number of the target population in their active social network—it does not require direct questioning of the target population. 12 For example, the participants are asked, ‘among your acquaintances, how many women have had abortion experiences?’ This indirect and anonymous question could desensitise the respondents to the topic and increase response rates and accuracy for two reasons: first, the question is not directly about the respondents themselves but about other people; second, they are not required to name those acquaintances or their relation to them; they merely provide the number. 12 , 13 The NSU method is based on the idea that the proportion of individuals known by participants is linearly proportional to the real size of the same subpopulation in the society. 12 However, one of the basic NSU assumptions, perfect awareness of their acquaintances' behaviours, is often not met; hence, visibility bias remains a major source of bias in estimations of hard-to-count populations. 14

Visibility bias describes respondents not being aware of all the behaviours among their active social network. This occurs more often for stigmatised or illegal behaviours. For example, respondents may not be aware of abortions that have happened in their network. 15 In the case of the NSU method, the obtained crude estimate should be adjusted accordingly. For example, if the visibility of a hidden behaviour was estimated at 50%, the NSU method's crude estimate should be doubled. Thus far, visibility rates have been estimated for hidden populations such as men who have sex with men (MSM), injection drug users (IDUs) and commercial sex workers (CSWs), as well as for certain types of cancer. 12 , 16–18 Only one study has estimated the visibility of abortion by asking gynaecologists and midwives to guess the visibility rate of abortion. 19 However, to the best of our knowledge, no study has used the standard method to estimate the abortion visibility (AV) rate. Therefore, in this study, we sought to estimate the visibility rate and its determinants for all types of abortion in an Iranian population to provide a more accurate estimate of abortion.

Study setting and study population

This cross-sectional study was part of a larger ongoing study in Kerman, Iran in 2015, the primary aim of which was to estimate the frequency of abortion. Kerman is the capital of the largest province of Iran and is located in the southeastern part of the country. Eligible participants were female residents of Kerman over the past 5 years who had a history of abortion during the previous year. A total of 222 women who had an abortion of any type within the previous year (74 elective, 74 medical and 74 spontaneous) were recruited. To obtain the study sample, both private and public centres were approached, including referral hospitals, private offices of gynaecologists and midwives. The critical factor in this study was gaining the trust of the reproductive health providers, so that they felt comfortable cooperating with data collection for elective abortion cases. This was difficult owing to the severe legal restrictions on abortions in Iran. Therefore, we held several meetings to explain the study method and assure them that their confidentiality and anonymity were paramount. They were also provided with financial incentives. Subsequently, these providers introduced us to women who had had an abortion and consented to be interviewed. Most participants were interviewed in person, but 33 (∼15%) were interviewed on the phone to further protect their privacy. After explaining the purpose of the study to the participants, reassuring them of their anonymity and the confidentiality of information, and obtaining verbal informed consent, we were permitted to collect data.

To obtain a sample of non-elective abortions—participants whose medical records listed a medical or spontaneous abortion within the previous year—we sought the help of gynaecologists and midwives in referral hospitals throughout the city. These participants were interviewed after they provided verbal consent. Written consent forms were not used owing to the cultural sensitivity of this topic and to help increase both participation and accuracy of responding. 20 All interviews were conducted in a private room at the same centre. Despite all these safeguards, the participation rates for elective, medical and spontaneous abortions were 39%, 70% and 62%, respectively. We are cognisant that non-random sampling and the relatively low response rate for elective cases, which were almost unavoidable, could affect the generalisability of the results; therefore, the estimated AV rate cannot be generalised to the whole population of women living in Kerman. The data were collected using a structured interview instrument administered by a trained female interviewer. The study protocol was approved by the ethics committee of Kerman University of Medical Sciences (ir.kmu.rec.1394.223).

Data collection

The interview form included four sections. The first provided an overview of the study and its objectives. In the second, a table listed the participant's active social network relationships in the rows. In the NSU method, the standard definition of an active social network is ‘people whom you know and who know you by name, with whom you can interact, if needed, and with whom you have had contact over the last two years personally, or by telephone or e-mail’. 12 , 13 For ease of recall and therefore increased accuracy, we divided the entire active social network into a list of comprehensive relationships and two main categories: family and non-family. The family group included consanguineal 1 and affinal 2 family. Both consanguineal and affinal family included two subgroups: immediate family (sometimes known as first-degree relatives, including parents, siblings and children) and extended family (including grandparents, aunts, uncles, cousins, nieces, nephews, etc). The non-family group included male and female friends from school, friends from university, friends from their neighbourhood, acquaintances from work, acquaintances from their husband's work, friends of their husband and other friends or acquaintances. The table included three columns (A, B and C). The first (column A) tallied the total number of persons from each relationship. The next column (B) indicated the number of adults (persons 18 years old and over) from each relationship, and the last (column C) indicated the number of adults who were aware of the abortion. (Participants were not asked about the awareness of those under 18 years old because any lack of knowledge on their part is more likely due to their age than to a low visibility rate.) Participants were prompted with questions such as ‘How many cousins do you have? How many of them are adults? And how many of these adults are aware of your abortion?’.

The third section assessed the abortion type. In addition, participants were asked whether their pregnancy was intended (planned), why the pregnancy was unintended, the number of children they already have, any previous pregnancies, age, marriage age, marital status, career, husband's career, and their level of education.

The last section included more sensitive questions. This section included questions to be completed in cases of elective abortion (such as the reason for the abortion, whether the man involved in the pregnancy (MIP) was aware and consented to the abortion, and what their marital status was at the time of the abortion). A self-completion form and a ballot box were used for this section in order to maintain the participant's privacy and to improve the accuracy of the data. The form was piloted in two studies and revised accordingly to increase acceptability and comprehension.

Data analysis

AV and 95% CI were estimated for each type of abortion and by different subgroups divided by abortion type ( table 1 and figure 1 ). The 95% CIs were computed by a bootstrapping procedure, drawing 1000 independent samples with replacement. The calculations for AV and 95% CI were performed separately for different demographic characteristics.

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Abortion visibility by demographic characteristics

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Abortion visibility in the city of Kerman, in 2015, divided by abortion type. (A) Abortion visibility, divided by abortion type. (B) Comparison of abortion visibility among women's husbands and female and male members of their social network, divided by abortion type. (C) Comparison of abortion visibility among women's consanguineal family, affinal family and non-family, divided by abortion type. (D) Comparison of abortion visibility among women's immediate and extended consanguineal family, divided by abortion type. The y axis shows abortion visibility as a percentage, which is calculated by dividing the number of adults who were aware of the abortion by the total number of adults listed in any given category. E, elective; M, medical; S, spontaneous; H, husband; F, females; M, males; CF, consanguineal family; AF, affinal family; NF, non-family; ICF, immediate consanguineal family; ECF, extended consanguineal family.

A zero-inflated negative binomial regression analysis was used to model the potential determinants of AV because so many acquaintances were not aware of the abortion, generating excess zero responses, and because of the large difference between the mean and variance of the data. To adjust for the correlation between each participant's responses about the members of her network, each participant was defined as a cluster layer, and cluster robust SE was used. Potential determinants of AV were tested in univariate analyses, and those with p values less than 0.2 were entered into a multifactorial model using backward elimination variable selection. We performed these analyses for each type of abortion separately; the results were similar in terms of effect sizes and levels of significance. Hence, we performed one regression for all of the data (including all types of abortion). The analyses were performed using Stata software (V.11.2) and Microsoft Excel (2007).

In this study, 222 women with a history of abortion in the previous year, including elective, medical and spontaneous abortions (74 cases of each type), were recruited. The mean (SD) age of elective, medical and spontaneous abortion cases was 31.4 (7.8), 29.0 (5.1) and 29.1 (6.5), respectively, and the respondents' mean years of education were 13.9, 12.6 and 11.8 years, respectively. The employment percentages were 31.1, 23.0 and 14.9 for respondents who had had elective, medical and spontaneous abortions, respectively. While all of the women with medical and spontaneous abortions were married, the corresponding figure was 82.4% for elective abortions; 9.5% of these participants were single, and 8.1% were divorced or widowed. While pregnancies ending in spontaneous and medical abortions were mainly intended (90.5% and 81.1%, respectively), most pregnancies terminated by elective abortion were unintended, with some of those being unwanted (31.1%) and mistimed (27.1%) pregnancies ( table 2 ). Elective abortions were conducted mainly with the agreement of both parents (66.2%). However, 31.1% were undertaken based only on the mother's wishes, and, in one-third of these cases, the MIP was not informed about the abortion. The remainder of the abortions were performed based only on the wish of the MIP (2.7%).

Elective abortion visibility divided by the reason for abortion

The number of family members in the participants' social networks totalled 25 974, consisting of 60% adults. Of the adults, 20% were immediate family members and 80% were extended family members. The corresponding figure for non-family adults was 6609. The average percentage of each subgroup in a participant's active social network was husband 1%, consanguineal family 42%, affinal family 27%, and non-family members 30%. The sex ratio of the participants' active social network was 48% male to 52% female ( table 1 ).

The visibility (95% CI) of elective, medical and spontaneous abortion was 8% (6% to 10%), 60% (54% to 66%) and 50% (43% to 57%), respectively ( figure 1 A). All abortion types were much more visible to husbands than to other members of the active social network (in the case of elective abortion, the difference between husbands and other members of the network was much higher than for the other two types of abortion) ( figure 1 B). The visibility of all abortion types was lower for non-family than for family, except for elective abortions, which were more visible to non-family than to family ( figure 1 C). The visibility of all types of abortion was higher for consanguineal family than for affinal family (although this difference was smaller for spontaneous abortion) ( figure 1 C); among consanguineal family members, all abortion types were more visible to immediate family than to extended family (but in elective cases, this difference was much higher than for the other two types) ( figure 1 D). With the exception of the husband, abortion was always more visible to women than to men in participants' networks ( figure 1 B). The difference in visibility between women and men who were immediate consanguineal family was not sizable for medical and spontaneous abortions, but the difference was high for elective abortion (55% for women vs 13% for men), meaning mothers and sisters were more likely to know about elective abortions than fathers and brothers.

In the univariate analysis, the visibility of abortion was not significantly (at the 0.2 level) associated with the participant's age and education or with the husband's occupation and education (results not shown). Therefore, these variables were not included in the multifactorial analysis. The number of children did not remain significant after adjustment for other variables in the multifactorial analysis.

The final multivariate model—after being adjusted for potential factors and backward elimination—showed that non-elective abortions were approximately twice as visible as elective ones (medical abortion was 98% (95% CI 1.58 to 2.48) and spontaneous abortion 96% (95% CI 1.56 to 2.46) more visible than elective abortion). In addition, the abortions of unmarried women were 66% (95% CI 0.22 to 0.52) less visible than those of married women. The abortions of self-employed women were 14% (95% CI 1.03 to 1.27) more visible than those of housewives. Abortions of intended pregnancies were 17% (95% CI 0.70 to 0.98) less visible than those of UPs, yet increasing the number of UPs decreased visibility (1 UP vs 0 UPs was 17% (95% CI 0.72 to 0.95) less visible and two or more UPs vs 0 UPs was 30% (95% CI 0.57 to 0.88) less visible).

Among acquaintances, compared with men, women were 19% (95% CI 1.13 to 1.26) more informed about abortions. Compared with non-family members in active social networks, the husband, immediate family members and extended family members were 91% (95% CI 1.69 to 2.18), 47% (95% CI 1.34 to 1.62) and 13% (95% CI 1.03 to 1.24) more informed about abortions ( table 3 ).

Determinants of abortion visibility

This study found that the visibility of abortion, particularly elective abortion, was very low in Kerman in 2015. Of all members of the participants' active social networks, their husbands had a very high probability of being informed about the abortion. In addition, women and consanguineal family were more likely to be informed of the abortion than men and affinal family. Non-family members had a low probability of being informed, yet non-family had the highest possibility of being informed of elective abortions. Other factors affecting visibility were marital and employment status, as well as the type of pregnancy and frequency of UPs.

To the best of our knowledge, only one study in the world has estimated the visibility of abortion, but it used a different method: Rastegari and coworkers 19 used gynaecologists’ and midwives' guesses to calculate the visibility rate of abortion in Iran. Their study estimated visibility at 20–34% for elective abortion (termed abortions without medical indications), which was higher than our estimate, and 43–75% for other types of abortion (termed abortions with medical indications), which was similar to our estimate but had wide variability and did not differentiate between spontaneous and medical abortions. Although that study was the first attempt to estimate AV, it is reasonable to suppose that this issue is best sourced not from clinicians but by the woman herself, as she knows far more about her own pattern of disclosure. Another study in Iran used a method similar to that used in this study to estimate the visibility of cancer, finding a cancer visibility rate of 86%. 18 Other studies have estimated visibilities of 1.4 for MSM in Japan, 76 for IDUs in Brazil, and 24, 57 and 34 for MSM, IDUs and CSWs, respectively, in Ukraine. 12 , 16 , 17 The observed differences in these visibility rates indicate variation in the stigma of each behaviour in different cultures. The visibility rate of abortion in this study was similar to, or even lower than, those of other stigmatised behaviours, which highlights that abortion is highly stigmatised in the study setting.

The rest of the literature has mainly compared self-reporting and medical record data, and they have also concluded that abortions are under-reported. 21 , 22 These studies have shown that most women who have a history of abortion (listed in their medical records) did not self-report the abortion. This is the case even in countries where there are no legal restrictions for abortion. 7 Abortion under-reporting, which could be an indicator of low AV, in addition to the sensitive nature of sexual matters such as abortion, is also due to social, cultural, religious and legal factors that are more pertinent in traditional, religious countries such as Iran. In Iran, sexual relationships outside marriage are highly stigmatised, particularly for women. 9 Hence, the stigma related to abortion differs by marital status. Married women are stigmatised for elective abortion because it is against religious law. 9 However, women who experience non-elective abortions could be labelled infertile or could be blamed by others. 23 , 24 In Iran, the expression ‘ojagh koor’ (which has a negative meaning and is pejorative) is applied to both men and women who are unable to have children. ‘This metaphoric expression is according to popular belief in Iran that an infertile couple will never have a house with a ‘warm kitchen’ (ojaghe koor)’. 23 As a result, many women hide their abortions from acquaintances. This might also explain the low visibility of intended pregnancies leading to abortion compared with UPs. On the other hand, a higher number of previous UPs decreased the level of visibility. Recently, Iranian families have tended to consider fewer children as a sign of higher social class; 10 therefore, informing others about repeated UPs could decrease their social standing and lead to humiliation for violating childbearing norms.

Unmarried women (single, divorced and widowed) tell a very different story; having sexual relationships outside marriage is the main reason for the stigma attached to abortions, regardless of the type. This stigma can be very devastating and can disrupt a person's life. For example, a pregnant single woman may lose the chance to be married and have a normal social life. This could even disgrace her family name. She is very likely to be blamed, rejected and subjected to physical or mental punishment by acquaintances. 9 The social stigma of abortion for unmarried women is much heavier than for married women, which explains the lower visibility in these women. Severe social stigma exists even for girls whose marriages are legally recorded but who do not yet share accommodation with their husbands and during which they still live with their parents (the ‘Aghd’ period). In this period, there is no legal restriction against having a sexual relationship with her husband and getting pregnant; however, from a traditional point of view, they should abstain from sexual activity until they share accommodation. 9 These norms could explain the low visibility observed for this group. Furthermore, current Iranian rules based on Islamic laws prohibit elective abortion, and there are legal penalties for reproductive health providers who perform abortions. 3 , 9 A new Iranian population growth policy 10 could enforce such restrictions, which could ultimately decrease AV further.

The visibility of abortion was significantly higher among self-employed women, those with no affiliation with the government. As abortion is unlawful, women who have government jobs might perceive it as a threat to their job, which would lead them not to disclose it and be more conservative than self-employed women. Moreover, in self-employed professions, such as hair styling, women might have more opportunities to speak with other women and to talk about personal issues 25 than do women in government jobs.

The highest AV was observed for husbands. This is due to his special position as the MIP and the provider of support for the woman in such a situation. 9 However, ∼10% of elective abortions were performed without informing the MIP. This could be explained by the father's religious prejudice or by different levels of involvement in the tasks of childbearing: in many societies, such as Iran, women are more often thought to be solely responsible for this task. 9 Other studies conducted in Iran have also found that men were less satisfied with their wives' terminating UPs and that women who had failed to gain their husband's consent were likely to obtain an abortion without. 9 With the exception of their husband, the women in this study were more likely to disclose their abortion to women than men. Other studies report that, in general, female-to-female disclosure is higher than female-to-male disclosure. 26 Moreover, the shame of disclosing sexual and reproductive issues to members of the opposite gender contributes to different levels of disclosure between men and women. Furthermore, the women disclosed their abortions to more consanguineal family members than affinal family members, which might be due to women being more likely to be blamed by affinal families than by consanguineal families. 24 , 27 However, in the case of elective abortions, the participants were more likely to disclose their abortion to non-family members than to family members, even consanguineal family members (which are the closest family members). This difference may be because women trust their peers and very close friends enough to disclose sensitive personal issues; 28 , 29 in addition, family members might be more likely than non-family members to want to prevent women from obtaining an elective abortion.

Strengths and limitations

We acknowledge that our study has several limitations; the most important challenge in this study was the low participation rates of women who had had abortions and reproductive health providers. Reproductive health providers were often unwilling to cooperate because of the severe legal restrictions on abortion in Iran. As a result, we tried to encourage their participation using different strategies, such as holding meetings to explain the study method, assuring them of confidentiality and anonymity protection, and providing financial incentives. We also had difficulty obtaining women's consent to participate, particularly in cases of elective abortion and for unmarried women. Sometimes women who had been introduced by the midwife or gynaecologist as a patient who had obtained an elective abortion denied the intentionality of the abortion; the midwife or gynaecologist had to reassure them of the confidentiality of the study.

Furthermore, it is very common in Iranian society to use herbal medicines that do not require prescriptions. We have not assessed these traditional methods of abortion, nor have we considered abortions performed by non-medical providers or by the woman herself. The visibility of abortion in such cases might differ from that of other cases, perhaps affected by factors such as low socioeconomic status because of the high costs of elective abortion services.

We also note two points for consideration, although they do not affect the level of visibility. The first is the possibility of recording elective abortions as non-elective (if the physician and patient agree to do so). 9 However, this did not affect our results for visibility because these women pretended their abortion was medical, and their disclosing behaviour is similar to that of women who had had a medical abortion. The second point is that some married women who became pregnant outside of marriage and thus obtained an elective abortion may have reported it as an unwanted or mistimed pregnancy. This could affect the classification of the reasons for abortion but not the visibility.

Despite these limitations, this is one of the rare studies estimating AV in Iran, or even the world. It can be considered a first step in highlighting the extent of the problem in a developing and traditional society, and even beyond such societies; the results could direct policymakers to appropriate policies by providing a more realistic picture of abortion.

In this study, AV was low, but differed among social network members and by the type of abortion. This difference might be explained by social and cultural norms and the stigma surrounding abortion. The low visibility rate that we observe might explain the low estimates of abortion rates found in other studies, and this issue should be considered by policymakers when planning women's healthcare services.

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Contributors MZ collected the data. MZ, MRB and AAH analysed the data. MZ and FZ wrote the manuscript. All the authors approved the final version of the manuscript.

Competing interests None declared.

Ethics approval Ethics committee of Kerman University of Medical Sciences.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

↵ 1 Blood-related family.

↵ 2 Marriage-related family, also called in-laws—that is, the husband's relatives.

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• Patient Saf Surg

The horror of unsafe abortion: case report of a life threatening complication in a 29-year old woman

Kaniz zehra naqvi.

1 Liaquat National Hospital and Medical Collage, 402, Al jannat plaza, M.A.Jinnah road, Karachi, Pakistan

Muhammad Muzzammil Edhi

Every year 42 million women with unintended pregnancies choose abortion, and fifty percent of these procedures, 20 million are unsafe. An unsafe abortion is defined as a procedure for terminating an unintended pregnancy carried out either by person lacking the necessary skills or in an environment that does not conform to minimal medical standards or both.

Pakistan is the one of the six countries where more than 50% of the world’s all maternal deaths occur. It is estimated that 890,000 induced abortions are performed annually in Pakistan, and estimate an annual abortion rate of 29 per 1000 women aged 15-49.

Case presentation

Here we present a case report of a 29-year old woman who underwent an unsafe abortion for unintended pregnancy resulting in uterine perforation. The unskilled provider pulled out her bowel through vagina after perforating the uterus, as a result she lost major portion of her small intestine resulting in short bowel syndrome.

The law of Pakistan only allows abortion during early stages of pregnancy for purpose of saving the life of a mother but does not cater for cases of rape, incest and fetal abnormalities or social reasons.

Only legalization of abortion is not sufficient, preventing unintended pregnancy should be the priority of all the nations and for this reason contraception should be widely accessible.

Practitioners need to become better trained in safer abortion methods and be to able transfer the patient to health facility when complications occur.

Pakistan is the one of the six countries where more than 50% of the world’s all maternal deaths occur [ 1 ].

It is estimated that 890,000 induced abortions are performed annually in Pakistan, and estimate an annual abortion rate of 29 per 1000 women aged 15-49 [ 2 ].

According to World Health Organization, every 8 minutes a women in a developing nations will die of complications arising from an unsafe abortion [ 3 ]. The fifth United Nations Millennium Development Goal recommends 75% reduction in maternal mortality by 2015. WHO deems unsafe abortion one of easiest preventable causes of maternal mortality and a public health issue.

Throughout Europe, except for Ireland and Poland, abortion is broadly legal, widely available and safe. Even United States legalized abortion nationwide and this is because of the realization that restrictive policies were instead of ending abortion were putting pressure on public health especially on those who could not afford to pay for safe abortion. Today, 60% of the world’s 1.55 billion women of reproductive age(15-44) live in countries where abortion is legal, the remaining 40% live where abortion is highly restricted, virtually all of them in developing countries [ 4 ]. Data suggests that even as the overall abortion rate has declined, the proportion of unsafe abortions is on the rise, especially in the developing nations [ 5 ]. It is clear that in those countries where contraceptive use increased the most, abortion rate dropped significantly but in countries like Pakistan which has 25% unmet need of contraception the incidence of unsafe abortion is still high 29 per 1000 women aged 15-49 [ 2 ].

Approximately 1 in 10 pregnancies end in an unsafe abortion, giving a ratio of 1 unsafe abortion to about 7 live births [ 6 ]. Approximately eighty million more women per year suffer post abortion complications that can lead to short or long term consequences [ 4 ].

Highest incidence of unsafe abortion takes place in Latin America, Africa and South East Asia [ 3 ]. According to Pakistan demographic survey 2006–7 with total fertility rate at 4.1%, stagnant contraception prevalence rate 29.6% and high 25% unmet need for contraception, and 1 out of every 4 birth unwanted, prospects of achieving MDG 4and 5 by 2015 look bleak [ 7 ].

It should not therefore come as a surprise that unwanted pregnancies are the leading cause of induced abortion in Pakistan [ 8 ].

40% of these abortions are performed by unskilled workers in back street clinics.

It is seen that in countries with restrictive laws, the women who are determined to end an unwanted pregnancy will seek out clandestine means. In Pakistan where average earnings of a person are less than $2 per day and fee for doctor assisted abortion is around $50-104, the services provided by untrained persons thrive. The shaming, blaming and the judgemental or punitive attitude of the staff are another factor which prevents these females from seeking post abortion medical care. So changing the laws is no guarantee that unsafe abortion will not take place. In Zambia a study findings revealed, high ratio of induced abortion mortality and more than half of those deaths were of schoolgirls. Although abortion is legal in Zambia on social and medical grounds but most females choose illegal abortion because of being expelled from school, unwillingness to reveal relationship, to protect the health of their previous baby [ 9 ].

The main causes of death or morbidity from unsafe abortion is due to haemorrhage, sepsis, genital trauma and bowel injury. Here we are presenting a case report of unsafe abortion in a young woman which resulted not only in unrecognized perforation of uterus, but also the removal of a significant portion of her small intestines via the uterine perforation and introitus causing severely shortened intestines and infection. The procedure was performed by an unskilled worker in one of the back street clinic of the city.

Case report

At 9 pm a ‘29-year old female’ Para 0 +0 was admitted via Accident and Emergency department of our hospital complaining of severe abdominal pain starting earlier in the afternoon. She reported recent attempts at termination of a 10 weeks unplanned and undesired pregnancy at an outside clinic. According to the patient about three to four weeks earlier as a part of workup done for fever revealed pregnancy of about 10 weeks duration. She took some abortificient to abort this unintended pregnancy. She developed bleeding per vagina following that, for which she had uterine evacuation at some small clinic. After that she came home, but next day she started to bleed heavily per vagina, so she went back to the same place and was prescribed tablet misoprostol twice daily. According to her she took this tablet for 1 week but as she continued to bleed so she again visited the same clinic and second uterine evacuation was performed on her. After 2 or 3 days she returned to the same clinic because her bleeding had not yet subsided. A third attempt on uterine evacuation was made but this time there was lots of pain which was unbearable, so the person attempting the evacuation gave her some intravenous sedation and completed her job. After returning home, the patient almost collapsed due to severe pain, so her family brought her to hospital.

On presentation to our hospital she was conscious, pale and in obvious discomfort, her BP was 115/77 mm Hg, pulse 99/min, temperature was 99.2°F. Abdominal examination revealed generalized tenderness and guarding all over the abdomen. Bowel sounds were absent. On per vagina examination, there was no active bleeding but vagina was hot, uterus was about 10–12 weeks size, mobile and cervical os was closed. Her blood investigation showed Hb 7 gm/dl, white cell count 9.6 × 10 9 /l, platelets were 278 × 10 9 /l. urea, creatinine and electrolytes were all within normal limits. Ultrasound pelvis showed fluid with echoes in pelvis, an empty uterus and normal looking ovaries. Suspecting uterine/bowel injury we also asked for x-ray abdomen both erect and supine and it showed gas under the diaphragm. A clinical diagnosis of uterine perforation leading to bowel injury was made and laparotomy planned after resuscitation of patient.

During the exploratory laparotomy, hemoperitoneum of about 500–800 ml was noted, additionally two separate segments of small bowel were identified lying at a distance from each other and in between mesentery was all bruised and necrosed (Figure  1 ).

Cut ends of small bowel.

When the bowel was run, we found that only about one and half feet of small bowel from duodeno-jejunal flexure and about 6 inches from ilieo-caecal junction intact, rest of the small bowel was missing completely. It transpired that while doing the evacuation the person had removed the whole of small gut except for those two small pieces. We also found a 2.5 cm perforation in the anterior wall of uterus close to cervical canal (Figure  2 ).

Perforation in anterior wall of uterus.

After resecting the nonviable portion of intestines an end to end anastomosis was performed. Primary repair of uterine perforation was done. Abdominal cavity washed and closed leaving a drain behind. Post operatively she was kept in high dependency unit. 3 units of packed red cells were transfused, broad spectrum antibiotics and intravenous fluids were given. She responded well to the treatment, on third post-operative day the intra-abdomen drain was removed and she was discharged on tenth post-operative day.

At the time of discharge the patient and her family was counselled regarding the implications of losing a major portion of her small bowel. They were told that she will suffer from repeated bouts of diarrhoea which may cause dehydration and malnutrition. Advice regarding small frequent meals, fluid in the form of ORS, nutritional supplements and medication to control diarrhoea was given. She was also referred to psychologist for support and therapy.

She was admitted twice through accident and emergency for treatment of dehydration because of diarrhoea. She has been under regular follow up and though has lost weight but her diarrhoea has improved.

Psychological support in the form of counselling of both the family and the patient was carried out but since there are no established support groups so whatever was done was on individual basis.

Uterine perforation and bowel injuries are the major complications after unsafe abortion. The reason for these complications is that most abortions are done by untrained personals i.e. unskilled workers in very unhygienic conditions [ 10 , 11 ]. The same happened with this unfortunate woman, the person doing the evacuation did not recognise that she had perforated the uterus and what she was pulling out was intestines and as a result this woman ended up with only one and half to two feet of small intestine. In one study 11.2% had bowel injury and most of the abortions were performed by unskilled workers [ 12 ]. In another study done at Khyber medical college and hospital in Peshawar Pakistan the incidence of gut injury after induced abortion was about 42% [ 13 ]. Despite the adverse outcome of abortions, the low socio-economic status of these women compels them to resort to abortion rather than practicing contraception as it entails a ‘one time’ cost compared to recurrent cost of buying contraception [ 8 ]. These unqualified providers are easily accessible to the clients in countries such as Pakistan.

Even safe abortions in the developing countries are still risky because it depends on the health facility, the training of the provider and the gestational age of the fetus. With unsafe abortion the risk of maternal morbidity and mortality depends on method of abortion and the willingness of the women to seek post abortion care [ 14 ].

Data on nonfatal long term health consequences are poor, but those documented are infertility, stool or urinary incontinence due to bowel or bladder injury and bowel resection along with psychological trauma.

There is a relationship between unsafe abortion and restrictive abortion laws. The median rate of unsafe abortions in the 82 countries with the most restrictive abortion laws is up to 23 of 1000 women compared with 2 of 1000 in nations that allow abortion [ 15 ].

Less restrictive abortion laws do not appear to increase the abortion rate overall. The world’s lowest rate is in Europe, where abortion is legal and easily available because the contraception use is high. Compared to Latin America, Africa and south east Asia where abortion laws are more restrictive and contraception use is low the rates ranges from mid 20 s to 39 per 1000 women [ 16 ].

In developing countries, two third of unintended pregnancies occur in women who are not using any contraception.

Complications due to unsafe abortion account for an estimated 13% of maternal deaths world over or 70,000 deaths per year [ 17 ].

Unsafe abortion is a significant problem both medical and social worldwide. It is seen that in developing countries most unsafe abortions are carried out by untrained persons resulting in high morbidity and mortality [ 18 ].

To reduce the morbidity and mortality associated with unsafe abortions, intensive dissemination of information and commitment at all levels is required. Use of various contraceptive methods should be promoted in order to prevent unintended pregnancies. Governments and non government organizations should find ways and means to overcome cultural and social misconceptions which restrict women from receiving health care.

Regular training courses for traditional birth attendants, nurses and doctors under the supervision of expert obstetrician should be carried out. All those facilities which provide such services should have appropriate equipment and trained staff and the service is provided at a reasonable cost. Post abortion family planning counselling should be the part of the service.

There is evidence that liberalizing abortion laws results in reduction in abortion related morbidities and mortalities but here the role of socio-political and religious organization comes into play.

By preventing 5 million abortions related complications and deaths worldwide we can save 220,000 children from becoming motherless.

Written informed consent was obtained from the patient for publication of this Case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interest

The authors declare that they have no competing interests.

Authors’ contributions

MME did manuscript drafting and KZN did critically review the manuscript. Both authors approved the final document of manuscript.

Acknowledgement

We great fully acknowledge all the staff member of obstetrics and gynaecology department of Liaquat National Hospital, Karachi, Pakistan for their help and cooperation.

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Series: Sex and Gender

The Most Important Abortion Case You Never Heard About

How we got to this week’s abortion showdown — and how Justice Scalia’s views could help shape the outcome.

by Nina Martin

Everyone considers Roe v. Wade, the 1973 decision that established a woman’s right to an abortion, to be the most important ruling ever on the issue by the Supreme Court. But this year, a lesser-known progeny of Roe occupies center stage in potentially the most momentous abortion case confronting the justices in a generation. After Roe established abortion rights, Planned Parenthood v. Casey reined them in, creating a new legal standard that gave states greater leeway to regulate the procedure. Many conservative legislatures took advantage to enact a series of increasingly tough laws that reproductive rights advocates argue have made it more difficult — and sometimes impossible — for women to obtain abortions.

One of those states was Texas, which in 2013 enacted H.B. 2, an omnibus bill whose multiple provisions include restrictions, known as TRAP laws , targeting abortion providers. Now the Supreme Court is being asked to decide the constitutionality of two of these laws — one requiring clinics to meet the same building codes as other types of outpatient surgical centers, the other requiring abortion doctors to have admitting privileges at a hospital within 30 miles — that have already shut down more than half of the state’s 41 clinics and could close 8 more. When the court holds oral arguments in Whole Woman’s Health v. Hellerstedt this week, the signs that protesters wave and the chants they chant will likely focus on Roe , but the outcome of the case will hinge on how justices interpret PP v. Casey .

Abortion rights advocates contend the Texas rules are “sham” laws that pretend to protect women’s health while erecting so many hurdles — what PP v. Casey calls an “undue burden” — that abortion becomes “an abstract right that doesn’t have any meaning,” in the words of Stephanie Toti, a Center for Reproductive Rights attorney representing the clinics. Abortion foes insist that TRAP laws have a genuine medical purpose. They want the court to abandon the “undue burden” standard and allow lawmakers to pass abortion regulations as long as they have a “rational basis,” without having to prove that the laws actually benefit women. If the court goes along, it could have a sweeping impact on access to abortion across the country, but especially in conservative states in the South and Midwest, triggering not just a new wave of TRAP laws but other types of restrictions as well.

PP v. Casey was decided in 1992, a time of many political parallels to today. Here is the background to the most important abortion decision you may never have heard about.

The Rise of Incrementalism

In the period immediately following Roe , abortion opponents mobilized and pushed for a federal constitutional amendment declaring that a fetus was a “person” entitled to “equal protection” under the 14th Amendment. But those efforts stalled. Abortion opponents began arguing for a new, pragmatic strategy known as “incrementalism.” Instead of attempting to overturn Roe outright, “you would argue that certain abortion restrictions and regulations were compatible with Roe ,” said Mary Ziegler, a law professor at Florida State University and author of “After Roe: The Lost History of the Abortion Debate” . The idea was “to chip away at abortion rights until Roe was so incoherent and so full of holes that courts would finally get rid of it.”

The approach required “an accurate understanding of political power, an assessment of what is politically achievable, [and] recognition of the imperfect world in which we live,” Clarke Forsythe, senior counsel for Americans United for Life , a key of architect of anti-abortion strategies, wrote in a law review article around that time. That translated into retail politics on the state level, the election of anti-abortion candidates, the passage of model legislation and the defense of those new laws in court. The approach was extremely effective: By the late 1980s, states had enacted dozens of restrictions. Moreover, the political makeup of the Supreme Court had turned more conservative, and the court’s jurisprudence on abortion had become splintered and, to some, confused. Forsythe, though, could read the tea leaves: The justices seemed ready to show “greater deference to state abortion laws — quite a contrast from the Roe decision.”

The Pennsylvania Law

The battles over the Pennsylvania Abortion Control Act were a prime example of incrementalism in action. A version of the law passed in 1982 was largely struck down by the U.S. Supreme Court four years later. But instead of giving up on the law, legislators amended it; the version signed by Gov. Robert Casey Sr. in 1989 included a 24-hour waiting period, informed consent rules for women seeking abortions, parental consent rules for minors and a requirement that married women notify their husbands before terminating a pregnancy. Planned Parenthood and other abortion providers challenged these rules, too. But this time, the Third U.S. Circuit Court of Appeals upheld all the provisions except spousal notification. Planned Parenthood appealed the case to the high court.

Another Nasty Fight for the Supreme Court

Consider the events of 1991–1992. A presidential election loomed; the first war in Iraq was over; racial unrest after the acquittal of four white police officers in the videotaped beating of Rodney King left Los Angeles in flames. Massive job layoffs led to widespread economic resentment, and a blunt-talking billionaire emerged out of nowhere to become a populist hero and presidential spoiler (this one’s name was Ross Perot ). On the abortion front, groups such as Operation Rescue were using aggressive, sometimes violent tactics to block access to abortion clinics. Then, in June 1991, an ailing Justice Thurgood Marshall resigned, touching off an epically ugly Supreme Court fight (although the one to replace Justice Antonin Scalia could make it seem like a model of decorum).

Clarence Thomas’s confirmation in October 1991 meant Republican appointees now clearly held the fate of abortion rights in their hands. “Our concern was that when the [Pennsylvania] case went before the Supreme Court, the majority would use this opportunity to go much further [than the Third Circuit appeals court] and say that any law that was rational, including the complete banning of abortion, would be constitutional,” said Kathryn Kolbert, the lead ACLU attorney challenging the Pennsylvania law, who is now director of the Athena Center for Leadership Studies at Barnard College. That was what many abortion opponents were urging : Indeed, they had been lobbying for the “rational basis” standard since Roe .

Figuring that they were going to lose anyway, Kolbert and her allies embarked on what author and legal analyst Jeffrey Toobin has called “ one of the most audacious litigation strategies in Supreme Court history. ” Instead of dragging the case out, they opted to “lose fast”: to push the case onto an exceptionally fast track in the hope it would be decided in the middle of the 1992 elections. And instead of making it a fight about Pennsylvania’s incremental law, they cast it as the ultimate showdown over Roe. This would let them take political advantage of the backlash that would ensue if abortion rights were gutted. According to Toobin, the conservative chief justice, William Rehnquist, resented this “transparent” ploy, but the court’s two liberal justices, Roe ’s author Harry Blackmun and John Paul Stevens, supported it and Rehnquist’s hand was forced. The case was argued on the last possible day of the 1991–92 term.

Justice Kennedy’s Compromise

A central question facing the justices was whether the state could comply with Roe v. Wade while requiring women to go through additional hoops before getting an abortion. Oral arguments left both sides convinced that abortion rights were in peril; when Blackmun’s papers became public years later, they showed that Rehnquist had drafted an opinion overruling Roe . But then the trio of Republican-appointed moderates — Anthony Kennedy, Sandra Day O’Connor and David Souter — had second thoughts. Instead of joining Rehnquist, they made a secret deal to thwart him .

The PP v. Casey decision, announced in June 1992, was stunning. By a 5–4 vote, the court reaffirmed Roe ’s “essential holding” that the right to abortion was protected by the Constitution. Not only that, the opinion embraced women’s equality as central to the abortion right in a way that Roe had not. With abortion, the liberty of the woman is at stake “in a sense unique to the human condition and so unique to the law,” the decision read. “Her suffering is too intimate and personal for the State to insist … upon its own vision of the woman’s role, however dominant that vision has been in the course of our history and of our culture.”

The structure of the ruling was also highly unusual: It was a “plurality” opinion by the three moderates — Kennedy, O’Connor and Souter — with the court’s two liberals agreeing with some parts and disagreeing with others. Kolbert notes that the plurality’s emphasis on “stare decisis,” the principle that courts must follow precedent, was a sign that the justices had understood “the challenge to the institutional integrity of the court was real.” Justice Kennedy in particular “did not want the court to be perceived as changing course” on abortion, Kolbert said, simply because the majority’s ideological balance had shifted.

But abortion foes like Paul Linton, later special counsel to the Thomas More Society , noted that a “moral ambiguity” about abortion pervaded the joint opinion, as well as “the nagging sense” that the three justices thought Roe had been wrongly decided but upheld it anyway: “That … does not promote respect for the judiciary, especially in a case where the stakes were so high.” Abortion opponents felt especially betrayed by Kennedy, a dismay that has only grown deeper over the years, as he has authored landmark opinions on gay rights and marriage equality. That’s one reason conservative expectations for the Texas abortion case are much more cautious today than they were for Casey . Kennedy “doesn’t have any clearly defined principles that allow you to predict what he’s going to do in any case, in any area,” said Lynn Wardle, a law professor at Brigham Young University who has written often about same-sex marriage and abortion. “The best test for being able to predict what he will do is to lick your finger and hold it out to the wind.”

A Clouded Victory for Abortion Rights

Even as PP v. Casey upheld the right to abortion, the plurality opinion took Roe v. Wade apart, starting with its foundation, the trimester framework. Under Roe , states were almost completely banned from regulating abortion during the first trimester. They had more flexibility to pass laws protecting a woman’s health in the second trimester, and they could prohibit most abortions in the third. In contrast, Casey declared, “[T]he State has legitimate interests from the outset of the pregnancy in protecting the health of the woman and the life of the fetus that may become a child.” Instead of the trimester approach, Casey established viability — the point at which the fetus can survive outside the womb — as the new dividing line for determining whether an abortion law was valid or not. (When Roe was decided, fetuses weren’t considered viable until 28 weeks, or the third trimester; by 1992, medical advances had pushed the line to around 24 weeks.) Before viability, Casey said, states could only try to persuade a woman not to have an abortion; laws that made it difficult or impossible for her to act on her decision did not pass muster. After viability, though, states could restrict abortions pretty much however they liked.

More significantly, Casey also rejected Roe ’s “strict scrutiny” test for evaluating abortion restrictions — a test that had stymied most state efforts to regulate the procedure — replacing it with the looser “undue burden” standard, which Justice O’Connor had proposed in dissents to earlier abortion rulings. An undue burden was defined as any law that had “the purpose or effect of placing a substantial obstacle in the path of a woman seeking an abortion.” Importantly for the pending Texas abortion case, this reasoning applied to medical rules as well as other restrictions: Although “the State may enact regulations to further the health or safety of a woman seeking an abortion,” the court held, “unnecessary health regulations that have the purpose or effect of presenting a substantial obstacle to a woman seeking an abortion impose an undue burden.” Still, the court reiterated, just because a law had “the incidental effect of making it more difficult or more expensive to procure an abortion” wasn’t enough to invalidate it.

Under the new standard, the Pennsylvania rules aimed at giving women more information and time to reflect on their decisions were valid. Only the spousal notification provision was deemed to be an undue burden and thus unconstitutional: “A state may not give to a man the kind of dominion over his wife that parents exercise over their children.”

Scalia’s Dissent: “Hopelessly Unworkable”

Casey prompted one of Antonin Scalia’s most famous and blistering dissents: The plurality’s reasoning, he fumed, was “really more than one should have to bear.” Much as he disliked Roe , at least the trimester framework laid down clear guidelines, he wrote. In contrast, Casey ’s “undue burden” standard was “created largely out of whole cloth,” “inherently manipulable,” and “hopelessly unworkable,” giving individual judges much more power to inject their own private beliefs into the abortion debate. “Its authors believe they are bringing to an end a troublesome era in the history of our Nation and of our Court,” Scalia scoffed. But he said the abortion wars would only be stoked by “this jurisprudence of confusion” — a view that would help frame the conversation about Casey for the next two decades. More recently, abortion rights advocates have fought back, arguing that Casey ’s reputation as “squishy law” is undeserved and part of a long effort to delegitimitize the undue burden standard, much as critics have sought to undermine Roe . “Excuse me for simplifying, but there’s a there there,” said Reva Siegel, a Yale Law professor who has written extensively on abortion and gender equity. One reason Casey may be so misunderstood: It gave each side half a loaf, so neither embraced it, even though it reflected how most ordinary people felt. The decision “speaks to an America divided by conflict over abortion,” Siegel said. “It’s summoning each side to engage respectfully with the other.”

Reshaping the Debate: “Partial Birth”

The 18 months or so immediately following Casey “were probably a low point in the history of the pro-life movement,” said Michael New, a conservative pundit and visiting assistant professor at Ave Maria University who has written often about abortion. At first most new restrictions introduced in the states were modeled closely on the Pennsylvania law. Then abortion opponents hit upon the mid–1990s version of last year’s Planned Parenthood videos: the rare but gruesome technique for third-trimester abortions that they dubbed “partial-birth abortion.”A flurry of bans on the procedure re-energized the incrementalists, providing new opportunities " to slowly convince [average] Americans that they're just as uncomfortable about abortion as pro-life folks are ," Jack Balkin, a professor of constitutional law at Yale University, told PBS' Frontline in 2005. That meant more chances to challenge not just Roe , but also Casey . Said Forsythe, of Americans United for Life: "The procedure served to humanize the unborn and produced a sea change in American public opinion on the issue."

Ultimately, it was the sea change on the Supreme Court during the administration of George W. Bush that mattered most. In 2007, the court upheld the federal ban on partial-birth abortion; Kennedy wrote the majority opinion using language suggesting he might be open to tighter abortion restrictions despite the undue burden standard, especially in areas of “medical uncertainty.” Abortion, he said, was “a decision … fraught with emotional consequence,” one in which women would “struggle with grief more anguished and sorrow more profound” if they really understood what this particular procedure involved. Conservative strategists saw the ruling as a victory not just against partial-birth abortion but against Casey .

How Big a Burden?

It took the huge Tea Party wave of 2010 for abortion opponents to gain the political clout to push through laws like Texas’ H.B. 2. Since 2011, states in the South and Midwest have passed more than 300 abortion restrictions — TRAP laws, rules for how medication abortions may be performed, bans on abortion after 20 weeks (and sometimes earlier), longer waiting periods and greater impediments to teenagers seeking abortions without parental approval. The central question raised by many of these laws goes directly to the 24-year-old ruling in Casey : How undue must a restriction become before it renders the right to abortion meaningless?

Even before Scalia’s death, the outcome of the Texas case was anyone’s guess; his demise makes it even more uncertain. The biggest question has always been whether Kennedy, the last remaining PP v. Casey co-author on the Supreme Court, will see that decision as an important part of his legacy that he wants to defend, or whether he will be inclined to give states more leeway to restrict the abortion right.

As Casey itself shows, all kinds of court alliances and plurality rulings are possible.

What is clear: The Texas case, whatever its outcome, probably won’t settle the abortion issue any more than Casey did.

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The Safety and Quality of Abortion Care in the United States (2018)

Chapter: 1 introduction, 1 introduction.

When the Institute of Medicine (IOM) 1 issued its 1975 report on the public health impact of legalized abortion, the scientific evidence on the safety and health effects of legal abortion services was limited ( IOM, 1975 ). It had been only 2 years since the landmark Roe v. Wade decision had legalized abortion throughout the United States and nationwide data collection was just under way ( Cates et al., 2000 ; Kahn et al., 1971 ). Today, the available scientific evidence on abortion’s health effects is quite robust.

In 2016, six private foundations came together to ask the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to conduct a comprehensive review of the state of the science on the safety and quality of legal abortion services in the United States. The sponsors—The David and Lucile Packard Foundation, The Grove Foundation, The JPB Foundation, The Susan Thompson Buffett Foundation, Tara Health Foundation, and William and Flora Hewlett Foundation—asked that the review focus on the eight research questions listed in Box 1-1 .

The Committee on Reproductive Health Services: Assessing the Safety and Quality of Abortion Care in the U.S. was appointed in December 2016 to conduct the study and prepare this report. The committee included 13 individuals 2 with research or clinical experience in anesthesiology,

___________________

1 In March 2016, the IOM, the division of the National Academies of Sciences, Engineering, and Medicine focused on health and medicine, was renamed the Health and Medicine Division.

2 A 14th committee member participated for just the first 4 months of the study.

obstetrics and gynecology, nursing and midwifery, primary care, epidemiology of reproductive health, mental health, health care disparities, health care delivery and management, health law, health professional education and training, public health, quality assurance and assessment,

statistics and research methods, and women’s health policy. Brief biographies of committee members are provided in Appendix A .

This chapter describes the context for the study and the scope of the inquiry. It also presents the committee’s conceptual framework for conducting its review.

ABORTION CARE TODAY

Since the IOM first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized controlled trials (RCTs), systematic reviews, and epidemiological studies examining abortion care. This research has focused on examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances ( Ashok et al., 2004 ; Autry et al., 2002 ; Bartlett et al., 2004 ; Borgatta, 2011 ; Borkowski et al., 2015 ; Bryant et al., 2011 ; Cates et al., 1982 ; Chen and Creinin, 2015 ; Cleland et al., 2013 ; Frick et al., 2010 ; Gary and Harrison, 2006 ; Grimes et al., 2004 ; Grossman et al., 2008 , 2011 ; Ireland et al., 2015 ; Kelly et al., 2010 ; Kulier et al., 2011 ; Lohr et al., 2008 ; Low et al., 2012 ; Mauelshagen et al., 2009 ; Ngoc et al., 2011 ; Ohannessian et al., 2016 ; Peterson et al., 1983 ; Raymond et al., 2013 ; Roblin, 2014 ; Sonalkar et al., 2017 ; Upadhyay et al., 2015 ; White et al., 2015 ; Wildschut et al., 2011 ; Woodcock, 2016 ; Zane et al., 2015 ). With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed ( Chen and Creinin, 2015 ; Jatlaoui et al., 2016 ; Lichtenberg and Paul, 2013 ). For example, the use of dilation and sharp curettage is now considered obsolete in most cases because safer alternatives, such as aspiration methods, have been developed ( Edelman et al, 1974 ; Lean et al, 1976 ; RCOG, 2015 ). The use of abortion medications in the United States began in 2000 with the approval by the U.S. Food and Drug Administration (FDA) of the drug mifepristone. In 2016, the FDA, citing extensive clinical research, updated the indications for mifepristone for medication abortion 3 up to 10 weeks’ (70 days’) gestation ( FDA, 2016 ; Woodcock, 2016 ).

Box 1-2 describes the abortion methods currently recommended by U.S. and international medical, nursing, and other health organizations that set professional standards for reproductive health care, including the American College of Obstetricians and Gynecologists (ACOG), the Society of Family Planning, the American College of Nurse-Midwifes, the National Abortion Federation (NAF), the Royal College of Obstetricians and Gynaecologists (RCOG) (in the United Kingdom), and the World

3 The terms “medication abortion” and “medical abortion” are used interchangeably in the literature.

Health Organization ( ACNM, 2011 , 2016 ; ACOG, 2013 , 2014 ; Costescu et al., 2016 ; Lichtenberg and Paul, 2013 ; NAF, 2017 ; RCOG, 2011 ; WHO, 2014 ).

A Continuum of Care

The committee views abortion care as a continuum of services, as illustrated in Figure 1-1 . For purposes of this study, it begins when a woman, who has decided to terminate a pregnancy, contacts or visits a provider seeking an abortion. The first, preabortion phase of care includes an initial clinical assessment of the woman’s overall health (e.g., physical examination, pregnancy determination, weeks of gestation, and laboratory and other testing as needed); communication of information on the risks and benefits of alternative abortion procedures and pain management options; discussion of the patient’s preferences based on desired anesthesia and weeks of gestation; discussion of postabortion contraceptive options if desired; counseling

and referral to services (if needed); and final decision making and informed consent. The next phases in the continuum are the abortion procedure itself and postabortion care, including appropriate follow-up care and provision of contraceptives (for women who opt for them).

A Note on Terminology

Important clinical terms that describe pregnancy and abortion lack consistent definition. The committee tried to be as precise as possible to avoid misinterpreting or miscommunicating the research evidence, clinical practice guidelines, and other relevant sources of information with potentially significant clinical implications. Note that this report follows Grimes and Stuart’s (2010) recommendation that weeks’ gestation be quantified using cardinal numbers (1, 2, 3...) rather than ordinal numbers (1st, 2nd, 3rd...). It is important to note, however, that these two numbering conventions are sometimes used interchangeably in the research literature despite having different meanings. For example, a woman who is 6 weeks pregnant has completed 6 weeks of pregnancy: she is in her 7th (not 6th) week of pregnancy.

This report also avoids using the term “trimester” where possible because completed weeks’ or days’ gestation is a more precise designation, and the clinical appropriateness of abortion methods does not align with specific trimesters.

Although the literature typically classifies the method of abortion as either “medical” or “surgical” abortion, the committee decided to specify methods more precisely by using the terminology defined in Box 1-2 . The term “surgical abortion” is often used by others as a catchall category that includes a variety of procedures, ranging from an aspiration to a dilation and evacuation (D&E) procedure involving sharp surgical and other instrumentation as well as deeper levels of sedation. This report avoids describing abortion procedures as “surgical” so as to characterize a method more accurately as either an aspiration or D&E. As noted in Box 1-2 , the term “induction abortion” is used to distinguish later abortions that use a

medication regimen from medication abortions performed before 10 weeks’ gestation.

See Appendix B for a glossary of the technical terms used in this report.

Regulation of Abortion Services

Abortion is among the most regulated medical procedures in the nation ( Jones et al., 2010 ; Nash et al., 2017 ). While a comprehensive legal analysis of abortion regulation is beyond the scope of this report, the committee agreed that it should consider how abortion’s unique regulatory environment relates to the safety and quality of abortion care.

In addition to the federal, state, and local rules and policies governing all medical services, numerous abortion-specific federal 4 and state laws and regulations affect the delivery of abortion services. Table 1-1 lists the abortion-specific regulations by state. The regulations range from prescribing information to be provided to women when they are counseled and setting mandatory waiting periods between counseling and the abortion procedure to those that define the clinical qualifications of abortion providers, the types of procedures they are permitted to perform, and detailed facility standards for abortion services. In addition, many states place limitations on the circumstances under which private health insurance and Medicaid can be used to pay for abortions, limiting coverage to pregnancies resulting from rape or incest or posing a medical threat to the pregnant woman’s life. Other policies prevent facilities that receive state funds from providing abortion services 5 or place restrictions on the availability of services based on the gestation of the fetus that are narrower than those established under federal law ( Guttmacher Institute, 2017h ).

Trends and Demographics

National- and state-level abortion statistics come from two primary sources: the Centers for Disease Control and Prevention’s (CDC’s) Abortion

4 Hyde Amendment (P.L. 94-439, 1976); Department of Defense Appropriations Act (P.L. 95-457, 1978); Peace Corps Provision and Foreign Assistance and Related Programs Appropriations Act (P.L. 95-481, 1978); Pregnancy Discrimination Act (P.L. 95-555, 1977); Department of the Treasury and Postal Service Appropriations Act (P.L. 98-151, 1983); FY1987 Continuing Resolution (P.L. 99-591, 1986); Dornan Amendment (P.L. 100-462, 1988); Partial-Birth Abortion Ban (P.L. 108-105, 2003); Weldon Amendment (P.L. 108-199, 2004); Patient Protection and Affordable Care Act (P.L. 111-148 as amended by P.L. 111-152, 2010).

5 Personal communication, O. Cappello, Guttmacher Institute, August 4, 2017: AZ § 15-1630, GA § 20-2-773; KS § 65-6733 and § 76-3308; KY § 311.800; LA RS § 40:1299 and RS § 4 0.1061; MO § 188.210 and § 188.215; MS § 41-41-91; ND § 14-02.3-04; OH § 5101.57; OK 63 § 1-741.1; PA 18 § 3215; TX § 285.202.

TABLE 1-1 Overview of State Abortion-Specific Regulations That May Impact Safety and Quality, as of September 1, 2017

a Excludes laws or regulations permanently or temporarily enjoined pending a court decision.

b States have abortion-specific requirements generally following the established principles of informed consent.

c The content of informed consent materials is specified in state law or developed by the state department of health.

d In-person counseling is not required for women who live more than 100 miles from an abortion provider.

e Counseling requirement is waived if the pregnancy is the result of rape or incest or the patient is younger than 15.

f Maximum distance requirement does not apply to medication abortions.

g Some states also exempt women whose physical health is at severe risk and/or in cases of fetal impairment.

h Some states have exceptions for pregnancies resulting from rape or incest, pregnancies that severely threaten women’s physical health or endanger their life, and/or in cases of fetal impairment.

SOURCES: Guttmacher Institute, 2017b , c , d , e , f , g , h , i , 2018b .

Surveillance System and the Guttmacher Institute’s Abortion Provider Census ( Jatlaoui et al., 2016 ; Jerman et al., 2016 ; Jones and Kavanaugh, 2011 ; Pazol et al., 2015 ). Both of these sources provide estimates of the number and rate of abortions, the use of different abortion methods, the characteristics of women who have abortions, and other related statistics. However, both sources have limitations.

The CDC system is a voluntary, state-reported system; 6 , 7 three states (California, Maryland, and New Hampshire) do not provide information ( CDC, 2017 ). The Guttmacher census, also voluntary, solicits information from all known abortion providers throughout the United States, including in the states that do not submit information to the CDC surveillance system. For 2014, the latest year reported by Guttmacher, 8 information was obtained directly from 58 percent of abortion providers, and data for nonrespondents were imputed ( Jones and Jerman, 2017a ). The CDC’s latest report, for abortions in 2013, includes approximately 70 percent of the abortions reported by the Guttmacher Institute for that year ( Jatlaoui et al., 2016 ).

Both data collection systems report descriptive statistics on women who have abortions and the types of abortion provided, although they define demographic variables and procedure types differently. Nevertheless, in the aggregate, the trends in abortion utilization reported by the CDC and Guttmacher closely mirror each other—indicating decreasing rates of abortion, an increasing proportion of medication abortions, and the vast majority of abortions (90 percent) occurring by 13 weeks’ gestation (see Figures 1-2 and 1-3 ) ( Jatlaoui et al., 2016 ; Jones and Jerman, 2017a ). 9 Both data sources are used in this chapter’s brief review of trends in abortions and throughout the report.

Trends in the Number and Rate of Abortions

The number and rate of abortions have changed considerably during the decades following national legalization in 1973. In the immediate years after

6 In most states, hospitals, facilities, and physicians are required by law to report abortion data to a central health agency. These agencies submit the aggregate utilization data to the CDC ( Guttmacher Institute, 2018a ).

7 New York City and the District of Columbia also report data to the CDC.

8 Guttmacher researchers estimate that the census undercounts the number of abortions performed in the United States by about 5 percent (i.e., 51,725 abortions provided by 2,069 obstetrician/gynecologist [OB/GYN] physicians). The estimate is based on a survey of a random sample of OB/GYN physicians. The survey did not include other physician specialties and other types of clinicians.

9 A full-term pregnancy is 40 weeks.

national legalization, both the number and rate 10 of legal abortions steadily increased ( Bracken et al., 1982 ; Guttmacher Institute, 2017a ; Pazol et al., 2015 ; Strauss et al., 2007 ) (see Figure 1-2 ). The abortion rate peaked in the

10 Reported abortion rates are for females aged 15 to 44.

1980s, and the trend then reversed, a decline that has continued for more than three decades ( Guttmacher Institute, 2017a ; Jones and Kavanaugh, 2011 ; Pazol et al., 2015 ; Strauss et al., 2007 ). Between 1980 and 2014, the abortion rate among U.S. women fell by more than half, from 29.3 to 14.6 per 1,000 women ( Finer and Henshaw, 2003 ; Guttmacher Institute, 2017a ; Jones and Jerman, 2017a ) (see Figure 1-2 ). In 2014, the most recent year for which data are available, the aggregate number of abortions reached a low of 926,190 after peaking at nearly 1.6 million in 1990 ( Finer and Henshaw, 2003 ; Jones and Jerman, 2017a ). The reason for the decline is not fully understood but has been attributed to several factors, including the increasing use of contraceptives, especially long-acting methods (e.g., intrauterine devices and implants); historic declines in the rate of unintended pregnancy; and increasing numbers of state regulations resulting in limited access to abortion services ( Finer and Zolna, 2016 ; Jerman et al., 2017 ; Jones and Jerman, 2017a ; Kost, 2015 ; Strauss et al., 2007 ).

Weeks’ Gestation

Length of gestation—measured as the amount of time since the first day of the last menstrual period—is the primary factor in deciding what abortion procedure is most appropriate ( ACOG, 2014 ). Since national legalization, most abortions in the United States have been performed in early pregnancy (≤13 weeks) ( Cates et al., 2000 ; CDC, 1983 ; Elam-Evans et al., 2003 ; Jatlaoui et al., 2016 ; Jones and Jerman, 2017a ; Koonin and Smith, 1993 ; Lawson et al., 1989 ; Pazol et al., 2015 ; Strauss et al., 2007 ). CDC surveillance reports indicate that since at least 1992 (when detailed data on early abortions were first collected), the vast majority of abortions in the United States were early-gestation procedures ( Jatlaoui et al., 2016 ; Strauss et al., 2007 ); this was the case for approximately 92 percent of all abortions in 2013 ( Jatlaoui et al., 2016 ). With such technological advances as highly sensitive pregnancy tests and medication abortion, procedures are being performed at increasingly earlier gestational stages. According to the CDC, the percentage of early abortions performed ≤6 weeks’ gestation increased by 16 percent from 2004 to 2013 ( Jatlaoui et al., 2016 ); in 2013, 38 percent of early abortions occurred ≤6 weeks ( Jatlaoui et al., 2016 ). The proportion of early-gestation abortions occurring ≤6 weeks is expected to increase even further as the use of medication abortions becomes more widespread ( Jones and Boonstra, 2016 ; Pazol et al., 2012 ).

Figure 1-3 shows the proportion of abortions in nonhospital settings by weeks’ gestation in 2014 ( Jones and Jerman, 2017a ).

Abortion Methods

Aspiration is the abortion method most commonly used in the United States, accounting for almost 68 percent of all abortions performed in 2013 ( Jatlaoui et al., 2016 ). 11 Its use, however, is likely to decline as the use of medication abortion increases. The percentage of abortions performed by the medication method rose an estimated 110 percent between 2004 and 2013, from 10.6 to 22.3 percent ( Jatlaoui et al., 2016 ). In 2014, approximately 45 percent of abortions performed up to 9 weeks’ gestation were medication abortions, up from 36 percent in 2011 ( Jones and Jerman, 2017a ).

Fewer than 9 percent of abortions are performed after 13 weeks’ gestation; most of these are D&E procedures ( Jatlaoui et al., 2016 ). Induction abortion is the most infrequently used of all abortion methods, accounting for approximately 2 percent of all abortions at 14 weeks’ gestation or later in 2013 ( Jatlaoui et al., 2016 ).

Characteristics of Women Who Have Abortions

The most detailed sociodemographic statistics on women who have had an abortion in the United States are provided by the Guttmacher Institute’s Abortion Patient Survey. Respondents to the 2014/2015 survey included more than 8,000 women who had had an abortion in 1 of 87 outpatient (nonhospital) facilities across the United States in 2014 ( Jerman et al., 2016 ; Jones and Jerman, 2017b ). 12 Table 1-2 provides selected findings from this survey. Although women who had an abortion in a hospital setting are excluded from these statistics, the data represent an estimated 95 percent of all abortions provided (see Figure 1-3 ).

The Guttmacher survey found that most women who had had an abortion were under age 30 (72 percent) and were unmarried (86 percent) ( Jones and Jerman, 2017b ). Women seeking an abortion were far more likely to be poor or low-income: the household income of 49 percent was below the federal poverty level (FPL), and that of 26 percent was 100 to 199 percent of the FPL ( Jerman et al., 2016 ). In comparison, the

11 CDC surveillance reports use the catchall category of “curettage” to refer to nonmedical abortion methods. The committee assumed that the CDC’s curettage estimates before 13 weeks’ gestation refer to aspiration procedures and that its curettage estimates after 13 weeks’ gestation referred to D&E procedures.

12 Participating facilities were randomly selected and excluded hospitals. All other types of facilities were included if they had provided at least 30 abortions in 2011 ( Jerman et al., 2016 ). Jerman and colleagues report that logistical challenges precluded including hospital patients in the survey. The researchers believe that the exclusion of hospitals did not bias the survey sample, noting that hospitals accounted for only 4 percent of all abortions in 2011.

TABLE 1-2 Characteristics of Women Who Had an Abortion in an Outpatient Setting in 2014, by Percent

NOTE: Percentages may not sum to 100 because of rounding.

SOURCES: (a) Jones and Jerman, 2017b (n = 8,098); (b) Jerman et al., 2016 (n = 8,380).

corresponding percentages among all women aged 15 to 49 are 16 and 18 percent. 13 Women who had had an abortion were also more likely to be women of color 14 (61.0 percent); overall, half of women who had had an abortion were either black (24.8 percent) or Hispanic (24.5 percent) ( Jones and Jerman, 2017b ). This distribution is similar to the racial and ethnic distribution of women with household income below 200 percent of the FPL, 49 percent of whom are either black (20 percent) or Hispanic (29 percent). 15 Poor women and women of color are also more likely than others to experience an unintended pregnancy ( Finer and Henshaw, 2006 ; Finer et al., 2006 ; Jones and Kavanaugh, 2011 ).

Many women who have an abortion have previously experienced pregnancy or childbirth. Among respondents to the Guttmacher survey, 59.3 percent had given birth at least once, and 44.8 percent had had a prior abortion ( Jerman et al., 2016 ; Jones and Jerman, 2017b ).

While precise estimates of health insurance coverage of abortion are not available, numerous regulations limit coverage. As noted in Table 1-1 , 33 states prohibit public payers from paying for abortions and other states have laws that either prohibit health insurance exchange plans (25 states) or private insurance plans (11 states) sold in the state from covering or paying for abortions, with few exceptions. 16 In the Guttmacher survey, only 14 percent of respondents had paid for the procedure using private insurance coverage, and despite the disproportionately high rate of poverty and low income among those who had had an abortion, only 22 percent reported that Medicaid was the method of payment for their abortion. In 2015, 39 percent of the 25 million women lived in households that earned less than 200 percent of the FPL in the United States were enrolled in Medicaid, and 36 percent had private insurance ( Ranji et al., 2017 ).

Number of Clinics Providing Abortion Care

As noted earlier, the vast majority of abortions are performed in nonhospital settings—either an abortion clinic (59 percent) or a clinic offering a variety of medical services (36 percent) ( Jones and Jerman, 2017a ) (see Figure 1-4 ). Although hospitals account for almost 40 percent of facilities offering abortion care, they provide less than 5 percent of abortions overall.

13 Calculation by the committee based on estimates from Annual Social and Economic Supplement (ASEC) to the Current Population Survey (CPS) .

14 Includes all nonwhite race and ethnicity categories in Table 1-2 . Data were collected via self-administered questionnaire ( Jones and Jerman, 2017b ).

15 Calculation by the committee based on estimates from Annual Social and Economic Supplement (ASEC) to the Current Population Survey (CPS) .

16 Some states have exceptions for pregnancies resulting from rape or incest, pregnancies that endanger the woman’s life or severely threaten her health, and in cases of fetal impairment.

The overall number of nonhospital facilities providing abortions—especially specialty abortion clinics—is declining. The greatest proportional decline is in states that have enacted abortion-specific regulations ( Jones and Jerman, 2017a ). In 2014, there were 272 abortion clinics in the United States, 17 percent fewer than in 2011. The greatest decline (26 percent) was among large clinics with annual caseloads of 1,000–4,999 patients and clinics in the Midwest (22 percent) and the South (13 percent). In 2014, approximately 39 percent of U.S. women aged 15 to 44 resided in a U.S. county without an abortion provider (90 percent of counties overall) ( Jones and Jerman, 2017a ). Twenty-five states have five or fewer abortion clinics; five states have one abortion clinic ( Jones and Jerman, 2017a ). A recent analysis 17 by Guttmacher evaluated geographic disparities in access to abortion by calculating the distance between women of reproductive age (15 to 44) and the nearest abortion-providing facility in 2014 ( Bearak et al., 2017 ). Figure 1-5 highlights the median distance to the nearest facility by county.

17 The analysis was limited to facilities that provided at least 400 abortions per year and those affiliated with Planned Parenthood that performed at least 1 abortion during the period of analysis.

The majority of facilities offer early medication and aspiration abortions. In 2014, 87 percent of nonhospital facilities provided early medication abortions; 23 percent of all nonhospital facilities offered this type of abortion ( Jones and Jerman, 2017a ). Fewer facilities offer later-gestation procedures, and availability decreases as gestation increases. In 2012, 95 percent of all abortion facilities offered abortions at 8 weeks’ gestation, 72 percent at 12 weeks’ gestation, 34 percent at 20 weeks’ gestation, and 16 percent at 24 weeks’ gestation ( Jerman and Jones, 2014 ).

STUDY APPROACH

Conceptual framework.

The committee’s approach to this study built on two foundational developments in the understanding and evaluation of the quality of health

care services: Donabedian’s (1980) structure-process-outcome framework and the IOM’s (2001) six dimensions of quality health care. Figure 1-6 illustrates the committee’s adaptation of these concepts for this study’s assessment of abortion care in the United States.

Structure-Process-Outcome Framework

In seminal work published almost 40 years ago, Donabedian (1980) proposed that the quality of health care be assessed by examining its structure, process, and outcomes ( Donabedian, 1980 ):

• Structure refers to organizational factors that may create the potential for good quality. In abortion care, such structural factors as the availability of trained staff and the characteristics of the clinical setting may ensure—or inhibit—the capacity for quality.
• Process refers to what is done to and for the patient. Its assessment assumes that the services patients receive should be evidence based and correlated with patients’ desired outcomes—for example, an early and complete abortion for women who wish to terminate an unintended pregnancy.
• Outcomes are the end results of care—the effects of the intervention on the health and well-being of the patient. Does the procedure achieve its objective? Does it lead to serious health risks in the short or long term?

Six Dimensions of Health Care Quality

The landmark IOM report Crossing the Quality Chasm: A New Health System for the 21st Century ( IOM, 2001 ) identifies six dimensions of health care quality—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The articulation of these six dimensions has guided public and private efforts to improve U.S. health care delivery at the local, state, and national levels since that report was published ( AHRQ, 2016 ).

In addition, as with other health care services, women should expect that the abortion care they receive meets well-established standards for objectivity, transparency, and scientific rigor ( IOM, 2011a , b ).

Two of the IOM’s six dimensions—safety and effectiveness—are particularly salient to the present study. Assessing both involves making relative judgments. There are no universally agreed-upon thresholds for defining care as “safe” versus “unsafe” or “effective” versus “not effective,” and decisions about safety and effectiveness have a great deal to do with the context of the clinical scenario. Thus, the committee’s frame of reference for evaluating safety, effectiveness, and other quality domains is of necessity a

relative one—one that entails not only comparing the alternative abortion methods but also comparing these methods with other health care services and with risks associated with not achieving the desired outcome.

Safety—avoiding injury to patients—is often assessed by measuring the incidence and severity of complications and other adverse events associated with receiving a specific procedure. If infrequent, a complication may be characterized as “rare”—a term that lacks consistent definition. In this report, “rare” is used to describe outcomes that affect fewer than 1 percent of patients. Complications are considered “serious” if they result in a blood transfusion, surgery, or hospitalization.

Note also that the term “effectiveness” is used differently in this report depending on the context. As noted in Box 1-3 , effectiveness as an attribute of quality refers to providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively). Elsewhere in this report, effectiveness denotes the clinical effectiveness of a procedure, that

is, the successful completion of an abortion without the need for a follow-up aspiration.

Finding and Assessing the Evidence

The committee deliberated during four in-person meetings and numerous teleconferences between January 2017 and December 2017. On March 24, 2017, the committee hosted a public workshop at the Keck Center of the National Academies of Sciences, Engineering, and Medicine in Washington, DC. The workshop included presentations from three speakers on topics related to facility standards and the safety of outpatient procedures. Appendix C contains the workshop agenda.

Several committee workgroups were formed to find and assess the quality of the available evidence and to draft summary materials for the full committee’s review. The workgroups conducted in-depth reviews of the epidemiology of abortions, including rates of complications and mortality, the safety and effectiveness of alternative abortion methods, professional standards and methods for performing all aspects of abortion care (as described in Figure 1-1 ), the short- and long-term physical and mental health effects of having an abortion; and the safety and quality implications of abortion-specific regulations on abortion.

The committee focused on finding reliable, scientific information reflecting contemporary U.S. abortion practices. An extensive body of research on abortion has been conducted outside the United States. A substantial proportion of this literature concerns the delivery of abortion care in countries where socioeconomic conditions, culture, population health, health care resources, and/or the health care system are markedly different from their U.S. counterparts. Studies from other countries were excluded from this review if the committee judged those factors to be relevant to the health outcomes being assessed.

The committee considered evidence from randomized controlled trials comparing two or more approaches to abortion care; systematic reviews; meta-analyses; retrospective cohort studies, case control studies, and other types of observational studies; and patient and provider surveys (see Box 1-4 ).

An extensive literature documents the biases common in published research on the effectiveness of health care services ( Altman et al., 2001 ; Glasziou et al., 2008 ; Hopewell et al., 2008 ; Ioannidis et al., 2004 ; IOM, 2011a , b ; Plint et al., 2006 ; Sackett, 1979 ; von Elm et al., 2007 ). Thus, the committee prioritized the available research according to conventional principles of evidence-based medicine intended to reduce the risk of bias in a study’s conclusions, such as how subjects were allocated to different types of abortion care, the comparability of study populations, controls

for confounding factors, how outcome assessments were conducted, the completeness of outcome reporting, the representativeness of the study population compared with the general U.S. population, and the degree to which statistical analyses helped reduce bias ( IOM, 2011b ). Applying these principles is particularly important with respect to understanding abortion’s

long-term health effects, an area in which the relevant literature is vulnerable to bias (as discussed in Chapter 4 ).

The committee’s literature search strategy is described in Appendix D .

ORGANIZATION OF THE REPORT

Chapter 2 of this report describes the continuum of abortion care including current abortion methods (question 1 in the committee’s statement of task [ Box 1-1 ]); reviews the evidence on factors affecting their safety and quality, including expected side effects and possible complications (questions 2 and 3), necessary safeguards to manage medical emergencies (question 6), and provision of pain management (question 7); and presents the evidence on the types of facilities or facility factors necessary to provide safe and effective abortion care (question 4).

Chapter 3 summarizes the clinical skills that are integral to safe and high-quality abortion care according to the recommendations of leading national professional organizations and abortion training curricula (question 5).

Chapter 4 reviews research examining the long-term health effects of undergoing an abortion (question 2).

Finally, Chapter 5 presents the committee’s conclusions regarding the findings presented in the previous chapters, responding to each of the questions posed in the statement of task. Findings are statements of scientific evidence. The report’s conclusions are the committee’s inferences, interpretations, or generalizations drawn from the evidence.

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Abortion is a legal medical procedure that has been provided to millions of American women. Since the Institute of Medicine first reviewed the health implications of national legalized abortion in 1975, there has been a plethora of related scientific research, including well-designed randomized clinical trials, systematic reviews, and epidemiological studies examining abortion care. This research has focused on examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances. With this growing body of research, earlier abortion methods have been refined, discontinued, and new approaches have been developed.

The Safety and Quality of Abortion Care in the United States offers a comprehensive review of the current state of the science related to the provision of safe, high-quality abortion services in the United States. This report considers 8 research questions and presents conclusions, including gaps in research.

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Recent Case Highlights

The center for reproductive rights is litigating dozens of cases in state, national and regional courts against harmful laws that restrict access to abortion and other reproductive rights..

Below are updates on some of the Center’s current and recent cases.

Center Files Complaints Against Texas Hospitals for Denying Women Emergency Care for Ectopic Pregnancies

The Center’s complaints argue that by refusing to provide care to two women with life-threatening ectopic pregnancies, the hospitals violated the Emergency Medical Treatment and Labor Act (EMTALA), which requires hospitals to provide “stabilizing” treatment.

Read more here.

Court Rules Native Hawaiian Midwives Can Resume Providing Care

Native Hawaiian midwives will be able to resume pregnancy and birth care in their communities for now after a  state court ruled  to temporarily block part of the state’s midwifery restriction law. The July 23 ruling came in Kahoʻohanohano v. State of Hawaiʻi , a case brought by the Center and its partners to challenge the law and defend reproductive autonomy.

Kansas Supreme Court Reaffirms Right to Abortion Under State Constitution

The Kansas Supreme Court reaffirmed on July 5 that the state constitution protects the right to abortion, striking down several abortion restrictions challenged by the Center for Reproductive Rights on behalf of Kansas abortion providers. The decision comes over four years after the court recognized that the state constitution protects the right to abortion —and nearly two years after Kansans voted to protect that right.

U.S. Supreme Court Refuses to Say Whether Hospitals Must Provide Stabilizing Abortion Care

The U.S. Supreme Court on June 27 refused to say whether federal law requires hospitals to provide stabilizing abortion care. The case involved a challenge by the U.S. Department of Justice to Idaho’s near-total abortion ban, which conflicts with the Emergency Medical Treatment and Labor Act (EMTALA)—a long-time federal law that requires hospital emergency rooms to provide “stabilizing treatment,” including emergency abortion care. The Court dismissed the case and reinstated a lower court ruling blocking Idaho’s abortion ban to the extent that it conflicts with EMTALA. The Center submitted  an amicus brief  in the case,  Idaho v. United States and Moyle et al. v. United States .

Michigan Abortion Restrictions Blocked by Court

A Michigan state court temporarily blocked three state abortion restrictions on June 25. The ruling came in a Center case filed February 2024, which asserts that the three restrictions—including a mandatory waiting period, a biased counseling requirement, and a prohibition on advanced practice clinicians providing abortion care—violate Michigan’s Reproductive Freedom for All constitutional amendment. The laws will remain blocked as the case proceeds.

Access to Abortion Medication Remains Unchanged After Ruling by the U.S. Supreme Court

Access to a widely used abortion medication remains unchanged after the  U.S. Supreme Court ruled  on June 13 that the plaintiffs suing the Food and Drug Administration (FDA) did not have standing to bring the case. The ruling in  Alliance for Hippocratic Medicine v. FDA  allows mifepristone to remain accessible through telemedicine and pharmacies—distribution permitted under the FDA’s recent actions to expand access to the drug. In deciding the case on the issue of standing, the Court did not weigh in on the merits of the case . The Center and its partners submitted an  amicus brief  in this case in support of the FDA’s actions.

Read about the Center’s medical exceptions cases.

Medical Exceptions to U.S. State Abortion Bans

Representing women denied abortion care despite facing severe and dangerous pregnancy complications, the Center seeks to clarify medical exceptions to U.S. state laws that have outlawed abortion and put health, lives and fertility at risk.

Texas Supreme Court Rules Against Women Denied Abortion Care

In a May 31 ruling, the Texas Supreme Court refused to clarify the exceptions to the state’s abortion bans and rejected claims brought by 20 women who were denied abortion care despite facing dire pregnancy complications. The decision in Zurawski v. State of Texas largely ignored the women who filed the case and failed to clarify when physicians can use their own medical judgement to provide abortion care without fear of prosecution. “This ruling means that pregnant Texans will continue to suffer because they can’t access the medical care they desperately need,” said Molly Duane, senior staff attorney at the Center.

Lawsuit Challenges Kansas Law Seeking Patients’ Reasons for Their Abortions

The Center and Planned Parenthood filed a legal challenge on May 20 to a new Kansas law that would force providers to report to the state patients’ reasons for seeking abortion care. The lawsuit asserts that the law, due to take effect July 1, directly interferes with Kansans’ bodily autonomy and their fundamental right to make their own decisions about health care, and that it violates patient privacy and jeopardizes provider-patient relationships. The lawsuit is asking the court to add this challenge to an ongoing case challenging other Kansas abortion restrictions.

U.S. Supreme Court Hears Its Second Major Abortion Case of the Term

The  U.S. Supreme Court  heard oral arguments on April 24 in a case that could deny pregnant patients access to emergency medical care and further upend abortion access across the country. The dispute concerns the State of Idaho’s near-total abortion ban, which conflicts with the Emergency Medical Treatment and Labor Act (EMTALA)—a federal law that requires hospitals to provide “stabilizing treatment” to patients seeking care in emergency rooms. The Center submitted an  amicus brief   in the case on behalf of pregnant women in states with abortion bans who were denied or delayed stabilizing abortion care while experiencing obstetrical emergencies. 

Honduras’s Abortion Ban Being Challenged at the UN Human Rights Committee

The Center and the Centro de Derechos de Mujeres (CDM) are challenging Honduras’s total abortion ban in a case involving an indigenous Honduran woman who became pregnant as a result of rape—then was forced to give birth after being denied emergency contraception and abortion care. The case marks the first time Honduras has been brought before the UN for its total abortion ban.

Learn about cases with global impact.

Landmark Cases

Find out about court rulings secured by the Center that have transformed the landscape of reproductive health and rights for people around the world.

Hearing Held in Tennessee “Medical Exceptions” Case

A hearing in Blackmon v. State of Tennessee , which challenges the state’s total abortion ban as applied to pregnant people with emergent medical conditions, was held April 4 at the Tennessee Twelfth Judicial District Court. 

View photos and media coverage here.

Florida Supreme Court Allows State to Ban Abortion

The Florida Supreme Court on April 1 overturned decades of precedent and ruled that the Florida constitution’s explicit right to privacy no longer protects abortion rights. By upholding the state’s 15-week abortion ban, the Court also cleared the way for its six-week ban to take effect. 

U.S. Supreme Court Hears Case That Threatens Access to Abortion Medication

The U.S. Supreme Court heard arguments March 26 in Alliance for Hippocratic Medicine v. FDA , a case filed by anti-abortion advocates challenging the FDA’s approval of the abortion drug mifepristone and seeking to remove it from the market nationwide.

Kenya Court of Appeal Affirms Right to Respectful Maternal Health Care

In a significant victory for all Kenyans, the Court of Appeal of Kenya affirmed the right to respectful maternal health care in the case of Josephine Majani—a pregnant woman who was physically and verbally abused by hospital staff, and left to deliver her baby on a concrete hospital floor. The  Court’s decision , issued February 23, upheld a landmark 2018 judgment by the Kenyan High Court defending the human rights of Majani in the case, which was brought by the Center.

Center Sues Hawaiʻi to Protect Midwifery Care

To restore access to safe, respectful, and culturally informed maternal care in Hawaiʻi communities, the Center and its partners filed a lawsuit on February 27 asking a state court to block a midwifery restriction law. The law is preventing pregnant people from receiving pregnancy and birth care from trusted, skilled midwives and has been particularly devastating for Native Hawaiian midwifery practitioners and families of color. 

Center Sues Michigan to Align Abortion Laws with State’s Reproductive Freedom Amendment

To help ensure that Michigan’s abortion laws align with the amendment approved by voters in 2022 to enshrine reproductive freedom in the state’s constitution, the Center filed a lawsuit on February 6 challenging three burdensome state abortion restrictions still on the books.  “ With this lawsuit, we hope to eliminate archaic and harmful restrictions that are outright contrary to the RFFA and help ensure the state’s laws reflect the will of Michigan voters,” said Rabia Muqaddam, senior staff attorney at the Center.

Center and Partners Warn SCOTUS About “Junk Science” in Medication Abortion Case

An amicus brief submitted January 30 to the U.S. Supreme Court by the Center, the American Civil Liberties Union, and The Lawyering Project in support of the FDA’s 2016 and 2021 actions on mifepristone outlines how the lower courts, in rejecting the robust scientific basis for the FDA’s actions, relied on “patently unreliable witnesses” and “ideologically tainted junk science” in their rulings. The brief was filed January 30 in Alliance for Hippocratic Medicine v. FDA . The case—which threatens access to the abortion medication nationwide—will be argued at the Supreme Court on March 26. 

Read more on the brief and the case .

Explore our cases in depth.

Case Archive

Index of the Center’s court cases by year, region and issue.

North Dakota Court Denies Request to Block Abortion Ban While Case Proceeds

In a preliminary ruling on January 23, a North Dakota state court  denied the Center’s request to block the state’s abortion ban in situations where an abortion is necessary to preserve the life or health of a pregnant person. The court did not address the constitutional questions that are the focus of the case and will issue a final ruling after a hearing on the merits of the case. In March 2023, the North Dakota Supreme Court blocked the state’s “trigger ban” as a violation of the state’s constitution. The following month, state lawmakers passed another total abortion ban, which is the law now at issue in the case.

More Women Denied Abortion Care Join Case Against Tennessee

On January 8, 2024, four more women joined the Center’s lawsuit against Tennessee, Blackmon v. State of Tennessee , after being denied medically necessary abortion care for their severe and dangerous pregnancy complications. There are now nine plaintiffs in the case, which challenges Tennessee’s total abortion ban as applied to pregnant people with emergent medical conditions. The Center also asked the court for a temporary injunction, which would immediately block Tennessee’s abortion ban as it applies to dangerous pregnancy complications while the case proceeds.

Idaho “Medical Exceptions” Case to Continue After Court Rejects State’s Motion to Dismiss

An Idaho Court on December 29, 2023 rejected the state’s motion to dismiss Adkins v. State of Idaho , a case challenging the limited scope of the medical exceptions to Idaho’s two abortion bans: a total trigger ban and a “vigilante”-style six-week ban. The court’s ruling allows the case to proceed. The case was brought on behalf of four women who were denied abortion care despite facing severe pregnancy complications; two Idaho physicians who provide obstetrical care; and a professional membership organization consisting of Idaho physicians, medical residents and medical students.

Supreme Court Will Hear Case That Could Undermine Abortion Pill Access Nationwide

The U.S. Supreme Court agreed on December 13, 2023 to take up Alliance for Hippocratic Medicine v. FDA , a case filed by anti-abortion advocates challenging the FDA’s approval of the abortion drug mifepristone and seeking to remove it from the market nationwide. Arguments have been scheduled for March 26. The case reaches the Supreme Court after an appellate court partially upheld a lower court ruling attempting to reinstate burdensome pre-2016 restrictions on mifepristone that make it much harder to access. That order is currently blocked and will remain blocked until the Supreme Court rules, likely in June 2024.

Texas Supreme Court Denies Woman’s Request for Emergency Abortion Care

The Texas Supreme Court ruled on December 11, 2023 to deny a pregnant woman’s request for emergency abortion care in the state. The plaintiff, Kate Cox, recently received confirmation that her pregnancy had Trisomy 18 and had no chance of survival. She was warned by her OB-GYN and MFN specialist that continuing to carry the pregnancy to term could jeopardize her health and future fertility. The Center filed the case, Cox v. Texas , on December 5, asking a state court to temporarily block Texas’s abortion bans so Cox was able to obtain the urgent care she needed to avoid the dangerous risks of being forced to stay pregnant.

Center Argues “Medical Exceptions” Case at the Texas Supreme Court

On November 28, 2023, the Center argued at the Texas Supreme Court to urge the court to uphold an  injunction issued  in August by a Texas district judge that the state’s abortion bans do not apply to patients with dangerous pregnancy complications. The ruling, which was appealed by Texas, also clarified that doctors can use their good-faith medical judgment to determine when to provide abortion care in those situations. The case, Zurawski v. State of Te xas , was brought on behalf of Texas physicians and women denied abortion care despite facing dangerous pregnancy complications.

Kansas State Court Blocks Abortion Restrictions

Although Kansas voters overwhelmingly rejected efforts to eliminate the fundamental right to abortion from the state constitution in 2022, state lawmakers enacted several onerous, harmful abortion restrictions that diminished access to care. On October 30, 2023, a Kansas state court judge blocked those restrictions, which were challenged by the Center and its partners in a lawsuit brought in June on behalf of Kansas abortion providers. The case argued that the restrictions violated the state constitution, including the rights to abortion and free speech.

Georgia Supreme Court Allows Six-Week Abortion Ban to Remain in Effect

On October 24, 2023, the Georgia Supreme Court ruled to allow the state’s law banning abortion after approximately six weeks of pregnancy to remain in effect, reversing a lower court decision that struck down the law.

The lower court had ruled that since the Georgia Constitution prohibits the legislature from passing laws that violate either the state or federal constitution, the abortion ban was void since it violated Roe v. Wade when it was enacted in 2019.

The case, SisterSong v. Georgia , will return to the trial court, which has not yet ruled on the remaining claims brought by the plaintiffs that the ban violates Georgians’ rights to privacy and equal protection under the state Constitution.

Court Blocks Montana Clinic Licensing Law

On September 27, 2023, a court blocked a Montana law challenged by the Center that requires abortion clinics to be licensed and the state to issue regulations detailing licensure requirements. Although the law was set to take effect October 1, in the three months since the law was enacted, the state has yet to even propose regulations, making it impossible for clinics to comply by the effective date.

Kenyan Court Exonerates Mother and Health Care Provider From Abortion Charges

After a five-year court battle, a health care provider and the mother of an adolescent girl—represented by the Center and the Reproductive Health Network of Kenya (RHNK)—were cleared of charges of procuring an abortion by a court in Makadara, Kenya. The September 25, 2023 dismissal of the case, Republic v. Samson Mwita & Grace Wanjiku , aligns with earlier court rulings in Kenya declaring that it is illegal to arrest and prosecute abortion patients and providers, and it sends a clear message affirming abortion as a health care right.

Another Challenge to South Carolina Abortion Ban

The Center and its partners, on behalf of abortion providers in the state, filed a new challenge to South Carolina’s six-week abortion ban . The lawsuit, filed September 14, 2023, asks the South Carolina Supreme Court to resolve ambiguity raised in its August decision that upheld the ban.

“Medical Emergency” Exceptions Complaints Filed in Three More States

Expanding its work on behalf of patients denied abortion care despite severe and dangerous pregnancy complications, on September 12, 2023, the Center filed complaints in Idaho, Tennessee and Oklahoma. The complaints seek to ensure that pregnant people in such dire situations can access abortion care and that doctors have clarity on “medical emergency” exceptions in their state’s abortion bans.

South Carolina Supreme Court Upholds Abortion Ban Almost Identical to One it Threw Out in January

After the makeup of the court changed, the South Carolina Supreme Court on August 23, 2023, upheld a law banning abortion at approximately six weeks of pregnancy. The ban is almost identical to the one it struck down in January and the ruling that will devastate abortion access in the state and throughout the region.

Court Denies Center’s Request to Ensure Access to Abortion Drug in Three States

On August 21, 2023, a federal court in Virginia denied the Center’s request for a preliminary injunction that would have protected access to the abortion pill mifepristone in Virginia, Montana, and Kansas.  The Center filed the request in Whole Woman’s Health Alliance v. FDA (WWH v. FDA) in May seeking to buttress the current access to mifepristone in line with a decision issued by a Washington court applicable to 17 states and D.C. In its ruling in WWH v. FDA , the court acknowledged the safety and importance of mifepristone, and the case will proceed in the trial court.

Access to mifepristone is threatened by an April 7 ruling by a Texas federal court in a separate case, Alliance for Hippocratic Medicine v. FDA , that attempted to block the FDA’s long-standing approval  of the drug. The ruling in WWH v. FDA came days after the Fifth Circuit Court of Appeals upheld in large part the Texas court’s ruling. (The Fifth Circuit ruling has not taken effect due to a U.S. Supreme Court stay, and the Government has asserted that it will appeal.)

Texas Ruling to Allow Abortions for Severe Pregnancy Complications is Blocked While Appeals Proceed

In a ruling August 4, 2023, on Zurawski v. State of Texas , a Texas district judge issued an injunction blocking Texas’s abortion bans as they apply to dangerous pregnancy complications, clarifying that doctors can use their own medical judgment to determine when to provide abortion care in emergency situations. The ruling also denied the state’s request to throw out the case, and it found S.B. 8—Texas’s citizen-enforced abortion ban—unconstitutional. The judge recognized in her ruling that the women who brought this case should have been given abortions.

The state immediately appealed the ruling directly to the Texas Supreme Court, putting the injunction on hold while appeals proceed. The Texas Supreme Court has set oral argument for November 28. 

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Hearing in zurawski v. state of texas.

A Texas state court will hear testimony and arguments July 19-20, 2023, in  Zurawski v. State of Texas , a lawsuit filed by the Center on behalf of Texas women denied abortion care despite facing severe pregnancy complications and risks to their health, fertility and lives. 

The hearing is scheduled for Wednesday, July 19 and Thursday, July 20 starting at 9 a.m. CT/10:00 a.m. ET at the Travis County Civil & Family Courts Facility in Austin. The Center will hold a press briefing, which will be  streamed live on Facebook , immediately after the hearing Wednesday.

Five plaintiffs in the case—four women denied abortions and an OB-GYN—and two experts in obstetrics and emergency medicine are scheduled to testify.  

Center Challenges Kansas Restrictions on Abortion Access

Even though abortion is protected as a fundamental right under the Kansas constitution, state lawmakers have singled out abortion providers and patients with medically unnecessary and harmful restrictions to make access to care more difficult. On behalf of Kansas abortion providers, on June 6, 2023, the Center and its partner filed a lawsuit in state court challenging several restrictions scheduled to take effect as early as July 1.

The restrictions include measures requiring providers to relay to patients at least five times that a medication abortion can be “reversed”—a false, and potentially dangerous, claim unsupported by scientific evidence; a requirement that patients receive inaccurate state-mandated information, including medically unfounded statements that abortion poses a “risk of premature birth in future pregnancies” and “risk of breast cancer;” and other rules to delay care.

Oklahoma Supreme Court Ruling Affirms Right to Life-Saving Abortion Care

On May 31, 2023, the Oklahoma Supreme Court  struck down  two citizen-enforced abortion bans mirroring Texas’ S.B. 8., affirming the court’s recent decision that the state constitution  protects the right to abortion in life-threatening situations . The high court confirmed that doctors must be able to use their medical judgement to determine whether to provide an abortion when a patient’s life is at risk. While abortion remains largely unavailable in Oklahoma and the state’s pre- Roe ban remains in effect, the ruling ensures that Oklahoma’s vigilante bans cannot hold doctors back from providing life-saving care.

Montana Supreme Court Strikes Down Law Prohibiting APRNs from Providing Abortion Care

On May 12, 2023, the Montana Supreme Court permanently struck down a law that prohibited advanced practice registered nurses (APRNs) from providing abortion care. In its unanimous decision, the Montana Supreme Court reaffirmed that the state constitution guarantees the right of Montanans to seek abortion care from a qualified healthcare provider of their choice. “Abortions remain one of the safest procedures when performed collectively by health care providers, including APRNs,” the justices wrote. The ruling expands the eligible pool of abortion providers in the state.

Medicaid Rule Limiting Abortion Access in Montana Is Blocked After Lawsuit by the Center and Partners

A Montana administrative rule that would have effectively eliminated abortion access for most Montanans insured through Medicaid was blocked May 1, 2023, in response to a  lawsuit filed April 28  by the Center and its partners. The lawsuit argues that the rule, which introduces restrictive new requirements for Medicaid-eligible Montanans seeking abortion care, violates the Montana Constitution. A Lewis and Clark County District Court judge issued a temporary restraining order   blocking the rule, which was to be enforced starting May 8.

Oklahoma Supreme Court Rules the Right to Abortion is Protected in Life-Threatening Situations

On March 21, 2023, the Oklahoma Supreme Court ruled that the state constitution protects the right to abortion in life-threatening situations, but declined to rule whether its constitution protects a broader right to abortion outside of those circumstances. In its ruling in  Oklahoma Call for Reproductive Justice v. Drummond , the court wrote that “the Oklahoma Constitution creates an inherent right of a pregnant woman to terminate a pregnancy when necessary to preserve her life” and struck down one of two total criminal abortion bans. The other ban remains in force, leaving abortion care unavailable for most Oklahomans.

Abortion Remains Legal in North Dakota as Court Blocks Total Ban

On March 16, 2023, the North Dakota Supreme Court ruled that the state’s total abortion ban will remain blocked, allowing abortion care to continue while the case proceeds in a lower court. The ruling came in a case filed in July by the Center and its partners on behalf of abortion providers, which argues that the ban is unconstitutional under the state’s constitution. In its ruling in Wrigley v. Romanick et al ., the North Dakota Supreme Court found that the challenge to the ban is likely to succeed.

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A case report of spontaneous abortion caused by Brucella melitensis biovar 3

• Hong-Xia Yang 1 , 3 ,
• Jun-Jun Feng 2 ,
• Qiu-Xiang Zhang 1 ,
• Rui-E Hao 1 ,
• Su-Xia Yao 1 ,
• Rong Zhao 1 ,
• Dong-Ri Piao 3 ,
• Bu-Yun Cui 3 &
• Hai Jiang 3  

Infectious Diseases of Poverty volume  7 , Article number:  31 ( 2018 ) Cite this article

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Brucellosis is a worldwide zoonotic disease caused by Brucella spp. Brucella invades the body through the skin mucosa, digestive tract, and respiratory tract. However, only a few studies on human spontaneous abortion attributable to Brucella have been reported. In this work, the patient living in Shanxi Province in China who had suffered a spontaneous abortion was underwent pathogen detection and Brucella melitensis biovar 3 was identified.

Case presentation

The patient in this study was 22 years old. On July 16, 2015, she was admitted to Shanxi Grand Hospital, Shanxi Province, China because of one day of vaginal bleeding and three days of abdominal distension accompanied by fever after five months of amenorrhea. A serum tube agglutination test for brucellosis and blood culture were positive. At the time of discharge, she was prescribed oral doxycycline (100 mg/dose, twice a day) and rifampicin (600 mg/dose, once daily) for 6 weeks as recommended by the World Health Organization (WHO). No recurrence was observed during the six months of follow-up after the cessation of antibiotic treatment.

Conclusions

This is the first reported case of miscarriage resulting from Brucella melitensis biovar 3 isolated from a pregnant woman who was infected through unpasteurized milk in China. Brucellosis infection was overlooked in the Maternity Hospital because of physician unawareness. Early recognition and prompt treatment of brucellosis infection are crucial for a successful outcome in pregnancy.

Multilingual abstract

Please see Additional file  1 for translation of the abstract into the five official working languages of the United Nations.

Brucellosis is a worldwide zoonotic disease caused by Brucella spp. The Law of the People’s Republic of China on Prevention and Treatment of Infectious Diseases classifies it as a Class B infection. Brucella invades the body through the skin mucosa, digestive tract, and respiratory tract. Livestock infected with Brucella often undergo spontaneous abortion and infertility, and have low reproductive and survival rates. Humans infected with Brucella mainly manifest fever, sweating, fatigue, and arthralgia, and can also suffer damages to the nervous, circulatory, and reproductive systems [ 1 ]. However, only few studies on spontaneous abortion attributable to Brucella have been reported. In this work, a patient living in Shanxi Province in China who had suffered a spontaneous abortion underwent pathogen detection to analyse the genetic characteristics of the spontaneous abortion-related Brucella strain. This helps to provide a scientific basis for the prevention and control of Brucella infection in pregnant women.

The patient in this study was 22 years old. She was admitted to Shanxi Grand Hospital, Shanxi Province, China, on July 16, 2015 because of one day of vaginal bleeding and three days of abdominal distension accompanied by fever after five months of amenorrhea. This patient had a history of regular menstruation, and her last menstrual period had been on February 20, 2015. An immunoassay showed her urine to be positive for human chronic gonadotrophin. The patient had no fever during early pregnancy and did not have a history of exposure to toxic, harmful, or radioactive materials. Down’s syndrome screening performed as part of a regular second-semester prenatal checkup showed no obvious fetal abnormality. The patient had abdominal distension with fever and received anti-infective treatment at a local hospital three days before coming to Shanxi Grand Hospital. One day before coming to Shanxi Grand Hospital, she suffered vaginal bleeding. She was given conventional tocolytic treatment, but the outcome was poor. The patient was examined after hospital admission and had a body temperature of 39 °C, pulse rate of 120 beats/min, breath rate of 21 breaths/min, and blood pressure of 90/53 mmHg, but no cardiopulmonary or abdominal abnormalities. Specialist examinations showed minor abdominal swelling, irregular contraction of the uterus palpable at two fingers under the uterus and umbilicus, and a small amount of vaginal bleeding. The fetal membrane was slightly ruptured, and the fetal heart rate was 170–180 beats/min. A complete blood count showed 16.6 × 10 9 /L white blood cells, 78.4% neutrophils, 16.5% lymphocytes, 4.9% monocytes, 3.63 × 10 12 /L erythrocytes, 106 g/L hemoglobin, 202.1 × 10 9  g/L platelets, and 102.16 mg/L C reaction protein. Intravenous ceftriaxone (2 g/d), 25% magnesium sulfate, and antipyretic treatments were administered to the patient after her admission to Shanxi Grand Hospital, but the patient had a miscarriage and vaginal delivery of a female fetus on July 19. Her body temperature continued to fluctuate after admission, increasing to 39.3 °C the afternoon of July 19. Further questions about the patient’s medical history showed that this patient had sheep at home but never came into direct contact with them. However, she had begun to drink unpasteurized goat milk during her fourth month of pregnancy and was thus suspected of having Brucella infection. A serum tube agglutination test (SAT) for brucellosis and blood culture were immediately performed. The SAT result was 1:800, confirming brucellosis. This patient was given antibiotic treatment for three consecutive days. She was discharged from the hospital on July 24 because the fever stopped. At the time of discharge, she was prescribed oral doxycycline (100 mg/dose, twice a day) and rifampicin (600 mg/dose, once daily) for 6 weeks as recommended by the World Health Organization (WHO). No recurrence was observed during the six months of follow-up after the cessation of antibiotic treatment. The onset, diagnosis, and treatment of the disease in this patient are shown in Fig.  1 .

The onset and outcome of disease, diagnosis, and treatment

Serological testing

The diagnosis of brucellosis was based on the serum standard tube agglutination test (SAT). The SAT result was 1:800.

Pathogen detection

Five milliliters of venous blood from the patient were collected and injected into a two-phase culture flask for culture. After detecting bacterial growth in the culture, traditional biological methods were used for the isolation and identification of the bacteria [ 2 ]. With the reference to the standard strain B. melitensis 16 M, colony morphology, Gram stain reaction, CO 2 requirements, H 2 S production, inhibition of growth by basic Fuchsin and Thionin, agglutination with monospecific antisera, and phage lysis testing were performed. Serum and bacteriophage were provided by the Brucellosis Laboratory, National Institute for Communicable Disease Control and Prevention, and the Chinese Center for Disease Control and Prevention.

Specific sequences of the 16 MLVA primers are described in previous work [ 3 ]. The reaction system for genotyping included 10 μl 2 ×  Taq PCR Mastermix, 0.4 μl each of the 10 pmol/μl primers, and 1 μl DNA template, with sterile distilled water to a total volume of 20 μl. The amplification conditions were: 95 °C denaturation; 40 cycles of denaturation at 95 °C for 30 s, annealing at 60 °C for 30 s, and elongation at 72 °C for 30 s. Amplification products were analysed by microsatellite sequencing to convert the repeated unit according to the size of the PCR products. BioNumerics (Version 5.0) software was used for cluster analysis to perform an online comparison between the typing and the Brucella database. Nucleic acid extraction was performed using a bacterial whole genome nucleic acid extraction kit [Tiangen Biotech (Beijing) Co., Ltd., Beijing, China]. MLVA primers were synthesized by Sangon Biotech (Shanghai) Co., Ltd. (Shanghai, China), and STR microsatellite sequencing was performed by Tianyi HuiYuan Biotech Co., Ltd. (Beijing, China).

Seven housekeeper genes ( dnaK , gyrB , trpE , aroA , cobQ , gap , and glk ), one outer membrane protein gene ( omp25 ), and one intergenic region int-hyp were used as the target genes of MLST for synthesis of the corresponding primers and for PCR [ 4 ]. PCR products were purified and subjected to bidirectional sequencing. The sequencing was completed by Tianyi HuiYuan Biotech Co., Ltd.. The tested sequences were compared to the sequences of allelic genotypes of the corresponding genes. The MLST online tool ( http://pubmlst.org/perl/mlstanalyse/mlstan-alyse.=pubmlst ) was used to analyse the alleles in the sequence.

Five milliliters of whole blood were extracted from the patient on July 20 and were found to have bacterial growth on July 26. The colonies were collarless and transparent, round in shape, and with smooth surfaces. Conventional identification by microscopy showed colonies to be gram-negative short bacilli that did not produce hydrogen sulfide and had positive monospecific antisera agglutination. The basic Fuchsin and Thionin tests and the bacteriophage Bk test were positive, while the Tb and Wb tests were negative, indicating that the colony was B. melitensis biovar 3, commonly found in sheep and goats. For MLVA-16 typing (Additional file 2 : Table S1), panel 1 showed the sample to be a type 42 (1–5–3-13-2-2-3-2), belonging to the Eastern Mediterranean type; panel 2 typing showed the sample to be a 4–40–8-4-4-3-8-5, which was completely identical to the goat type 3 Brucella (2012167) strain in MLVA genotyping [ 5 ]. For MLST, the ST allele spectrum was 3–2–3-2-1-5-3-8-2, and MLST sequence typing was ST8 (Additional file 3 ) , which is a common sequence type found in China [ 6 ].

Discussion and conclusions

Spontaneous abortion is a common complication of brucellosis in animals. The infection tends to localize to the placenta, which is associated with erythritol (a bovine growth stimulant). Although erythritol is not present in human placental tissues, brucellosis can lead to spontaneous abortion in human, especially in early pregnancy [ 7 ]. Khan et al. studied 92 cases of brucellosis during pregnancy in a hospital in Saudi Arabia during 1983–1995 and found a rate of spontaneous abortion in the first and second trimesters of 43% [ 8 ]. Roushan et al. studied 19 cases of brucellosis during pregnancy in the Babol region in Iran and observed 10 cases of spontaneous abortion, accounting for 53% of all cases [ 9 ]. Al-Tawfiq et al. reviewed the literature covering brucellosis during pregnancy from 1954 to 2011 and found that the incidence of spontaneous abortion and stillbirth among 430 cases ranged from 31 to 46%, which was much higher than in other pregnant women [ 10 ]. However, Gulsun et al. conducted a case-control study on brucellosis during pregnancy from 2003 to 2010 and showed no significant differences in fetal congenital malformations and/or mortality between patients infected with Brucella and the control group, but Brucella did cause premature birth and low birth weight [ 11 ]. The present case study of brucellosis-induced spontaneous abortion in the second trimester provides clinical evidence for miscarriage caused by Brucella infection. The B. melitensis biovar 3 isolated from the blood culture belonged to the dominant strain found in Shanxi Province. Further study of the mechanism underlying miscarriage caused by Brucella will be necessary, and genome sequencing is in progress.

Milk from cattle, goats, and other animals with brucellosis contains large numbers of Brucella . It is possible to acquire brucellosis through the consumption of unpasteurized milk and dairy products [ 12 ]. The symptoms of brucellosis are atypical, and cases are easily misdiagnosed. In this study, the patient was treated in our hospital due to miscarriage and atypical symptoms of brucellosis. However, during her hospitalization, the patient did not immediately mention consuming goat’s milk. Although our staff had been actively looking for the cause of the fever, we only suspected Brucella infection after the patient’s miscarriage. We confirmed the diagnosis five days after her admission to the hospital.

It is difficult for antibiotics and antibodies to enter cells, so single-drug therapy cannot completely eliminate the bacteria. The WHO Expert Committee recommends brucellosis be treated using a combination of doxycycline (200 mg oral admission daily) and rifampicin (600–900 mg oral admission daily) for six weeks [ 7 ]. In this study, the patient was given combination therapy of doxycycline and rifampicin for six weeks and showed no recurrence during follow-up. The basic factor in the treatment of brucellosis is to ensure the effectiveness and adequate course of antibiotic treatment. Patients are urged to complete their full course.

In summary, this is the first reported case of miscarriage resulted from Brucella melitensis biovar 3 isolated from a pregnant woman who was infected through unpasteurized milk in China. Brucellosis infection was easily overlooked in the Maternity Hospital because of physician unawareness. The early recognition and prompt treatment of brucellosis infection are crucial for a successful outcome in pregnancy.

Abbreviations

Multilocus sequencing typing

Multiple-locus variable number tandem repeat analysis

Sequencing typing

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Acknowledgements

We are grateful to Hong-Yan Zhao and Guo-Zhong Tian for experimental guidance.

This study was supported by the Science and Technology Project of the Shanxi Province Health and Family Planning Commission (No. 2011077) and the National Natural Science Foundation of China (No. 81271900). The funders contributed to the study design and data collection.

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All data generated or analysed during this study are included in this published article.

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Disease Inspection Laboratory, Shanxi Center for Disease Control and Prevention, Taiyuan, China

Hong-Xia Yang, Qiu-Xiang Zhang, Rui-E Hao, Su-Xia Yao & Rong Zhao

Clinical Laboratory, Shanxi Dayi Hospital, Taiyuan, China

Jun-Jun Feng

State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China

Hong-Xia Yang, Dong-Ri Piao, Bu-Yun Cui & Hai Jiang

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Contributions

H-X Y performed the majority of the pathogen detection testing, coordinated all work related to the study, performed data analysis, drafted the manuscript, and participated in the design of the study; J-J F collected the case clinical data; R-E H, S-X Y, R Z, and D-R P performed MLVA and MLST and participated in data analysis; B-Y C participated in the design of the study and critically reviewed the manuscript. H J participated in the design of the study and managed the project. All of the authors read and approved the final manuscript.

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Correspondence to Hai Jiang .

Ethics declarations

Ethics approval and consent to participate.

This research was carried out according to the principles of the Declaration of Helsinki and was approved by the Ethics Committees of the National Institute for Communicable Disease Control and Prevention and the Chinese Center for Disease Control and Prevention (No.: ICDC-2014005). No animal work was carried out as part of this study.

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The authors declare that they have no competing interests.

Additional files

Additional file 1:.

Multilingual abstracts in the five official working languages of the United Nations. (PDF 502 kb)

Additional file 2:

Table S1. Product size and repeat unit of 16 loci. (DOCX 68 kb)

Additional file 3:

ST sequence data of 9 genes. (DOCX 17 kb)

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Yang, HX., Feng, JJ., Zhang, QX. et al. A case report of spontaneous abortion caused by Brucella melitensis biovar 3. Infect Dis Poverty 7 , 31 (2018). https://doi.org/10.1186/s40249-018-0411-x

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• We don't hold a waiting list, if we are at the points of emergencies only, the patient doesn't need an emergency appointment and there are no pre-bookable appointments available, the patient has the option to put in an econsult the next day, call for an appointment the next day or if they feel it can't wait contact 111, IUC etc. This is the one bit of our system that I don't like as I would like a solution that doesn't require a patient to call back. The reason we don't add them to the list for the next day is that a sig proportion never call back and we can't fill up the following days capacity as the system fails. 
• We do use apex Edenbridge to monitor our appointments, as I think it would be hard to challenge our approach if we are also demonstrating that we are offering more than the average number of appointments per 1000 patients per week than the other practices in our ICB. 

This has made a huge difference to our clinicians. We spend longer with patients but it is based on a realistic rota which also enables us to do the clinical administrative work and complete all tasks in the allotted time so I no longer work 2 sessions in a day which actually take 11 hours to complete, this use to be the case. 

Case study: Standard and on-call days

Standard gp day.

Morning 

• 12 x 15mins consultations (face-to-face or phone) - split between advance and on-the-day. 
• 2 x 15mins consultations for GPs to book into (eg. Telcon with DN or task necessitating them to initiate call to patient). 

Lunch 

• 1x visit maximum (unless at care home, where may be 2x).

Afternoon 

• 12 x 15mins consultations, as per morning.  

On-call GP day

• As per standard day. 
• As per standard day but ONLY visits if all others have a visit already (duty triages requests). 
• 6x 15mins advance-booked consultations. 
• 3x 15mins 111-bookable slots. 
• Rest of afternoon for admin, answering queries from reception and urgent (EOL/hot kids/DN calls), also reviews and actions any abnormal bloods/urgent scripts coming in after 5pm. 

Case study: Practice example using triage

This practice serves 20,000 patients in a deprived, multi-cultural population using a GP led total clinical triage called CAS (clinical assessment screen) GPs. 

• Patients access appointments via reception, telcon or accuRx. 
• GP appointments default to telephone: 11 telcons and 3 face-to-face per session. If more face-to-face sessions are needed, telcons are blocked.
• Slot types are either red (same day), amber (1 week), amber (2 weeks), or routine.
• AHPs such as ANPs/paramedics/MHP are used for face-to-face appointments only.
• CAS GPs have no booked appointments - they make clinical decisions on RAG rating of clinical triage and use F12 protocol to communicate this. Routine patients may go on a waiting list if there are not enough appointments.
• CAS screen is capped at either 3:30pm or when each CAS GP has clinically triaged 50 patients per session (which may happen earlier at 2pm). When the cap is reached, all on-line access is closed and patients are told it's urgent only, which are first triaged by care navigators and then CAS GP.  
• GPs much happier 
• Continuity much higher 
•  Complaints have gone up as patients don't like waiting when it's not urgent.

Case study: Fully online triage

Breakdown by day .

• 12 patient consultations every 4 hours (counted as one session). 
• Face-to-face majority, couple of phonically, and 2 GP Follow ups (mainly MH and continuity of care). 
• 13-minute appointments.  
• One third protected admin time. 
• 15-minute break per session worked.  

System was fully online triage:  

• initially Egerton and then switch to Accurx
• clinical triage by GP in the morning (previously did two sets of triage, am and pm, but this proved difficult to manage workload and demand, as too open ended and labour intensive in terms of GP time and resource)
• window for online triage forms open from 7.30am to 11.00am - clear communication to patients re timings (used to be open over the weekend and all day, but risky in terms of safety if people ignore the red flags, and demand management)
• closed earlier if capacity reached, or if staff sickness etc.

Capacity is mapped out, and a RAG (Red/Amber/Green) rating approach taken according to clinical prioritisation, patients with specific needs and vulnerabilities have alerts on system:  

• on the day urgent: red
• less urgent but not routine: amber (48 hours)
• routine - next available: green (safe to wait, no clinical urgency). 

Appointments capacity mapped out in terms of:

• clinicians 
• practice - in house 
• enhanced access - GP Fed - on the day evening and any the weekend (routine) 
• PCN: mole clinic, women's health, minor surgery, social prescriber, physio (this is in addition to the city wide FPOC physio)
• straight to physio (FPOC city wide offer) 
• external services eg Pharmacy first, minor ailments.  

We stopped the PCN MHPs, and reverted to direct practice ones as the MH trust offer didn't really address our needs.

Booking of appointments

• Patients are sent booking links to self-book face to face on the day via Accurx (this helps reduce DNAs as patients can pick the most convenient time). 
• Appointments can be booked in via telephone for nurse and bloods/smears etc (helps prevent inappropriate booking). 
• If patients are unable to use online triage, the forms are completed on their behalf by reception or direct booking into an appointment.  

In tandem with the above, we use an Oncall GP:  

• they have a lighter clinic in place, with empty slots for ad hoc queries  
• their capacity would be used only if the on the day capacity had been reached, and for those patients that could not wait  
• they would also deal with urgent docman (usually mental health or safe guarding. cases), third party queries and review urgent bloods that needed to be actioned for those clinicians that were not in  
• the workload of the on call has greatly reduced since the introduction of total triage ( I used to do the Mondays and art times would have 26 urgent consultations in addition to usual workload, from the morning!)
• if the urgent, moderately urgent and routine appointments are all used up patients are either signposted to other services or, if not appropriate, informed that they will be allocated an appointment once this becomes available
• all text messages including failed contacted have safety netting advice included with NHS111 contact information.  

Case study: A new system for patients

This example is from a practice that services 23.5k patients, semi-rural, deprived population with no UCC locally.

We are not quite down to 25 contacts a day yet but at 28 on routine days and 15 per session for on call clinicians (mix of GPs and ANPs).  

Some routine appointments are pre-bookable, some embargoed for on the day use (more embargoed on Mondays). 14 appointments per session, about half face to face although many of us convert telephone/online slots to face-to-face if needed. All appointments are fifteen minutes.

Triage hub 

2-3 clinicians per session in a triage hub with receptionists. 2 clinicians ‘on call’ seeing the urgent face to face appointments booked by the hub clinicians - 15-minute appointments.  

Can flex clinicians if needed to/from triage/on call.  

We switch off incoming electronic forms when the hub clinicians judge that we have no more slots to book into. Usually they go off around three pm but can be earlier or later depending on demand and clinical capacity. Patients can then ring in and will be triaged if emergency/directed to 111 if absolutely no capacity left.  

Recently we’ve changed so that if we are on maximum clinicians off for leave we load more on the day appointments.  

Separate appointments

We have separate twenty-minute appointments for coils, implants, first menopause appointments and joint injections. We have a GP with an hour blocked for visits (and visiting matrons) and one with an hour blocked to deal with the blood results of any clinician not in that day.  

Clinicians are generally happier than when we had unending duty demand. Patients objected at first but now seem to be mostly okay with the system. 

Help Center

5 Best Crisis Communication Case Studies and Examples

Cristina Hure

 on  Sep 6, 2024

in  Internal Communications

Today’s uncertain times increase the need for organizations to prepare for unexpected events. Explore these real-life examples of crisis communications case studies to protect your reputation and operations – in case fire lands on your doorstep one day! 

Every brand, no matter how big or small, will face challenges from time to time. These can range from minor issues like a typo in a marketing campaign to major crises with global implications. 

Some brands navigate these situations skillfully, while others struggle. Real-life crisis communication examples—including both best crisis communication examples and bad crisis communication examples—offer crucial insights into effective crisis communication strategies. 

Whether dealing with internal crisis communication examples or broader corporate crisis communication examples, studying case study crisis communication scenarios helps organizations develop a robust crisis communication plan that effectively responds to difficult circumstances. For internal communicators and HR leaders, the crisis communication case studies in this article serve as valuable lessons in the art and science of dealing with crises.

Unmissable employee comms

Always get your message across with contactmonkey., what is crisis communication.

Crisis communication involves the technologies, systems, and protocols that enable an organization to efficiently communicate during a crisis. This strategic communication function is designed to mitigate damage to the organization’s reputation by asserting control in situations that could potentially be chaotic and damaging. 

When communicators ensure consistent messaging, manage stakeholder expectations and maintain trust through transparency and prompt updates, effective crisis communication plays a critical role in mitigating damage.

How Does Internal Communications Play a Role in Crisis Communications?

In a crisis, internal communications are not just about damage control—they’re about safeguarding your organization’s most valuable asset: its people. Knowing what to do—and what to avoid—when managing an internal communications crisis can make all the difference in how your organization emerges on the other side.

As an internal communicator, your responsibilities go beyond fostering engagement and connection. You must also be prepared to respond swiftly and effectively when disaster strikes, demonstrating the importance of internal communications . Clear, consistent, and empathetic communication is essential in guiding employees through the turmoil, and ensuring that everyone understands the organization’s stance and next steps.

The insights below will help create a comprehensive crisis communication plan template to navigate crises with transparency, speed, and accountability.

Crisis Communication Best Practices

To handle crisis communications, communicators should adhere to key principles outlined in a wide-range of crisis communication case studies:

• Stay consistent with your message: Every message should align with the organization’s overall narrative. For instance, if transparency is a priority, all internal updates should reflect this value, as seen in corporate crisis communication examples.
• Practice what you preach: Deliver on promises. If safety measures are announced, promptly implement them to build trust—another common theme in many case study crisis communication examples.
• Balance speed with accuracy: Timing is key in a crisis, but so is accuracy. Rather than rushing to communicate incomplete information, prioritize getting the facts right. For example, if there’s an incident affecting operations, promptly acknowledge it, but follow up with detailed, accurate information as soon as it’s available. Successful crisis communication plans balance both speed with accuracy to maintain credibility.
• Lead with empathy: Recognize the emotional impact of a crisis on employees and tailor your communication to acknowledge their concerns. For instance, if layoffs are imminent, express understanding and support, offering resources like counseling or career transition services. Internal crisis communication examples show that addressing concerns compassionately can strengthen trust.

By following these principles, you can navigate crises more effectively and maintain the trust and confidence of your audiences. And, if you’re looking for more on this front, our internal communications best practices article can help. 

5 Best Crisis Communication Case Studies to Know for 2024

1. marriott: authentic leadership in times of crisis.

Authentic leadership goes beyond being just a buzzword—it’s about genuinely acting and communicating in ways that build trust and inspire loyalty. Arne Sorenson, CEO of Marriott International, exemplified this approach in a 6-minute video directed at employees, shareholders, and customers during the COVID-19 crisis. 

Following the video’s release, what exactly did Sorenson do to earn overwhelming praise? This crisis communication case study is a prime example of effective crisis communication:

Context: As the COVID-19 pandemic caused unprecedented disruptions to the travel and hospitality industry, Marriott International faced significant challenges, including drastic reductions in business, employee layoffs, and financial losses. Arne Sorenson’s video message became a key crisis communication case study by setting a benchmark for crisis communication strategies.

Analysis: Sorenson’s video was marked by its raw emotion, as he candidly acknowledged the severe impact of the pandemic on the company. He shared personal anecdotes, including his own battle with cancer, which humanized him and strengthened the message’s authenticity. As a prime example of crisis communications and effective planning, Sorenson communicated difficult decisions, such as employee layoffs, with empathy and transparency, helping to maintain trust and morale among Marriott employees.

Discussion: The video highlighted how authenticity in corporate crisis communication examples can strengthen organizational values and unity. By speaking openly about the challenges facing Marriott and his personal struggles, Sorenson connected with employees on a human level, which is often difficult to achieve in corporate communications.

Conclusion: This case study underscores the importance of transparency, emotional intelligence, and authenticity in crisis communication, providing valuable lessons for leaders in all industries.

Win at internal communications 

2. slack: honesty is the best policy when failures occur.

Effective crisis communication is about managing a message and building trust through honesty and transparency. Slack showed exactly how to do this during a service outage that left many users without access. Let’s take a look at the details behind Slack’s standout crisis management: 

Context: In February 2022, Slack, a widely used messaging platform, experienced a significant outage that left many users unable to access its services. The disruption was attributed to a configuration change that unexpectedly increased activity on the company’s database infrastructure, causing instability and downtime.

Analysis: Slack’s swift and transparent response serves as a strong crisis communication case study. The company posted updates on its status page approximately every 30 minutes, detailing its progress toward a solution and openly acknowledging any errors made during the process. Additionally, Slack used Twitter to keep users informed, using a tone that was both apologetic and sincere. This multi-channel approach ensured that users were kept in the loop throughout the five-hour disruption, demonstrating Slack’s commitment to honest and transparent communication. Discussion: By being open about the problem, promptly sharing updates, and acknowledging their missteps, Slack reinforced its reputation as a customer-focused company. Their communication strategy aligned with best practices by being timely, transparent, and empathetic, which are essential elements in maintaining trust and credibility during a crisis. Moreover, Slack’s decision to use multiple platforms—its status page for detailed updates and Twitter for real-time communication—ensured that a wide audience was reached.

Conclusion: As one of the best crisis communication examples, Slack’s handling of the 2022 outage is a compelling case study in crisis communication. Their approach illustrates the importance of transparency, timely updates, and multi-platform engagement in managing public perception and maintaining trust during a crisis. By being forthright about the situation and openly acknowledging their errors, Slack not only managed to preserve user trust but also set a strong example for other brands on how to communicate effectively in the face of adversity.

3. Cracker Barrel: No Response is a Response

When Cracker Barrel unexpectedly found itself at the center of a social media storm over the firing of an employee, many expected the company to respond swiftly. However, Cracker Barrel opted for an unconventional crisis communication approach by letting the internet frenzy unfold without any public comment. This approach demonstrated that sometimes silence can be an effective part of a crisis management plan . 

Our next case study explores how the brand’s decision to remain quiet during a viral crisis became a surprising example of how no response can be a powerful crisis communication strategy.

Context: In February 2017, Cracker Barrel faced a crisis when a customer named Bradley Reid publicly questioned why his wife, Nanette, was fired from her retail manager position after 11 years. His post on Cracker Barrel’s corporate website went viral, and the hashtag #JusticeforBradsWife began trending across social media. The situation quickly escalated, with over 17,000 signatures on a Change.org petition, altered Yelp and Google pages, and viral content on YouTube plus other platforms mocking the brand.

Analysis: Despite the growing public outcry and media attention, Cracker Barrel chose to remain silent. The company did not issue a public response, comment on the controversy, or acknowledge the online movement. While some brands and internet users capitalized on the situation for humor or publicity, Cracker Barrel’s silence became a notable aspect of the crisis.

Discussion: Cracker Barrel’s handling of the incident challenges traditional crisis communication techniques. While this strategy defied conventional wisdom, it ultimately had minimal impact on the brand’s core customer base, showcasing that an effective crisis communication plan can sometimes involve choosing not to engage. 

Conclusion: The key takeaway for brands is that while silence carries risk, it can also prevent further escalation, especially when the crisis is fueled primarily by online chatter rather than significant operational failures or ethical breaches. 💡 PRO TIP: While certain situations are better left to fizzle out on their own, some require an internal communications response and plan to strengthen customer relationships. Read our article on how internal communication impacts customer engagement to learn more.

Plan like a pro: 2024 Internal Communications Calendar

Your blueprint for meeting kpis., 4. johnson & johnson: immediate corrective action saves the day .

In 1982, Johnson & Johnson found itself at the heart of a public health crisis. Instead of deflecting blame, the company launched an immediate, transparent response that set a new benchmark for crisis management.

This crisis communication case study is now one of the most notable examples of crisis communication. Read on to find out how the company’s approach became a model for corporate crisis response worldwide.

Context: Johnson & Johnson faced a major crisis when seven people in Chicago died after consuming Tylenol capsules laced with cyanide. Despite evidence suggesting that the tampering occurred after the product reached store shelves, the company’s handling of the situation became a benchmark for effective crisis communication examples.

Analysis: Johnson & Johnson immediately took decisive action by halting all Tylenol advertising, issuing safety warnings, and sending 450,000 messages to healthcare facilities and stakeholders. The company maintained full transparency and did not attempt to downplay the situation, even expressing regret for not switching to tamper-proof packaging sooner.

Discussion: The company’s response set a standard for crisis management, emphasizing transparency, accountability, and swift action. Johnson & Johnson’s efforts were widely praised by the media and public, helping the Tylenol brand recover and setting a precedent for how companies handle similar situations. Conclusion: This crisis communication case study is considered one of the best examples of effective crisis management in corporate history. By prioritizing consumer safety, transparent communication, and taking immediate corrective action, the company not only reduced the impact of the crisis but also reinforced its reputation for integrity and responsibility.

5. Pepsi: Taking Responsibility Builds Trust

When Pepsi released an ad featuring Kendall Jenner, the company quickly found itself at the center of a public relations firestorm.  This crisis communication case study explores how Pepsi managed the crisis with rapid communication and what lessons can be learned from their approach.

Context: In April 2017, Pepsi launched an advertisement featuring Kendall Jenner that quickly led to controversy. The ad portrayed Jenner leaving a modeling shoot to join a protest, ultimately handing a police officer a can of Pepsi to “resolve” tensions. The ad was immediately criticized for trivializing social justice movements and co-opting serious issues to sell a product. The backlash was intense, with widespread condemnation across social media and traditional news outlets, labeling it as tone-deaf and culturally insensitive.

Analysis: Initially, Pepsi defended the campaign by describing it as a message of global unity and harmony. However, within less than 24 hours, the company shifted its stance in response to the overwhelming criticism. Pepsi pulled the ad from all platforms and issued a second statement acknowledging its mistake: “Pepsi was trying to project a global message of unity, peace, and understanding. Clearly, we missed the mark, and we apologize.” This rapid decision-making showcased Pepsi’s agility in crisis management and its recognition of the public’s sentiment.

Discussion: Pepsi’s response was notable for its speed and directness. By quickly retracting the ad and publicly admitting fault, the company took a proactive stance that demonstrated accountability and empathy. This helped contain the immediate fallout and prevent a prolonged controversy that could have further damaged the brand’s reputation. Despite the initial uproar, Pepsi’s brand weathered the crisis relatively well, thanks largely to its quick acknowledgment of error and efforts to communicate openly with its audience.

Conclusion: Pepsi’s swift apology and the decision to pull the ad were crucial first steps in mitigating negative reactions. By responding quickly and sincerely, Pepsi managed to limit the damage to its reputation. This crisis communication case study demonstrates the importance of prompt, empathetic communication and taking responsibility in a crisis, which can help protect a brand’s image and maintain public trust. 

Worst Crisis Communication Examples

1. open ai: surprises aren’t always a good thing.

After OpenAI abruptly fired its CEO, Sam Altman, the news sent shockwaves through the tech world. The decision, announced on a Friday afternoon with little explanation and no immediate plan for leadership succession, quickly escalated into a crisis. Let’s examine the missteps and lessons learned from this controversial episode in tech leadership.

Context: In November 2023, OpenAI faced a PR crisis when news broke that CEO Sam Altman had been abruptly fired. The announcement came on a Friday afternoon, catching the tech world by surprise and leaving major stakeholders, including Microsoft, in the dark.

Analysis: OpenAI’s response to the crisis was poorly managed and an example of bad crisis communications. The company failed to prepare for the backlash, and communication was inconsistent, with no immediate follow-up to address concerns. The decision to release the news on a Friday, without a clear successor or explanation, fueled confusion and criticism.

Discussion: This situation illustrates the pitfalls of inadequate crisis management. OpenAI’s lack of preparedness, inconsistent messaging, and poor timing resulted in a loss of trust among stakeholders and negative media attention. The newly appointed CEO later admitted that the process had not been handled smoothly, further highlighting the missteps.

Conclusion: The key lessons are clear: have a crisis communications plan in place, avoid releasing significant news on a Friday expecting it to pass unnoticed, and ensure consistent, clear communication with all stakeholders. Proper preparation and transparency are essential to maintaining trust and minimizing damage in such situations.

2. Twitter: Confusion and Controversy Aren’t the Way 

When Elon Musk acquired Twitter for $44 billion, his unconventional approach to managing the platform quickly became a crisis. 

This social media crisis communication example examines whether Musk’s unorthodox methods were reckless or a calculated risk — and what lessons can be learned from this high-profile rebranding saga.

Context: Since the Twitter acquisition, Musk had introduced a series of controversial changes, including firing employees, banning and unbanning users, charging for verification badges, and rebranding Twitter to “X” in 2023 without prior announcement. Analysis: Musk remained active on the platform, nonchalantly implementing these changes without formal crisis communication strategies. The sudden rebranding unsettled some advertisers and users but eventually normalized as people adapted to the new brand name, “X.”

Discussion: While Musk’s unconventional approach garnered significant media attention, it demonstrated a lack of strategic PR planning. The rebranding could have been managed more effectively to avoid initial confusion and backlash.

Conclusion: Musk’s handling of Twitter’s rebranding offers a critical lesson: purposeful and well-communicated changes are crucial for maintaining brand trust and stability. The controversy underscored the need for structured crisis communication plans, especially during significant transitions.

💡 PRO TIP : If you’re experiencing challenges with organizational alignment, read our article on how to avoid miscommunication in the workplace . 

3. Facebook: Slow and Vague Responses Breed Distrust

In the 2010s, Facebook found itself at the center of a massive data privacy scandal. This case study explores how Facebook’s delayed reaction to the scandal turned a breach of trust into one of the most significant PR disasters of the decade.

Context : Facebook faced a major crisis when it was revealed that Cambridge Analytica, a political consulting firm, had collected data from up to 87 million users without their consent through a third-party app. This data was then used to influence the 2016 U.S. presidential election, sparking public outrage and leading to one of the biggest PR crises.

Analysis : Facebook’s response to the scandal was slow and marked by a lack of transparency, making it one of the worst crisis communication examples. It took several days for CEO Mark Zuckerberg to publicly address the issue, explain what had happened, and identify those affected. By the time a formal apology was issued, significant reputational damage had already occurred, and trust in the platform was compromised.

Discussion : This crisis communication case study underscores the importance of a timely and transparent response in crisis management, especially when dealing with sensitive user data. The company’s initial failure to clearly communicate the facts of the situation and outline corrective measures compounded the fallout.

Conclusion : The Cambridge Analytica scandal serves as an example of crisis communication failure, emphasizing the need for prompt action to prevent lasting harm to a brand’s reputation. The key lesson for companies is to quickly explain what went wrong, who was affected, and what steps are being taken to prevent future issues.

Connect teams during crisis

Most fast with sms and ensure everyone gets the memo., how contactmonkey can help with crisis communication.

ContactMonkey can play a prominent role in crisis communication by providing internal communicators and HR leaders with the tools they need to deliver clear, timely, and effective messages. From email templates to emergency SMS text alerts , here’s what you’re offered to enhance crisis communication plans:

• Real-time internal email tracking : Helps communicators monitor who opens and clicks links emails, and engages with the content.
• Avoids spam filters : Reduces friction through the Outlook and Gmail integration to ensure emails don’t end up in junk mail. 
• Integrated email templates : Provides ready-to-use templates for crisis communication through the email builder , ensuring consistency and speed when delivering urgent messages.
• Segmentation and personalization : Allows targeted communication to specific groups within the organization, reducing confusion and ensuring relevant information reaches the right people.
• Analytics and feedback : Collects data on email performance and employee feedback through the analytics and reporting dashboard , enabling better decision-making and response adjustments during a crisis.
• Lead with speed : Take advantage of our SMS for internal communications to reach employees quickly and reliably. 

Ready to unlock the benefits of managing crisis comms effectively? Book a free demo and connect with our team to learn more about how to optimize your crisis communication strategy with ContactMonkey, today! 

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Business Case

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In today’s dynamic business environment, organizations must constantly evaluate new opportunities and projects to stay competitive. To make informed decisions, it’s essential to create a robust business case that outlines the potential benefits, risks, and costs of a proposed initiative. In this article, we’ll provide an overview of what a business case is, how to create one, and answer some common questions about the process.

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What is a Business Case?

A business case is a detailed document that outlines the rationale for initiating a new project or opportunity, along with the potential benefits, costs, and risks. It typically includes an analysis of the current situation, a proposed solution, a cost-benefit analysis, and an evaluation of the feasibility of the initiative.

How to Create a Business Case

Step 1: identify the problem or opportunity.

Start by identifying the problem or opportunity that your business case will address. Clearly define the issue and explain why it’s important to your organization.

Step 2: Develop a proposed solution

Next, develop a proposed solution to the problem or opportunity. Explain how this solution will address the issue and provide specific details on how it will work.

Step 3: Conduct a cost-benefit analysis

Perform a cost-benefit analysis to determine the financial impact of the proposed initiative. Estimate the costs and benefits of the project over its lifespan, and compare them to determine the net value.

Step 4: Evaluate the feasibility

Evaluate the feasibility of the initiative, taking into account factors like technical requirements, organizational capabilities, and legal considerations.

Step 5: Present your findings

Finally, present your findings in a clear and concise manner, using visual aids like graphs and charts to help convey your message.

What are some business case analysis examples?

Some examples of business case analyses include market research, feasibility studies, cost-benefit analyses, and SWOT analyses.

What are some case study examples of successful business cases?

Successful business case examples include Netflix’s decision to shift from DVD rentals to streaming, Amazon’s development of its Prime service, and Apple’s creation of the iPhone.

What are some project cost estimate examples?

Project cost estimate examples include direct costs (like labor and materials), indirect costs (like administrative expenses and marketing), and contingency costs (like unexpected expenses).

A well-crafted business case can help organizations make informed decisions about new opportunities and projects. By following the steps outlined above and incorporating best practices from successful case study examples, businesses can create a comprehensive and compelling case that drives strategic action planning and ensures success.

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