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Willis B, Church K, Perttu E, Thompson H, Weerasinghe S, Macias-Konstantopoulos W. The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries. Sex Reprod Health Matters 2023; 31:2250618. [PMID: 37712508 PMCID: PMC10506426 DOI: 10.1080/26410397.2023.2250618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
Previous studies have found high levels of unintended pregnancy among female sex workers (FSW), but less attention has been paid to their abortion practices and outcomes. This study is the first to investigate abortion-related mortality among FSW across eight countries: Angola, Brazil, Democratic Republic of Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa. The Community Knowledge Approach (CKA) was used to survey a convenience sample of FSW (n = 1280). Participants reported on the deaths of peer FSW in their social networks during group meetings convened by non-governmental organisations (n = 165 groups, conducted across 24 cities in 2019). Details on any peer FSW deaths in the preceding five years were recorded. The circumstances of abortion-related deaths are reported here. Of the 1320 maternal deaths reported, 750 (56.8%) were due to unsafe abortion. The number of abortion-related deaths reported was highest in DRC (304 deaths reported by 270 participants), Kenya (188 deaths reported by 175 participants), and Nigeria (216 deaths reported by 312 participants). Among the abortion-related deaths, mean gestational age was 4.6 months and 75% occurred outside hospital. Unsafe abortion methods varied by country, but consumption of traditional or unknown medicines was most common (37.9% and 29.9%, respectively). The 750 abortion-related deaths led to 1207 children being left motherless. The CKA successfully recorded a stigmatised practice among a marginalised population, identifying very high levels of abortion-related mortality. Urgent action is now needed to deliver comprehensive sexual and reproductive healthcare to this vulnerable population, including contraption, safe abortion, and post-abortion care.
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Affiliation(s)
- Brian Willis
- Director, Global Health Promise, Portland, OR, USA
| | - Kathryn Church
- Independent Consultant, London, UK; Honorary Assistant Professor, Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emily Perttu
- Director of Data Analysis, Global Health Promise, Portland, OR, USA
| | - Heather Thompson
- Maternal Health Advisor, Global Health Promise, Portland, OR, USA; Adjunct Professor, Schulich School of Medicine, McMaster Faculty of Medicine; & Obstetrician/Gynecologist, Grey Bruce Health Services, Hamilton, Ontario, Canada
| | - Swarna Weerasinghe
- Biostatistician, Global Health Promise, Portland, OR, USA; Associate Professor, Department of Community Health and Epidemiology, Dalhousie University, Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Wendy Macias-Konstantopoulos
- Global Policy Advisor, Global Health Promise, Portland, OR, USA; Director, Center for Social Justice and Health Equity, Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Anjur-Dietrich S, Omoluabi E, OlaOlorun FM, Mosso R, Wood SN, Moreau C, Bell SO. Partner involvement in abortion trajectories and subsequent abortion safety in Nigeria and Côte d'Ivoire. BMC Womens Health 2022; 22:530. [PMID: 36528560 PMCID: PMC9759876 DOI: 10.1186/s12905-022-02115-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Unsafe abortions contribute to maternal mortality and morbidity worldwide, with disproportionate impacts in lower-income countries. Identifying factors associated with an elevated risk of experiencing an abortion under the most unsafe conditions is an important component of addressing this burden. The partner's role in obtaining a safe or unsafe abortion is not well understood. This study provides a quantitative assessment of the relationship between partner involvement and subsequent abortion safety. METHODS The data are drawn from the PMA2020 female surveys and abortion follow-up surveys, fielded in Nigeria and Côte d'Ivoire between 2018 and 2020. The sample includes 1144 women in Nigeria and 347 women in Côte d'Ivoire who reported having ever experienced an abortion. We assess partner involvement in discussing the abortion decision and/or in selecting the method or source and evaluate the relationship between partner involvement and most unsafe abortion (using non-recommended methods from a non-clinical source) versus safe or less safe abortion, adjusting for sociodemographic characteristics. RESULTS We find a strong association between experiencing any partner involvement and decreased odds of experiencing a most unsafe abortion (Nigeria: aOR = 0.34, 95% CI 0.26-0.45; Côte d'Ivoire: aOR = 0.27, 95% CI 0.16-0.47). Analyzing the two types of partner involvement separately, we find that partner involvement in the decision is associated with lower odds of most unsafe abortion in both countries (Nigeria: aOR = 0.48, 95% CI 0.39-0.72; Côte d'Ivoire: aOR = 0.34, 95% CI 0.19-0.60); partner involvement in selecting the method and/or source was only significantly associated with lower odds of most unsafe abortion in Nigeria (Nigeria: aOR = 0.53, 95% CI 0.39-0.72; Côte d'Ivoire: aOR = 0.65, 95% CI 0.32-1.32). CONCLUSION In Nigeria and in Côte d'Ivoire, respondents whose partners were involved in their abortion trajectory experienced safer abortions than those whose partners were not involved. These findings suggest the potential importance of including men in education on safe abortion care and persistent need to make safe abortion accessible to all, regardless of partner support.
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Affiliation(s)
- Selena Anjur-Dietrich
- grid.21107.350000 0001 2171 9311Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Elizabeth Omoluabi
- Centre for Research, Evaluation Resources and Development, Ile-Ife, Nigeria
| | - Funmilola M. OlaOlorun
- grid.9582.60000 0004 1794 5983Department of Community Medicine, University of Ibadan, Ibadan, Oyo Nigeria
| | - Rosine Mosso
- grid.508476.80000 0001 2107 3477École Nationale Supérieure de Statistique et d’Économie Appliquée, Abidjan, Côte d’Ivoire
| | - Shannon N. Wood
- grid.21107.350000 0001 2171 9311Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
| | - Caroline Moreau
- grid.21107.350000 0001 2171 9311Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA ,grid.7429.80000000121866389CESP Centre for Research in Epidemiology and Population Health, INSERM (Institut National de la Santé et de la Recherche Médicale), Villejuif, France
| | - Suzanne O. Bell
- grid.21107.350000 0001 2171 9311Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Strong J, Lamptey NLS, Quartey NK, Owoo NKR. "If I Am Ready": Exploring the relationships between masculinities, pregnancy, and abortion among men in James Town, Ghana. Soc Sci Med 2022; 314:115454. [PMID: 36274458 DOI: 10.1016/j.socscimed.2022.115454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022]
Abstract
The ability to exercise full sexual and reproductive health and rights is shaped by the contextual environment, meaning that women and pregnant people must navigate patriarchal norms when seeking care. Despite growing evidence that men are able to influence pregnancy outcomes, there remains a paucity of research on how and why men are able to involve themselves in pregnancy and abortion decision-making. This study interrogates the mechanisms that drive men's involvement in pregnancies and abortions in James Town, Ghana. Data from a survey (n = 296) and in-depth interviews (n = 37) were collected between July 2020 and January 2021. The mixed-method analysis critically examined the relationship between men's support for a pregnancy or abortion and their constructions of masculinities. Findings framed sex and reproduction as both a facilitator and a threat to men's masculinity. Reproduction was an essential component of being a man. Men discussed the need to fulfil masculine ideals of being independent, provide financially, and be in an acceptable relationship in order to be 'ready' for fatherhood. However, men similarly operationalised the notion of 'readiness' as the driving force behind their involvement in abortion decision-making. As being a father without being ready could lead to social ostracism and derision, men discussed forcing their abortion desires onto their sexual partners and other pregnant people. Achieving masculine ideals, therefore, was a critical motivation for controlling women and pregnant people's bodies. Understanding the role of masculinities is critical in acknowledging the contextual and environmental factors that women and pregnant people navigate, which contribute to continued reproductive injustices.
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Affiliation(s)
- Joe Strong
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, 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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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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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Katz AJ, Ramirez AM, Bercu C, Filippa S, Dirisu O, Egwuatu I, Nmezi S, Palmer L, Baum SE. “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] [What about the content of this article? (0)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Keogh SC, Otupiri E, Castillo PW, Li NW, Apenkwa J, Polis CB. Contraceptive and abortion practices of young Ghanaian women aged 15-24: evidence from a nationally representative survey. Reprod Health 2021; 18:150. [PMID: 34275462 PMCID: PMC8286596 DOI: 10.1186/s12978-021-01189-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/21/2021] [Indexed: 11/29/2022] Open
Abstract
Background Young Ghanaian women experience high rates of unmet need for contraception and unintended pregnancy, and face unique barriers to accessing sexual and reproductive health services. This study provides a comprehensive national analysis of young women’s contraceptive and abortion practices and needs. Methods In 2018, we conducted a nationally representative survey of women aged 15–49, including 1039 women aged 15–24. We used descriptive statistics, multivariable logistic and multinomial regression to compare young versus older (25–49 year-old) women’s preferred contraceptive attributes, reasons for discontinuing contraception, quality of counseling, use of Primolut N-tablet, method choice correlates, and friends’ and partners’ influence. We also examined youth’s self-reported abortion incidence, abortion methods, post-abortion care, and barriers to safe abortion. Results Among Ghanaian 15–24 year-olds who had ever had sex, one-third (32%) were using contraception. Compared to older women, they had higher desires to avoid pregnancy, lower ever use of contraception, more intermittent sexual activity, and were more likely to report pregnancies as unintended and to have recently ended a pregnancy. Young contraceptors most commonly used condoms (22%), injectables (21%), withdrawal (20%) or implants (20%); and were more likely than older women to use condoms, withdrawal, emergency contraception, and N-tablet. They valued methods for effectiveness (70%), no risk of harming health (31%) nor future fertility (26%), ease of use (20%), and no effect on menstruation (19%). Infrequent sex accounted for over half of youth contraceptive discontinuation. Relative to older women, young women’s social networks were more influential on contraceptive use. The annual self-reported abortion rate among young women was 30 per thousand. Over half of young women used abortion methods obtained from non-formal providers. Among the third of young women who experienced abortion complications, 40% did not access treatment. Conclusions Young people’s intermittent sexual activity, desire for methods that do not harm their health, access barriers and provider bias, likely contribute to their greater use of coital-dependent methods. Providers should be equipped to provide confidential, non-discriminatory counseling addressing concerns about infertility, side effects and alternative methods. Use of social networks can be leveraged to educate around issues like safe abortion and correct use of N-tablet. Young Ghanaian women can experience difficulties accessing sexual and reproductive health services, and many are not using contraception despite wanting to avoid pregnancy. To better understand their needs, we describe their preferences and behaviors around contraception and abortion. We surveyed a nationally representative sample of women aged 15–49, and compared young (15–24) versus older (25–49) women’s contraceptive preferences, reasons for stopping contraception, quality of counseling, friends’ and partners’ influence on contraceptive use, and use of abortion. One-third of 15–24 year-olds who ever had sex were using contraception. Compared to older women, young women’s pregnancies were more likely to be unintended and to end in abortion. Young women most commonly used condoms, injectables, withdrawal or implants; and were more likely than older women to use condoms, withdrawal, emergency contraception, and Primolut N-tablet. They preferred methods that were effective, did not harm their health or future fertility, were easy to use, and did not disrupt their menstrual cycle. Over half of young women who stopped contraception did so because they were not having sex regularly. Friends had more influence on contraceptive use among young women than older women. Each year on average, there were 30 abortions per 1000 young women. Over half of young women who had abortions used methods from non-formal providers, and 40% of those who had complications did not get treated. Providers should be equipped to provide confidential, non-discriminatory counseling about contraceptive side effects and options. Social networks can be used to educate women about safe abortion.
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Affiliation(s)
- Sarah C Keogh
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, 10038, USA.
| | - Easmon Otupiri
- Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Naomi W Li
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, 10038, USA
| | - Joana Apenkwa
- St. Michael's Nursing and Midwifery Training College, Pramso, Ghana
| | - Chelsea B Polis
- Guttmacher Institute, 125 Maiden Lane, 7th Floor, New York, NY, 10038, USA
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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: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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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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12
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Moseson H, Herold S, Filippa S, Barr-Walker J, Baum SE, Gerdts C. Self-managed abortion: A systematic scoping review. Best Pract Res Clin Obstet Gynaecol 2019; 63:87-110. [PMID: 31859163 DOI: 10.1016/j.bpobgyn.2019.08.002] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 12/20/2022]
Abstract
Self-managed abortion, when a person performs their own abortion without clinical supervision, is a model of abortion care used across a range of settings. To provide a comprehensive synthesis of the available literature on self-managed abortion, we conducted a systematic search for peer-reviewed research in April 2019 in PubMed, Embase, Web of Science, Popline, PsycINFO, Google Scholar, Scielo, and Redalyc. We included studies that had a research question focused on self-managed abortion; and were published in English or Spanish. The combined search returned 7167 studies; after screening, 99 studies were included in the analysis. Included studies reported on methods, procurement, characteristics of those who self-managed, effectiveness, safety, reasons for self-managed abortion, and emotional and physical experiences. Numerous abortion methods were reported, most frequently abortion with pills and herbs. Studies reporting on self-managed medication abortion reported high-levels of effectiveness. We identify gaps in the research, and make recommendations to address those gaps.
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Affiliation(s)
- Heidi Moseson
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
| | - Stephanie Herold
- Advancing New Standards in Reproductive Health, 1330 Broadway Suite 1100, Oakland, CA, 94612, USA.
| | - Sofia Filippa
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
| | - Jill Barr-Walker
- Zuckerberg San Francisco General (ZSFG) Library, University of California, 1001 Potrero Avenue, San Francisco, CA, 94110, USA.
| | - Sarah E Baum
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
| | - Caitlin Gerdts
- Ibis Reproductive Health, 1736 Franklin Street, Oakland, CA, 94612, USA.
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13
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Abstract
PURPOSE OF REVIEW Abortion services are essential in sexual and reproductive health and should be held to the same standards as other health services. Patient (or person)-centeredness is a key dimension of healthcare quality that incorporates the perspectives of patients in care provision. The purpose of this review is to summarize studies published in the last year examining women's experiences with abortion care and to describe facilitators and barriers to person-centered care. RECENT FINDINGS Considering person-centeredness in abortion care using dimensions of dignity, autonomy, privacy, communication, social support, supportive care and health facility environment allows for critical evaluation of data describing women's experiences with abortion and postabortion services. Review of the available literature shed light on the impact of social stigma, health policy and abortion restrictions on women's abortion experiences. SUMMARY Considering multiple domains and varied settings, current data suggest abortion services worldwide generally fail to provide person-centered care. Institutions and providers may be limited in their ability to provide patient-centered abortion care because of deeply embedded social stigma, institutional regulations and legal restrictions.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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