Advocating safe abortion: outcomes of a multi‐country needs assessment on the potential role of national societies of obstetrics and gynecology

May combine two claims.

Factors that facilitated reform in these countries were organizational commitments to reduce maternal mortality and a vocal public health sector, in addition to an active civil society movement, favorable public opinion, and the right political momentum.

“Factors that facilitated reform in these countries were organizational commitments to reduce maternal mortality and a vocal public health sector, in addition to an active civil society movement, favorable public opinion, and the right political momentum.18, 24, 28, 32”

• cites [18] Chavkin W, Stifani BM, Bridgman‐Packer D, Greenberg JMS, Favier M. Implementing and expanding safe abortion care: An international comparative case study of six countries. Int J Gynecol Obstet. 2018; 143: 3– 11. 30374987 sourcePartly supported

  The Context and Lessons Learned sections link reform to concern about maternal mortality, health-sector participation, civil society advocacy, and political will. But the Context section says health sectors were less involved in advocacy in South Africa and Colombia, and our copy does not establish favorable public opinion as a facilitator across the six countries. Page numbers are unavailable in our copy. (LLM, conf=0.85)

  Experimental — accuracy not yet measured
• cites [24] Holcombe SJ. Medical society engagement in contentious policy reform: The Ethiopian Society for Obstetricians and Gynecologists (ESOG) and Ethiopia's 2005 reform of its Penal Code on abortion. Health Policy Plan. 2018; 33: 583– 591. 29538641 PMC5894080 sourceDisputed

  Split into 2 atoms — 1 confirmed, 0 partially supported, 1 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Checked by a reasoning model — may be wrong.

  Experimental — accuracy not yet measured
• cites [28] Briozzo L. From risk and harm reduction to decriminalizing abortion: The Uruguayan model for women's rights. Int J Gynecol Obstet. 2016; 134: S3– S6. 28748587 sourceNot checked — no full text of the source

May combine two claims.

A reduction of unintended pregnancies in developing regions does not coincide with a reduction in abortion rates, indicating that the need for safe abortion care remains besides contraceptive services.

“Studies show that a reduction of unintended pregnancies in the developing regions does not coincide with a reduction in abortion rates, indicating that besides a need for contraceptive services, the need for safe abortion care remains.11”

• cites [11] Bearak J, Popinchalk A, Alkema L, Sedgh G. Global, regional, and subregional trends in unintended pregnancy and its outcomes from 1990 to 2014: Estimates from a Bayesian hierarchical model. Lancet Glob Heal. 2018; 6: e380– e389. PMC6055480 29519649 sourceSupported

Probably not a substantial claim: may not pass S2 (checkable).

Healthcare providers and healthcare institutions are in a unique position to become advocates for women's sexual and reproductive health and rights, including access to safe abortion care.

“While their primary role is to offer healthcare services, these actors are in a unique position to become advocates for women's sexual and reproductive health and rights, including access to safe abortion care.19, 20”

• cites [19] Gasman N, Blandon MM, Crane BB. Abortion, social inequity, and women's health: Obstetrician‐gynecologists as agents of change. Int J Gynecol Obstet. 2006; 94: 310– 316. 16839553 sourcePartly supported

  The Introduction says obstetrician-gynecologists, individually and as a professional group, are uniquely positioned to advocate for women and improve access to sexual and reproductive healthcare, including safe abortion. The section on ob-gyn societies also describes advocacy for reproductive rights. The claim extends that position to healthcare providers generally and healthcare institutions, which the cited passages do not establish. (LLM, conf=0.85)

  Experimental — accuracy not yet measured
• cites [20] Turner K, Weiss E, Gulati‐Partee G. Providers as advocates for safe abortion care: A training manual. Chapel Hill: IPAS; 2009.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Abortion has become medically more feasible and safer with increased availability and use of misoprostol and mifepristone.

“Abortion has become medically more feasible and safer with the increased availability and use of misoprostol and mifepristone.14”

• cites [14] Winikoff B, Sheldon W. Use of medicines changing the face of abortion. Int Perspect Sex Reprod Health. 2012; 38: 164– 166. 23018138 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Advocacy strategies for safe abortion that seem to work are context specific, but often based on deep and well-informed understanding of abortion, a public health approach synthesized with human rights, and strategic involvement of multiple stakeholders.

“Advocacy strategies for safe abortion that seem to work are context specific, but often based on deep and well‐informed understanding of abortion, a public health approach synthesized with the articulation of human rights, and the strategic involvement of multiple stakeholders.16, 17, 18”

• cites [16] Hord C. Making safe abortion accessible: A practical guide for advocates. Chapel Hill: IPAS; 2001.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [17] Hessini L. Global progress in abortion advocacy and policy: An assessment of the decade since ICPD. Reprod Health Matters. 2005; 13: 88– 100. 16035601 sourceNot checked — no full text of the source
• cites [18] Chavkin W, Stifani BM, Bridgman‐Packer D, Greenberg JMS, Favier M. Implementing and expanding safe abortion care: An international comparative case study of six countries. Int J Gynecol Obstet. 2018; 143: 3– 11. 30374987 sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

  Experimental — accuracy not yet measured

May combine two claims.

In restrictive settings, 75% of abortions are unsafe, compared with 12.5% in countries without restrictions.

“in restrictive settings 75% of the abortions are unsafe, compared with 12.5% in countries without restrictions.6”

• cites [6] Ganatra B, Gerdts C, Rossier C, et al. Global, regional, and subregional classification of abortions by safety, 2010‐14: Estimates from a Bayesian hierarchical model. Lancet. 2017; 390: 2372– 2381. 28964589 PMC5711001 sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

The phenomenon of medical societies struggling to raise an institutional voice on politically sensitive issues is not new, as described by Holcombe.

“This phenomenon is not new, given the historical experience and empirical evidence as described by Holcombe.24”

• cites [24] Holcombe SJ. Medical society engagement in contentious policy reform: The Ethiopian Society for Obstetricians and Gynecologists (ESOG) and Ethiopia's 2005 reform of its Penal Code on abortion. Health Policy Plan. 2018; 33: 583– 591. 29538641 PMC5894080 sourceSupported

Classified as probably not a substantial claim.

The gaps in data on incidence of abortion were perceived as a barrier to have an evidence-based debate and influence policy and change.

“The gaps in data on incidence of abortion were perceived as a barrier to have an evidence‐based debate and influence policy and change.”

May combine two claims.

The countries assessed had diverse legal frameworks; except Mozambique, where abortion is legal on request, the countries had either semi-liberalized or restrictive legal frameworks.

“The countries assessed had diverse legal frameworks. Except Mozambique, where abortion is legal on request, the countries had either semi‐liberalized or restrictive legal frameworks (Table 2).”

May combine two claims.

At the time of study, the law did not always align with additional legal documents such as the penal code or a judicial decree, leaving space for ambiguous interpretation of the legal framework.

“In addition, at the time of study, the law did not always align with additional legal documents such as the penal code or a judicial decree. This leaves space for an ambiguous interpretation of the legal framework.”

May combine two claims.

Panama was the only country that had a national register, as all legally permitted therapeutic abortions need to be approved by the National Multidisciplinary Commission of Therapeutic Abortion.

“Panama was the only country that had a national register, as all legally permitted therapeutic abortions need to be approved by the National Multidisciplinary Commission of Therapeutic Abortion.”

May combine two claims.

Post-abortion care was more readily available in most urban areas, but often severely limited in rural areas.

“Post‐abortion care was more readily available in most urban areas, but often severely limited in rural areas.”

May combine two claims.

Respondents confirmed that providers are not aware of or do not acknowledge the ethical obligation to refer when a patient is in need of services, or provide timely care when referral is not an option but delay would jeopardize a patient's health.

“Respondents confirmed that providers often feel the right to exempt themselves from abortion care or counsel the patient not to abort, but are not aware of or do not acknowledge the ethical obligation to refer when a patient is in need of services, or provide timely care when referral is not an option but delay would jeopardize a patient's health.”

May combine two claims.

The willingness and efforts of policy makers to provide technical guidelines and facilitate implementation depended on the current powers, meaning the level of operation at ministries can change per political term.

“The willingness and efforts of policy makers to provide technical guidelines and facilitate implementation depended on the current powers, meaning the level of operation at ministries can change per political term.”

May combine two claims.

It often remains unclear who provides the services and a good referral network was generally lacking, especially in the rural areas.

“It often remains unclear who provides the services and a good referral network was generally lacking, especially in the rural areas.”

May combine two claims.

The social construction of stigma varied across countries, though it was generally based on social and gender perceptions, underscored by cultural and religious norms.

“The social construction of stigma varied across countries, though it was generally based on social and gender perceptions, underscored by cultural and religious norms.”

Classified as probably not a substantial claim.

ObGyn societies were mentioned to be well-respected actors in all countries.

“As the ObGyn societies were mentioned to be well‐respected actors in all countries, they can easily build on existing initiatives by strengthening their own institutional positioning on safe abortion.”

May combine two claims.

Abortion stigma remains a common and crosscutting issue and is present at all levels from individual to community and national level.

“Abortion stigma remains a common and crosscutting issue and is present at all levels from individual to community and national level.”

May combine two claims.

The stigma was not only related to abortion, but also to sexual and reproductive health in general, including sexuality education, unintended pregnancy, family planning, and adolescent sexual health.

“The stigma was not only related to abortion, but also to sexual and reproductive health in general, including sexuality education, unintended pregnancy, family planning, and adolescent sexual health.”

May combine two claims.

Respondents confirmed that providers often feel the right to exempt themselves from abortion care or counsel the patient not to abort.

“Respondents confirmed that providers often feel the right to exempt themselves from abortion care or counsel the patient not to abort, but are not aware of or do not acknowledge the ethical obligation to refer when a patient is in need of services, or provide timely care when referral is not an option but delay would jeopardize a patient's health.”

May combine two claims.

Where guidelines were available, they were often not updated, well disseminated, or used in practice, leaving health professionals unaware of rights, obligations, and medical guidance.

“In addition, where guidelines were available, they were often not updated, well disseminated, or used in practice. This leaves health professionals unaware of rights, obligations, and medical guidance.”

May combine two claims.

The needs assessment identified possible barriers and opportunities for advocacy for ObGyn societies and their partners, explored the contexts the societies work in, and showed how the socio-political environment and deeply rooted stigma pose challenges on them to work constructively on safe abortion advocacy.

“It identified possible barriers and opportunities for advocacy for ObGyn societies and their partners, explored the contexts the societies work in, and showed how the socio‐political environment and deeply rooted stigma pose challenges on them to work constructively on safe abortion advocacy.”

May combine two claims.

The needs assessment found gaps in service delivery including lack of trained and willing providers, limited dissemination of guidelines, and scarce commodities.

“Other reported gaps in service delivery included lack of trained and willing providers, limited dissemination of guidelines, and scarce commodities.”

May combine two claims.

In some countries, positions on abortion were highly divided and a number of vocal opponents of safe abortion seemed unlikely to change position.

“In some countries, positions were highly divided and a number of vocal opponents of safe abortion seemed unlikely to change position.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In the public sector, provision of safe abortion was limited and hence, according to key stakeholders, it is difficult to hold facilities accountable for the services that should be provided according to the law.

“In the public sector, provision of safe abortion was limited and hence, according to key stakeholders, it is difficult to hold facilities accountable for the services that should be provided according to the law.”

May combine two claims.

All assessed ObGyn societies had a wide network of partners and strong relations with their respective Ministry of Health.

“All ObGyn societies had a wide network of partners and strong relations with their respective Ministry of Health.”

May combine two claims.

Across countries, some general strengths in relation to safe abortion advocacy were identified, in addition to unique society-specific strengths.

“While unique society‐specific strengths such as organizational and scientific capacities were identified in each country, some general strengths in relation to safe abortion advocacy were identified across countries.”

May combine two claims.

In some countries opposing actors were powerful, with the capacity to mobilize public opposition, while pro safe abortion actors were not always outspoken or unified.

“In some countries opposing actors were powerful, with the capacity to mobilize public opposition, while pro safe abortion actors were not always outspoken or unified.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The reinstatement of the global gag rule had not only enforced the fear of losing United States funding, but also strengthened the opposing actors.

“The reinstatement of the global gag rule for example had not only enforced the fear of losing United States funding, but also strengthened the opposing actors.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The explicit focus on advocacy for safe abortion was an approach that is not immediately comfortable to all.

“The explicit focus on advocacy for safe abortion was an approach that is not immediately comfortable to all.”

May combine two claims.

Respondents in all countries confirmed that the availability of safe abortion services was limited and centralized around capital cities.

“Respondents in all countries confirmed that the availability of safe abortion services was limited and centralized around capital cities.”

May combine two claims.

Stigma around abortion is a global phenomenon and was mentioned to be present in all countries at the individual, community, organizational, and political level, including among healthcare providers.

“Stigma around abortion is a global phenomenon and was mentioned to be present in all countries at the individual, community, organizational, and political level, including among healthcare providers:”

Probably not a substantial claim: may not pass S3 (load-bearing).

In all countries a key member of the ObGyn society checked and concluded that the waiver was applicable for a needs assessment in their specific country.

“In all countries a key member of the ObGyn society checked and concluded that the waiver was applicable for a needs assessment in their specific country.”

Probably not a substantial claim: may not pass S3 (load-bearing).

International human rights bodies and UN expert committees have characterized unsafe abortion or lack of access to safe abortion as a human rights issue.

“In the past two decades, international human rights bodies and United Nations (UN) expert committees have characterized unsafe abortion or lack of access to safe abortion as a human rights issue concerning violations to girls and women's rights to health; privacy; non‐discrimination; and freedom of cruel, inhuman, and degrading treatment.12, 13”

• cites [12] OHCHR. Abortion; Information series on sexual and reproductive health and rights. 2015 https://www.ohchr.org/Documents/Issues/Women/WRGS/SexualHealth/INFO_Abortion_WEB.pdf. Accessed September 6, 2018.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [13] Fine JB, Mayall K, Sepúlveda L. The role of international human rights norms in the liberalization of abortion laws globally. Health Hum Rights. 2017; 19: 69– 80. 28630542 PMC5473039Not checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The reports were translated into English, or the local language where needed, and checked for accuracy by the bilingual international researchers.

“The reports were translated into English, or the local language where needed, and checked for accuracy by the bilingual international researchers.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The results of the cross-country analysis were presented and validated by representatives from the ObGyn societies during a finalization and planning workshop in London.

“The results of this overall analysis were presented and validated by representatives from the ObGyn societies during a finalization and planning workshop in London.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

All notes and recordings were given a code to ensure confidentiality, and data could only be re-identified by the researchers who kept this information in a secure place.

“All notes and recordings were given a code to ensure confidentiality. Data could only be re‐identified by the researchers, who kept this information in a secure place.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Data collection was consistent across the 10 countries, using a similar desk review tool, interview topic guides, and workshop outline.

“Data collection was consistent across the 10 countries, using a similar desk review tool, interview topic guides, and workshop outline.”

Probably not a substantial claim: may not pass S3 (load-bearing).

An ethical waiver was obtained from the Research Ethics Committee of KIT Royal Tropical Institute on the consideration that the needs assessment related to semi-structured interviews with professionals covering professional duties and public domain information.

“An ethical waiver was obtained on January 22, 2018, from the Research Ethics Committee of KIT Royal Tropical Institute on the consideration that the needs assessment related to semi‐structured interviews with professionals that cover information related to the professional duties of the respondents and information in the public domain.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Country reports were written by a pair of national and international researchers and peer-reviewed for quality assurance by senior experts in qualitative research and key members in the ObGyn society.

“Country reports (accessible through the FIGO website22) were written by a pair of national and international researchers in English, French, or Spanish, and peer‐reviewed for quality assurance by senior experts in qualitative research and key members in the ObGyn society.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Participants for KIIs and stakeholder workshops were purposively selected to ensure a high variety of knowledgeable informants.

“For the KIIs and stakeholder workshop, participants were purposively selected to ensure a high variety of knowledgeable informants.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Written consent was obtained and, where permitted, interviews were recorded in addition to extensive note-taking.

“Written consent was obtained and, where permitted, interviews were recorded in addition to extensive note‐taking.”

Classified as probably not a substantial claim. May combine two claims.

Because ObGyn societies were mentioned to be well-respected actors in all countries, they can easily build on existing initiatives by strengthening their own institutional positioning on safe abortion.

“As the ObGyn societies were mentioned to be well‐respected actors in all countries, they can easily build on existing initiatives by strengthening their own institutional positioning on safe abortion.”

May combine two claims.

Limited technical support staff is a genuine stumbling block to advancing advocacy initiatives and leads to irregular and insufficient communication to members, contributing to a limited capacity to broker knowledge.

“This is a genuine stumbling block to advancing advocacy initiatives and leads to irregular and insufficient communication to members, contributing to a limited capacity to broker knowledge.”

Probably not a substantial claim: may not pass S3 (load-bearing).

All consultants who worked on the data analysis were involved in data collection as well.

“All consultants that worked on the data analysis were involved in data collection as well.”

Classified as probably not a substantial claim.

The stage of debate and discourse around abortion limits both the scope for advocacy and opportunities to identify strategic angles, including terminologies, from which safe abortion can be positioned and consolidated within public debate.

“The stage of debate and discourse around abortion not only limits the scope for advocacy, but also opportunities in identifying the strategic angles (including terminologies) from which safe abortion can be positioned and consolidated within the public debate.”

May combine two claims.

Advocacy opportunities on safe abortion are diverse across countries and depend on existent legal frameworks, the stage of public debate and discourse around abortion, and the role and strength of multiple key stakeholders for safe abortion.

“Advocacy opportunities on safe abortion are diverse across countries as they depend on various factors, namely: (1) existent legal frameworks, (2) the stage of public debate and discourse around abortion, and (3) the role and strength of multiple key stakeholders for safe abortion.”

Probably not a substantial claim: may not pass S3 (load-bearing).

There was a feeling that data saturation was achieved in each country.

“It aimed to include a wide range of stakeholders and while there was a feeling that saturation of data was achieved in each country, the voices opposed to or indifferent to abortion were heard relatively infrequently.”

May combine two claims.

The needs assessment confirmed that ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers' advocacy role for safe abortion.

“At the same time, the needs assessment confirmed that ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers’ advocacy role for safe abortion.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The limitation of non-verbatim transcription was mitigated by having extensive notes and recordings as back-up that were used to fill gaps.

“This limitation was mitigated by having extensive notes and recordings as back‐up that were used to fill gaps.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Interviews and stakeholder workshops were not transcribed verbatim due to the set-up of the assessment.

“Due to the set‐up of the assessment, interviews and stakeholder workshops were not transcribed verbatim.”

May combine two claims.

Unavailability of services, lack of technical guidance, unawareness and ambiguity about the possibilities the existing legal framework may provide, and absence of accurate data all coincide and contribute to poor women's health and rights and maternal mortality as a result of unsafe abortion.

“Unavailability of services, lack of technical guidance, unawareness and ambiguity about the possibilities the existing legal framework may provide, and absence of accurate data all coincide and contribute to poor women's health and rights and maternal mortality as a result of unsafe abortion.”

May combine two claims.

In some countries, opponents or indifferent stakeholders responded to interview invitations; in others it was difficult to get them involved in the needs assessment.

“In some countries they responded to interview invitations, in others it was difficult to get them involved in the needs assessment.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Voices opposed to or indifferent to abortion were heard relatively infrequently.

“It aimed to include a wide range of stakeholders and while there was a feeling that saturation of data was achieved in each country, the voices opposed to or indifferent to abortion were heard relatively infrequently.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The data analysis was enriched with consultants' direct experiences and observations.

“Therefore, the data analysis was enriched with their direct experiences and observations.”

Classified as probably not a substantial claim. May combine two claims.

ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers' advocacy role.

“However, ObGyn societies have a strong position due to their strategic networks and technical credibility and can be a facilitator in healthcare providers’ advocacy role.”

May combine two claims.

More recently, ObGyn societies in Uruguay and Ireland supported abortion reform.

“and more recently this happened in Uruguay28 and Ireland.29”

• cites [28] Briozzo L. From risk and harm reduction to decriminalizing abortion: The Uruguayan model for women's rights. Int J Gynecol Obstet. 2016; 134: S3– S6. 28748587 sourceNot checked — no full text of the source
• cites [29] Royal College of Physicians of Ireland (RCPI). Statement from the Institute of Obstetricians and Gynecologists. 10 January 2018 https://www.rcpi.ie/news/releases/statement-from-the-institute-of-obstetricians-and-gynecologists/. Accessed November 2, 2018.Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

Abortion advocacy requires substantial organizational investments and time that clinicians in scarce environments often do not have.

“Abortion advocacy requires substantial organizational investments, time that clinicians in scarce environments often do not have, implying a need to make people and time available to drive the change.”

May combine two claims.

The Royal College of Obstetricians and Gynaecologists (RCOG) has recently established an abortion task force, advocating the decriminalization of abortion and bringing abortion services back into the public health sector.

“In the United Kingdom, the Royal College of Obstetricians and Gynaecologists (RCOG) has recently established an abortion task force, advocating the decriminalization of abortion and bringing abortion services back into the public health sector.30, 31”

• cites [30] Dunn C. Abortion care: Our responsibility. RCOG Membership Magazine Spring 2017: 16– 19. https://www.rcog.org.uk/globalassets/documents/members/membership-news/og-magazine/spring-2017/abortion-care-services.pdf. Accessed November 2, 2018.Not checked yet

  Not checked in the free run.

• cites [31] RCOG. RCOG backs decriminalisation of abortion. 2017 https://www.rcog.org.uk/en/news/rcog-backs-decriminalisation-of-abortion/. Accessed November 2, 2018.Not checked yet

  Not checked in the free run.