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Sheehy G, Moreau C, Otupiri E, Keogh S, Guiella G, Bell SO. Exploring women's knowledge of abortion legality and association with source of abortion care using population-based survey data in Côte d'Ivoire and Ghana. Reprod Health 2024; 21:132. [PMID: 39267133 PMCID: PMC11391610 DOI: 10.1186/s12978-024-01871-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/25/2024] [Indexed: 09/14/2024] Open
Abstract
BACKGROUND Knowledge of the conditions under which abortion is legal is important so that people can advocate for their right to abortion care. Yet minimal research has explored the association between women's knowledge of abortion legality and the induced abortion care they receive, particularly using population-based survey data. METHODS Using national survey data collected by Performance Monitoring for Action (PMA) in Côte d'Ivoire and Ghana, we aimed to compare the prevalence of accurate knowledge of abortion legality, factors associated with knowledge of the law, and the association between knowledge of abortion legality and the source of women's induced abortion care in these two settings. We ran bivariate and multivariable logistic regressions to assess the relationships of interest. RESULTS We found that awareness and knowledge of the abortion law were low in both Côte d'Ivoire and Ghana. In Cote d'Ivoire, women who were older, more educated, and with past abortion experience were more likely to be aware of the law. In Ghana, knowledge of the law did not vary significantly by demographic characteristics. However, in Ghana, knowledge of the law was correlated with women's use of the formal healthcare system for abortion care, with greater use of clinical sources in rural areas. CONCLUSIONS It is possible that for populations with reduced access to abortion services, such as those in rural areas, knowledge of the law is advantageous for those seeking facility-based abortion care, particularly in settings where abortion is legal for a range of indications. Interventions seeking to improve access to facility-based abortion care in settings where abortion is legal on various grounds should incorporate education on the legal grounds for abortion.
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Affiliation(s)
- Grace Sheehy
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Caroline Moreau
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Easmon Otupiri
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Georges Guiella
- Institut Supérieur Des Sciences de La Population (ISSP), Université of Ouagadougou, Ouagadougou, Burkina Faso
| | - Suzanne O Bell
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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McLean E, Miljeteig I, Blystad A, Mirkuzie AH, Haaland MES. From political priority to service delivery: complexities to real-life priority of abortion services in Ethiopia. Health Policy Plan 2024; 39:831-840. [PMID: 38978118 PMCID: PMC11384106 DOI: 10.1093/heapol/czae061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 06/04/2024] [Accepted: 07/06/2024] [Indexed: 07/10/2024] Open
Abstract
Improving access to abortion services has been coined a high priority by the Ethiopian Federal Ministry of Health. Nevertheless, many women are still struggling to access abortion services. The dedicated commitment to expanding abortion services by central authorities and the difficulties in further improving access to the services make for an interesting case to explore the real-life complexities of health priority setting. This article thus explores what it means to make abortion services a priority by drawing on in-depth interviews with healthcare bureaucrats and key stakeholders working closely with abortion service policy and implementation. Data were collected from February to April 2022. Health bureaucrats from 9 of the 12 regional states in Ethiopia and the Federal Ministry of Health were interviewed in addition to key stakeholders from professional organizations and NGOs. The study found that political will and priority to abortion services by central authorities were not necessarily enough to ensure access to the service across the health sector. At the regional and local level, there were considerable challenges with a lack of funding, equipment and human resources for implementing and expanding access to abortion services. The inadequacy of indicators and reporting systems hindered accountability and made it difficult to give priority to abortion services among the series of health programmes and priorities that local health authorities had to implement. The situation was further challenged by the contested nature of the abortion issue itself, both in the general population, but also amongst health bureaucrats and hospital leaders. This study casts a light on the complex and entangled processes of turning national-level priorities into on-the-ground practice and highlights the real-life challenges of setting and implementing health priorities.
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Affiliation(s)
- Emily McLean
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, Bergen 5020, Norway
- Medical department, Nordland Hospital, Ivar Bergsmoes gate 3, Stokmarknes 8450, Norway
| | - Ingrid Miljeteig
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, Bergen 5020, Norway
| | - Astrid Blystad
- Global Health Anthropology Research Group, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, Bergen 5020, Norway
| | - Alemnesh H Mirkuzie
- John Snow Research and Training Inc, Edna Mall Area, Addis Ababa, Ethiopia
- Institute for Health Metrics and Evaluation, University of Washington, 3980 15th Ave NE, Seattle, WA 98195, USA
| | - Marte E S Haaland
- Global Health Anthropology Research Group, Department of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, Bergen 5020, Norway
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Lubeya MK, Munakampe MN, Mwila M, Makasa M, Mukosha M, Jacobs C, Phiri CC, Vwalika B, Sichone V, Mangala B, Haketa MM, Kumwenda A, Kaonga P. Post-abortion care services in Zambian health facilities: a qualitative study of users' experiences and perceptions. BMC Womens Health 2024; 24:414. [PMID: 39039469 PMCID: PMC11265459 DOI: 10.1186/s12905-024-03179-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 06/03/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Despite attempts to increase Universal Health Coverage, availability, accessibility, acceptability, and quality-related challenges remain barriers to receiving essential services by women who need them. We aimed to explore the experiences and perceptions of women receiving post-abortal care services in Zambia, within a human-rights framework. METHODS A qualitative case study was conducted between August and September 2021 in Lusaka and Copperbelt provinces of Zambia. Fifteen (15) women seeking post-abortion care services were` interviewed using audio recorders; transcribed data was analyzed using thematic analysis. We report women's experiences and perceptions of the healthcare system, their experiences of abortion, and healthcare-seeking behaviour. We used the availability, accessibility, acceptability, and quality (AAAQ) framework to understand how women claimed their right to healthcare as they sought and utilized post-abortion care services. RESULTS Women who experienced spontaneous abortions delayed seeking health care by viewing symptoms as 'normal pregnancy symptoms' and not dangerous. Women also delayed seeking care because they feared the negative attitudes from their communities and the health care providers towards abortion in general, despite it being legal in Zambia. Some services were considered costly, impeding their right to access quality care. CONCLUSIONS Women delayed seeking care compounded by fear of negative attitudes from the community and healthcare providers. To ensure the provision and utilization of quality all abortion-related healthcare services, there is a need to increase awareness of the availability and legality of safe abortion services, the importance of seeking healthcare early for any abortion-related discomfort, and the provision and availability of free services at all levels of care should be emphasized.
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Affiliation(s)
- Mwansa Ketty Lubeya
- Department of Obstetrics and Gynecology, School of Medicine, University of Zambia, P/B RW1X, Nationalist Road, Lusaka, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka, Zambia
- Young Emerging Scientists Zambia, Lusaka, Zambia
- School of Public Health, University of The Witwatersrand, Johannesburg, South Africa
| | - Margarate Nzala Munakampe
- Department of Health Policy and Management, School of Public Health, University of Zambia, Nationalist Road, Lusaka, Zambia.
| | - Meek Mwila
- Young Emerging Scientists Zambia, Lusaka, Zambia
| | - Musonda Makasa
- Department of Obstetrics and Gynecology, School of Medicine, University of Zambia, P/B RW1X, Nationalist Road, Lusaka, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Moses Mukosha
- School of Public Health, University of The Witwatersrand, Johannesburg, South Africa
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Choolwe Jacobs
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Christabel Chigwe Phiri
- Young Emerging Scientists Zambia, Lusaka, Zambia
- Levy Mwanawasa University Teaching Hospital, Lusaka, Zambia
| | - Bellington Vwalika
- Department of Obstetrics and Gynecology, School of Medicine, University of Zambia, P/B RW1X, Nationalist Road, Lusaka, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka, Zambia
- Young Emerging Scientists Zambia, Lusaka, Zambia
| | - Victor Sichone
- Department of Obstetrics and Gynecology, Kitwe Teaching Hospital, Kitwe, Zambia
- Zambia Association of Gynecologists and Obstetricians, Lusaka, Zambia
| | | | | | - Andrew Kumwenda
- Department of Obstetrics and Gynecology, School of Medicine, University of Zambia, P/B RW1X, Nationalist Road, Lusaka, Zambia
- Women and Newborn Hospital, University Teaching Hospitals, Lusaka, Zambia
- Young Emerging Scientists Zambia, Lusaka, Zambia
- School of Public Health, University of The Witwatersrand, Johannesburg, South Africa
| | - Patrick Kaonga
- Department of Epidemiology and Biostatistics, School of Public Health, University of Zambia, Lusaka, Zambia
- Department of Bioethics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Ouedraogo R, Wanjiru S, Zan ML, Rossier C, Owolabi O, Athero S, Oduor C, Bangha M. "I always know she cannot betray me." Disclosure of abortion and methods of abortion used in informal settlements in Nairobi, Kenya. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003252. [PMID: 39018278 PMCID: PMC11253939 DOI: 10.1371/journal.pgph.0003252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 06/11/2024] [Indexed: 07/19/2024]
Abstract
Despite abortion being stigmatized and legally restricted in Kenya, women still disclose their abortions within their network. Evidence has shown how stigma can influence and regulate individual abortion disclosure decisions and behaviors. This paper seeks to understand why and how women make the decisions to disclose their abortion and the associated methods used. The data are from a qualitative formative study and a respondent-driven sampling survey conducted between 2020 and 2021 in two informal settlements in Nairobi, Kenya. The data were analyzed using a descriptive analysis approach for the quantitative data, and thematic analysis for the qualitative data. Our findings reveal that information sharing about abortion is enclosed in a social dynamic of secrecy. This dynamic contributes to making abortion a secret that respondents decided to share with confidants in 81% of the abortion cases. These confidants include intimate relationships such as trusted friends (62%), followed by female relatives. Information was shared in many cases either to get support (i.e. method to use), or because participants had close ties with the confidants. Regarding the methods used, unidentified pills were the most used regardless of the confidant; followed by traditional methods especially among those who sought help with their mothers/aunts/grandmothers (33%), while Medical Abortion and Manual Vacuum Aspiration were rarely used, mostly by those who confided in friends or sisters/cousins. Our findings show that the disclosure of abortion is a complex process embedded in existing codes regarding the circulation of information on sensitive issues and "help" seeking. Our findings show that the need for information on safe abortion and lack of financial resources frequently empowers them to overcome the fear of stigma and disclose their abortion. However, this often resulted in use of unsafe procedures. The findings suggest the need for strengthening the circulation of information on safe methods within communities, using community champions and intermediaries to increase the likelihood of women being directed through safe methods to enhance their use.
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Affiliation(s)
| | - Shelmith Wanjiru
- Graduate Institute of International and Development Studies, Geneva, Switzerland
| | - Moussa L. Zan
- Institut Supérieur des Sciences de la Population, Ouagadougou, Burkina Faso
| | | | - Onikepe Owolabi
- Guttmacher Institute, New York, New York, United States of America
| | - Sherine Athero
- African Population and Health Research Center, Nairobi, Kenya
| | - Clement Oduor
- African Population and Health Research Center, Nairobi, Kenya
| | - Martin Bangha
- African Population and Health Research Center, Nairobi, Kenya
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Tang BWJ, Ibrahim BB, Shorey S. Complex journeys of adolescents after induced abortion: A qualitative systematic review. J Pediatr Nurs 2024; 77:e67-e80. [PMID: 38553284 DOI: 10.1016/j.pedn.2024.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 07/07/2024]
Abstract
PROBLEM Adolescents face unique challenges in accessing sexual healthcare, particularly regarding induced abortion experiences. Prior research, often quantitative or biased towards young adults, overlooks this. This review aims to address adolescents' specific post-abortion experiences to inform comprehensive reproductive healthcare needs. ELIGIBILITY CRITERIA Qualitative and mixed-methods studies exploring the experiences of adolescents following induced abortion were included. Studies reporting these experiences from third-person perspectives were excluded. SAMPLE Five electronic databases (CINAHL, PubMed, PsycINFO, Web of Science, and Embase) were searched from the databases' inception through March 2024. Of the 2834 articles retrieved, 45 studies were included in this review. RESULTS Using a meta-synthesis approach combining Sandelowski & Barroso's qualitative metasummary with Braun & Clarke's thematic analysis, three main themes emerged: Post-abortion experiences and emotions, Social dynamics and support, and Life post-abortion and future perspectives. CONCLUSIONS Adolescents who underwent abortion faced physical and emotional challenges, adopted various coping strategies, and had mixed experiences with social support and healthcare providers. To address these challenges, the provision of comprehensive reproductive health information, access to safe and legal abortion options, and support for their physical, social, and emotional well-being is necessary. Healthcare providers must ensure that adolescents are equipped with necessary skills to navigate their reproductive health journeys with informed choices and confidence. IMPLICATIONS Future research exploring adolescents' experiences, considering cultural beliefs, involving multiple stakeholders, and conducting longitudinal studies, is warranted. Healthcare providers should implement practice changes, including providing accurate information, offering tailored mental health support, and undergoing adolescent-friendly training, to enhance care for adolescents.
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Affiliation(s)
- Byoray Wen Jia Tang
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Shefaly Shorey
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Rosen JG, Mbizvo MT, Chelwa N, Phiri L, Cresswell JA, Filippi V, Kayeyi N. Identifying Profiles of Support for Legal Abortion Services in Zambia: A Latent Class Analysis. Stud Fam Plann 2024; 55:45-59. [PMID: 38351302 PMCID: PMC10960669 DOI: 10.1111/sifp.12257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
Relative to neighboring countries, Zambia has among the most progressive abortion policies, but numerous sociopolitical constraints inhibit knowledge of pregnancy termination rights and access to safe abortion services. Multistage cluster sampling was used to randomly select 1,486 women aged 15-44 years from households in three provinces. We used latent class analysis (LCA) to partition women into discrete groups based on patterns of endorsed support for legalized abortion on six socioeconomic and health conditions. Predictors of probabilistic membership in latent profiles of support for legal abortion services were identified through mixture modeling. A three-class solution of support patterns for legal abortion services emerged from LCA: (1) legal abortion opponents (∼58 percent) opposed legal abortion across scenarios; (2) legal abortion advocates (∼23 percent) universally endorsed legal protections for abortion care; and (3) conditional supporters of legal abortion (∼19 percent) only supported legal abortion in circumstances where the pregnancy threatened the fetus or mother. Advocates and Conditional supporters reported higher exposure to family planning messages compared to opponents. Relative to opponents, advocates were more educated, and Conditional supporters were wealthier. Findings reveal that attitudes towards abortion in Zambia are not monolithic, but women with access to financial/social assets exhibited more receptive attitudes towards legal abortion.
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Affiliation(s)
- Joseph G. Rosen
- Department of International Health, Johns Hopkins Bloomberg
School of Public Health, Baltimore, Maryland, United States
| | | | | | | | - Jenny A. Cresswell
- Centre for Maternal, Adolescent, Reproductive, and Child
Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Veronique Filippi
- Department of Infectious Disease Epidemiology, London
School of Hygiene and Tropical Medicine, London, United Kingdom
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VandeVusse AJ, Mueller J, Kirstein M, Strong J, Lindberg LD. "Technically an abortion": Understanding perceptions and definitions of abortion in the United States. Soc Sci Med 2023; 335:116216. [PMID: 37741188 PMCID: PMC10552775 DOI: 10.1016/j.socscimed.2023.116216] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/24/2023] [Accepted: 09/01/2023] [Indexed: 09/25/2023]
Abstract
Anti-abortion legislation in the United States exploits misinformation and ignores medical definitions to curtail access to essential healthcare. Little is known about how individuals most likely to need this care define abortion, in general or as distinct from miscarriage, and how this might impact access to, utilization of, and experiences of care. Using mixed-method card sort and vignette data from cognitive interviews (n = 64) and a national online survey (n = 2009), we examined individuals' understandings of pregnancy outcomes including abortion and miscarriage. Our findings show that people hold varying ideas of what constitutes an abortion. Many respondents considered 'intent' when classifying pregnancy outcomes and focused on intervention to distinguish between miscarriages and abortions. Particularly, medical intervention was found as a defining feature of abortion. Lack of knowledge regarding pregnancy experiences and ambiguity surrounding early stages of pregnancy also influenced respondents' understanding of abortion. We find that abortion and miscarriage definitions are socially constructed and multi-layered. Advancing our understanding of abortion and miscarriage definitions improves reproductive health research by elucidating potential areas of confusion that may lead to misreporting of reproductive experiences as well as highlighting ways that blurred definitions may be exploited by abortion opponents.
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Affiliation(s)
| | - Jennifer Mueller
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, USA
| | | | - Joe Strong
- London School of Economics, Department of Social Policy, Houghton Street, London, WC2A 2AE, UK
| | - Laura D Lindberg
- Rutgers School of Public Health, 1 Riverfront Plaza, Suite 1010, Newark, NJ, 07102, USA
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Strong J, Coast E, Fetters T, Chiweshe M, Getachew A, Griffin R, Tembo L. "I was waiting for my period": Understanding pregnancy recognition among adolescents seeking abortions in Ethiopia, Malawi, and Zambia. Contraception 2023; 123:110006. [PMID: 36931547 PMCID: PMC7616401 DOI: 10.1016/j.contraception.2023.110006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVES For a person seeking an abortion, the ability to recognize a pregnancy is a critical first step. Pregnancy recognition is complex and shaped by numerous factors. This paper explores the experiences of pregnancy recognition among adolescents in Ethiopia, Malawi, and Zambia. STUDY DESIGN The final sample included 313 adolescents aged 10 to 19 who had sought abortion-related care at urban public facilities in Ethiopia (N = 99), Malawi (N = 104), and Zambia (N = 110). Researchers collected mixed-method data on how adolescents came to recognize that they were pregnant and thematically analyzed qualitative data alongside descriptive statistics from quantitative data. RESULTS Most adolescents reported that their main mode of recognizing a pregnancy was medical pregnancy tests or late menstruation. Reasons for not recognizing a pregnancy included irregular menses or recent menarche and attribution of signs and symptoms to other medical conditions. Psychological barriers to pregnancy recognition were important, including the refusal to accept a pregnancy and denial of a pregnancy. Timing of recognition shaped the abortion care available for adolescents and the affordability of care. For some adolescents, their capacity to recognize their pregnancy led to involuntary or voluntary disclosure, which decreased their reproductive autonomy. CONCLUSIONS Adolescent experiences of pregnancy recognition complement existing evidence, illustrating critical barriers across age and context. Interrogating pregnancy recognition among adolescents exposed the critical implications for the availability, accessibility, affordability, and autonomy of their abortion trajectory. IMPLICATIONS Pregnancy recognition is complex and can influence adolescents' ability to exercise their reproductive rights and access abortion care of their choosing. Programmes to improve awareness of the signs of a pregnancy, increasing the provision of affordable and accessible pregnancy testing and further research on pregnancy recognition are necessary to support adolescents' reproductive autonomy.
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Affiliation(s)
- Joe Strong
- London School of Economics and Political Science, Department of Social Policy, London, UK.
| | - Ernestina Coast
- London School of Economics and Political Science, Department of International Development, London, UK
| | | | - Malvern Chiweshe
- Critical Studies in Sexualities and Reproduction, Rhodes University, Makhanda, South Africa
| | - Abrham Getachew
- St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Kayondo SP, Kaye DK, Nabatanzi SL, Nassuuna S, Musana O, Namagembe I, Nsanja JP, Morris J, Fawzi H, de Koning K, Kaur J, Pretty M. Challenges and opportunities from using abortion harm reduction and value clarification and attitude transformation engagements for safe abortion advocacy in Uganda. Reprod Health 2023; 20:97. [PMID: 37381001 DOI: 10.1186/s12978-023-01637-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/05/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND From 2018, the International Federation of Gynecologists and Obstetricians (FIGO) implemented the Advocating Safe Abortion project to support national obstetrics and gynecology (Obs/gyn) societies from ten member countries to become leaders of Sexual and Reproductive Health and Rights (SRHR). We share experiences and lessons learnt about using value clarification and attitude transformation (VCAT) and abortion harm reduction (AHR) as strategies for our advocacy engagements. METHODS The advocacy goal of ending abortion-related deaths followed predefined pathways from an extensive needs assessment prior to the project. These pathways were strengthening capacity of the Obs/gyn society as safe abortion advocates; establishing a vibrant network of partners; transforming social and gender norms; raising awareness of the legal and policy environment regarding abortion, and promoting the generation and use abortion data for evidence-informed policy and practice. Our advocacy targeted multiple stakeholders including media, policy makers judicio-legal, political and religious leaders, health workers and the public. RESULTS During each engagement, facilitators required audiences to identify what roles they can play along the continuum of strategies that can reduce maternal death from abortion complications. The audiences acknowledged abortion complications as a major problem in Uganda. Among the root causes for the abortion context, audiences noted absence of an enabling environment for abortion care, which was characterized by low awareness about the abortion laws and policy, restricted abortion laws, cultural and religious beliefs, poor quality of abortion care services and abortion stigma. CONCLUSION VCAT and AHR were critical in enabling us to develop appropriate messages for different stakeholders. Audiences were able to recognize the abortion context, distinguish between assumptions, myths and realities surrounding unwanted pregnancy and abortion; recognize imperative to address conflict between personal and professional values, and identify different roles and values which inform empathetic attitudes and behaviors that mitigate abortion harms. The five pathways of the theory of change reinforced each other. Using the AHR model, we delineate strategies and activities which stakeholders could use to end abortion deaths. VCAT enables critical reflection of views, beliefs and values versus professional obligations and responsibilities, and promotes active attitude and behavior change and commitment to end abortion-related deaths.
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Affiliation(s)
- Simon Peter Kayondo
- Association of Obstetricians and Gynecologists of Uganda, P.O. Box 11966, Kampala, Uganda
| | - Dan Kabonge Kaye
- Association of Obstetricians and Gynecologists of Uganda, P.O. Box 11966, Kampala, Uganda.
| | | | - Susan Nassuuna
- Association of Obstetricians and Gynecologists of Uganda, P.O. Box 11966, Kampala, Uganda
| | - Othiniel Musana
- Association of Obstetricians and Gynecologists of Uganda, P.O. Box 11966, Kampala, Uganda
| | - Imelda Namagembe
- Association of Obstetricians and Gynecologists of Uganda, P.O. Box 11966, Kampala, Uganda
| | - John Paul Nsanja
- Association of Obstetricians and Gynecologists of Uganda, P.O. Box 11966, Kampala, Uganda
| | - Jessica Morris
- International Federation of Gynecologists and Obstetricians (FIGO), FIGO Headquarters, London, UK
| | - Hani Fawzi
- International Federation of Gynecologists and Obstetricians (FIGO), FIGO Headquarters, London, UK
| | | | - Jameen Kaur
- International Federation of Gynecologists and Obstetricians (FIGO), FIGO Headquarters, London, UK
| | - Matthew Pretty
- International Federation of Gynecologists and Obstetricians (FIGO), FIGO Headquarters, London, UK
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Lokubal P, Corcuera I, Balil JM, Frischer SR, Kayemba CN, Kurinczuk JJ, Opondo C, Nair M. Abortion decision-making process trajectories and determinants in low- and middle-income countries: A mixed-methods systematic review and meta-analysis. EClinicalMedicine 2022; 54:101694. [PMID: 36277313 PMCID: PMC9579809 DOI: 10.1016/j.eclinm.2022.101694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND About 45.1% of all induced abortions are unsafe and 97% of these occur in low- and middle-income countries (LMICs). Women's abortion decisions may be complex and are influenced by various factors. We aimed to delineate women's abortion decision-making trajectories and their determinants in LMICs. METHODS We searched Medline, EMBASE, PsychInfo, Global Health, Web of Science, Scopus, IBSS, CINAHL, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest, and Google Scholar for primary studies and reports published between January 1, 2000, and February 16, 2021 (updated on June 06, 2022), on induced abortion decision-making trajectories and/or their determinants in LMICs. We excluded studies on spontaneous abortion. Two independent reviewers extracted and assessed quality of each paper. We used "best fit" framework synthesis to synthesise abortion decision-making trajectories and thematic synthesis to synthesise their determinants. We analysed quantitative findings using random effects model. The study protocol is registered with PROSPERO number CRD42021224719. FINDINGS Of the 6960 articles identified, we included 79 in the systematic review and 14 in the meta-analysis. We identified nine abortion decision-making trajectories: pregnancy awareness, self-reflection, initial abortion decision, disclosure and seeking support, negotiations, final decision, access and information, abortion procedure, and post-abortion experience and care. Determinants of trajectories included three major themes of autonomy in decision-making, access and choice. A meta-analysis of data from 7737 women showed that the proportion of the overall women's involvement in abortion decision-making was 0.86 (95% CI:0.73-0.95, I2 = 99.5%) and overall partner involvement was 0.48 (95% CI:0.29-0.68, I2 = 99.6%). INTERPRETATION Policies and strategies should address women's perceptions of safe abortion socially, legally, and economically, and where appropriate, involvement of male partners in abortion decision-making processes to facilitate safe abortion. Clinical heterogeneity, in which various studies defined "the final decision-maker" differentially, was a limitation of our study. FUNDING Nuffield Department of Population Health DPhil Scholarship for PL, University of Oxford, and the Medical Research Council Career Development Award for MN (Grant Ref: MR/P022030/1).
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Affiliation(s)
- Paul Lokubal
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Corresponding author at: National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Headington OX3 7LF Oxford, UK.
| | - Ines Corcuera
- Chelsea and Westminster Hospital, NHS Foundation Trust, London, UK
| | | | - Sandrena Ruth Frischer
- Ethox Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Christine Nalwadda Kayemba
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jennifer J. Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Charles Opondo
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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Hinson L, Bhatti AM, Sebany M, Bell SO, Steinhaus M, Twose C, Izugbara C. How, when and where? A systematic review on abortion decision making in legally restricted settings in sub-Saharan Africa, Latin America, and the Caribbean. BMC Womens Health 2022; 22:415. [PMID: 36217197 PMCID: PMC9552475 DOI: 10.1186/s12905-022-01962-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/19/2022] [Indexed: 11/07/2022] Open
Abstract
Background With increasing global availability of medication abortion drugs, a safer option exists for many women to terminate a pregnancy even in legally restrictive settings. However, more than 22,000 women die each year from unsafe abortion, most often in developing countries where abortion is highly legally restricted. We conducted a systematic review to compile existing evidence regarding factors that influence women’s abortion-related decision making in countries where abortion is highly legally restricted.
Methods We searched ten databases in two languages (English and Spanish) for relevant literature published between 2000 and 2019 that address women’s decision-making regarding when, where and how to terminate a pregnancy in sub-Saharan African, Latin American and the Caribbean countries where abortion is highly legally restricted.
Results We identified 46 articles that met the review’s inclusion criteria. We found four primary factors that influenced women’s abortion-related decision-making processes: (1) the role of knowledge, including of laws, methods and sources; (2) the role of safety, including medical, legal and social safety; (3) the role of social networks and the internet, and; (4) cost affordability and convenience. Conclusions The choices women make after deciding to terminate a pregnancy are shaped by myriad factors, particularly in contexts where abortion is highly legally restricted. Our review catalogued the predominant influences on these decisions of when, where and how to abort. More research is needed to better understand how these factors work in concert to best meet women’s abortion needs to the full limit of the law and within a harm reduction framework for abortions outside of legal indications. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-022-01962-0.
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Affiliation(s)
- Laura Hinson
- grid.419324.90000 0004 0508 0388International Center for Research on Women, Washington, DC USA
| | | | | | - Suzanne O. Bell
- grid.21107.350000 0001 2171 9311Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | | | - Claire Twose
- grid.21107.350000 0001 2171 9311Welch Medical Library, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Chimaraoke Izugbara
- grid.419324.90000 0004 0508 0388International Center for Research on Women, Washington, DC USA
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12
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Klu D, Yeboah I, Kayi EA, Okyere J, Essiaw MN. Utilization of abortion services from an unsafe provider and associated factors among women with history of induced abortion in Ghana. BMC Pregnancy Childbirth 2022; 22:705. [PMID: 36100858 PMCID: PMC9469529 DOI: 10.1186/s12884-022-05034-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa (SSA), numerous studies have examined women's choice of abortion methods and services using hospital-based data, community-based surveys and nationally representative data. Little research focuses on the factors influencing a woman's choice of abortion provider. This study sought to identify factors that are associated with why a woman seeks abortion care services from an unsafe provider in Ghana. METHODS We used nationally representative data of women from the 2017 Ghana Maternal Health Survey (GMHS). Data analysis was restricted to women aged 15-49 with a recent history of induced abortion. Analyses focused on a weighted sample of 1,880. Descriptive analysis and the chi-square test were used to examine the proportion of women utilizing abortion services from unsafe providers. Factors hypothesized to affect the utilization of abortion services from unsafe providers were examined using both bivariable and multivariable logistic regression analyses. RESULTS The proportion of survey respondents who reported that they utilize abortion service from unsafe providers were 57.5%. After adjusting for confounders, those who have knowledge of abortion legality [aOR: 0.381 (0.271-0.541)] and those who have attained secondary or higher education [aOR: 0.613 (0.411-0.914)] were less likely to use abortion services from unsafe providers. On the other hand, women belonging to the Ewe ethnic group [aOR: 0.696 (0.508-0.953)], those residing in the middle belt zone [aOR: 1.743 (1.113-2.728)], younger women aged 15-29 years [aOR: 2.037 (1.234-3.362)] were more likely to use abortion services from unsafe abortion providers. CONCLUSIONS This research suggests that increasing the knowledge of women on the legal status of abortion through public education and encouraging more women to pursue secondary or higher education can contribute to reducing the use of abortion services from unsafe providers. These interventions should be targeted among younger women and those who reside in the middle belt zones of Ghana.
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Affiliation(s)
- Desmond Klu
- Institute of Health Research, University of Health and Allied Sciences, PMB 31, Ho, Volta Region, Ghana
| | - Isaac Yeboah
- Institute of Work, Employment and Society, University of Professional Studies, P.O. Box LG 149, Legon, Accra, Ghana.
| | - Esinam Afi Kayi
- Department of Adult Education and Human Resource Studies, School of Continuing and Distance Education, University of Ghana, P.O. Box LG 25, Accra, Legon, Ghana
| | - Joshua Okyere
- Department of Population and Health, University of Cape Coast, PMB 40, Cape Coast, Ghana
| | - Mary Naana Essiaw
- Institute of Work, Employment and Society, University of Professional Studies, P.O. Box LG 149, Legon, Accra, Ghana
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Duffy D, Mishtal J, Grimes L, Murphy M, Reeves K, Chakravarty D, Chavkin W, Favier M, Horgan P, Stifani B, Lavelanet AF. Information flow as reproductive governance. Patient journey analysis of information barriers and facilitators to abortion care in the republic of Ireland. SSM Popul Health 2022; 19:101132. [PMID: 35711728 PMCID: PMC9194449 DOI: 10.1016/j.ssmph.2022.101132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/08/2022] [Accepted: 05/15/2022] [Indexed: 11/27/2022] Open
Abstract
Background Information flow - information communication and transmission pathways and practices within healthcare systems - impacts patient journeys. Historically, regulating information flow was a key technology of reproductive governance in the Republic of Ireland. Pre-2018, law and the State sustained informational barriers to and through abortion care in Ireland. An expanded abortion service was implemented in January 2019. Method Patient Journey Analysis (PJA) interrogates informational facilitators and barriers to/through post-2019 abortion care in Ireland. We focus on information flow at the interfaces between the 'public' sphere and 'point of entry', 'point of entry' and primary care, and primary and secondary care. Materials The paper uses data from a mixed-method study. A tool for assessing online abortion service information (ASIAT), desktop research, and qualitative data from 108 in-depth interviews with providers, policy-makers, advocacy groups, and service users informed the analysis. Results Abortion patient journeys vary. Information flow issues, e.g. communication of how to access services, referral systems, and information handover, act as barriers and facilitators. Barriers increase where movement from primary to secondary is needed. Applications The article identifies good practice in information flow strategy, as well as areas for development. It illustrates the significance of information flow in accomplishing reproductive governance.
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Affiliation(s)
- Deirdre Duffy
- Department of Social Work and Social Care, Manchester Metropolitan University, Manchester, United Kingdom
| | - Joanna Mishtal
- Department of Anthropology, University of Central Florida, Orlando, FL, USA
| | - Lorraine Grimes
- Social Science Institute, Maynooth University, Republic of Ireland
| | - Mark Murphy
- Eldon Family Practice, Dublin, Republic of Ireland
| | - Karli Reeves
- Department of Anthropology, University of Central Florida, Orlando, FL, USA
| | | | | | - Mary Favier
- Parklands Surgery, Cork, Republic of Ireland
| | | | - Bianca Stifani
- Department of Obstetrics, Gynecology and Women’s Health, Montefiore Medical Center, New York, USA
| | - Antonella F. Lavelanet
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland
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Strong J. Men's involvement in women's abortion-related care: a scoping review of evidence from low- and middle-income countries. Sex Reprod Health Matters 2022; 30:2040774. [PMID: 35323104 PMCID: PMC8956302 DOI: 10.1080/26410397.2022.2040774] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Men’s involvement in abortion is significant, intersecting across the individual, community and macro factors that shape abortion-related care pathways. This scoping review maps the evidence from low- and middle-income countries relating to male involvement in abortion trajectories. Five databases were searched, using search terms, to yield 7493 items published in English between 01.01.2010 and 20.12.2019. 37 items met the inclusion criteria for items relating to male involvement in women’s abortion trajectories and were synthesised using an abortion-related care-seeking framework. The majority of studies were conducted in sub-Saharan Africa and were qualitative. Evidence indicated that male involvement was significant, shaping the ability for a woman or girl to disclose her pregnancy or abortion decision. Men as partners were particularly influential, controlling resources necessary for abortion access and providing or withdrawing support for abortions. Denial or rejection of paternity was a critical juncture in many women’s abortion trajectories. Men’s involvement in abortion trajectories can be both direct and indirect. Contextual realities can make involving men in abortions a necessity, rather than a choice. The impact of male (lack of) involvement undermines the autonomy of a woman or girl to seek an abortion and shapes the conditions under which abortion-seekers are able to access care. This scoping review demonstrates the need for better understanding of the mechanisms, causes and intensions behind male involvement, centring the abortion seeker within this.
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Affiliation(s)
- Joe Strong
- PhD Researcher, Department of Social Policy, London School of Economics and Political Science, London, UK. Correspondence:
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15
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McLean KE. Contemplating abortion: a qualitative study of men and women’s reactions to unplanned pregnancy in Sierra Leone. CULTURE, HEALTH & SEXUALITY 2022; 25:444-458. [PMID: 35297735 DOI: 10.1080/13691058.2022.2052186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Globally, millions of unintended pregnancies result in unsafe abortions each year. In Sierra Leone, abortion-related complications are a major driver of maternal mortality. Despite these costs, women continue to seek unsafe abortions, yet how individuals understand the risks and benefits of pregnancy termination remains under-researched. This study seeks to understand perceptions of abortion by women and men experiencing unplanned pregnancy and to highlight factors that inform their abortion trajectories. Findings indicate that abortion was contemplated in response to anxieties regarding caring for a child, interruptions to schooling, and stigma associated with extra-marital pregnancy. While many women and men preferred not to abort-due to cultural values tied to parenthood-others faced obstacles stemming from lack of knowledge of and access to services. Findings can be used to inform interventions to support women and men in realising their fertility preferences in the face of unplanned pregnancy.
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16
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“I just have to hope that this abortion should go well”: Perceptions, fears, and experiences of abortion clients in Nigeria. PLoS One 2022; 17:e0263072. [PMID: 35130269 PMCID: PMC8820635 DOI: 10.1371/journal.pone.0263072] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/10/2022] [Indexed: 01/23/2023] Open
Abstract
This qualitative study aimed to examine how abortion clients in Nigeria perceive abortion and explore the role their beliefs and fears play in their care-seeking experiences and interactions with providers. Abortion is severely legally restricted in Nigeria but remains common. We conducted in-depth interviews with 25 people who obtained abortion services through three distinct models of care. We coded interview transcripts and conducted thematic analysis. Clients perceived negative attitudes toward abortion in their communities, though clients’ own beliefs were more nuanced. Clients recounted a range of fears, and nearly all mentioned worrying that they might die as a result of their abortion. Despite their concerns, clients relied on social networks and word-of-mouth recommendations to identify providers they perceived as trustworthy and safe. Kind and non-judgmental treatment, clear instructions, open communication, and reassurance of privacy and confidentiality by providers alleviated client fears and helped clients feel supported throughout their abortion process. Within restrictive contexts, the mobilization of information networks, provision of high-quality care through innovative models, and personalization of care to individual needs can assuage fears and contribute to reducing stigma and increasing access to safe abortion services.
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17
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Byrne ME, Omoluabi E, OlaOlorun FM, Moreau C, Bell SO. Determinants of women's preferred and actual abortion provision locations in Nigeria. Reprod Health 2021; 18:240. [PMID: 34838089 PMCID: PMC8627088 DOI: 10.1186/s12978-021-01290-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 11/11/2021] [Indexed: 11/22/2022] Open
Abstract
Background Unsafe abortion remains a leading cause of maternal mortality globally. Many factors can influence women’s decisions around where to seek abortion care; however, little research has been done on abortion care decisions at a population-level in low-resource settings, particularly where abortion is legally restricted. Methods This analysis uses data from a 2019–2020 follow-up survey of 1144 women in six Nigerian states who reported an abortion experience in a 2018 cross-sectional survey. We describe women’s preferred and actual primary abortion care provider/location by distinguishing clinical, pharmacy/chemist, or other non-clinical providers or locations. We also examine factors that influence women’s decisions about where to terminate their pregnancy and identify factors hindering women’s ability to operationalize their preferences. We then examine the characteristics of women who were not able to use their preferred provider/location. Results Non-clinical providers (55.0%) were more often used than clinical providers (45.0%); however, clinical providers were preferred by most women (55.6%). The largest discrepancies in actual versus preferred abortion provider/location were private hospitals (7.6% actual versus 37.2% preferred), government hospitals (4.3% versus 22.6%), chemists (26.5% versus 5.9%) and pharmacies (14.9% versus 6.6%). “Privacy/confidentiality” was the most common main reason driving women’s abortion provider/location choice (20.7%), followed by “convenience” (16.9%) and “recommended” by someone (12.3%), most often a friend (60.8%), although top reasons differed by type of provider/location. Cost and distance were the two most common reasons that women did not use their preferred provider/location (46.1% and 21.9%, respectively). There were no statistically significant differences in the sociodemographic characteristics between women who were able to use their preferred provider/location and those who were not able to implement their preferred choice, with the exception of state of residence. Conclusions These findings provide insights on barriers to abortion care in Nigeria, suggesting discretion is key to many women’s choice of abortion location, while cost and distance prevent many from seeking their preferred care provider/location. Results also highlight the diversity of women’s abortion care preferences in a legally restrictive environment. Many factors influence a woman’s pathway to obtaining an abortion, even in a setting with strict laws prohibiting the practice. This study aims to explore where women in Nigeria would prefer to and actually obtain their abortions, reasons why they could or could not use their preferred provider/location, and differences between women who were and were not able to use their preferred provider/location. The findings show that most women would opt to use a clinical source, such as a government or private hospital, especially among women who did not use their preferred source. Privacy/confidentiality, convenience, and recommendation from someone like a friend or partner drove women’s abortion care preferences, although these influences differed by type of provider/location (clinical, pharmacy/chemist, or other non-clinical). Issues like cost, distance, and lack of privacy were barriers that prevented women from using their preferred provider/location, instead obtaining their abortion from a less desired provider. However, the sociodemographic characteristics of women who did and did not use their preferred provider/location did not differ significantly, except by state. These findings provide insights on barriers to safe abortion care in Nigeria, suggesting social safety drives many women to seek care outside of the healthcare system, while cost and distance prevented many from seeking clinical services. Results also highlight the diversity of women’s abortion preferences in a setting where abortion is legally restricted.
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Affiliation(s)
- Meagan E Byrne
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Elizabeth Omoluabi
- Centre for Research, Evaluation Resources and Development, Ile-Ife, Nigeria.,Statistics and Population Studies Department, University of the Western Cape, Cape Town, South Africa
| | | | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.,Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, 94805, Villejuif, France
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
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18
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Giorgio M, Sully E, Chiu DW. An Assessment of Third-Party Reporting of Close Ties to Measure Sensitive Behaviors: The Confidante Method to Measure Abortion Incidence in Ethiopia and Uganda. Stud Fam Plann 2021; 52:513-538. [PMID: 34762302 PMCID: PMC9298764 DOI: 10.1111/sifp.12180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Indirect estimation techniques are important tools for measuring sensitive and stigmatized behaviors. This includes third‐party reporting methods, which have become increasingly common in the field of abortion measurement, where direct survey approaches notoriously lead to underreporting. This paper provides the first in‐depth assessment of one of the most widely used of these techniques in the field of abortion measurement: the confidante method. We outline six key assumptions behind the confidante method and describe how violations of these assumptions can bias resulting estimates. Using data from modules added to the performance monitoring for action surveys in Uganda and Ethiopia in 2018, we compute one‐year abortion incidence estimates using the confidante method. We also perform a validation check, using the method to estimate intrauterine device /implant use. Our results revealed implementation problems in both settings. Several of the method's foundational assumptions were violated, and efforts to adjust for these violations either failed or only partially addressed the resulting bias. Our validation check also failed, resulting in a gross overestimate of intrauterine device/implant use. These results have implications more broadly for the potential biases that can be introduced in using third‐party reporting of close ties to measure other sensitive or stigmatized behaviors.
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19
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Lokubal P, Frischer SR, Corcuera I, Balil JM, Nalwadda Kayemba C, Kurinczuk JJ, Nair M. Abortion decision-making trajectories and factors influencing such trajectories in low- and middle-income countries: a protocol for mixed-methods systematic review. BMJ Open 2021; 11:e049507. [PMID: 34725075 PMCID: PMC8562532 DOI: 10.1136/bmjopen-2021-049507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Globally, about half of all pregnancies are unintended and/or unwanted and three-fifths of these end in induced abortion. When faced with a choice to terminate pregnancy, women's abortion decision-making processes are often complex and multiphasic and maybe amplified in low- and middle-income countries (LMICs) which bear the major burden of abortion-related morbidity and mortality. Our review aims to (1) describe abortion decision-making trajectories for women in LMICs and (2) investigate factors influencing the choice of abortion decision-making trajectories in LMICs. METHODS AND ANALYSIS We will search and retrieve published and unpublished qualitative, quantitative and mixed-methods, community and/or hospital-based studies conducted in LMICs from 1 January 2000 up to 16 February 2021. We will search Ovid Medline, Ovid EMBASE, Ovid PsycInfo, Ovid Global Health, Web of Science (including Social Science Citation Index), Scopus, IBSS, CINAHL via EBSCO, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest and Google Scholar. We will search reference lists of eligible studies and contact experts for additional data/information, if required. We will extract all relevant data to answer our research questions and assess study quality using the appropriate appraisal tools. Depending on the extracted data, our analysis will use sequential or convergent synthesis methods proposed by Hong et al. For qualitative studies, we will synthesise evidence using thematic synthesis, meta-ethnography or 'best-fit' framework synthesis; and for quantitative findings, we will provide a narrative synthesis and/or meta-analysis. We will do sensitivity analyses and assess confidence in our findings using Grades of Recommendation, Assessment, and Evaluation -Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQUal) for qualitative findings and Grades of Recommednation, Assessment, and Evaluation (GRADE) for quantitative findings. ETHICS AND DISSEMINATION We did not require ethics approval for this systematic review. We will publish our findings in an open-access peer-reviewed journal with global and maternal health readership. We will also present our findings at national and international scientific conferences.
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Affiliation(s)
- Paul Lokubal
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Ines Corcuera
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Christine Nalwadda Kayemba
- Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
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20
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Harries J, Daskilewicz K, Bessenaar T, Gerdts C. Understanding abortion seeking care outside of formal health care settings in Cape Town, South Africa: a qualitative study. Reprod Health 2021; 18:190. [PMID: 34556120 PMCID: PMC8460179 DOI: 10.1186/s12978-021-01243-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/13/2021] [Indexed: 11/26/2022] Open
Abstract
Background Although abortion was legalized in South Africa in 1996, barriers to safe, legal abortion services remain, and women continue to seek abortions outside of the formal healthcare sector. This study explored the decision-making processes that women undertake when faced with an unintended pregnancy, the sources of information used to make their decisions and the factors that contribute to their seeking of informal sector abortion in Cape Town, South Africa. Methods We conducted 15 semi-structured in-depth interviews in English with women who had accessed an abortion outside of the formal health care sector. Women were recruited with the assistance of a community-based key informant. Data was analyzed using a thematic analysis approach. Results Participants were aware that abortions were legal and accessible in public clinics, however they were concerned that others would find out about their unintended pregnancy and abortion if they went to legal providers. Women were also concerned about judgment and mistreatment from providers during their care. Rather than seek care in the formal sector, women looked past concerns around the safety and effectiveness of informal sector abortions and often relied on their social networks for referrals to informal providers. Conclusions The findings highlight the decision-making processes employed by women when seeking abortion services in a setting where abortion is legal and demonstrate the role of institutional and societal barriers to safe abortion access. Abortion service delivery models should adapt to women’s needs to enhance the preferences and priorities of those seeking abortion care-including those who prefer facility-based care as well as those who might prefer self-managed medical abortions. Although abortion was legalized in South Africa in 1996, barriers to safe, legal abortion services remain, and women continue to seek abortions outside of the formal healthcare sector. This study explored the decision-making processes that women undertake when faced with an unintended pregnancy, who they discuss and seek help from, and the factors that influence their decision to seek an abortion outside of the formal health care sector. We interviewed 15 women who had obtained an abortion outside of the health care sector in Cape Town, South Africa. Women were aware that abortions were legal and available in public clinics, but they were concerned about negative and judgmental attitudes from health care providers even though some women were aware of the possible health safety issues related to seeking an abortion outside of the clinic setting. Abortion services should adapt to women’s needs and offer them options of facility-based care but also self-managed medical abortions under the guidance of health care providers.
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Affiliation(s)
- Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Kristen Daskilewicz
- Women's Health Research Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Caitlin Gerdts
- Ibis Reproductive Health, 1736 Franklin St, Oakland, CA, USA
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21
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Moore B, van der Meulen Rodgers Y, Coast E, Lattof SR, Poss C. History and scientific background on the economics of abortion. PLoS One 2021; 16:e0257360. [PMID: 34516575 PMCID: PMC8437296 DOI: 10.1371/journal.pone.0257360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Approximately one quarter of all pregnancies globally end in abortion, making it one of the most common gynecological practices worldwide. Despite the high incidence of abortion around the globe, the synthesis of known economic outcomes of abortion care and policies is lacking. Using data from a systematic scoping review, we synthesized the literature on the economics of abortion at the microeconomic, mesoeconomic, and mesoeconomic levels and presented the results in a collection of studies. This article describes the history and scientific background for collection, presents the scoping review framework, and discusses the value of this knowledge base. METHODS AND FINDINGS We conducted a scoping review using the PRISMA extension for Scoping Reviews. Studies reporting on qualitative and/or quantitative data from any world region were considered. For inclusion, studies must have examined one of the following outcomes: costs, impacts, benefits, and/or value of abortion-related care or policies. Our searches yielded 19,653 unique items, of which 365 items were included in our final inventory. Studies most often reported costs (n = 262), followed by impacts (n = 140), benefits (n = 58), and values (n = 40). Approximately one quarter (89/365) of studies contained information on the secondary outcome on stigma. Economic factors can lead to a delay in abortion care-seeking and can restrict health systems from adequately meeting the demand for abortion services. Provision of post-abortion care (PAC) services requires more resources then safe abortion services. Lack of insurance or public funding for abortion services can increase the cost of services and the overall economic impact on individuals both seeking and providing care. CONCLUSIONS Consistent economic themes emerge from research on abortion, though evidence gaps remain that need to be addressed through more standardized methods and consideration to framing of abortion issues in economics terms. Given the highly charged political nature of abortion around the world, it is imperative that researchers continue to build the evidence base on economic outcomes of abortion services and regulations.
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Affiliation(s)
- Brittany Moore
- Ipas, Chapel Hill, North Carolina, United States of America
| | - Yana van der Meulen Rodgers
- Department of Labor Studies and Employment Relations, Department of Women’s and Gender Studies, Rutgers University, Piscataway, New Jersey, United States of America
| | - Ernestina Coast
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Cheri Poss
- Ipas, Chapel Hill, North Carolina, United States of America
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Chiweshe M, Fetters T, Coast E. Whose bodies are they? Conceptualizing reproductive violence against adolescents in Ethiopia, Malawi and Zambia. AGENDA (DURBAN, SOUTH AFRICA) 2021; 35:12-23. [PMID: 39206050 PMCID: PMC7616403 DOI: 10.1080/10130950.2021.1964220] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
We use a violence lens to visibilize how adolescents who sought abortion-related care in three African countries are coerced, controlled and punished with regards to their sexual and reproductive health. We suggest the use of the concept of reproductive violence to characterize these diverse experiences. Our data comes from a comparative study on adolescent contraceptive and abortion seeking behaviours in Ethiopia, Malawi and Zambia. We conducted 313 interviews that generated both quantitative and qualitative evidence in each country (2018 - 2019). Our analysis shows how adolescent bodies are subject to reproductive violence by parents, partners and healthcare workers, situated within a broader framework of structural violence. Reproductive violence manifests in multiple ways, often within a single abortion trajectory, including coercion to accept post-abortion contraception after receiving facility-based abortion services; having few to no choices of contraceptive methods prior to or after pregnancy; parents and relatives coercing adolescents to not/use abortion or contraception; lack of decision-making regarding sexuality or sexual identity; sex and contraceptive use in relationships rooted in gendered and power dynamics with partners; and - ultimately - adolescents' lack of control over their own bodies. We show how these experiences make adolescents vulnerable to the experience and perpetuation of reproductive violence.
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Affiliation(s)
- Malvern Chiweshe
- Department of Psychology, Rhodes University, Makhanda, South Africa
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Coast E, Lattof SR, van der Meulen Rodgers Y, Moore B, Poss C. The microeconomics of abortion: A scoping review and analysis of the economic consequences for abortion care-seekers. PLoS One 2021; 16:e0252005. [PMID: 34106927 PMCID: PMC8189560 DOI: 10.1371/journal.pone.0252005] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/10/2021] [Indexed: 11/19/2022] Open
Abstract
Background The economic consequences of abortion care and abortion policies for
individuals occur directly and indirectly. We lack synthesis of the economic
costs, impacts, benefit or value of abortion care at the micro-level (i.e.,
individuals and households). This scoping review examines the microeconomic
costs, benefits and consequences of abortion care and policies. Methods and findings Searches were conducted in eight electronic databases and applied
inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews.
For inclusion, studies must have examined at least one of the following
outcomes: costs, impacts, benefits, and value of abortion care or abortion
policies. Quantitative and qualitative data were extracted for descriptive
statistics and thematic analysis. Of the 230 included microeconomic studies,
costs are the most frequently reported microeconomic outcome (n = 180),
followed by impacts (n = 84), benefits (n = 39), and values (n = 26).
Individual-level costs of abortion-related care have implications for the
timing and type of care sought, globally. In contexts requiring multiple
referrals or follow-up visits, these costs are multiplied. The ways in which
people pay for abortion-related costs are diverse. The intersection between
micro-level costs and delay(s) to abortion-related care is substantial.
Individuals forego other costs and expenditures, or are pushed further into
debt and/or poverty, in order to fund abortion-related care. The evidence
base on the economic impacts of policy or law change is from high-income
countries, dominated by studies from the United States. Conclusions Delays underpinned by economic factors can thwart care-seeking, affect the
type of care sought, and impact the gestational age at which care is sought
or reached. The evidence base includes little evidence on the micro-level
costs for adolescents. Specific sub-groups of abortion care-seekers
(transgendered and/or disabled people) are absent from the evidence and it
is likely that they may experience higher direct and indirect costs because
they may experience greater barriers to abortion care.
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Affiliation(s)
- Ernestina Coast
- Department of International Development, London School of Economics and
Political Science, London, United Kingdom
- * E-mail:
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and
Political Science, London, United Kingdom
| | - Yana van der Meulen Rodgers
- Department of Labor Studies and Employment Relations, Rutgers University,
Piscataway, New Jersey, United States of America
- Department of Women’s and Gender Studies, Rutgers University, Piscataway,
New Jersey, United States of America
| | - Brittany Moore
- Ipas, Chapel Hill, North Carolina, United States of
America
| | - Cheri Poss
- Ipas, Chapel Hill, North Carolina, United States of
America
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Rossier C, Marchin A, Kim C, Ganatra B. Disclosure to social network members among abortion-seeking women in low- and middle-income countries with restrictive access: a systematic review. Reprod Health 2021; 18:114. [PMID: 34098958 PMCID: PMC8186048 DOI: 10.1186/s12978-021-01165-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 05/23/2021] [Indexed: 12/18/2022] Open
Abstract
Background Health care for stigmatized reproductive practices in low- and middle-income countries (LMICs) often remains illegal; when legal, it is often inadequate, difficult to find and / or stigmatizing, which results in women deferring care or turning to informal information sources and providers. Women seeking an induced abortion in LMICs often face obstacles of this kind, leading to unsafe abortions. A growing number of studies have shown that abortion seekers confide in social network members when searching for formal or informal care. However, results have been inconsistent; in some LMICs with restricted access to abortion services (restrictive LMICs), disclosure appears to be limited. Main body This systematic review aims to identify the degree of disclosure to social networks members in restrictive LMICs, and to explore the differences between women obtaining an informal medical abortion and other abortion seekers. This knowledge is potentially useful for designing interventions to improve information on safe abortion or for developing network-based data collection strategies. We searched Pubmed, POPLINE, AIMS, LILACS, IMSEAR, and WPRIM databases for peer-reviewed articles, published in any language from 2000 to 2018, concerning abortion information seeking, communication, networking and access to services in LMICs with restricted access to abortion services. We categorized settings into four types by possibility of anonymous access to abortion services and local abortion stigma: (1) anonymous access possible, hyper stigma (2) anonymous access possible, high stigma (3) non-anonymous access, high stigma (4) non-anonymous access, hyper stigma. We screened 4101 references, yielding 79 articles with data from 33 countries for data extraction. We found a few countries (or groups within countries) exemplifying the first and second types of setting, while most studies corresponded to the third type. The share of abortion seekers disclosing to network members increased across setting types, with no women disclosing to network members beyond their intimate circle in Type 1 sites, a minority in Type 2 and a majority in Type 3. The informal use of medical abortion did not consistently modify disclosure to others. Conclusion Abortion-seeking women exhibit widely different levels of disclosure to their larger social network members across settings/social groups in restrictive LMICs depending on the availability of anonymous access to abortion information and services, and the level of stigma. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01165-0. Women seeking an induced abortion in LMICs often face inexistent or inadequate, difficult to find and/ or stigmatizing legal services, leading to the use of informal methods and providers, and unsafe abortions. A growing number of studies have shown that abortion seekers contact social network members beyond their intimate circle when seeking care. However, results have been inconsistent. We searched Pubmed, POPLINE, AIMS, LILACS, IMSEAR, and WPRIM databases for peer-reviewed articles published in any language from 2000 to 2018, concerning abortion information seeking, communication, networking and access to services in restrictive LMICs. We screened 4101 references, yielding 79 articles with data from 33 countries for extraction. We grouped countries (or social groups within countries) into four types of settings: (1) anonymous access possible, hyper stigma; (2) anonymous access possible, high stigma; (3) non-anonymous access, high stigma; (4) non-anonymous access, hyper stigma. Most studies fitted Type 3. Disclosing to network members increased across setting types: no women confided in network members in Type 1 settings, a minority in Type 2 and a majority in Type 3. No setting fitted Type 4. The informal use of medical abortion did not modify disclosure to others. Abortion seekers in restrictive LMICs frequently contact their social network in some settings/groups but less frequently in others, depending on the availability of anonymous access to abortion care and the level of stigma. This knowledge is useful for designing interventions to improve information on safe abortion and for developing network-based data collection strategies.
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Affiliation(s)
- Clémentine Rossier
- Université de Genève, Geneva, Switzerland. .,Institut National d'Etudes Démographiques, Paris, France.
| | | | - Caron Kim
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Bela Ganatra
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
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25
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Honkavuo L. Women's experiences of cultural and traditional health beliefs about pregnancy and childbirth in Zambia: An ethnographic study. Health Care Women Int 2021; 42:374-389. [PMID: 33939594 DOI: 10.1080/07399332.2021.1898613] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Zambian women's pregnancy and childbirth are linked to a variety of cultural and traditional practices, activities and beliefs. These existential events affect the women's health and the newborn's care. In this study we used an interpretative ethnographic design. Individual deep interviews with eight Zambian women were carried out. The formation of family, pregnancy and childbirth are important for strengthening generational traditions and preserving culture. Having many children is especially important for Zambian men as it increases their status in the society. Family continuity is related to the legacy of generations through the spirits of the ancestors.
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Affiliation(s)
- Leena Honkavuo
- Faculty of Education and Welfare Studies, Department of Caring Science, Åbo Akademi University, Vasa, Finland
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26
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Footman K, Chelwa N, Douthwaite M, Mdala J, Mulenga D, Brander C, Church K. Treading the Thin Line: Pharmacy Workers' Perspectives on Medication Abortion Provision in Lusaka, Zambia. Stud Fam Plann 2021; 52:179-194. [PMID: 33826147 DOI: 10.1111/sifp.12151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT Despite liberal abortion laws, safe abortion access in Zambia is impeded by limited legal awareness, lack of services, and restrictive clinical policies. As in many countries with restricted abortion access, women frequently seek abortions informally from pharmacies. METHODS We conducted 16 in-depth interviews in 2019 to understand the experiences and motivations of pharmacy workers who sell medication abortion (MA) drugs in Lusaka. RESULTS We found that pharmacy staff reluctantly assume a gatekeeper role for MA due to competing pressures from clients and from regulatory constraints. Pharmacy staff often decide to provide MA, motivated by their duty of care and desire to help clients, as well as financial interests. However, pharmacy workers' motivation to protect themselves from legal and business risk perpetuates inequalities in abortion access, as pharmacy workers improvise additional eligibility criteria based on personal risk and values such as age, partner approval, reason for abortion, and level of desperation. CONCLUSION These findings highlight how pharmacy staff informally determine women's abortion access when laws and policies prevent comprehensive access to safe abortion. Reform of clinical guidelines, public education, strengthened public sector availability, task sharing, and improved access to prescription services are needed to ensure women can legally access safe abortion.
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Affiliation(s)
- Katharine Footman
- MSI Reproductive Choices, London, W1T 6LP, UK.,Department of Social Policy, London School of Economics and Political Science
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Asiimwe BB, Kiiru J, Mshana SE, Neema S, Keenan K, Kesby M, Mwanga JR, Sloan DJ, Mmbaga BT, Smith VA, Gillespie SH, Lynch AG, Sandeman A, Stelling J, Elliott A, Aanensen DM, Kibiki GE, Sabiiti W, Holden MTG. Protocol for an interdisciplinary cross-sectional study investigating the social, biological and community-level drivers of antimicrobial resistance (AMR): Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA). BMJ Open 2021; 11:e041418. [PMID: 34006022 PMCID: PMC7942251 DOI: 10.1136/bmjopen-2020-041418] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 01/14/2021] [Accepted: 01/25/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Antimicrobial resistance (AMR) is a global health threat that requires urgent research using a multidisciplinary approach. The biological drivers of AMR are well understood, but factors related to treatment seeking and the social contexts of antibiotic (AB) use behaviours are less understood. Here we describe the Holistic Approach to Unravel Antibacterial Resistance in East Africa, a multicentre consortium that investigates the diverse drivers of drug resistance in urinary tract infections (UTIs) in East Africa. METHODS AND ANALYSIS This study will take place in Uganda, Kenya and Tanzania. We will conduct geospatial mapping of AB sellers, and conduct mystery client studies and in-depth interviews (IDIs) with drug sellers to investigate AB provision practices. In parallel, we will conduct IDIs with doctors, alongside community focus groups. Clinically diagnosed patients with UTI will be recruited from healthcare centres, provide urine samples and complete a questionnaire capturing retrospective treatment pathways, sociodemographic characteristics, attitudes and knowledge. Bacterial isolates from urine and stool samples will be subject to culture and antibiotic sensitivity testing. Genomic DNA from bacterial isolates will be extracted with a subset being sequenced. A follow-up household interview will be conducted with 1800 UTI-positive patients, where further environmental samples will be collected. A subsample of patients will be interviewed using qualitative tools. Questionnaire data, microbiological analysis and qualitative data will be linked at the individual level. Quantitative data will be analysed using statistical modelling, including Bayesian network analysis, and all forms of qualitative data analysed through iterative thematic content analysis. ETHICS AND DISSEMINATION Approvals have been obtained from all national and local ethical review bodies in East Africa and the UK. Results will be disseminated in communities, with local and global policy stakeholders, and in academic circles. They will have great potential to inform policy, improve clinical practice and build regional pathogen surveillance capacity.
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Affiliation(s)
- Benon B Asiimwe
- School of Biomedical Sciences, Makerere University, Kampala, Uganda
| | - John Kiiru
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Stephen E Mshana
- Department of Microbiology and Immunology, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Stella Neema
- College of Humanities and Social Science, Makerere University, Kampala, Uganda
| | - Katherine Keenan
- Geography and Sustainable Development, University of St Andrews, St Andrews, Fife, UK
| | - Mike Kesby
- Geography and Sustainable Development, University of St Andrews, St Andrews, Fife, UK
| | - Joseph R Mwanga
- School of Public Health, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Derek J Sloan
- School of Medicine, University of St Andrews, St Andrews, UK
| | - Blandina T Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical Centre and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - V Anne Smith
- School of Biology, University of St Andrews, St Andrews, UK
| | | | - Andy G Lynch
- School of Medicine, University of St Andrews, St Andrews, UK
- School of Mathematics and Statistics, University of St Andrews, St Andrews, UK
| | - Alison Sandeman
- School of Medicine, University of St Andrews, St Andrews, UK
| | - John Stelling
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alison Elliott
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
- Immunomodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Institute, Kampala, Uganda
| | - David M Aanensen
- Centre for Genomic Pathogen Surveillance, Wellcome Genome Campus, Cambridge, UK
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Wilber Sabiiti
- School of Medicine, University of St Andrews, St Andrews, UK
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28
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Moore B, Poss C, Coast E, Lattof SR, van der Meulen Rodgers Y. The economics of abortion and its links with stigma: A secondary analysis from a scoping review on the economics of abortion. PLoS One 2021; 16:e0246238. [PMID: 33600471 PMCID: PMC7891754 DOI: 10.1371/journal.pone.0246238] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 01/18/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Although abortions are a common aspect of people's reproductive lives, the economic implications of abortion and the stigmas that surround abortion are poorly understood. This article provides an analysis of secondary data from a scoping review on the economic impact of abortion to understand the intersections between stigma and economics outcomes at the microeconomic (i.e., abortion seekers and their households), mesoeconomic (i.e., communities and health systems), and macroeconomic (i.e., societies and nation states) levels. METHODS AND FINDINGS We conducted a scoping review using the PRISMA extension for Scoping Reviews. Studies reporting on qualitative and/or quantitative data from any world region were considered. For inclusion, studies must have examined one of the following microeconomic, mesoeconomic, or macroeconomic outcomes: costs, benefits, impacts, and/or value of abortion-related care or abortion policies. Our searches yielded 19,653 items, of which 365 items were included in our final inventory. As a secondary outcome, every article in the final inventory was screened for abortion-related stigma, discrimination, and exclusion. One quarter (89/365) of the included studies contained information on stigma, though only 32 studies included stigma findings directly tied to economic outcomes. Studies most frequently reported stigma's links with costs (n = 24), followed by economic impact (n = 11) and economic benefit (n = 1). Abortion stigma can prevent women from obtaining correct information about abortion services and laws, which can lead to unnecessary increases in costs of care and sizeable delays in care. Women who are unable to confide in and rely on their social support network are less likely to have adequate financial resources to access abortion. CONCLUSIONS Abortion stigma has a clear impact on women seeking abortion or post-abortion care at each level. Programmatic interventions and policies should consider how stigma affects delays to care, access to accurate information, and available social and financial support, all of which have economic and health implications.
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Affiliation(s)
- Brittany Moore
- Ipas, Chapel Hill, North Carolina, United States of America
| | - Cheri Poss
- Ipas, Chapel Hill, North Carolina, United States of America
| | - Ernestina Coast
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Samantha R. Lattof
- Department of International Development, London School of Economics and Political Science, London, United Kingdom
| | - Yana van der Meulen Rodgers
- Department of Labor Studies and Employment Relations, Rutgers University, Piscataway, New Jersey, United States of America
- Department of Women’s and Gender Studies, Rutgers University, Piscataway, New Jersey, United States of America
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29
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Strong J. Exploring the roles of men and masculinities in abortion and emergency contraception pathways, Ghana: a mobile phone-based mixed-methods study protocol. BMJ Open 2021; 11:e042649. [PMID: 33550252 PMCID: PMC7925914 DOI: 10.1136/bmjopen-2020-042649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Global commitments have established goals of achieving universal sexual and reproductive health and rights (SRHR) access, but critical obstacles remain. Emergency contraception and induced abortion are overlooked in policy and research. Men's roles in the SRHR of others are significant, particularly as obstacles to universal SRHR. Evidence on gender, masculinities and SRHR is essential to understand and reduce the barriers faced by individuals seeking to avoid the conception or continuation of a pregnancy. METHODS AND ANALYSIS This study aims to understand men's masculinities and their relationships with emergency contraception and abortion. The protocol presents a multimethod study of men aged over 18 years in James Town, Accra, Ghana. In response to the COVID-19 pandemic, the research will use two mobile-based methods: a survey and in-depth interviews. Using respondent-driven sampling, an estimated 789 men will be recruited to participate in the survey, asking questions on their knowledge, attitude, behaviours and roles in emergency contraception and abortion. In-depth interviews focused on constructions of masculinity will be conducted with a purposive sample of men who participated in the survey. Data will be analysed concurrently using multiple regression analyses of quantitative data and abductive analysis of qualitative data. ETHICS AND DISSEMINATION Ethical approval has been granted by the London School of Economics and Political Science and the Ghana Health Service. The findings in this study will: engage with emerging research on masculinities and SRHR in Ghana and elsewhere; offer methodological insight for future research; and provide evidence to inform interventions to reduce obstacles for emergency contraception and abortion care seekers. Dissemination will occur at all levels-policy, academic, community-including multiple academic articles, policy briefs, workshops and presentations, conference papers, and theatre/radio-based performances of key messages.
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Affiliation(s)
- Joe Strong
- Department of Social Policy, London School of Economics and Political Science, London, UK
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30
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Haaland MES, Mumba Zulu J, Moland KM, Haukanes H. When abortion becomes public - Everyday politics of reproduction in rural Zambia. Soc Sci Med 2020; 265:113502. [PMID: 33183861 DOI: 10.1016/j.socscimed.2020.113502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 09/15/2020] [Accepted: 11/03/2020] [Indexed: 11/19/2022]
Abstract
This article takes the public reaction to the discovery of an aborted foetus in a rural Zambian community as the empirical starting point for exploring the everyday politics of reproduction. It builds on eleven months of ethnographic fieldwork on abortion and abortion policy in Zambia in 2017 and 2018, including participant observation in the community where the episode took place and interviews with clinic staff and neighbours. The article explores local dynamics of abortion opposition in a country where abortion is legally permitted on broad grounds. By analysing this case as an anthropological event, it discusses how opposition to abortion is dynamic and changes depending on the situation at hand. While abortions that avoid public attention may be silently tolerated, abortions that become openly known are harshly condemned. Through scrutiny of a specific case of collective moral judgement of abortion, the article examines how values like responsible motherhood, sexual virtue and protection of life emerge and are shared, allowing participants to protect and accumulate their own integrity in a moral economy that forges stronger social ties within the community. The article argues that even the harshest expressions of opposition to abortion may not be as categorical as they first appear. It calls for increased attention to dynamics of moral and political opposition to abortion to understand what is socially at stake for those who engage in it.
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Affiliation(s)
- Marte E S Haaland
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Norway; Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Norway.
| | | | - Karen Marie Moland
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Norway; Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Norway
| | - Haldis Haukanes
- Department of Health Promotion and Development, University of Bergen, Bergen, Norway
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31
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Kangaude G, Coast E, Fetters T. Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia. Sex Reprod Health Matters 2020; 28:1832291. [PMID: 33121392 PMCID: PMC7887923 DOI: 10.1080/26410397.2020.1832291] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Universal Health Coverage (UHC) forces governments to consider not only how services will be provided – but which services – and to whom, when, where, how and at what cost. This paper considers the implications for achieving UHC through the lens of abortion-related care for adolescents. Our comparative study design includes three countries purposively selected to represent varying levels of restriction on access to abortion: Ethiopia (abortion is legal and services implemented); Zambia (legal, complex services with numerous barriers to implementations and provision of information); Malawi (legally highly restricted). Our policy and legal analyses are supplemented by comparative vignettes based on interviews (n = 330) in 2018/2019 with adolescents aged 10–19 who have sought abortion-related care in each country. We focus on an under-considered but critical legal framing for adolescents – the age of consent. We compare legal and political commitments to advancing adolescent sexual and reproductive health and rights, including abortion-related care. Ethiopia appears to approach UHC for safe abortion care, and the legal provision for under 18-year-olds appears to be critical. In Malawi, the most restrictive legal environment for abortion, little progress appears to have been made towards UHC for adolescents. In Zambia, despite longstanding legal provision for safe abortion on a wide range of grounds, the limited services combined with low levels of knowledge of the law mean that the combined rights and technical agendas of UHC have not yet been realised. Our comparative analyses showing how policies and laws are framed have critical implications for equity and justice.
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Affiliation(s)
- Godfrey Kangaude
- Postdoctoral Fellow, Centre for Human Rights, University of Pretoria, Pretoria, South Africa
| | - Ernestina Coast
- Professor of Health and International Development, London School of Economics, London, UK. Correspondence :
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32
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Makleff S, Wilkins R, Wachsmann H, Gupta D, Wachira M, Bunde W, Radhakrishnan U, Cislaghi B, Baum SE. Exploring stigma and social norms in women's abortion experiences and their expectations of care. Sex Reprod Health Matters 2020; 27:1661753. [PMID: 31551027 PMCID: PMC7887901 DOI: 10.1080/26410397.2019.1661753] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Abortion is a common and essential component of sexual and reproductive health care, yet social norms and stigma influence women’s decision-making and create barriers to safe abortion care. This qualitative study in Kenya and India explores abortion-related fears, expectations and perceptions of stigma among women who have obtained abortion services. In 2017, we conducted 34 semi-structured interviews and 2 focus groups with women who had obtained abortion services in Maharashtra state in India and Thika and Eldoret in Kenya. Thematic analysis was informed by the individual-level abortion stigma framework and theory of normative conduct. We aimed to learn about the diversity of women’s experiences, analysing pooled data from the two countries. Most participants reported that before seeking abortion they had little prior knowledge about the service, expected to be judged during care, and feared the service would be ineffective or have negative health consequences. Many reported that community members disapprove of abortion and that a woman’s age or marital status could exacerbate judgement. Some reported limiting disclosure of their abortion to avoid judgement. Negative stories, the secrecy around abortion, perceived stigma, social norms, and fear of sanctions all contributed to women’s fears and low expectations. These findings elucidate the relationship between social norms and stigma and how expectations and concerns affect women’s experiences seeking care. The results have implications for practice, with potential to inform improvements to services and help organisations address stigma as a barrier to care. This may be particularly relevant for younger or unmarried women.
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Affiliation(s)
- Shelly Makleff
- Independent Consultant, Ibis Reproductive Health , Oakland , CA , USA
| | - Rebecca Wilkins
- Head, Global Comprehensive Abortion Care Initiative, International Planned Parenthood Federation , London , UK
| | - Hadassah Wachsmann
- Programme Adviser, International Planned Parenthood Federation , London , UK
| | - Deepesh Gupta
- Senior Project Adviser - SRHR, International Planned Parenthood Federation/South Asia Regional Office , Delhi , India
| | - Muthoni Wachira
- Project Coordinator, International Planned Parenthood Federation/Africa Regional Office , Nairobi , Kenya
| | - Wilson Bunde
- Project Manager, Family Health of Kenya , Nairobi , Kenya
| | - Usha Radhakrishnan
- Manager, Monitoring & Evaluation, Family Planning Association of India , Mumbai , India
| | - Beniamino Cislaghi
- Assistant Professor in Social Norms, London School of Hygiene and Tropical Medicine , London , UK
| | - Sarah E Baum
- Associate, Ibis Reproductive Health , Oakland , CA , USA . Correspondence:
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33
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Essie DEM, Ndinga H, Niama A, Oyere G, Kifoueni G, Ibara JR. [Clandestine abortion complications and street drugs in Brazzaville]. Pan Afr Med J 2020; 36:143. [PMID: 32874407 PMCID: PMC7436636 DOI: 10.11604/pamj.2020.36.143.18816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 05/01/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction clandestine abortions increase maternal morbi-mortality in sub-Saharan Africa and are closely linked to restrictive legislation and low contraceptive prevalence. In Brazzaville street drugs are commonly used to induce abortion. The purpose of this study is to determine street drug prevalence and socio-demographic characteristics of these patients. Methods we conducted a longitudinal study of 67 patients with induced abortion complications admitted to the Talangaï Hospital from July to December 2018. (i) Socio-demographic (ii) and obstetrical (iii) characteristics as well as abortion features (procedure, Manganguiste involvement, abortion rank and cost) were collected and analyzed using EPI info 7 software. We compared the means using student's test, proportions with CHI-2, p value was set to < 0.05. Results the average age of patients was 25 years ± 6.6; 59.7% of them were attending college, 53.8% had no income-generating activity, 38.8% lived alone and in 15% of cases biological father had denied paternity. Street drugs had been used in 74.5% of cases, mean abortion cost was 3500 CFA (US$7) and 29500CFA (US$59) when it had been performed by health-care professionals. High school respondents were more likely (73.69%) to know at least contraceptive methods (p<0.05). Greater numbers of singles (p=0.000) and of those who knew a contraceptive method (p=0.003) expressed the intention to use contraception. Conclusion: combatting the use of street drugs and securing the right to safe voluntary abortion are necessary to limit complications due to clandestine abortions.
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Affiliation(s)
- Darius Eryx Mbou Essie
- Faculté des Sciences de la Santé, Université Marien Ngouabi, Brazzaville, République du Congo.,Service de Gynécologie-Obstétrique, Hôpital de Référence de Talangaï, Brazzaville, République du Congo.,Direction des Soins de Santé Primaires, Ministère de la Santé, Brazzaville, République du Congo
| | - Hermann Ndinga
- Faculté des Sciences de la Santé, Université Marien Ngouabi, Brazzaville, République du Congo.,Service de Gynécologie-Obstétrique, Hôpital de Référence de Talangaï, Brazzaville, République du Congo
| | - Ange Niama
- Faculté des Sciences de la Santé, Université Marien Ngouabi, Brazzaville, République du Congo
| | - Guy Oyere
- Service de Gynécologie-Obstétrique, Hôpital de Référence de Talangaï, Brazzaville, République du Congo
| | - Grace Kifoueni
- Service de Gynécologie-Obstétrique, Hôpital de Référence de Talangaï, Brazzaville, République du Congo
| | - Jean-Rosaire Ibara
- Faculté des Sciences de la Santé, Université Marien Ngouabi, Brazzaville, République du Congo
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Palmer JJ, Jones C, Surur EI, Kelly AH. Understanding the Role of the Diagnostic 'Reflex' in the Elimination of Human African Trypanosomiasis. Trop Med Infect Dis 2020; 5:tropicalmed5020052. [PMID: 32244778 PMCID: PMC7345297 DOI: 10.3390/tropicalmed5020052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 03/20/2020] [Accepted: 03/26/2020] [Indexed: 11/16/2022] Open
Abstract
To successfully eliminate human African trypanosomiasis (HAT), healthcare workers (HCWs) must maintain their diagnostic acuity to identify cases as the disease becomes rarer. HAT experts refer to this concept as a ‘reflex’ which incorporates the idea that diagnostic expertise, particularly skills involved in recognising which patients should be tested, comes from embodied knowledge, accrued through practice. We investigated diagnostic pathways in the detection of 32 symptomatic HAT patients in South Sudan and found that this ‘reflex’ was not confined to HCWs. Indeed, lay people suggested patients test for HAT in more than half of cases using similar practices to HCWs, highlighting the importance of the expertise present in disease-affected communities. Three typologies of diagnostic practice characterised patients’ detection: ‘syndromic suspicion’, which closely resembled the idea of an expert diagnostic reflex, as well as ‘pragmatic testing’ and ‘serendipitous detection’, which depended on diagnostic expertise embedded in hospital and lay social structures when HAT-specific suspicion was ambivalent or even absent. As we approach elimination, health systems should embrace both expert and non-expert forms of diagnostic practice that can lead to detection. Supporting multidimensional access to HAT tests will be vital for HCWs and lay people to practice diagnosis and develop their expertise.
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Affiliation(s)
- Jennifer J. Palmer
- Department of Global Health & Development, London School of Hygiene & Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK
- Centre of African Studies, University of Edinburgh, 15a George Square, Edinburgh EH8 9LD, UK
- Correspondence:
| | - Caroline Jones
- Kemri-Wellcome Trust Research Programme, P.O. Box 230, Kilifi 80108, Kenya;
| | | | - Ann H. Kelly
- Department of Global Health & Social Medicine, King’s College London, 30 Aldwych, London WC2B 4BG, UK;
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Silent politics and unknown numbers: Rural health bureaucrats and Zambian abortion policy. Soc Sci Med 2020; 251:112909. [DOI: 10.1016/j.socscimed.2020.112909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 11/23/2022]
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Bain LE. Mandatory pre-abortion counseling is a barrier to accessing safe abortion services. Pan Afr Med J 2020; 35:80. [PMID: 32537083 PMCID: PMC7250210 DOI: 10.11604/pamj.2020.35.80.22043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 02/27/2020] [Indexed: 11/28/2022] Open
Abstract
Empirical research showcases that pre-abortion counseling scarcely reverses the woman’s decision either to terminate a pregnancy or not. Growing evidence regarding the high levels of decisional certainty among women seeking abortions renders a careful rethink of the place of mandatory pre-abortion counseling packages. Mandatory counseling packages, when inscribed in the laws, at times contain false information that can deter women from going in for safe abortions. Mandatory waiting times indirectly label opting for an abortion as not being the right thing to do. In areas where abortion stigma from health care providers and communities remains highly prevalent, women are forced to incur extra expenses by travelling to other countries. I argue that pre-abortion counseling on opting-in grounds is ethically sound (enhances the woman’s reproductive autonomy), since most clients in need of abortions are certain on their decisions before the abortion care provider and do not regret these decisions after the process. Regrets are prone to be more prevalent in areas with high unsafe abortion practices, generally due to complications from excessive bleeding, pain, and post abortion infections. Allowing systematic mandatory pre-abortion counseling practice as the rule in a competent adult is unjustified ethically and empirically, is time consuming and presents the legality of abortions in most settings an oxymoron.
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Affiliation(s)
- Luchuo Engelbert Bain
- Centre for Population Studies and Health Promotion, Yaounde, Cameroon.,Athena Institute for Research on Innovation and Communication in the Health and Life Sciences, Vrije Universiteit, Amsterdam, Netherlands
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Makleff S, Labandera A, Chiribao F, Friedman J, Cardenas R, Sa E, Baum SE. Experience obtaining legal abortion in Uruguay: knowledge, attitudes, and stigma among abortion clients. BMC Womens Health 2019; 19:155. [PMID: 31815617 PMCID: PMC6902415 DOI: 10.1186/s12905-019-0855-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 11/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The abortion law in Uruguay changed in 2012 to allow first trimester abortion on request. Implementation of the law in Uruguay has been lauded, but barriers to care, including abortion stigma, remain. This study aimed to assess women's experiences seeking abortion services and related attitudes and knowledge following implementation of the law in Uruguay. METHODS We interviewed 207 eligible women seeking abortion services at a high-volume public hospital in Montevideo in 2014. We generated univariate frequencies to describe women's experiences in care. We conducted regression analysis to examine variations in experiences of stigma by women's age and number of abortions. RESULTS Most of the women felt that abortion was a right, were satisfied with the services they received, and agreed with the abortion law. However, 70% found the five-day waiting period unnecessary. Women experienced greater self-judgement than worries about being judged by others. Younger women in the sample (ages 18-21) reported being more worried about judgment than women 22 years or older (1.02 vs. 0.71 on the ILAS sub-scale). One quarter of participants reported feeling judged while obtaining services. Women with more than one abortion had nearly three times the odds of reporting feeling judged. CONCLUSIONS These findings highlight the need to address abortion stigma even after the law is changed. Some considerations from Uruguay that may be relevant to other jurisdictions reforming abortion laws include: the need for strategies to reduce judgmental behavior from staff and clinicians towards women seeking abortions, including training in counseling skills and empathic communication; addressing stigmatizing attitudes about abortion through community outreach or communications campaigns; mitigating the potential stigma that may be perpetuated through policies to prevent "repeat" abortions; ensuring that younger women and those with more than one abortion feel welcome and are not mistreated during care; and assessing the necessity of a waiting period. The rapid implementation of legal, voluntary abortion services in Uruguay can serve in many ways as an exemplar, and these findings may inform the process of abortion law reform in other countries.
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Affiliation(s)
- Shelly Makleff
- International Planned Parenthood Federation/Western Hemisphere Region, 125 Maiden Lane, 9th Floor, New York, NY 10038 USA
- Ibis Reproductive Health, 1736 Franklin St, Suite 600, Oakland, CA 94612 USA
| | - Ana Labandera
- Iniciativas Sanitarias, Hospital Pereira Rossell, Bulevar Artigas 1550, 16600 Montevideo, CP Uruguay
| | - Fernanda Chiribao
- Iniciativas Sanitarias, Hospital Pereira Rossell, Bulevar Artigas 1550, 16600 Montevideo, CP Uruguay
| | - Jennifer Friedman
- International Planned Parenthood Federation/Western Hemisphere Region, 125 Maiden Lane, 9th Floor, New York, NY 10038 USA
| | - Roosbelinda Cardenas
- International Planned Parenthood Federation/Western Hemisphere Region, 125 Maiden Lane, 9th Floor, New York, NY 10038 USA
- Hampshire College, 893 West Street, Amherst, MA 01002 USA
| | - Eleuthera Sa
- International Planned Parenthood Federation/Western Hemisphere Region, 125 Maiden Lane, 9th Floor, New York, NY 10038 USA
| | - Sarah E. Baum
- Ibis Reproductive Health, 1736 Franklin St, Suite 600, Oakland, CA 94612 USA
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Casey SE, Steven VJ, Deitch J, Dumas EF, Gallagher MC, Martinez S, Morris CN, Rafanoharana RV, Wheeler E. "You must first save her life": community perceptions towards induced abortion and post-abortion care in North and South Kivu, Democratic Republic of the Congo. Sex Reprod Health Matters 2019; 27:1571309. [PMID: 31533559 PMCID: PMC7887765 DOI: 10.1080/09688080.2019.1571309] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Structural barriers such as a restrictive legal environment, limited medical resources, and high-costs inhibit access to safe abortion in the Democratic Republic of the Congo (DRC); these barriers are exacerbated by two decades of conflict. Socio-normative barriers further complicate access to safe abortion and post-abortion care (PAC) in DRC, where fear of abortion-related stigma may lead women to avoid PAC services. Programme partners support the Ministry of Health to provide good quality contraceptive and PAC services in North and South Kivu, DRC. This paper presents results from focus group discussions that explored community members' attitudes towards women who induce abortion and their care-seeking behaviour in programme areas. Results indicate that while abortion stigma was widespread, community members' attitudes towards women who induced abortions were not one-dimensional. Although they initially expressed negative opinions regarding women who induced abortion, beliefs became more nuanced as discussion shifted to the specific situations that could motivate a woman to do so. For example, many considered it understandable that a woman would induce abortion after rape: perhaps unsurprising, given the prevalence of conflict-related sexual violence in this area. While community members believed that fear of stigma or associated negative social consequences dissuaded women from seeking PAC, a majority believed that all women should have access to life-saving PAC. This commitment to ensuring that women who induced abortion have access to PAC, in addition to the professed acceptability of induced abortion in certain situations, indicates that there could be an opening to destigmatise abortion access in this context.
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Affiliation(s)
- Sara E Casey
- Director, RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Victoria J Steven
- Research Assistant, RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Julianne Deitch
- Research Assistant, RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Erin Files Dumas
- Technical Advisor, Sexual and Reproductive Health and Rights, CARE USA, Atlanta, GA, USA
| | - Meghan C Gallagher
- Doctoral Candidate, Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Stephanie Martinez
- Research Assistant, RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Catherine N Morris
- Research Assistant, RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA
| | | | - Erin Wheeler
- Contraception and Abortion Care Advisor, International Rescue Committee, New York, NY, USA
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Almonte MT, Lynch CA. Impact of internal female migration on unmet need for modern contraception in Zambia. Reprod Health 2019; 16:169. [PMID: 31730493 PMCID: PMC6858709 DOI: 10.1186/s12978-019-0803-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 09/02/2019] [Indexed: 11/25/2022] Open
Abstract
Background Unmet need for contraception, the proportion of women who want to limit or delay childbirth but use no form of contraception, is the core indicator to evaluate the effectiveness of family planning programs. Understanding how migration influences unmet need is important to identify to whom and how to target sexual and reproductive health programs. We assessed how migration status in rural and urban settings is associated with having an unmet need for family planning. Methods Data on sexually active, fecund, reproductive-aged (15–49 years) women from the 2013–14 Zambia Demographic and Health Survey were analysed through univariate and multivariate logistic regression models. Results Unmet need for modern contraceptive methods was significantly higher among rural to rural migrant women (OR 1.30, 95%CI 1.00–1.70 p < 0.05) and rural non-migrant women (OR 1.41, 95%CI 1.06–1.85 p < 0.01) compared to urban non-migrant women after controlling for age, marital status, parity, religion, education and wealth. Conclusion Women residing in, and migrating between, rural areas were significantly more likely to have an unmet need for contraception. Our findings highlight the importance of understanding migration and migrant streams to strengthen family planning programs. In Zambia, a focus on rural-rural migrants, rural non-migrants and the poorest could improve the health of the entire population.
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Affiliation(s)
- Melanie T Almonte
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Caroline A Lynch
- Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK.
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Solheim IH, Moland KM, Kahabuka C, Pembe AB, Blystad A. Beyond the law: Misoprostol and medical abortion in Dar es Salaam, Tanzania. Soc Sci Med 2019; 245:112676. [PMID: 31810016 DOI: 10.1016/j.socscimed.2019.112676] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 10/25/2022]
Abstract
Misoprostol has during the past few years become an important obstetric drug used for different purposes both within and outside hospitals in Tanzania. In this paper, we analyze how misoprostol is perceived, accessed and used off-label as an abortion drug in the city and region of Dar es Salaam. The study took place in Dar es Salaam's three districts from July to November 2015, and had a qualitative explorative approach. We carried out in-depth interviews (42) with the following main categories of informants: women having undergone medical abortion (15), health care workers with experiences from post abortion care (16) and drug vendors (11). Focus group discussions (10) were carried out with young women. A client simulation study was carried out in 64 drugstores across Dar es Salaam assessing the availability of misoprostol and the advice given concerning its use. In addition, shorter qualitative interviews were carried out with representatives of NGOs and public agencies working with sexual and reproductive health issues (17). Our findings reveal that in Dar es Salaam, misoprostol is well known, available and accessed for abortion purposes through drugstores and health providers. Women tend to prefer misoprostol over other abortion methods since it allows for a private, low-cost, safer and less uncomfortable abortion experience. But, while misoprostol facilitates women's agency in the process of seeking abortion, a series of obstacles shaped by a restrictive abortion law and an unregulated pharmaceutical market hinder its safe use. Central obstacles are profit-seeking providers, suboptimal user instructions and poor provider follow-up. In the discussion of the material we draw upon Van der Geest, Hardon and Whyte's concept of the 'social life of pharmaceuticals' and indicate the ways in which misoprostol acts as an agent of change in the social relations connected to abortion.
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Affiliation(s)
- I H Solheim
- Global Health Anthropology Research Group at the Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen (UiB), Norway.
| | - K M Moland
- Global Health Anthropology Research Group at the Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen (UiB), Norway; Centre for Intervention Science in Maternal and Child Health (CISMAC), UiB, Norway
| | - C Kahabuka
- CSK Research Solutions, Dar es Salaam, Tanzania
| | - A B Pembe
- Muhimbili University of Health and Associated Sciences, Dar es Salaam, Tanzania
| | - A Blystad
- Global Health Anthropology Research Group at the Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen (UiB), Norway; Centre for Intervention Science in Maternal and Child Health (CISMAC), UiB, Norway
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Påfs J, Rulisa S, Klingberg-Allvin M, Binder-Finnema P, Musafili A, Essén B. Implementing the liberalized abortion law in Kigali, Rwanda: Ambiguities of rights and responsibilities among health care providers. Midwifery 2019; 80:102568. [PMID: 31698295 DOI: 10.1016/j.midw.2019.102568] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 10/10/2019] [Accepted: 10/24/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Rwanda amended its abortions law in 2012 to allow for induced abortion under certain circumstances. We explore how Rwandan health care providers (HCP) understand the law and implement it in their clinical practice. DESIGN Fifty-two HCPs involved in post-abortion care in Kigali were interviewed by qualitative individual in-depth interviews (n =32) and in focus group discussions (n =5) in year 2013, 2014, and 2016. All data were analyzed using thematic analysis. FINDINGS HCPs express ambiguities on their rights and responsibilities when providing abortion care. A prominent finding was the uncertainties about the legal status of abortion, indicating that HCPs may rely on outdated regulations. A reluctance to be identified as an abortion provider was noticeable due to fear of occupational stigma. The dilemma of liability and litigation was present, and particularly care providers' legal responsibility on whether to report a woman who discloses an illegal abortion. CONCLUSION The lack of professional consensus is creating barriers to the realization of safe abortion care within the legal framework, and challenge patients right for confidentiality. This bring consequences on girl's and women's reproductive health in the setting. IMPLICATIONS FOR PRACTICE To implement the amended abortion law and to provide equitable maternal care, the clinical and ethical guidelines for HCPs need to be revisited.
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Affiliation(s)
- Jessica Påfs
- Department of Women's and Children's Health/ IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden.
| | - Stephen Rulisa
- Department of Obstetrics & Gynecology, College of Medicine and Health Sciences, School of Medicine and Pharmacy, University of Rwanda, P.O.Box 3286, Kigali, Rwanda; Department of Clinical Research, University Teaching Hospital of Kigali, BP 655 Kigali, Rwanda
| | - Marie Klingberg-Allvin
- School of Education, Health and Social Studies, Dalarna University, SE-791 88 Falun, Sweden
| | - Pauline Binder-Finnema
- Department of Women's and Children's Health/ IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden
| | - Aimable Musafili
- Department of Women's and Children's Health/ IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden; Department of Pediatrics and Child Health, College of Medicine and Health Sciences, School of Medicine, University of Rwanda, P.O.Box 217 Butare, Huye, Rwanda
| | - Birgitta Essén
- Department of Women's and Children's Health/ IMCH, Uppsala University, Akademiska Sjukhuset, SE-751 85 Uppsala, Sweden
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Nandagiri R. "Like a mother-daughter relationship": Community health intermediaries' knowledge of and attitudes to abortion in Karnataka, India. Soc Sci Med 2019; 239:112525. [PMID: 31499333 DOI: 10.1016/j.socscimed.2019.112525] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 10/26/2022]
Abstract
Community Health Intermediaries (CHIs)- ANMs, ASHAs, and pharmacists- are key to realising task-sharing efforts to increase abortion access in LMICs, but their knowledge of and attitudes to abortion remains underexplored. Evidence on abortion task-sharing has focused primarily on CHIs' technical and clinical abilities, overlooking social contexts and norms that influence attitudes and behaviours. This mixed-methods study describes the abortion knowledge, attitudes, and roles of three cadres of CHIs in rural districts of Karnataka, India. Quantitative data on CHIs' abortion attitudes (n = 118) were collected using the Stigmatising Attitudes, Behaviours, and Actions Scale (SABAS), followed by in-depth interviews (n = 21) with a subset of the population over eight months in 2017. Findings show that CHIs, present at multiple points in women's abortion trajectories, serve as barriers or facilitate access to abortion care. Their abortion attitudes reflect social contexts and environments, drawing on social norms surrounding fertility, woman- and mother-hood. They demonstrate poor knowledge of abortion laws, conflating them with sex-selection laws. CHIs also reflect poor knowledge of abortion methods. They report little to no training on abortion. CHIs contend with entrenched social and structural inequalities in carrying out their tasks, affecting the kind and quality of care they are able to provide. Understanding CHIs' experiences, knowledge and attitudes can advance abortion care-provision, support task-sharing efforts, and potentially improve the quality of women's abortion-seeking experiences.
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Affiliation(s)
- Rishita Nandagiri
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, United Kingdom.
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Zulu JM, Haaland MES. Situating the Mexico City Policy: what shapes contraceptive access and abortion? LANCET GLOBAL HEALTH 2019; 7:e984-e985. [DOI: 10.1016/s2214-109x(19)30278-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/30/2019] [Indexed: 11/30/2022]
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Abstract
INTRODUCTION Abortion is a common feature of people's reproductive lives. However, the economic implications of abortion and policies affecting abortion provision are poorly understood. This scoping review aims to systematically review social science literature for studies that have investigated the impact of abortion care (ie, un/safe abortion, post-abortion care) or abortion policies on economic outcomes at the micro-levels (ie, abortion seekers and their households), meso-levels (ie, communities and health systems) and macro-levels (ie, societies and nation states). Informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline for protocols, this protocol details the scoping review's methodological and analytical approaches. METHODS AND ANALYSIS This scoping review will utilise the PRISMA extension for Scoping Reviews (PRISMA-ScR) tool. Studies reporting on qualitative and/or quantitative data from any world region will be considered. For inclusion, studies must examine one of the following economic outcomes at the micro-levels, meso-levels and/or macro-levels: costs, benefits, impacts and/or value of abortion care or abortion policies. Searches will be conducted in eight electronic databases. We will conduct the searches and application of inclusion/exclusion criteria according to the PRISMA-ScR flow approach. No assessments of items' quality will be made, as the purpose of this scoping review is to synthesise and describe the coverage of the evidence. After extracting all data, we will inductively develop an economic framework around the economics of abortion. The analysis will synthesise the evidence base and identify knowledge gaps on the costs and benefits of abortion to stakeholders at various levels. ETHICS AND DISSEMINATION Formal ethical approval is not required, as primary data will not be collected in this study. The findings of this study will be disseminated through peer-reviewed publications, conference presentations, and condensed summaries for key stakeholders and partners in the field.
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Affiliation(s)
- Ernestina Coast
- International Development, London School of Economics, London, UK
| | - Samantha R Lattof
- International Development, London School of Economics and Political Science, London, UK
| | | | - Brittany Moore
- Scientific and Technical Divison, IPAS, Chapel Hill, North Carolina, USA
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Steven VJ, Deitch J, Dumas EF, Gallagher MC, Nzau J, Paluku A, Casey SE. "Provide care for everyone please": engaging community leaders as sexual and reproductive health advocates in North and South Kivu, Democratic Republic of the Congo. Reprod Health 2019; 16:98. [PMID: 31286984 PMCID: PMC6615084 DOI: 10.1186/s12978-019-0764-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 06/30/2019] [Indexed: 11/28/2022] Open
Abstract
Background Inadequate infrastructure, security threats from ongoing armed conflict, and conservative socio-cultural and gender norms that favour large families and patriarchal power structures contribute to poor sexual and reproductive health (SRH) outcomes in North and South Kivu provinces, Democratic Republic of the Congo (DRC). In order to expand contraceptive and post-abortion care (PAC) access in North and South Kivu, CARE, the International Rescue Committee and Save the Children provided technical support to the Ministry of Health and health facilities in these regions. Partners acknowledged that community leaders, given their power to influence local customs, could play a critical role as agents of change in addressing inequitable gender norms, stigma surrounding SRH service utilization, and topics traditionally considered taboo within Congolese society. As such, partners actively engaged with community leaders through a variety of activities such as community mapping exercises, values clarification and transformation (VCAT) activities, situational analyses, and education. Methods This manuscript presents findings from 12 key informant interviews (KIIs) with male political and non-political community leaders conducted in six rural health zones of North and South Kivu, DRC. Transcripts were analysed thematically to explore community leaders’ perceptions of their role in addressing the issue of unintended pregnancy in their communities. Results While community leaders in this study expressed overall positive impressions of contraception and strong support for ensuring access to PAC services following spontaneous and induced abortions, the vast majority held negative beliefs concerning women who had induced abortion. Contrasting with their professed opposition to induced abortion, leaders’ commitment to mediating interpersonal conflict arising between community members and women who had abortions was overwhelming. Conclusion Results from this study suggest that when thoughtfully engaged by health interventions, community leaders can be empowered to become advocates for SRH. While study participants were strong supporters of contraception and PAC, they expressed negative perceptions of induced abortion. Given the hypothesized link between the presence of induced abortion stigma and care-avoidance behavior, further engagement and values clarification exercises with leaders must be integrated into community mobilization and engagement activities in order to increase PAC utilization.
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Affiliation(s)
- Victoria J Steven
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B2, New York, NY, 10032, USA
| | - Julianne Deitch
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B2, New York, NY, 10032, USA
| | | | - Meghan C Gallagher
- Save the Children, 899 North Capitol Street, Suite 900, Washington, DC, 20002, USA
| | - Jimmy Nzau
- CARE USA, 151 Ellis St NE, Atlanta, GA, 30303, USA
| | - Augustin Paluku
- International Rescue Committee, 63, Ave Colonel Mondjiba, Kinshasa, Democratic Republic of the Congo
| | - Sara E Casey
- RAISE Initiative, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, 60 Haven Ave, B2, New York, NY, 10032, USA.
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Chemlal S, Russo G. Why do they take the risk? A systematic review of the qualitative literature on informal sector abortions in settings where abortion is legal. BMC Womens Health 2019; 19:55. [PMID: 30961574 PMCID: PMC6454783 DOI: 10.1186/s12905-019-0751-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 03/28/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Restrictive abortion laws are the single most important determinant of unsafe abortion, a major, yet preventable, global health issue. While reviews have been conducted on the extent of the phenomenon, no study has so far analysed the evidence of why women turn to informal sector providers when legal alternatives are available. This work provides a systematic review of the qualitative literature on informal sector abortion in setting where abortion is legal. METHODS We used the PRISMA guidelines to search Pubmed, Web of Science, Sciencedirect and Google Scholar databases between January and February 2018. 2794 documents in English and French were screened for eligibility against pre-determined inclusion and exclusion criteria. Articles investigating women's reasons for aborting in the informal sector in settings where abortion is legal were included. In total, sixteen articles were identified as eligible for this review. Findings were reported following the PRISMA guidelines. RESULTS The review highlights the diverse reasons women turn to the informal sector, as abortions outside of legal health facilities were reported to be a widespread and normalised practice in countries where legal abortion is provided. Women cited a range of reasons for aborting in the informal sector; these included fear of mistreatment by staff, long waiting lists, high costs, inability to fulfil regulations, privacy concerns and lack of awareness about the legality of abortion or where to procure a safe and legal abortion. Not only was unsafe abortion spoken of in terms of medical and physical safety, but also in terms of social and economic security. CONCLUSION The use of informal sector abortions (ISAs) is a widespread and normalised practice in many countries despite the liberalisation of abortion laws. Although ISAs are not inherently unsafe, the practice in a setting where it is illegal will increase the likelihood that women will not be given the necessary information, or that they will be punished. This study brings to the fore the diverse reasons why women opt to abort outside formal healthcare settings and their issues with provision of abortion services in legal contexts, providing an evidence base for future research and policies.
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Affiliation(s)
- Sonia Chemlal
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Giuliano Russo
- Centre for Primary Care and Public Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner street, London, E1 2AB UK
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Moore AM, Dennis M, Anderson R, Bankole A, Abelson A, Greco G, Vwalika B. Comparing women's financial costs of induced abortion at a facility vs. seeking treatment for complications from unsafe abortion in Zambia. REPRODUCTIVE HEALTH MATTERS 2019; 26:1522195. [PMID: 30388961 PMCID: PMC6331180 DOI: 10.1080/09688080.2018.1522195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Although abortion is legal in Zambia under a variety of broad conditions, unsafe abortion remains common. The purpose of this project was to compare the financial costs for women when they have an induced abortion at a facility, with costs for an induced abortion outside a facility, followed by care for abortion-related complications. We gathered household wealth data at one point in time (T1) and longitudinal qualitative data at two points in time (T1 and T2, three-four months later), in Lusaka and Kafue districts, between 2014 and 2015. The data were collected from women (n = 38) obtaining a legal termination of pregnancy (TOP), or care for unsafe abortions (CUA). The women were recruited from four health facilities (two hospitals and two private clinics, one of each per district). At T2, CUA cost women, on average, 520 ZMW (USD 81), while TOP cost women, on average, 396 ZMW (USD 62). About two-thirds of the costs had been incurred by T1, while an additional one-third of the total costs was incurred between T1 and T2. Women in all three wealth tertiles sought a TOP in a health facility or an unsafe abortion outside a facility. Women who obtained CUA tended to be further removed from the money that was used to pay for their abortion care. Women's financial dependence leaves them unequipped to manage a financial shock such as an abortion. Improved TOP and post-abortion care are needed to reduce the health sequelae women experience after both types of abortion-related care.
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Affiliation(s)
- Ann M Moore
- a Principal Research Scientist , Guttmacher Institute , New York , NY , USA
| | | | - Ragnar Anderson
- c Research Associate , Guttmacher Institute , New York , NY , USA
| | | | | | - Giulia Greco
- e Assistant Professor and MRC Fellow (Economics of Health) , London School of Hygiene and Tropical Medicine , London , UK
| | - Bellington Vwalika
- f Head of Obstetrics and Gynaecology-UTH-Lusaka, Department of Obstetrics and Gynaecology, School of Medicine , University of Zambia , Lusaka , Zambia
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Predictors of Unsafe Induced Abortion among Women in Ghana. J Pregnancy 2019; 2019:9253650. [PMID: 30854238 PMCID: PMC6378005 DOI: 10.1155/2019/9253650] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 12/27/2018] [Accepted: 01/19/2019] [Indexed: 01/10/2023] Open
Abstract
Background Unsafe induced abortion is a major contributor to maternal morbidity and mortality in Ghana. Objective This study aimed to explore the predictors of unsafe induced abortion among women in Ghana. Methods The study used data from the 2017 Ghana Maternal Health Survey. The association between women's sociodemographic, obstetric characteristics, and unsafe induced abortion was explored using logistic regression. The analysis involved a weighted sample of 1880 women aged 15-49 years who induced abortion in the period 2012-2017. Analysis was carried out using STATA/IC version 15.0. Statistical significance was set at p <0.05. Results Of the 1880 women, 64.1% (CI: 60.97-67.05) had an unsafe induced abortion. At the univariate level, older women (35-49 years) (odds ratio=0.50, 95% CI: 0.28-0.89) and married women (odds ratio=0.61, 95% CI:0.44-0.85) were less likely to have an unsafe induced abortion while women who did not pay for abortion service (odds ratio=4.44, 95% CI: 2.24-8.80), who had no correct knowledge of the fertile period (odds ratio =1.47, 95% CI: 1.10-1.95), who did not know the legal status of abortion in Ghana (odds ratio =2.50, 95% CI: 1.68-3.72) and who had no media exposure (odds ratio =1.34, 95% CI: 1.04-1.73) had increased odds for an unsafe induced abortion. At the multivariable level, woman's age, payment for abortion services, and knowledge of the legal status of abortion in Ghana were predictors of unsafe induced abortion. Conclusion Induced abortion is a universal practice among women. However, unsafe abortion rate in Ghana is high and remains an issue of public health concern. We recommend that contraceptives and safe abortion services should be made available and easily accessible to women who need these services to reduce unwanted pregnancies and unsafe abortion rates, respectively, in the context of women's health. Also, awareness has to be intensified on abortion legislation in Ghana to reduce the stigma associated with abortion care seeking.
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Haaland MES, Haukanes H, Zulu JM, Moland KM, Michelo C, Munakampe MN, Blystad A. Shaping the abortion policy - competing discourses on the Zambian termination of pregnancy act. Int J Equity Health 2019; 18:20. [PMID: 30691459 PMCID: PMC6348644 DOI: 10.1186/s12939-018-0908-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 12/25/2018] [Indexed: 11/30/2022] Open
Abstract
Introduction The Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds, but access to safe abortion services is limited and this constitutes a considerable problem for rights to sexual and reproductive health. The case of Zambia provides an opportunity to explore the relationship between a legal framework that permits abortion on diverse grounds, the moral and political disputes around abortion and access to sexual and reproductive health services. Methods This paper draws upon eleven months of ethnographic fieldwork in Zambia. The fieldwork included 28 open-ended interviews with key stakeholders as well as the collection of archival material related to the origins of Zambia’s legal framework for abortion. The archival material and the interview data were analyzed thematically, using theoretical perspectives on discourse and the anthropology of policies. Results The study findings show that the Zambian case is not easily placed into standard categories of liberal or restrictive abortion laws. The archival material reveals that restrictive elements were in focus when the Zambian Termination of Pregnancy Act was passed (1972). The restrictive aspects of the law were emphasized further when Zambia was later declared as a Christian nation. Some of these restrictive elements are still readily recognized in today’s abortion debate. Currently there are multiple opinions on whether Zambian abortion policy is liberal, restrictive or neither. The law emerges as ambiguous, and this ambiguity is actively used by both those working to increase access to safe and legal abortion services, and those who work to limit such access. Coupled with a lack of knowledge about the law, its ambiguity may work to reduce access to safe abortion services on the grounds permitted by the law. Conclusions We argue that the Zambian Termination of Pregnancy Act is ambiguous and leaves much room for interpretation. This paper challenges the notion that the Zambian abortion law is liberal and opens up for further discussion on the relationship between how a law is described and perceived by the public, and the rights to health and services ensured by it.
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Affiliation(s)
- Marte E S Haaland
- Centre for international Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway. .,Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway.
| | - Haldis Haukanes
- Department of Health Promotion and Development, University of Bergen, Bergen, Norway
| | | | - Karen Marie Moland
- Centre for international Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
| | - Charles Michelo
- School of Public Health, University of Zambia, Lusaka, Zambia
| | | | - Astrid Blystad
- Centre for international Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Centre for Intervention Science in Maternal and Child Health (CISMAC), University of Bergen, Bergen, Norway
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Freeman E, Coast E. Conscientious objection to abortion: Zambian healthcare practitioners' beliefs and practices. Soc Sci Med 2019; 221:106-114. [DOI: 10.1016/j.socscimed.2018.12.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 11/27/2022]
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