Orientador: Aloisio Jose Bedone / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-14T08:07:19Z (GMT). No. of bitstreams: 1 Silva_DanielaForneldeOliveira_M.pdf: 972669 bytes, checksum: 320b3154e074527b3b86e49612602038 (MD5) Previous issue date: 2009 / Resumo: Introdução: O aborto inseguro corresponde a uma das principais causas de mortalidade materna no mundo. Na última década, o acesso a métodos seguros para o aborto, principalmente o misoprostol, tem contribuído para um declínio nos relatos de morbidade relacionada ao aborto. Na cidade de Campinas, a mortalidade materna por aborto, que era uma das primeiras causas de morte na década passada, parece ter-se reduzido consideravelmente. Esses dados podem refletir o maior uso de misoprostol pelas mulheres que optam por induzir o aborto. Objetivos: Verificar a proporção de abortos induzidos com misoprostol e outros métodos, e comparar as complicações observadas. Sujeitos e Métodos: De julho de 2008 a abril de 2009 as mulheres internadas com diagnóstico de aborto em dois hospitais de Campinas foram entrevistadas e submetidas a uma lista de verificação que continha os critérios da OMS para a classificação de abortos induzidos. De acordo com estes critérios, as mulheres foram classificadas como abortos possivelmente, provavelmente e certamente induzidos; as mulheres que não apresentaram qualquer um dos critérios foram classificadas como abortos espontâneos. As pacientes classificadas como aborto possível, provável ou certamente provocado, responderam também a um questionário. Resultados: Das 543 mulheres internadas com diagnóstico de aborto, 5 não tiveram suas entrevistas concluídas e foram identificadas 259 (48%), que possivelmente, provavelmente ou certamente provocaram o aborto: 222 (85,7%), 11(4,3%) e 26 (10,0%), respectivamente. Dentre os 259 questionários aplicados, somente 25 mulheres assumiram ter feito uso de algum método para indução do aborto e dentre estas apenas 9 referiram uso de misoprostol. O número de complicações infecciosas e hemorrágicas observado foi pequeno. Foram observadas diferenças significativas nos índices de complicações entre mulheres que assumiram a indução do aborto em relação àquelas que não assumiram. Entretanto esta diferença não foi significativa entre as mulheres que usaram misoprostol e as que usaram outros métodos. A única variável que esteve relacionada significativamente com tipo de aborto e complicações foi o estado marital: as mulheres sem parceiro fixo apresentaram maior índice de abortos provavelmente e certamente induzidos e de complicações hemorrágicas. Oitenta por cento das mulheres que disseram não desejar a gravidez estavam usando métodos contraceptivos. Conclusão: Houve um número pequeno de abortos confessadamente induzidos e uma baixa incidência de complicações. A coincidência do estudo com notícias de perseguição policial a mulheres que abortaram pode ter interferido na disposição dessas pacientes em relatar manobras, enquanto o uso de misoprostol exclui sinais da indução. Os dados confirmam o conceito generalizado de ter havido uma redução na freqüência e gravidade das complicações associadas à prática do aborto; entretanto não permitem verificar até que ponto o uso de misoprostol é responsável por essa redução, como observada em outros estudos. Será necessário esperar algum tempo até que essas notícias de perseguição policial às mulheres que abortaram saiam da mídia e fiquem esquecidas, para se tentar obter informações mais verídicas. Além disso, faz-se necessário repetir estudos mais apurados sobre mortalidade materna que permitam verificar se efetivamente a mortalidade materna associada ao aborto é tão baixa como aparece nas estimativas oficiais. / Abstract: Introduction: The unsafe abortion corresponds to one of the major causes of maternal death in the world. During the last decade, the access to safer methods to abortion, mainly misoprostol, has contributed to decrease of abortion morbidity. In Campinas, the maternal mortality by abortion seems to have fallen considerably. This can have occurred because of the great use of misoprostol by women who chose to induce the abortion. Objectives: Verify the proportion of induced abortion with misoprostol and other methods, and to compare the complications observed. Subjects and methods: From July 2008 until April 2009, the women who had an abortion and were admitted to two hospitals in Campinas were interviewed, a check-list with the WHO criteria of induced abortion was used to verify if the abortion was induced or not. To obtain more information about women whose abortion was classified as possible, provable or certainly induced a structured pre-tested questionnaire was applied. Results: Among 543 women hospitalized due to abortion, 5 women din't finish their interview and 259 women (48%) had their abortion classified as possible, probable or certainly induced: 222 (85,7%), 11(4,3%) e 26 (10,0%), respectively. Only 25 women (among 259 questionnaires obtained) assumed to have induced abortion and only 9 of these reported the use of misoprostol. The incidence of infection and hemorrhagic complications was small. There was a significant difference between complications rates in women that assumed have induced abortion and in women that didn't assume it. However, there was no significant difference between complications in women that used misoprostol and in women that used other methods. The marital status was the only sociodemographic characteristic that demonstrated some relation with abortion classification and with complications: women without a partner had a superior rate of probable and certainly induced abortion and hemorrhagic complications. Eighty percent of women who didn't desire the gestation were using contraceptives methods. Conclusion: There was a small number of assumed induced abortions and a low incidence of complications. The coincidence of this study with news of police prosecution of women suspected of induced abortion may have interfered on women willingness to be sincere, while the use of misoprostol prevents any sign of induction. The data confirm the opinion that the frequency and severity of abortion complications had gone down, but do not allow to verify which role misoprostol played in that process. It will be necessary to wait some time until those news of police prosecution disappear from the headlines to then be possible to obtain more reliable data. Besides that, it is necessary to execute detailed studies about maternal mortality, which allow us to verify if the rate of maternal mortality related with abortion is as low as the national statistics rate. / Mestrado / Tocoginecologia / Mestre em Tocoginecologia

M.Cur. / South African women, including black adolescents, had wishes, hopes and expectations that the liberation of the abortion law would bring them a new lease on life. The promulgation of the Choice on Termination of Pregnancy Act, 92 of 1996, was viewed by most women, including black adolescents, as a means by which their wishes and expectations were going to be realised for the first time. Women were happy that they were going to terminate a pregnancy inside the country and under the supervision of a person whose identity will not be concealed from them. These women, including black adolescents, expected the Choice on Termination of Pregnancy Act 92 of 1996, was going to afford them an opportunity to express and share their feelings, without pretending to be emotionally strong. Since it is difficult to identify with certainty which women, who terminate their pregnancy, are being emotionally strong, the Choice of Termination of Pregnancy Act 92 of 1996 has made provision for counselling be afforded to all women. The counselling provided to women, including black adolescents who chose to terminate a pregnancy, was observed by the researcher to be more of a cognitive nature. It is focusing on orientating women towards what is to be expected from them during the procedure of termination of pregnancy. The researcher observed that the counselling is not focusing on the emotional aspect of these women. The researcher developed an interest to listen to the voices of the black adolescents, as part of the community of women who chose to terminate a pregnancy, to form a better understanding of their experiences so as to be able to mobilise resources in order to support them. A qualitative, explorative, descriptive and contextual research study was conducted to identify the experiences of black adolescents who chose to terminate a pregnancy. Permission was obtained from gatekeepers. A pilot phenomenological interview was conducted with a black adolescent who chose to terminate a pregnancy and who met the selection criteria. The phenomenological interviews were conducted in English and Tswana with nine black adolescents that volunteered to participate in the study. Steps were taken to ensure trustworthiness. Tesch's Method of data-analysis was followed to analyse the data. The results indicated that black adotescents who chose to terminate a pregnancy, experienced emotional turmoil; physical distress; and used psychological defence mechanisms as a way to cope and some indicated that they experienced emotional maturity from the experience of terminating a pregnancy. From the findings of the research study in Phase 1 (one ) guidelines are described in phase two (2) for the advanced psychiatric nurse practitioner to support black adolescents who chose to terminate a pregnancy. The possibility of applying the results of the research in nursing education, nursing research and nursing praFtice have been described. The black adolescents who choose to terminate their pregnancies need support from the advanced psychiatric nurse practitioner as well as from nurses engaged in the termination of pregnancies in different health facilities, in order to promote their mental health.

Abortion, the termination of pregnancy, is safe when provided as a surgical procedure by a trained provider or when the correct dosage of the drugs mifepristone and/or misoprostol are used. Despite this, many barriers to abortion care exist. In the United States (US), targeted state-level abortion restrictions create barriers to care, which make it so that people who wish to utilize abortion care face difficulty or are unable to do so. Such barriers to care have important public health implications, as studies have shown that individuals who cannot access wanted abortion care have poorer psychological, physical, social, and economic outcomes than those who obtained care. This dissertation aims to examine one component of abortion access, accessibility, operationalized as the drive time from a woman’s home to the nearest abortion-providing facility. We employ a novel measure of abortion accessibility constructed from three data sources: (1) the Advancing New Standards in Reproductive Health facility database; (2) US Census estimates and shapefiles; and (3) OpenStreetMap data. In the first study, we used geographic information systems (GIS) to explore the effect of programmatic and policy changes related to telemedicine for medication abortion services (TMAB) on population-level measures of abortion accessibility, or drive time to the nearest abortion-providing facility. We found that either expansions in TMAB services or removal of TMAB bans could improve abortion accessibility in the US. For these two exposure scenarios, compared to the current abortion provision scenario, increases in the proportion of women within a 30-, 60-, and 90-minute drive time of an abortion-providing facility ranged from 1.25 percentage points, or an additional 781,556 US women aged 15-44 years with accessibility, to 5.66 percentage points, or an additional 3,530,423 US women aged 15-44 years with accessibility. In the second study, we used GIS to assess the potential effect of the geographic unit of analysis (i.e., block group, ZIP code tabulation area [ZCTA], or county) on misclassification of the proportion of US women of reproductive age within a 30-minute drive time of an abortion-providing facility relative to a measure calculated using Census blocks. We found that block group- or ZCTA-based estimates of abortion accessibility were an underestimate, but resulted in little misclassification relative to measures constructed using Census blocks at the national level; however, county-based measures substantially underestimated abortion accessibility compared with Census block-based measures. Nationwide, the Census block-based abortion accessibility estimate was 0.35 percentage points greater than the block group-based estimate, 2.72 percentage points greater than the ZCTA-based estimate, and 24.21 percentage points greater than the county-based estimate. By state, the Census block-based abortion accessibility estimate ranged from 0 to 8.51 percentage points greater than the block group-based estimate, from 0 to 27.86 percentage points greater than the ZCTA-based estimate, and from 0 to 79.49 percentage points greater than the county-based estimate. Given that state-level ZCTA-based estimates could be substantially different from the Census block-based estimate, ZCTA-based estimates are likely not appropriate for state-level analyses or US analyses stratified by state. Finally, in the third study, we assessed the relationship between level of accessibility in an abortion client’s home ZCTA and the gestational age at which the client obtained abortion care, using fine stratification by propensity score to control confounding. We found that compared with living in a ZCTA with >0% accessibility, living in a ZCTA with 0% accessibility was associated with a decreased risk of being at or beyond 14 weeks’ gestation at abortion visit. These unexpected findings could be due to a selection bias induced by limiting the sample to those who obtained abortion care, uncontrolled or poorly controlled confounding, misclassification of exposure and/or outcome, and/or unidentified effect measure modification by state abortion provision landscape. Through these three dissertation studies, we highlighted the potential impact on abortion accessibility in the US with different changes in programming and policy, quantified misclassification of abortion accessibility, and examined how misclassification varied by geographic measure and location. The third study in this dissertation suggests a need for more research to identify how selection bias may affect studies of abortion access in the US that rely on data only from those who are able to access care.

This dissertation consists of three essays on Health Economics. Chapter 1 analyzes the effects of abortion costs for minors on abortions, sexual behavior, and births. We exploit a 2015 change in parental involvement (PI) laws in Spain as a natural experiment in costs, together with rich population-level data on abortions and births. Using the exact date of teenager birth, we first document a decrease in abortions by 17-years-olds using a difference-in-difference comparison with 18-years-olds, consistent with the law that targeted Spanish minors. Using bunching methods from the Public Finance literature, we show evidence of temporal displacement. Some 17-years-old delayed their abortion and waited until they turned 18 and thereby avoided involving their parents. Second, we consider how the law change may have influenced health-related behaviors, finding implicitly that sexual behaviors changed so as to reduce the likelihood of becoming pregnant before turning 18 (and thereby internalized the cost of parental involvement). This is seen in the permanent shift in the number of abortions at age 18 that exists after removing the temporal displacement abortions around the age 18 threshold and an increase in the number of births to mothers who were pregnant at age 17. This paper finds that an important dimension of risky youth behavior responds to incentives contained in parental notification laws. Chapter 2 analyzes the effects of abortion costs on sex-selection by exploiting a 2010 abortion liberalization in Spain and the difference in son-preferences by nationality and child order documented in the literature. We show using a difference-in-difference comparison a significant increase in the fraction of boys for Chinese parents giving birth to their third child or above relative to children born of Spanish parents. Consistent with the literature, we do not find any effect on the fraction of boys for the first or the second child. Using the provincial number of abortion centers per person as a measure of access to abortion, we show, at the correlation level, that the effects come from those provinces with higher access to abortions. Finally, we find suggestive evidence that birth outcomes of Chinese girls who are the third children, and thus are now more likely to be ``wanted'' after the reform, improve. Gestational weeks increase, and the chance of being born prematurely decrease although our evidence suffers from lack of power. Finally, chapter 3 analyzes the effects of a universal, unconditional cash transfer announcement on birth outcomes by exploiting the 2007 cheque bebé policy in Spain that provided 2,500 euros per child to all mothers giving birth immediately after its announcement (Jul 2007). We use a difference-in-difference analysis comparing those born before and after the announcement. By exploiting the timing of the policy announcement we can avoid the composition effects caused by the incentives to have children generated by the policy. We show that the birth weight of those children born after the policy announcement (Sept-Dec) significantly improved relative to those born before (Apr-Jun) using previous years to control for the seasonal effects. Moreover, we provide suggestive evidence that those who are more vulnerable, as measured by the average municipality income level, parents' marital status, or parents' age, experience the most substantial improvements on birth weight.

Uppsatsens syfte är att undersöka hur läkarvetenskapen uttrycker sig om medicinska fosterfördrivningar under tidsperioden 1870–1900 samt studera om det har skett ett medikaliserande av fosterfördrivning. Till uppsatsens syfte hör även att studera hur förhållningssättet till de medicinska fosterfördrivningarna förändrades under den aktuella tidsperioden samt undersöka om det förekom ett motstånd mot utförandet av medicinska fosterfördrivningar inom den medicinska diskursen. Frågor som ställs för undersökningen är vilka föreställningar om medicinsk fosterfördrivning som uttrycks i samtida medicinska skrifter, om det i dessa går att utläsa ett motstånd inom den medicinska vetenskapen beträffande utförandet av de medicinska fosterfördrivningarna, vilken medicinsk fosterfördrivningstradition beträffande medicinska metoder och regelverk som kännetecknar de olika nedslagsperioderna 1870–1875; 1885–1890; 1895–1900 samt hur förhållningssättet till de medicinska fosterfördrivningarna har förändrats över tid.Med en utgångspunkt i Foucaults diskursanalys samt begreppen föreställning, tradition, förändring och medikalisering studeras det hur läkarvetenskapen under perioden 1870–1900 har förhållit sig till utförandet av medicinska fosterfördrivningar samt vad som har varit möjligt att uttrycka inom den medicinska diskursen beträffande dessa.Resultatet visar att början av tidsperioden innehåller en medicinsk fosterfördrivning som inte utfördes under resten av tidsperioden. Det rör sig om en fosterfördrivning i ett tidigt skede av graviditeten. Generellt sett så sker oftast en medicinsk fosterfördrivning annars i samband med en komplicerad förlossning. Utöver ett direkt förgörande av fostret inuti livmodern så problematiseras även igångsättningar av en tidig förlossning då dessa av lagstiftningen klassade som en sådan vid tidpunkten. Undersökningen visar att utförandet av medicinska fosterfördrivningar till stor del var allmänt accepterade av läkarvetenskapen även om det sker ett visst motstånd inifrån det egna medicinska ledet. Tydligt är även att läkarvetenskapen vid tidpunkten ser kvinnan som huvudpatient och inte fostret.

Bakgrund: Varje år genomgår 35000–38000 kvinnor abort i Sverige. Upplevelser av autonomi, skuld och skam finns beskrivet. En stor del av den svenska befolkningen läser dagstidningar varje dag och massmedia anses ha en viktig roll angående opinionsbildningen. Barnmorskans förhållningssätt ska präglas av kvinnans autonomi och kvinnan ska ses som en kompetent individ som självständigt kan fatta beslut. I barnmorskans arbete ingår att stå upp för kvinnans rättigheter och god kunskap i att framföra dessa rättigheter på basis av evidens och forskning. Kunskap om abortframställandet i dagstidningar är viktigt för barnmorskan då det kan påverka kvinnans beslut och hennes tankar kring aborten. Syfte: Att undersöka hur svenska dagstidningar framställer bilden av abort och abortvård i Sverige Metod: En kvalitativ innehållsanalys med induktiv ansats har tillämpats. Analys har genomförts av 126 artiklar från de fem svenska dagstidningar som har störst räckvidd. Resultat: Aborträtten och kvinnans rätt till autonomi framställs som om den står på spel, fostrets rätt till liv och abortförsvarande krafter engagerar. Fyra kategorier och nio subkategorier framkom ur analysen. Konklusion: Ovanliga och dramatiska aborter och aborthändelser framställs i massmedia framför den okomplicerade majoritetsaborten. Skildringen av abort och abortvård i svenska tidningar kan ses som problematisk då synen på abort i samhället riskerar att stigmatiseras och därmed i slutändan drabba kvinnans autonomi, reproduktiva och sexuella rättigheter. / Background: 35,000-38,000 women undergo abortion in Sweden every year. Experiences of autonomy, guilt and shame are described. A large part of the Swedish population reads newspapers and the mass media is considered to have an important role in public opinion formation. The midwife's approach must be characterized by the woman's autonomy and be seen as a competent individual who can make decisions independently. The midwife's work includes standing up for women's rights and good knowledge in asserting these rights on the basis of evidence and research. Knowledge abort presentation on abortion in newspapers is important for the midwife then it can affect the woman’s decision about abortion. Purpose: To investigate how Swedish newspapers present the image of abortion and abortion care in Sweden. Method: A qualitative analysis with inductive approach has been applied. An analysis of 128 articles from five Swedish daily newspapers with the greatest reach has been carried out. Outcome: The right to abortion and women's right to autonomy are presented as being at stake, the fetus's right to life and women’s right to abortion is engaging. Four categories and nine subcategories are presented. Conclusion: Unusual and dramatic abortions and abortion events are presented in mass media in front of the uncomplicated majority abortion. The portrayal of abortion and abortion care in Swedish media can be seen as problematic as the view of abortion in society risks being stigmatized, and thereby ultimately affecting women's autonomy and reproductive, sexual rights.

Bakgrund: I Sverige utförs ett stort antal aborter varje år. I barnmorskans kompetensområde ingår det att ge kvinnor vård vid abort. Tidigare forskning beskriver att ju senare abort desto svårare upplevs det för både kvinnan och barnmorskan. Det finns många tidigare studier om kvinnors upplevelser av abortvård, desto mindre finns beskrivet om barnmorskans upplevelser. Syfte: Syftet med arbetet var att beskriva barnmorskors erfarenheter av abortvård på sjukhus. Metod: Arbetet utgick från en kvalitativ design med induktiv ansats. Materialet baseras på semi-strukturerade individuella intervjuer med 11 barnmorskor. Datan analyserades med kvalitativ innehållsanalys. Resultat: I resultatet framträdde fyra kategorier: Att sätta kvinnan i centrum, ett känsloladdat arbete, att arbeta professionellt och önskan om en bättre abortvård. Kategorierna bestod av 13 subkategorier: Att se individen, att stödja kvinnan, att ge information, att vara närvarande, att göra någonting betydelsefullt, utmaningar i abortvård, att värna om aborträtten, etiska dilemman inom abortvård, att lägga egna värderingar åt sidan, att vara i behov av stöd, att lindra smärta, behov av bättre smärtlindring och att ha abortvård på egen avdelning. Slutsats: Abortvård ses som ett givande och viktigt arbete. Barnmorskornas erfarenheter var att kvinnor som genomgår abort behöver stöd, närvaro, information, smärtlindring, tillgång till kurator och att alla dessa aspekter är individanpassade. / Background: A large number of abortions are performed every year in Sweden. The midwife’s area of expertise includes providing women with care in the event of an abortion. Previous research describes that the later the abortion the more difficult it is for both the woman and the midwife. There are many previous studies on women's experiences of abortion care, less is described about the experiences of the midwife. Aim: The aim of the work was to describe midwives’ experiences of abortion care. Method: The work was based on a qualitative design with an inductive approach. Based on individual semi-structured interviews conducted with eleven midwives. The interviews were analyzed with qualitative content analysis. Result: Four categories were found: to focus on the woman, an emotional work, to work professionally and the desire for better abortion care. Thirteen subcategories were created and formed the categories. Conclusion: Abortion care is seen as a rewarding and important job. The midwives experience was that women who undergo abortion need support, presence, information, pain relief, access to a counselor and that all these aspects are individualised.

Unintended pregnancies resulted in $21 billion in avoidable health care costs in the United States as of the most recently available data in 2010 and are associated with myriad negative health effects for mothers and children. They disparately impact vulnerable groups of women, such as those 18-29 years old, Black women, low-income women, single women, and less educated women. A medication abortion is one method of terminating a pregnancy which is over 95% effective, safe (with major adverse events in less than 0.5% of cases), has minor side effects, and costs less than 20% of a live birth.However, states have different levels of medication abortion utilization: in 2020, percentages ranged from 13.7% in Missouri to 96.6% in Wyoming in 2020. The FDA’s abortifacient protocol is more restrictive than medically necessary to ensure women’s safety. For example, although the FDA expanded medication abortions for use up to ten weeks of gestation in 2016 from the previous seven-week limit, studies show safety and efficacy beyond ten weeks of gestation. Many states have laws which restrict access to medication abortions beyond their laws that restrict access to all abortions. Additionally, many states have laws that regulate access to medication abortions more strictly than the FDA. These laws can result in a delay in obtaining abortion care, possibly past the FDA’s ten-week limit for medication abortions, which could make the patient ineligible for a medication abortion in some states. A state’s percentage of medication abortion utilization may depend upon which law(s) that state has in place restricting access. This is the first study to examine that relationship. There is a gap in the literature as to why medication abortion is underutilized given that a majority of abortions occur within the FDA’s ten-week time limit and that the majority of women who received an abortion would have preferred to receive it earlier than they did. The goal of this dissertation is to examine the impact of certain laws restricting medication abortion access on medication abortion utilization in states with such laws in place as compared to states without such laws in place. The aims of the proposed dissertation were threefold. Study one examined medication abortion utilization among women who obtained abortions in states with laws that restrict public and/or private insurance coverage of abortion as compared to states with no insurance coverage restrictions from 2010 to 2019. It was expected that restricting public and/or private insurance coverage of abortion would be statistically significantly associated with lower state medication abortion utilization as compared to states without public and/or private insurance coverage restrictions. Study two examined medication abortion utilization among women who obtained abortions in states that required both in-person physician involvement prior to the abortion and that the first dose be administered in person in the presence of a physician and states with only one physician involvement requirement as compared to states with neither physician involvement requirement from 2010 to 2019. It was expected that state laws requiring either or both in-person physician involvement prior to the abortion and/or that the first dose be administered in the presence of a physician will be statistically significantly associated with lower medication abortion utilization as compared to states requiring no in-person physician involvement. Study three examined medication abortion utilization among women who obtained abortions in states that require both in-person physician involvement prior to the abortion and that the first dose be administered in person in the presence of a physician and states with only one physician involvement requirement as compared to states with neither physician involvement requirement, adjusting for the percentage of women aged 15-44 living in counties without an abortion provider in 2017. It was expected that state laws requiring either or both in-person physician involvement prior to the abortion and/or that the first dose be administered in the presence of a physician would be statistically significantly associated with lower medication abortion utilization as compared to states requiring no in-person physician involvement, adjusting for the percentage of women aged 15-44 living in counties without an abortion provider in 2017. We used multiple imputation of data in all three of our studies, linear mixed model analyses in the first two, and a regression analysis in the third. While our studies did not uncover any statistically significant associations between the laws examined alone and medication abortion utilization, there were some statistically significant secondary findings. All three of our studies found states with higher percentages of patients who were at least ten weeks pregnant at the time of their abortions to be associated with lower percentages of medication abortion utilization. Our first study found that having had no previous live births was associated with a higher percentage of medication abortion utilization in states with laws restricting Health Exchange insurance plans from covering abortions, regardless of whether there were other laws restricting insurance coverage of abortion in place. Both our first and second studies found that being over thirty years of age at the time of obtaining an abortion was associated with a higher percentage of medication abortion utilization in states with at least one form of abortion insurance coverage restriction law and regardless of how many in-person physician interactions were required, respectively. These findings should guide both future research aimed at taking further steps toward understanding states’ disparate levels of medication abortion utilization as well as policymakers’ efforts at improving access to medication abortion services. / Public Health

Despite legal and technological advances, women still face barriers to abortion care in legally restricted or low-resource settings. The advent of medication abortion using misoprostol with or without mifepristone, has enabled women to self-manage their abortions outside of the formal healthcare system. Self-managed abortions are often assisted by telemedicine services, which provide women with evidence-based guidance on managing the abortion process on their own. This thesis explores two separate abortion telemedicine services operating in legally restricted and/or low resource settings – a global online telemedicine service and an abortion support hotline in Venezuela – and evaluates the outcomes associated with each. By interviewing counsellors at a Venezuelan abortion support hotline and the women who used the service, we gained a stronger understanding of the hotline’s successes, barriers, and areas for improvement. We conclude that abortion telemedicine services provide effective and acceptable care, in general, and we recommend greater access to misoprostol in Venezuela.

This thesis utilizes a reproductive justice framework to discuss the impact of anti-abortion legislation and the anti-abortion movement on women of color and low-income women, arguing that reduced access to abortion is oppressive to minority women. Chapter 1 outlines the theoretical framework of this thesis, focusing on feminist Marxism, Intersectionality, Critical Race Theory, and radical and third wave feminist perspectives. Chapter 2 provides an overview of the anti-abortion movement and the major state and federal laws and court cases that have defined women's access to abortion in the United States, including Roe v Wade, the Hyde Amendment, Planned Parenthood v Casey, and TRAP laws. Chapter 3 discusses the oppressive effects of these laws by connecting anti-abortion legislation and the anti-abortion movement to larger historical systems of oppression and examining the effect of reduced access to abortion on women's reproductive choices and socioeconomic status. This chapter argues that reduced access to abortion is oppressive because it encourages sterilization among minority women who may have chosen other birth control options given the choice, and funnels minority women into an oppressive and exploitative US welfare system. Chapter 4 discusses minority women's potential to overcome this oppression and examines some real-world examples of reproductive rights activism. This thesis expands the current discussion on abortion access by centering the discussion on minority women and arguing that reduced access to abortion is systematically oppressive rather than simply discriminatory.