- Email: [email protected]
Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion
IJG-08454; No of Pages 4 International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
1
CLINICAL ARTICLE
4Q2
Sarah Baum a,⁎, Teresa DePiñeres b, Daniel Grossman a,c a
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a r t i c l e
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Article history: Received 23 December 2014 Received in revised form 2 June 2015 Accepted 27 August 2015
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Keywords: Abortion Colombia Delay to care Second trimester
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Ibis Reproductive Health, Oakland, CA, USA Fundación Oriéntame, Bogotá, Colombia Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Services, University of California, San Francisco, San Francisco, CA, USA
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Objective: To evaluate delays before first- or second-trimester legal abortion and barriers to care in Colombia. Methods: A secondary analysis was undertaken of data from a prospective cohort study of women undergoing first-trimester (b12 weeks) and second-trimester (12–15 weeks) abortion between February and July 2012. Participants (aged ≥18 years with access to a telephone) reported key dates in their abortion process and barriers to care. Univariate and multivariate analyses were performed. Results: Overall, 100 women in the first trimester and 200 in the second trimester were included. Second-trimester clients experienced longer delays in each step of the abortion process than did first-trimester clients (P b 0.001 for all three intervals examined), with the largest delay being time to suspicion of pregnancy (37 days vs 17 days). Difficulty accessing care was associated with the second trimester (odds ratio 5.1, 95% CI 2.9–9.1) and low socioeconomic status (odds ratio 2.3, 95% CI 1.2–4.3). Financial barriers were the most common (30 [30.0%] first-trimester clients; 86 [43.0%] second-trimester clients). Conclusion: Despite partial decriminalization of abortion in 2006, Colombian women still face barriers to legal services that probably contribute to late presentation. Interventions promoting early pregnancy recognition and information about how to access legal abortion could reduce the need for second-trimester services. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion
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1. Introduction
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Although the overall risk of maternal mortality is lower in Latin America and the Caribbean than in some other regions, the proportion of maternal deaths accounted for by unsafe abortion (10%) is higher than has been reported elsewhere [1]. The risk of mortality increases with length of pregnancy, and therefore most deaths occur in the second trimester [2]. Whereas several jurisdictions in the region, including Uruguay and Mexico City, have expanded legal first-trimester services in Latin America in recent years, few have addressed abortion care later in pregnancy. In 2006, the Constitutional Court in Colombia lifted the complete ban and decriminalized abortion in three circumstances: rape or incest, endangerment to the woman’s life or health, and fetal malformations incompatible with life [3]. This law has made Colombia one of the only countries in Latin America that provides legal abortion without time limits. A recent prospective comparative study at an outpatient clinic in Bogotá, Colombia [4], demonstrated that early second-trimester abortion (at 12–15 weeks) was being provided safely, and that few
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⁎ Corresponding author at: Ibis Reproductive Health, 1330 Broadway Street #1100, Oakland, CA 94612, USA. Tel.: +1 510 986 8953; fax: +1 510 986 8960. E-mail address: [email protected] (S. Baum).
clients experienced adverse events. Satisfaction was high among both first- and second-trimester clients [4]. Despite decriminalization of abortion, Colombian women continue to face obstacles when attempting to access abortion services. La Mesa por la Vida y la Salud de las Mujeres—a collective advocating for sexual and reproductive rights in Colombia—produced a report in 2014 [5] identifying both institutional and women-centered barriers that could contribute to delays in accessing care. These barriers include lack of training for providers and referral protocols, conscientious objection among individual providers or institutions, stigma, lack of knowledge of where to obtain legal services, and fear of reporting sexual violence [5]. Studies outside of Latin America in the USA [6–8], England and Wales [9], and South Africa [10] have identified lack of knowledge about pregnancy as one of the primary delays to care. All these studies noted that timing of abortion care is often influenced by multiple factors, which can include health-service barriers, lack of information, feelings of fear about the abortion process or judgment from others, and financial and other logistical constraints [6–10]. A study in Mexico City [11] found that abortion clients were more likely to report obstacles accessing care if they were unmarried or had completed at most primary education. Little research in Latin America has explored the key intervals between suspecting pregnancy and obtaining care, or the main factors
http://dx.doi.org/10.1016/j.ijgo.2015.06.036 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Baum S, et al, Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.06.036
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A secondary analysis was performed of data from a prospective comparative study of women undergoing surgical first-trimester abortion (11 weeks and 6 days or less since the last menstrual period [LMP]) and second-trimester abortion (12–15 weeks since LMP). The methods of the prospective comparative study have been reported previously [4]. Briefly, between February 1 and July 31, 2012, women were recruited from one of the Fundación Oriéntame clinics in Bogotá, Colombia. Women who were aged 18 years or older, were undergoing first- or second-trimester abortion, were able to give consent, and had access to a telephone for follow-up were eligible to participate and were recruited at the time of their first abortion visit by a clinic staff member. The study was approved by Allendale Investigational Review Board (Old Lyme, CT, USA) and the Ethics Committee of Fundación Oriéntame. Before the procedure, trained study interviewers asked women whether they had difficulty accessing services at the clinic after their decision to terminate and, if so, to identify the most substantial barrier. Participant response to the question about the most substantial barrier was open-ended, and the interviewer documented the answer in pre-identified categories or provided further detail in the category “Other.” Women were asked about three key dates in their abortion process [7]: date on which pregnancy was suspected, date on which pregnancy was confirmed, and date on which the decision to terminate was made. A fourth relevant date—that of the procedure—was also recorded by the interviewer. Additionally, the interviewer reviewed clinical charts to collect information on participants’ demographics and reproductive history. Socioeconomic stratum in Colombia is measured primarily by neighborhood of residence; each neighborhood has a different stratum (1–5) which is determined by the city. Women who reported strata one or two were categorized as having a low socioeconomic status; strata three and four were classified as middle, and strata five or six as high. Women were given a store voucher worth the equivalent of approximately US$10 as compensation for their time. On the basis of the dates provided by participants, the number of days was calculated for three intervals leading up to the abortion: 1) conception to suspicion of pregnancy, 2) suspicion of pregnancy to decision to terminate, and 3) decision to terminate to procedure. Date of conception was calculated on the basis of gestational age (determined by ultrasonography at the time of the procedure). Pregnancy confirmation was excluded from the timeline because it occurred at different times in the process for different women. Most women reported confirming their pregnancy on the same day they decided to terminate (54%), whereas for other women it occurred before their decision to terminate (31%) or after they decided to terminate (15%). In addition to the key dates, the proportion of women who were in the second trimester (12–15 weeks since LMP) at the end of each time interval was assessed. Reported barriers to accessing care were categorized into five main factors: logistical, financial, interpersonal, emotional, and delayed pregnancy recognition. Logistical barriers included not knowing where to go, the distance to a clinic, and difficulty getting time off work, childcare, or a driver to the appointment. Financial factors included not having enough money to pay for services and fear of not having enough money. Interpersonal factors include unsupportive partner or family. Emotional factors included ambivalence, fear of complications, fear or experience of abortion-related stigma, or religious conflict. The sample size was based on satisfaction, one of study’s primary outcomes. Using satisfaction rates reported in a questionnaire in
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2. Materials and methods
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A total of 300 women (100 in the first trimester and 200 in the second trimester) provided information about delays and barriers to care and were included in the analysis. The mean age was 25.5 years (range 18–42), and most were single (78.0%), in the middle socioeconomic strata (51.3%), and had at least one prior pregnancy (57.7%) (Table 1). Demographics were similar for first- and second-trimester clients, except women in the second trimester were younger than were those in the first trimester (P = 0.001) (Table 1). The mean number of days between conception and the procedure was 41.4 days (median 35 days; range 14–69) for women presenting in their first trimester and 80.8 days (median 77 days; range 70–95) for women in their second trimester (Fig. 1). For each of the three
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Table 1 Characteristics of participants undergoing first- and second-trimester abortion.a,b
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P
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a previous study [12], it was hypothesized that 90% of first-trimester clients and 76% of second-trimester clients would be very satisfied with their care. The necessary sample size was calculated as 300. Twice as many second-trimester participants were enrolled because this was the population of interest and because of study staff time constraints. Analysis was conducted using StataIC version 12.0 (StataCorp, College Station, TX, USA). Univariate and bivariate analyses were performed to compare the timelines and barriers between the firstand second-trimester groups; other key subgroups were compared using χ2 tests and t tests. P b 0.05 was considered statistically significant. Multivariate logistic regression was used to examine demographic factors associated with reporting difficulty in accessing care. The model included dichotomized covariates that were associated with difficulty in accessing care in the bivariate analysis at a level of P ≤ 0.2. Age was also included in the model because younger women were significantly more likely to present in their second trimester in our sample, and younger women have been previously shown to have a significantly harder time accessing care [6,7].
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associated with presenting for abortion care later in pregnancy. The aim of the present study was to evaluate differences in the key intervals among women obtaining legal abortion care in their first and second trimester in Bogotá, Colombia, and to assess obstacles experienced by both groups.
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Age, y 18–25 26–35 N35 Number of years of education completed ≤5 6–11 ≥12 Relationship status Single Married Separated/divorced Socioeconomic strata Low Middle High Paid for work Currently in school Prior pregnancy 0 ≥1 Prior induced abortion Length of pregnancy on date of procedure b10 wk 10 wk to 11 wk, 6 d 12 wk to 13 wk, 6 d 14–16 wk a b
Study population (n = 300)
First Trimester (n = 100)
Second Trimester (n = 200)
P value
25.5 182 (60.7) 98 (32.7) 20 (6.7)
26.9 50 (50.0) 38 (38.0) 12 (12.0)
24.8 132 (66.0) 60 (30.0) 8 (4.0)
0.001
0.886 16 (5.3) 140 (46.7) 142 (47.3)
6 (6.0) 45 (45.0) 48 (48.0)
10 (5.0) 95 (47.5) 94 (47.0)
234 (78.0) 46 (15.3) 19 (6.3)
73 (73.0) 19 (19.0) 7 (7.0)
161 (80.5) 27 (13.5) 12 (6.0)
137 (45.7) 154 (51.3) 2 (0.6) 148 (49.3) 71 (23.7)
46 (46.0) 49 (49.0) 1 (1.0) 53 (53.0) 21 (21)
91 (45.5) 105 (52.5) 1 (0.5) 95 (47.5) 50 (25)
92 (30.7) 207 (69.0) 98 (32.7) 11.5
32 (32.0) 67 (67.0) 34 (34.0) 7.7
60 (30.0) 140 (70.0) 64 (32.0) 13.4
77 (25.7) 23 (7.7) 119 (39.7) 81 (27.0)
77 (25.7) 23 (7.7) – –
– – 119 (59.5) 81 (40.5)
0.272
0.830
0.326 0.442 0.682
0.685
b0.001
Values are given as mean or number (percentage), unless indicated otherwise. Column numbers do not always sum to total because of missing data.
Please cite this article as: Baum S, et al, Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.06.036
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t1:3
t1:4 t1:5 t1:6 t1:7 t1:8 t1:9 t1:10 t1:11 t1:12 t1:13 t1:14 t1:15 t1:16 t1:17 t1:18 t1:19 t1:20 t1:21 t1:22 t1:23 t1:24 t1:25 t1:26 t1:27 t1:28 t1:29 t1:30 t1:31 t1:32 t1:33 t1:34
S. Baum et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
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Conception to suspected pregnancy First trimester
17.4
10.6
Suspected to decision to terminate
41.4
13.4
Decision to date of procedure
Second trimester
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0
10
19.5
20
30
40
24.2
50
60
80.8
70
80
90
Days 100% 100.0% % of women in 50% 2nd trimester
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30.0% 7.5% Suspected pregnancy
Decision to terminate
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Date of procedure
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In the present study, women requesting a legal abortion in the second trimester of pregnancy spent significantly longer on each step leading up to their abortion procedure than did women presenting in the first trimester. Delay in suspecting pregnancy contributed the most time to later abortion care and was identified by 10% of women presenting in the second trimester as their primary barrier. Studies in
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Table 2 Primary barriers to accessing care.
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the USA [6,7], England and Wales [9], and South Africa [10] have had similar findings. The proportion of women who reported difficulty accessing care in the present study was higher among women in their second trimester than among those in the first trimester. In particular, second-trimester clients had more logistical challenges, such as not knowing where to go and difficulty getting to the clinic. This finding is in line with two previous studies [6,7]. It is important to note that 70% of second-trimester clients in the present study were still in their first trimester when they decided to have the abortion. Therefore, although the longest delays were in pregnancy recognition, barriers to accessing services further compounded these delays, which contributed to women ultimately seeking abortion care in the second trimester. These findings differ from those of a study of US women seeking abortion services up to 23 weeks [7], which found that most women (65%) were already in their second trimester when they decided to have an abortion. Similar to previous studies [6,7,11,13], difficulty accessing abortion care was twice as likely to be reported among women with low socioeconomic status than among those of a higher socioeconomic status in the present study. It is well documented that low socioeconomic status is associated with poor access to health services [14,15]. On the basis of
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intervals examined, second-trimester patients had significantly longer mean intervals than did women presenting in the first trimester (P b 0.001 for each). The largest contribution to delay for all women was the delay to suspicion of pregnancy, which occurred a mean of 17.4 days (median 15 days; range 0–47) after conception for women presenting in their first trimester and 37.1 days (median 34 days; range 0–84) after conception for second-trimester patients. Women also experienced delays in making the decision to terminate (10.6 days after suspecting pregnancy for first-trimester patients [median 8 days; range 0–53], and 19.5 days for second-trimester patients [median 13 days; range 0–93]) and obtaining an abortion procedure (13.4 days after deciding to terminate for first-trimester patients [median 10 days; range 0–54], and 24.2 days for secondtrimester patients [median 16 days; range 0–88]). Among patients in the second trimester at the time of the procedure, 15 (7.5%) were already in the second trimester when they suspected pregnancy and 60 (30.0%) were in the second trimester when they decided to terminate. Therefore, most second-trimester clients were still in the first trimester of pregnancy when they decided to terminate. A significantly higher proportion of second-trimester patients than first-trimester patients reported difficulty accessing services at the clinic (P b 0.001) (Table 2). In multivariate logistic regression controlling for fixed demographic covariates including gestational age (trimester), education, socioeconomic status, age, and prior pregnancy, the odds of difficulty accessing services were significantly increased among women presenting in the second trimester (odds ratio 5.1, 95% confidence interval 2.9–9.1) and among women of low socioeconomic status (odds ratio 2.3, 95% confidence interval 1.2–4.3). Among all participants who said they had difficulty accessing care, the most commonly reported barrier was financial (Table 2), which generally was described as perceiving that they did not have enough money for the procedure. Compared with women in their first trimester, second-trimester clients were more likely to report that their primary barrier was delay in pregnancy recognition (P = 0.001) or logistical delays (P = 0.014) (Table 2). Few women reported interpersonal or emotional barriers to accessing care (Table 2).
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Fig. 1. Mean number of days between stages before abortion (top) and percentage of women in second trimester at the time of the procedure who were already in their second trimester at each stage (bottom).
Reported ≥1 barrier to accessing care Logistical Not knowing where to go Unsuccessful services from different provider Distance to the clinic Difficulty in getting time off work Difficulty in getting childcare Difficulty in getting a driver Other Financial Interpersonal Unsupportive partner Unsupportive family Emotional Ambivalence Fear of complications Fear of judgment Religious conflict Late pregnancy recognition a
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First trimester (n = 100)a
Second trimester (n = 200)
P value
t2:3
50 (50.0) 11 (11.0) 5 (5.0) 0
162 (81.0) 47 (23.5) 28 (14.0) 2 (1.0)
b0.001 0.014
2 (2.0) 3 (3.0) 1 (1.0) 0 0 30 (30.0) 1 (1.0) 1 (1.0) 0 7 (7.0) 1 (1.0) 6 (6.0) 0 0 0
2 (1.0) 7 (3.5) 0 5 (2.5) 3 (1.5) 86 (43.0) 1 (0.5) 0 1 (0.5) 9 (4.5) 3 (1.5) 3 (1.5) 2 (1) 1 (0.5) 20 (10.0)
t2:4 t2:5 t2:6 t2:7 t2:8 t2:9 t2:10 t2:11 t2:12 t2:13 t2:14 t2:15 t2:16 t2:17 t2:18 t2:19 t2:20 t2:21 t2:22 t2:23
0.438 0.616
0.364
0.001
Column numbers do not add up to total due to missing data.
Please cite this article as: Baum S, et al, Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.06.036
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S. Baum et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
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This research is supported by a grant from an anonymous foundation.
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[1] Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2(6):e323–33. [2] Harris LH, Grossman D. Confronting the challenge of unsafe second-trimester abortion. Int J Gynecol Obstet 2011;115(1):77–9. [3] Constitutional Court of Colombia. Constitutional Claim Decision C- 355 de 2006 (in Spanish). http://www.corteconstitucional.gov.co/relatoria/2006/c-355-06.htm; 10 May 2006. Accessed May 26, 2015. [4] DePiñeres T, Baum S, Grossman D. Acceptability and clinical outcomes of first- and second-trimester surgical abortion by suction aspiration in Colombia. Contraception 2014;90(3):242–8. [5] Coalition for the Life and Health of Women. Barriers to the right to abortion. http:// www.despenalizaciondelaborto.org.co/index.php/documentos/1-publicaciones. Published 2014. Accessed June 1, 2015. [6] Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Timing of steps and reasons for delays in obtaining abortions in the United States. Contraception 2006; 74(4):334–44. [7] Drey EA, Foster DG, Jackson RA, Lee SJ, Cardenas LH, Darney PD. Risk factors associated with presenting for abortion in the second trimester. Obstet Gynecol 2006; 107(1):128–35. [8] Kiley JW, Yee LM, Niemi CM, Feinglass JM, Simon MA. Delays in request for pregnancy termination: comparison of patients in the first and second trimesters. Contraception 2010;81(5):446–51. [9] Ingham R, Lee E, Clements SJ, Stone N. Reasons for second trimester abortions in England and Wales. Reprod Health Matters 2008;16(31 Suppl):18–29. [10] Harries J, Orner P, Gabriel M, Mitchell E. Delays in seeking an abortion until the second trimester: a qualitative study in South Africa. Reprod Health 2007;4:7. [11] Becker D, Diaz-Olavarrieta C, Juarez C, Garcia SG, Sanhueza Smith P, Harper CC. Sociodemographic factors associated with obstacles to abortion care: findings from a survey of abortion patients in Mexico City. Womens Health Issues 2011; 21(3 Suppl):S16–20. [12] Henshaw RC, Naji SA, Russell IT, Templeton AA. Comparison of medical abortion with surgical vacuum aspiration: women's preferences and acceptability of treatment. BMJ 1993;307(6906):714–7. [13] Bracken MB, Kasl SV. Psychosocial correlates of delayed decisions to abort. Health Educ Monogr 1976;4(1):6–44. [14] Adler NE, Ostrove JM. Socioeconomic status and health: what we know and what we don't. Ann N Y Acad Sci 1999;896:3–15. [15] Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and access to health care in developing countries. Ann N Y Acad Sci 2008;1136:161–71.
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The authors have no conflicts of interest.
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the present findings and the recent study in Mexico City that found that women with limited education were more likely to report a higher number of obstacles to abortion care [11], future work in Colombia should explore how best to inform these vulnerable populations about where and how to access legal abortion services irrespective of a woman’s ability to pay. Real or perceived financial barriers were the most common obstacles reported by women in the present study. It is important to consider these findings within the context of insurance coverage for abortion in Colombia. Since 2006, surgical and medical abortion has been included as part of the basic universal health plan available to every woman. However, some women—particularly those who are poor or have a low level of education—might not know how to access even this basic plan. Women in Colombia might seek abortion services outside the public sector at a clinic like the site of the present study for various reasons, including not knowing where or if public services are available, fear of stigmatization, being turned away from the public sector, or being more familiar with reproductive health services at private clinics. Women probably anticipate that they have to pay out-of-pocket for services outside the public sector and might not know that the cost of the procedure at some private facilities, such as the site of the present study, can be adjusted according to the client’s ability to pay. The present study has several limitations. Because women were asked to retrospectively report the dates leading up to their abortion, the data are subject to recall bias. Additionally, the sample included only women seeking abortion up to 15 weeks of pregnancy at one particular clinic, so the results cannot be assumed to apply to or reflect women in Colombia presenting later in pregnancy or those not presenting to a clinic at all. Second-trimester abortion is a critical component of comprehensive reproductive health services. As later legal abortion services are scaled up in Colombia, it is important to address some of the factors contributing to delay that have been identified in the present study, including helping women to recognize pregnancy as early as possible and informing women about where legal abortion services are available irrespective of ability to pay. Helping women to access abortion care as early as possible can help to improve health outcomes and reduce costs for both women and the health system.
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Please cite this article as: Baum S, et al, Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.06.036
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
1
CLINICAL ARTICLE
4Q2
Sarah Baum a,⁎, Teresa DePiñeres b, Daniel Grossman a,c a
8
a r t i c l e
9 10 11 12
Article history: Received 23 December 2014 Received in revised form 2 June 2015 Accepted 27 August 2015
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Keywords: Abortion Colombia Delay to care Second trimester
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Ibis Reproductive Health, Oakland, CA, USA Fundación Oriéntame, Bogotá, Colombia Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Services, University of California, San Francisco, San Francisco, CA, USA
a b s t r a c t
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Objective: To evaluate delays before first- or second-trimester legal abortion and barriers to care in Colombia. Methods: A secondary analysis was undertaken of data from a prospective cohort study of women undergoing first-trimester (b12 weeks) and second-trimester (12–15 weeks) abortion between February and July 2012. Participants (aged ≥18 years with access to a telephone) reported key dates in their abortion process and barriers to care. Univariate and multivariate analyses were performed. Results: Overall, 100 women in the first trimester and 200 in the second trimester were included. Second-trimester clients experienced longer delays in each step of the abortion process than did first-trimester clients (P b 0.001 for all three intervals examined), with the largest delay being time to suspicion of pregnancy (37 days vs 17 days). Difficulty accessing care was associated with the second trimester (odds ratio 5.1, 95% CI 2.9–9.1) and low socioeconomic status (odds ratio 2.3, 95% CI 1.2–4.3). Financial barriers were the most common (30 [30.0%] first-trimester clients; 86 [43.0%] second-trimester clients). Conclusion: Despite partial decriminalization of abortion in 2006, Colombian women still face barriers to legal services that probably contribute to late presentation. Interventions promoting early pregnancy recognition and information about how to access legal abortion could reduce the need for second-trimester services. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion
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1. Introduction
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Although the overall risk of maternal mortality is lower in Latin America and the Caribbean than in some other regions, the proportion of maternal deaths accounted for by unsafe abortion (10%) is higher than has been reported elsewhere [1]. The risk of mortality increases with length of pregnancy, and therefore most deaths occur in the second trimester [2]. Whereas several jurisdictions in the region, including Uruguay and Mexico City, have expanded legal first-trimester services in Latin America in recent years, few have addressed abortion care later in pregnancy. In 2006, the Constitutional Court in Colombia lifted the complete ban and decriminalized abortion in three circumstances: rape or incest, endangerment to the woman’s life or health, and fetal malformations incompatible with life [3]. This law has made Colombia one of the only countries in Latin America that provides legal abortion without time limits. A recent prospective comparative study at an outpatient clinic in Bogotá, Colombia [4], demonstrated that early second-trimester abortion (at 12–15 weeks) was being provided safely, and that few
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⁎ Corresponding author at: Ibis Reproductive Health, 1330 Broadway Street #1100, Oakland, CA 94612, USA. Tel.: +1 510 986 8953; fax: +1 510 986 8960. E-mail address: [email protected] (S. Baum).
clients experienced adverse events. Satisfaction was high among both first- and second-trimester clients [4]. Despite decriminalization of abortion, Colombian women continue to face obstacles when attempting to access abortion services. La Mesa por la Vida y la Salud de las Mujeres—a collective advocating for sexual and reproductive rights in Colombia—produced a report in 2014 [5] identifying both institutional and women-centered barriers that could contribute to delays in accessing care. These barriers include lack of training for providers and referral protocols, conscientious objection among individual providers or institutions, stigma, lack of knowledge of where to obtain legal services, and fear of reporting sexual violence [5]. Studies outside of Latin America in the USA [6–8], England and Wales [9], and South Africa [10] have identified lack of knowledge about pregnancy as one of the primary delays to care. All these studies noted that timing of abortion care is often influenced by multiple factors, which can include health-service barriers, lack of information, feelings of fear about the abortion process or judgment from others, and financial and other logistical constraints [6–10]. A study in Mexico City [11] found that abortion clients were more likely to report obstacles accessing care if they were unmarried or had completed at most primary education. Little research in Latin America has explored the key intervals between suspecting pregnancy and obtaining care, or the main factors
http://dx.doi.org/10.1016/j.ijgo.2015.06.036 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Baum S, et al, Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.06.036
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A secondary analysis was performed of data from a prospective comparative study of women undergoing surgical first-trimester abortion (11 weeks and 6 days or less since the last menstrual period [LMP]) and second-trimester abortion (12–15 weeks since LMP). The methods of the prospective comparative study have been reported previously [4]. Briefly, between February 1 and July 31, 2012, women were recruited from one of the Fundación Oriéntame clinics in Bogotá, Colombia. Women who were aged 18 years or older, were undergoing first- or second-trimester abortion, were able to give consent, and had access to a telephone for follow-up were eligible to participate and were recruited at the time of their first abortion visit by a clinic staff member. The study was approved by Allendale Investigational Review Board (Old Lyme, CT, USA) and the Ethics Committee of Fundación Oriéntame. Before the procedure, trained study interviewers asked women whether they had difficulty accessing services at the clinic after their decision to terminate and, if so, to identify the most substantial barrier. Participant response to the question about the most substantial barrier was open-ended, and the interviewer documented the answer in pre-identified categories or provided further detail in the category “Other.” Women were asked about three key dates in their abortion process [7]: date on which pregnancy was suspected, date on which pregnancy was confirmed, and date on which the decision to terminate was made. A fourth relevant date—that of the procedure—was also recorded by the interviewer. Additionally, the interviewer reviewed clinical charts to collect information on participants’ demographics and reproductive history. Socioeconomic stratum in Colombia is measured primarily by neighborhood of residence; each neighborhood has a different stratum (1–5) which is determined by the city. Women who reported strata one or two were categorized as having a low socioeconomic status; strata three and four were classified as middle, and strata five or six as high. Women were given a store voucher worth the equivalent of approximately US$10 as compensation for their time. On the basis of the dates provided by participants, the number of days was calculated for three intervals leading up to the abortion: 1) conception to suspicion of pregnancy, 2) suspicion of pregnancy to decision to terminate, and 3) decision to terminate to procedure. Date of conception was calculated on the basis of gestational age (determined by ultrasonography at the time of the procedure). Pregnancy confirmation was excluded from the timeline because it occurred at different times in the process for different women. Most women reported confirming their pregnancy on the same day they decided to terminate (54%), whereas for other women it occurred before their decision to terminate (31%) or after they decided to terminate (15%). In addition to the key dates, the proportion of women who were in the second trimester (12–15 weeks since LMP) at the end of each time interval was assessed. Reported barriers to accessing care were categorized into five main factors: logistical, financial, interpersonal, emotional, and delayed pregnancy recognition. Logistical barriers included not knowing where to go, the distance to a clinic, and difficulty getting time off work, childcare, or a driver to the appointment. Financial factors included not having enough money to pay for services and fear of not having enough money. Interpersonal factors include unsupportive partner or family. Emotional factors included ambivalence, fear of complications, fear or experience of abortion-related stigma, or religious conflict. The sample size was based on satisfaction, one of study’s primary outcomes. Using satisfaction rates reported in a questionnaire in
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3. Results
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2. Materials and methods
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A total of 300 women (100 in the first trimester and 200 in the second trimester) provided information about delays and barriers to care and were included in the analysis. The mean age was 25.5 years (range 18–42), and most were single (78.0%), in the middle socioeconomic strata (51.3%), and had at least one prior pregnancy (57.7%) (Table 1). Demographics were similar for first- and second-trimester clients, except women in the second trimester were younger than were those in the first trimester (P = 0.001) (Table 1). The mean number of days between conception and the procedure was 41.4 days (median 35 days; range 14–69) for women presenting in their first trimester and 80.8 days (median 77 days; range 70–95) for women in their second trimester (Fig. 1). For each of the three
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Table 1 Characteristics of participants undergoing first- and second-trimester abortion.a,b
t1:1 t1:2
P
83
80 81
a previous study [12], it was hypothesized that 90% of first-trimester clients and 76% of second-trimester clients would be very satisfied with their care. The necessary sample size was calculated as 300. Twice as many second-trimester participants were enrolled because this was the population of interest and because of study staff time constraints. Analysis was conducted using StataIC version 12.0 (StataCorp, College Station, TX, USA). Univariate and bivariate analyses were performed to compare the timelines and barriers between the firstand second-trimester groups; other key subgroups were compared using χ2 tests and t tests. P b 0.05 was considered statistically significant. Multivariate logistic regression was used to examine demographic factors associated with reporting difficulty in accessing care. The model included dichotomized covariates that were associated with difficulty in accessing care in the bivariate analysis at a level of P ≤ 0.2. Age was also included in the model because younger women were significantly more likely to present in their second trimester in our sample, and younger women have been previously shown to have a significantly harder time accessing care [6,7].
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associated with presenting for abortion care later in pregnancy. The aim of the present study was to evaluate differences in the key intervals among women obtaining legal abortion care in their first and second trimester in Bogotá, Colombia, and to assess obstacles experienced by both groups.
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Age, y 18–25 26–35 N35 Number of years of education completed ≤5 6–11 ≥12 Relationship status Single Married Separated/divorced Socioeconomic strata Low Middle High Paid for work Currently in school Prior pregnancy 0 ≥1 Prior induced abortion Length of pregnancy on date of procedure b10 wk 10 wk to 11 wk, 6 d 12 wk to 13 wk, 6 d 14–16 wk a b
Study population (n = 300)
First Trimester (n = 100)
Second Trimester (n = 200)
P value
25.5 182 (60.7) 98 (32.7) 20 (6.7)
26.9 50 (50.0) 38 (38.0) 12 (12.0)
24.8 132 (66.0) 60 (30.0) 8 (4.0)
0.001
0.886 16 (5.3) 140 (46.7) 142 (47.3)
6 (6.0) 45 (45.0) 48 (48.0)
10 (5.0) 95 (47.5) 94 (47.0)
234 (78.0) 46 (15.3) 19 (6.3)
73 (73.0) 19 (19.0) 7 (7.0)
161 (80.5) 27 (13.5) 12 (6.0)
137 (45.7) 154 (51.3) 2 (0.6) 148 (49.3) 71 (23.7)
46 (46.0) 49 (49.0) 1 (1.0) 53 (53.0) 21 (21)
91 (45.5) 105 (52.5) 1 (0.5) 95 (47.5) 50 (25)
92 (30.7) 207 (69.0) 98 (32.7) 11.5
32 (32.0) 67 (67.0) 34 (34.0) 7.7
60 (30.0) 140 (70.0) 64 (32.0) 13.4
77 (25.7) 23 (7.7) 119 (39.7) 81 (27.0)
77 (25.7) 23 (7.7) – –
– – 119 (59.5) 81 (40.5)
0.272
0.830
0.326 0.442 0.682
0.685
b0.001
Values are given as mean or number (percentage), unless indicated otherwise. Column numbers do not always sum to total because of missing data.
Please cite this article as: Baum S, et al, Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.06.036
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t1:3
t1:4 t1:5 t1:6 t1:7 t1:8 t1:9 t1:10 t1:11 t1:12 t1:13 t1:14 t1:15 t1:16 t1:17 t1:18 t1:19 t1:20 t1:21 t1:22 t1:23 t1:24 t1:25 t1:26 t1:27 t1:28 t1:29 t1:30 t1:31 t1:32 t1:33 t1:34
S. Baum et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
3
Conception to suspected pregnancy First trimester
17.4
10.6
Suspected to decision to terminate
41.4
13.4
Decision to date of procedure
Second trimester
37.1
0
10
19.5
20
30
40
24.2
50
60
80.8
70
80
90
Days 100% 100.0% % of women in 50% 2nd trimester
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30.0% 7.5% Suspected pregnancy
Decision to terminate
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Date of procedure
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In the present study, women requesting a legal abortion in the second trimester of pregnancy spent significantly longer on each step leading up to their abortion procedure than did women presenting in the first trimester. Delay in suspecting pregnancy contributed the most time to later abortion care and was identified by 10% of women presenting in the second trimester as their primary barrier. Studies in
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211 212 213 214 215
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Table 2 Primary barriers to accessing care.
t2:1 t2:2
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the USA [6,7], England and Wales [9], and South Africa [10] have had similar findings. The proportion of women who reported difficulty accessing care in the present study was higher among women in their second trimester than among those in the first trimester. In particular, second-trimester clients had more logistical challenges, such as not knowing where to go and difficulty getting to the clinic. This finding is in line with two previous studies [6,7]. It is important to note that 70% of second-trimester clients in the present study were still in their first trimester when they decided to have the abortion. Therefore, although the longest delays were in pregnancy recognition, barriers to accessing services further compounded these delays, which contributed to women ultimately seeking abortion care in the second trimester. These findings differ from those of a study of US women seeking abortion services up to 23 weeks [7], which found that most women (65%) were already in their second trimester when they decided to have an abortion. Similar to previous studies [6,7,11,13], difficulty accessing abortion care was twice as likely to be reported among women with low socioeconomic status than among those of a higher socioeconomic status in the present study. It is well documented that low socioeconomic status is associated with poor access to health services [14,15]. On the basis of
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intervals examined, second-trimester patients had significantly longer mean intervals than did women presenting in the first trimester (P b 0.001 for each). The largest contribution to delay for all women was the delay to suspicion of pregnancy, which occurred a mean of 17.4 days (median 15 days; range 0–47) after conception for women presenting in their first trimester and 37.1 days (median 34 days; range 0–84) after conception for second-trimester patients. Women also experienced delays in making the decision to terminate (10.6 days after suspecting pregnancy for first-trimester patients [median 8 days; range 0–53], and 19.5 days for second-trimester patients [median 13 days; range 0–93]) and obtaining an abortion procedure (13.4 days after deciding to terminate for first-trimester patients [median 10 days; range 0–54], and 24.2 days for secondtrimester patients [median 16 days; range 0–88]). Among patients in the second trimester at the time of the procedure, 15 (7.5%) were already in the second trimester when they suspected pregnancy and 60 (30.0%) were in the second trimester when they decided to terminate. Therefore, most second-trimester clients were still in the first trimester of pregnancy when they decided to terminate. A significantly higher proportion of second-trimester patients than first-trimester patients reported difficulty accessing services at the clinic (P b 0.001) (Table 2). In multivariate logistic regression controlling for fixed demographic covariates including gestational age (trimester), education, socioeconomic status, age, and prior pregnancy, the odds of difficulty accessing services were significantly increased among women presenting in the second trimester (odds ratio 5.1, 95% confidence interval 2.9–9.1) and among women of low socioeconomic status (odds ratio 2.3, 95% confidence interval 1.2–4.3). Among all participants who said they had difficulty accessing care, the most commonly reported barrier was financial (Table 2), which generally was described as perceiving that they did not have enough money for the procedure. Compared with women in their first trimester, second-trimester clients were more likely to report that their primary barrier was delay in pregnancy recognition (P = 0.001) or logistical delays (P = 0.014) (Table 2). Few women reported interpersonal or emotional barriers to accessing care (Table 2).
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Fig. 1. Mean number of days between stages before abortion (top) and percentage of women in second trimester at the time of the procedure who were already in their second trimester at each stage (bottom).
Reported ≥1 barrier to accessing care Logistical Not knowing where to go Unsuccessful services from different provider Distance to the clinic Difficulty in getting time off work Difficulty in getting childcare Difficulty in getting a driver Other Financial Interpersonal Unsupportive partner Unsupportive family Emotional Ambivalence Fear of complications Fear of judgment Religious conflict Late pregnancy recognition a
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First trimester (n = 100)a
Second trimester (n = 200)
P value
t2:3
50 (50.0) 11 (11.0) 5 (5.0) 0
162 (81.0) 47 (23.5) 28 (14.0) 2 (1.0)
b0.001 0.014
2 (2.0) 3 (3.0) 1 (1.0) 0 0 30 (30.0) 1 (1.0) 1 (1.0) 0 7 (7.0) 1 (1.0) 6 (6.0) 0 0 0
2 (1.0) 7 (3.5) 0 5 (2.5) 3 (1.5) 86 (43.0) 1 (0.5) 0 1 (0.5) 9 (4.5) 3 (1.5) 3 (1.5) 2 (1) 1 (0.5) 20 (10.0)
t2:4 t2:5 t2:6 t2:7 t2:8 t2:9 t2:10 t2:11 t2:12 t2:13 t2:14 t2:15 t2:16 t2:17 t2:18 t2:19 t2:20 t2:21 t2:22 t2:23
0.438 0.616
0.364
0.001
Column numbers do not add up to total due to missing data.
Please cite this article as: Baum S, et al, Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.06.036
t2:24
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This research is supported by a grant from an anonymous foundation.
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[1] Say L, Chou D, Gemmill A, Tunçalp Ö, Moller AB, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health 2014;2(6):e323–33. [2] Harris LH, Grossman D. Confronting the challenge of unsafe second-trimester abortion. Int J Gynecol Obstet 2011;115(1):77–9. [3] Constitutional Court of Colombia. Constitutional Claim Decision C- 355 de 2006 (in Spanish). http://www.corteconstitucional.gov.co/relatoria/2006/c-355-06.htm; 10 May 2006. Accessed May 26, 2015. [4] DePiñeres T, Baum S, Grossman D. Acceptability and clinical outcomes of first- and second-trimester surgical abortion by suction aspiration in Colombia. Contraception 2014;90(3):242–8. [5] Coalition for the Life and Health of Women. Barriers to the right to abortion. http:// www.despenalizaciondelaborto.org.co/index.php/documentos/1-publicaciones. Published 2014. Accessed June 1, 2015. [6] Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Timing of steps and reasons for delays in obtaining abortions in the United States. Contraception 2006; 74(4):334–44. [7] Drey EA, Foster DG, Jackson RA, Lee SJ, Cardenas LH, Darney PD. Risk factors associated with presenting for abortion in the second trimester. Obstet Gynecol 2006; 107(1):128–35. [8] Kiley JW, Yee LM, Niemi CM, Feinglass JM, Simon MA. Delays in request for pregnancy termination: comparison of patients in the first and second trimesters. Contraception 2010;81(5):446–51. [9] Ingham R, Lee E, Clements SJ, Stone N. Reasons for second trimester abortions in England and Wales. Reprod Health Matters 2008;16(31 Suppl):18–29. [10] Harries J, Orner P, Gabriel M, Mitchell E. Delays in seeking an abortion until the second trimester: a qualitative study in South Africa. Reprod Health 2007;4:7. [11] Becker D, Diaz-Olavarrieta C, Juarez C, Garcia SG, Sanhueza Smith P, Harper CC. Sociodemographic factors associated with obstacles to abortion care: findings from a survey of abortion patients in Mexico City. Womens Health Issues 2011; 21(3 Suppl):S16–20. [12] Henshaw RC, Naji SA, Russell IT, Templeton AA. Comparison of medical abortion with surgical vacuum aspiration: women's preferences and acceptability of treatment. BMJ 1993;307(6906):714–7. [13] Bracken MB, Kasl SV. Psychosocial correlates of delayed decisions to abort. Health Educ Monogr 1976;4(1):6–44. [14] Adler NE, Ostrove JM. Socioeconomic status and health: what we know and what we don't. Ann N Y Acad Sci 1999;896:3–15. [15] Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and access to health care in developing countries. Ann N Y Acad Sci 2008;1136:161–71.
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The authors have no conflicts of interest.
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the present findings and the recent study in Mexico City that found that women with limited education were more likely to report a higher number of obstacles to abortion care [11], future work in Colombia should explore how best to inform these vulnerable populations about where and how to access legal abortion services irrespective of a woman’s ability to pay. Real or perceived financial barriers were the most common obstacles reported by women in the present study. It is important to consider these findings within the context of insurance coverage for abortion in Colombia. Since 2006, surgical and medical abortion has been included as part of the basic universal health plan available to every woman. However, some women—particularly those who are poor or have a low level of education—might not know how to access even this basic plan. Women in Colombia might seek abortion services outside the public sector at a clinic like the site of the present study for various reasons, including not knowing where or if public services are available, fear of stigmatization, being turned away from the public sector, or being more familiar with reproductive health services at private clinics. Women probably anticipate that they have to pay out-of-pocket for services outside the public sector and might not know that the cost of the procedure at some private facilities, such as the site of the present study, can be adjusted according to the client’s ability to pay. The present study has several limitations. Because women were asked to retrospectively report the dates leading up to their abortion, the data are subject to recall bias. Additionally, the sample included only women seeking abortion up to 15 weeks of pregnancy at one particular clinic, so the results cannot be assumed to apply to or reflect women in Colombia presenting later in pregnancy or those not presenting to a clinic at all. Second-trimester abortion is a critical component of comprehensive reproductive health services. As later legal abortion services are scaled up in Colombia, it is important to address some of the factors contributing to delay that have been identified in the present study, including helping women to recognize pregnancy as early as possible and informing women about where legal abortion services are available irrespective of ability to pay. Helping women to access abortion care as early as possible can help to improve health outcomes and reduce costs for both women and the health system.
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Please cite this article as: Baum S, et al, Delays and barriers to care in Colombia among women obtaining legal first- and second-trimester abortion, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/j.ijgo.2015.06.036