In This Issue
Following the 2011 revolution against the regime of Egypt's then-president Hosni Mubarak, an integrated reproductive and maternal and child health program was implemented in Upper and Lower Egypt amid concerns about neonatal mortality and early-childhood stunting. The program emphasized maternal nutrition, exclusive breast-feeding, infant care and feeding, and postpartum family planning. Chelsea Cooper and colleagues examined outcomes related to postpartum family planning using data from a baseline household survey in September–October 2012 and an endline survey in January–February 2014. In Upper Egypt, modern contraceptive use decreased in both intervention and comparison areas, while in Lower Egypt, method use remained unchanged in intervention sites and decreased slightly in comparison sites; in both regions, the intervention was positively associated with the difference in differences between groups. The intervention also appeared to have a positive effect on knowledge of optimal birthspacing in Upper Egypt, on desire to delay the next pregnancy in Lower Egypt and on the proportion of women at risk of pregnancy in both regions.
In 2006, the Constitutional Court of Colombia decriminalized abortion, allowing the procedure when the life or health of the woman is at risk, when a fetal anomaly is incompatible with life or when the pregnancy is the result of rape, incest or forced insemination. The Court also established a legal framework for conscientious objection: It is afforded to individual clinicians, not to institutions; it may not involve "disregard for the rights of women"; and mechanisms must be in place to ensure immediate referral. Despite consistent case law, improperly invoked conscientious objection has raised barriers leading women to seek abortion outside of the formal sector, often in unsafe settings. In in-depth interviews with 15 Colombian physicians who self-identified as conscientious objectors, Lauren K. Fink and colleagues explored their attitudes, beliefs and behaviors regarding abortion. One group, categorized as extreme objectors, refused to perform abortions or make referrals, often lectured their patients and provided misleading or false medical and legal information to dissuade them from having an abortion. A second group, moderate objectors, would not perform abortions but did provide referrals. The third group, partial objectors, made decisions about performing abortions on the basis of gestational age or on a case-by-case basis. According to the authors, the unethical behavior reported by numerous respondents provides evidence that the Court's framework for conscientious objection is not being enforced.
Although female genital cutting (also called female circumcision) has been banned in Egypt in the wake of campaigns emphasizing its harmful effects, the majority of girls continue to be cut. Moreover, medicalization of circumcision has been rapid, raising concerns that perceived harm reduction may be perpetuating the practice. Using quantitative and qualitative data from mothers with young daughters, Sepideh Modrek and Maia Sieverding examined the role of doctors in circumcision decisions and practice. Of mothers who had had or planned to have their daughters circumcised, 91% said they had had or would have it done by a doctor. In addition, about one-third of mothers planned to consult a doctor to help them decide whether to have their daughters circumcised, the vast majority because they did not know if girls should be circumcised or if circumcision might be medically indicated for their daughter. How doctors addressed mothers' uncertainty varied, with some recommending the procedure, some advising against it and others telling the mother to have her daughter reexamined in the future. Given the great trust women place in doctors, the authors conclude, doctors could contribute to abandonment of female genital cutting if they consistently recommended against it.
In Iran, where abortion is legal only in case of danger to a woman's life or severe fetal anomaly, data on levels and trends in abortion incidence are limited. Using 2009 and 2014 data on married women from the Tehran Survey of Fertility, Amir Erfani found a decline in the general abortion rate (from 6.6 to 5.4 abortions per 1,000 women); however, the proportion of pregnancies ending in abortion remained stable at just under 9%. Between the two surveys, the share of abortions obtained for nonmedical reasons rose from 68% to 81%. In 2014, abortion rates were elevated among women who were more educated, wealthier, employed, urban migrants or not highly religious, as well as among those who had had no live births. Half of pregnancies ending in abortion resulted from withdrawal failure, but only one-fourth of women who had been using the method when they became pregnant switched to a modern method after their abortion. The author concludes that some subgroups of women may benefit from interventions to prevent unwanted pregnancies.