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Ba DM, Zhang Y, Pasha-Razzak O, Khunsriraksakul C, Maiga M, Chinchilli VM, Ssentongo P. Factors associated with pregnancy termination in women of childbearing age in 36 low-and middle-income countries. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001509. [PMID: 36963033 PMCID: PMC10021843 DOI: 10.1371/journal.pgph.0001509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 12/31/2022] [Indexed: 03/06/2023]
Abstract
Lack of access to safe, affordable, timely and adequate pregnancy termination care, and the stigma associated with abortion in low-middle income countries (LMICs), pose a serious risk to women's physical and mental well-being throughout the lifespan. Factors associated with pregnancy termination and their heterogeneity across countries in LMICs previously have not been thoroughly investigated. We aim to determine the relative significance of factors associated with pregnancy termination in LMICs and its variation across countries. Analysis of cross-sectional nationally representative household surveys carried out in 36 LMICs from 2010 through 2018. The weighted population-based sample consisted of 1,236,330 women of childbearing aged 15-49 years from the Demographic and Health Surveys. The outcome of interest was self-report of having ever had a pregnancy terminated. We used multivariable logistic regression models to identify factors associated with pregnancy termination. The average pooled weighted prevalence of pregnancy termination in the present study was 13.3% (95% CI: 13.2%-13.4%), ranging from a low of 7.8 (95% CI: 7.2, 8.4%) in Namibia to 33.4% (95% CI: 32.0, 34.7%) in Pakistan. Being married showed the strongest association with pregnancy termination (adjusted OR, 2.94; 95% CI, 2.84-3.05; P < 0.001) compared to unmarried women. Women who had more than four children had higher odds of pregnancy termination (adjusted OR, 2.45; 95% CI, 2.33-2.56; P < 0.001). Moreover, increased age and having primary and secondary levels of education were associated with higher odds of pregnancy termination compared to no education. In this study, married women, having one or more living children, those of older age, and those with at least primary level of education were associated with pregnancy termination in these 36 LMICs. The findings highlighted the need of targeted public health intervention to reduce unintended pregnancies and unsafe abortions.
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Affiliation(s)
- Djibril M Ba
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States of America
| | - Yue Zhang
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States of America
| | - Omrana Pasha-Razzak
- Department of Medicine, Division of Hospital Medicine, Penn State Health Medical Center, Hershey, Pennsylvania, United States of America
| | - Chachrit Khunsriraksakul
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States of America
| | - Mamoudou Maiga
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, United States of America
| | - Vernon M Chinchilli
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States of America
| | - Paddy Ssentongo
- Department of Public Health Sciences, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States of America
- Department of Medicine, Penn State Health Medical Center, Hershey, Pennsylvania, United States of America
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Lindberg LD, Maddow‐Zimet I, Mueller J, VandeVusse A. Randomized experimental testing of new survey approaches to improve abortion reporting in the United States. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2022; 54:142-155. [PMID: 36511507 PMCID: PMC10107886 DOI: 10.1363/psrh.12217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
CONTEXT Abortions are substantially underreported in surveys due to social stigma, compromising the study of abortion, pregnancy, fertility, and related demographic and health outcomes. METHODS In this study, we evaluated six methodological approaches identified through formative mixed-methods research to improve the measurement of abortion in surveys. These approaches included altering the placement of abortion items in the survey, the order of pregnancy outcome questions, the level of detail, the introduction to the abortion question, and the context of the abortion question, and using graduated sensitivity. We embedded a preregistered randomized experiment in a newly designed online survey about sexual and reproductive health behaviors (N = 6536). We randomized respondents to experimental arms in a fully crossed factorial design; we estimated an average treatment effect using standardized estimators from logistic regression models, adjusted for demographic covariates associated with reporting. RESULTS None of the experimental arms significantly improved abortion reporting compared to the control condition. CONCLUSION More work is needed to improve reporting of abortion in future surveys, particularly as abortion access becomes increasingly restricted in the United States. Despite this study's null results, it provides a promising path for future efforts to improve abortion measurement. It is proof of concept for testing new approaches in a less expensive, faster, and more flexible format than embedding changes in existing national fertility surveys.
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Affiliation(s)
- Laura D. Lindberg
- Department of Urban‐Global HealthRutgers School of Public Health (formerly at the Guttmacher Institute)PiscatawayNew JerseyUSA
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Yargawa J, Machiyama K, Ponce Hardy V, Enuameh Y, Galiwango E, Gelaye K, Mahmud K, Thysen SM, Kadengye DT, Gordeev VS, Blencowe H, Lawn JE, Baschieri A, Cleland J. Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study. Popul Health Metr 2021; 19:6. [PMID: 33557851 PMCID: PMC7869206 DOI: 10.1186/s12963-020-00227-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND An estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes. METHODS The EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017-2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight. RESULTS Missing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64-0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63-0.79), and report stillbirths (aOR 0.57, 95% CI 0.44-0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64-0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention. CONCLUSIONS We found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.
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Affiliation(s)
- Judith Yargawa
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Kazuyo Machiyama
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Victoria Ponce Hardy
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Yeetey Enuameh
- Kintampo Health Research Centre, Kintampo, Ghana
- Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Edward Galiwango
- IgangaMayuge Health and Demographic Surveillance System, Makerere University Centre for Health and Population Research, Makerere, Uganda
| | - Kassahun Gelaye
- Dabat Research Centre Health and Demographic Surveillance System, Dabat, Ethiopia
- Department of Epidemiology and Biostatistics, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Kaiser Mahmud
- Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh
| | - Sanne M. Thysen
- Bandim Health Project, Bissau, Guinea-Bissau
- Research Centre for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Research Open Patient data Explorative Network (OPEN), University of Southern Denmark, Odense, Denmark
| | - Damazo T. Kadengye
- Data, Measurement and Evaluation Unit, African Population and Health Research Centre, Nairobi, Kenya
| | - Vladimir Sergeevich Gordeev
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Hannah Blencowe
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Joy E. Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Angela Baschieri
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - John Cleland
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
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Kwesiga D, Tawiah C, Imam MA, Tesega AK, Nareeba T, Enuameh YAK, Biks GA, Manu G, Beedle A, Delwar N, Fisker AB, Waiswa P, Lawn JE, Blencowe H. Barriers and enablers to reporting pregnancy and adverse pregnancy outcomes in population-based surveys: EN-INDEPTH study. Popul Health Metr 2021; 19:15. [PMID: 33557858 PMCID: PMC7869448 DOI: 10.1186/s12963-020-00228-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Risks of neonatal death, stillbirth and miscarriage are highest in low- and middle-income countries (LMICs), where data has most gaps and estimates rely on household surveys, dependent on women reporting these events. Underreporting of pregnancy and adverse pregnancy outcomes (APOs) is common, but few studies have investigated barriers to reporting these in LMICs. The EN-INDEPTH multi-country study applied qualitative approaches to explore barriers and enablers to reporting pregnancy and APOs in surveys, including individual, community, cultural and interview level factors. METHODS The study was conducted in five Health and Demographic Surveillance System sites in Guinea-Bissau, Ethiopia, Uganda, Bangladesh and Ghana. Using an interpretative paradigm and phenomenology methodology, 28 focus group discussions were conducted with 82 EN-INDEPTH survey interviewers and supervisors and 172 women between February and August 2018. Thematic analysis was guided by an a priori codebook. RESULTS Survey interview processes influenced reporting of pregnancy and APOs. Women found questions about APOs intrusive and of unclear relevance. Across all sites, sociocultural and spiritual beliefs were major barriers to women reporting pregnancy, due to fear that harm would come to their baby. We identified several factors affecting reporting of APOs including reluctance to speak about sad memories and variation in recognition of the baby's value, especially for APOs at earlier gestation. Overlaps in local understanding and terminology for APOs may also contribute to misreporting, for example between miscarriages and stillbirths. Interviewers' skills and training were the keys to enabling respondents to open up, as was privacy during interviews. CONCLUSION Sociocultural beliefs and psycho-social impacts of APOs play a large part in underreporting these events. Interviewers' skills, careful tool development and translation are the keys to obtaining accurate information. Reporting could be improved with clearer explanations of survey purpose and benefits to respondents and enhanced interviewer training on probing, building rapport and empathy.
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Affiliation(s)
- Doris Kwesiga
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Centre of Excellence for Maternal Newborn and Child Health Research, Makerere University, Kampala, Uganda
- Department of Women and Children’s Health, Uppsala University, Uppsala, Sweden
| | | | - Md Ali Imam
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Adane Kebede Tesega
- Dabat Research Centre Health and Demographic Surveillance System, Dabat, Ethiopia
- Department of Health Systems and Policy, University of Gondar Institute of Public Health, Gondar, Ethiopia
| | - Tryphena Nareeba
- IgangaMayuge Health and Demographic Surveillance System, Makerere University Centre for Health and Population Research, Makerere, Uganda
| | - Yeetey A K Enuameh
- Kintampo Health Research Centre, Kintampo, Ghana
- Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Gashaw A. Biks
- Dabat Research Centre Health and Demographic Surveillance System, Dabat, Ethiopia
- Department of Health Systems and Policy, University of Gondar Institute of Public Health, Gondar, Ethiopia
| | - Grace Manu
- Kintampo Health Research Centre, Kintampo, Ghana
| | - Alexandra Beedle
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Nafisa Delwar
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Ane B. Fisker
- Bandim Health Project, Bissau, Guinea-Bissau
- Research Centre for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
- Open Patient data Explorative Network (OPEN), Uni. of Southern Denmark, Odense, Denmark
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Centre of Excellence for Maternal Newborn and Child Health Research, Makerere University, Kampala, Uganda
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Joy E. Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Hannah Blencowe
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - the Every Newborn-INDEPTH Study Collaborative Group
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Centre of Excellence for Maternal Newborn and Child Health Research, Makerere University, Kampala, Uganda
- Department of Women and Children’s Health, Uppsala University, Uppsala, Sweden
- Kintampo Health Research Centre, Kintampo, Ghana
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Dabat Research Centre Health and Demographic Surveillance System, Dabat, Ethiopia
- Department of Health Systems and Policy, University of Gondar Institute of Public Health, Gondar, Ethiopia
- IgangaMayuge Health and Demographic Surveillance System, Makerere University Centre for Health and Population Research, Makerere, Uganda
- Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
- Bandim Health Project, Bissau, Guinea-Bissau
- Research Centre for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
- Open Patient data Explorative Network (OPEN), Uni. of Southern Denmark, Odense, Denmark
- Centre of Excellence for Maternal Newborn and Child Health Research, Makerere University, Kampala, Uganda
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Tollman SM, Byass P, Waiswa P, Blencowe H, Yargawa J, Lawn JE. Count Every Newborn: EN-INDEPTH study to improve pregnancy outcome measurement in population-based surveys. Popul Health Metr 2021; 19:5. [PMID: 33557864 PMCID: PMC7868673 DOI: 10.1186/s12963-020-00243-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Stephen M Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Agincourt, South Africa
- Division of Health and Population, University of the Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Peter Byass
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, Makerere University School of Public Health, Kampala, Uganda
- Centre of Excellence for Maternal Newborn and Child Health Research, Makerere University, Kampala, Uganda
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Hannah Blencowe
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Judith Yargawa
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive & Child Health (MARCH) Centre, London School of Hygiene & Tropical Medicine, London, UK.
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