The World Health Organization estimates that 56 million abortions take place each year, approximately 25 million (or 45%) of which are considered unsafe. Unsafe abortions mainly occur in countries with restrictive laws or policies and carry significant risk of injury, disability, and death, accounting for 8-18% of maternal deaths worldwide. Misoprostol offers a high- quality, safe alternative to unsafe methods of clandestine abortion and is associated with decreased abortion-related morbidity and mortality in countries where abortion is legally restricted, however a large percentage of women do not know that this option exists, or where to access it. There is also a lack of information on the correct dosage of misoprostol, its side effects, and when to seek emergency care. To mitigate these barriers, a number of organizations have set hotlines to connect women with unwanted pregnancies to information on misoprostol and other safe methods of abortion. This dissertation analyses the factors that have impeded and facilitated the implementation of these local hotlines, as well as an international hotline that attempted to reach women in Nicaragua, a country with some of the most restrictive abortion laws.
Chapter 1 investigates the three main challenges that face local hotlines: 1) ensuring that women who call in have access to safe abortion medicines and services, 2) promoting their hotlines in a way that prevents them from getting shut down by the government, and 3) procuring the resources necessary to make their hotlines sustainable. It also investigates the strategies that local hotlines have used to overcome these challenges. Examples include training pharmacists to disseminate correct information, setting up a rotating fund to subsidize costs for low-income women, using volunteers to staff the hotlines, and finding inexpensive loopholes in telecommunication services. It concludes by discussing the main challenge that remains: reaching women on a large scale, and suggests several strategies that could be used to overcome it.
Chapter 2 investigates public experiences of abortion in Nicaragua, a country where restrictive abortion and freedom of information laws have prevented even the most active feminist groups from starting up a hotline. A study of 1,200 men and women from across the country investigates the demographic, knowledge and geographic factors associated with knowing a women who terminated her pregnancy, and the factors associated with the use of safe abortion methods. The population most likely to carry out an abortion are adolescent females that have a secondary education or higher. The only factor significantly associated with knowing a woman who terminated her pregnancy safely was exposure to at least one of three safe abortion campaigns/programs. These findings that suggest that public information plays a central role in promoting safe abortion.
Chapter 3 analyzes an innovative intervention that attempted to apply the lessons learned from local hotlines to the Nicaraguan context. The Global Hotline for Women’s Health is a project that was supposed to connect women in countries with restrictive abortion policies to a hotline in Mexico City, providing information about the safe abortion options available without putting hotline operators at risk. This study identifies both factors that facilitated and impeded the implementation of the Global Hotline guided by the Consolidated Framework for Implementation Research. While full implementation was never realized, many lessons emerged that may be useful to future efforts to implement a global hotline for safe abortion or to implement another harm reduction strategy carried out in low and middle income countries with restrictive abortion policies. The dissertation concludes by delineating a set of policy recommendations for improving access to safe abortion and avenues for future research.