abortion clinics research paper

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.

ACNM (American College of Nurse-Midwives). 2011. Position statement: Reproductive health choices . http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000087/Reproductive_Choices.pdf (accessed August 1, 2017).

ACNM. 2016. Position statement: Access to comprehensive sexual and reproductive health care services . http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000087/Access-to-Comprehensive-Sexual-and-Reproductive-Health-Care-Services-FINAL-04-12-17.pdf (accessed August 1, 2017).

ACOG (American College of Obstetricians and Gynecologists). 2013. Practice Bulletin No. 135: Second-trimester abortion. Obstetrics & Gynecology 121(6):1394–1406.

ACOG. 2014. Practice Bulletin No. 143: Medical management of first-trimester abortion (reaffirmed). Obstetrics & Gynecology 123(3):676–692.

AHRQ (Agency for Healthcare Research and Quality). 2016. The six domains of health care quality. https://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/create/sixdomains.html (accessed May 3, 2017).

Altman, D. G., K. F. Schulz, D. Moher, M. Egger, F. Davidoff, D. Elbourne, P. C. Gøtzsche, and T. Lang. 2001. The revised CONSORT statement for reporting randomized trials: Explanation and elaboration. Annals of Internal Medicine 134(8):663–694.

Ashok, P. W., A. Templeton, P. T. Wagaarachchi, and G. M. Flett. 2004. Midtrimester medical termination of pregnancy: A review of 1002 consecutive cases. Contraception 69(1):51–58.

Autry, A. M., E. C. Hayes, G. F. Jacobson, and R. S. Kirby. 2002. A comparison of medical induction and dilation and evacuation for second-trimester abortion. American Journal of Obstetrics and Gynecology 187(2):393–397.

Bartlett, L. A., C. J. Berg, H. B. Shulman, S. B. Zane, C. A. Green, S. Whitehead, and H. K. Atrash. 2004. Risk factors for legal induced abortion-related mortality in the United States. Obstetrics & Gynecology 103(4):729–737.

Bearak, J. M., K. L. Burke, and R. K. Jones. 2017. Disparities and change over time in distance women would need to travel to have an abortion in the USA: A spatial analysis. The Lancet Public Health 2(11):e493–e500.

Borgatta, L. 2011. Labor induction termination of pregnancy. Global library for women’s medicine . https://www.glowm.com/section_view/heading/Labor%20Induction%20Termination%20of%20Pregnancy/item/443 (accessed September 13, 2017).

Borkowski, L., J. Strasser, A. Allina, and S. Wood. 2015. Medication abortion. Overview of research & policy in the United States . http://publichealth.gwu.edu/sites/default/files/Medication_Abortion_white_paper.pdf (accessed January 25, 2017).

Bracken, M. B., D. H. Freeman, Jr., and K. Hellenbrand. 1982. Hospitalization for medical-legal and other abortions in the United States 1970–1977. American Journal of Public Health 72(1):30–37.

Bryant, A. G., D. A. Grimes, J. M. Garrett, and G. S. Stuart. 2011. Second-trimester abortion for fetal anomalies or fetal death: Labor induction compared with dilation and evacuation. Obstetrics & Gynecology 117(4):788–792.

Cates, Jr., W., K. F. Schulz, D. A. Grimes, A. J. Horowitz, F. A. Lyon, F. H. Kravitz, and M. J. Frisch. 1982. Dilatation and evacuation procedures and second-trimester abortions. The role of physician skill and hospital setting. Journal of the American medical Association 248(5):559–563.

Cates, Jr., W., D. A. Grimes, and K. F. Schulz. 2000. Abortion surveillance at CDC: Creating public health light out of political heat. American Journal of Preventive Medicine 19(1, Suppl. 1):12–17.

CDC (Centers for Disease Control and Prevention). 1983. Surveillance summary abortion surveillance: Preliminary analysis, 1979–1980—United States. MMWR Weekly 32(5): 62–64. https://www.cdc.gov/mmwr/preview/mmwrhtml/00001243.htm (accessed September 18, 2017).

CDC. 2017. CDC’s abortion surveillance system FAQs . https://www.cdc.gov/reproductivehealth/data_stats/abortion.htm (accessed June 22, 2017).

Chen, M. J., and M. D. Creinin. 2015. Mifepristone with buccal misoprostol for medical abortion: A systematic review. Obstetrics & Gynecology 126(1):12–21.

Cleland, K., M. D. Creinin, D. Nucatola, M. Nshom, and J. Trussell. 2013. Significant adverse events and outcomes after medical abortion. Obstetrics & Gynecology 121(1):166–171.

Costescu, D., E. Guilbert, J. Bernardin, A. Black, S. Dunn, B. Fitzsimmons, W. V. Norman, H. Pymar, J. Soon, K. Trouton, M. S. Wagner, and E. Wiebe. 2016. Medical abortion. Journal of Obstetrics and Gynaecology Canada 38(4):366–389.

Donabedian, A. 1980. The definition of quality and approaches to its assessment. In Explorations in quality assessment and monitoring. Vol. 1. Ann Arbor, MI: Health Administration Press.

Edelman, D. A., W. E. Brenner, and G. S. Berger. 1974. The effectiveness and complications of abortion by dilatation and vacuum aspiration versus dilatation and rigid metal curettage. American Journal of Obstetrics and Gynecology 119(4):473–480.

Elam-Evans, L. D., L. T. Strauss, J. Herndon, W. Y. Parker, S. V. Bowens, S. Zane, and C. J. Berg. 2003. Abortion surveillance—United States, 2000. MMWR Surveillance Summaries 52(SS-12):1–32. https://www.cdc.gov/mmwr/preview/mmwrhtml/ss5212a1.htm (accessed September 18, 2017).

FDA (U.S. Food and Drug Administration). 2016. MIFEPREX ® : Highligh ts of prescribing information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/020687s020lbl.pdf (accessed September 11, 2017).

Finer, L. B., and S. K. Henshaw. 2003. Abortion incidence and services in the United States in 2000. Perspectives on Sexual and Reproductive Health 35(1):6–15.

Finer, L. B., and S. K. Henshaw. 2006. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health 38(2):90–96.

Finer, L. B., and M. R. Zolna. 2016. Declines in unintended pregnancy in the United States, 2008–2011. New England Journal of Medicine 374(9):843–852.

Finer, L. B., L. F. Frohwirth, L. A. Dauphinee, S. Singh, and A. M. Moore. 2006. Timing of steps and reasons for delays in obtaining abortions in the United States. Contraception 74(4):334–344.

Frick, A. C., E. A. Drey, J. T. Diedrich, and J. E. Steinauer. 2010. Effect of prior cesarean delivery on risk of second-trimester surgical abortion complications. Obstetrics & Gynecology 115(4):760–764.

Gary, M. M., and D. J. Harrison. 2006. Analysis of severe adverse events related to the use of mifepristone as an abortifacient. Annals of Pharmacotherapy 40(2):191–197.

Glasziou, P., E. Meats, C. Heneghan, and S. Shepperd. 2008. What is missing from descriptions of treatment in trials and reviews? British Medical Journal 336(7659):1472–1474.

Grimes, D. A., and G. Stuart. 2010. Abortion jabberwocky: The need for better terminology. Contraception 81(2):93–96.

Grimes, D. A., S. M. Smith, and A. D. Witham. 2004. Mifepristone and misoprostol versus dilation and evacuation for midtrimester abortion: A pilot randomised controlled trial. British Journal of Obstetrics & Gynaecology 111(2):148–153.

Grossman, D., K. Blanchard, and P. Blumenthal. 2008. Complications after second trimester surgical and medical abortion. Reproductive Health Matters 16(31 Suppl.):173–182.

Grossman, D., K. Grindlay, T. Buchacker, K. Lane, and K. Blanchard. 2011. Effectiveness and acceptability of medical abortion provided through telemedicine. Obstetrics & Gynecology 118(2 Pt. 1):296–303.

Guttmacher Institute. 2017a. Fact sheet: Induced abortion in the United States. https://www.guttmacher.org/fact-sheet/induced-abortion-united-states (accessed November 10, 2017).

Guttmacher Institute. 2017b. Bans on specific abortion methods used after the first trimester. https://www.guttmacher.org/state-policy/explore/bans-specific-abortion-methods-used-after-first-trimester (accessed September 12, 2017).

Guttmacher Institute. 2017c. Counseling and waiting periods for abortion. https://www.guttmacher.org/state-policy/explore/counseling-and-waiting-periods-abortion (accessed September 12, 2017).

Guttmacher Institute. 2017d. Medication abortion. https://www.guttmacher.org/state-policy/explore/medication-abortion (accessed September 12, 2017).

Guttmacher Institute. 2017e. An overview of abortion laws. https://www.guttmacher.org/state-policy/explore/overview-abortion-laws (accessed September 12, 2017).

Guttmacher Institute. 2017f. Requirements for ultrasound. https://www.guttmacher.org/state-policy/explore/requirements-ultrasound (accessed September 12, 2017).

Guttmacher Institute. 2017g. State funding of abortion under Medicaid. https://www.guttmacher.org/state-policy/explore/state-funding-abortion-under-medicaid (accessed September 12, 2017).

Guttmacher Institute. 2017h. State policies on later abortions. https://www.guttmacher.org/state-policy/explore/state-policies-later-abortions (accessed September 12, 2017).

Guttmacher Institute. 2017i. Targeted regulation of abortion providers. https://www.guttmacher.org/state-policy/explore/targeted-regulation-abortion-providers (accessed September 12, 2017).

Guttmacher Institute. 2018a. Abortion reporting requirements. https://www.guttmacher.org/state-policy/explore/abortion-reporting-requirements (accessed January 22, 2018).

Guttmacher Institute. 2018b. Restricting insurance coverage of abortion. https://www.guttmacher.org/state-policy/explore/restricting-insurance-coverage-abortion (accessed January 24, 2018).

Hopewell, S., M. Clarke, D. Moher, E. Wager, P. Middleton, D. G. Altman, K. F. Schulz, and the CONSORT Group. 2008. CONSORT for reporting randomized controlled trials in journal and conference abstracts: Explanation and elaboration. PLoS Medicine 5(1):e20.

Ioannidis, J. P., S. J. Evans, P. C. Gøtzsche, R. T. O’Neill, D. G. Altman, K. Schulz, D. Moher, and the CONSORT Group. 2004. Better reporting of harms in randomized trials: An extension of the CONSORT statement. Annals of Internal Medicine 141(10):781–788.

IOM (Institute of Medicine). 1975. Legalized abortion and the public health . Washington, DC: National Academy Press.

IOM. 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

IOM. 2011a. Clinical practice guidelines we can trust. Washington, DC: The National Academies Press.

IOM. 2011b. Finding what works in health care: Standards for systematic reviews. Washington, DC: The National Academies Press.

Ireland, L. D., M. Gatter, and A. Y. Chen. 2015. Medical compared with surgical abortion for effective pregnancy termination in the first trimester. Obstetrics & Gynecology 126(1):22–28.

Jatlaoui, T. C., A. Ewing, M. G. Mandel, K. B. Simmons, D. B. Suchdev, D. J. Jamieson, and K. Pazol. 2016. Abortion surveillance—United States, 2013. MMWR Surveillance Summaries 65(No. SS-12):1–44.

Jerman, J., and R. K. Jones. 2014. Secondary measures of access to abortion services in the United States, 2011 and 2012: Gestational age limits, cost, and harassment. Women’s Health Issues 24(4): e419–e424.

Jerman J., R. K. Jones, and T. Onda. 2016. Characteristics of U.S. abortion patients in 2014 and changes since 2008 . https://www.guttmacher.org/sites/default/files/report_pdf/characteristics-us-abortion-patients-2014.pdf (accessed October 17, 2016).

Jerman, J., L. Frohwirth, M. L. Kavanaugh, and N. Blades. 2017. Barriers to abortion care and their consequences for patients traveling for services: Qualitative findings from two states. Perspectives on Sexual and Reproductive Health 49(2):95–102.

Jones, R. K., and H. D. Boonstra. 2016. The public health implications of the FDA update to the medication abortion label. New York: Guttmacher Institute. https://www.guttmacher.org/article/2016/06/public-health-implications-fda-update-medication-abortion-label (accessed October 27, 2017).

Jones, R. K., and J. Jerman. 2017a. Abortion incidence and service availability in the United States, 2014. Perspectives on Sexual and Reproductive Health 49(1):1–11.

Jones, R. K., and J. Jerman. 2017b. Characteristics and circumstances of U.S. women who obtain very early and second trimester abortions. PLoS One 12(1):e0169969.

Jones, R. K., and M. L. Kavanaugh. 2011. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstetrics & Gynecology 117(6):1358–1366.

Jones, R. K., L. B. Finer, and S. Singh. 2010. Characteristics of U.S. abortion patients, 2008. New York: Guttmacher Institute.

Kahn, J. B., J. P. Bourne, J. D. Asher, and C. W. Tyler. 1971. Technical reports: Surveillance of abortions in hospitals in the United States, 1970. HSMHA Health Reports 86(5):423–430.

Kelly, T., J. Suddes, D. Howel, J. Hewison, and S. Robson. 2010. Comparing medical versus surgical termination of pregnancy at 13–20 weeks of gestation: A randomised controlled trial. British Journal of Obstetrics & Gynaecology 117(12): 1512–1520.

Koonin, L. M., and J. C. Smith. 1993. Abortion surveillance—United States, 1990. MMWR Surveillance Summaries 42(SS-6):29–57. https://www.cdc.gov/mmwr/preview/mmwrhtml/00031585.htm (accessed September 18, 2017).

Kost, K. 2015. Unintended pregnancy rates at the state level: Estimates for 2010 and trends since 2002. New York: Guttmacher Institute.

Kulier, R., N. Kapp, A. M. Gulmezoglu, G. J. Hofmeyr, L. Cheng, and A. Campana. 2011. Medical methods for first trimester abortion. The Cochrane Database of Systematic Reviews (11):CD002855.

Lawson, H. W., H. K. Atrash, A. F. Saftlas, L. M. Koonin, M. Ramick, and J. C. Smith. 1989. Abortion surveillance, United States, 1984–1985. MMWR Surveillance Summaries 38(SS-2):11–15. https://www.cdc.gov/Mmwr/preview/mmwrhtml/00001467.htm (accessed September 18, 2017).

Lean, T. H., D. Vengadasalam, S. Pachauri, and E. R. Miller. 1976. A comparison of D & C and vacuum aspiration for performing first trimester abortion. International Journal of Gynecology and Obstetrics 14(6):481–486.

Lichtenberg, E. S., and M. Paul. 2013. Surgical abortion prior to 7 weeks of gestation. Contraception 88(1):7–17.

Lohr, A. P., J. L. Hayes, and K. Gemzell Danielsson. 2008. Surgical versus medical methods for second trimester induced abortion. Cochrane Database of Systematic Reviews (1):CD006714.

Low, N., M. Mueller, H. A. Van Vliet, and N. Kapp. 2012. Perioperative antibiotics to prevent infection after first-trimester abortion. Cochrane Database of Systematic Reviews (3):CD005217.

Mauelshagen, A., L. C. Sadler, H. Roberts, M. Harilall, and C. M. Farquhar. 2009. Audit of short term outcomes of surgical and medical second trimester termination of pregnancy. Reproductive Health 6(1):16.

NAF (National Abortion Federation). 2017. 2017 Clinical policy guidelines for abortion care . Washington, DC: NAF.

Nash, E., R. B. Gold, L. Mohammed, O. Cappello, and Z. Ansari-Thomas. 2017. Laws affecting reproductive health and rights: State policy trends at midyear, 2017 . Washington, DC: Guttmacher Institute. https://www.guttmacher.org/article/2017/07/laws-affecting-reproductive-health-and-rights-state-policy-trends-midyear-2017 (accessed September 21, 2017).

Ngoc, N. T., T. Shochet, S. Raghavan, J. Blum, N. T. Nga, N. T. Minh, V. Q. Phan, B. Winikoff. 2011. Mifepristone and misoprostol compared with misoprostol alone for second-trimester abortion: A randomized controlled trial. Obstetrics & Gynecology 118(3):601–608.

Ohannessian, A., K. Baumstarck, J. Maruani, E. Cohen-Solal, P. Auquier, and A. Agostini. 2016. Mifepristone and misoprostol for cervical ripening in surgical abortion between 12 and 14 weeks of gestation: A randomized controlled trial. European Journal of Obstetrics & Gynecology and Reproductive Biology 201:151–155.

Pazol, K., A. A. Creanga, and S. B. Zane. 2012. Trends in use of medical abortion in the United States: Reanalysis of surveillance data from the Centers for Disease Control and Prevention, 2001–2008. Contraception 86(6):746–751.

Pazol, K., A. A. Creanga, and D. J. Jamieson. 2015. Abortion surveillance—United States, 2012. Morbidity and Mortality Weekly Report 64(SS-10):1–40.

Peterson, W. F., F. N. Berry, M. R. Grace, and C. L. Gulbranson. 1983. Second-trimester abortion by dilatation and evacuation: An analysis of 11,747 cases. Obstetrics & Gynecology 62(2):185–190.

Plint, A. C., D. Moher, A. Morrison, K. Schulz, D. G. Altman, C. Hill, and I. Gaboury. 2006. Does the CONSORT checklist improve the quality of reports of randomised controlled trials? A systematic review. Medical Journal of Australia 185(5):263–267.

Ranji, U., A. Salganicoff, L. Sobel, C. Rosenzweig, and I. Gomez. 2017. Financing family planning services for low-income women: The role of public programs. https://www.kff.org/womens-health-policy/issue-brief/financing-family-planning-services-for-low-income-women-the-role-of-public-programs (accessed September 9, 2017).

Raymond, E. G., C. Shannon, M. A. Weaver, and B. Winikoff. 2013. First-trimester medical abortion with mifepristone 200 mg and misoprostol: A systematic review. Contraception 87(1):26–37.

RCOG (Royal College of Obstetricians and Gynaecologists). 2011. The care of women requesting induced abortion (Evidence-based clinical guideline number 7). London, UK: RCOG Press. https://www.rcog.org.uk/globalassets/documents/guidelines/abortion-guideline_web_1.pdf (accessed July 27, 2017).

RCOG. 2015. Best practice in comprehensive abortion care (Best practice paper no. 2). London, UK: RCOG Press. https://www.rcog.org.uk/globalassets/documents/guidelines/best-practice-papers/best-practice-paper-2.pdf (accessed September 11, 2017).

Roblin, P. 2014. Vacuum aspiration. In Abortion care, edited by S. Rowlands. Cambridge, UK: Cambridge University Press.

Sackett, D. L. 1979. Bias in analytic research. Journal of Chronic Diseases 32(1–2):51–63.

Sonalkar, S., S. N. Ogden, L. K. Tran, and A. Y. Chen. 2017. Comparison of complications associated with induction by misoprostol versus dilation and evacuation for second-trimester abortion. International Journal of Gynaecology & Obstetrics 138(3):272–275.

Strauss, L. T., S. B. Gamble, W. Y. Parker, D. A. Cook, S. B. Zane, and S. Hamdan. 2007. Abortion surveillance—United States, 2004. MMWR Surveillance Summaries 56 (SS-12):1–33.

Upadhyay, U. D., S. Desai, V. Zlidar, T. A. Weitz, D. Grossman, P. Anderson, and D. Taylor. 2015. Incidence of emergency department visits and complications after abortion. Obstetrics & Gynecology 125(1):175–183.

von Elm, E., D. G. Altman, M. Egger, S. J. Pocock, P. C. Gøtzsche, and J. P. Vandenbrouke. 2007. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. PLoS Medicine 4(10):e296.

White, K., E. Carroll, and D. Grossman. 2015. Complications from first-trimester aspiration abortion: A systematic review of the literature. Contraception 92(5):422–438.

WHO (World Health Organization). 2012. Safe abortion: Technical and policy guidance for health systems (Second edition). http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf (accessed September 12, 2017).

WHO. 2014. Clinical practice handbook for safe abortion. Geneva, Switzerland: WHO Press. http://apps.who.int/iris/bitstream/10665/97415/1/9789241548717_eng.pdf?ua=1&ua=1 (accessed November 15, 2016).

Wildschut, H., M. I. Both, S. Medema, E. Thomee, M. F. Wildhagen, and N. Kapp. 2011. Medical methods for mid-trimester termination of pregnancy. The Cochrane Database of Systematic Reviews (1):Cd005216.

Woodcock, J. 2016. Letter from the director of the FDA Center for Drug Evaluation and Research to Donna Harrison, Gene Rudd, and Penny Young Nance. Re: Docket No. FDA-2002-P-0364. Silver Spring, MD: FDA.

Zane, S., A. A. Creanga, C. J. Berg, K. Pazol, D. B. Suchdev, D. J. Jamieson, and W. M. Callaghan. 2015. Abortion-related mortality in the United States: 1998–2010. Obstetrics & Gynecology 126(2):258–265.

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.

READ FREE ONLINE

Welcome to OpenBook!

You're looking at OpenBook, NAP.edu's online reading room since 1999. Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website.

Do you want to take a quick tour of the OpenBook's features?

Show this book's table of contents , where you can jump to any chapter by name.

...or use these buttons to go back to the previous chapter or skip to the next one.

Jump up to the previous page or down to the next one. Also, you can type in a page number and press Enter to go directly to that page in the book.

Switch between the Original Pages , where you can read the report as it appeared in print, and Text Pages for the web version, where you can highlight and search the text.

To search the entire text of this book, type in your search term here and press Enter .

Share a link to this book page on your preferred social network or via email.

View our suggested citation for this chapter.

Ready to take your reading offline? Click here to buy this book in print or download it as a free PDF, if available.

Get Email Updates

Do you enjoy reading reports from the Academies online for free ? Sign up for email notifications and we'll let you know about new publications in your areas of interest when they're released.

How Far Is Too Far? New Evidence on Abortion Clinic Closures, Access, and Abortions

We document the effects of abortion-clinic closures on clinic access, abortions, and births using variation generated by a law that shuttered nearly half of Texas' clinics. Increases in distance have significant effects for women initially living within 200 miles of a clinic. The largest effect is for those nearest to clinics for whom a 25-mile increase reduces abortion 10%. We also demonstrate the importance of congestion with a proxy capturing effects of closures which have little impact on distance but which reduce clinics per-capita. These effects account for 59% of the effects of clinic closures on abortion.

An earlier version of this paper was circulated in November 2016 under the title “The effect of abortion facility closures on fertility, sexual health and human capital.” An earlier version of this paper was circulated in November 2016 under the title “The effect of abortion facility closures on fertility, sexual health and human capital.” We are grateful to Christine Durrance, Ted Joyce, Analisa Packham, David Slusky, and Glen Waddell for helpful comments, along with seminar participants at Middlebury College, Sam Houston University, Southern Methodist University, the University of California-Merced, University of Kansas, Victoria University, and Williams College, and participants at the Stata Texas Empirical Microeconomics Conference, 2017 Annual Conference of the Southern Economic Association, 2018 Annual Conference of the Eastern Economic Association, and 2018 NBER Health Economics meeting. Anna Cerf and Birgitta Cheng provided expert assistance in creating our maps. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

MARC RIS BibTeΧ

Download Citation Data

• April 26, 2017
• June 20, 2017
• January 17, 2018

Published Versions

Mentioned in the news, more from nber.

In addition to working papers , the NBER disseminates affiliates’ latest findings through a range of free periodicals — the NBER Reporter , the NBER Digest , the Bulletin on Retirement and Disability , the Bulletin on Health , and the Bulletin on Entrepreneurship  — as well as online conference reports , video lectures , and interviews .

What can economic research tell us about the effect of abortion access on women’s lives?

Subscribe to the center for economic security and opportunity newsletter, caitlin knowles myers and caitlin knowles myers john g. mccullough professor of economics; co-director, middlebury initiative for data and digital methods - middlebury college @caitlin_k_myers morgan welch morgan welch senior research assistant & project coordinator - center on children and families, economic studies, brookings institution.

November 30, 2021

• 21 min read

On September 20, 2021, a group of 154 distinguished economists and researchers filed an amicus brief to the Supreme Court of the United States in advance of the Mississippi case, Dobbs v. Jackson Women’s Health Organization . For a full review of the evidence that shows how causal inference tools have been used to measure the effects of abortion access in the U.S., read the brief here .

Introduction

Dobbs v. Jackson Women’s Health Organization considers the constitutionality of a 2018 Mississippi law that prohibits women from accessing abortions after 15 weeks of pregnancy. This case is widely expected to determine the fate of Roe v. Wade as Mississippi is directly challenging the precedent set by the Supreme Court’s decisions in Roe , which protects abortion access before fetal viability (typically between 24 and 28 weeks of pregnancy). On December 1, 2021, the Supreme Court will hear oral arguments in Dobbs v. Jackson . In asking the Court to overturn Roe , the state of Mississippi offers reassurances that “there is simply no causal link between the availability of abortion and the capacity of women to act in society” 1 and hence no reason to believe that abortion access has shaped “the ability of women to participate equally in the economic and social life of the Nation” 2 as the Court had previously held.

While the debate over abortion often centers on largely intractable subjective questions of ethics and morality, in this instance the Court is being asked to consider an objective question about the causal effects of abortion access on the lives of women and their families. The field of economics affords insights into these objective questions through the application of sophisticated methodological approaches that can be used to isolate and measure the causal effects of abortion access on reproductive, social, and economic outcomes for women and their families.

Separating Correlation from Causation: The “Credibility Revolution” in Economics

To measure the causal effect of abortion on women’s lives, one must differentiate its effects from those of other forces, such as economic opportunity, social mores, the availability of contraception. Powerful statistical methodologies in the causal inference toolbox have made it possible for economists to do just that, moving beyond the maxim “correlation isn’t necessarily causation” and applying the scientific method to figure out when it is.

This year’s decision by the Economic Sciences Prize Committee recognized the contributions 3 of economists David Card, Joshua Angrist, and Guido Imbens, awarding them the Nobel Prize for their pathbreaking work developing and applying the tools of causal inference in a movement dubbed “the credibility revolution” (Angrist and Pischke, 2010). The gold standard for establishing such credibility is a well-executed randomized controlled trial – an experiment conducted in the lab or field in which treatment is randomly assigned. When economists can feasibly and ethically implement such experiments, they do. However, in the social world, this opportunity is often not available. For instance, one cannot feasibly or ethically randomly assign abortion access to some individuals but not others. Faced with this obstacle, economists turn to “natural” or “quasi” experimental methods, ones in which they are able to credibly argue that treatment is as good as randomly assigned.

Related Content

Elaine Kamarck

October 5, 2021

Katherine Guyot, Isabel V. Sawhill

July 29, 2019

Pioneering applications of this approach include work by Angrist and Krueger (1991) leveraging variation in compulsory school attendance laws to measure the effects of schooling on earnings and work by Card and Krueger (1994) leveraging minimum wage variation across state borders to measure the effects of the minimum wages on employment outcomes. The use of these methods is now widespread, not just in economics, but in other social sciences as well. Fueled by advances in computing technology and the availability of data, quasi-experimental methodologies have become as ubiquitous as they are powerful, applied to answer questions ranging from the effects of economic shocks on civil conflict (Miguel, Sayanath, and Sergenti, 2004), to the effects of the Clean Water Act on water pollution levels (Keiser and Shapiro, 2019), and effects of access to food stamps in childhood on later life outcomes (Hoynes, Schanzenbach, Almond 2016; Bailey et al., 2020).

Research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers.

Economists also have applied these tools to study the causal effects of abortion access. Research drawing on methods from the “credibility revolution” disentangles the effects of abortion policy from other societal and economic forces. This research demonstrates that abortion access does, in fact, profoundly affect women’s lives by determining whether, when, and under what circumstances they become mothers, outcomes which then reverberate through their lives, affecting marriage patterns, educational attainment, labor force participation, and earnings.

The Effects of Abortion Access on Women’s Reproductive, Economic, and Social Lives

Evidence of the effects of abortion legalization.

The history of abortion legalization in the United States affords both a canonical and salient example of a natural experiment. While Roe v. Wade legalized abortion in most of the country in 1973, five states—Alaska, California, Hawaii, New York, and Washington—and the District of Columbia repealed their abortion bans several years in advance of Roe . Using a methodology known as “difference-in-difference estimation,” researchers compared changes in outcomes in these “repeal states” when they lifted abortion bans to changes in outcomes in the rest of the country. They also compared changes in outcomes in the rest of the country in 1973 when Roe legalized abortion to changes in outcomes in the repeal states where abortion already was legal. This difference-in-differences methodology allows the states where abortion access is not changing to serve as a counterfactual or “control” group that accounts for other forces that were impacting fertility and women’s lives in the Roe era.

Among the first to employ this approach was a team of economists (Levine, Staiger, Kane, and Zimmerman, 1999) who estimated that the legalization of abortion in repeal states led to a 4% to 11% decline in births in those states relative to the rest of the country. Levine and his co-authors found that these fertility effects were particularly large for teens and women of color, who experienced birth rate reductions that were nearly three times greater than the overall population as a result of abortion legalization. Multiple research teams have replicated the essential finding that abortion legalization substantially impacted American fertility while extending the analysis to consider other outcomes. 4 For example, Myers (2017) found that abortion legalization reduced the number of women who became teen mothers by 34% and the number who became teen brides by 20%, and again observed effects that were even larger for Black teens. Farin, Hoehn-Velasco, and Pesko (2021) found that abortion legalization reduced maternal mortality among Black women by 30-40%, with little impact on white women, offering the explanation that where abortion was illegal, Black women were less likely to be able to access safe abortions by traveling to other states or countries or by obtaining a clandestine abortion from a trusted health care provider.

The ripple effects of abortion access on the lives of women and their families

This research, which clearly demonstrates the causal relationship between abortion access and first-order demographic and health outcomes, laid the foundation for researchers ­to measure further ripple effects through the lives of women and their families. Multiple teams of authors have extended the difference-in-differences research designs to study educational and labor market outcomes, finding that abortion legalization increased women’s education, labor force participation, occupational prestige, and earnings and that all these effects were particularly large for Black women (Angrist and Evans, 1996; Kalist, 2004; Lindo, Pineda-Torres, Pritchard, and Tajali, 2020; Jones, 2021).

Additionally, research shows that abortion access has not only had profound effects on women’s economic and social lives but has also impacted the circumstances into which children are born. Researchers using difference-in-differences research designs have found that abortion legalization reduced the number of children who were unwanted (Bitler and Zavodny, 2002a, reduced cases of child neglect and abuse (Bitler and Zavodny, 2002b; 2004), reduced the number of children who lived in poverty (Gruber, Levine, and Staiger, 1999), and improved long-run outcomes of an entire generation of children by increasing the likelihood of attending college and reducing the likelihood of living in poverty and receiving public assistance (Ananat, Gruber, Levine, and Staiger, 2009).

Access to abortion continues to be important to women’s lives

The research cited above relies on variation in abortion access from the 1970s, and much has changed in terms of both reproductive technologies and women’s lives. Recent research shows, however, that even with the social, economic, and legal shifts that have occurred over the last few decades and even with expanded access to contraception, abortion access remains relevant to women’s reproductive lives. Today, nearly half of pregnancies are unintended (Finer and Zolna, 2016). About 6% of young women (ages 15-34) experience an unintended pregnancy each year (Finer, Lindberg, and Desai, 2018), and about 1.4% of women of childbearing age obtain an abortion each year (Jones, Witwer, and Jerman, 2019). At these rates, approximately one in four women will receive an abortion in their reproductive lifetimes. The fact is clear: women continue to rely on abortion access to determine their reproductive lives.

But what about their economic and social lives? While women have made great progress in terms of their educational attainment, career trajectories, and role in society, mothers face a variety of challenges and penalties that are not adequately addressed by public policy. Following the birth of a child, it’s well documented that working mothers face a “motherhood wage penalty,” which entails lower wages than women who did not have a child (Waldfogel, 1998; Anderson, Binder, and Krause, 2002; Kelven et al., 2019). Maternity leave may combat this penalty as it allows women to return to their jobs following the birth of a child – encouraging them to remain attached to the labor force (Rossin-Slater, 2017). However, as of this writing, the U.S. only offers up to 12 weeks of unpaid leave through the FMLA, which extends coverage to less than 60% of all workers. 5 And even if a mother is able to return to work, childcare in the U.S. is costly and often inaccessible for many. Families with infants can be expected to pay around $11,000 a year for childcare and subsidies are only available for 1 in 6 children that are eligible under the federal program. 6 Without a federal paid leave policy and access to affordable childcare, the U.S. lacks the infrastructure to adequately support mothers, and especially working mothers – making the prospect of motherhood financially unworkable for some.

This is relevant when considering that the women who seek abortions tend to be low-income mothers experiencing disruptive life events. In the most recent survey of abortion patients conducted by the Guttmacher Institute, 97% are adults, 49% are living below the poverty line, 59% already have children, and 55% are experiencing a disruptive life event such as losing a job, breaking up with a partner, or falling behind on rent (Jones and Jerman, 2017a and 2017b). It is not a stretch to imagine that access to abortion could be pivotal to these women’s financial lives, and recent evidence from “The Turnaway Study” 7 provides empirical support for this supposition. In this study, an interdisciplinary team of researchers follows two groups of women who were typically seeking abortions in the second trimester: one group that arrived at abortion clinics and learned they were just over the gestational age threshold for abortions and were “turned away” and a second that was just under the threshold and were provided an abortion. Miller, Wherry, and Foster (2020) match individuals in both groups to their Experian credit reports and observe that in the months leading up to the moment they sought an abortion, financial outcomes for both groups were trending similarly. At the moment one group is turned away from a wanted abortion, however, they began to experience substantial financial distress, exhibiting a 78% increase in past-due debt and an 81% increase in public records related to bankruptcies, evictions, and court judgments.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase.

If Roe were overturned, the number of women experiencing substantial obstacles to obtaining an abortion would dramatically increase. Twelve states have enacted “trigger bans” designed to outlaw abortion in the immediate aftermath of a Roe reversal, while an additional 10 are considered highly likely to quickly enact new bans. 8 These bans would shutter abortion facilities across a wide swath of the American south and midwest, dramatically increasing travel distances and the logistical costs of obtaining an abortion. Economics research predicts what is likely to happen next. Multiple teams of economists have exploited natural experiments arising from mandatory waiting periods (Joyce and Kaestner, 2001; Lindo and Pineda-Torres, 2021; Myers, 2021) and provider closures (Quast, Gonzalez, and Ziemba, 2017; Fischer, Royer, and White, 2018; Lindo, Myers, Schlosser, and Cunningham, 2020; Venator and Fletcher, 2021; Myers, 2021). All have found that increases in travel distances prevent large numbers of women seeking abortions from reaching a provider and that most of these women give birth as a result. For instance, Lindo and co-authors (2020) exploit a natural experiment arising from the sudden closure of half of Texas’s abortion clinics in 2013 and find that an increase in travel distance from 0 to 100 miles results in a 25.8% decrease in abortions. Myers, Jones, and Upadhyay (2019) use these results to envision a post- Roe United States, forecasting that if Roe is overturned and the expected states begin to ban abortions, approximately 1/3 of women living in affected regions would be unable to reach an abortion provider, amounting to roughly 100,000 women in the first year alone.

Restricting, or outright eliminating, abortion access by overturning Roe v. Wade  would diminish women’s personal and economic lives, as well as the lives of their families.

Whether one’s stance on abortion access is driven by deeply held views on women’s bodily autonomy or when life begins, the decades of research using rigorous methods is clear: there is a causal link between access to abortion and whether, when, and under what circumstances women become mothers, with ripple effects throughout their lives. Access affects their education, earnings, careers, and the subsequent life outcomes for their children. In the state’s argument, Mississippi rejects the causal link between access to abortion and societal outcomes established by economists and states that the availability of abortion isn’t relevant to women’s full participation in society. Economists provide clear evidence that overturning Roe would prevent large numbers of women experiencing unintended pregnancies—many of whom are low-income and financially vulnerable mothers—from obtaining desired abortions. Restricting, or outright eliminating, that access by overturning Roe v. Wade would diminish women’s personal and economic lives, as well as the lives of their families.

Caitlin Knowles Myers did not receive financial support from any firm or person for this article. She has received financial compensation from Planned Parenthood Federation of America and the Center for Reproductive Rights for serving as an expert witness in litigation involving abortion regulations. She has not and will not receive financial compensation for her role in the amicus brief described here. Other than the aforementioned, she has not received financial support from any firm or person with a financial or political interest in this article. Caitlin Knowles Myers is not currently an officer, director, or board member of any organization with a financial or political interest in this article.

Abboud, Ali, 2019. “The Impact of Early Fertility Shocks on Women’s Fertility and Labor Market Outcomes.” Available from SSRN: https://ssrn.com/abstract=3512913

Anderson, Deborah J., Binder, Melissa, and Kate Krause, 2002. “The motherhood wage penalty: Which mothers pay it and why?” The American Economic Review 92(2). Retrieved from https://www.aeaweb.org/articles?id=10.1257/000282802320191606

Ananat, Elizabeth Oltmans, Gruber, Jonathan, Levine, Phillip and Douglas Staiger, 2009. “Abortion and Selection.” The Review of Economic Statistics 91(1). Retrieved from https://direct.mit.edu/rest/article-abstract/91/1/124/57736/Abortion-and-Selection?redirectedFrom=fulltext .

Angrist, Joshua D., and Alan B. Krueger, 1999. “Does Compulsory School Attendance Affect Schooling and Earnings?” The Quarterly Journal of Economics 106(4). Retrieved from https://doi.org/10.2307/2937954 .

Angrist, Joshua D., and William N. Evans, 1996. “Schooling and Labor Market Consequences of the 1970 State Abortion Reforms.” National Bureau of Economic Research Working Paper 5406. Retrieved from https://www.nber.org/papers/w5406 .

Angrist, Joshua D., and Jörn-Steffen Pischke, 2010. “The Credibility Revolution in Empirical Economics: How Better Research Design Is Taking the Con out of Econometrics.” Journal of Economic Perspectives 24(2). Retrieved from https://www.aeaweb.org/articles?id=10.1257/jep.24.2.3

Bailey, Martha J., Hoynes, Hilary W., Rossin-Slater, Maya and Reed Walker, 2020. “Is the Social Safety Net a Long-Term Investment? Large-Scale Evidence from the Food Stamps Program” National Bureau of Economic Research Working Paper 26942 , Retrieved from https://www.nber.org/papers/w26942

Bitler, Marianne, and Madeline Zavodny, 2002a. “Did Abortion Legalization Reduce the Number of Unwanted Children? Evidence from Adoptions.” Perspectives on Sexual and Reproductive Health, 34 (1): 25-33. Retrieved from https://www.jstor.org/stable/3030229?origin=JSTOR-pdf

Bitler, Marianne, and Madeline Zavodny, 2002b. “Child Abuse and Abortion Availability.” American Economic Review , 92 (2): 363-367. Retrieved from https://www.aeaweb.org/articles?id=10.1257/000282802320191624

Bitler, Marianne, and Madeline Zavodny, 2004. “Child Maltreatment, Abortion Availability, and Economic Conditions.” Review of Economics of the Household 2: 119-141. Retrieved from https://doi.org/10.1023/B:REHO.0000031610.36468.0e

Farin, Sherajum Monira, Hoehn-Velasco, Lauren, and Michael Pesko, 2021. “The Impact of Legal Abortion on Maternal Health: Looking to the Past to Inform the Present.” Retrieved from SSRN: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3913899

Finer, Lawrence B., and Mia R. Zolna, 2016. “Declines in Unintended Pregnancy in the United States, 2008–2011” New England Journal of Medicine 374. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26962904/

Finer, Lawrence B., Lindberg, Laura, D., and Sheila Desai. “A prospective measure of unintended pregnancy in the United States.” Contraception 98(6). Retrieved from https://pubmed.ncbi.nlm.nih.gov/29879398/

Fischer, Stefanie, Royer, Heather, and Corey White, 2017. “The Impacts of Reduced Access to Abortion and Family Planning Services on Abortion, Births, and Contraceptive Purchases.” National Bureau of Economic Research Working Paper 23634 . Retrieved from https://www.nber.org/papers/w23634

Gruber, Jonathan, Levine, Phillip, and Douglas Staiger, 1999. “Abortion Legalization and Child Living Circumstances: Who Is the ‘Marginal Child’?” Quarterly Journal of Economics 114. Retrieved from https://doi.org/10.1162/003355399556007

Guldi, Melanie, 2008. “Fertility effects of abortion and birth control pill access for minors.” Demography 45 . Retrieved from https://doi.org/10.1353/dem.0.0026

Hoynes, Hilary, Schanzenbach, Diane Whitmore, and Douglas Almond, 2016. “Long-Run Impacts of Childhood Access to the Safety Net.” American Economic Review 106(4). Retrieved from https://www.aeaweb.org/articles?id=10.1257/aer.20130375

Jones, Kelly, 2021. “At a Crossroads: The Impact of Abortion Access on Future Economic Outcomes.” American University Working Paper . Retrieved from https://doi.org/10.17606/0Q51-0R11 .

Jones, Rachel K., Witwer, Elizabeth, Jerman, Jenna, September 18, 2018. “Abortion Incidence and Service Availability in the United States, 2017.” Guttmacher Institute. Retrieved from https://www.guttmacher.org/sites/ default/files/report_pdf/abortion-inciden ce-service-availability-us-2017.

Jones Rachel K., and Janna Jerman, 2017a. ”Population group abortion rates and lifetime incidence of abortion: United States, 2008–2014.”  American Journal of Public Health 107 (12). Retrieved from https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.304042

Jones, Rachel K. and Jenna Jerman, 2017b. “Characteristics and Circumstances of U.S. Women Who Obtain Very Early and Second-Trimester Abortions.” PLoS One . Retrieved from https://pubmed.ncbi.nlm.nih.gov/28121999/

Joyce, Ted, and Robert Kaestner, 2001. “The Impact of Mandatory Waiting Periods and Parental Consent Laws on the Timing of Abortion and State of Occurrence among Adolescents in Mississippi and South Carolina.” Journal of Policy Analysis and Management 20(2) . Retrieved from https://www.jstor.org/stable/3325799 .

Kalist, David E., 2004. “Abortion and Female Labor Force Participation: Evidence Prior to Roe v. Wade.” Journal of Labor Research 25 (3) .

Keiser, David, and Joseph Shapiro, 2019. “Consequences of the Clean Water Act and the Demand for Water Quality.” The Quarterly Journal of Economics 134 (1).

Kleven, Henrik, Landais, Camille, Posch, Johanna, Steinhauer, Andreas, and Josef Zweimuleler, 2019. “Child Penalties Across Countries: Evidence and Explanations.” AEA Papers and Proceedings 109. Retrieved from https://www.aeaweb.org/articles?id=10.1257/pandp.20191078/

Levine, Phillip, Staiger, Douglas, Kane, Thomas, and David Zimmerman, 1999. “Roe v. Wade and American Fertility.” American Journal Of Public Health 89(2) . Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1508542/

Lindo, Jason M., Myers, Caitlin Knowles, Schlosser, Andrea, and Scott Cunningham, 2020. “How Far Is Too Far? New Evidence on Abortion Clinic Closures, Access, and Abortions” Journal of Human Resources 55. Retrieved from http://jhr.uwpress.org/content/55/4/1137.refs

Lindo, Jason M., Pineda-Torres, Mayra, Pritchard, David, and Hedieh Tajali, 2020. “Legal Access to Reproductive Control Technology, Women’s Education, and Earnings Approaching Retirement.” AEA Papers and Proceedings 110. Retrieved from https://www.aeaweb.org/articles?id=10.1257/pandp.20201108

Lindo, Jason M., and Mayra Pineda-Torres, 2021. “New Evidence on the Effects of Mandatory Waiting Periods for Abortion.” J ournal of Health Econ omics. Retrieved from https://pubmed.ncbi.nlm.nih.gov/34607119/

Miguel, Edward, Satyanath, Shanker, and Ernest Sergenti, 2004. “Economic Shocks and Civil Conflict: An Instrumental Variables Approach.” Journal of Political Economy 112(4). Retrieved from https://www.jstor.org/stable/10.1086/421174

Miller, Sarah, Wherry, Laura R., and Diana Greene Foster, 2020. “The Economic Consequences of Being Denied an Abortion.” National Bureau of  Economic Research, Working Paper 26662 . Retrieved from https://www.nber.org/papers/w26662 .

Myers, Caitlin Knowles, 2017. “The Power of Abortion Policy: Reexamining the Effects of Young Women’s Access to Reproductive Control” Journal of Political Economy 125(6) .  Retrieved from https://doi.org/10.1086/694293 .

Myers, Caitlin Knowles, Jones, Rachel, and Ushma Upadhyay, 2019. “Predicted changes in abortion access and incidence in a post-Roe world.” Contraception 100(5). Retrieved from https://pubmed.ncbi.nlm.nih.gov/31376381/

Myers, Caitlin Knowles, 2021. “Cooling off or Burdened? The Effects of Mandatory Waiting Periods on Abortions and Births.” IZA Institute of Labor Economics No. 14434. Retrieved from https://www.iza.org/publications/dp/14434/cooling-off-or-burdened-the-effects-of-mandatory-waiting-periods-on-abortions-and-births

Quast, Troy, Gonzalez, Fidel, and Robert Ziemba, 2017. “Abortion Facility Closings and Abortion Rates in Texas.” Inquiry: A Journal of Medical Care Organization, Provision and Financing 54 . Retrieved from https://journals.sagepub.com/doi/full/10.1177/0046958017700944

Rossin-Slater, Maya, 2017. “Maternity and Family Leave Policy.” National Bureau of Economic Research Working Paper 23069. Retrieved from https://www.nber.org/papers/w23069

Venator, Joanna, and Jason Fletcher, 2020. “Undue Burden Beyond Texas: An Analysis of Abortion Clinic Closures, Births, and Abortions in Wisconsin.” Journal of Policy Analysis and Management 40(3). Retrieved from https://doi.org/10.1002/pam.22263

Waldfogel, Jane, 1998. “The family gap for young women in the United States and Britain: Can maternity leave make a difference?” Journal of Labor Economics 16(3).

• Thomas E. Dobbs v. Jackson Women’s Health Organization. On Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, Brief in Support of Petitioners, No. 19-1392.
• Thomas E. Dobbs v. Jackson Women’s Health Organization. On Writ of Certiorari to the United States Court of Appeals for the Fifth Circuit, Brief for Petitioners, No. 19-139, Retrieved from https://www.supremecourt.gov/DocketPDF/19/19-1392/184703/20210722161332385_19-1392BriefForPetitioners.pdf
• The Nobel Prize. 2021. “Press release: The Prize in Economic Sciences 202.” Retrieved from https://www.nobelprize.org/prizes/economic-sciences/2021/press-release/
• See Angrist and Evans (1996), Gruber et al. (1999), Ananat et al. (2009), Guldi (2008), Myers (2017), Abboud (2019), Jones (2021).
• Brown, Scott, Herr, Jane, Roy, Radha , and Jacob Alex Klerman, July 2020. “Employee and Worksite Perspectives of the FMLA Who Is Eligible?” U.S. Department of Labor. Retrieved from https://www.dol.gov/sites/dolgov/files/OASP/evaluation/pdf/WHD_FMLA2018PB1WhoIsEligible_StudyBrief_Aug2020.pdf
• Whitehurst, Grover J., April 19, 2018. “What is the market price of daycare and preschool?” Brookings Institution. Retrieved from https://www.brookings.edu/research/what-is-the-market-price-of-daycare-and-preschool/; Chien, Nina, 2021. “Factsheet: Estimates of Child Care Eligibility & Receipt for Fiscal Year 2018.” U.S. Department of Health and Human Services. Retrieved from https://aspe.hhs.gov/sites/default/files/20 21-08/cy-2018-child-care-subsidy-eligibility.pdf
• Advancing New Standards in Reproductive Health (NSIRH). “The Turnaway Study.” Retrieved from https://www.ansirh.org/research/ongoing/turnaway-study.
• Center for Reproductive Rights, 2021. “What If Roe Fell?” Retrieved from https://maps.reproductiverights.org/what-if-roe-fell

Economic Studies

Center for Economic Security and Opportunity

Vanessa Williamson

May 14, 2024

Simon Hodson

May 8, 2024

The Brookings Institution, Washington D.C.

10:00 am - 11:15 am EDT

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• 27 February 2024

Influential abortion-pill studies retracted: the science behind the decision

• Mariana Lenharo

You can also search for this author in PubMed   Google Scholar

Early this month, a scientific publisher retracted two studies 1 , 2 cited by a federal judge in Texas when he ruled that the abortion pill mifepristone should be taken off the market , suggesting that the drug causes a burden on the public-health system. It also retracted a third 3 that surveyed abortion providers in Florida, linking them to malpractice and disciplinary issues. According to Sage Publications , the first two papers had problems with study design and methodology and errors in data analysis. And all three included unsupported assumptions and misleading data presentations. In addition, the studies’ authors, many of whom are affiliated with anti-abortion organizations, failed to declare conflicts of interest, Sage said in its retraction notice.

Access options

Access Nature and 54 other Nature Portfolio journals

Get Nature+, our best-value online-access subscription

24,99 € / 30 days

cancel any time

Subscribe to this journal

Receive 51 print issues and online access

185,98 € per year

only 3,65 € per issue

Rent or buy this article

Prices vary by article type

Prices may be subject to local taxes which are calculated during checkout

doi: https://doi.org/10.1038/d41586-024-00556-0

Studnicki, J. et al. Health Serv. Res. Manag. Epidemiol . https://doi.org/10.1177/23333928211053965 (2021); retraction https://doi.org/10.1177/23333928231216699 (2024).

Article   PubMed   Google Scholar  

Studnicki, J. et al. Health Serv. Res. Manag. Epidemiol . https://doi.org/10.1177/23333928221103107 (2022); retraction https://doi.org/10.1177/23333928231216699 (2024).

Studnicki, J. et al. Health Serv. Res. Manag. Epidemiol . https://doi.org/10.1177/2333392819841211 (2019); retraction https://doi.org/10.1177/23333928231216699 (2024).

Raymond, E. G., Shannon, C., Weaver, M. A. & Winikoff, B. Contraception 87 , 26–27 (2013).

Coleman, P. K. Br. J. Psychiatry 119 , 180–186 (2011).

Article   Google Scholar  

Littell, J. H. et al. BMJ 384 , e076518 (2024).

Google Scholar  

Download references

Reprints and permissions

Supplementary Information

• 23.11.29-Letter-from-D.-Shaneyfelt-to-R.-Sander-and-enclosed-explanation-_Redacted

Related Articles

• Public health

Egypt is building a $1-billion mega-museum. Will it bring Egyptology home?

News Feature 22 MAY 24

Pay researchers to spot errors in published papers

World View 21 MAY 24

Harassment of scientists is surging — institutions aren’t sure how to help

News Feature 21 MAY 24

Trials that infected people with common colds can inform today’s COVID-19 challenge trials

Correspondence 21 MAY 24

A global pandemic treaty is in sight: don’t scupper it

Editorial 21 MAY 24

Could bird flu in cows lead to a human outbreak? Slow response worries scientists

News 17 MAY 24

Why babies in South Korea are suing the government

News 20 MAY 24

US TikTok ban: how the looming restriction is affecting scientists on the app

News 09 MAY 24

Judge dismisses superconductivity physicist’s lawsuit against university

News 25 APR 24

Editor (Structural biology, experimental and/or computational biophysics)

We are looking for an Editor to join Nature Communications, the leading multidisciplinary OA journal, publishing high-quality scientific research.

London or New York - hybrid working model.

Springer Nature Ltd

Wissenschaftliche/r Mitarbeiter/in - Quantencomputing mit gespeicherten Ionen

Wissenschaftliche/r Mitarbeiter/in - Quantencomputing mit gespeicherten Ionen Bereich: Fakultät IV - Naturwissenschaftlich-Technische Fakultät | St...

Siegen, Nordrhein-Westfalen (DE)

Universität Siegen

Wissenschaftliche/r Mitarbeiter/in (PostDoc) - Quantencomputing mit gespeicherten Ionen

Wissenschaftliche/r Mitarbeiter/in (PostDoc) - Quantencomputing mit gespeicherten Ionen Bereich: Fakultät IV - Naturwissenschaftlich-Technische Fak...

Professor Helminthology

Excellent track record on the biology and immunobiology of zoonotic helminths and co-infections, with a strong scientific network.

Antwerp, New York

Institute of Tropical Medicine

Assistant Professor in Plant Biology

The Plant Science Program in the Biological and Environmental Science and Engineering (BESE) Division at King Abdullah University of Science and Te...

Saudi Arabia (SA)

King Abdullah University of Science and Technology

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

• Skip to main content
• Keyboard shortcuts for audio player

• Your Health
• Treatments & Tests
• Health Inc.
• Public Health

Reproductive rights in America

Despite state bans, abortions nationwide are up, driven by telehealth.

Elissa Nadworny

Abortion rights activists at the Supreme Court in Washington, D.C. on March 26, the day the case about the abortion drug mifepristone was heard. The number of abortions in the U.S. increased, a study says, surprising researchers. Drew Angerer/AFP via Getty Images hide caption

Abortion rights activists at the Supreme Court in Washington, D.C. on March 26, the day the case about the abortion drug mifepristone was heard. The number of abortions in the U.S. increased, a study says, surprising researchers.

In the 18 months following the Supreme Court's decision that ended federal protection for abortion, the number of abortions in the U.S. has continued to grow, according to The Society of Family Planning's WeCount project .

"We are seeing a slow and small steady increase in the number of abortions per month and this was completely surprising to us," says Ushma Upadhyay , a professor and public health scientist at the University of California, San Francisco who co-leads the research. According to the report, in 2023 there were, on average, 86,000 abortions per month compared to 2022, where there were about 82,000 abortions per month. "Not huge," says Upadhyay, "but we were expecting a decline."

Shots - Health News

What's at stake in the supreme court mifepristone case.

The slight increase comes despite the fact that 14 states had total abortion bans in place during the time of the research. According to the report, there were about 145,000 fewer abortions in person in those states since the Dobbs decision, which triggered many of the restrictive state laws.

"We know that there are people living in states with bans who are not getting their needed abortions," says Upadhyay. "The concern we have is that that might be overlooked by these increases."

Florida, California and Illinois saw the largest surges in abortions, which is especially interesting given Florida's recent 6-week ban that started on May 1.

Abortion rights opponents demonstrate in New York City, on March 23. Some states' abortion bans are known as "heartbeat bills," because they make abortion illegal after cardiac activity starts, usually around six weeks of pregnancy. Kena Betancur/AFP via Getty Images hide caption

Abortion rights opponents demonstrate in New York City, on March 23. Some states' abortion bans are known as "heartbeat bills," because they make abortion illegal after cardiac activity starts, usually around six weeks of pregnancy.

The latest report also captures for the first time the impact of providers offering telehealth abortions from states with protections for doctors and clinics known as shield laws – statutes that say they can't be prosecuted or held liable for providing abortion care to people from other states.

Between July and December 2023, more than 40,000 people in states with abortion bans and telehealth restrictions received medication abortion through providers in states protected by shield laws. Abortion pills can be prescribed via telehealth appointments and sent through the mail; the pills can safely end pregnancies in the first trimester.

The report includes abortions happening within the U.S. health care system, and does not include self-managed abortions, when people take pills at home without the oversight of a clinician. For that reason, researchers believe these numbers are still an undercount of abortions happening in the U.S.

Tessa Longbons Cox is a senior research associate at Charlotte Lozier Institute, a research organization that opposes abortion. She says the WeCount report, "highlights a concerning trend" that policies around mail-order abortion pills are boosting abortion rates. "By recklessly removing in-person medical visits and safeguards, abortion advocates have put women's health and safety last," Longbons Cox says in a statement.

Accounting for the increases

A major factor in the uptick in abortions nationwide is the rise of telehealth, made possible in part by regulations first loosened during the coronavirus pandemic.

According to the report, telehealth abortions now make up 19% of all abortions in the U.S. In comparison, the first WeCount report which spanned April 2022 through August 2022 showed telehealth abortions accounted for just 4% of all abortions. Research has shown that telehealth abortions are as safe and effective as in-clinic care.

"It's affordable, it's convenient, and it feels more private," says Jillian Barovick, a midwife in Brooklyn and one of the co-founders of Juniper Midwifery , which offers medication abortion via telehealth to patients in six states where abortion is legal. The organization saw its first patient in August 2022 and now treats about 300 patients a month.

A Supreme Court abortion pill case with potential consequences for every other drug

"Having an in-clinic abortion, even a medication abortion, you could potentially be in the clinic for hours, whereas with us you get to sort of bypass all of that," she says. Instead, patients can connect with a clinician using text messages or a secure messaging platform. In addition to charging $100 dollars for the consultation and medication – which is well below the average cost of an abortion – Barovick points to the cost savings of not having to take off work or arrange child care to spend multiple hours in a clinic.

She says her patients receive their medication within 1 to 4 business days, "often faster than you can get an appointment in a clinic."

A study published in JAMA Internal Medicine on Monday followed about 500 women who had medication abortions with the pills distributed via mail order pharmacy after an in-person visit with a doctor. More than 90% of the patients were satisfied with the experience; there were three serious adverse events that required hospitalization.

In addition to expansions in telehealth, there have been new clinics in states like Kansas, Illinois and New Mexico, and there's been an increase in funding for abortion care – fueled by private donors and abortion funds.

The impact of shield laws

During the period from October to December 2023, nearly 8,000 people per month in states with bans or severe restrictions accessed medication abortions from clinicians providing telehealth in the 5 states that had shield laws at the time. That's nearly half of all monthly telehealth abortions.

"It's telemedicine overall that is meeting the need of people who either want to or need to remain in their banned or restricted state for their care," says Angel Foster, who founded The MAP, a group practice operating a telehealth model under Massachusetts' shield laws. "If you want to have your abortion care in your state and you live in Texas or Mississippi or Missouri, right now, the shield law provision is by far the most dominant way that you'd be able to get that care."

Foster's group offers medication abortions for about 500 patients a month. About 90% of their patients are in banned or restrictive states; about a third are from Texas, their most common state of origin, followed by Florida.

"Patients are scared that we are a scam," she says, "they can't believe that we're legit."

Since the WeCount data was collected, additional states including Maine and California have passed shield laws protecting providers who offer care nationwide. The new shield laws circumvent traditional telemedicine laws, which often require out-of-state health providers to be licensed in the states where patients are located. States with abortion bans or restrictions and/or telehealth bans hold the provider at fault, not the patient.

The NPR Politics Podcast

One small pill — one big court case.

Existing lawsuits brought by abortion opponents, including the case awaiting a Supreme Court decision, have the potential to disrupt this telehealth surge by restricting the use of the drug mifepristone nationwide. If the Supreme Court upholds an appeals court ruling, providers would be essentially barred from mailing the drug and an in-person doctor visit would be required.

There is also an effort underway in Louisiana to classify abortion pills as a controlled substance.

• abortion bans
• Abortion rights

Numbers, Facts and Trends Shaping Your World

Read our research on:

Full Topic List

Regions & Countries

• Publications
• Our Methods
• Short Reads
• Tools & Resources

Read Our Research On:

Broad Public Support for Legal Abortion Persists 2 Years After Dobbs

By more than 2 to 1, americans say medication abortion should be legal, table of contents.

• Other abortion attitudes
• Overall attitudes about abortion
• Americans’ views on medication abortion in their states
• How statements about abortion resonate with Americans
• Acknowledgments
• The American Trends Panel survey methodology

Pew Research Center conducted this study to understand Americans’ views on the legality of abortion, as well as their perceptions of abortion access. For this analysis, we surveyed 8,709 adults from April 8 to 14, 2024. Everyone who took part in this survey is a member of the Center’s American Trends Panel (ATP), an online survey panel that is recruited through national, random sampling of residential addresses. This way nearly all U.S. adults have a chance of selection. The survey is weighted to be representative of the U.S. adult population by gender, race, ethnicity, partisan affiliation, education and other categories. Read more about the ATP’s methodology .

Here are the questions used for the report and its methodology .

Nearly two years after the Supreme Court overturned the 1973 Roe v. Wade decision guaranteeing a national right to abortion, a majority of Americans continue to express support for abortion access.

About six-in-ten (63%) say abortion should be legal in all or most cases. This share has grown 4 percentage points since 2021 – the year prior to the 2022 decision in Dobbs v. Jackson Women’s Health Organization that overturned Roe.

The new Pew Research Center survey, conducted April 8-14, 2024, among 8,709 adults, surfaces ongoing – and often partisan – divides over abortion attitudes:

• Democrats and Democratic-leaning independents (85%) overwhelmingly say abortion should be legal in all or most cases, with near unanimous support among liberal Democrats.
• By comparison, Republicans and Republican leaners (41%) are far less likely to say abortion should be legal in all or most cases. However, two-thirds of moderate and liberal Republicans still say it should be.

Since before Roe was overturned, both parties have seen a modest uptick in the share who say abortion should be legal.

As in the past, relatively few Americans (25%) say abortion should be legal in all cases, while even fewer (8%) say it should be illegal in all cases. About two-thirds of Americans do not take an absolutist view: 38% say it should be legal in most cases, and 28% say it should be illegal in most cases.

Related: Americans overwhelmingly say access to IVF is a good thing

Women’s abortion decisions

A narrow majority of Americans (54%) say the statement “the decision about whether to have an abortion should belong solely to the pregnant woman” describes their views extremely or very well. Another 19% say it describes their views somewhat well, and 26% say it does not describe their views well.

Views on an embryo’s rights

About a third of Americans (35%) say the statement “human life begins at conception, so an embryo is a person with rights” describes their views extremely or very well, while 45% say it does not describe their views well.

But many Americans are cross-pressured in their views: 32% of Americans say both statements about women’s decisions and embryos’ rights describe their views at least somewhat well.

Abortion access

About six-in-ten Americans in both parties say getting an abortion in the area where they live would be at least somewhat easy, compared with four-in-ten or fewer who say it would be difficult.

However, U.S. adults are divided over whether getting an abortion should be easier or harder:

• 31% say it should be easier for someone to get an abortion in their area, while 25% say it should be harder. Four-in-ten say the ease of access should be about what it is now.
• 48% of Democrats say that obtaining an abortion should be easier than it is now, while just 15% of Republicans say this. Instead, 40% of Republicans say it should be harder (just 11% of Democrats say this).

As was the case last year, views about abortion access vary widely between those who live in states where abortion is legal and those who live in states where it is not allowed.

For instance, 20% of adults in states where abortion is legal say it would be difficult to get an abortion where they live, but this share rises to 71% among adults in states where abortion is prohibited.

Medication abortion

Americans say medication abortion should be legal rather than illegal by a margin of more than two-to-one (54% vs. 20%). A quarter say they are not sure.

Like opinions on the legality of abortion overall, partisans differ greatly in their views of medication abortion:

• Republicans are closely split but are slightly more likely to say it should be legal (37%) than illegal (32%). Another 30% aren’t sure.
• Democrats (73%) overwhelmingly say medication abortion should be legal. Just 8% say it should be illegal, while 19% are not sure.

Across most other demographic groups, Americans are generally more supportive than not of medication abortion.

Across demographic groups, support for abortion access has changed little since this time last year.

Today, roughly six-in-ten (63%) say abortion should be legal in all (25%) or most (38%) cases. And 36% say it should be illegal in all (8%) or most (28%) cases.

While differences are only modest by gender, other groups vary more widely in their views.

Race and ethnicity

Support for legal abortion is higher among Black (73%) and Asian (76%) adults compared with White (60%) and Hispanic (59%) adults.

Compared with older Americans, adults under 30 are particularly likely to say abortion should be legal: 76% say this, versus about six-in-ten among other age groups.

Those with higher levels of formal education express greater support for legal abortion than those with lower levels of educational attainment.

About two-thirds of Americans with a bachelor’s degree or more education (68%) say abortion should be legal in all or most cases, compared with six-in-ten among those without a degree.

White evangelical Protestants are about three times as likely to say abortion should be illegal (73%) as they are to say it should be legal (25%).

By contrast, majorities of White nonevangelical Protestants (64%), Black Protestants (71%) and Catholics (59%) say abortion should be legal. And religiously unaffiliated Americans are especially likely to say abortion should be legal (86% say this).

Partisanship and ideology

Democrats (85%) are about twice as likely as Republicans (41%) to say abortion should be legal in all or most cases.

But while more conservative Republicans say abortion should be illegal (76%) than legal (27%), the reverse is true for moderate and liberal Republicans (67% say legal, 31% say illegal).

By comparison, a clear majority of conservative and moderate Democrats (76%) say abortion should be legal, with liberal Democrats (96%) overwhelmingly saying this.

Views of abortion access by state

About six-in-ten Americans (58%) say it would be easy for someone to get an abortion in the area where they live, while 39% say it would be difficult.

This marks a slight shift since last year, when 54% said obtaining an abortion would be easy. But Americans are still less likely than before the Dobbs decision to say obtaining an abortion would be easy.

Still, Americans’ views vary widely depending on whether they live in a state that has banned or restricted abortion.

In states that prohibit abortion, Americans are about three times as likely to say it would be difficult to obtain an abortion where they live as they are to say it would be easy (71% vs. 25%). The share saying it would be difficult has risen 19 points since 2019.

In states where abortion is restricted or subject to legal challenges, 51% say it would be difficult to get an abortion where they live. This is similar to the share who said so last year (55%), but higher than the share who said this before the Dobbs decision (38%).

By comparison, just 20% of adults in states where abortion is legal say it would be difficult to get one. This is little changed over the past five years.

Americans’ attitudes about whether it should be easier or harder to get an abortion in the area where they live also varies by geography.

Overall, a decreasing share of Americans say it should be harder to obtain an abortion: 33% said this in 2019, compared with 25% today.

This is particularly true of those in states where abortion is now prohibited or restricted.

In both types of states, the shares of Americans saying it should be easier to obtain an abortion have risen 12 points since before Roe was overturned, as the shares saying it should be harder have gradually declined.

By comparison, changes in views among those living in states where abortion is legal have been more modest.

While Americans overall are more supportive than not of medication abortion (54% say it should be legal, 20% say illegal), there are modest differences in support across groups:

• Younger Americans are somewhat more likely to say medication abortion should be legal than older Americans. While 59% of adults ages 18 to 49 say it should be legal, 48% of those 50 and older say the same.
• Asian adults (66%) are particularly likely to say medication abortion should be legal compared with White (55%), Black (51%) and Hispanic (47%) adults.
• White evangelical Protestants oppose medication abortion by about two-to-one (45% vs. 23%), with White nonevangelicals, Black Protestants, Catholics and religiously unaffiliated adults all being more likely than not to say medication abortion should be legal.
• Republicans are closely divided over medication abortion: 37% say it should be legal while 32% say it should be illegal. But similar to views on abortion access overall, conservative Republicans are more opposed (43% illegal, 27% legal), while moderate and liberals are more supportive (55% legal, 14% illegal).

Just over half of Americans (54%) say “the decision about whether to have an abortion should belong solely to the pregnant woman” describes their views extremely or very well, compared with 19% who say somewhat well and 26% who say not too or not at all well.

Democrats (76%) overwhelmingly say this statement describes their views extremely or very well, with just 8% saying it does not describe their views well.

Republicans are more divided: 44% say it does not describe their views well while 33% say it describes them extremely or very well. Another 22% say it describes them somewhat well.

Fewer Americans (35%) say the statement “human life begins at conception, so an embryo is a person with rights” describes their views extremely or very well. Another 19% say it describes their views somewhat well while 45% say it describes them not too or not at all well.

(The survey asks separately whether “a fetus is a person with rights.” The results are roughly similar: 37% say that statement describes their views extremely or very well.)

Republicans are about three times as likely as Democrats to say “an embryo is a person with rights” describes their views extremely or very well (53% vs. 18%). In turn, Democrats (66%) are far more likely than Republicans (25%) to say it describes their views not too or not at all well.

Some Americans are cross-pressured about abortion

When results on the two statements are combined, 41% of Americans say the statement about a pregnant woman’s right to choose describes their views at least somewhat well , but not the statement about an embryo being a person with rights. About two-in-ten (21%) say the reverse.

But for nearly a third of U.S. adults (32%), both statements describe their views at least somewhat well.

Just 4% of Americans say neither statement describes their views well.

Sign up for our weekly newsletter

Fresh data delivery Saturday mornings

Sign up for The Briefing

Weekly updates on the world of news & information

• Partisanship & Issues

Support for legal abortion is widespread in many places, especially in Europe

Public opinion on abortion, americans overwhelmingly say access to ivf is a good thing, what the data says about abortion in the u.s., nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, most popular, report materials.

1615 L St. NW, Suite 800 Washington, DC 20036 USA (+1) 202-419-4300 | Main (+1) 202-857-8562 | Fax (+1) 202-419-4372 |  Media Inquiries

Research Topics

• Email Newsletters

ABOUT PEW RESEARCH CENTER  Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of  The Pew Charitable Trusts .

Copyright 2024 Pew Research Center

• Open access
• Published: 21 May 2024

Tanzanian adolescents’ attitudes toward abortion: innovating video vignettes in survey research on health topics

• Anna Bolgrien   ORCID: orcid.org/0000-0002-1954-2403 1 &
• Deborah Levison   ORCID: orcid.org/0000-0002-3718-3432 2  

Reproductive Health volume  21 , Article number:  66 ( 2024 ) Cite this article

Metrics details

The purpose of this study was to pilot an innovative cartoon video vignette survey methodology to learn about young people’s perspectives on abortion and sexual relationships in Tanzania. The Animating Children’s Views methodology used videos shown on tablets to engage young people in conversations. Such conversations are complicated because abortion is highly stigmatized, inaccessible, and illegal in Tanzania.

The cartoon video vignette methodology was conducted as a part of a quantitative survey using tablet computers. Hypothetical situations and euphemistic expressions were tested in order to engage adolescents on sensitive topics in low-risk ways. Qualitative interviews and focus groups validated and further explored the perspectives of the young respondents.

Results indicate that 12–17 year-olds usually understand euphemistic expressions for abortion and are aware of social stigma and contradictory norms surrounding abortion from as young as age twelve. Despite the risks involved with abortion, this study finds adolescents sometimes view abortion as a reasonable solution to allow a girl to remain in school. Additional findings show that as adolescents wrestle with how to respond to a schoolgirl’s pregnancy, they are considering both the (un)affordability of healthcare services and also expectations for gender roles.

Conclusions

Digital data collection, such as the Animating Children’s Views cartoon video vignettes used in this study, allows researchers to better understand girls’ and boys’ own perspectives on their experiences and reproductive health.

Plain English Summary

The Animating Children’s Views project used cartoon video vignettes to collect quantitative and qualitative data on girls’ and boys’ (infrequently included) perspectives about this sensitive topic as these young people aged into and figured out how to navigate sexual maturity in rural and urban Tanzania. This novel survey technique leveraged digital technology to better engage young people’s perspectives about sensitive health topics. Despite the risks involved with abortion, this study finds adolescents sometimes view abortion as a reasonable solution to allow a girl to remain in school. Additional findings show that as adolescents wrestle with how to respond to a schoolgirl’s pregnancy, they are considering both the (un)affordability of healthcare services and also expectations for gender roles. We argue that digital data collection allows survey research to include girls and boys, to better understand how reproductive health outcomes are inextricably linked to their future lives.

Peer Review reports

Introduction

“Sometimes bad luck happens, and a girl gets pregnant when she is still studying. And if the teacher knows about it, she might not attend school. And she can either abort the pregnancy or deliver and care for the baby. Some of the students are curious. They might know she is pregnant. It will be a shame on her. They can report her to the teacher, and she might be dismissed from school. The teachers will not understand her situation; they will not know it’s something that you did not plan for. They will feel you did it deliberately.” [girl, age 15, focus group, urban]

Approximately one-quarter of Tanzanian adolescents girls become pregnant between the ages of 15 to 19 years [ 43 ]. Many young people in Tanzania are sexually active from as young as 10–14 years of age or plan to become sexually active before marriage [ 27 ,  15 ]. Some girls have sex because boys are not expected to be abstinent, and they expect their girlfriends to have sex with them. In addition to seeking sexual relationships out of desire, girls may enter into consensual transactional sexual relationships with older boys or men as a way to secure financial stability [ 25 ,  46 ]. Peer pressure, lack of familial financial support, lack of information about health services, and poverty all strongly correlate with high rates of teenage pregnancy [  29 ]. Cultural barriers make it difficult for schools, non-governmental organizations, and parents to communicate appropriate and accurate reproductive health information to youth [ 34 ,  45 ]. Girls may face difficulties obtaining and paying for contraceptives [ 23 ] or for an abortion after an unplanned pregnancy.

Girls experience stigma at multiple levels of society when navigating teenage sexual relationships and their education [ 18 ,  33 ]. To surmount these and other challenges, Tanzanian girls and boys are convinced that “education is the key to life” ( Elimu ni ufunguo wa maisha. See Vavrus [ 44 ]). Becoming pregnant while in school puts a girl at risk of social isolation and being labeled a “bad girl” [ 11 ]. Additionally, at the time of this study the legal reality was that pregnant girls were expelled from school [ 8 ]. In 2021, the World Bank’s influence and change in Tanzanian leadership have led to changes in the government’s approach to schoolgirl pregnancy and motherhood (Reuters [ 35 ]). However, implementation of the revised policy requires separate schools for young mothers, which are unlikely to be accessible for much of the population any time soon.

What results is a culture of secrecy where young people hide their relationships from parents and peers alike. Abortion – illegal in Tanzania – may seem like a way of escaping a life-long penalty for premarital sexual activity. Yet, unsafe abortions account for a substantial fraction of maternal deaths in Tanzania [ 17 ]. Anti-abortion sentiment arises from religious objections; pro-choice discourse from public health aims to reduce maternal mortality rates due to unsafe illegal abortions; and human rights organizations call for women to have a choice in their reproductive health [ 36 ]. In the event of a pregnancy, secrecy can be maintained only through unsafe and potentially deadly abortion services, as the great majority of girls cannot raise the necessary funds for safer illegal abortions in private clinics [ 39 ].

Given the consequences of the lack of social support, accurate health information, and significant impacts to their lives, it is important to learn more about how young people are navigating the competing pressures of engaging in sexual relationships and staying in school if policy makers and researchers are to help improve outcomes for adolescents. While the overall study was methodologically driven and featured various topics and themes relating to the lives of adolescents in Tanzania, this paper focuses on how a cartoon video vignette methodology engaged young people in order to learn about how they weighed the risks and benefits of abortion in a context where teen pregnancy may be the end of education for girls.

In this paper, we present mixed-methods results using quantitative and qualitative data collected in response to a story about teen pregnancy. We find children and adolescents understood concerns about social stigma and were aware of contradictory norms surrounding abortion. They also shared their perceptions of inadequate health care services and views on gendered decision-making. Our results show that adolescents were considering complex social, medical, ethical, and pragmatic factors surrounding teenage pregnancy and abortion. In addition to the substantive findings, this paper also argues that a vignette methodology can be a useful way to collect survey data on children’s perspectives, made possible through advances in the usability and affordability of digital technology in field work. We describe two techniques – the use of euphemistic expressions and asking questions about hypotheticals – to learn children’s opinions about sensitive topics like abortion.

Methodology: using video vignettes in survey research

The relationship between high rates of teenage pregnancy and unknown rates of abortion – both sensitive topics – is examined primarily in qualitative research because researchers can take more time to establish rapport and build trust, thereby reducing risks to and vulnerability felt by participants [ 9 ]. Qualitative research is ideal for understanding nuances of how youth are interpreting cultural norms towards abortion and how they are thinking about access, effectiveness, and safety of abortion services in the event that they may at some point face an unplanned pregnancy. However, qualitative studies of youth’s experience and attitudes towards abortion across sub-Saharan Africa typically engage with older girls, most often between 15 and 24 years old, such as Bajoga et al. [ 3 ] and Otoide et al. [ 31 ] in Nigeria, Silburschmidt and Rasch [ 39 ] in Tanzania, Hall et al. [ 11 ] in Ghana, and Marlow et al. [ 22 ] in Kenya. Data on boys of all ages and younger girls are limited; one exception is Sommer et al. [ 40 ].

It can be difficult to gather quantitative data on experiences of abortion. Survey research on abortion in Tanzania and elsewhere generally focuses on adult women and occasionally men. While married or older women may feel less stigma associated with sexual behaviors, survey respondents may still feel uncomfortable responding to abortion-related topics that may be inappropriate to discuss in public, topics that would lead to admitting an illegal action, or topics where a truthful answer would be a violation of a social norm [ 42 ]. In the case of abortion, qualitative interviews with adult women in Tanzania and elsewhere who have experienced abortion frequently report that internalized stigma results in abortions being underreported or omitted from survey data (e.g., Astbury-Ward et al. [ 1 ] for the UK; Haws et al. [ 13 ] for Tanzania). Quantitative surveys typically avoid sensitive topics, particularly in contexts where privacy may be impossible. This is of high importance when engaging with vulnerable people. Adolescents may be particularly alert to sensitive topics and not feel comfortable disclosing their experiences in direct conversation [ 4 ]. If the children or adolescents are overheard saying anything that an adult deems inappropriate, they could be physically punished, have food withheld or be otherwise penalized. Quantitative studies of adolescents in Tanzania include a few examples of young people’s sexual experiences but these do not specifically discuss abortion [ 32 ,  28 ,  38 ].

Vignettes are one way that survey researchers can learn respondents’ views, by asking them about characters in a story instead of about personal experiences [ 10 , 30 , 14 ]. Vignettes can be written text, cartoons, read-aloud, or videos; respondents answer questions based on details in the story. Videos shown on tablets are similar to methods of communication that many young people in Tanzania are familiar with: 100% of our respondents had seen a video before. Instead of solely using a traditional question-answer format – which may feel to adolescents like an examination – videos creatively allowed participants to engage with stories.

Vignettes about abortion have been used in previous studies with adults (Sastre et al. [ 37 ] in France, Hans and Kimberly [ 12 ] in USA, Kavanaugh et al. [ 16 ] in Nigeria and Zambia). In a study in neighboring Kenya, Mitchell et al. [ 24 ] used vignettes to compare adolescents’ recommendations to a fictional couple, their own hypothetical future, and real examples of peers’ unplanned pregnancies and abortions. Their results suggest that respondents held different expectations for the vignette couple than for themselves or their peers.

The research presented in this paper fills a gap in the literature: young people’s perspectives – especially those of younger girls and of boys – are often excluded from research on abortion and sexual relationships. We show results from a novel methodology designed to illuminate the perspectives of children in low-income countries while reducing participation risks for young respondents.

Methodology: Animating Children’s Views (ACV)

The Animating Children’s Views (ACV) methodology developed by Levison and Bolgrien [ 21 ] used cartoon vignettes to present short stories to 12-to-17-year-olds in rural and urban northern Tanzania. While the use of tablet computers to collect survey data in the field is not a new technology, the ability to incorporate short videos during the survey allowed the field team to better engage young respondents during the interview. Respondents watched the cartoons and then responded to survey questions posed by interviewers about the situation and possible outcomes for characters in the stories. The innovation in using tablets to show videos establishes a way to create an experience where the respondent is expressing perspectives or opinions on a qualitative topic, but responses are coded as quantitative data collected during a survey.

In pilots of the ACV methodology, we developed several vignettes representing situations that are commonly understood by Tanzanian adolescents. As discussed above, the primary method of reducing risk was to present stories to young respondents on tablet computers, using audio heard privately through headphones. The stories were followed by questions about the stories conducted using a typical interviewer-led survey, but with reference to the videos that would be unlikely for nearby adults to understand (since they didn’t hear the videos). This, in turn, reduced the risk of participants being punished for responses viewed as inappropriate. Using free software and simple drawings, we created short cartoon videos with young protagonists along with recorded voice-overs in Swahili. The cartoon characters lack physical or contextual characteristics that would associate them with any particular ethnicity or socio-economic status. Figure  1 shows two of the images from the story about teen pregnancy.

Images of pregnant girl and “getting herbs or medicine” from ACV teen pregnancy vignette. Artist credit: Hillary Carter-Liggett

As described above, respondents watched a video and then answered survey questions about the dilemma it described. Some response options used a 5-point “Smiley Scale”: respondents could point at a face emoji (very sad/angry to very happy). Other questions required responses of a word or phrase. To better understand the quantitative results, some young respondents participated in brief qualitative interviews after the conclusion of the quantitative survey data collection, and some joined sex- and age-specific focus groups. All stories were validated in collaboration with the Tanzanian field team and through cognitive interviews with Tanzanian adolescents.

In the vignette analyzed in this paper, a schoolgirl with a boyfriend finds herself pregnant. The story explains that the girl would like children at some point, but now is not the right time. The girl recognizes that it is difficult for pregnant girls and mothers to remain in school. The cartoon girl thinks about several possible outcomes for the pregnancy, including getting an abortion, marrying the boy, or asking grandparents to care for the baby. Girls heard a female voice telling the story from the point of view of the cartoon girl. Boys were shown exactly the same video images but heard a male voice narrating from the point of view of the father of the fetus. No information about the cartoon couples’ exact ages, education levels, or family backgrounds was given, though our pretesting of the story suggests most respondents interpreted the characters as young people of similar ages to themselves.

Interviewer effects on survey data are a persistent concern for researchers especially when interviewing children and adolescents [ 19 ]. In an attempt to please interviewers, respondents may answer questions in ways that are consistent with a dominant social narrative; Morris [ 26 ] calls such responses “scripts” based on her research with adolescents in Zanzibar, Tanzania. For example, Mitchell et al. [ 24 ] found that children in Kenya often referenced textbook sentiments about abortions. In our study, survey questions following the vignette asked what the cartoon characters should do. The question wording allowed the respondent to keep the conversation firmly in the hypothetical third person (about the cartoon character) instead of asking respondents to share information about their personal opinions or experiences. Although Mitchell et al. [ 24 ] found that their respondents were more understanding of peers and of themselves than of vignette characters, in our focus groups young people often used local examples or even slipped into the first person when describing what the cartoon character should do in a difficult situation. This is a local example:

“I was studying with this girl. She got pregnant. The father of this girl came to school, and the teachers said, ‘we can’t accept this girl back because she is pregnant.’ The girl dropped out of school. But as her friends, we were not happy about the situation.” [boy, 17, focus group, rural].

Even though we explicitly did not request information about young people’s own experiences, these came up naturally in qualitative discussions. Similar to Mitchell et al.’s [ 24 ] conclusions, we demonstrate below that Tanzanian youth express opinions that sometimes conform to but also sometimes contradict social narratives or scripts, even when discussing hypothetical vignettes.

Some of the quotes presented in this paper may make it seem as if a child were asked directly about abortion or were asked to describe personal experiences. This was not the case. During interactions between field researchers and young respondents, we aimed to minimize any discussion using the word “abortion” in order to protect the adolescent from repercussions from conversing with a stranger about a sensitive topic. As corporal punishment is common in Tanzania, ethical protection of children as a vulnerable population necessitated extra caution on behalf of the research team to mitigate the potential of a child being punished by an adult who overheard the interview [ 41 ]. Instead of speaking directly about abortions, the euphemism “take herbs and medicine to get her period back” was used in Swahili. The results section will show that most young respondents understood this euphemism. If a child voluntarily used the word “abortion” or mentioned other sensitive topics, field researchers were trained to continue the conversation only if the location of the interview was private enough that there was no risk of being overheard by adults or other children. We conducted a small follow-up study with respondents in the pilot and none reported any risk or discomfort following the interview ([ 21 ], pg S152). We attribute our success to these precautions.

Data Collection

The vignette methodology was piloted in two locations in northern Tanzania in 2018 using a mixed-methods approach as shown in Fig.  2 . This project was approved on May 18, 2018, by the IRB of the University of Minnesota (STUDY00003131) and by the Commission for Science and Technology (COSTECH) on May 10, 2018, in Tanzania. Adult and child participants were given a small gift of sugar, school supplies or a small monetary payment based on recommendations by local collaborators. The first pilot location was a village in the Arusha District that was purposefully selected based on the diversity of ethnicities (predominantly Chagga and Iraqw), religions (Christian and Muslim) and occupations (farming, herding, and small businesses). Following the rural pilot, a second pilot was conducted in urban areas in Arusha District. We used a household-based instead of a school-based sample and did not require literacy to identify our study population. The pilots used a two-stage systematic random sampling of households in wards and neighborhoods drawn for the purpose of this study by the field team with support from local village and community leaders, as discussed in Bolgrien and Levison [ 6 ]. In each household, an adult answered a questionnaire about household demographics, and all available children ages 12–17 in the household were asked to participate in a face-to-face administered survey that included vignettes. Adults gave consent for household and child participation and children gave assent to the interviewer prior to the start of the survey. Survey teams were trained to conduct the survey in a public (visible) area but out of earshot of adults, to create privacy for the child respondents during in-person surveys and one-on-one interviews; training also included other methods to reduce perceived power disparities between adult interviewers and young interviewees [ 7 ]. Each pilot included teams of 4–6 experienced young Tanzanian interviewers; the authors and local staff conducted additional training in survey data collection and qualitative methods with adolescents.

Study development and pilot studies in Tanzania 2018

Table  1 shows sample characteristics for young survey respondents. In total, 327 children in 248 households were surveyed. Most came from relatively large households of about six people (including themselves). In each household, each available (and assenting) 12–17 year-old was included in the survey. In both samples, especially the rural village, the sample was skewed toward younger ages. Older children were often away in boarding school or had left home to work. The urban field research was conducted during the beginning of a school holiday so more older adolescents were available. Although all survey participants had attended school at some point, more than one-quarter of the rural children were no longer enrolled in school. The vignette about teen pregnancy was only one of several possible vignette topics the children watched. Children were asked between each video if they would like to continue participating. In the rural village, children were shown up to four videos in a random order. During the rural pilot, one-third of respondents did not watch all four vignette videos, but data on the reason for discontinuing – a child’s decision, a field team member determining the child was fatigued or distracted, or an adult interrupting the interview – was not collected. Based on feedback from the field team after the rural pilot, we modified the survey design for the urban pilot to present 3 videos in a set order to reduce respondent burden. In the urban pilot, only 4% of respondents did not complete the 3 videos. A subset of 291 out of the 327 surveyed adolescents watched the story about teen pregnancy and answered its follow-up questions.

To better interpret the results from the quantitative survey data collected from households and children, we also collected concurrent qualitative data from the child respondents. After participating in the survey, a subset of 152 children assented to participate in semi-structured interviews which took place directly following the child’s survey. Children were asked about their answers to some of the survey questions about one or more of the videos. Finally, children who participated in the survey were asked if they would like to participate in focus groups. Interested and available children were organized into focus group discussions of three to 10 participants, grouped by sex and similar ages, to have conversations about the vignettes. The aim of these short interviews and focus groups was to assess the understandability of the vignettes, the degree of personal connection the children felt in regard to each story, and to explore ideas children had about possible outcomes for the story. The focus group discussions and interviews were conducted, recorded, transcribed verbatim, translated from Swahili to English by the field team, and coded using ATLAS.ti 8 (Version 8.4.24.0) [ 2 ] in a collaborative and iterative effort by both authors and a project assistant. The story about teen pregnancy was discussed in 90 of the interviews and focus groups, and the topic of abortion was discussed 87 times. Language used in this paper will attempt to be true to the respondents’ language, e.g. referring to the cartoon boy as the “father” and saying “baby” instead of “fetus.”

Results and discussion about using a euphemism for abortion

As discussed above, we avoided using the term “abortion,” instead using the euphemism “the girl could take herbs or medicine to get her period back,” similar to other researchers’ use of euphemistic phrases like “sleep with someone” and “to make love” instead of “sexual intercourse” [ 33 ,  5 ]. During the preparation and training for the field work, this phrase was generally understood by respondents. We continued to validate that this phrase was understood during the qualitative interviews that followed the survey.

Based on the follow-up interviews, older respondents of both sexes understood the language around “herbs and medicine” to be referring to abortion. When abortion was discussed, 26 respondents used language that indicated their understanding that the situation implied abortion or terminating the pregnancy. For example:

Interviewer: And then she uses herbs or medicines to get her periods back, what do you think is going to happen?

Respondent: abortion

Interviewer: what are the effects of it?

Respondent: The unborn baby will die. [boy, 14, urban]

In another 13 interviews, the young respondent’s language indicated clearly that she or he understood the purpose of using herbs and medicine but did not refer to abortion directly. Instead, language such as “bringing back normal periods,” “losing the baby,” “grief,” and “negative effects” are examples of how respondents referenced the termination of a pregnancy. A 14-year-old girl indicated in the survey that the cartoon girl was somewhat happy to take herbs and medicine, and during the interview the respondent described happiness resulting from using the herbs. The interviewer asked, “what are other effects after she gets her period back?” and the girl replied, “abortion.” After this, the respondent became less talkative and responsive and changed the subject.

Seven interviewees (both genders, age 12–15) likely did not understand the nuanced language of “herbs and medicine” to imply abortion. One (boy, 13, rural) misunderstood that herbs or medicine referred to birth control or pre-natal care given at hospitals. Additionally, some younger boys and girls did not make the connection between menstruation and pregnancy. Education (formal or informal) about reproduction and reproductive health is very limited for younger children in Tanzania [ 27 ]. Whereas girls may be warned about the possibility of pregnancy when they begin menstruating, this may not happen for boys entering puberty. Several of the older boys incorrectly described female reproductive anatomy and how or when to use birth control.

Results and discussion on young people’s perspectives on abortion

A survey question about the teen pregnancy vignette asked respondents to identify what was most likely to happen to the cartoon kids. As shown in Table  2 , among the options presented, 18% of respondents reported that the girl would abort the baby; it was the third highest-ranking option out of the five options, behind getting married and taking the baby to the girl’s family. In an open-ended question (not shown) that asked the respondent to imagine the most likely outcome to the story if it happened “around here,” 11% chose abortion.

The relative popularity of the options about getting married or having parents of the girl or boy help to care for the baby is consistent with the qualitative findings from the interviews and focus groups. Respondents often described the cartoon girl and boy as considering possible outcomes in order of desirability: If it was unlikely the cartoon couple could marry or care for the baby themselves, they would next approach one or both sets of parents; if that was unsuccessful or undesirable, then an abortion was considered. For example,

She will feel happy because it’s something she did not really like and did not expect it. So, if he [presumably the cartoon boyfriend] goes to his parent, first if he goes to the parents of the girl. I mean they can reject [the pregnancy or baby] and they can hate him. So she was, I mean … that’s why I said she would feel happy. Because, I mean, she probably can’t afford it and she might need to reduce her responsibilities. Because if she used those herbs to abort the pregnancy, you will find that she can continue with her normal things. [boy, 14, urban, 5 on Smiley Scale]

When we asked young respondents how they felt about abortion using the Smiley Scale, 56% of them thought abortion was a negative outcome (sad/angry or very sad/angry) for the cartoon couple, as shown in Table  3 . An additional 18% reported a neutral feeling (3 on the Smiley Scale). 25% reported that abortion would be a positive outcome (happy or very happy). Girls were less likely to be very happy than boys and more likely to be very sad/angry, but a chi-square test for the Smiley Scale cross tabulation by gender was significant only at the 11% level. T-tests for differences in the specific Smiley Scale responses by gender were significant only for “very happy” ( P  = 0.012, not shown). The results from the qualitative analysis of interviews and focus groups helped us understand these quantitative results.

Of the respondents who indicated that abortion was a positive outcome, the primary reason mentioned was that an abortion would allow the cartoon girl to return to her normal life and possibly stay in school or go back to school.

She may feel happy because, if you have not got your periods for a while, it could be a problem. So, it is better to look for herbs/medicines that will help. She has to deal with that in order to get her periods back. [girl, 17, urban, 5 on Smiley Scale]

She has very big dreams in her life. She has dreams that will take her five years to reach: ‘I want to be a certain type of person later.’ The boy came and shortened her dream. She will make sure… she aborts the pregnancy so that she achieves her dreams… [girl, focus group ages 14-17-year-old, rural]

These positive reactions are consistent with strong social norms in Tanzania for children to complete their education before starting a family [ 44 ]. Based on the qualitative evidence, both girls and boys felt that the cartoon girl should be in school, and abortion was the mechanism that would allow that.

Many of the reasons given for a negative reaction to abortion were consistent with moral and ethical qualms associated with it. In our study, children said that ending the pregnancy will make the girl sad because “the baby will die” (multiple respondents). Other reasons for negative responses towards abortion reflected the dangers of illegal abortion services, particularly in rural areas where undergoing abortions may be especially risky for the mother. Mitchell et al. [ 24 ] noted that such dangers, while real, are greatly exaggerated in Kenyan schools and educational materials; this may also be true in Tanzania.

She feels sad because she might die in the process of abortion, that is why she will feel very sad. [girl, 14, urban, 2 on Smiley Scale]

Given the strong social norms of remaining in school and cultural stigmatization of teen pregnancy and abortion in Tanzania, the results of strong negative and strong positive opinions found in the quantitative smiley-scale and accompanying qualitative validation are not surprising. But why would a respondent feel neutrally about abortion? In follow-up interviews, some respondents described the complexity of a situation that could involve abortion. One older boy said:

When I said abortion, I assumed the boy denies the pregnancy and leaves the girl to decide on her own. The girl can abort the pregnancy so as to look like other girls…She can go to school and feel young as other girls. She will decide to abort the pregnancy so she can match with other girls of her age and also [have the abortion] when the pregnancy is not noticeable to other people. Most girls end up doing this when the boys deny the pregnancies. [boy, 17, urban, 3 on Smiley Scale]

The cartoon boy denying that the baby was his and abandoning his girlfriend seemed likely to this respondent, who chose abortion to spare the cartoon girl from stigma and other troubles. Because he saw both negatives (denying paternity, abandonment) and positives (being able to hide the pregnancy), he chose the middle Smiley emoji.

Results and discussion on healthcare access and gendered decision-making

Survey results show that there is variation in how children and adolescents are thinking about cultural norms, social stigma, and the choices about hypothetical, yet possible, decisions that they or their peers may face in their own communities. The findings from the ACV methodology show that young people understand and interpret teenage pregnancy as a complex situation with multiple overlapping expectations, including staying in school and abstaining from sex while in school. Two additional themes appeared during the qualitative conversations about abortion: unaffordable health care and gendered decision making. Both of these topics are central to broader conversations about sexual and reproductive health access and female empowerment in Tanzania.

Respondents were acutely aware of the life-threatening nature of illegal abortions, particularly using local medicine or witch doctors as opposed to costly private clinics. One girl (age 17, urban) spoke of hearing about a girl going to a witch doctor for an abortion, but it was unsuccessful and resulted in an infection. The expense of an abortion was often directly connected to discussions about who would decide whether the fetus would be carried to term.

In the quantitative survey respondents indicated whom they thought would be the decision maker in the vignette about pregnancy. Table  4 shows that almost half of surveyed participants (48%; including 50% of girls and 46% of boys) reported the cartoon boy would make the decision and only 17% thought it would be the cartoon girl; only 3% thought the boy and girl would make the decision together. Other young respondents thought that adults such as parents or leaders (31%) or a combination of adults and adolescents (1%) would make the decision.

Many conversations in the qualitative interviews and focus groups talked about gender roles and decision-making when considering the cost of abortion and safe access to the healthcare system. The father of the baby was typically expected to determine whether to abort, either via positive support (the contribution of funds to pay for the abortion) or negative coercion (abandoning the cartoon girl and forcing her to make a decision between single motherhood or abortion).

For example, here is an excerpt from a focus group discussion among boys ages 13 and 14 [rural]:

Boy 1: He [another boy in focus group] says that the girl is the one to decide about aborting the pregnancy because the pregnancy is within her body. She is the one with the decision of abortion because that boy, even if he can manage to tell her to abort the pregnancy, she is the one with the decision. She can make the decision to go to search for drugs, get them, and abort that pregnancy.

Boy 2: I think that will not be possible, because where will she get the money? And you might find that her parents are against her. She cannot do it. They [the girl and boy] will have to sit together and negotiate about the pregnancy…They have to say whether they are getting married, should get married. If they have to abort, then abort…But one of them cannot get the ideas [alone] because they will go into the wrong direction.

Other respondents described the father of the unborn baby – the cartoon boy – as being the head of the family. They felt it was therefore up to the cartoon boy to find money for the girl and to help the girl decide what to do about the pregnancy. Both girls and boys took this patriarchal position. For example:

The boy has the power to do anything and also he is the head of the family. Probably, this girl wouldn’t be able to raise the baby or provide the basic needs for the baby. [girl, 12, rural]

The cartoon boy is the one with decisions to abort the pregnancy because he is the one who knows how he will take care for the child or how he will raise it. [boy, focus group ages13-14, rural]

Conversely, many girls (and some boys) were more likely to assert that the cartoon girl had the final decision about what to do about the pregnancy since the girl was the one carrying the baby and the one who faced the most risks if the pregnancy or abortion went wrong. Conversations in some female focus groups described situations where the cartoon girl would be able to find the money from her parents or by working. Some girls were also acutely aware that the final decision would often be left to the cartoon girl if the boy abandoned her or decided to deny that the baby was his, as in this case:

She will have thought ‘Maybe this boy will reject me? Will I fail to raise my child?’ Maybe she will also go to people who will advise her to abort the pregnancy so that she can go back to how she used to be. [girl, 17, urban]

As shown in Table  4 , while half of the girls responded that the cartoon boy would make the decision about the outcome of the story, 23% of the female respondents reported that the cartoon girl would be the final decision maker. This was the second most popular result for female respondents whereas the cartoon girl’s parents was the second most popular option (16%) for male respondents. Excluding the cartoon girl from the decision regarding her own pregnancy reflects the strong patriarchal norms in Tanzanian society (Leshabari et al. [ 20 ]).

Both our study and Mitchell et al. [ 24 ] suggest that East African children and adolescents have complex understandings about pregnancy and abortion, with discourse that may be heavily influenced by religious or other teachings but with pragmatic, less-judgmental responses to actual situations. These results show that there is variation in how children and adolescents are thinking about cultural norms, social stigma, and the choices about hypothetical, yet possible, decisions that they or their peers may face in their own communities.

Before exploring the results on views on abortion, stigmatization, access, and decision making, we first needed to confirm that the majority of children in the study understood the phrase “take herbs and medicine to get her period back” to be a euphemism for having an abortion. A limitation in our study is that we did not test directly using the word “abortion” because that would have exposed young respondents to increased risk of harm. This methodological innovation was successful as young respondents’ use of language indicated an awareness about social norms when discussing a sensitive topic with researchers (adult strangers). Participants likely considered their comfort level about interacting with the field researcher, as well as the likelihood of others overhearing the conversation. While our team took many precautions to avoid increasing risk to respondents, including monitoring the environment during the interview for anyone who might be listening, respondents were also actively making decisions about what language they used and their levels of openness in their responses. We argue that the benefits of being able to ask vulnerable populations questions about a sensitive subject are worth potential misunderstandings by a small minority of participants.

The findings from the ACV methodology show that young people understand and interpret teenage pregnancy as a complex situation with multiple overlapping expectations, including staying in school and abstaining from sex while in school. Our findings on the mixed positive and negative perspectives of abortion in the quantitative survey would have been difficult to interpret without the qualitative interviews. The video vignette methodology in this study successfully engaged with young people about a complex and sensitive topic in ways that showed that adolescents could formulated complex and thoughtful opinions on such topics. Young people’s quantitative answers to survey questions and qualitative comments reflected the lack of safe and affordable options and services for youths. Even though abortion was clearly perceived as physical risky and socially stigmatized, both girls and boys promoted it as a solution that would leave the cartoon girl in school, where they felt she belonged. An early, secret abortion could protect the girl from being expelled from school. However, respondents indicated that the cartoon boy must participate in this scheme because girls on their own were not expected to have the resources to seek a lower-risk abortion.

Even at a young age, girls and boys are balancing the high risk of unsafe abortions against the benefits of keeping the pregnancy secret and avoiding social stigmatization for either pregnancy or early school-leaving. In our sample, respondents of all ages and both genders discussed abortion with maturity and understanding. Boys’ perspectives are infrequently included in studies about abortion or reproductive health care services, but the findings from this mixed methods study show that boys (and girls) are considering the nuanced role of boys and men in supporting or funding an illegal abortion. Framing the decision of an abortion as involving not only the pregnant girl but also other influential people such as the boyfriend or the girl’s parents can inform sexual and reproductive health policies to better support young people. However, the sample sizes in these pilot studies are too small to identify patterns correlated with demographic characteristics.

The secrecy and stigmatization of teen sexual relationships and illegality of abortion have made it very hard for researchers (let alone policymakers) to understand how adolescents are weighing trade-offs and navigating the competing pressures from peers, relationships, and familial expectations about education. Using the Animating Children’s View methodology, the sensitive topic of abortion was discussed with adolescents and children as young as 12 in a way that allowed them to share their perspectives without divulging personal information about sexual behaviors. Video cartoons engaged their attention leading to serious questions and sometimes conversations about hypothetical cartoon characters. In a context where pregnancy and motherhood mean the end of schooling for girls, respondents grappled with difficult decisions the cartoon couple faced regarding pregnancy and potential abortion. In future research, it will be imperative to explore adolescents’ perspectives regarding abortion for schoolgirls as it relates to increased access to education for pregnant girls. The ACV methodology can be used to engage adolescent girls and boys about pregnancy, abortion, contraceptive access, and cultural norms and stigma so their voices are included in such policy decisions.

Availability of data and materials

Participants of this study did not consent for their data to be shared publicly.

Abbreviations

Animating Children’s Views

Astbury-Ward E, Parry O, Carnwell R. Stigma, abortion, and disclosure-findings from a qualitative study. J Sex Med. 2012;9(12):3137–47. https://doi.org/10.1111/j.1743-6109.2011.02604.x .

ATLAS.ti Scientific Software Development GmbH [ATLAS.ti 8 Windows]. (2019). Retrieved from https://atlasti.com .

Bajoga UA, Atagame KL, Okigbo CC. Media influence on sexual activity and contraceptive use: a cross sectional survey among young women in urban Nigeria. Afr J Reprod Health. 2015;19(3):100–10.

Baker C, Renold E. I wanna tell you a story’: exploring the application of vignettes in qualitative research with children and young people. Int J Soc Res Methodol. 2000;3(4):307–23. https://doi.org/10.1080/13645570050178594 .

Bell SO, Sheehy G, Hyacinthe AK, Guiella G, and Moreau C. Induced abortion incidence and safety in Côte d’Ivoire. PLoS ONE. 2020;15(5):1–15. https://doi.org/10.1371/journal.pone.0232364 .

Article   CAS   Google Scholar  

Bolgrien A, Levison D. Challenges of designing and implementing three sampling frames targeting children in Tanzania and Nepal: proportional stratified, multi-stage, and geographically dispersed sampling techniques. Minnesota Population Center Working Paper series. 2021. 2021-2. https://doi.org/10.18128/MPC2021-02 .

Bolgrien A, Levison D, Vavrus F. Complicating research on children’s right to be heard: generational power and risk,. In: Levison D, Maynes MJ, and Vavrus F, editors. Children and Youth as Subjects, Objects, Agents: Innovative Approaches to Research Across Space and Time. New York: Palgrave Macmillan; 2021. p. 227–43.

Cardoso JC, Mwolo MP. Assessment of non-formal sexual education strategies for adolescent girls: the case of Tanzania. Ensaio. 2017;25(95):527–47. https://doi.org/10.1590/S0104-40362017002501111 .

Dickson-Swift V, James EL, Kippen S, Liamputtong P. Doing sensitive research: what challenges do qualitative researchers face? Qualitative Res. 2007;7(3):327–53. https://doi.org/10.1177/1468794107078515 .

Gourlay A, Mshana G, Birdthistle I, Bulugu G, Zaba B, Urassa M. Using vignettes in qualitative research to explore barriers and facilitating factors to the uptake of prevention of mother-to-child transmission services in rural Tanzania: a critical analysis. BMC Med Res Methodol. 2014;14(21):1–11.

Hall KS, Manu A, Morhe E, Dalton VK, Challa S, Loll D, et al. Bad girl and unmet family planning needs among sub-Saharan African adolescents: the role of sexual and reproductive health stigma. Qualitative Res Med Healthc. 2018;2(1):55–64.

Hans JD, Kimberly C. Abortion attitudes in context: a multidimensional vignette approach. Soc Sci Res. 2014;48:145–56. https://doi.org/10.1016/j.ssresearch.2014.06.001 .

Haws RA, Mashasi I, Mrisho M, Schellenberg JA, Darmstadt GL, Winch PJ. ‘These are not good things for other people to know’: how rural Tanzanian women’s experiences of pregnancy loss and early neonatal death may impact survey data quality. Soc Sci Med. 2010;71(10):1764–72. https://doi.org/10.1016/j.socscimed.2010.03.051 .

Hughes R, Huby M. The construction and interpretation of vignettes in social research. Social Work Social Sci Rev. 2004;11(1):36–51. https://doi.org/10.1921/17466105.11.1.36 .

Kakoko DCV. Reported heterosexual intercourse and related behaviours among primary school pupils in Kinondoni District, Dar Es Salaam, Tanzania. Cult Health Sex. 2013;15(2):235–45.

Article   PubMed   Google Scholar  

Kavanaugh ML, Moore AM, Akinyemi O, Adewole I, Dzekedzeke K, Awolude O, et al. Community attitudes toward childbearing and abortion among HIV-positive women in Nigeria and Zambia. Cult Health Sexuality. 2013;15(2):160–74. https://doi.org/10.1038/jid.2014.371 .

Keogh SC, Kimaro G, Muganyizi P, Philbin J, Kahwa A, Ngadaya E, et al. Incidence of induced abortion and post-abortion care in Tanzania. PLoS ONE. 2015;10(9):e0133933. https://doi.org/10.1371/journal.pone.0133933 .

Kumar A, Hessini L, Mitchell EMH. Conceptualising abortion stigma. Cult Health Sexuality. 2009;11(6):625–39. https://doi.org/10.1080/13691050902842741 .

Leone T, Sochas L, Coast E. Depends who’s asking: interviewer effects in Demographic and Health Surveys abortion data. Demography. 2021;58(1):31–50. https://doi.org/10.1215/00703370-8937468 .

Leshabari MT, Mpangile GS, Kaaya SF, Kihwele DJ. From teenage unwanted pregnancy to induced abortion: who facilitates links? Int J Adolescence Youth. 1994;4(3–4):195–210. https://doi.org/10.1080/02673843.1994.9747736 .

Levison D, Bolgrien A. Using cartoon videos to survey children and adolescents in the Global South: a Tanzanian example. Stat J IAOS. 2020;36(S1):S147–59. https://doi.org/10.3233/SJI-200698 .

Marlow HM, Wamugi S, Yegon E, Fetters T, Wanaswa L, Msipa-Nbebele S. Women’s perceptions about abortion in their communities: perspectives from Western Kenya. Reprod Health Matters. 2014;22(43):149–58.

McCleary-Sills J, Douglas Z, Rwehumbiza A, Hamisi A, Mabala R. Gendered norms, sexual exploitation and adolescent pregnancy in rural Tanzania. Reprod Health Matters. 2013;21(41):97–105. https://doi.org/10.1016/S0968-8080(13)41682-8 .

Mitchell EMH, Halpern CT, Kamathi EM, Owino S. Social scripts and stark realities: Kenyan adolescents’ abortion discourse. Cult Health Sex. 2006;8(6):515–28.

Mojola S. Love, Money, and HIV: Becoming a Modern African Woman in the Age of AIDS. Oakland, CA: University of California Press; 2014.

Book   Google Scholar  

Morris E. 2018. Performing Graduates, Dropouts, and Pushouts: The Gendered Scripts and Aspirations of Secondary School Students in Zanzibar. [Doctoral dissertation, University of Minnesota.] UMN Repository.  https://conservancy.umn.edu/bitstream/handle/11299/206429/Morris_umn_0130E_19596 pdf.

Njau B, Mtweve S, Manongi R, Jalipa H. Gender differences in intention to remain a virgin until marriage among school pupils in rural Northern Tanzania. Afr J AIDS Res. 2009;8(2):157–66.

Nkata H, Teixeira R, Barros H. A scoping review on sexual and reproductive health behaviors among Tanzanian adolescents. Public Health Rev. 2019;40(1):1–15. https://doi.org/10.1186/s40985-019-0114-2 .

Nyangarika A, Nombo NM, Mtani M. Teen pregnancies among day government secondary school students in Ruvuma Region Tanzania. Int J Adv Res Innovative Ideas Educ. 2020;6(4):157–66.

O’Dell L, Crafter S, de Abreu G, Cline T. The problem of interpretation in vignette methodology in research with young people. Qualitative Res. 2012;12(6):702–14. https://doi.org/10.1177/1468794112439003 .

Otoide VO, Oronsaye F, Okonofua FE. Why Nigerian adolescents seek abortion rather than contraception: evidence from focus-group discussions. Int Fam Plan Perspect. 2001;27(2):77–81. https://doi.org/10.2307/2673818 .

Plummer ML, Ross DA, Wight D, Changalucha J, Mshana G, Wamoyi J, Todd J, et al. A bit more truthful’: the validity of adolescent sexual behaviour data collected in rural Northern Tanzania using five methods. Sex Transm Infect. 2004a;80(SUPPL 2):49–56. https://doi.org/10.1136/sti.2004.011924 .

Plummer ML, Wight D, Ross DA, Balira R, Anemona A, Todd J, Salamba Z, et al. Asking semi-literate adolescents about sex behaviour: the validity of Assisted Self-Completion Questionnaire (ASCQ) data in rural Tanzania. Trop Med Int Health. 2004b;9(6):737–54.

Remes P, Renju J, Nyalali K, Medard L, Kimaryo M, Changalucha J, et al. Dusty discos and dangerous desires: community perceptions of adolescent sexual and reproductive health risks and vulnerability and the potential role of parents in rural Mwanza, Tanzania. Cult Health Sex. 2010;12(3):279–92.

Reuters. 2021. Tanzania to Offer Alternative Education for School Dropouts Including Pregnant Girls -Official. https://www.usnews.com/news/world/articles/2021-06-22/tanzania-to-offer-alternative-education-for-school-dropouts-including-pregnant-girls-official .

Sambaiga R, Haukanes H, Moland KM, Blystad A. Health, life and rights: a discourse analysis of a hybrid abortion regime in Tanzania. Int J Equity Health. 2019;18(1):1–12. https://doi.org/10.1186/s12939-019-1039-6 .

Sastre MTM, Peccarisi C, Legrain E, Mullet E, Sorum P. Acceptability in France of induced abortion for adolescents. Am J Bioeth. 2007;7(8):26–32. https://doi.org/10.1080/15265160701462368 .

Shayo FK, Kalomo MH. Prevalence and correlates of sexual intercourse among sexually active in-school adolescents: an analysis of five sub-Sahara African Countries for the adolescent’s sexual health policy implications. BMC Public Health. 2019;19(1):1–8. https://doi.org/10.1186/s12889-019-7632-1 .

Silberschmidt M, Rasch V. Adolescent girls, illegal abortions and ‘sugar-daddies’ in Dar es Salaam: vulnerable victims and active social agents. Soc Sci Med. 2001;52(12):1815–26. https://doi.org/10.1016/S0277-9536(00)00299-9 .

Sommer M, Likindikoki S, Kaaya S. Bend a fish when the fish is not yet dry’: adolescent boys’ perceptions of sexual risk in Tanzania. Arch Sex Behav. 2015;44(3):583–95. https://doi.org/10.1007/s10508-014-0406-z .

Sungwa R, Jackson L, Kahembe J. Corporal punishment in preschool and at home in Tanzania: a children’s rights challenge. SpringerBriefs Educ. 2022. https://doi.org/10.1007/978-981-19-1569-7 .

Tourangeau R, Yan T. Sensitive questions in surveys. Psychol Bull. 2007;133(5):859–83. https://doi.org/10.1037/0033-2909.133.5.859 .

UNFPA Tanzania. Fact Sheet: Teenage Pregnancy Success Story from the Field. 2018.

Google Scholar  

Vavrus F. Desire and Decline: Schooling amid Crisis in Tanzania. New York: Peter Lang; 2003.

Wamoyi J, Fenwick A, Urassa M, Zaba B, Stones W. Parent-child communication about sexual and reproductive health in rural Tanzania: implications for young people’s sexual health interventions. Reprod Health. 2010;7(1):1–18. https://doi.org/10.1186/1742-4755-7-6 .

Wamoyi J, Heise L, Meiksin R, Kyegombe N, Nyato D, Buller AM. Is transactional sex exploitative? A social norms perspective, with implications for interventions with adolescent girls and young women in Tanzania. PLoS ONE. 2019;14(4):1–16. https://doi.org/10.1371/journal.pone.0214366 .

Download references

Acknowledgements

We are grateful to the Interdisciplinary Center for the Study of Global Change (ICGC) and the Humphrey School of Public Affairs at the University of Minnesota; also to Binu Sharma, and Deborah S. DeGraff for their assistance. We thank the field team members who collected the quantitative and qualitative data: Gloria Gerald, Haikael Mjema, Juliet Mongi, Masai Loreu, Rachel Gerald, Godfrey Rwiza, Nancy Laiser, Helen Urio, and David Mollel.

Permission to reproduce material from other sources

This work was supported from the Human Rights Initiative Fund of the University of Minnesota 2018 and 2019; the University of Minnesota’s Grants-in-Aid of Research, Artistry and Scholarship 2018–2019; and the Minnesota Population Center, funded through a grant (P2C HD041023) from the Eunice Kennedy Shriver National Institute for Child Health and Human Development or NICHD. The funder had no role in the study design, data collection, analysis, interpretation, or reporting.

Author information

Authors and affiliations.

Institute for Social Research and Data Innovation, University of Minnesota Twin Cities, 225 – 19th Avenue South, Minneapolis, MN, 55455, USA

Anna Bolgrien

Hubert H. Humphrey School of Public Affairs, University of Minnesota Twin Cities, 301 – 19th Avenue South, Minneapolis, MN, 55455, USA

Deborah Levison

You can also search for this author in PubMed   Google Scholar

Contributions

All authors contributed to conceptualization, data curation, formal analysis, and writing this manuscript.

Corresponding author

Correspondence to Anna Bolgrien .

Ethics declarations

Ethics approval and consent to participate.

This project was approved by the IRB of the University of Minnesota (STUDY00003131) and by the Commission for Science and Technology (COSTECH) in Tanzania.

Consent for publication

Competing interests.

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Bolgrien, A., Levison, D. Tanzanian adolescents’ attitudes toward abortion: innovating video vignettes in survey research on health topics. Reprod Health 21 , 66 (2024). https://doi.org/10.1186/s12978-024-01809-x

Download citation

Received : 29 December 2023

Accepted : 08 May 2024

Published : 21 May 2024

DOI : https://doi.org/10.1186/s12978-024-01809-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Sexual and reproductive health
• Survey methods

Reproductive Health

ISSN: 1742-4755

• General enquiries: [email protected]

Educate your inbox

Subscribe to Here’s the Deal, our politics newsletter for analysis you won’t find anywhere else.

Thank you. Please check your inbox to confirm.

Dasha Litvinova, Associated Press Dasha Litvinova, Associated Press

Leave your feedback

• Copy URL https://www.pbs.org/newshour/politics/abortion-restrictions-in-russia-spark-outrage-as-the-country-takes-a-conservative-turn

Abortion restrictions in Russia spark outrage as the country takes a conservative turn

TALLINN, Estonia (AP) — Despite its last-minute scheduling, the meeting at a bookstore in Russia’s westernmost city of Kaliningrad still drew about 60 people, with many outraged by a lawmaker’s efforts to ban abortions in local private clinics.

The weeknight turnout surprised and heartened Dasha Yakovleva, one of the organizers, amid recent crackdowns on political activism under President Vladimir Putin.

READ MORE: Abortion rights supporters far outraise opponents, out-of-state money flowing to Ohio

“Right now, there is no room for political action in Russia. The only place left is our kitchens,” Yakovleva, co-founder of the Feminitive Community women’s group, told The Associated Press. “And here, it was a public place, well-known in Kaliningrad, and everyone spoke out openly about how they see this measure, why they think it’s unjustified, inappropriate.”

Although abortion is still legal and widely available in Russia, recent attempts to restrict it have touched a nerve across the increasingly conservative country. Activists are urging supporters to make official complaints, circulating online petitions and even staging small protests.

A ‘gradual erosion’ of abortion access

While only a proposal for now in Kaliningrad, private clinics elsewhere have begun to stop providing abortions. Nationwide, the Health Ministry has drawn up talking points for doctors to discourage women from terminating their pregnancies, and new regulations soon will make many emergency contraceptives virtually unavailable and drive up the cost of others.

“It’s clear that there is a gradual erosion of abortion access and rights in Russia, and this is similar to what has taken place in the U.S.,” said Michele Rivkin-Fish, an anthropologist at the University of North Carolina at Chapel Hill.

READ MORE: U.S. warns of Russian efforts to sow doubt over upcoming elections around the globe

Last year’s U.S. Supreme Court decision rescinding a five-decade-old right to abortion has reshaped American abortion policy, shifting power to states. About half of U.S. states have adopted bans or major restrictions, although not all are being enforced due to legal challenges.

In the Soviet Union, abortion laws meant that some women had the procedure multiple times due to difficulties in obtaining contraceptives.

After the USSR’s collapse, government and health experts promoted family planning and birth control, sending abortion rates falling. At the same time, laws allowed women to terminate a pregnancy up until 12 weeks without any conditions; and until 22 weeks for many “social reasons,” like divorce, unemployment or income.

That changed under Putin, who has forged a powerful alliance with the Russian Orthodox Church, promoting “traditional values” and seeking to boost population growth. Health Minister Mikhail Murashko has condemned women for prioritizing education and career over childbearing.

Waiting periods, consults, approval by a priest

Over the decades, the number of abortions in Russia fell from 4.1 million in 1990 to 517,000 in 2021.

Only in instances of rape is an abortion legally allowed between 12 and 22 weeks. Some regions hold “Days of Silence,” when public clinics don’t provide them. Women must wait 48 hours or even a week -– depending on what stage of pregnancy -– between their first appointment and the abortion, in case they reconsider. They also are offered psychological consultations designed to discourage abortions, according to state-issued guidelines reviewed by AP.

READ MORE: Survey finds that abortions in the U.S. rose slightly overall after new restrictions started in some states

Health authorities have introduced an online “motivational questionnaire” outlining state support if women continue the pregnancy, according to a state clinic gynecologist who was not authorized to comment publicly and spoke on condition of anonymity.

She said the waiting periods were psychologically hard for some of her patients. “During that week (of waiting), she might start getting nauseous and experience other symptoms of pregnancy,” she added. “They don’t understand the point.”

State clinics in one region referred women to a priest before getting an abortion. Authorities maintained the consultation was voluntary, but some women told the media they had to get a priest to sign off to get an abortion.

Restricting abortion pills

The anti-abortion push comes as Russian women appear to be in no rush to have more children amid the war in Ukraine and economic uncertainty. Sales of abortion pills in 2022 were up 60 percent, according to Nikolay Bespalov, development director of the RNC Pharma analytical company. They fell 35 percent this year, still higher than pre-2022 levels. Sales of contraceptive medications also have been rising in 2022-23, he said.

A recent Health Ministry decree restricted circulation of abortion pills, used to terminate pregnancies in the first trimester. The decree puts mifepristone and misoprostol, used in the pills, on a registry of controlled substances requiring strict record-keeping and storage.

For hospitals and clinics, where the pills are usually dispensed, the move will add more paperwork but not much else, said Dr. Yekaterina Hivrich, head of gynecology at Lahta Clinic, a private clinic in St. Petersburg.

READ MORE: Why post-Roe abortion restrictions worry domestic violence experts

But it will affect the availability of emergency contraceptives, sometimes known as morning-after pills, which are taken within days of unprotected sex to prevent pregnancy. Three out of six brands available in Russia contain mifepristone in a lower dose, meaning they’ll be severely restricted once the decree takes effect Sept. 1, 2024.

They will require a special prescription, and not all pharmacies will stock them, said Irina Fainman, an activist in the northern region of Karelia, adding that getting a prescription takes time that women might not have when they need the pills.

The Health Ministry did not respond to questions on whether it will exclude morning-after pills in the decree. Officials earlier promised it won’t affect those pills, but some pharmacies already list those with mifepristone as available only under strict prescription conditions.

After the restrictions were announced, Fainman said she and other activists stocked up on the pills to distribute in case of shortages.

Sales of emergency contraceptives soared 71 percent through August 2023, over the same period last year, according to Bespalov. Those containing mifepristone account for about half the market. New measures likely will increase the cost of unrestricted medications and possibly lead to short-term shortages.

Abortion bans in private clinics

Senior lawmaker Pyotr Tolstoy said that by spring, lawmakers would strive to adopt a nationwide ban on abortion in private clinics, where about 20 percent took place in recent years, according to state statistics.

Conservative lawmakers failed to enact such a ban before, but the Health Ministry now says it is ready to consider it.

To Irina Volynets, an abortion opponent and children’s rights ombudswoman in the Tatarstan region, “it gives hope that this procedure will be taken out of private clinics” eventually. She also wants increased state support for women with children as an incentive for boosting birthrates.

Regional authorities have tried to get private clinics to stop offering abortions, with varying success. Kaliningrad is mulling a region-wide ban. In Tatarstan, about a third of all private clinics no longer provide them, officials said. In the Chelyabinsk region in the Urals, three clinics agreed to halt them.

“It’s important to understand that the pressure on women will be growing” even in the absence of a total ban, said Kaliningrad psychotherapist and activist Lina Zharin, who helped organize the recent bookstore meeting. An online petition against the ban in Kaliningrad has gathered nearly 27,000 signatures.

Pressured to give birth

In seven other regions, the Health Ministry is using another pilot project: having gynecologists try to get women to reconsider having an abortion.

A document obtained by AP and cited by other media outlines language doctors are told to use, including saying pregnancy is “a beautiful and natural condition for every woman,” while an abortion is “harmful to your health and a risk of developing complications.”

Natalya Moskvitina, founder of Women For Life, which aids women who decide against abortion, said she helped develop the instructions and is introducing similar scripts for doctors in several regions.

Moskvitina made headlines in August after the region of Mordovia adopted a law she helped draft to ban “encouraging” abortions. At least one other region is considering a similar ban. Her program, which instructs doctors to congratulate women on being pregnant and gives baby-themed presents and information on support resources, has driven the abortion rate down 40 percent in Mordovia, she and local officials said.

For women with doubts about abortion, such conversations might indeed help them reach a decision but for others, they could be deeply uncomfortable.

Olga Mindolina was contemplating an abortion in 2020, traumatized by an earlier, difficult pregnancy. But when a doctor in a state clinic in the western city of Voronezh asked her what she wanted to do, she said she didn’t know -– and was told, “In this case, you should give birth.”

A clinic psychologist told her that women sometimes regret abortion, advising her to talk to her husband. A lawyer also told her about state benefits she could get if she gave birth. Mindolina decided to continue the pregnancy.

Anastasia, a Muscovite who sought an abortion in 2020, said it “wasn’t very pleasant” when a doctor urged her to change her mind.

“I simply don’t want any children,” she told AP, asking that her last name not be used for fear of reprisals.

Dr. Lyubov Yeroveyeva, a gynecologist who spearheaded family planning projects in the 1990s, believes the key is preventing unwanted pregnancies with education about birth control and making contraceptives widely available.

Instead of talking a woman out of an abortion, authorities should “do everything so she doesn’t have to seek one,” she said.

Support Provided By: Learn more

The link between a lack of reproductive rights and domestic violence

Health Jul 14

Cultural Relativity and Acceptance of Embryonic Stem Cell Research

Article sidebar.

Main Article Content

There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole . Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus. [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

[1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[2] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice.  Orthopedic reviews ,  14 (3), 37498. https://doi.org/10.52965/001c.37498

[3] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk ; Kimmelman, J., Hyun, I., Benvenisty, N.  et al.  Policy: Global standards for stem-cell research.  Nature   533 , 311–313 (2016). https://doi.org/10.1038/533311a

[4] International Society for Stem Cell Research. (2023). Laboratory-based human embryonic stem cell research, embryo research, and related research activities . International Society for Stem Cell Research. https://www.isscr.org/guidelines/blog-post-title-one-ed2td-6fcdk

[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

Sandel M. J. (2004). Embryo ethics--the moral logic of stem-cell research.  The New England journal of medicine ,  351 (3), 207–209. https://doi.org/10.1056/NEJMp048145 ; George, R. P., & Lee, P. (2020, September 26). Acorns and Embryos . The New Atlantis. https://www.thenewatlantis.com/publications/acorns-and-embryos ; Sagan, A., & Singer, P. (2007). The moral status of stem cells. Metaphilosophy , 38 (2/3), 264–284. http://www.jstor.org/stable/24439776 ; McHugh P. R. (2004). Zygote and "clonote"--the ethical use of embryonic stem cells.  The New England journal of medicine ,  351 (3), 209–211. https://doi.org/10.1056/NEJMp048147 ; Kurjak, A., & Tripalo, A. (2004). The facts and doubts about beginning of the human life and personality.  Bosnian journal of basic medical sciences ,  4 (1), 5–14. https://doi.org/10.17305/bjbms.2004.3453

[6] Vazin, T., & Freed, W. J. (2010). Human embryonic stem cells: derivation, culture, and differentiation: a review.  Restorative neurology and neuroscience ,  28 (4), 589–603. https://doi.org/10.3233/RNN-2010-0543

[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

[8] Sherley v. Sebelius , 644 F.3d 388 (D.C. Cir. 2011), citing 45 C.F.R. 46.204(b) and [42 U.S.C. § 289g(b)]. https://www.cadc.uscourts.gov/internet/opinions.nsf/6c690438a9b43dd685257a64004ebf99/$file/11-5241-1391178.pdf

[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

[11] Hurlbut, W. B. (2006). Science, Religion, and the Politics of Stem Cells.  Social Research ,  73 (3), 819–834. http://www.jstor.org/stable/40971854

[12] Akpa-Inyang, Francis & Chima, Sylvester. (2021). South African traditional values and beliefs regarding informed consent and limitations of the principle of respect for autonomy in African communities: a cross-cultural qualitative study. BMC Medical Ethics . 22. 10.1186/s12910-021-00678-4.

[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

[15] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics, 22(2), 112–122. https://doi.org/10.1111/dewb.12324

[16] Jackson, C.S., Pepper, M.S. Opportunities and barriers to establishing a cell therapy programme in South Africa.  Stem Cell Res Ther   4 , 54 (2013). https://doi.org/10.1186/scrt204 ; Pew Research Center. (2014, May 1). Public health a major priority in African nations . Pew Research Center’s Global Attitudes Project. https://www.pewresearch.org/global/2014/05/01/public-health-a-major-priority-in-african-nations/

[17] Department of Health Republic of South Africa. (2021). Health Research Priorities (revised) for South Africa 2021-2024 . National Health Research Strategy. https://www.health.gov.za/wp-content/uploads/2022/05/National-Health-Research-Priorities-2021-2024.pdf

[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[19] United States Bureau of Citizenship and Immigration Services. (1998). Tunisia: Information on the status of Christian conversions in Tunisia . UNHCR Web Archive. https://webarchive.archive.unhcr.org/20230522142618/https://www.refworld.org/docid/3df0be9a2.html

[20] Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

[23] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[24] Wang, Y., Xue, Y., & Guo, H. D. (2022). Intervention effects of traditional Chinese medicine on stem cell therapy of myocardial infarction.  Frontiers in pharmacology ,  13 , 1013740. https://doi.org/10.3389/fphar.2022.1013740

[25] Li, X.-T., & Zhao, J. (2012). Chapter 4: An Approach to the Nature of Qi in TCM- Qi and Bioenergy. In Recent Advances in Theories and Practice of Chinese Medicine (p. 79). InTech.

[26] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[27] Luo, D., Xu, Z., Wang, Z., & Ran, W. (2021). China's Stem Cell Research and Knowledge Levels of Medical Practitioners and Students.  Stem cells international ,  2021 , 6667743. https://doi.org/10.1155/2021/6667743

[28] Zhang, J. Y. (2017). Lost in translation? accountability and governance of Clinical Stem Cell Research in China. Regenerative Medicine , 12 (6), 647–656. https://doi.org/10.2217/rme-2017-0035

[29] Wang, L., Wang, F., & Zhang, W. (2021). Bioethics in China’s biosecurity law: Forms, effects, and unsettled issues. Journal of law and the biosciences , 8(1).  https://doi.org/10.1093/jlb/lsab019 https://academic.oup.com/jlb/article/8/1/lsab019/6299199

[30] Chen, H., Wei, T., Wang, H.  et al.  Association of China’s two-child policy with changes in number of births and birth defects rate, 2008–2017.  BMC Public Health   22 , 434 (2022). https://doi.org/10.1186/s12889-022-12839-0

[31] Azuma, K. Regulatory Landscape of Regenerative Medicine in Japan.  Curr Stem Cell Rep   1 , 118–128 (2015). https://doi.org/10.1007/s40778-015-0012-6

[32] Harris, R. (2005, May 19). Researchers Report Advance in Stem Cell Production . NPR. https://www.npr.org/2005/05/19/4658967/researchers-report-advance-in-stem-cell-production

[33] Park, S. (2012). South Korea steps up stem-cell work.  Nature . https://doi.org/10.1038/nature.2012.10565

[34] Resnik, D. B., Shamoo, A. E., & Krimsky, S. (2006). Fraudulent human embryonic stem cell research in South Korea: lessons learned.  Accountability in research ,  13 (1), 101–109. https://doi.org/10.1080/08989620600634193 .

[35] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia.  BMC medical ethics ,  21 (1), 35. https://doi.org/10.1186/s12910-020-00482-6

[38] Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: Interviews with researchers from Saudi Arabia. BMC medical ethics , 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6

Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf

[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

[53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life . Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/

[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

[55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association , 12 (4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf.

[56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52.  https://doi.org/10.5372/1905-7415.0801.260

[57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation.  Journal of Religion and Health ,  30 (1), 35–41. http://www.jstor.org/stable/27510629 ; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva . A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm

[59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. (( King James Bible . (1999). Oxford University Press. (original work published 1769))

Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…”

In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David.

Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…”

These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth.

[60] It should be noted that abortion is not supported as well.

[61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day . Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html

[62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells . Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html ; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology . Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf.

[63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed . Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/

[64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society , (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law).  Journal of assisted reproduction and genetics ,  25 (6), 271–276. https://doi.org/10.1007/s10815-008-9221-6

[66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet) . Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en

[67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.),  Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues  (pp. 79-94). Berkeley: University of California Press.  https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005

[68] Gert, B. (2007). Common morality: Deciding what to do . Oxford Univ. Press.

[69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA , 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association .; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979).  The Belmont report: Ethical principles and guidelines for the protection of human subjects of research . U.S. Department of Health and Human Services.  https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html

[70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes.  Journal of assisted reproduction and genetics ,  35 (7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine , 10 (12), 1715–1716. https://doi.org/10.1002/sctm.21-0234

[71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA.  Reproductive biomedicine online ,  18 (5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8

[72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa.  Clinical trials (London, England) ,  3 (3), 306–313. https://doi.org/10.1191/1740774506cn150oa

[73] Veatch, Robert M.  Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict . Georgetown University Press, 2012.

[74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity.  Research Ethics ,  14 (3), 1-17.  https://doi.org/10.1177/1747016117739939

[75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry.  Voices in Bioethics ,  8 . https://doi.org/10.52214/vib.v8i.9894

[76] Stem Cell Tourism: False Hope for Real Money . Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism , See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis.  Voices in Bioethics ,  3 . https://doi.org/10.7916/vib.v3i.6027

[77] Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation,  New Genetics and Society , 30:2, 141-153, DOI:  10.1080/14636778.2011.574375

[78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East.  Nature  510, 189. https://doi.org/10.1038/510189a

[79] International Society for Stem Cell Research. (2024). Standards in stem cell research . International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research

[80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier . Stanford University Press.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

Article Details

This work is licensed under a Creative Commons Attribution 4.0 International License .

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol

Foluso ishola.

Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Purvis Hall 1020 Pine Avenue West, Montreal, Quebec H3A 1A2 Canada

U. Vivian Ukah

Arijit nandi, associated data.

A country’s abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women’s access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women’s health services and outcomes in LMICs.

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women’s health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women’s health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

Systematic review registration

PROSPERO CRD42019126927

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-021-01739-w.

An estimated 25·1 million unsafe abortions occur each year, with 97% of these in developing countries [ 1 – 3 ]. Despite its frequency, unsafe abortion remains a major global public health challenge [ 4 , 5 ]. According to the World health Organization (WHO), nearly 8% of maternal deaths were attributed to unsafe abortion, with the majority of these occurring in developing countries [ 5 , 6 ]. Approximately 7 million women are admitted to hospitals every year due to complications from unsafe abortion such as hemorrhage, infections, septic shock, uterine and intestinal perforation, and peritonitis [ 7 – 9 ]. These often result in long-term effects such as infertility and chronic reproductive tract infections. The annual cost of treating major complications from unsafe abortion is estimated at US$ 232 million each year in developing countries [ 10 , 11 ]. The negative consequences on children’s health, well-being, and development have also been documented. Unsafe abortion increases risk of poor birth outcomes, neonatal and infant mortality [ 12 , 13 ]. Additionally, women who lack access to safe and legal abortion are often forced to continue with unwanted pregnancies, and may not seek prenatal care [ 14 ], which might increase risks of child morbidity and mortality.

Access to safe abortion services is often limited due to a wide range of barriers. Collectively, these barriers contribute to the staggering number of deaths and disabilities seen annually as a result of unsafe abortion, which are disproportionately felt in developing countries [ 15 – 17 ]. A recent systematic review on the barriers to abortion access in low- and middle-income countries (LMICs) implicated the following factors: restrictive abortion laws, lack of knowledge about abortion law or locations that provide abortion, high cost of services, judgmental provider attitudes, scarcity of facilities and medical equipment, poor training and shortage of staff, stigma on social and religious grounds, and lack of decision making power [ 17 ].

An important factor regulating access to abortion is abortion law [ 17 – 19 ]. Although abortion is a medical procedure, its legal status in many countries has been incorporated in penal codes which specify grounds in which abortion is permitted. These include prohibition in all circumstances, to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, and on request with no requirement for justification [ 18 – 20 ].

Although abortion laws in different countries are usually compared based on the grounds under which legal abortions are allowed, these comparisons rarely take into account components of the legal framework that may have strongly restrictive implications, such as regulation of facilities that are authorized to provide abortions, mandatory waiting periods, reporting requirements in cases of rape, limited choice in terms of the method of abortion, and requirements for third-party authorizations [ 19 , 21 , 22 ]. For example, the Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds. It is considered liberal, as it permits legal abortions for more indications than most countries in Sub-Saharan Africa; however, abortions must only be provided in registered hospitals, and three medical doctors—one of whom must be a specialist—must provide signatures to allow the procedure to take place [ 22 ]. Given the critical shortage of doctors in Zambia [ 23 ], this is in fact a major restriction that is only captured by a thorough analysis of the conditions under which abortion services are provided.

Additionally, abortion laws may exist outside the penal codes in some countries, where they are supplemented by health legislation and regulations such as public health statutes, reproductive health acts, court decisions, medical ethic codes, practice guidelines, and general health acts [ 18 , 19 , 24 ]. The diversity of regulatory documents may lead to conflicting directives about the grounds under which abortion is lawful [ 19 ]. For example, in Kenya and Uganda, standards and guidelines on the reduction of morbidity and mortality due to unsafe abortion supported by the constitution was contradictory to the penal code, leaving room for an ambiguous interpretation of the legal environment [ 25 ].

Regulations restricting the range of abortion methods from which women can choose, including medication abortion in particular, may also affect abortion access [ 26 , 27 ]. A literature review contextualizing medication abortion in seven African countries reported that incidence of medication abortion is low despite being a safe, effective, and low-cost abortion method, likely due to legal restrictions on access to the medications [ 27 ].

Over the past two decades, many LMICs have reformed their abortion laws [ 3 , 28 ]. Most have expanded the grounds on which abortion may be performed legally, while very few have restricted access. Countries like Uruguay, South Africa, and Portugal have amended their laws to allow abortion on request in the first trimester of pregnancy [ 29 , 30 ]. Conversely, in Nicaragua, a law to ban all abortion without any exception was introduced in 2006 [ 31 ].

Progressive reforms are expected to lead to improvements in women’s access to safe abortion and health outcomes, including reductions in the death and disabilities that accompany unsafe abortion, and reductions in stigma over the longer term [ 17 , 29 , 32 ]. However, abortion law reforms may yield different outcomes even in countries that experience similar reforms, as the legislative processes that are associated with changing abortion laws take place in highly distinct political, economic, religious, and social contexts [ 28 , 33 ]. This variation may contribute to abortion law reforms having different effects with respect to the health services and outcomes that they are hypothesized to influence [ 17 , 29 ].

Extant empirical literature has examined changes in abortion-related morbidity and mortality, contraceptive usage, fertility, and other health-related outcomes following reforms to abortion laws [ 34 – 37 ]. For example, a study in Mexico reported that a policy that decriminalized and subsidized early-term elective abortion led to substantial reductions in maternal morbidity and that this was particularly strong among vulnerable populations such as young and socioeconomically disadvantaged women [ 38 ].

To the best of our knowledge, however, the growing literature on the impact of abortion law reforms on women’s health services and outcomes has not been systematically reviewed. A study by Benson et al. evaluated evidence on the impact of abortion policy reforms on maternal death in three countries, Romania, South Africa, and Bangladesh, where reforms were immediately followed by strategies to implement abortion services, scale up accessibility, and establish complementary reproductive and maternal health services [ 39 ]. The three countries highlighted in this paper provided unique insights into implementation and practical application following law reforms, in spite of limited resources. However, the review focused only on a selection of countries that have enacted similar reforms and it is unclear if its conclusions are more widely generalizable.

Accordingly, the primary objective of this review is to summarize studies that have estimated the causal effect of a change in abortion law on women’s health services and outcomes. Additionally, we aim to examine heterogeneity in the impacts of abortion reforms, including variation across specific population sub-groups and contexts (e.g., due to variations in the intensity of enforcement and service delivery). Through this review, we aim to offer a higher-level view of the impact of abortion law reforms in LMICs, beyond what can be gained from any individual study, and to thereby highlight patterns in the evidence across studies, gaps in current research, and to identify promising programs and strategies that could be adapted and applied more broadly to increase access to safe abortion services.

The review protocol has been reported using Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 40 ] (Additional file 1 ). It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database CRD42019126927.

Eligibility criteria

Types of studies.

This review will consider quasi-experimental studies which aim to estimate the causal effect of a change in a specific law or reform and an outcome, but in which participants (in this case jurisdictions, whether countries, states/provinces, or smaller units) are not randomly assigned to treatment conditions [ 41 ]. Eligible designs include the following:

• Pretest-posttest designs where the outcome is compared before and after the reform, as well as nonequivalent groups designs, such as pretest-posttest design that includes a comparison group, also known as a controlled before and after (CBA) designs.
• Interrupted time series (ITS) designs where the trend of an outcome after an abortion law reform is compared to a counterfactual (i.e., trends in the outcome in the post-intervention period had the jurisdiction not enacted the reform) based on the pre-intervention trends and/or a control group [ 42 , 43 ].
• Differences-in-differences (DD) designs, which compare the before vs. after change in an outcome in jurisdictions that experienced an abortion law reform to the corresponding change in the places that did not experience such a change, under the assumption of parallel trends [ 44 , 45 ].
• Synthetic controls (SC) approaches, which use a weighted combination of control units that did not experience the intervention, selected to match the treated unit in its pre-intervention outcome trend, to proxy the counterfactual scenario [ 46 , 47 ].
• Regression discontinuity (RD) designs, which in the case of eligibility for abortion services being determined by the value of a continuous random variable, such as age or income, would compare the distributions of post-intervention outcomes for those just above and below the threshold [ 48 ].

There is heterogeneity in the terminology and definitions used to describe quasi-experimental designs, but we will do our best to categorize studies into the above groups based on their designs, identification strategies, and assumptions.

Our focus is on quasi-experimental research because we are interested in studies evaluating the effect of population-level interventions (i.e., abortion law reform) with a design that permits inference regarding the causal effect of abortion legislation, which is not possible from other types of observational designs such as cross-sectional studies, cohort studies or case-control studies that lack an identification strategy for addressing sources of unmeasured confounding (e.g., secular trends in outcomes). We are not excluding randomized studies such as randomized controlled trials, cluster randomized trials, or stepped-wedge cluster-randomized trials; however, we do not expect to identify any relevant randomized studies given that abortion policy is unlikely to be randomly assigned. Since our objective is to provide a summary of empirical studies reporting primary research, reviews/meta-analyses, qualitative studies, editorials, letters, book reviews, correspondence, and case reports/studies will also be excluded.

Our population of interest includes women of reproductive age (15–49 years) residing in LMICs, as the policy exposure of interest applies primarily to women who have a demand for sexual and reproductive health services including abortion.

Intervention

The intervention in this study refers to a change in abortion law or policy, either from a restrictive policy to a non-restrictive or less restrictive one, or vice versa. This can, for example, include a change from abortion prohibition in all circumstances to abortion permissible in other circumstances, such as to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, or on request with no requirement for justification. It can also include the abolition of existing abortion policies or the introduction of new policies including those occurring outside the penal code, which also have legal standing, such as:

• National constitutions;
• Supreme court decisions, as well as higher court decisions;
• Customary or religious law, such as interpretations of Muslim law;
• Medical ethical codes; and
• Regulatory standards and guidelines governing the provision of abortion.

We will also consider national and sub-national reforms, although we anticipate that most reforms will operate at the national level.

The comparison group represents the counterfactual scenario, specifically the level and/or trend of a particular post-intervention outcome in the treated jurisdiction that experienced an abortion law reform had it, counter to the fact, not experienced this specific intervention. Comparison groups will vary depending on the type of quasi-experimental design. These may include outcome trends after abortion reform in the same country, as in the case of an interrupted time series design without a control group, or corresponding trends in countries that did not experience a change in abortion law, as in the case of the difference-in-differences design.

Outcome measures

Primary outcomes.

• Access to abortion services: There is no consensus on how to measure access but we will use the following indicators, based on the relevant literature [ 49 ]: [ 1 ] the availability of trained staff to provide care, [ 2 ] facilities are geographically accessible such as distance to providers, [ 3 ] essential equipment, supplies and medications, [ 4 ] services provided regardless of woman’s ability to pay, [ 5 ] all aspects of abortion care are explained to women, [ 6 ] whether staff offer respectful care, [ 7 ] if staff work to ensure privacy, [ 8 ] if high-quality, supportive counseling is provided, [ 9 ] if services are offered in a timely manner, and [ 10 ] if women have the opportunity to express concerns, ask questions, and receive answers.
• Use of abortion services refers to induced pregnancy termination, including medication abortion and number of women treated for abortion-related complications.

Secondary outcomes

• Current use of any method of contraception refers to women of reproductive age currently using any method contraceptive method.
• Future use of contraception refers to women of reproductive age who are not currently using contraception but intend to do so in the future.
• Demand for family planning refers to women of reproductive age who are currently using, or whose sexual partner is currently using, at least one contraceptive method.
• Unmet need for family planning refers to women of reproductive age who want to stop or delay childbearing but are not using any method of contraception.
• Fertility rate refers to the average number of children born to women of childbearing age.
• Neonatal morbidity and mortality refer to disability or death of newborn babies within the first 28 days of life.
• Maternal morbidity and mortality refer to disability or death due to complications from pregnancy or childbirth.

There will be no language, date, or year restrictions on studies included in this systematic review.

Studies have to be conducted in a low- and middle-income country. We will use the country classification specified in the World Bank Data Catalogue to identify LMICs (Additional file 2 ).

Search methods

We will perform searches for eligible peer-reviewed studies in the following electronic databases.

• Ovid MEDLINE(R) (from 1946 to present)
• Embase Classic+Embase on OvidSP (from 1947 to present)
• CINAHL (1973 to present); and
• Web of Science (1900 to present)

The reference list of included studies will be hand searched for additional potentially relevant citations. Additionally, a grey literature search for reports or working papers will be done with the help of Google and Social Science Research Network (SSRN).

Search strategy

A search strategy, based on the eligibility criteria and combining subject indexing terms (i.e., MeSH) and free-text search terms in the title and abstract fields, will be developed for each electronic database. The search strategy will combine terms related to the interventions of interest (i.e., abortion law/policy), etiology (i.e., impact/effect), and context (i.e., LMICs) and will be developed with the help of a subject matter librarian. We opted not to specify outcomes in the search strategy in order to maximize the sensitivity of our search. See Additional file 3 for a draft of our search strategy.

Data collection and analysis

Data management.

Search results from all databases will be imported into Endnote reference manager software (Version X9, Clarivate Analytics) where duplicate records will be identified and excluded using a systematic, rigorous, and reproducible method that utilizes a sequential combination of fields including author, year, title, journal, and pages. Rayyan systematic review software will be used to manage records throughout the review [ 50 ].

Selection process

Two review authors will screen titles and abstracts and apply the eligibility criteria to select studies for full-text review. Reference lists of any relevant articles identified will be screened to ensure no primary research studies are missed. Studies in a language different from English will be translated by collaborators who are fluent in the particular language. If no such expertise is identified, we will use Google Translate [ 51 ]. Full text versions of potentially relevant articles will be retrieved and assessed for inclusion based on study eligibility criteria. Discrepancies will be resolved by consensus or will involve a third reviewer as an arbitrator. The selection of studies, as well as reasons for exclusions of potentially eligible studies, will be described using a PRISMA flow chart.

Data extraction

Data extraction will be independently undertaken by two authors. At the conclusion of data extraction, these two authors will meet with the third author to resolve any discrepancies. A piloted standardized extraction form will be used to extract the following information: authors, date of publication, country of study, aim of study, policy reform year, type of policy reform, data source (surveys, medical records), years compared (before and after the reform), comparators (over time or between groups), participant characteristics (age, socioeconomic status), primary and secondary outcomes, evaluation design, methods used for statistical analysis (regression), estimates reported (means, rates, proportion), information to assess risk of bias (sensitivity analyses), sources of funding, and any potential conflicts of interest.

Risk of bias and quality assessment

Two independent reviewers with content and methodological expertise in methods for policy evaluation will assess the methodological quality of included studies using the quasi-experimental study designs series risk of bias checklist [ 52 ]. This checklist provides a list of criteria for grading the quality of quasi-experimental studies that relate directly to the intrinsic strength of the studies in inferring causality. These include [ 1 ] relevant comparison, [ 2 ] number of times outcome assessments were available, [ 3 ] intervention effect estimated by changes over time for the same or different groups, [ 4 ] control of confounding, [ 5 ] how groups of individuals or clusters were formed (time or location differences), and [ 6 ] assessment of outcome variables. Each of the following domains will be assigned a “yes,” “no,” or “possibly” bias classification. Any discrepancies will be resolved by consensus or a third reviewer with expertise in review methodology if required.

Confidence in cumulative evidence

The strength of the body of evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system [ 53 ].

Data synthesis

We anticipate that risk of bias and heterogeneity in the studies included may preclude the use of meta-analyses to describe pooled effects. This may necessitate the presentation of our main findings through a narrative description. We will synthesize the findings from the included articles according to the following key headings:

• Information on the differential aspects of the abortion policy reforms.
• Information on the types of study design used to assess the impact of policy reforms.
• Information on main effects of abortion law reforms on primary and secondary outcomes of interest.
• Information on heterogeneity in the results that might be due to differences in study designs, individual-level characteristics, and contextual factors.

Potential meta-analysis

If outcomes are reported consistently across studies, we will construct forest plots and synthesize effect estimates using meta-analysis. Statistical heterogeneity will be assessed using the I 2 test where I 2 values over 50% indicate moderate to high heterogeneity [ 54 ]. If studies are sufficiently homogenous, we will use fixed effects. However, if there is evidence of heterogeneity, a random effects model will be adopted. Summary measures, including risk ratios or differences or prevalence ratios or differences will be calculated, along with 95% confidence intervals (CI).

Analysis of subgroups

If there are sufficient numbers of included studies, we will perform sub-group analyses according to type of policy reform, geographical location and type of participant characteristics such as age groups, socioeconomic status, urban/rural status, education, or marital status to examine the evidence for heterogeneous effects of abortion laws.

Sensitivity analysis

Sensitivity analyses will be conducted if there are major differences in quality of the included articles to explore the influence of risk of bias on effect estimates.

Meta-biases

If available, studies will be compared to protocols and registers to identify potential reporting bias within studies. If appropriate and there are a sufficient number of studies included, funnel plots will be generated to determine potential publication bias.

This systematic review will synthesize current evidence on the impact of abortion law reforms on women’s health. It aims to identify which legislative reforms are effective, for which population sub-groups, and under which conditions.

Potential limitations may include the low quality of included studies as a result of suboptimal study design, invalid assumptions, lack of sensitivity analysis, imprecision of estimates, variability in results, missing data, and poor outcome measurements. Our review may also include a limited number of articles because we opted to focus on evidence from quasi-experimental study design due to the causal nature of the research question under review. Nonetheless, we will synthesize the literature, provide a critical evaluation of the quality of the evidence and discuss the potential effects of any limitations to our overall conclusions. Protocol amendments will be recorded and dated using the registration for this review on PROSPERO. We will also describe any amendments in our final manuscript.

Synthesizing available evidence on the impact of abortion law reforms represents an important step towards building our knowledge base regarding how abortion law reforms affect women’s health services and health outcomes; we will provide evidence on emerging strategies to influence policy reforms, implement abortion services, and scale up accessibility. This review will be of interest to service providers, policy makers and researchers seeking to improve women’s access to safe abortion around the world.

Acknowledgements

We thank Genevieve Gore, Liaison Librarian at McGill University, for her assistance with refining the research question, keywords, and Mesh terms for the preliminary search strategy.

Abbreviations

Authors’ contributions.

FI and AN conceived and designed the protocol. FI drafted the manuscript. FI, UVU, and AN revised the manuscript and approved its final version.

The authors acknowledge funding from the Fonds de recherche du Quebec – Santé (FRQS) PhD doctoral awards and Canadian Institutes of Health Research (CIHR) Operating Grant, “Examining the impact of social policies on health equity” (ROH-115209).

Declarations

Not applicable

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Foluso Ishola, Email: [email protected] .

U. Vivian Ukah, Email: [email protected] .

Arijit Nandi, Email: [email protected] .

This paper is in the following e-collection/theme issue:

Published on 22.5.2024 in Vol 26 (2024)

The Power of Rapid Reviews for Bridging the Knowledge-to-Action Gap in Evidence-Based Virtual Health Care

Authors of this article:

• Megan MacPherson, PhD   ; 
• Sarah Rourke, MSN  

Fraser Health, Surrey, BC, Canada

Corresponding Author:

Megan MacPherson, PhD

Fraser Health

400-13450 102nd Avenue

Surrey, BC, V3T 0H1

Phone: 1 6045616605

Email: [email protected]

Despite the surge in popularity of virtual health care services as a means of delivering health care through technology, the integration of research evidence into practice remains a challenge. Rapid reviews, a type of time-efficient evidence synthesis, offer a potential solution to bridge the gap between knowledge and action. This paper aims to highlight the experiences of the Fraser Health Authority’s Virtual Health team in conducting rapid reviews. This paper discusses the experiences of the Virtual Health team in conducting 15 rapid reviews over the course of 1.5 years and the benefit of involving diverse stakeholders including researchers, project and clinical leads, and students for the creation of user-friendly knowledge products to summarize results. The Virtual Health team found rapid reviews to be a valuable tool for evidence-informed decision-making in virtual health care. Involving stakeholders and focusing on implementation considerations are crucial for maximizing the impact of rapid reviews. Health care decision makers are encouraged to consider implementing rapid review processes to improve the translation of research evidence into practice, ultimately enhancing patient outcomes and promoting a culture of evidence-informed care.

Introduction

Virtual health care services, which involve the delivery of health care through information and communication technologies, have gained popularity among health care providers, patients, and organizations. In recent decades, several initiatives have been undertaken to implement virtual care and improve the access, quality, and safety of health care delivery in Canada [ 1 ]; however, technological advancement and a rapidly expanding evidence base make supporting virtual care with research evidence challenging. Specifically, to adequately support virtual care, health care decision makers are expected to keep up with available technologies, their applications, and evidence of their effectiveness among a variety of health conditions.

Despite decision makers recognizing the need to consider research evidence in the context of public health problems [ 2 , 3 ], there is still a knowledge-to-action (KTA) gap between what is known and what is put into practice clinically [ 4 - 6 ], with health care professionals worldwide demonstrating suboptimal use of research evidence within clinical practice [ 7 - 14 ]. Further, it has been estimated that one-third of patients do not receive treatments that have proven efficacious, one-quarter receive treatments that are potentially harmful, and up to three-quarters of patients and half of clinicians do not receive the information necessary for research-informed decision-making [ 15 ]. Clearly, there is a need to improve the translation of research evidence into practice, particularly in the case of virtual care where technological innovations and research evidence are rapidly expanding.

Knowledge Translation

The field of knowledge translation (KT) strives to enhance the usefulness of research evidence through the design and conduct of stakeholder-informed, patient-oriented studies as well as the dissemination and implementation of research findings into practice [ 16 ]. The Canadian Institutes for Health Research defines KT as the ethical exchange, synthesis, and application of knowledge among researchers and users to accelerate the benefits of research for Canadian people [ 17 ]. The ultimate goal of KT has been further described as the facilitation of evidence-informed decision-making [ 18 ] and the integration of various forms of evidence into public health practice and policy.

The Canadian Institutes for Health Research describes 2 “Death Valleys” on the continuum from research to action, which contributes to the KTA gap [ 19 ]. Valley 1 refers to the reduced ability to translate basic biomedical research discoveries from the laboratory to the bedside and to effectively commercialize health innovations. Valley 2 refers to the reduced ability to synthesize, disseminate, and integrate research findings more broadly into clinical practice and clinical decision-making. To improve the utility of biomedical and clinical research, enhance health outcomes, and ensure an evidence-based and sustainable health care system, strategic attempts to bridge these valleys must be made.

Rapid Reviews

One way to help overcome the second valley is through evidence syntheses such as systematic, scoping, and rapid reviews [ 20 ]. Evidence syntheses have emerged as valuable methods for KT as they can compile large bodies of evidence into a single knowledge product, making them an essential tool for decision makers to enhance evidence-informed decision-making [ 21 , 22 ]. Systematic reviews offer a comprehensive synthesis of available evidence on a particular topic, playing an ever-expanding role in informing policy making and practice [ 23 , 24 ]; however, the resource-intensive nature of conducting systematic reviews, in terms of both time and cost, presents a significant obstacle to facilitating prompt and efficient decision-making [ 25 ].

Given the time constraints health care practitioners and policy makers often face [ 26 ], rapid reviews provide a more resource- and time-efficient means to conduct evidence syntheses that offer actionable evidence in a more relevant manner compared to other types of evidence syntheses such as systematic or scoping reviews [ 20 , 26 - 34 ]. Specifically, rapid reviews are a form of evidence synthesis in which systematic review steps are streamlined to generate actionable evidence within a condensed time frame [ 35 ]. To expedite the review process, rapid reviews often compromise on the rigor typically associated with systematic reviews, resulting in a less precise and robust evaluation in comparison [ 32 ]. That being said, rapid reviews have gained traction in health systems’ policy making, health-related intervention development, and health technology assessment [ 34 - 36 ]. This paper outlines the experiences of the Fraser Health (FH) Authority Virtual Health team in rapidly producing and disseminating rapid review results to date. Rapid reviews were chosen as they are often highly driven by end-user demands [ 37 ] and have been highlighted as a viable tool to disseminate knowledge within the rapidly growing field of virtual health [ 33 ].

FH Authority Context

As the largest regional health authority in British Columbia, Canada, FH serves more than 1.9 million people in Canada [ 38 ]. In recent years, FH has prioritized the expansion of virtual care [ 39 ], conducting over 1.9 million virtual visits between January 2019 and 2023 (roughly 27% of all visits). Within the Virtual Health department at FH, the “research and evaluation team” aims to improve the translation of research into practice while engaging in ongoing collaborative evaluation of existing Virtual Health programming. During Virtual Health strategic planning, rapid reviews have emerged as a central tool for knowledge dissemination and have been used to inform the development of frameworks, services, and program scale-up. This paper highlights FH’s experience in conducting 15 rapid reviews over the course of 1.5 years. This paper is meant to serve as an overview on the utility and feasibility of rapid reviews within a health authority; for more information on rapid review methods to aid in conducting reviews within a team-based setting, see MacPherson et al [ 33 ].

Rapid reviews are used within the Virtual Health team to provide an overview of available evidence addressing a research question related to a single topic produced within a short time frame (typically 1 week to 4 months). From October 2022 until March 2024, the Virtual Health team conducted 15 rapid reviews following published recommendations [ 33 ]. Questions posed to date include the following:

• What are the perspectives on virtual care among immigrant, refugee, and Indigenous people in Canada [ 40 ]?
• What virtual care solutions exist for people with heart failure [ 41 ]?
• What virtual care solutions exist for people with diabetes [ 41 ]?
• What virtual care solutions exist for people with chronic obstructive pulmonary disease (COPD) [ 41 ]?
• What are currently used decision guides or algorithms to inform escalation within remote patient monitoring services for people with heart failure?
• What barriers, facilitators, and recommendations exist for remote patient monitoring services within the context of respiratory care [ 42 ]?
• What virtual care or digital innovations are used by physicians in acute care [ 43 ]?
• What barriers and facilitators exist for patient-to-provider virtual messaging (eg, SMS text messaging) [ 44 ]?
• What is the existing evidence for centralized remote patient monitoring services [ 45 ]?
• What domains are included within virtual care frameworks targeting appropriateness and safety?
• What are patient and provider barriers to virtual care [ 46 ]?
• What is the evidence for virtual hospital programs [ 47 ]?
• What KT strategies exist that could be used by the Virtual Health research and evaluation team in their efforts to translate research findings into practice?
• What is the available evidence on virtual decision-making and clinical judgment?
• What is the available evidence for, and are there existing validated assessment criteria for nursing assessment frameworks?

Team members assisting with the rapid reviews included researchers, project leads, clinical leads, and students previously unfamiliar with the review process. Knowledge users within the Virtual Health team (eg, clinical leads and clinical directors) were involved throughout the entirety of the review process from developing the research questions to the presentation of research findings in Virtual Health team meetings and the implementation of findings into Virtual Health practice.

Similar to other rapid reviews [ 20 ], results were collated and narratively or visually summarized (eg, through infographics) and presented to Virtual Health team members. The final knowledge products were created to offer a high-level overview of the evidence arranged in a user-friendly manner, aiming to provide VH team members with a high-level understanding of the available evidence [ 41 ].

Experiences and Lessons Learned

The Virtual Health team’s journey in conducting 15 rapid reviews over the course of 1.5 years has provided valuable insights into the feasibility and utility of rapid reviews within a health authority setting. These lessons learned are from the perspectives of the authors of this paper. MM is the research and KT lead of the Virtual Health department at the FH Authority. Prior to creating the rapid review program within the Virtual Health department, she has prior experience conducting systematic, scoping, and rapid reviews. SR is a clinical nurse specialist within the Virtual Health department at FH. As a system-level leader, SR leverages evidence to informed clinical and service model changes to optimize patient care and outcomes and support strategic priorities. Prior to her involvement in the Virtual Health rapid review program, SR had no previous experience with conducting evidence reviews.

Importance of Defining a Clear and Actionable Research Question

Throughout this journey, one of the key lessons learned was about the importance of the research question being actionable to ensure that the results of rapid reviews can be readily integrated into practice. Initially, our reviews had broader scopes aimed at informing future Virtual Health service implementations across various populations such as COPD, diabetes, and heart failure. While these reviews were informative, they did not lead to immediate changes in Virtual Health practice and required strategic efforts to disseminate findings and integrate results into practice. Subsequently, we learned that focusing on specific programs or initiatives within the Virtual Health setting yields more actionable results. For instance, a review focused on identifying patient and provider barriers to virtual care was conducted with the explicit purpose of informing the development of a framework to improve video visit uptake among primary care providers. This targeted approach enabled us to directly address the identified barriers through the development of a framework focused on the uptake of safe and appropriate video visits within primary care.

Benefits and Challenges Involving Knowledge Users

The involvement of knowledge users such as clinical leads and directors in the rapid review process proved to be invaluable. First, they helped focus the scope of reviews by providing insights into the practical needs and priorities within the FH context. For example, the reviews focusing on virtual care solutions for patients with heart failure, COPD, and diabetes were initiated by 1 of the directors within Virtual Health and included an occupational therapist and clinical nurse specialist on the review team. The diverse insights offered by clinician team members helped shape the review questions, search strategy, and analysis, ensuring it addressed the practical needs in delivering virtual care to this specific patient population.

Second, the engagement of nonresearchers, students, and health care professionals in the review process not only enhanced the quality and relevance of the rapid reviews but also provided an opportunity for experiential learning and professional development. By participating in the rapid review process, students and other team members developed essential skills such as critical appraisal, evidence synthesis, and scientific communication. This approach has the potential to bridge the gap between research and practice by building a generation of clinicians who are well versed in evidence-based practice and can effectively translate research findings into clinical decision-making. For example, a team of nursing students participated in a rapid review focused on algorithms for care escalation within remote patient monitoring services for patients with heart failure. While they lacked prior review experience, their fresh perspectives and familiarity with health care practice as it relates to heart failure brought unique insights helping to shape the clinician-oriented KT efforts.

While involving knowledge users throughout the review process offers numerous benefits, it can also extend the time required to complete a review. This is often due to the necessity for these individuals to familiarize themselves with new software while simultaneously mastering the intricacies of conducting reviews and adhering to all associated steps. For instance, several Virtual Health team members have observed that during their initial and subsequent reviews, they encountered difficulties in efficiently navigating the study screening phase. The abundance of potentially relevant literature posed a challenge, with concerns arising about potentially overlooking papers containing valuable insights or “hidden gems.” This underscores the importance of establishing clear eligibility criteria and providing comprehensive training from the outset to ensure reviewers feel empowered to exclude papers confidently, even those that may initially appear intriguing.

Resources and Staff Time Involved

Readers interested in starting a rapid review program in their own health systems may find it helpful to understand the resources and staff time involved in our process. As the research and KT lead within the Virtual Health team, MM has been responsible for building the rapid review program, training team members, and leading rapid reviews. Her full-time role allows for dedicated focus on these as well as other research and KT-related activities, ensuring the smooth operation of the rapid review process.

Additionally, strong leadership support within the Virtual Health team has been instrumental in fostering a culture of evidence-informed decision-making and facilitating the integration of research evidence into practice. While we do not have a core team with a dedicated full-time equivalent specifically for rapid reviews, a call is put out to the Virtual Health department at the beginning of a review to identify who has the capacity to assist in a review. A testament to the value of these reviews is that VH team members have begun autonomously conducting rapid reviews with the research and KT lead acting as an advisor, not a lead on the reviews. For example, a nurse who was tasked with creating a framework for a virtual nursing assessment requested assistance in running a search for her team to complete a rapid review, to ensure that the resulting framework did not miss any key components seen in the literature.

Rapid Review Process

The overall process map for our team (an adaptation of MacPherson et al [ 33 , 48 ]) can be found in Figure 1 . Our journey in conducting rapid reviews has been accompanied by several challenges and the implementation of quality assurance measures to ensure the integrity of our findings. The overall process of reviews within the Virtual Health team includes Virtual Health team members submitting a request or having an informal meeting with the research and KT lead outlining the scope and purpose of the review, which is then refined to ensure that it will result in actionable evidence relevant to the Virtual Health team and is in alignment with organizational priorities.

Challenges or obstacles encountered during the rapid review process have included resource constraints. When there are not enough people to assist with a review, either the time to complete the review needs to be extended or additional constraints must be placed on the review question. Time limitations have also been a factor, especially when there is an urgent request. Clear communication on how the results will be used is needed to refine the review topic and search strategy to quickly produce actionable evidence. Given the wealth of research, we have started all reviews by first exploring if our questions can be answered by conducting a review of reviews. This has allowed for the timely synthesis of evidence instead of relying on individual studies. We have also found that decision makers value the most up-to-date evidence (especially regarding virtual health care technologies); as such, many of our reviews have imposed limitations to the past 5-10 years to ensure their relevance to decision makers. Additionally, difficulties in accessing relevant literature have been noted, as health authorities often do not have access to the same resources as academic institutions. This results in increased time to secure papers through interlibrary loans, which can be overcome by collaborating with academics.

Another strength of the Virtual Health team’s rapid review approach was the development of easily digestible knowledge products highlighting key data synthesized in the review. Rather than providing end users with lengthy reports that often go unread, clinicians within the Virtual Health team helped to create brief summaries and infographics highlighting the main findings and recommendations. This approach was aimed at improving the uptake of research evidence into practice by presenting the information in a format that was easily accessible and understandable for clinicians and other stakeholders. By creating visually appealing and user-friendly knowledge products, the Virtual Health team was able to efficiently communicate key takeaways from the rapid reviews, thus facilitating their dissemination and implementation within the FH context. This approach also helped to overcome a common challenge of KT, where research evidence can be difficult to access, understand, and apply in practice. By presenting the information in a format that was relevant and easily digestible, the Virtual Health team was able to enhance the applicability of the rapid reviews, thereby building clinician capacity and increasing their potential impact on patient outcomes.

Leveraging Rapid Reviews for Clinically Based Tools

Our most recent reviews were focused on developing a virtual nursing assessment and virtual nursing decision-making framework. Unlike traditional KT efforts used within other reviews, where the focus often lies on creating user-friendly summaries and infographics, our approach took a slightly different path. We aimed to directly inform the development of clinical decision support tools (DSTs).

Rather than developing traditional KT products, the raw data extracted from these reviews served as a foundational resource for the development of the clinical DSTs. Each piece of information was carefully referenced and integrated into the tool, providing evidence-based support for specific components and functionalities. This direct integration of research evidence into the tool development process not only strengthened the validity and credibility of the tool but also facilitated the transparent communication of the evidence behind each recommendation or feature.

Within these reviews, the active participation of those who were responsible for the development of the DSTs proved invaluable. Their involvement was crucial in ensuring understanding and confidence in the information as well as in merging research evidence with their own clinical expertise. By involving end users in the review process, we could tailor the outcomes to their specific needs and preferences, ultimately enhancing the relevance and applicability of the extracted evidence. This collaborative approach ensured that the resulting DSTs were not only evidence based but also resonated effectively with the clinical context they were intended for.

Principal Findings

The Virtual Health team’s experience with conducting 15 rapid reviews over the course of 1.5 years highlights the potential of rapid reviews as a time-efficient tool for improving the translation and uptake of research evidence into Virtual Health programming. Compared to more traditional review types (eg, systematic or scoping), which can take more than a year to complete [ 49 ], rapid reviews provide a practical way of synthesizing available evidence to inform clinical decision-making. The ability to produce a high-quality evidence summary in a shorter time frame can be particularly valuable in rapidly evolving areas of health care, such as virtual health. While rapid reviews are not new, our program offers insights into their application in a dynamic and rapidly evolving field such as virtual health. The lessons learned from FH’s rapid review program have important implications for evidence-based decision-making and KT within health care settings.

One of our primary lessons learned underscores the importance of establishing clear and actionable research questions. By outlining precise objectives, rapid reviews can ensure the relevance and applicability of their results, thus facilitating their seamless integration into clinical practice. Moreover, our experiences highlight the transformative impact of involving knowledge users throughout the review process. This collaborative approach not only enhances the quality and relevance of the evidence synthesized but also fosters a culture of evidence-informed decision-making within the organization. This type of early and continued engagement of knowledge users in research endeavors has been increasingly recognized as pivotal for establishing research priorities and enhancing the utility of research findings in real-world health care contexts [ 50 , 51 ]. In line with this, the overarching goal of knowledge-user engagement in health research is to coproduce knowledge that directly addresses the needs of decision makers. By involving knowledge users from the outset, research priorities can be aligned with the practical requirements of health care delivery, thereby increasing the relevance and utility of research outputs [ 52 - 54 ].

Limitations of Rapid Reviews

Despite its benefits, the rapid review approach is not without limitations. Loss of rigor, as mentioned earlier in this paper, remains a concern. The rapid nature of the process may compromise the depth and comprehensiveness of the literature search and synthesis, potentially leading to oversights or biases in the evidence presented. Furthermore, within the context of virtual health, the rapid pace of technological advancements poses a challenge. New technologies may outpace the generation of peer-reviewed literature, resulting in a lag between their implementation and the availability of robust evidence.

In response to the challenge posed by rapidly evolving technologies, FH’s Virtual Health department has used creative solutions to capture relevant evidence. While peer-reviewed literature remains a primary source, we have also incorporated gray literature, such as news articles, trade publications, and reports, from other health care authorities or departments within the review processes when applicable. Additionally, to supplement reviews and provide more contextual evidence, additional research and evaluation methodologies are used (time permitting) to inform Virtual Health service development such as consulting Patient and Family Advisory Councils within FH, conducting interviews with patient and clinician partners, and conducting analyses on existing data within FH.

Next Steps for FH’s Rapid Review Program

We remain committed to advancing the rapid review program to meet the evolving needs of the Virtual Health department at FH. While we have heard anecdotally that knowledge users value the user-friendly knowledge products developed for rapid reviews, the next steps of this program include an evaluation of our knowledge dissemination to assess the reach and impact the reviews are having within the Virtual Health department.

Conclusions

Rapid reviews are a valuable tool for the timely synthesis of available research evidence to inform health care decision-making. The Virtual Health team’s experience with conducting rapid reviews highlights the importance of involving a diverse range of knowledge users in the review process and the need to focus on implementation considerations. By engaging knowledge users beyond designated researchers, and particularly by involving clinicians across the research process, rapid reviews become more robust, applicable, and aligned with the practical needs of health care providers and organizations, which can help to bridge the KTA gap.

Conflicts of Interest

None declared.

• Goodridge D, Marciniuk D. Rural and remote care: overcoming the challenges of distance. Chron Respir Dis. 2016;13(2):192-203. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Bowen S, Zwi AB. Pathways to "evidence-informed" policy and practice: a framework for action. PLoS Med. 2005;2(7):e166. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Jacobs JA, Jones E, Gabella BA, Spring B, Brownson RC. Tools for implementing an evidence-based approach in public health practice. Prev Chronic Dis. 2012;9:E116. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Davis D, Evans M, Jadad A, Perrier L, Rath D, Ryan D, et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ. 2003;327(7405):33-35. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients' care. Lancet. 2003;362(9391):1225-1230. [ CrossRef ] [ Medline ]
• Grol R, Jones R. Twenty years of implementation research. Fam Pract. 2000;17(Suppl 1):S32-S35. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Straus SE, McAlister FA. Evidence-based medicine: a commentary on common criticisms. CMAJ. 2000;163(7):837-841. [ FREE Full text ] [ Medline ]
• Mellis C. Evidence-based medicine: what has happened in the past 50 years? J Paediatr Child Health. 2015;51(1):65-68. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Villar J, Carroli G, Gülmezoglu AM. The gap between evidence and practice in maternal healthcare. Int J Gynaecol Obstet. 2001;75(Suppl 1):S47-S54. [ Medline ]
• Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001;39(8 Suppl 2):II46-II54. [ CrossRef ] [ Medline ]
• Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the United States? Milbank Q. 1998;76(4):517-563. [ FREE Full text ] [ CrossRef ] [ Medline ]
• McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Lauer MS, Skarlatos S. Translational research for cardiovascular diseases at the National Heart, Lung, and Blood Institute: moving from bench to bedside and from bedside to community. Circulation. 2010;121(7):929-933. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Lang ES, Wyer PC, Haynes RB. Knowledge translation: closing the evidence-to-practice gap. Ann Emerg Med. 2007;49(3):355-363. [ CrossRef ] [ Medline ]
• Kitson AL, Straus SE. Identifying knowledge to action gaps. Knowledge Transl Health Care. 2013:97-109. [ FREE Full text ] [ CrossRef ]
• Graham ID, Logan JL, Harrison MB, Straus SE, Tetroe J, Caswell W, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26(1):13-24. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Knowledge translation strategy 2004-2009: innovation in action. Canadian Institutes of Health Research. 2004. URL: https://cihr-irsc.gc.ca/e/26574.html [accessed 2024-04-25]
• Ciliska D, Thomas H, Buffett C. A compendium of critical appraisal tools for public health practice. National Collaborating Centre for Methods and Tools. 2008. URL: https://www.nccmt.ca/uploads/media/media/0001/01/b331668f85bc6357f262944f0aca38c14c89c5a4.pdf [accessed 2024-04-25]
• Canada's strategy for patient-oriented research. Government of Canada. Canadian Institutes of Health Research. 2011. URL: https://cihr-irsc.gc.ca/e/44000.html#a1.1 [accessed 2023-04-06]
• Khangura S, Konnyu K, Cushman R, Grimshaw J, Moher D. Evidence summaries: the evolution of a rapid review approach. Syst Rev. 2012;1(1):10. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Chambers D, Wilson PM, Thompson CA, Hanbury A, Farley K, Light K. Maximizing the impact of systematic reviews in health care decision making: a systematic scoping review of knowledge-translation resources. Milbank Q. 2011;89(1):131-156. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implement Sci. 2012;7(1):50. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Bosch-Capblanch X, Lavis JN, Lewin S, Atun R, Røttingen JA, Dröschel D, et al. Guidance for evidence-informed policies about health systems: rationale for and challenges of guidance development. PLoS Med. 2012;9(3):e1001185. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Oxman AD, Lavis JN, Lewin S, Fretheim A. SUPPORT tools for evidence-informed health policymaking (STP). Norwegian Knowledge Centre for the Health Services. 2010. URL: https://fhi.brage.unit.no/fhi-xmlui/bitstream/handle/11250/2378076/NOKCrapport4_2010.pdf?sequence=1 [accessed 2023-11-22]
• Oliver K, Innvar S, Lorenc T, Woodman J, Thomas J. A systematic review of barriers to and facilitators of the use of evidence by policymakers. BMC Health Serv Res. 2014;14(1):2. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Ganann R, Ciliska D, Thomas H. Expediting systematic reviews: methods and implications of rapid reviews. Implement Sci. 2010;5(1):56. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Moore G, Redman S, Rudge S, Haynes A. Do policy-makers find commissioned rapid reviews useful? Health Res Policy Syst. 2018;16(1):17. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Flores EJ, Jue JJ, Giradi G, Schoelles K, Mull NK, Umscheid CA. AHRQ EPC Series on improving translation of evidence: use of a clinical pathway for C. Difficile treatment to facilitate the translation of research findings into practice. Jt Comm J Qual Patient Saf. 2019;45(12):822-828. [ CrossRef ] [ Medline ]
• Hartling L, Guise J, Kato E, Anderson J, Belinson S, Berliner E, et al. A taxonomy of rapid reviews links report types and methods to specific decision-making contexts. J Clin Epidemiol. 2015;68(12):1451-1462.e3. [ CrossRef ] [ Medline ]
• Hartling L, Guise JM, Kato E, Anderson J, Aronson N, Belinson S, et al. EPC Methods: An Exploration of Methods and Context for the Production of Rapid Reviews. Rockville, MD. Agency for Healthcare Research and Quality; 2015.
• Hartling L, Guise JM, Hempel S, Featherstone R, Mitchell MD, Motu'apuaka ML, et al. Fit for purpose: perspectives on rapid reviews from end-user interviews. Syst Rev. 2017;6(1):32. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Featherstone RM, Dryden DM, Foisy M, Guise JM, Mitchell MD, Paynter RA, et al. Advancing knowledge of rapid reviews: an analysis of results, conclusions and recommendations from published review articles examining rapid reviews. Syst Rev. 2015;4(1):50. [ FREE Full text ] [ CrossRef ] [ Medline ]
• MacPherson MM, Wang RH, Smith EM, Sithamparanathan G, Sadiq CA, Braunizer AR. Rapid reviews to support practice: a guide for professional organization practice networks. Can J Occup Ther. 2023;90(3):269-279. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Watt A, Cameron A, Sturm L, Lathlean T, Babidge W, Blamey S, et al. Rapid reviews versus full systematic reviews: an inventory of current methods and practice in health technology assessment. Int J Technol Assess Health Care. 2008;24(2):133-139. [ CrossRef ] [ Medline ]
• Polisena J, Garritty C, Kamel C, Stevens A, Abou-Setta AM. Rapid review programs to support health care and policy decision making: a descriptive analysis of processes and methods. Syst Rev. 2015;4(1):26. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Harker J, Kleijnen J. What is a rapid review? A methodological exploration of rapid reviews in health technology assessments. Int J Evid Based Healthc. 2012;10(4):397-410. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Garritty C, Gartlehner G, Nussbaumer-Streit B, King VJ, Hamel C, Kamel C, et al. Cochrane Rapid Reviews Methods Group offers evidence-informed guidance to conduct rapid reviews. J Clin Epidemiol. 2021;130:13-22. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Fraser Health. 2023. URL: https://www.fraserhealth.ca/ [accessed 2023-04-06]
• Virtual Health. Fraser Health. URL: https://www.fraserhealth.ca/patients-and-visitors/virtual-health [accessed 2023-04-06]
• MacPherson M. Immigrant, refugee, and Indigenous Canadians' experiences with virtual health care services: rapid review. JMIR Hum Factors. 09, 2023;10:e47288. [ FREE Full text ] [ CrossRef ] [ Medline ]
• MacPherson M. Virtual care in heart failure, chronic obstructive pulmonary disease, and diabetes: a rapid review protocol. OSF Registries. 2023. URL: https://osf.io/xn2pe [accessed 2023-09-11]
• MacPherson M. Barriers, facilitators, and recommendations to inform the expansion of remote patient monitoring services for respiratory care: a rapid review. OSF Registries. 2022. URL: https://osf.io/asf2v/ [accessed 2024-04-25]
• MacPherson M. Virtual health services in the context of acute care: a rapid review. OSF Registries. 2023. URL: https://osf.io/ub2d8/ [accessed 2024-04-25]
• MacPherson MM, Kapadia S. Barriers and facilitators to patient-to-provider messaging using the COM-B model and theoretical domains framework: a rapid umbrella review. BMC Digit Health. 2023;1(1):33. [ FREE Full text ] [ CrossRef ]
• Chan L, MacPherson M. Remote patient monitoring: an evidence synthesis. OSF Registries. 2023. URL: https://osf.io/7wqb8/ [accessed 2024-04-25]
• Montenegro M, MacPherson M. Barriers to virtual care experienced by patients and healthcare providers: a rapid umbrella review. OSF Registries. 2023. URL: https://osf.io/nufg4/ [accessed 2024-04-25]
• Montenegro M, MacPherson M. Virtual hospitals: a rapid review. OSF Registries. 2023. URL: https://osf.io/m3a4b/ [accessed 2024-04-25]
• Attribution 4.0 International (CC BY 4.0). Creative Commons. URL: https://creativecommons.org/licenses/by/4.0/ [accessed 2024-05-13]
• Borah R, Brown AW, Capers PL, Kaiser KA. Analysis of the time and workers needed to conduct systematic reviews of medical interventions using data from the PROSPERO registry. BMJ Open. 2017;7(2):e012545. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Deverka PA, Lavallee DC, Desai PJ, Esmail LC, Ramsey SD, Veenstra DL, et al. Stakeholder participation in comparative effectiveness research: defining a framework for effective engagement. J Comp Eff Res. 2012;1(2):181-194. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Bragge P, Clavisi O, Turner T, Tavender E, Collie A, Gruen RL. The Global Evidence Mapping Initiative: scoping research in broad topic areas. BMC Med Res Methodol. 2011;11(1):92. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Langlois EV, Montekio VB, Young T, Song K, Alcalde-Rabanal J, Tran N. Enhancing evidence informed policymaking in complex health systems: lessons from multi-site collaborative approaches. Health Res Policy Syst. 2016;14(1):20. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Vindrola-Padros C, Pape T, Utley M, Fulop NJ. The role of embedded research in quality improvement: a narrative review. BMJ Qual Saf. 2017;26(1):70-80. [ FREE Full text ] [ CrossRef ] [ Medline ]
• Ghaffar A, Langlois EV, Rasanathan K, Peterson S, Adedokun L, Tran NT. Strengthening health systems through embedded research. Bull World Health Organ. 2017;95(2):87. [ FREE Full text ] [ CrossRef ] [ Medline ]

Abbreviations

Edited by Z Yin; submitted 22.11.23; peer-reviewed by W LaMendola, M Willenbring, Y Zhang, P Blasi; comments to author 10.03.24; revised version received 15.03.24; accepted 13.04.24; published 22.05.24.

©Megan MacPherson, Sarah Rourke. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 22.05.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

• Apply to UMaine

UMaine News

Giudice co-authors award winning guidance on robot guide dogs

Nicholas Giudice, professor of spatial computing at the University of Maine, co-authored an award winning paper about developing robot guide dogs to assist people with visual impairments.

In an effort led by researchers from the University of Massachusetts Amherst , Giudice helped outline the first user-driven guidelines on the needs and design specifications for robot guide dogs. The research article, available online , won a Best Paper Award at CHI 2024: Conference on Human Factors in Computing Systems, the leading venue for human-computer interaction research.  

The study involved interviewing and observing guide dog users to better comprehend the handler-dog relationship and how it could be accurately modeled, according to Giudice, co-founder and chief research scientist at VEMI Lab. A longtime guide dog user, Giudice said the paper serves as a first step toward understanding user needs and specifications and as a starting point for the next era of research in robotic guide dog technology.

“In my head, the robotic guide dog is not a replacement to an animal guide, it is a complement to be used in situations where I don’t want to take my dog but still want similar guidance,” Giudice said. “For instance, in situations where it is not safe, such as if there is glass on the ground or if it is too hot or cold outside, if it is too loud (like at fireworks displays or concerts) or too busy (such as at a crowded bar or sporting event). These are places where I wouldn’t want to take my ‘real’ guide dog but where a robotic guide dog would be fine.”

Read the full story on the UMaine Spatial Computing website . 

Contact: Allen Adams, [email protected]

• UMaine Today Magazine
• Submit news