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      Health care providers' attitudes towards termination of pregnancy: A qualitative study in South Africa

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      BMC Public Health
      BioMed Central

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          Abstract

          Background

          Despite changes to the abortion legislation in South Africa in 1996, barriers to women accessing abortion services still exist including provider opposition to abortions and a shortage of trained and willing abortion care providers. The dearth of abortion providers undermines the availability of safe, legal abortion, and has serious implications for women's access to abortion services and health service planning.

          In South Africa, little is known about the personal and professional attitudes of individuals who are currently working in abortion service provision. Exploring the factors which determine health care providers' involvement or disengagement in abortion services may facilitate improvement in the planning and provision of future services.

          Methods

          Qualitative research methods were used to collect data. Thirty four in-depth interviews and one focus group discussion were conducted during 2006 and 2007 with health care providers who were involved in a range of abortion provision in the Western Cape Province, South Africa. Data were analysed using a thematic analysis approach.

          Results

          Complex patterns of service delivery were prevalent throughout many of the health care facilities, and fragmented levels of service provision operated in order to accommodate health care providers' willingness to be involved in different aspects of abortion provision. Related to this was the need expressed by many providers for dedicated, stand-alone abortion clinics thereby creating a more supportive environment for both clients and providers. Almost all providers were concerned about the numerous difficulties women faced in seeking an abortion and their general quality of care. An overriding concern was poor pre and post abortion counselling including contraceptive counselling and provision.

          Conclusion

          This is the first known qualitative study undertaken in South Africa exploring providers' attitudes towards abortion and adds to the body of information addressing the barriers to safe abortion services. In order to sustain a pool of abortion providers, programmes which both attract prospective abortion providers, and retain existing providers, needs to be developed and financial compensation for abortion care providers needs to be considered.

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          Most cited references28

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          The epidemiology of rape and sexual coercion in South Africa: an overview.

          During 1999 the issue of rape in South Africa was debated at the highest levels. The epidemiology of rape has become an issue of considerable political importance and sensitivity, with President Mbeki demanding an answer to the question: how much rape is there in South Africa? The purpose of this paper is both to summarise and synthesise the findings of research to provide an overview of the epidemiology of rape of women in South Africa and to show how difficult it is to answer the President's question. The review begins by considering why rape is so difficult to research. Data available shows that rape reported to the police (240 incidents of rape and attempted rape per 100,000 women each year) represents the tip of an ice berg of sexual coercion. Representative community-based surveys have found, for example, that in the 17-48 age group there are 2070 such incidents per 100,000 women per year. Non-consensual sex in marriage and dating relationships is believed to be very common but is usually not well reported in surveys. Forced sexual initiation is reported by almost a third of adolescent girls. In addition coerced consensual sex is a common problem in schools, workplaces and amongst peers. Knowledge of causal and contributory factors influencing the high levels of rape are also discussed. We conclude that the rape statistic for the country is currently elusive but levels of non-consensual and coerced sex are clearly very high. International comparison needs to be approached with caution because most developing countries lack the infrastructure for accurate crime reporting and do not have such a substantial body of survey data.
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            Gender-based violence, relationship power, and risk of HIV infection in women attending antenatal clinics in South Africa.

            Gender-based violence and gender inequality are increasingly cited as important determinants of women's HIV risk; yet empirical research on possible connections remains limited. No study on women has yet assessed gender-based violence as a risk factor for HIV after adjustment for women's own high-risk behaviours, although these are known to be associated with experience of violence. We did a cross-sectional study of 1366 women presenting for antenatal care at four health centres in Soweto, South Africa, who accepted routine antenatal HIV testing. Private face-to-face interviews were done in local languages and included assessement of sociodemographic characteristics, experience of gender-based violence, the South African adaptation of the Sexual Relationship Power Scale (SRPS), and risk behaviours including multiple, concurrent, and casual male partners, and transactional sex. After adjustment for age and current relationship status and women's risk behaviour, intimate partner violence (odds ratio 1.48, 95% CI 1.15-1.89) and high levels of male control in a woman's current relationship as measured by the SRPS (1.52, 1.13-2.04) were associated with HIV seropositivity. Child sexual assault, forced first intercourse, and adult sexual assault by non-partners were not associated with HIV serostatus. Women with violent or controlling male partners are at increased risk of HIV infection. We postulate that abusive men are more likely to have HIV and impose risky sexual practices on partners. Research on connections between social constructions of masculinity, intimate partner violence, male dominance in relationships, and HIV risk behaviours in men, as well as effective interventions, are urgently needed.
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              Risk factors for legal induced abortion-related mortality in the United States.

              To assess risk factors for legal induced abortion-related deaths. This is a descriptive epidemiologic study of women dying of complications of induced abortions. Numerator data are from the Abortion Mortality Surveillance System. Denominator data are from the Abortion Surveillance System, which monitors the number and characteristics of women who have legal induced abortions in the United States. Risk factors examined include age of the woman, gestational length of pregnancy at the time of termination, race, and procedure. Main outcome measures include crude, adjusted, and risk factor-specific mortality rates. During 1988-1997, the overall death rate for women obtaining legally induced abortions was 0.7 per 100000 legal induced abortions. The risk of death increased exponentially by 38% for each additional week of gestation. Compared with women whose abortions were performed at or before 8 weeks of gestation, women whose abortions were performed in the second trimester were significantly more likely to die of abortion-related causes. The relative risk (unadjusted) of abortion-related mortality was 14.7 at 13-15 weeks of gestation (95% confidence interval [CI] 6.2, 34.7), 29.5 at 16-20 weeks (95% CI 12.9, 67.4), and 76.6 at or after 21 weeks (95% CI 32.5, 180.8). Up to 87% of deaths in women who chose to terminate their pregnancies after 8 weeks of gestation may have been avoidable if these women had accessed abortion services before 8 weeks of gestation. Although primary prevention of unintended pregnancy is optimal, among women who choose to terminate their pregnancies, increased access to surgical and nonsurgical abortion services may increase the proportion of abortions performed at lower-risk, early gestational ages and help further decrease deaths. II-2
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                Author and article information

                Journal
                BMC Public Health
                BMC Public Health
                BioMed Central
                1471-2458
                2009
                18 August 2009
                : 9
                : 296
                Affiliations
                [1 ]Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa
                Article
                1471-2458-9-296
                10.1186/1471-2458-9-296
                2734857
                19689791
                f15fa46e-440b-43a2-9057-65a7f9290f66
                Copyright © 2009 Harries et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 19 March 2009
                : 18 August 2009
                Categories
                Research Article

                Public health
                Public health

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