nivaquine, quinine, panadol, ergometrine (ergot alkaloids), oral hormonal medications or injectable oxytocin.1,2,16–19 ■ Manipulating the abdomen, by locating the fetal mass through external palpations and then attempting to dislodge it by massaging or beating the lower abdomen.2,4,10,11,19,20 ■ Engaging in traumatic or injurious physical activity, such as jumping from the top of the stairs or roof, falling, lifting heavy objects or exercising excessively.2,11,19,21 ■ Trying other folk techniques, such as inserting a tube to blow air into the uterus to induce labor or placing a hot stone on the abdomen to “melt” the fetus.20 BOX ABORTION WORLDWIDE 23 steps and require financial resources that many of these countries do not have. To the extent that medication abortion requires relatively little training and few resources, its widespread adoption can help speed the process. At the same time, the situation needs to be monitored, because an overemphasis on medication abortion could reduce access to surgical abortion—limiting women’s choice. The case of Mexico City, the only one of Mexico’s 32 federal entities that has liberalized abortion, is a good example of what is possible with strong political commitment. Immediately after the liberalization of the abortion law in 2007, public-sector facilities had a hard time responding to demand. Adaptive strategies of shifting provision to specialized public health clinics118 and of using misoprostol alone (until mifepristone was approved in 2011110) helped extend and improve services. The proportion of public-sector procedures that were medication abortions thus rose from 25% in 2007 to 83% in 2014119 (Figure 4.2, page 24). Uruguay— another Latin American setting where abortion was recently liberalized—has taken steps to extend the availability of legal abortion throughout the country: As of 2014, roughly equal proportions of legal abortions take place in the private and public sectors.120 Access to legal abortion can be impeded if large numbers of providers claim conscientious objection, which in the absence of efficient referral systems can translate to delays, in turn leading to riskier procedures at later gestations, or even the denial of legal care.121 Greater acceptability of medication abortion could help address this barrier to timely care, especially right after legal reform when health professionals are expected to transition to provision of a new service.122 In fact, evidence from several countries shows that health professionals may be more willing to provide medication abortion than surgical abortion, because they are more removed from the process of the abortion itself.123 However, widespread refusal by both public- and private-sector providers to offer abortion at all—or to refer women to willing providers nearby, which is usually required in conscientious objection policies—continues to be a substantial barrier to implementing abortion services in countries that recently liberalized their law. Indeed, a legal challenge in Uruguay succeeded in allowing a wider range of medical professionals to refuse to provide a legal service on the basis of conscientious objection.124 Laws or guidelines that permit where abortion is highly legally restricted. The riskiest abortions—i.e., those performed by untrained providers or self-induced not using misoprostol—are estimated to account for much higher proportions of procedures among poor and rural women (62% and 55%) than among nonpoor and urban women (36% and 38%).114 In addition, this inequity is intensified when access to postabortion care is considered, because the disadvantaged women who can least afford the costs of treating complications from unsafe abortion are the ones most likely to develop complications and need care.115,116 How much women pay for an abortion varies widely by country, which reflects differences in the types of providers primarily used, the specific procedures used and the local cost of living. For example, based on information from health professional surveys conducted from 2008 to 2012, the average amount women paid for a first-trimester abortion (adjusted for inflation up to 2015) was US$21 for two countries in South Asia, US$38 for five countries in Sub-Saharan Africa and US$76 for the sole Latin American country with a comparable cost estimate, Colombia.117 According to a 2011–2012 study in Uganda, women paid an average of US$49 for an unsafe abortion and follow-up care—an exorbitant amount in a country where the monthly per capita income is just US$43.115 Conditions are variable where abortion was liberalized recently The abortion-provision picture is mixed for the countries that liberalized their laws within roughly the past two decades (Figure 3.3, page 18). One of the first challenges to instituting safe services is communicating that abortion is now legal and where it is available. Informing health professionals and women of a newly granted right is an enormous challenge, especially where rates of illiteracy and poverty are high, and where abortion continues to be strongly stigmatized. The fact that many countries have unclear laws and service provision guidelines that sometimes conflict with the law makes this challenge even more difficult to overcome. Scaling-up provision of a recently legalized but still highly stigmatized service can take years. Not only does it