Impact of abortion law reforms on health services and health outcomes in low- and middle-income countries: a systematic review

Abstract

While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, expanding the grounds on which abortion can be performed legally. However, the implications of these reforms on women’s access to and use of health services, as well as their health outcomes, are uncertain. This systematic review aimed to evaluate and synthesize empirical research evidence concerning the effects of abortion law reforms on women’s health services and health outcomes in LMICs. We searched Medline, Embase, CINAHL and Web of Science databases, as well as grey literature and reference lists of included studies. We included pre–post and quasi-experimental studies that aimed to estimate the causal effect of a change in abortion law on at least one of four outcomes: (1) use of and access to abortion services, (2) fertility rates, (3) maternal and/or neonatal morbidity and mortality and (4) contraceptive use. We assessed the quality of studies using the quasi-experimental study design series checklist and synthesized evidence through a narrative description. Of the 2796 records identified by our search, we included 13 studies in the review, which covered reforms occurring in Uruguay, Ethiopia, Mexico, Nepal, Chile, Romania, India and Ghana. Studies employed pre–post, interrupted time series, difference-in-differences and synthetic control designs. Legislative reforms from highly restrictive to relatively liberal were associated with reductions in fertility, particularly among women from 20 to 34 years of age, as well as lower maternal mortality. Evidence regarding the impact of abortion reforms on other outcomes, as well as whether effects vary by socioeconomic status, is limited. Further research is required to strengthen the evidence base for informing abortion legislation in LMICs. This review explicitly points to the need for rigorous quasi-experimental studies with sensitivity analyses to assess underlying assumptions. The systematic review was registered in PROSPERO database CRD42019126927.

A realist review of interventions targeting maternal health in low- and middle-income countries

“…These outcomes were associated with intervention mechanisms associated with acceptability of intervention, increased knowledge and awareness and improved access to healthcare. 23,27,36,40 Quality of maternal care. Improved quality of maternal care was reported in the majority of CMO relationships.…”

“…25,28,31 Papers also reported sufficient healthcare and organizational staff as necessary for the effective organization, implementation and monitoring of interventions. 23,36,67 Training, supervision and support. Reviews emphasized the importance of providing sufficient training and supervision to healthcare professionals (HCPs) to both safely and effectively carry out the proposed intervention and to ensure that staff felt confident and supported in their tasks.…”

“…Reviews emphasized the importance of providing sufficient training and supervision to healthcare professionals (HCPs) to both safely and effectively carry out the proposed intervention and to ensure that staff felt confident and supported in their tasks. 23,24,27,36,40,48,67 Availability and quality of existing health services. The availability and quality of pre-existing healthcare services is another contextual factor at the healthcare system level.…”

“…For example, an individual's lack of knowledge about abortion laws or locations that provide abortion services can restrict the effect of interventions to access to services for women. 36 HCPs knowledge of their required skills and ability to explain care to their patients is an enabler of interventions that aim to increase women's use and trust of maternal care services. 40 Policies and procedures.…”

Knowledge, Attitude and Associated Factors Toward Ethiopian Abortion Law Among Reproductive Age Women in Bule Hora Town, Southern Oromia, Ethiopia, 2022

“…Roughly half of the abortions (21.6 million) performed worldwide are unsafe, and nearly all unsafe abortions (98%) occur in developing nations. 6 In Mexico, more than half of the women did not know about the legal status of abortion; as a result, they believed that abortions were never legal which increased the unsafe abortion problem in Mexico. 7 Because of restrictive laws in the United States, approximately 300,000 to 400,000 abortions take place each year; the majority of these are performed "underground," with appalling maternal morbidity and mortality.…”