Abortion experiences among Zanzibari women: a chain-referral sampling study

Describing the safety of abortion at the population level using network-based survey approaches

BACKGROUND

Despite the negative impact of unsafe abortions on women's health and rights, the degree of abortion safety remains strikingly undocumented for a large share of abortions globally. Data on how women induce abortions (method, setting, provider) are central to the measurement of abortion safety. However, health-facility statistics and direct questioning in population surveys do not yield representative data on abortion care seeking pathways in settings where access to abortion services is highly restricted. Recent developments in survey methodologies to study stigmatized / illegal behaviour and hidden populations rely on the fact that such information circulates within social networks; however, such efforts have yet to give convincing results for unsafe abortions.

OBJECTIVE

This article presents the protocol of a study whose purpose is to apply and develop further two network-based methods to contribute to the generation of reliable population-level information on the safety of abortions in contexts where access to legal abortion services is highly restricted.

METHODS

This study plans to obtain population-level data on abortion care seeking in two Health and Demographic Surveillance Systems in urban Kenya and rural Burkina Faso by applying two methods: Anonymous Third-Party Reporting (ATPR) (also known as confidantes' method) and Respondent Driven Sampling (RDS). We will conduct a mixed methods formative study to determine whether these network-based approaches are pertinent in the study contexts. The ATPR will be refined notably by incorporating elements of the Network Scale-Up Method (NSUM) to correct or account for certain of its biases (transmission, barrier, social desirability, selection). The RDS will provide reliable alternative estimates of abortion safety if large samples and equilibrium can be reached; an RDS multiplex variant (also including social referents) will be tested.

DISCUSSION

This study aims at documenting abortion safety in two local sites using ATPR and RDS. If successful, it will provide data on the safety profiles of abortion seekers across sociodemographic categories in two contrasted settings in sub-Saharan Africa. It will advance the formative research needed to determine whether ATPR and RDS are applicable or not in a given context. It will improve the questionnaire and correcting factors for the ATPR, improve the capacity of RDS to produce quasi-representative data on abortion safety, and advance the validation of both methods.

A Qualitative Exploration of Factors Explaining Non-Uptake of Hormonal Contraceptives Among Adolescent Girls in Rural Ghana: The Adolescent Girls' Perspective

BACKGROUND

Adolescent pregnancy remains a public health concern globally. The use of hormonal contraceptive methods are proven ways of preventing pregnancies and in turn unsafe abortions. However, research shows that use of hormonal contraceptive methods is rather low among African adolescent girls, of which Ghana is no exception.

OBJECTIVE

This manuscript uses the socio-ecological model to guide our understanding of the factors associated with non-use of hormonal contraceptives among adolescent girls in Ghana.

METHODS

An explorative study was done using qualitative data collection methods. Two focus group discussions and sixteen in-depth interviews were conducted among adolescent girls aged 15-19 years (N = 38) in the Kintampo area of Ghana to determine factors affecting uptake of hormonal contraceptives.

RESULTS

Adolescents showed a lack of in-depth knowledge related to the different hormonal contraceptive types. Negative attitudes towards adolescent hormonal contraceptive use, fear of real and perceived side effects of hormonal contraceptives, lack of self-efficacy to use contraceptives, fear of disclosure of use and fear of societal stigma related to sexual intercourse and its related issues among adolescents may explain why adolescent girls in this context do not use hormonal contraceptive methods.

CONCLUSION

To promote hormonal contraceptives among adolescent girls, a combination of multifaceted social-psychological, personal and community level interventions are needed.

Disclosure to social network members among abortion-seeking women in low- and middle-income countries with restrictive access: a systematic review

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.

Insights into preventing female genital mutilation/cutting in Sri Lanka: a qualitative interpretative study

Background

FGM/C is a cultural practice associated with adverse health outcomes that involves the partial or complete removal of the external female genitalia or injury to the genitalia. FGM/C is a form of violence against women and girls. There are no laws that specifically outlaw FGM/C in Sri Lanka and no national prevalence data. There is a lack of evidence about this practice to inform prevention efforts required to achieve the Sustainable Development Goal (SDG) target 5.3.2, which focuses on the elimination of all harmful practices, including FGM/C.

Methods

We undertook a qualitative interpretative study to explore the knowledge and perceptions of community members, religious leaders and professionals from the health, legal and community work sectors in five districts across Sri Lanka. We aimed to identify strategies to end this practice.

Results

Two-hundred-and twenty-one people participated in focus group discussions and key informant interviews. A template analysis identified five top-level themes: Providers, procedures and associated rituals; demand and decision-making; the role of religion; perceived benefits and adverse outcomes; ways forward for prevention.

Conclusions

This study delivered detailed knowledge of FGM/C related beliefs, perceptions and practitioners and provided opportunities to develop an integrated programming strategy that incorporates interventions across three levels of prevention.

Beyond the law: Misoprostol and medical abortion in Dar es Salaam, Tanzania

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.

Health, life and rights: a discourse analysis of a hybrid abortion regime in Tanzania

BACKGROUND

Unsafe abortion continues to be a major hazard for maternal health in Sub-Saharan Africa, where abortion remains highly controversial and access to safe abortion services is unequally distributed. Although national abortion laws are central in indicating women's potential for accessing safe abortion services, the character of an abortion law may alone say little about national discursive abortion landscapes and access scenarios. The article calls for the study and problematization of the relationship between legal abortion frameworks on the one hand, and discourses surrounding abortion on the other, in an attempt to move closer to an understanding of the complexity of factors that influence knowledge about and access to safer abortion services. With the restrictive abortion law in Tanzania as a starting point, the paper explores the ways in which the major global abortion discourses manifest themselves in the country and indicate potential implications of a hybrid abortion regime.

METHODS

The study combined a review of major legal and policy documents on abortion, a review of publications on abortion in Tanzanian newspapers between 2000 and 2015 (300 articles), and 23 semi-structured qualitative interviews with representatives from central institutions and organizations engaged in policy- or practical work related to reproductive health.

RESULTS

Tanzania's abortion law is highly restrictive, but the discursive abortion landscape is diverse and is made manifest through legal- and policy documents and legal- and policy related disputes. The discourses were characterized by diverse frames of reference based in religion, public health and in human rights-based values, and as such reflect the major global discourses. Fairclough's concepts interdiscursivity and recontextualization were drawn upon to develop an understanding of how the concepts health, rights and life emerge across the discourses, but are employed in contrasting lines of argumentation in struggles for hegemony and legitimacy.

DISCUSSION AND CONCLUSIONS

The paper demonstrates that a hybrid discursive regime relating to abortion characterizes the legally restrictive abortion context of Tanzania. We argue that such a complex discursive landscape, which cuts across the restrictive - liberal divide, generates an environment that seems to open avenues for enhanced access to abortion related knowledge and services.

Legal rights to safe abortion: knowledge and attitude of women in North-West Ethiopia toward the current Ethiopian abortion law

OBJECTIVE

To assess women's knowledge and attitude toward Ethiopian current abortion law.

STUDY DESIGN

A quantitative, community-based cross-sectional survey.

METHODS

Women of reproductive age in three selected lower districts in Bahir Dar, North-West Ethiopia, were included. Multi-stage simple random sampling and simple random sampling were used to select the districts and respondents, respectively. Data were collected using a structured questionnaire comprising questions related to knowledge and attitude toward legal status of abortion and cases where abortion is currently allowed by law in Ethiopia. Descriptive statistics were used to summarize the data and multivariable logistic regression computed to assess the magnitude and significance of associations.

RESULTS

Of 845 eligible women selected, 774 (92%) consented to participate and completed the interview. A total of 512 (66%) women were aware of the legal status of the Ethiopian abortion law and their primary sources of information were electronic media such as television and radio (43%) followed by healthcare providers (38.7%). Among women with awareness of the law, 293 (57.2%) were poor in knowledge, 188 (36.7%) fairly knowledgeable, and 31 (6.1%) good in knowledge about the cases where abortion is allowed by law. Of the total 774 women included, 438 (56.5%) hold liberal and 336 (43.5%) conservative attitude toward legalization of abortion. In the multivariable logistic regression, age had a significant association with knowledge, whereas occupation had a significant association with attitude toward the law. Women who had poor knowledge toward the law were more likely to have conservative attitude toward the law (adjusted odds ratio, 0.40; 95% confidence interval, 0.23-0.61).

CONCLUSION

Though the Ethiopian criminal code legalized abortion under certain circumstances since 2005, a significant number of women knew little about the law and several protested legalization of abortion. Countries such as Ethiopia with high maternal mortality records need to lift high-impact interventions that would trigger women to understand and exercise their legal rights to safe abortion and other reproductive health securities.