To keep or not to keep? Decision making in adolescent pregnancies in Jamestown, Ghana

« Éloigne cette honte de moi! »: une étude qualitative des normes sociales entourant les expériences d’avortement chez les adolescentes et jeunes femmes au Bénin

In Africa, the rights of adolescent girls and young women in terms of sexual and reproductive health are strongly influenced by social norms. This article delves into the pivotal role these norms play in the abortion decisions and experiences of young women aged 15-24 in Benin. An ethnographic approach was adopted for data collection among young women who have undergone abortion, their confidants, and other community members. The findings reveal that these young women face a threefold normative burden in their social environment. They juggle contradictory norms that simultaneously stigmatise early pregnancies, hinder proper sexual education, and strongly condemn abortion. These normative pressures often drive their resort to abortions, typically carried out under unsafe conditions. The study also highlights the significant role parents play in the abortion decisions and processes of teenagers under 20. When men are involved in seeking care for abortion, adolescents and young women usually access safer procedures. However, their access to aftercare and contraception following an abortion is hindered by the social norms of healthcare professionals. In addition to broadening the conditions of access to abortion in Benin in October 2021, it is imperative to implement interventions centred on value clarification, raising awareness of adolescents' rights, combating obstetric violence, and social stigmatisation. These measures are crucial to alleviate the weight of social norms bearing down on these young women. DOI: 10.1080/26410397.2023.2294793.

Healthcare Professionals' Perceptions about the Implementation of Shared Decision-Making in Primary Care: A Qualitative Study from a Virtual Community of Practice

Background

The incorporation of shared decision making (SDM) is a central part of empowerment processes, as it facilitates greater activation on the part of patients, increasing the likelihood of them gaining control over their healthcare and developing skills to solve their health problems. Despite these benefits, there are still difficulties in the implementation of SDM among healthcare professionals due to internal and external factors related to the context and health systems.

Aim

To explore primary care professionals (PCPs)' perceptions of the SDM model, based on their preconceptions and experience in clinical practice.

Methods

A framework analysis was conducted on qualitative data derived from a virtual community practice forum, within a cluster-randomized clinical trial developed in the e-MPODERA project.

Results

The most important points in the opinions of the PCPs were: exploring the patients' values, preferences and expectations, providing them with and checking their understanding of up-to-date and evidence-based health information. The analysis revealed three themes: determinants of the implementation process of SDM, lack of consistency and dilemmas and benefits of PCP active listening, motivation and positive expectations of SDM.

Discussion

In our initial analysis, we examined the connections between the categories of the TDC model and its application in the primary care context. The categories related to the model reflect the theoretical understanding of professionals, while those related to perceptions of its application and use show certain discrepancies. These discrepancies could indicate a lack of understanding of the model and its real-world implications or insufficient commitment on the part of professionals or the organization to ensure its effective implementation.

Conclusions

Specific targeted training that addresses knowledge, attitudes and practice may resolve the aforementioned findings.

Perceptions and attitudes of Rohingya community stakeholders to pregnancy termination services: a qualitative study in camps of Cox's Bazar, Bangladesh

BACKGROUND

Rohingya women suffer from inaccessibility to sexual and reproductive health services in Myanmar. After the forcible displacement of the Rohingya from Myanmar to Bangladesh in 2017, pregnancy termination services have been increasingly important and desired, while knowledge gaps and obstacles to access services still exist. The role of community stakeholders is critical as gatekeepers and decision-makers to improve and strengthen pregnancy termination services for women in camps. However, there is paucity of evidence on their perspectives about pregnancy termination. This qualitative study aims to understand the perception and attitudes of Rohingya community stakeholders to pregnancy termination in the camps of Cox's Bazar.

METHODS

We used purposive sampling to select 48 participants from the community stakeholders, 12 from each group: majhis (Rohingya leaders), imams (religious leaders), school teachers, and married men. We conducted in-depth interviews of all the participants between May-June 2022 and October-November 2022. Data were coded on Atlas.ti and analysed using a thematic content analysis approach.

RESULTS

Multiple socio-cultural and religious factors, gendered norms and stigma associated with pregnancy termination acted as barriers to women seeking services for it. From a religious stance, there was greater acceptance of pregnancy termination in the earlier period than in the later period of pregnancy. We observed that pregnancy termination among community stakeholders in earlier stages of pregnancy than later. However, circumstances, such as a woman's marital status, whether she sought her husband's permission or her ability of childcare capacity, were often framed by community stakeholders as 'acceptable' for pregnancy termination. Health concerns and social and contextual factors can influence community stakeholders supporting pregnancy termination.

CONCLUSIONS

The community stakeholders perspectives on barriers and enablers of pregnancy termination were variable with the context. These perspectives may support or impede women's ability to choice to seek pregnancy termination services. To improve women's choice to pregnancy termination, it is critical to consider roles of community stakeholders in creating their supporting attitudes to women's choice and access, and to designing targeted culturally appropriate interventions with communities support and engagement.

Factors Influencing Abortion Decision-Making of Adolescents and Young Women: A Narrative Scoping Review

INTRODUCTION

Globally, about half of all induced abortions have been estimated to be unsafe, which results in 13% of maternal deaths yearly. Of these induced abortions, 41% of unsafe abortions have been reported in young women who are dependent on their parents for their livelihood. They are often left in a vulnerable position and may have difficulty in making a decision regarding abortion. This study aimed to (1) characterize and map factors that influence abortion decision-making of adolescents and young women, and (2) identify the care and support that they need in their decision-making process.

METHODS

We conducted a scoping review following the JBI method and PRISMA-ScR checklist. We comprehensively searched MEDLINE (PubMed), Embase, Cochrane Library, CINAHL, and PsycInfo, and hand searched publications in the Google Scholar database between November 2021 and October 2023. The search included all English language qualitative and mixed methods research articles published on the database up to October 2023 that included participants aged 10-24 years. The CASP checklist was used as a guide for the qualitative analysis. NVivo was used to synthesize the findings.

RESULTS

There were 18 studies from 14 countries (N = 1543 young women) that met the inclusion criteria. Three domains and eleven categories were included as follows: personal (desire for self-realization and unwanted pregnancy), interpersonal (parental impact, reaction of partner, roles of peers and friends, existence of own child, and lack of support), and social circumstances (sexual crime, financial problem, limitation of choice, and underutilized healthcare services). Decision-making factors regarding abortions were also found across all three domains.

CONCLUSION

The abortion decision-making of young women is influenced by various external factors regardless of country. Parents are especially influential and tend to force their daughters to make a decision. Young women experienced suffering, frustration, and lack of autonomy in making decisions based on their preference. This emphasizes the importance of autonomous decision-making. In this regard, healthcare services should be used. However, there are barriers to accessing these services. To improve such access, the following are required: staff training to provide adolescent and youth-friendly health services, counseling based on women's needs, counseling including the parents or guardians that is confidential and ethical, promotion of decision aids, and affordable accessible care.

Access to adolescent sexual and reproductive health services in Accra, Ghana: An exploratory qualitative study

Nearly 31% of the Ghanaian population are adolescents, and these populations persistently face high rates of teenage pregnancies and unsafe abortions. This is despite sexual and reproductive health (SRH) being taught in the school curriculum. In this qualitative study, we explore the factors affecting adolescents' access to, and experiences of, SRH services in Accra, Ghana. We conducted 12 focus group discussions (FGDs) with adolescents and 13 key informant interviews (KIs) in Ghana. The FGDs were conducted with school-going and out-of-school adolescents. KIIs were conducted with various stakeholders working with adolescents or in SRH services. All interviews were conducted in English, audio recorded and transcribed verbatim. We applied the Dahlgren-Whitehead Rainbow model of health determinants and used a thematic analysis. Eight themes were identified, across micro, meso and macro levels, that influence adolescents' SRH access and experience in Accra. These included: family, social networks, the role of schools, health providers and services, the policy landscape, gender norms, cultural norms, and poverty. The findings highlight several factors that influence adolescents' access to appropriate SRH services in this context and demonstrate the need for a multisectoral effort to address structural factors such as harmful gender norms and persistent poverty.

Women leaders perceived barriers and consequences of safe abortion in Rwanda: a qualitative study

BACKGROUND

Between 2010 and 2014, approximately 25 million unsafe abortions were performed annually across the globe. Africa alone accounted for 29% of all unsafe abortions, and 62% of the related deaths. Women living in poverty, especially adolescents, lack information about where and how to access safe abortion services. They often lack adequate insight to make informed decisions. The purpose of this study was to explore the empowered perspectives of women leaders in Rwanda about the recent policy change for safe abortion. The study identifies women leaders' perceived barriers and their attitudes about resulting consequences toward safe abortion.

METHOD

In this qualitative study, seven focus group discussions and eight key informant interviews were performed in October 2019. A total of 51 women leaders participated, their age ranging from 38 to 60 years. Participants were drawn from three districts, namely Gasabo, Kicukiro, and Nyarugenge. For variability of data, participants came from parliament, government ministries, government parastatals, and civil society organizations. All interviews were conducted in Kinyarwanda and later translated into English. Data were analyzed using qualitative content analysis.

RESULTS

The emerging theme Strong barriers and numerous consequences of safe abortion illustrates how women leaders perceive barriers to safe abortion and its related consequences in Rwanda. The theme is divided into two categories: (1) Perceived barriers of safe abortion and (2) Consequences of providing safe abortion. The sub-categories for the first category are Reluctance to fully support safe abortion due to perceived unjustified abortions", Abortion-related stigma, Abortion is against cultural and religious beliefs, Emotional attachment to the unborn and Lack of awareness of abortion. The sub-categories for the second category are Perceived physiological trauma, Cause for barrenness/infertility, Increase in services abuse by adolescents/women, Increase of workload for healthcare providers, "Increase in sexual activities and STIs, and Abortion-related physiological trauma.

CONCLUSION

The subject of safe abortion evokes mixed reactions among participants, and is entangled with unsafe abortion in most cases. Participants stress that the word 'abortion' disturbs, regardless of whether it relates to being safe or unsafe. Participants believe the word 'abortion' outweighs the word 'safe'. Societal expectations play a major role in the decision-making process of any adolescent or a family member faced with a pregnant adolescent regardless of the existing safe abortion law. Community mobilization and sensitization are crucial if safe abortion in accordance with abortion law is to be embraced. Messages that reinforce safe abortion as acceptable and address stigma, fears of trauma, and barrenness should be developed to educate adolescents, parents, and women leaders about safe abortion, to mitigate unsafe abortion-related complications.

The Effects of Pregnancy: A Systematic Review of Adolescent Pregnancy in Ghana, Liberia, and Nigeria

There is a high incidence of adolescent pregnancy in West Africa. The objective of this study is to highlight the health impacts of adolescent pregnancy through a systematic review. A search was conducted in the electronic databases of Google, Google Scholar, SCOPUS, EBSCO, CINAHL, Web of Science, African Journals Online (AJOL), and the Demographic Health Surveys (DHS) Program. The study found anemia, complications of pregnancy, obstetric and gynecological risks, unsafe abortions, and psychological effects to adversely impact the health of adolescent girls in Ghana, Liberia, and Nigeria. Pregnancy could be deleterious to the health and well-being of adolescent girls in various forms. In addition, adolescent pregnancy could expose adolescent girls to gender-based violence, exclusions, and inequities, be detrimental to upholding women's sexual and reproductive health rights, and could also have implications for Sustainable Development Goal 3. Targeted interventions to prevent pregnancy in young women and mitigate these effects by stakeholders are encouraged.

Abortion decision-making process trajectories and determinants in low- and middle-income countries: A mixed-methods systematic review and meta-analysis

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).

Socio-cultural factors influencing adolescent pregnancy in Ghana: a scoping review

Background

Adolescent pregnancy is a public health challenge that has well-defined causes, associated health risks, and social and economic consequences for adolescent, their families, communities, and society. The purpose of this scoping review is to summarize studies published on socio-cultural determinants of adolescent pregnancy in Ghana.

Methods

Search for records was done in four major databases, including PubMed CENTRAL, Science Direct and JSTOR. Records from Google and Google Scholar were also added, and results and findings from published and unpublished studies were included. All the 22 studies that met the eligibility criteria, were critically appraised. The guidelines for conducting scoping reviews by Arksey and O’Malley were followed.

Results

The result revealed that poverty, peer influence, low level of education, dysfunctional family, lack of communication between parents and their daughters, lack of sexual and reproductive health education, child marriage, coerced sex, misconception and non-usage of contraceptives, and decline in cultural values such as puberty rites and virginity inspection are some of the determinants of adolescent pregnancy in Ghana. The study also showed that there is a lack of high-quality observational studies that adjust for confounding variables.

Conclusion

Interventions and policies should be designed to take into consideration the needs, context, and background of adolescents. Programmes to enhance adolescent reproductive health need to consider multilevel factors such as person, family, community, institutions, national, and global issues that affect such programmes.

Patterns of Socioeconomic Inequities in SDGs Relating to Children's Well-Being in Thailand and Policy Implications

Thailand faces many wealth inequities and child health-related problems. This study aimed to describe Thai child health and determine socioeconomic inequities following the child flourishing index, a tool used to measure children's wellbeing based on the key relevant Sustainable Development Goals. The data from Thailand Multiple Indicator Cluster Survey 2019 were used to examine five indicators where Thailand had not yet achieved good results. The association of socioeconomic status with the five outcomes was explored using logistic regressions, comparing pseudo R-squared, and population attributable fraction analyses. Household wealth, urbanization, education, and primary language were significantly associated with Thai child health. Over 10% of children under 5 years were stunted and had a low birth weight. Fourteen percent of teenage girls had already become mothers. Living in poor households and rural areas, having a head-of-household who was non-Thai speaking, non-Buddhist, and had a low education were identified as risk factors for children with undernutrition status and low birth weight. However, having a head-of-household who spoke a non-Thai language was a protective factor against teenage mothers and having early marriages. Households with better economic status and education provided significant benefits for children and women's health. The result of this study calls for public policies and multisectoral actions in the wider social and economic spheres that address the social determinants that span across lives and generations. Furthermore, specific social protection programs should be designed to be accessible by these most vulnerable and disadvantaged people.

Perspective Chapter: Factors that Influence Young Women’s Decision-Making in Contraceptive Use in Ashiedu Keteke of Accra, Ghana

Every young woman has the right to reproductive health care. It is quite important for every woman to make an informed decision when choosing contraception. This is because women of today face a lot of challenges when it comes to the issue of reproductive health care. Young women choose contraception to prevent unwanted pregnancies and other reproductive health-related risks. The increase in abortion and pregnancy complication rates among young women is far too much and needs to be critically addressed to reduce maternal deaths (MD) and infant mortality. The decision made on the use of contraception by many young women has interfered with some factors that prevent them from making the right decisions. This piece is to identify those factors that influence young women’s reluctance of using contraception and how to promote contraceptive usage among Ghanaian women.

Ethical implications of the widespread use of informal mHealth methods in Ghana

BACKGROUND

Informal mHealth is widely used by community health nurses in Ghana to extend healthcare delivery services to clients who otherwise might have been excluded from formal health systems or would experience significant barriers in their quest to access formal health services. The nurses use their private mobile phones or devices to make calls to their clients, health volunteers, colleagues or superiors. These phone calls are also reciprocal in nature. Besides, the parties exchange or share other health data and information through text messages, pictures, videos or voice clips. There are some ethical dimensions that are inherent in these practices that ought to be critically scrutinised by bioethicists.

OBJECTIVE

The author has argued in this paper that informal mHealth at large scale adoption in Ghana is associated with some bioethical challenges.

METHODS

This essay was largely based on an analysis of an empirical study published by Hampshire et al in 2021 on the use of informal mHealth methods in Ghana.

RESULTS

Widespread adoption of Informal mHealth in Ghana is associated with privacy invasion of both the nurses and their clients, breaches confidentiality of the parties, discredits the validity of informed consent processes and may predispose the nurses to some other significant aggregated harms.

CONCLUSION

The author affirms his partial support for a formalised adoption process of informal mHealth in Ghana but has reiterated that the current ethical challenges associated with informal mHealth in Ghana cannot escape all the debilitating bioethical challenges, even if it is formalised.

Men's involvement in women's abortion-related care: a scoping review of evidence from low- and middle-income countries

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.

Contemplating abortion: a qualitative study of men and women’s reactions to unplanned pregnancy in Sierra Leone

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.

Identified needs of peripartum adolescents in Sub-Saharan Africa from 2013 to 2021: a mapping of domains for strengthening psychosocial interventions

Adolescent pregnancy and early motherhood pose significant socioeconomic and health risks in Sub-Saharan Africa, leading to considerable morbidity and mortality. To learn more about the needs of this population, we reviewed 24 articles featuring 21 samples covering 12,490 adolescents from 14 countries. Our coding revealed that adolescent mothers were studied more (85.7% of samples) than pregnant adolescents (61.9%). We summarized needs as per six categories. Resource needs were most prevalent, reported by 100% of samples, followed by ecology (85.7%), mental health (76.2%), medical (61.9%), other (61.9%), and education (33.3%). The most frequently reported resource needs were low income and unemployment. Low social support, low family functioning, and exposure to negative cultural norms were ecological needs prevalent in most samples. Among mental health concerns, depression was the most commonly reported problem, whereas other problems, such as anxiety, substance use, and suicidality, were reported much less frequently. HIV-positive status was the most frequently reported medical concern. Intervention developers should consider the range of challenges when designing psychosocial services for this population.

Individual and community-level factors associated with modern contraceptive use among adolescent girls and young women in Ethiopia: a multilevel analysis of 2016 Ethiopia demographic and health survey

Background

The importance of contraception use is immense for young girls of age 15–24 years. In literatures, there were significant attempts made to study factors associated with adolescent and young women contraception use in Africa. Despite the resulting interventions followed those studies, the contraception uses among youth population in Africa remained below average. Thus, this study is aimed to assess individual and community-level factors associated with contraceptive use in Ethiopian context to support further interventions.

Methods

Our analysis was based on the secondary data from Ethiopia Demography and Health Survey (EDHS) 2016. Adolescent girls and young women (AGYW) aged 15–24 years were the target population. Means, standard deviations, and proportions were used to describe the study population. To control for the variations due to the differences between clusters, a series of multilevel logistic regression modeling steps were followed and determinants of contraceptive use were outplayed. All variables with bivariate p-value < 0.25 were included in the models and p-value < 0.05 was used to declare associations.

Results

The prevalence of modern contraceptive use among AGYW in Ethiopia was 34.89% [95% CI, 0.32, 0.36]. Married adolescents were 2.01 times [AOR = 2.01, 95% CI = 1.39,3.16], having work was 1.36 times [AOR = 1.36, 95% CI = 1.06,1.71], living in urban areas was 1.61 times [AOR = 1.61, 95% CI = 1.16,2.45], being in middle wealth status was 1.9 times [AOR = 1.90, 95% CI = 1.32,2.65], being in rich wealth quintile was 1.99 time [AOR = 1.99, 95% CI = 1.35,2.68], and having TV exposure was 1.61 times [AOR = 1.6, 95% CI = 1.17,2.20] more likely associated with modern contraceptive uses.

Conclusion

The use of modern contraception among AGYW in the country remained appealing and factors like region, residence, marital status, wealth index, religion, working status, parity, husband desire children, ever aborted AGYW, and the television exposures were attributed for the poor improvements. Therefore, the enhancements that consult those factors remained remarkable in improving contraception use, while further increasing in educational engagement, access to health services, and economic empowerment of the AGYW might be the good advantages for the improvements.

Understanding the meaning of autonomy in adolescent pregnancy decision-making: lessons from Ghana

Introduction

adolescent pregnancy in Ghana, like in most low and middle income countries, is an issue of immense public health importance. Pregnant adolescents are faced with the stronger dilemma of either terminating the unwanted pregnancy or keeping it. This discourse which is based on findings from empirical research in Accra Ghana aims at contributing to the usefulness of understanding the meaning and scope of autonomy when it comes to providing ethically grounded, and adolescent friendly, reproductive health care services to pregnant adolescents. The aim of this work was to document the meaning and determinants of autonomous decision making among pregnant adolescents in the James Town area of Accra, Ghana.

Methods

thirty (30) semi-structured in depth interviews were conducted among adolescents who had been pregnant at least once, 23 in depth interviews among purposively selected stakeholders (parents, teachers, NGO staff working in reproductive health, community volunteers), and 8 focus group discussions among parents, teachers, adolescent students who had not been pregnant before, and adolescents who had at least one pregnancy in the past. Data were transcribed verbatim and analyzed thematically.

Results

most adolescents reported that the final decision to continue a pregnancy to term or go in for an abortion was taken by them. The partner´s willingness to take responsibility of the pregnant adolescent and baby, as well as financial considerations, were main players in deciding upon the pregnancy outcomes. Cultural desirability for children and health care provider/father paternalism (power dynamics) in the decision-making process were central considerations in the decision-making process. Unaffordable and unfriendly safe abortion services pushed adolescents to either continue pregnancies to term against their will, or opt to visit unsafe abortion care providers.

Conclusion

adolescents stand to make truly autonomous decisions if they are provided with the right information, at the right time, at the right place, by the right persons, and in the right way. Health system, economic, and cultural factors play significant roles in rendering pregnant adolescent autonomy meaningful when deciding upon their pregnancy outcomes. Continuing pregnancies to term against one´s will or being forced to go in for an abortion are ethically unjustified. Further research is required to examine the long-term consequences of forced pregnancy terminations or births.

Abortion decision-making trajectories and factors influencing such trajectories in low- and middle-income countries: a protocol for mixed-methods systematic review

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.

Beyond counting intended pregnancies among young women to understanding their associated factors in sub-Saharan Africa

Background

In this article we report the prevalence and determinants of intended or wanted pregnancies among young women 15–24 y of age in selected sub-Saharan African countries.

Methods

This cross-sectional study used pooled data from current Demographic and Health Surveys conducted between 1 January 2010 and 31 December 2019 in 29 countries in sub-Saharan Africa (SSA). The sample size comprised 14 257 young women (15–24 y of age). Multivariable binary logistic regression models were used to present the results as adjusted odds ratios.

Results

The prevalence of intended pregnancies was 67.7%, with the highest and lowest prevalence in Gambia (89.9%) and Namibia (37.7%), respectively. Intended pregnancy was lower among young women who had knowledge of modern contraceptives, those with a secondary/higher education and those with four or more births. Lower odds of intended pregnancy were observed among young women in the richer wealth quintile and those who lived in southern Africa.

Conclusions

To reduce intended pregnancies in sub-Saharan African countries such as Gambia, Burkina Faso and Nigeria, there is a need for government and non-governmental organisations to recalibrate current and past interventions such as investment in increasing formal education for women and poverty alleviation programmes, as well as augmenting job creation, including skill-building. These interventions have to be sensitive to the cultural realities of each setting, especially with regards to early marriages and womanhood.

Contraceptive and abortion practices of young Ghanaian women aged 15-24: evidence from a nationally representative survey

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.

Predictors of Pregnancy Termination among Young Women in Ghana: Empirical Evidence from the 2014 Demographic and Health Survey Data

Pregnancy termination remains a delicate and contentious reproductive health issue because of a variety of political, economic, religious, and social reasons. The present study examined the associations between demographic and socio-economic factors and pregnancy termination among young Ghanaian women. This study used data from the 2014 Demographic and Health Survey of Ghana. A sample size of 2114 young women (15-24 years) was considered for the study. Both descriptive (frequency, percentages, and chi-square tests) and inferential (binary logistic regression) analyses were carried out in this study. Statistical significance was pegged at p < 0.05. Young women aged 20-24 were more likely to have a pregnancy terminated compared to those aged 15-19 (AOR = 3.81, CI = 2.62-5.54). The likelihood of having a pregnancy terminated was high among young women who were working compared to those who were not working (AOR = 1.60, CI = 1.19-2.14). Young women who had their first sex at the age of 20-24 (AOR = 0.19, CI = 0.10-0.39) and those whose first sex occurred at first union (AOR = 0.57, CI = 0.34-0.96) had lower odds of having a pregnancy terminated compared to those whose first sex happened when they were less than 15 years. Young women with parity of three or more had the lowest odds of having a pregnancy terminated compared to those with no births (AOR = 0.39, CI = 0.21-0.75). The likelihood of pregnancy termination was lower among young women who lived in rural areas (AOR = 0.65, CI = 0.46-0.92) and those in the Upper East region (AOR = 0.18, CI = 0.08-0.39). The findings indicate the importance of socio-demographic factors in pregnancy termination among young women in Ghana. Government and non-governmental organizations in Ghana should help develop programs (e.g., sexuality education) and strategies (e.g., regular sensitization programs) that reduce unintended pregnancies which often result in pregnancy termination. These programs and strategies should include easy access to contraceptives and comprehensive sexual and reproductive health education. These interventions should be designed considering the socio-demographic characteristics of young women. Such interventions will help to achieve Sustainable Development Goal 3.1 that seeks to reduce the global maternal mortality ratio to fewer than 70 per 100,000 live births by 2030.

Barriers and motivators of contraceptive use among young people in Sub-Saharan Africa: A systematic review of qualitative studies

Background

In sub-Saharan Africa, about 80% of young women either use a traditional method or do not use any form of contraception at all. The objectives of this review were to ascertain the barriers and motivators of contraceptive use among young people in Sub–Saharan Africa.

Materials and methods

We conducted electronic literature searches in PubMed, EMBASE, Ebsco/PsycINFO and Scopus. We identified a total of 4,457 publications and initially screened 2626 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A total of 13 qualitative studies were retained for the final analysis based on the Joanna Briggs criteria for assessing qualitative studies. The systematic review is registered on PROSPERO with identifier CRD42018081877.

Results

Supportive social networks, respect for privacy and confidentiality, ready availability, affordability and accessibility of contraceptives, as well as the desire to prevent unintended pregnancy and sexually transmitted infections were the motivators of contraceptive use among young people in sub-Saharan Africa. Despite these motivators, myriad of personal, societal, and health systems-based barriers including myths and misconceptions, known side effects of contraceptives, prohibitive social norms, and negative attitude of health professionals were the major barriers to contraceptive use among young people.

Conclusion

Sub-Saharan African countries with widespread barriers to contraceptive use among young people may not be able to achieve the Sustainable Development Goal 3.8 target of achieving health for all by the year 2030. Interventions intended to improve contraceptive use need to be intersectoral and multi-layered, and designed to carefully integrate the personal, cultural, organizational and political dimensions of contraception.

Exploring the roles of men and masculinities in abortion and emergency contraception pathways, Ghana: a mobile phone-based mixed-methods study protocol

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.

Decision-making preferences and risk factors regarding early adolescent pregnancy in Ghana: stakeholders' and adolescents' perspectives from a vignette-based qualitative study

BACKGROUND

Worldwide, over half of the adolescent pregnancies recorded are unintended. The decision to continue the pregnancy to term or to opt for an abortion is a constant dilemma that is directly or indirectly influenced by stakeholders and also by the wider social environment. This study aimed at understanding the perceived decision-making preferences and determinants of early adolescent pregnancy in the Jamestown area of Accra in Ghana.

METHODS

A vignette-based qualitative study design was used. Eight focus group discussions were carried among various purposively selected groups of participants: parents, teachers, adolescent students who had not been pregnant before, and adolescents who had had at least one pregnancy in the past. The vignette was a hypothetical case of a 15-year-old high school student who had not experienced her menses for the past 6 weeks. The data were analyzed using a thematic analysis approach.

RESULTS

Lack of parent-daughter communication, the taboo on discussing sex-related issues in households and weak financial autonomy were considered to be the main contributing factors to the high early adolescent pregnancy rates in the community. Partner readiness to assume responsibility for the girl and the baby was a key consideration in either continuing the pregnancy to term or opting for an abortion. The father was overwhelmingly considered to be the one to take the final decision regarding the pregnancy outcome. Irrespective of the fact that the respondents were very religious, opting for an abortion was considered acceptable under special circumstances, especially if the pregnant adolescent was doing well in school.

CONCLUSION

Inadequate and inappropriate communication practices around sexuality issues, as well as weak financial autonomy are the major predictors of early adolescent pregnancy in this community. The father is perceived to be the main decision maker regarding a young adolescent's pregnancy outcome. Policy-makers should carefully evaluate the implications of this overwhelming perceived desire for the father to be the final decision-maker regarding adolescent pregnancy outcomes in this community.

Attitudes towards abortion and decision-making capacity of pregnant adolescents: perspectives of medicine, midwifery and law students in Accra, Ghana

Objectives: Because medical, midwifery and law students in Ghana constitute the next generation of health care and legal practitioners, this study aimed to evaluate their attitudes towards abortion and their perceptions of the decision-making capacity of pregnant adolescents.Methods: We conducted a cross-sectional survey among 340 medical, midwifery and law students. A pretested and validated questionnaire was used to collect relevant data on respondents' sociodemographic characteristics, attitudes towards abortion and the perceived capacity and rationality of pregnant adolescents' decisions. The χ² test of independency and Fischer's exact test were used where appropriate.Results: We retained 331 completed questionnaires for analysis. Respondents' mean age was 21.0 ± 2.9 years and the majority (95.5%) were of the Christian faith. Women made up 77.9% (n = 258) of the sample. Most students (70.1%) were strongly in favour of abortion if it was for health reasons. More than three-quarters (78.0%) of the students strongly disagreed on the use of abortion for the purposes of sex selection. Most respondents (89.0%) were not in favour of legislation to make abortion available on request for pregnant adolescents, with medical students expressing a more negative attitude compared with law and midwifery students (p < 0.001). Over half of the midwifery students (52.6%) believed that adolescents should have full decision-making capacity regarding their pregnancy outcome, compared with law and medical students (p < 0.001).Conclusion: Tensions between adolescent reproductive autonomy, the accepted culture of third party involvement (parents and partners), and the current abortion law may require keen reflection if an improvement in access to safe abortion services is envisioned.