Welcome to the Global Health Nursing Education Module

 

This module explores global health issues through the lens of women’s reproductive health. Throughout the world, women continue to experience unintended pregnancy and preventable pregnancy-related health issues. Poverty, lack of education, and lack of socioeconomic opportunities perpetuate high birth rates, especially in adolescents, which in turn contribute to maternal health problems. Improving family planning services and increasing access to safe abortion would reduce maternal morbidity and mortality.

In each scenario, the link between public policy and women’s health is explored. The first case study presents actual events with real people to explore policy in El Salvador where access to safe abortion is extremely limited. Latin America has made the least progress of any region in the world in meeting the Millennium Development Goal to reduce maternal mortality. The second case study is a composite of several firsthand stories that takes place in South Africa, a country where model legislation was created to expand access to safe abortion, yet the public health problem of maternal deaths from unsafe abortion persists. A third case study is designed for in-class work using actual events to explore the link between religion and public policy in contributing to the death of a pregnant woman in Ireland and a comparable situation in the U.S.

How to Use This Module 

Provide’s Nursing Education Curriculum is designed for a flipped classroom model to incorporate unintended pregnancy prevention and care into existing curricula.

Students are encouraged to complete the Pre-Assessment below and then work through the module. Definitions and Orienting Facts provide context for the Patient Situations, which are clinical scenarios designed to raise critical issues and questions to put unintended pregnancy prevention and care in the context of Global Health. Students may complete the Recommended Reading at any time while going through the Patient Situations. Please complete the Post-Assessment after finishing the module.

Faculty are encouraged to open the Faculty Guide tab below to access teaching tips, exercises and handouts for incorporating module content into the classroom, and to learn more about obtaining a “Site Code” to download and access students’ Pre- and Post-Assessment data.

Pre- and Post-Assessments

Please complete the Pre- and Post-Assessments. A new window will open to a Survey Monkey Pre-Assessment and the window must remain open while you work with the module. Once you have completed the module you will return to the Survey Monkey window to complete the Post-Assessment. If your faculty requires completion of this module as a course requirement, please check with them about due dates and credit allocations.

Learning Objectives

  • Identify causes of maternal mortality worldwide.
  • Analyze the effect of country specific public policy and legislation on the reproductive health needs of women.
  • Understand the impact of the lack of quality family planning services in a global context.
  • Compare and contrast legislative and religious barriers to legal abortion globally and in the U.S.

Relevant UPPC Essential Competencies

Through a national Delphi study, Essential Competencies in Unintended Pregnancy Prevention and Care for Nursing Education (Hewitt, C. and Cappiello, J., 2015) 85 nursing experts in unintended pregnancy prevention and care reached consensus on 27 core educational competencies for nursing education which provide a framework for curricular development in an important area of nursing education. The following competencies are relevant to this nursing education module.

  1. Demonstrate knowledge of the nurse’s professional responsibilities in providing health care to clients in need of unintended pregnancy prevention and care.
  2. Demonstrate ability to recognize unique reproductive health needs of women from vulnerable and special populations (e.g. adolescents, women with mental or physical disabilities, survivors of violence) affected by many factors (e.g. relationship status, sexual orientation).
  3. Demonstrate knowledge of current evidenced-based guidelines for primary prevention of unintended pregnancy.

Cairo Convention:  In Reproductive Health and Family Planning the Cairo Convention (1994) urged governments to provide universal access to family planning information and services and to decrease unsafe abortion. In Gender Equality and Empowerment, the Convention stated that human development cannot be sustained unless women are guaranteed equal rights and equal status with men. Full access to education is the single most important element to equality and empowerment of women. All legal, social and cultural barriers that discriminate against women and prevent women’s full participation in society, including in public and political life must be removed.

Induced or Therapeutic Abortion (commonly referred to as “abortion”):  An abortion that is brought about intentionally, also called a therapeutic abortion. Medical terminology refers to induced and spontaneous abortion (commonly referred to as a miscarriage).

Maternal Morbidity:  According to the CDC maternal morbidity includes physical and psychological conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman’s health. Maternal morbidity (MM) is difficult to measure because the definition of MM differs among countries and researchers, the criteria to diagnose diseases can vary, and surveys estimating the prevalence of MM are difficult to conduct in some countries.

Maternal Mortality:  According to the World Health Organization, maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to, or aggravated by the pregnancy or its management, but not from accidental or incidental causes. The maternal mortality ratio (per 100 000 live births) represents the risk associated with each pregnancy and is a Millennium Development Goal indicator.

Medication Abortion:  This method of early abortion is currently used up to 63 days of pregnancy in the U.S. The most commonly used regimen includes mifepristone (formerly known as RU486) followed by misoprostol. Generally a woman has an appointment with a provider for mifepristone after which she self-administers misoprostol in 1-3 days at home. Within a few hours, she has a miscarriage with cramping and bleeding which ends the pregnancy.

United Nations Millennium Development Goals for 2015:  In 2000, 189 nations made a promise to free people from extreme poverty and multiple deprivations. This pledge turned into the eight Millennium Development aimed at eradicating extreme hunger and poverty, achieving universal primary education, promoting gender equality and empowering women, reducing child mortality, improving maternal health, combating HIV/AIDS, malaria and other diseases, ensuring environmental sustainability, and developing a global partnership for development.

  • Unsafe abortion is a major public health concern and a social justice issue. On a global scale, unsafe abortion is an important determinant of women’s reproductive mortality and morbidity. Unsafe abortions are the third largest cause of maternal mortality worldwide.
  • Currently, more than 60% of the world’s population live in countries where induced abortion is permitted either for a wide range of reasons or without restriction as to reason. In contrast, more than 25% of all people reside in countries where abortion is generally prohibited, while nearly 14% live in countries where abortion is permitted solely to preserve the woman’s health.
  • Unsafe Abortion in 2008: Global and Regional Levels and Trends reports that 43.8 million abortions were performed worldwide, representing the termination of one fifth of all pregnancies. The WHO estimates that in 2008, 21.6 million unsafe abortions took place globally, leading to the deaths of 47,000 women and disabilities for an additional 5 million.
  • According to the United Nations Fund for Population Activities (UNFPA) the main causes of death for adolescent girls in most developing countries are complications in pregnancy and childbirth. Adolescent girls under the age of 15 are most at risk of dying from pregnancy-related conditions.
  • Raymond (2014) states that abortion is safe and has lower morbidity and mortality than childbirth when carried out by trained practitioners in sanitary conditions, but, according to the WHO, nearly half of the abortions done in the world are unsafe.
  • Some of the world’s most restrictive abortion laws exist in Latin America: Nicaragua, El Salvador, Chile, Honduras and the Dominican Republic ban abortion completely, even when a woman’s life is in danger.

Kassenbaum et al. (2014) identify maternal mortality rates in 2013:

Ireland 3.3 deaths per 100,000 live births
U.S.18.5 deaths per 100,000 live births
El Salvador65.8 deaths per 100,000 live births
South Africa174.1 deaths per 100,000 live births
  • According to the CDC, there are racial disparities in pregnancy-related mortality in the U.S. in 2011:
  • 12.5 deaths per 100,000 live births for white women.
  • 17.3 deaths per 100,000 live births for women of other races.
  • 42.8 deaths per 100,000 live births for black women.
  • According to Finer and Zolna (2014) half of pregnancies among American women are unintended, and four in 10 of these are terminated by abortion.
  • The Guttmacher Institute reports that “the average American woman spends about five years pregnant, postpartum or trying to become pregnant, and three decades—more than three-quarters of her reproductive life—trying to avoid an unintended pregnancy.” Guttmacher’s Fact Sheet on Induced Abortion in the United States indicates the likelihood of having an abortion rises over the course of a lifetime: 1 in 10 women will have an abortion by age 20, and 1 in 3 will have an abortion by age 45.
  • The Guttmacher Institute also reports that births resulting from unintended or closely spaced pregnancies are associated with adverse maternal and child health outcomes such as delayed prenatal care, premature birth and negative physical and mental health effects for children.

Each scenario described in this module is broken into sections to enable self-guided learning. Detailed information is provided on the patient and the setting in addition to the patient scenario that deals with the complex and often controversial nature of unintended pregnancy prevention and care. The patient scenarios in these modules are based on actual events.

El Salvador (Patient Situation #1)

The Patient

Beatriz, a 22-year-old woman from rural El Salvador, becomes pregnant for a second time. Her 20 month old son was born premature and as a result, is experiencing developmental delays. Beatriz has a history of lupus, a chronic inflammatory disease that occurs when the body’s immune system attacks its own tissues and organs, and suffers from kidney disease resulting from the lupus.

The Setting

In 1998 in El Salvador, a Penal Code banned abortion in all circumstances, without exception. Criminal penalties included two to eight years in prison for the woman and six to twelve years for health professionals who assist women by providing abortion care (Penal Code of El Salvador, 1998, Chapter 2). An amendment to the Constitution recognized the right to life from the moment of conception.

What Happened

At about 9 weeks of pregnancy, Beatriz goes to a doctor for an ultrasound and the fetus is diagnosed with anencephaly, a neural tube defect resulting in the absence of major portions of the brain and malformation of the brainstem. The cranium does not close and the vertebral canal remains a groove. Anencephaly is thought to be caused by a combination of genetic and environmental factors. This condition is not compatible with life.

What are Beatriz's options?
In some countries with restrictive abortion laws and policies, there are exceptions for cases where the woman’s health is in danger, but this is not the case in El Salvador. The restrictive Penal code in El Salvador bans all forms of abortion in all circumstances, without exception, even if the woman’s life is in danger.

Access to essential health services including abortion care is critical to women’s health. A joint report from Ibis Reproductive Health and the Center for Reproductive Rights, Evaluating Priorities: Measuring Women’s and Children’s Health and Well-being Against Abortion Restrictions in the States, shows that states with more abortion restrictions performed worse on women’s and infant’s health indicators compared with states that had fewer restrictions, including higher maternal and infant mortality rates.

At about 16 weeks of pregnancy Beatriz’s health begins to deteriorate. Her physicians treating her request an opinion from the Medical Committee of San Salvador’s National Specialized Maternity Hospital regarding the legal situation as the physicians feel that continuing the pregnancy would result in further pregnancy complications or jeopardize her life. The Medical Committee recommends terminating the pregnancy but soon after the Institute of Legal Medicine recommends she continue with the pregnancy. Doctors are fearful to assist Beatriz without legal support from the courts because the maximum penalty for terminating a pregnancy in El Salvador is 12 years in prison.

Beatriz’ legal team appeals to the Salvador Supreme Court of Justice. Despite the medical urgency, the Court takes six days to agree to hear the case and then does not issue a ruling. Beatriz’s care providers turn to regional human rights groups and women’s advocacy groups for support. Her case is appealed to the American Commission on Human Rights (IACHR). The IACHR grants Beatriz “protective measures” urging El Salvador to provide medical treatment as recommended by her physicians, in accordance with her wishes, within 72 hours. No action is taken.

Following the IACHR appeal, a similar attempt is instituted by United Nations human rights experts and a long list of organizations and institutions within El Salvador—including the Ministry of Health, the Society of Gynecology and Obstetrics, the National Bioethics Council and the Office for the Defense of Human Rights. These organizations publicly call for the government to grant Beatriz treatment.

At this point, the case of Beatriz is of international interest. Supportive letters are being sent and demonstrations are being organized outside Salvadoran embassies in Latin America and Europe. Beatriz releases a video pleading for her life.

A month lapses from the initial appeal to the Supreme Court before the court decides to hear the appeal. Beatriz appears in court but during the hearing she experiences a hypertensive crisis which requires an emergency transfer to the hospital. Without further testimony, the Court states they will issue a definitive ruling within 15 days.

When a ruling is not released, the Inter-American Court of Human Rights orders the state to take all necessary steps to enable Beatriz’ doctors to treat her without interference.

Another month passes and the Salvadoran government finally permits Beatriz to have an early caesarean section. Their delays had forced Beatriz to wait until she had passed the 20th week of pregnancy.

Why would the courts delay the process until 20 weeks?
In El Salvador at 20 weeks gestation the end of the pregnancy is no longer medically classified as an abortion, but rather as induced labor. With this delay, the court was able to claim that no new legal precedent had been set and that the total prohibition on abortion had been upheld.

As expected, the newborn died hours after birth as parts of its head and brain were missing. Beatriz survived and it is not clear what the long-term effects of the delay in treatment will be on her health.

What If…

This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.

Beatriz lived in a different Latin American country?
Restrictive legislation exists in most other Latin American countries. The 2012 Guttmacher Institute brief, Facts on Abortion in Latin America and the Caribbean, provides country-specific data and a chart on the legality of abortion, categorizing countries into different levels of abortion access including:

  1. Prohibited altogether, or no explicit legal exception to save the life of a woman
  2. To save the life of a woman
  3. To preserve physical health (and to save a woman’s life)
  4. To preserve mental health (and all of the above reasons)
  5. Socioeconomic grounds (and all of the above reasons)
  6. Without restriction as to reason

Only a few Latin American countries permit abortion without restriction as to the reason. Cuba and Guyana have no restrictions in place. In 2007 Mexico City legalized abortion procedures in the first 12 weeks of pregnancy. Approximately 8% of the country’s population lives in Mexico City. In 2012, Uruguay waived criminal penalties for abortion in the first 12 weeks of gestation, with certain procedural requirements, and in the first 14 weeks of gestation in the cases of rape. Women in other Latin American countries cite fear of legal consequences, high cost, lack of access to trained professionals, and stigma as major barriers to obtaining safe abortions. The chart First Trimester Abortion: A Comparison of Procedures from the National Abortion Federation shows a side-by-side comparison of three types of abortion procedures and how they work as well as advantages and disadvantages to each.

In many countries, a variety of medications are available without a prescription or pharmacists are not strict in requiring a prescription. Misoprostol, a synthetic prostaglandin E1 analog, is used to reduce the risk of gastric ulcers caused by nonsteroidal anti-inflammatory drugs and is also used for medication abortion. Misoprostol can be purchased without a prescription in some countries or obtained without one. A study by Lara et al. (2011) of 165 randomly selected pharmacies in Mexico showed that pharmacists often provide inaccurate and incomplete information to clients about using misoprostol for abortion. In the study, access to misoprostol was influenced by neighborhood socioeconomic level, pharmacy location and pharmacy type.

There are other means of obtaining medication to terminate a pregnancy. A women’s health advocacy group, called Women on Web will refer women to a licensed physician for medication abortion pills in some countries where abortion is illegal. Their operational guidelines to provide services include: living in a country where access to safe abortion is restricted, less than 9 weeks of pregnancy and no severe illnesses. A pregnancy test and ultrasound are required to verify dates are suggested. After completing an online consultation, and if no contraindications are identified, misoprostol is shipped to the woman in need. The woman must have access to emergency medical care in the rare case that there are complications.

Access to Medication Abortion
The fact sheet What is Medical Abortion? from the National Abortion Federation (NAF) defines and provides details of medication abortions including how the medications work, how long they take, possible complications, and follow-up care. NAF also defines Mifepristone, a medication that blocks the action of progesterone, discusses how it works, effectiveness as an abortifacent when combined with Misoprostol, possible side effects, and what women can expect when using it in this fact sheet: Facts About Mifepristone (RU-486).

South Africa (Patient Situation #2)

The Patient

Afia is 17 and has been sexually active for four years. She has been receiving monthly contraceptive injections because that is the method given to young women at the clinic closest to her home. However, she has found it difficult to return to the clinic for follow-up injections. A few months ago, she left school early in order to take the bus to the clinic. When she arrived at the clinic at 4:05 pm, the staff person was rude to Afia and told her the clinic was closed. Afia went home without her injection. Now she had to save bus fare money again, and will need to leave school early once more. In addition, her mother found a new job from which she does not return home until 5:30 pm and Afia is expected to watch over her younger siblings after school until her mother returns home. She doesn’t return to the clinic. Afia and her current boyfriend use condoms frequently.

The Setting

In 1996, soon after apartheid ended, South Africa passed the Choice on Termination of Pregnancy Act (CTOP Act) legalizing abortion. The goal of the act was to ensure the health of all women, to ensure that women were treated equally, and ensure that women’s rights were defined in the new South African Constitution.

What Happened

Afia finds out that she is pregnant. She is not sure how far along she is but guesses close to three months. Afia is aware that she can receive prenatal care and abortion care through the public health system in South Africa. Afia thinks she is too young to have a baby and she wants to finish school before becoming a mother. She doesn’t have any money or source of income nor any particular job skills. Her boyfriend is a student and he is not interested in becoming a father. If she continues the pregnancy, Afia thinks she will raise the child by herself.  She decides that she wants to terminate the pregnancy.

What are Afia’s options?
The ending of apartheid was a time of re-energizing the goals of South African society. The protection and expansion of women’s rights and human rights were fundamental to changes in health care. The Choice on Termination of Pregnancy Act (CTOP Act) repealed the previous restrictive provisions that criminalized abortion in South Africa. The CTOP enacted that any woman could access abortion for any reason during the first 12 weeks of pregnancy. Parental consent is not required for minors. From 13-20 weeks, a termination of pregnancy (TOP) is permitted if, in consultation with a medical practitioner, the woman meets one of the following requirements:

  • Continuing the pregnancy will post a risk to the woman’s physical or mental health.
  • There exists a substantial risk that the fetus will suffer from severe physical or mental abnormalities.
  • The pregnancy resulted from rape or incest.
  • The continued pregnancy would significantly affect the social or economic circumstances of the woman.

From 20 weeks on, TOPs are available under limited circumstances if the pregnancy would endanger the woman’s life, result in a severe malformation or pose a risk of injury to the fetus.

Afia guesses she is more than three months pregnant. Abortion procedures beyond 12-14 weeks of a woman’s last menstrual period are typically performed by dilatation and evacuation (D & E), a safe and effective method of induced abortion. Cervical preparation using misoprostol or osmotic dilators is frequently done prior to the D & E. The Safety of Abortion publication from the U.S. National Abortion Federation details the safety of different types of abortion procedures, possible complications, complication management techniques, and aftercare.

Marie Stopes is a health care organization that offers a wide array of reproductive health services including safe abortion procedures, contraceptive services, well woman exams, and STI testing at clinic locations throughout South Africa.

Afia is able to save money for bus fare and skips school one day to travel to a clinic that provides abortions. This clinic is much further away than the clinic where she received contraceptive injections. When she arrives at the clinic she is told that there is no abortion provider on staff that day.

What are the barriers to accessing abortion in South Africa?

Lack of Trained, Qualified Providers

The CTOP act established that only a trained a health care provider could provide abortion services. The definition has been interpreted to mean that provision of abortion is within the scope of professional nursing and midwifery practice. Midwives and nurses provide almost all the first trimester termination of pregnancies (TOPs) in the country while physicians provide TOPs from 12-20 weeks or more. To prepare the nursing workforce, a required national curriculum in abortion training was developed and is required of nurses and midwives interested in providing abortion.

However, TOP services are not readily accessible in many areas, the quality of the service varies and there is a shortage of trained nursing/midwifery providers. Women have become frustrated by limited services, delays for appointments and deliberate obstruction to TOP services by the anti-choice movement. Although the numbers of deaths and severe infections from unsafe abortion have dropped since 1996, some women like Afia turn to either self-induction or unskilled providers.

Lack of Knowledge

A 2006 study found that 1/3 of sexually active women attending public health clinics in a rural province did not know that abortion was legal. To further complicate the picture in South Africa, there is a high rate of violence and sexual assault against women with many unintended pregnancies as a result.

Stigma

TOP is associated with stigma in many communities and in the professional work environment as well. This has led to some nurses leaving the field after only a few months of TOP service provision.  In an ethnic subgroup of Tswane, there is not even a word for TOP or abortion. Rather one nurse had to adopt the local terminology of referring to TOP as “go boya tseleng”, meaning “you did not go on with your pregnancy”.

Overloaded Health Care System

The South African public health care system, as with many health care systems in the world, is strained with the task of meeting the health care needs of the population. The AIDS epidemic continues to consume much of the health care budget so that prevention and direct services for other health care needs is often not met.

Afia fears she will not have time to save enough money to come back to the clinic and she cannot afford to miss another day of school as finals are coming up. Afia decides to contact a women in a neighboring town she heard of who might be able to perform an abortion procedure in her home.

After Afia tells her boyfriend of this plan, he raises enough money for bus fare to take them to a licensed facility. Afia is able to have a termination at the clinic that is closest to her when a qualified midwife visits the clinic on rotation from a hospital in Johannesburg the next week.

What If…

This section offers a twist or a different perspective on “What Happened” to guide and encourage learners to tease apart various aspects of the Patient Situation.

Afia had a procedure done with an unqualified abortion provider?
In Safe Abortion: Technical and Policy Guidelines for Health Systems the World Health Organization (WHO) defines unsafe abortion as “a procedure for terminating an unintended pregnancy, carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both.” This report describes unsafe abortion procedures that may involve insertion of an object or substance (e.g. a root, catheter, traditional medicines) into the uterus; ingestion of harmful substances; dilation and curettage performed by an unskilled or untrained provider; and/or physical force such as pummeling the woman’s abdomen, which could cause uterine rupture, endangering the woman’s life.

According to the WHO in Unsafe Abortion Incidence and Mortality: Global and Regional Levels in 2008 and Trends During 1990-2008 one in ten pregnancies end in an unsafe abortion, almost all of which take place in developing countries. Of these, approximately 13% result in maternal death, mainly caused by severe bleeding, infection, or organ damage. In 2008, 62% of maternal deaths occurred as a result of unsafe abortion were in Africa.

Some health workers, especially doctors, refuse to treat a woman’s vaginal bleeding if they suspected it was caused by a self-induced abortion. The Health Professions Council of South Africa, the statutory body for medical practitioners, issued a directive that any doctor refusing to treat a woman who is bleeding would be guilty of misconduct. The South African Nursing Council made a similar ruling.

The CTOP Act does not mention a right of professional conscience in regard to the provision of abortion services but does set out duties in terms of how health professionals are expected to act. Health care providers must provide information, non-directive counseling and referrals but are not required to perform a termination of pregnancy. The CTOP Act states that “Any person who…  prevents the lawful termination of a pregnancy or obstructs access to a facility for the termination of a pregnancy… shall be guilty of an offence and liable on conviction to a fine or to imprisonment.

Please see the Professional Ethics nursing education module to engage in learning about professional and ethical responsibilities in reproductive health care in the United States.

Abortion on a Global Stage

Safe Abortion: Technical and Policy Guidelines for Health Systems (WHO, 2012)
This document from the World Health Organization provides evidence-based best practices for the provision of abortion services to guide policymakers, program managers, and abortion providers to protect the health of women worldwide.

Access to Safe Abortion in the Developing World: Saving Lives While Advancing Rights (Cohen, S.A., 2012)
This article from the Guttmacher Institute provides current data on abortion worldwide through a human rights lens.

U.S. Overseas Family Planning Program, Perennial Victim of Abortion Politics, Is Once Again Under Siege (Cohen, S.A., 2011)
This article from the Guttmacher Institute provides analysis on the impact of the Mexico City Policy (also called the Global Gag Rule) on international abortion services in countries that accept U.S. aid.

Abortion Worldwide
This four-minute video from the Guttmacher Institute discusses abortion rates and practices worldwide, addressing the consequences of unsafe abortions and the benefits of expanded access to contraceptive use.

Unsafe Abortion: Global and Regional Estimates of the Incidence of Unsafe Abortion and Associated Mortality in 2008 (WHO, 2008)
This report from the World Health Organization presents global and regional estimates, as well as consequences, of unsafe abortions worldwide.

Unsafe Abortion: A Neglected Crisis in Women’s Health
This seven-minute video from Ipas addresses abortion practices and the implications of lack of access to safe abortions in the developing world.

Saving Women’s Lives (WHO, 2014)
This infographic from the World Health Organization illustrates the need for safe pregnancy and unintended pregnancy related care, including contraception and abortion services, in the developing world.

Unsafe Abortion: The Missing Link in Global Efforts to Improve Maternal Health (Barot, S., 2011)
This article from the Guttmacher Institute provides causes and consequences to unsafe abortion and details the global response to reduce maternal morbidity and mortality.

Health Care Providers’ Attitudes Towards Termination of Pregnancy: A Qualitative Study in South Africa (Harries, J., et al., 2009)
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. This study explores the personal and professional attitudes of health care providers (primarily nurses) working in abortion service provision, including the factors that determine health care providers’ involvement or disengagement in abortion services.

Unsafe Abortion Incidence and Mortality: Global and Regional Levels in 2008 and Trends During 1990-2008 (WHO, 2012)
This information sheet from the World Health Organization provides global and regional rates and trends of unsafe abortion and associated mortality rates.

Persecuted. Political Process and Abortion Legislation in El Salvador: A Human Rights Analysis
This report from The Center for Reproductive Rights examines how restrictive legislations in El Salvador violate women’s reproductive rights, which are recognized in international human rights treaties that have been signed by El Salvador.

Legal Abortion Worldwide in 2008: Levels and Recent Trends (Sedgh, G., et al., 2011)
The author states the country-specific rates of abortion point to the great need for effective family planning services in many countries.

Facts on Abortion in Latin America and the Caribbean
This Guttmacher Institute brief provides country-specific data and a chart on “Legality of Abortion” which categorizes abortion access.

Improve Maternal Health: Where Do We Stand
This graph illustrates thee progress of the Millennium Development Goals of reduction of maternal deaths related to pregnancy. In 2013, almost 300,000 women died globally from causes related to pregnancy and childbirth. Sub-Saharan Africa made the most progress while Latin America made the least.

The World’s Abortion Laws, 2014
This map from the Center for Reproductive Rights shows a comparison of the legal status of induced abortion in different countries—and advocates for greater progress in ensuring access to safe and legal abortion services for all women worldwide. The legal status of abortion is an important indicator of women’s ability to enjoy their reproductive rights. Legal restrictions on abortion often cause high levels of illegal and unsafe abortion, and there is a proven link between unsafe abortion and maternal mortality. The table illustrates the varying degrees to which countries worldwide permit access to abortion. Depending on such factors as public support for abortion rights, the views of government officials and providers, and individual circumstances, laws in each category may be interpreted more broadly or restrictively.

Unsafe Abortion in South Africa: A Preventable Pandemic (Osman, S. and Thompson, A., 2012)
As nations reaffirmed the Cairo Programme of Action, many countries expressed their frustration with the lack of progress in critical areas of sexual and reproductive rights. South African Minister of Social Development Bathabile Dlamini declared: “In Africa we are not doing well in terms of the substantive economic emancipation of women. Women continue to be marginalized by the mainstream economy. It is for this reason that efforts to transform the economy…cannot be divorced from all sexual and reproductive rights, including abortion rights and services, as part of a comprehensive and more radical approach to reproductive justice.”

Abortions in the U.S.

Abortion Restrictions in the U.S. Foreign Aid: The History and Harms of the Helms Amendment (Barot, S., 2013)
This article from the Guttmacher Institute analyzes the impact of U.S. abortion policies and foreign aid on international family planning programs and abortion services.

Evaluating Priorities: Measuring Women’s and Children’s Health and Well-being Against Abortion Restrictions in the States
This publication from the Center for Reproductive Rights shows that in the U.S, states with more abortion restrictions performed worse overall on women’s and infant’s health indicators compared with states that had fewer restrictions, including higher maternal and infant mortality rates.

Mortality of Inducted Abortion, Other Outpatient Surgical Procedures and Common Activities in the United States (Raymond, E.G., et al., 2014)
The safety of induced abortion as practiced in the United States for the past decade met or exceeded expectations for outpatient surgical procedures and compared favorably to that of two common nonmedical voluntary activities.

Abortion in the United States
This three-minute video from the Guttmacher Institute provides abortion data and statistics in the United States.

Providing Abortion Care: A Professional Toolkit for Nurse-Midwives, Nurse Practitioners, and Physician Assistants
This toolkit provides a thoroughly researched and referenced discussion of scope of practice and abortion care as pertains to APNs and physician assistants.

Miscarriage of Medicine: The Growth of Catholic Hospitals and the Threat to Reproductive Health Care (ACLU, 2013)
Religious restrictions govern health care at Catholic-sponsored hospitals and networks. Within these systems, health professionals are prohibited from providing specific health services or honoring patients’ health care decision-making when it conflicts with religious doctrine. Often health professionals are prohibited from providing basic counseling and referrals for services prohibited on religious grounds, such as counseling and referrals for unplanned pregnancy.

A Surge of State Abortion Restrictions Puts Providers—and the Women They Serve—in the Crosshairs (Guttmacher Institute, 2014)
This report highlights the state-specific barriers that exist for access to abortion care including mandatory waiting periods, doctor and clinic restrictions, and limits on insurance coverage. The report also draws attention to the overall lack of abortion providers.

Maternal Mortality in the United States: A Human Rights Failure (Bingham, D., et al., 2011)
United Nations data shows that between 1990 and 2008 maternal mortality nearly doubled in the United States and the authors argue that this is not just a matter of public health, but a human rights failure.

Pregnancy-related Mortality in the United States: 1998-2005 (Berg, C.J., et al., 2010)
This study estimates the risk of women dying from pregnancy-related complications, and examines risk factors for such deaths. From 1998 to 2005, the mortality ratio was 14.5 per 100,00 live births, higher than the previous 20 years, and African American women were at three to four times greater risk of maternal mortality.

When There’s a Heartbeat: Miscarriage Management in Catholic-owned Hospitals (Freedman, L.R., et al., 2008)
This article presents five cases from a qualitative study of physician’s experiences with miscarriage management with in Catholic institutions. 

A Piece of My Mind: A Question of Faith (Raghavan, R., 2007)
In this article a physician husband describes his inability to advocate for the care his wife needed. His wife had an ectopic pregnancy but the religious-based hospital could not provide the evidenced-based interventions required. The woman had to transfer care to another hospital in the midst of an emergency.

Safe Abortions

Safety of Abortion
This publication from the National Abortion Federation details the safety of different types of abortion procedures, possible complications, complication management techniques, and aftercare.

Abortion: Quality Care and Public Health Implications
This course from the University of California, San Francisco addresses abortion in a global context, discusses professionalism and patient-centered care, explains different abortion procedures, and reviews obstacles to access.

First Trimester Abortion: A Comparison of Procedures
This chart from the National Abortion Federation shows a side-by-side comparison of three types of abortion procedures, how they work as well as the advantages and disadvantages of each.

What is Medical Abortion?
This fact sheet from the National Abortion Federation defines and provides details of medication abortions, including how the medications work, how long they take, possible complications, and follow-up care.

Facts About Mifepristone (RU-486)
This fact sheet from the National Abortion Federation defines Mifepristone—a medication that blocks the action of progesterone—discusses how Mifepristone works, effectiveness as an abortifacient when combined with Misoprostol, possible side effects, and what women can expect when using it.

Manual Vacuum Aspiration
This “Quick Reference Guide for Clinicians” from the Association of Reproductive Health Professionals (ARHP) presents a summary of clinical information on manual vacuum aspiration, including indications for use and clinical components of the procedure.

National Abortion Federation 2015 Clinical Policy Guidelines
These evidence-based guidelines and standards on abortion care from the National Abortion Federation include clinical practices on patient care and counseling and different types of abortions. These guidelines, which are revised annually, are based on rigorous review of medical literature and known patient outcomes to support and educate providers on the most current information, standards, and recommendations. The following modules are specific to this competency:

  • Module 6: Early Medication Abortion
  • Module 7: First-Trimester Aspiration Abortion
  • Module 9: Abortion by Dilation and Evacuation
  • Module 10: Second-Trimester Induction Abortion

Early Abortion Training Workbook
Chapter 5 and Chapter 7 of this workbook from Advancing New Standards in Reproductive Health (ANSIRH) provides details on uterine aspiration and on medication abortion, respectively, including step-by-step instructions, managing complications, and exercises with relevant questions to evaluate the learner’s understanding. This is a comprehensive resource on abortion care with recommendations and guidance on issues ranging from confidentiality and consent procedures to medications and pain management for different abortion procedures.

Abortion Theory and Research

Stigma in Abortion Care: Application to a Grounded Theory Study (Lipp, A., 2011)
The author from the United Kingdom applies a stigma theory to explore the intersection of nursing care and the stigma of providing abortion care.

Self-Preservation in Abortion Care: a Grounded Theory Study (Lipp, A., 2011)
Using a grounded theory approach this article examines why and how U.K. nurses concede and conceal their judgment of women seeking medication abortion services.

Nurses in Abortion Care: Identifying and Managing Stress (Lipp, A., and Fothergill, A., 2009)
Using model of stress comprising stressors, moderators and stress outcomes as a framework this paper examines the potential increase in stress in nurses caused by participating in medical abortions in the U.K.

A Woman Centered Service in Termination of Pregnancy: A Grounded Theory Study (Lipp, A., 2008)
This grounded theory study explores how nurses and midwives perceive their role in working with women undergoing termination of pregnancy and how they manage their increased involvement with these women in the U.K.

Values Clarification

The Abortion Option: A Values Clarification Guide for Health Care Professionals
These exercises from the National Abortion Federation are designed to help nurses critically examine factors that might influence their beliefs about parenting, adoption, and abortion and, for some, their desire to become involved in abortion care. There are tools for clarifying values related to abortion, views about the role of health care providers, and case studies are used to identify and examine potential biases.

Values Clarification and Options Counseling for Unintended Pregnancy (Hart, J.A., et al., 2013)
This article emphasizes the importance of providing unbiased, compassionate, and factual options counseling for women experiencing unintended pregnancy, and identifies the difficulties of counseling women with religious affiliations to help them address any potentially conflicting feelings between their religious beliefs and their abortion decision.

Film and Literature

Bring the Popcorn: Using Film to Teach Sexual and Reproductive Health (Cappiello, J.D. and Kerryellen, V., 2011)
This article discusses the use of film for nursing students to explore the intersection of science, theory, and personal values to prepare for providing sexual and reproductive health care for patients.

Vera Drake (2004)
This 2004 film is 125 minutes long and rated R for depiction of strong thematic material. Set in a 1950 working class neighborhood in London, Vera Drake is a devoted family woman, who cleans houses for a living. Out of the goodness of her heart and not for compensation, Vera provides abortions to poor women in desperate situations in a pre-legal abortion era.

Discussion topics:

  • Access to abortions; in many countries in the world, women do not have access to safe abortion procedures. Compare maternal mortality rates in such countries compared to the U.S. and Western Europe and the amount of health care budgets dedicated to treating infections related to unsafe abortions.
  • The impact of the procedure that Vera provides: illegal, unsterile, and outside the health care system.
  • Issues of class and access to health care; in the film, wealthier women are able to access care in a private, safe, and legal clinic while poor women resort to unsafe procedures.

Abortion Democracy: Poland/South Africa (2008)
This documentary contrasts legislative changes in Poland and South Africa regarding abortion and the subsequent impact on the lives of women. After the fall of communism in the 1990’s, Poland banned abortion due to the increasing influence of the Catholic Church; around the same time South Africa reformed the health system after the fall of apartheid, legalizing abortion. The film also illustrates the paradox that the implementation of such laws had little effect on the accessibility of abortion services: illegal abortions are more accessible in Poland than legal ones in South Africa.

Half the Sky: Turning Oppression into Opportunity for Women Worldwide (Kristoff, N. and WuDunn, S., 2009)
This book documents human rights violations that women face throughout the world. In addition, the authors outline the effects of U.S. policy of defunding global health programs that address women’s reproductive health, including safe abortion.

This module examines the barriers to safe abortion care, and the impact of politics and legislation, on a global scale. Unsafe abortions continue to be a leading cause of maternal mortality, with the majority of unsafe abortions occurring in the developing world. Patient scenarios are based on true stories from South Africa, El Salvador, Ireland and the United States.

These modules are designed to use with a flipped classroom model in which students are directed to complete the module as homework, including the Pre- and Post-Assessments. Once students have completed the module in its entirety, including the recommended reading, faculty can use the Teaching Tips document and materials from the Exercises and Handouts section below to integrate concepts from the module into the classroom or group setting.

Teaching Tips

Exercises and Handouts

These materials can be used to enhance classroom learning. The Teaching Tips document provides recommendations on how to incorporate these materials into a classroom or group setting.

Global Health Patient Scenario: This handout from Provide describes two patient scenarios, one that occurred in Ireland, and another that occurred in Arizona. The Teaching Tips document for this module provides guidance on facilitating classroom discussion related to the scenarios described in this handout.

The Abortion Option: A Values Clarification Guide for Health Care Professionals: These exercises from the National Abortion Federation include tools that can be used in class for clarifying values related to abortion and discussing the role of health care providers.

Global Health In-Class Presentation

For a more traditional approach to classroom learning, content from the Global Health online module was used to develop this 15 – 20 minute presentation. Faculty can use this presentation in the classroom as a substitute for students completing the module independently. The Teaching Tips document and exercises and handouts that are provided as part of the module can be used to supplement this presentation and incorporate student participation in class.

Accessing Student Pre- and Post-Assessment Data

Pre- and Post-Assessments are designed to measure students’ satisfaction with the module as well as what they have learned. To be able to complete the Assessments students will need to enter a “Site Code” prior to working through the online module. Faculty will use this Site Code to download and review students’ Pre- and Post-Assessment data. To obtain a Site Code your institution must e-mail Provide. In the text of the email, please include your name (as instructor), the name of the institution, and the module(s) for which you would like to access data. Provide will send you 1) a Site Code for your students to enter at the beginning of the assessment, 2) a web link to access the results from each module, and 3) an “answer key” to help grade your students’ responses. You may also assign a unique Student Code to each student that you would like to assess on an individual basis. Students must enter the correct Site Code for faculty to be able to access their data.

Can’t find the article you’re looking for?

Help us keep our content current! Email Provide.