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Dozier JL, Burke AE, McMahon HV, Berger BO, Quasebarth M, Sufrin C, Bell SO. "Maybe if we weren't in the pandemic, I would have reconsidered": Experiences of abortion care-seeking during the COVID-19 pandemic in Maryland. Perspect Sex Reprod Health 2024. [PMID: 38655782 DOI: 10.1111/psrh.12265] [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] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE To understand the COVID-19 pandemic's impact on abortion care-seeking in Maryland, a state with Medicaid coverage for abortion, high service availability, and laws supporting abortion rights. METHODS We conducted semi-structured telephone interviews with 15 women who had an abortion between January 2021 and March 2022 at a hospital-based clinic in a mid-sized Maryland city. We purposively recruited participants with varied pandemic financial impacts. Interview questions prompted participants to reflect on how the pandemic affected their lives, pregnancy decisions, and experiences seeking abortion care. We analyzed our data for themes. RESULTS All participants had some insurance coverage for their abortion; over half paid using Medicaid. Many participants experienced pandemic financial hardship, with several reporting job, food, and housing insecurity as circumstances influencing their decision to have an abortion. Most women who self-reported minimal financial hardship caused by the pandemic indicated they sought an abortion for reasons unrelated to COVID-19. In contrast, women with economic hardship viewed their pregnancies as unsupportable due to COVID-19 exacerbating financial instability, even when they desired to continue the pregnancy. All participants expressed that having an abortion was the best decision for their lives. Yet, when making decisions about their pregnancy, the most financially disadvantaged women weighed their desires against the pandemic's constraints on their reproductive self-determination. CONCLUSIONS The pandemic changed abortion care-seeking circumstances even in a setting with minimal access barriers. Financial hardship influenced some women to have an abortion for a pregnancy that-while unplanned-they may have preferred to continue.
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Affiliation(s)
- Jessica L Dozier
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anne E Burke
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hayley V McMahon
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Blair O Berger
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Madeline Quasebarth
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Carolyn Sufrin
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Ngondo D, Karp C, Kayembe D, Basile KS, Moreau C, Akilimali P, Bell SO. Abortion information-seeking experiences among women who obtained abortions in Kinshasa, DRC: Results from a qualitative study. PLOS Glob Public Health 2024; 4:e0002383. [PMID: 38381761 PMCID: PMC10880974 DOI: 10.1371/journal.pgph.0002383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/22/2023] [Indexed: 02/23/2024]
Abstract
Little is known about the process of seeking information related to abortion care options among women in the Democratic Republic of Congo (DRC). Understanding how women obtain information can help identify opportunities for intervention to increase awareness and use of safe pregnancy termination options. Using qualitative data collected from women in Kinshasa, DRC who reported having an abortion in the last 10 years, this study aims to determine how women navigate obtaining information about their options for abortion and the role of their social network in their information-seeking processes. Data for this analysis come from a mixed-method study of abortion in Kinshasa conducted from December 2021 to April 2022. Fifty-two qualitative interviews followed a structured interview guide, including open-ended questions and probes, developed by a multidisciplinary team of researchers in Kinshasa and the United States. Inductive thematic analysis was conducted using Atlas.ti, and a thematic analysis matrix was used to describe the major themes and subthemes. Thematic analysis revealed two main themes with nested subthemes. The first and most salient theme highlighted the highly selective and narrow information search process women engaged in, involving no others or very few individuals (e.g., partners, women in one's community, or providers) that the pregnant woman chose strategically. The second theme revealed the heterogeneous and often stigmatizing nature of these interactions, including attempts at deterrence from many sources and information of varying completeness and accuracy. While the recent liberalization of the abortion law in the DRC is essential to improve access to safe abortion, public health gains will not materialize unless they are accompanied by community-level actions to raise awareness about the legality and availability of safe abortions services, including medication abortion pills for safe self-managed abortion.
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Affiliation(s)
- Denise Ngondo
- Department of Biostatistical Epidemiology, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Dynah Kayembe
- Department of Biostatistical Epidemiology, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Kisulu Samyonga Basile
- Department of Biostatistical Epidemiology, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France
| | - Pierre Akilimali
- Department of Nutrition, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Bell SO, Makumbi F, Sarria I, Kibira SPS, Zimmerman LA. Reproductive autonomy and the experience of later-than-desired pregnancy: results from a cross-sectional survey of reproductive-aged women in Uganda. Reprod Health 2024; 21:20. [PMID: 38321541 PMCID: PMC10848551 DOI: 10.1186/s12978-024-01750-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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/30/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND The focus of reproductive autonomy research has historically been on the experience of unintended pregnancy and use of contraceptive methods. However, this has led to the neglect of a different group of women who suffer from constraints on their reproductive autonomy-women who experience pregnancies later than they desire or who are unable to become pregnant. This study examines the extent of later-than-desired pregnancy among women and evaluates the sociodemographic and reproductive factors associated with this experience in Uganda. METHODS We use data from the Performance Monitoring for Action Uganda 2022 female survey. We restricted the nationally representative sample of reproductive-aged women to those who were currently pregnant or who had ever given birth (n = 3311). We compared the characteristics of women across fertility intention categories (wanted pregnancy earlier, then, later, or not at all) of their current or most recent birth and used multivariable logistic regression to examine factors independently associated with having a pregnancy later than desired compared to at a desired time. RESULTS Overall, 28.3% of women had a later-than-desired pregnancy. Nearly all sociodemographic and reproductive characteristics were associated with the desired pregnancy timing of women's current or most recent pregnancy. Having higher education [adjusted odds ratio (aOR) 2.41, 95% confidence interval (CI) 1.13-5.13], having sought care for difficulties getting pregnant (aOR 2.12, 95% CI 1.30-3.46), and having less than very good self-rated health (good health aOR 1.74, 95% CI 1.12-2.71; moderate health aOR 1.77, 95% CI 1.09-2.86; very bad health aOR 4.32, 95% CI 1.15-16.26) were all independently significantly associated with increased odds of having a later-than-desired pregnancy. Being nulliparous (aOR 1.98, 95% CI 0.99-3.95) was also borderline significantly associated with having a later-than-desired pregnancy. CONCLUSIONS Identifying those who have later-than-desired pregnancies is essential if we seek to make progress towards supporting women and couples in achieving their reproductive goals, not just preventing pregnancies. Research on desired pregnancy timing in sub-Saharan Africa should be expanded to capture later-than-desired pregnancies, a population which is invisible in existing data. This work has public health implications due to commonalities in the factors associated with mistimed and unintended pregnancies and their link to poorer health and potentially poorer pregnancy outcomes.
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Affiliation(s)
- Suzanne O Bell
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA.
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Isabella Sarria
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Simon P S Kibira
- Department of Community Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Linnea A Zimmerman
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA
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Onadja Y, Compaoré R, Yugbaré DB, Thomas HL, Guiella G, Lougué S, Ouedraogo HG, Bazie F, Kouanda S, Moreau C, Bell SO. Postabortion care service availability, readiness, and access in Burkina Faso: results from linked female-facility cross-sectional data. BMC Health Serv Res 2024; 24:84. [PMID: 38233874 PMCID: PMC10792903 DOI: 10.1186/s12913-023-10538-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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 12/29/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Little is known about postabortion care (PAC) services in Burkina Faso, despite PAC's importance as an essential and life-saving component of emergency obstetric care. This study aims to evaluate PAC service availability, readiness, and accessibility in Burkina Faso. METHODS Data for this study come from the Performance Monitoring for Action (PMA) Burkina Faso project and the Harmonized Health Facility Assessment (HHFA) conducted by the Institut de Recherche en Sciences de la Santé and the Ministry of Health. PMA data from a representative sample of women aged 15-49 (n = 6,385) were linked via GPS coordinates to HHFA facility data (n = 2,757), which included all public and private health facilities in Burkina Faso. We assessed readiness to provide basic and comprehensive PAC using the signal functions framework. We then calculated distance to facilities and examined percent within 5 kms of a facility with any PAC, basic PAC, and comprehensive PAC overall and by women's background characteristics. RESULTS PAC services were available in 46.4% of health facilities nationwide; only 38.3% and 35.0% of eligible facilities had all basic and comprehensive PAC signal functions, respectively. Removal of retained products of conception was the most common missing signal function for both basic and comprehensive PAC, followed by provision of any contraception (basic) or any LARC (comprehensive). Nearly 85% of women lived within 5 km of a facility providing any PAC services, while 50.5% and 17.4% lived within 5 km of a facility providing all basic PAC and all comprehensive PAC signal functions, respectively. Women with more education, greater wealth, and those living in urban areas had greater odds of living within 5 km of a facility with offering PAC, basic PAC, or comprehensive PAC. CONCLUSIONS Results indicate a need for increased PAC availability and readiness, prioritizing basic PAC services at the primary level-the main source of care for many women-which would reduce structural disparities in access. The current deficiencies in PAC signal a need for broader strengthening of the primary healthcare services in Burkina Faso to reduce the burden of unsafe abortion-related morbidity and mortality while improving maternal health outcomes more broadly.
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Affiliation(s)
- Yentéma Onadja
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, 03 BP 7118, Burkina Faso.
| | - Rachidatou Compaoré
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | | | - Haley L Thomas
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, 03 BP 7118, Burkina Faso
| | - Siaka Lougué
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | | | - Fiacre Bazie
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, 03 BP 7118, Burkina Faso
| | - Seni Kouanda
- Institut de Recherche en Sciences de la Santé (IRSS), Ouagadougou, Burkina Faso
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, F-94800, France
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Bell SO, Dozier JL, Casubhoy I, Sufrin C. Impact of new abortion restrictions on people in prison: Estimated number of incarcerated people without abortion access and distance to abortion providers. Contraception 2024; 129:110278. [PMID: 37673362 DOI: 10.1016/j.contraception.2023.110278] [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] [Received: 06/07/2023] [Revised: 08/28/2023] [Accepted: 08/31/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVES This study aimed to estimate the annual number of incarcerated pregnant people in state and federal prisons needing an abortion. STUDY DESIGN We used 2021 Bureau of Justice Statistics data and prior studies' findings to estimate the number of pregnant incarcerated people, then calculated state-specific abortion ratios to determine the number potentially needing an abortion. RESULTS Of 638 pregnant people incarcerated in prisons annually, 110 would be expected to need an abortion, including 55 in states where abortion is currently banned or restricted. CONCLUSIONS Under Dobbs, many incarcerated pregnant people will be forced to continue unwanted pregnancies to term.
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
| | - Jessica L Dozier
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Imaima Casubhoy
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Carolyn Sufrin
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Cartwright AF, Bell SO, Upadhyay UD. Separating Procedure-related Fears From Future Fertility Concerns Among a Cohort Seeking Abortion Information Online. Womens Health Issues 2024; 34:45-50. [PMID: 37479629 PMCID: PMC10796831 DOI: 10.1016/j.whi.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION The general public and abortion patients in the United States have misinformation about the risks of infertility associated with abortion, which may influence abortion care-seeking. METHODS The Google Ads Abortion Access Study was a national study of people considering abortion and searching online for information. Participants completed baseline and follow-up surveys, providing free text responses to questions about barriers and facilitators to abortion. We conducted an exploratory analysis of the free text responses related to fertility and used thematic analysis to identify concerns raised about links between abortion and future fertility. RESULTS Of 864 participants who provided free text responses in the follow-up survey, 32 specifically mentioned fertility. Few expressed fear that complications from the abortion procedure would somehow lead to infertility; rather, most discussed complex and overlapping thoughts about how abortion factored into their reproductive life plans. These included age-related concerns, missing out on their "chance" to have a child, fear of being punished by God with infertility for having an abortion, and conflicting emotions if they had previously been told they were subfecund or infertile. CONCLUSION Although previous research has focused on misinformation about the link between abortion and infertility, participants in this study rarely mentioned it as a concern. Researchers and practitioners should be attuned to the distinctions people make between infertility occurring as a result of abortion and other fears they might have about not achieving their future reproductive aspirations, ask questions, and provide counseling accordingly.
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Affiliation(s)
- Alice F Cartwright
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Suzanne O Bell
- Bill & Melinda Gates Institute for Population and Reproductive Health, Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ushma D Upadhyay
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, Oakland, California
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Akilimali P, Moreau C, Byrne M, Kayembe D, Larson E, Bell SO. Estimating induced abortion incidence and the use of non-recommended abortion methods and sources in two provinces of the Democratic Republic of the Congo (Kinshasa and Kongo Central) in 2021: results from population-based, cross-sectional surveys of reproductive-aged women. Sex Reprod Health Matters 2023; 31:2207279. [PMID: 37216481 DOI: 10.1080/26410397.2023.2207279] [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] [Indexed: 05/24/2023] Open
Abstract
The changing abortion legal and practice landscape in the DRC in recent years calls for a re-examining of induced abortion experiences. The current study provides population-level estimates of induced abortion incidence and safety by women's characteristics in two provinces using direct and indirect approaches to assess indirect method performance. We use representative survey data on women aged 15-49 in Kinshasa and Kongo Central collected from December 2021 to April 2022. The survey had questions on respondents' and their closest friends' experience with induced abortion, including methods and sources used. We estimated one-year abortion incidence and proportion using non-recommended methods and sources overall and by background characteristics for each province separately for respondents and friends. The fully adjusted one-year friend abortion rate was 105.3 per 1000 women of reproductive age in Kinshasa and 44.3 per 1000 in Kongo Central in 2021; these were substantially higher than corresponding respondent estimates. Women earlier in their reproductive lifespan were more likely to have had a recent abortion. Approximately 17.0% of abortions in Kinshasa and one-third of abortions in Kongo Central involved non-recommended methods and sources according to respondent and friend estimates. The more accurate friend abortion incidence estimates indicate that women in the DRC often rely on abortion to regulate their fertility. Many use non-recommended means and sources to terminate, thus, significant work remains to actualise the commitments made in the Maputo Protocol to provide comprehensive reproductive health services that combine primary and secondary prevention services to reduce unsafe abortion and its consequences.
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Affiliation(s)
- Pierre Akilimali
- Professor, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, DRC
| | - Caroline Moreau
- Associate Professor, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif F-94800, France
| | - Meagan Byrne
- Senior Program Officer, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Dynah Kayembe
- Field Coordinator, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, DRC
| | - Elizabeth Larson
- PhD Student, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Suzanne O Bell
- Assistant Professor, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Thomas HL, Alzouma S, Oumarou S, Moreau C, Bell SO. Postabortion care availability, readiness, and accessibility in Niger in 2022: results from linked facility-female cross-sectional data. BMC Health Serv Res 2023; 23:1171. [PMID: 37891572 PMCID: PMC10612209 DOI: 10.1186/s12913-023-10107-4] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Postabortion care (PAC), which is an essential element of emergency obstetric care, is underresearched in Niger. The study aims to assess the availability, readiness, and accessibility of facility-based PAC services in Niger. METHODS This study uses female and facility data from Performance Monitoring for Action Niger. The female data include a nationally representative sample of women aged 15-49 (n = 3,696). Using GPS coordinates, these female data were linked to a sample of public and private facilities (n = 258) that are expected to provide PAC. We assessed PAC availability and facility readiness to provide basic and comprehensive PAC using the signal functions framework, overall and by facility type. We then calculated the distance between women and their closest facility and estimated the proportion of women living within five kilometers (5 km) of a facility providing any PAC, basic PAC, and comprehensive PAC, overall and by women's background characteristics. RESULTS Only 36.4% and 14% of eligible facilities had all basic and comprehensive PAC signal functions, respectively. Oxytocics and laparotomy were the most missing signal function for basic and comprehensive PAC, respectively. Private facilities were the least ready to provide the full range of PAC services. While 47% of women lived within 5 km of a facility providing any PAC services, only 33.4% and 7.9% lived within 5 km of a facility providing all basic and all comprehensive PAC signal functions, respectively. Women who were divorced/widowed, had higher levels of education, and were living in urban areas had increased odds of living within 5 km of a facility with any or basic PAC. Women who were never married had increased odds of living within 5 km of a facility with comprehensive PAC, while urban residence was fully predictive of living within 5 km of a facility with comprehensive PAC. CONCLUSIONS This study found PAC availability and readiness to be insufficient in Niger, with inadequate and disparate accessibility to facilities providing PAC services. We recommended stakeholders ensure stock of essential commodities and availability of PAC services at primary facilities in order to mitigate the negative maternal health repercussions of unsafe abortion in this setting.
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Affiliation(s)
- Haley L Thomas
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street., Baltimore, MD, 21205, USA.
| | | | - Sani Oumarou
- Institut National de la Statistique du Niger, Niamey, Niger
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street., Baltimore, MD, 21205, USA
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, F-94800, France
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street., Baltimore, MD, 21205, USA
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Bell SO, Oumarou S, Larson EA, Alzouma S, Moreau C. Abortion incidence and safety in Niger in 2021: Findings from a nationally representative cross-sectional survey of reproductive-aged women using direct and indirect measurement approaches. PLOS Glob Public Health 2023; 3:e0002353. [PMID: 37831640 PMCID: PMC10575533 DOI: 10.1371/journal.pgph.0002353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/07/2023] [Indexed: 10/15/2023]
Abstract
Niger is a country in which legal restrictions and a dearth of research has long limited our understanding of the extent and safety of induced abortion. The current study is the first national study of induced abortion in Niger. It uses direct (self-report) and indirect (best friend method) to provide nationally representative estimates of induced abortion incidence and safety and evaluates the performance of the indirect measurement approach. We used cross-sectional, representative survey data on women aged 15-49 in Niger collected between January and May 2022; final sample included 3,696 women. The survey included questions on respondents' and their closest female friends' experience with abortion, including methods and sources used. We calculated one-year abortion incidence and the proportion of abortions involving non-recommended methods and/or sources to determine safety separately for respondents and friends, overall and by background characteristics. The fully adjusted one-year friend abortion rate was 6.7 abortions per 1,000 women in 2021, which was substantially higher than the corresponding respondent rate of 0.4 per 1,000 women. Confidence intervals were wide, but friend estimates suggest higher abortion rates among women in their 20s, those with secondary or higher education, and those with no children. Nearly all abortions were unsafe (97% respondents, 100% friends), involving non-recommended methods and/or sources. While abortion numbers were small, unsafe abortion appeared more common among older women, married women, those with children, and those residing in rural areas. Our findings indicate that, despite legal restrictions, some women undergo abortions in Niger at great risk to their physical safety. Ensuring adequate access to quality voluntary family planning services to prevent unintended pregnancy and postabortion care to treat complications is essential to reducing the risk of unsafe abortion in the country.
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Affiliation(s)
- Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Sani Oumarou
- Institut National de la Statistique, Niamey, Niger
| | - Elizabeth A. Larson
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Soins Primaires et Prévention, Centre de Recherche en Epidémiologie et Santé des Populations, U1018, Inserm, Villejuif, France
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Giorgio M, Makumbi F, Kibira SPS, Shiferaw S, Seme A, Bell SO, Sully E. Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys. PLOS Glob Public Health 2023; 3:e0002340. [PMID: 37682781 PMCID: PMC10490852 DOI: 10.1371/journal.pgph.0002340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 08/08/2023] [Indexed: 09/10/2023]
Abstract
Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda.
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Affiliation(s)
| | - Fredrick Makumbi
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Suzanne O. Bell
- Johns Hopkins Bloomberg School of Public Health, Department of Population, Family, and Reproductive Health, Baltimore, MD, United States of America
| | - Elizabeth Sully
- Guttmacher Institute, New York, NY, United States of America
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Gemmill A, Bradley SEK, Berger BO, Bell SO. The Relationship Between Contraceptive Method Use and Return of Fecundity Among Women Attempting Pregnancy in Low- and Middle-Income Countries. Demography 2023; 60:1163-1179. [PMID: 37449662 PMCID: PMC10529236 DOI: 10.1215/00703370-10877719] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
One of the most common barriers to using effective family planning methods is the belief that hormonal contraceptives and contraceptive devices have adverse effects on future fertility. Recent evidence from high-income settings suggests that some hormonal contraceptive methods are associated with delays in return of fecundity, yet it is unclear if these findings generalize to low- and middle-income populations, especially in regions where the injectable is widely used and pressure to bear children is significant. Using reproductive calendar data pooled across 47 Demographic and Health Surveys, we find that the unadjusted 12-month probability of pregnancy for women attempting pregnancy after discontinuing traditional methods, condoms, the pill, and the IUD ranged from 86% to 91%. The 12-month probability was lowest among those who discontinued injectables and implants, with approximately 1 out of 5 women not becoming pregnant within one year after discontinuation. Results from multivariable analysis showed that compared with users of either periodic abstinence or withdrawal, users of the pill, IUD, injectable, and implant had lower fecundability following discontinuation, with the largest reductions occurring among women who used injectables and implants. These findings indicate that women's concerns about potential short-term reductions in fecundity following contraceptive use are not unfounded.
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Affiliation(s)
- Alison Gemmill
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Blair O Berger
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Bell SO, Stuart EA, Gemmill A. Texas' 2021 Ban on Abortion in Early Pregnancy and Changes in Live Births. JAMA 2023; 330:281-282. [PMID: 37382968 PMCID: PMC10311422 DOI: 10.1001/jama.2023.12034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023]
Abstract
This study evaluates changes in the number of births in Texas after passage of Texas’ Senate Bill 8 (SB8), which bans abortions as early as 5 weeks’ gestation.
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Affiliation(s)
- Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth A. Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alison Gemmill
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Magalona S, Thomas HL, Akilimali PZ, Kayembe D, Moreau C, Bell SO. Abortion care availability, readiness, and access: linking population and health facility data in Kinshasa and Kongo Central, DRC. BMC Health Serv Res 2023; 23:658. [PMID: 37340470 DOI: 10.1186/s12913-023-09647-6] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/05/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND The Democratic Republic of Congo (DRC) legalized abortion in 2018 to preserve health and pledged to provide quality postabortion care (PAC), yet little is known about the availability of abortion care services and if facilities are prepared to provide them; even less is known about the accessibility of these services. Using facility and population-based data in Kinshasa and Kongo Central, this study examined the availability of abortion services, readiness of facilities to provide them, and inequities in access. METHODS Data on 153 facilities from the 2017-2018 DRC Demographic and Health Survey Service Provision Assessment (SPA) were used to examine signal functions and readiness of facilities to provide services across three abortion care domains (termination of pregnancy, basic treatment of abortion complications, and comprehensive treatment of abortion complications). To examine PAC and medication abortion provision before and after abortion decriminalization, we compared estimates from the 2017-2018 SPA facilities to estimates from the Performance Monitoring for Action (PMA) data collected in 2021 (n = 388). Lastly, we assessed proximity to PAC and medication abortion using PMA by geospatially linking facilities to representative samples of 2,326 and 1,856 women in Kinshasa and Kongo Central, respectively. RESULTS Few facilities had all the signal functions under each abortion care domain, but most facilities had many of the signal functions: overall readiness scores were > 60% for each domain. In general, readiness was higher among referral facilities compared to primary facilities. The main barriers to facility readiness were stock shortages of misoprostol, injectable antibiotics, and contraception. Overall, provision of services was higher post-decriminalization. Access to facilities providing PAC and medication abortion was almost universal in urban Kinshasa, but patterns in rural Kongo Central showed a positive association with education attainment and wealth. CONCLUSION Most facilities had many of the necessary signal functions to provide abortion services, but the majority experienced challenges with commodity availability. Inequities in accessibility of services also existed. Interventions that address supply chain challenges may improve facility readiness to provide abortion care services, and further efforts are needed to narrow the gap in accessibility, especially among poor women from rural settings.
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Affiliation(s)
- Sophia Magalona
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Haley L Thomas
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Pierre Z Akilimali
- Department of Biostatistics and Epidemiology, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Dynah Kayembe
- Performance Monitoring for Action DRC, Kinshasa, Democratic Republic of Congo
| | - Caroline Moreau
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale, Villejuif, France
| | - Suzanne O Bell
- Department 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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Sully EA, Seme A, Shiferaw S, Chiu DW, Bell SO, Giorgio M. Impact of the global gag rule on women's contraceptive use and reproductive health outcomes in Ethiopia: a pre-post and difference-in-difference analysis. BMJ Open 2023; 13:e063099. [PMID: 37147096 PMCID: PMC10163537 DOI: 10.1136/bmjopen-2022-063099] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023] Open
Abstract
OBJECTIVE To assess the impacts of the Protecting Life through Global Health Assistance policy (otherwise known as the expanded global gag rule (GGR)) on women's sexual and reproductive health (SRH) in Ethiopia. The GGR prohibits all non-US non-governmental organisations (NGOs) receiving US Government global health funding from providing, referring or advocating for abortion. DESIGN Pre-post analysis and difference-in-difference analysis. SETTING Six regions of Ethiopia (Tigray, Afar, Amhara, Oromiya, SNNPR and Addis Ababa). PARTICIPANTS Panel of 4909 reproductive-age women recruited from the Performance Monitoring for Accountability 2018 survey, administered face-to-face surveys in 2018 and 2020. MEASURES We assessed impacts of the GGR on contraceptive use, pregnancies, births and abortions. Due to the 2019 'Pompeo Expansion' and widespread application of the GGR, we use a pre-post analysis to investigate changes in women's reproductive outcomes. We then use a difference-in-differences design to measure the additional effect of NGOs refusal to comply with the policy and the resulting loss in funding; districts are classified as more exposed if organisations impacted by lost funding were providing services there and women are classified based on their district. RESULTS At baseline, 27% (n=1365) of women were using a modern contraceptive (7% using long-acting reversible contraceptive methods (LARCs) and 20% using short-acting methods. The pre-post analysis revealed statistically significant declines from 2018 to 2020 in the use of LARCs (-0.9, 95% CI: -1.6 to -0.2) and short-acting methods (-1.0, 95% CI: -1.8 to -0.2). These changes were deviations from prior trends. In our difference-in-differences analysis, women exposed to non-compliant organisations experienced greater declines in LARC use (-1.5, 95% CI: -2.9 to -0.1) and short-acting method use (-1.7, 95% CI: -3.2 to -0.1) as compared with less-exposed women. CONCLUSIONS The GGR resulted in a stagnation in the previous growth in contraceptive use in Ethiopia. Longer-term strategies are needed to ensure that SRH progress globally is protected from changes in US political administrations.
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Affiliation(s)
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Doris W Chiu
- Guttmacher Institute, New York city, New York, USA
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Bell SO, Berger BO, Sufrin C, Dozier JL, Burke AE. An exploratory study of COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia. Perspect Sex Reprod Health 2023; 55:12-22. [PMID: 36751866 DOI: 10.1363/psrh.12220] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVES This exploratory study aimed to assess COVID-19-related changes in abortion service availability and use in Washington, DC, Maryland, and Virginia. DESIGN Data came from a convenience sample of eight abortion clinics in this region. We implemented a cross-sectional survey and collected retrospective aggregate monthly abortion data overall and by facility type, abortion type, and patient characteristics for March 2019-August 2020. We evaluated changes in the distribution of the total number of patients for March-August in 2019 compared to March-August 2020. We also conducted segmented regression analyses and produced scatter plots of monthly abortion patients overall and by facility type, abortion type, and patient characteristics, with separate fitted regression lines from the segmented regression models for the pre- and during-COVID-19 periods. RESULTS Five clinics reported a reduced number of appointments early in the pandemic while four reported increased call volume. There were declines in the monthly abortion trend at hospital-based clinics at the outset of the pandemic. Monthly number of medication abortions increased from March 2020 through August 2020 compared to pre-COVID-19 trends while instrumentation abortions 11 up to 19 weeks decreased. The share of abortions to Black individuals increased during the early phase of the pandemic, as did the monthly trend in abortions among this group. We also saw changes in payment type, with declines in patients paying out-of-pocket. CONCLUSIONS Results revealed differences in abortion services, numbers, and types during the early stages of the COVID-19 pandemic in Washington, DC, Maryland, and Virginia.
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Blair O Berger
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Carolyn Sufrin
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jessica L Dozier
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Anne E Burke
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Bell SO, Shankar M, OlaOlorun F, Omoluabi E, Khanna A, Ahmad D, Guiella G, Moreau C. Menstrual regulation: examining the incidence, methods, and sources of care of this understudied health practice in three settings using cross-sectional population-based surveys. BMC Womens Health 2023; 23:73. [PMID: 36804033 PMCID: PMC9938613 DOI: 10.1186/s12905-023-02216-3] [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: 09/06/2022] [Accepted: 02/08/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Menstrual regulation is a practice that may exist within the ambiguity surrounding one's pregnancy status and has been the subject of limited research. The aim of this study is to measure the annual rate of menstrual regulation in Nigeria, Cote d'Ivoire, and Rajasthan, India, overall and by background characteristics and to describe the methods and sources women use to bring back their period. METHODS Data come from population-based surveys of women aged 15-49 in each setting. In addition to questions on women's background characteristics, reproductive history, and contraceptive experiences, interviewers asked women whether they had ever done something to bring back their period at a time when they were worried they were pregnant, and if so, when it occurred and what methods and source they used. A total of 11,106 reproductive-aged women completed the survey in Nigeria, 2,738 in Cote d'Ivoire, and 5,832 in Rajasthan. We calculated one-year incidence of menstrual regulation overall and by women's background characteristics separately for each context using adjusted Wald tests to assess significant. We then examined the distribution of menstrual regulation methods and sources using univariate analyses. Method categories included surgery, medication abortion pills, other pills (including unknown pills), and traditional or "other" methods. Source categories included public facilities or public mobile outreach, private or non-governmental facilities or doctors, pharmacy or chemist shops, and traditional or "other" sources. RESULTS Results indicate substantial levels of menstrual regulation in West Africa with a one-year incidence rate of 22.6 per 1,000 women age 15-49 in Nigeria and 20.6 per 1,000 in Cote d'Ivoire; women in Rajasthan reported only 3.3 per 1,000. Menstrual regulations primarily involved traditional or "other" methods in Nigeria (47.8%), Cote d'Ivoire (70.0%), and Rajasthan (37.6%) and traditional or "other" sources (49.4%, 77.2%, and 40.1%, respectively). CONCLUSION These findings suggest menstrual regulation is not uncommon in these settings and may put women's health at risk given the reported methods and sources used. Results have implications for abortion research and our understanding of how women manage their fertility.
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Affiliation(s)
- Suzanne O. Bell
- grid.21107.350000 0001 2171 9311Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe St. Suite W4041, Baltimore, MD 21205 USA
| | - Mridula Shankar
- grid.21107.350000 0001 2171 9311Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe St. Suite W4041, Baltimore, MD 21205 USA
| | - Funmilola OlaOlorun
- grid.9582.60000 0004 1794 5983College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Elizabeth Omoluabi
- Center for Research, Evaluation Resources and Development, Ile-Ife, Nigeria ,grid.8974.20000 0001 2156 8226Statistics and Population Studies Department, University of the Western Cape, Bellville, South Africa
| | - Anoop Khanna
- grid.464858.30000 0001 0495 1821Indian Institute of Health Management Research, Jaipur, India
| | - Danish Ahmad
- grid.464858.30000 0001 0495 1821Indian Institute of Health Management Research, Jaipur, India
| | - Georges Guiella
- grid.218069.40000 0000 8737 921XInstitut Supérieur Des Sciences de La Population (ISSP), Université of Ouagadougou, Ouagadougou, Burkina Faso
| | - Caroline Moreau
- grid.21107.350000 0001 2171 9311Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, 615 N. Wolfe St. Suite W4041, Baltimore, MD 21205 USA ,grid.7429.80000000121866389Soins Et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, 94805 Villejuif, France
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Bell SO, Karp C, Moreau C, Gemmill A. "If I use family planning, I may have trouble getting pregnant next time I want to": A multicountry survey-based exploration of perceived contraceptive-induced fertility impairment and its relationship to contraceptive behaviors. Contracept X 2023; 5:100093. [PMID: 37114162 PMCID: PMC10127128 DOI: 10.1016/j.conx.2023.100093] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Indexed: 04/29/2023] Open
Abstract
Objectives We aim to assess women's perceptions regarding contraceptive effects on fertility across a diversity of settings in sub-Saharan Africa and how they vary by women's characteristics. We also aim to examine how such beliefs relate to women's contraceptive practices and intentions. Study design This study uses cross-sectional survey data among women aged 15 to 49 in nine sub-Saharan African geographies from the Performance Monitoring for Action project. Our main measure of interest assessed women's perceptions of contraceptive-induced fertility impairment. We examined factors related to this belief and explored the association between perceptions of contraceptive-induced fertility impairment and use of medicalized contraception (intrauterine device, implant, injectable, pills, emergency contraception) and intention to use contraception (among nonusers). Results Between 20% and 40% of women across study sites agreed or strongly agreed that contraception would lead to later difficulties becoming pregnant. Women at risk of an unintended pregnancy who believed contraception could cause fertility impairment had reduced odds of using medicalized contraception in five sites; aORs ranged from 0.07 to 0.62. Likewise, contraceptive nonusers who wanted a/another child and perceived contraception could cause fertility impairment were less likely to intend to use contraception in seven sites, with aORs between 0.34 and 0.66. Conclusions Our multicountry study findings indicate women's perception of contraceptive-induced fertility impairment is common across diverse sub-Saharan African settings, likely acting as a deterrent to using medicalized contraceptive methods. Implications Findings from this study can help improve reproductive health programs by addressing concerns about contraception to help women achieve their reproductive goals.
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Affiliation(s)
- Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Corresponding author.
| | - Celia Karp
- Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France
| | | | - Alison Gemmill
- Department of Population, Family and Reproductive Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 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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Bell SO, Guiella G, Anjur-Dietrich S, Bazie F, Onadja Y, Ahmed S, Moreau C. Social Network-Based Induced Abortion Incidence Estimation in Burkina Faso: Examining the Impact of the Network Generating Question. Stud Fam Plann 2022; 53:639-655. [PMID: 36210613 PMCID: PMC10092449 DOI: 10.1111/sifp.12213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Social network-based methods are increasingly used to estimate induced abortion incidence and investigate correlates. Approaches differ in the social tie definitions used to identify which social network members' abortion experiences respondents will report. This study compares the effect of using the "best friend" (closest female friend) versus "confidante" (specifying mutual sharing of personal information) definition on abortion incidence estimation. We use data from a nationally representative survey of women aged 15-49 in Burkina Faso (conducted in 2020-2021) where respondents were randomized into two versions of an abortion module, using different friend definitions. We computed abortion rate estimates by friend definition and adjusted for assumption violations (transmission bias, surrogate sample selection bias). Unadjusted incidence rates varied from 11.7 [4.1-19.2] abortions per 1,000 women to 15.6 [9.7-21.4], depending on friend definition. The confidante definition yielded higher adjusted estimates (36.2 [25.1-47.2]) than the best friend definition (17.0 [8.7-25.3]) due to greater transmission bias adjustment. Both estimates exceeded the respondent self-reported abortion incidence (4.0 [2.2-5.9]). Our results indicate that either friend definition produces higher incidence estimates than self-report but suggest a potential advantage for the "best friend" over the "confidante" definition given lower transmission bias. Further research should assess generalizability of these findings in other contexts.
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Selena Anjur-Dietrich
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Fiacre Bazie
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Yentema Onadja
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.,Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, F-94800, France
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Giorgio M, Makumbi F, Kibira SPS, Bell SO, Chiu DW, Firestein L, Sully E. An investigation of the impact of the Global Gag Rule on women's sexual and reproductive health outcomes in Uganda: a difference-in-differences analysis. Sex Reprod Health Matters 2022; 30:2122938. [PMID: 36259938 PMCID: PMC9586624 DOI: 10.1080/26410397.2022.2122938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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] [Indexed: 11/07/2022] Open
Abstract
In 2017, the Trump administration reinstated the Global Gag Rule (GGR), making non-U.S. non-governmental organisations ineligible for US government global health assistance if they provide access to or information about abortion. Little is known about the impact of the Trump administration’s GGR on women’s outcomes. Data for this analysis come from a panel of women surveyed in 2018 and 2019 in Uganda (n = 2755). We also used data from meetings with key stakeholders to create a detailed measure of exposure to the GGR within Uganda, classifying districts as more or less exposed to the GGR. Multivariable regression models were used to assess changes in contraceptive use, all births, unplanned births, and abortion from before to during implementation of the GGR. Difference-in-differences (DID) estimates were determined by calculating predicted probabilities from interaction terms for exposure/survey round. Descriptive analyses showed long-acting reversible contraceptive use increased more rapidly among women in less exposed districts after GGR implementation. DID estimates for contraceptive use were small. We observed a DID estimate of 3.5 (95% CI −0.9, 7.9) for all births and 2.9 (95% CI −0.2, 6.0) for unplanned births for women in more exposed districts during the period the policy was in effect. Our results suggest that the GGR may have attenuated Uganda’s recent progress in improving SRHR outcomes, with women in less exposed districts continuing to benefit from this progress, while previously increasing trends for women in more exposed districts levelled off. Although the GGR was rescinded in January 2021, the impact of these disruptions may be felt for years to come.
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Affiliation(s)
- Margaret Giorgio
- Senior Research Scientist, Guttmacher Institute, 125 Maiden Lane 7th Floor, New York, NY10038, USA. Correspondence:
| | - Fredrick Makumbi
- Senior Lecturer and Departmental Chair, Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Simon P. S. Kibira
- Lecturer, School of Public Health, College of Health Sciences, Makerere University, New Mulago Hill Road, Kampala, Uganda
| | - Suzanne O. Bell
- Assistant Professor, Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Doris W. Chiu
- Senior Research Assistant, Guttmacher Institute, New York, NY, USA
| | | | - Elizabeth Sully
- Senior Research Scientist, Guttmacher Institute, New York, NY, USA
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21
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Bazié F, Thomas HL, Byrne ME, Kindo B, Bell SO, Moreau C. Typologies of women’s abortion trajectories in Burkina Faso: findings from a qualitative study. Reprod Health 2022; 19:212. [DOI: 10.1186/s12978-022-01526-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/10/2022] [Indexed: 11/29/2022] Open
Abstract
Abstract
Background
Abortion is a legally restricted, yet common reproductive life event among women in Burkina Faso; however, women’s abortion experiences vary greatly depending on their social and economic capital, partner involvement, and level of knowledge. We sought to classify women’s abortion care-seeking experiences across the life course and social conditions into typologies using qualitative data.
Methods
An initial quantitative survey among a nationally representative sample of women ages 15–49 years collected information on women’s induced abortion experiences. Women who reported an abortion in the last 10 years were asked if they would agree to participate in a subsequent in-depth interview (IDI) to learn more about their abortion experience. Twenty-five women, identified via purposive sampling, completed an IDI. Using a process of typology construction, we identified attributes of each woman’s condition at the time of her abortion and aspects of her abortion experience, created a matrix of attributes and cases, and identified emerging relationships. Three types were identified through this process.
Results
Twenty-three IDIs were analyzed, and women’s abortion experiences were grouped into three types: abortion to delay childbearing in adolescence; abortion to space childbirth among women in union; abortion to avoid childbearing among single mothers. Two cases were identified as outliers. Cases were grouped based on the context of their pregnancy, the reason for the abortion and involved decision-makers, and their patterns of care-seeking, including methods and sources used.
Conclusion
Structural inequities related to gender and wealth were prominent forces shaping women’s abortion experiences. Comprehensive sexuality education coupled with community-based interventions to promote gender-equitable relationships and address social stigma related to women’s sexuality could reduce reproductive coercion and unintended pregnancies.
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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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McMahon HV, Karp C, Bell SO, Shiferaw S, Seme A, Yihdego M, Zimmerman LA. Availability of Postabortion Care Services in Ethiopia: Estimates from a 2020 National Sample of Public Facilities. Contracept X 2022; 4:100087. [DOI: 10.1016/j.conx.2022.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/27/2022] [Accepted: 10/09/2022] [Indexed: 11/07/2022] Open
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24
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Dozier JL, Sufrin C, Berger BO, Burke AE, Bell SO. COVID-19 impacts on abortion care-seeking experiences in the Washington, DC, Maryland, and Virginia regions of the United States. Perspect Sex Reprod Health 2022; 54:68-79. [PMID: 35790127 PMCID: PMC9349554 DOI: 10.1363/psrh.12202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
CONTEXT Many people wanted to avoid or delay childbearing during the COVID-19 pandemic. This study sought to examine the extent COVID-19 influenced abortion care-seeking in a region that did not enact policy restricting abortion due to the pandemic, has high service availability, and few abortion-restrictive policies. METHODOLOGY We conducted telephone surveys with adults (n=72) requesting abortion appointments between September 2020 and March 2021 at five clinics in Washington, DC, Maryland, and Virginia. We used χ2 tests to compare sociodemographic, reproductive history, service delivery characteristics, and pandemic-related life changes by whether COVID-19 influenced abortion care-seeking. RESULTS Most respondents (93%) had an abortion at the time of the survey, 4% were awaiting their scheduled appointment, and 3% did not have an appointment scheduled. Nearly 40% of people reported COVID-19 influenced their decision to have an abortion. These individuals were significantly more likely to report "not financially prepared" (44% vs. 16%) as a reason for termination compared to people reporting no influence of COVID-19. They were also more likely to have lost or changed their health insurance due to pandemic-related employment changes (15% vs. 2%), report substantial money difficulties due to COVID-19 (59% vs. 33%), and report that paying for their abortion was "very difficult" (25% vs. 2%). CONCLUSION COVID-19 influenced many people to have an abortion, particularly those financially disadvantaged by the pandemic. Expansion of Medicaid abortion coverage in Washington, DC and Virginia could reduce financial barriers to care and help people to better meet their reproductive needs amid future crises.
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Affiliation(s)
- Jessica L. Dozier
- Department of Population, Family and Reproductive HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Carolyn Sufrin
- Department of Gynecology and ObstetricsJohns Hopkins School of MedicineBaltimoreMarylandUSA
- Department of Health, Behavior, and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Blair O. Berger
- Department of Population, Family and Reproductive HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | - Anne E. Burke
- Department of Population, Family and Reproductive HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
- Department of Gynecology and ObstetricsJohns Hopkins School of MedicineBaltimoreMarylandUSA
| | - Suzanne O. Bell
- Department of Population, Family and Reproductive HealthJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
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25
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Magalona S, Byrne M, OlaOlorun FM, Mosso R, Omoluabi E, Moreau C, Bell SO. Contraceptive Use Before and After Abortion: A Cross-Sectional Study from Nigeria and Côte d'Ivoire. Stud Fam Plann 2022; 53:433-453. [PMID: 35856923 PMCID: PMC9545736 DOI: 10.1111/sifp.12208] [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] [Indexed: 11/27/2022]
Abstract
Post‐abortion contraception enables women to effectively manage their fertility to prevent unintended pregnancies. Using data from population‐based surveys of women aged 15–49 in Nigeria and Côte d'Ivoire, we examined contraceptive dynamics immediately before and after an abortion and examined factors associated with these changes using multivariable logistic regressions. Covariates included sociodemographic characteristics, abortion source, post‐abortion contraceptive communication (wanting to and actually talking to someone about contraception after abortion), and perceived contraceptive autonomy. We observed higher contraceptive use after abortion than before abortion. In Nigeria, wanting to talk to someone about contraception post‐abortion was associated with increased adoption and decreased discontinuation, whereas talking to someone about contraception post‐abortion was associated with increased adoption. Obtaining care from a clinical abortion source was associated with increased adoption and decreased discontinuation. Both post‐abortion contraceptive communication variables were associated with post‐abortion contraceptive use in both countries, whereas clinical source was only associated with post‐abortion contraceptive use in Nigeria. Our findings suggest that ensuring that women have access to safe abortion as part of the formal health care system and receive comprehensive, high‐quality post‐abortion care services that include contraceptive counseling enables them to make informed decisions about their fertility that align with their reproductive goals.
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Affiliation(s)
- Sophia Magalona
- Sophia Magalona is a PhD student, Meagan Byrne is PMA Survey Operations Lead, Caroline Moreau is Associate Professor, and Suzanne O. Bell is Assistant Professor, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Meagan Byrne
- Sophia Magalona is a PhD student, Meagan Byrne is PMA Survey Operations Lead, Caroline Moreau is Associate Professor, and Suzanne O. Bell is Assistant Professor, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Funmilola M OlaOlorun
- Funmilola M. OlaOlorun is Senior Lecturer, Department of Community Medicine, University of Ibadan, Ibadan, Oyo, Nigeria
| | - Rosine Mosso
- Rosine Mosso is Lecturer and Researcher, École Nationale Supérieure de Statistique et d'Économie Appliquée, Abidjan, Côte d'Ivoire
| | - Elizabeth Omoluabi
- Elizabeth Omoluabi is Managing Director, Centre for Research, Evaluation Resources and Development, Ile-Ife, Nigeria
| | - Caroline Moreau
- Sophia Magalona is a PhD student, Meagan Byrne is PMA Survey Operations Lead, Caroline Moreau is Associate Professor, and Suzanne O. Bell is Assistant Professor, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Caroline Moreau is Epidemiologist, CESP Centre for Research in Epidemiology and Population Health, INSERM (Institut National de la Santé et de la Recherche Médicale), Villejuif, France
| | - Suzanne O Bell
- Sophia Magalona is a PhD student, Meagan Byrne is PMA Survey Operations Lead, Caroline Moreau is Associate Professor, and Suzanne O. Bell is Assistant Professor, Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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26
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Gerdts C, Bell SO, Shankar M, Jayaweera RT, Owolabi O. Beyond safety: the 2022 WHO abortion guidelines and the future of abortion safety measurement. BMJ Glob Health 2022; 7:bmjgh-2022-009557. [PMID: 35725242 PMCID: PMC9214389 DOI: 10.1136/bmjgh-2022-009557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 05/31/2022] [Indexed: 12/04/2022] Open
Affiliation(s)
| | - Suzanne O Bell
- Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mridula Shankar
- Department of General Practice, Monash University, Nottinghill, Victoria, Australia
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27
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Sully EA, Shiferaw S, Seme A, Bell SO, Giorgio M. Impact of the Trump Administration's Expanded Global Gag Rule Policy on Family Planning Service Provision in Ethiopia. Stud Fam Plann 2022; 53:339-359. [PMID: 35639923 PMCID: PMC9328269 DOI: 10.1111/sifp.12196] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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] [Indexed: 11/29/2022]
Abstract
The Global Gag Rule (GGR) makes non‐U.S. nongovernmental organizations (NGOs) ineligible for U.S. Government global health funding if they provide, refer, or promote access to abortion. This study quantitatively examines the impacts of the GGR on family planning service provision in Ethiopia. Using a panel of health facilities (2017–2020), we conduct a pre–post analysis to investigate the overall changes in family planning service provision before and after the policy came into effect in Ethiopia. Our pre–post analyses revealed post‐GGR reductions in the proportions of facilities reporting family planning provision through community health volunteers (−5.6, 95% CI [−10.2, −1.0]), mobile outreach visits (−13.1, 95% CI [−17.8, −8.4]), and family planning and postabortion care service integration (−4.8, 95% CI: [−9.1, −0.5]), as well as a 6.1 percentage points increase in contraceptive stock‐outs over the past three months (95% CI [−0.6, 12.8]). We further investigate the impacts of the GGR on facilities exposed to noncompliant organizations that did not sign the policy and lost U.S. funding. We do not find any significant additional impacts on facilities in regions more exposed to noncompliant organizations. Overall, while the GGR was slow to fully impact NGOs in Ethiopia, it ultimately resulted in negative impacts on family planning service provision.
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Affiliation(s)
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA
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Bell SO, Larson E, Wood SN. Let's Talk About Sex: Improving Measurement of Contraceptive Use in Cross-Sectional Surveys by Accounting for Sexual Activity Recency. Glob Health Sci Pract 2022; 10:GHSP-D-21-00597. [PMID: 35487552 PMCID: PMC9053161 DOI: 10.9745/ghsp-d-21-00597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022]
Abstract
Findings suggest that the contraceptive use of unmarried women and those who were not recently sexually active are less likely to be captured in standard measures of current contraceptive use. Incorporating information from questions about contraceptive use at last sex may better capture coital-dependent method use and provide a more accurate assessment of who is protected against an unintended pregnancy at next sex. Introduction: Standard measures of contraceptive prevalence have known biases given that they do not reflect sexual activity and true exposure to the risk of an unintended pregnancy. In this study, we aim to understand the extent to which women protect themselves against unintended pregnancy, taking into account exposure to sex, by examining contraceptive use patterns by marital status and recent sexual activity. Methods: Data come from population-based surveys of reproductive age women in 9 low-resource settings. We estimated contraceptive prevalence using (1) the standard current contraceptive use measure, (2) a new measure of contraceptive use at last sex, and (3) a comprehensive measure that combines current use and use at last sex. Analyses are stratified by site and examine patterns by marital status only, and by both marital status and sexual activity separately. We then examined method mix by each contraceptive measure. Results: Study findings reveal distinct patterns in contraceptive use in relation to marital status and sexual recency across sites. Overall, married women tended to report higher levels of current contraceptive use compared to use at last sex, whereas unmarried women reported higher levels of contraceptive use at last sex. When examining these measures by sexual activity and marital status, results indicate lower levels of contraceptive use among women who had not had sex in the month prior to the survey, for both married and unmarried women. The comprehensive measure of contraceptive use yielded the highest estimates, by design. Method mix varied consistently by contraceptive measure, with current use tending to capture more permanent and long-acting methods and use at last sex more likely to capture short-acting and coital-dependent methods. Discussion: These findings have important implications for how the family planning field evaluates unintended pregnancy risk and unmet need for contraception within low-resource settings, given different estimates yield discrepant estimates for who is “at risk.”
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Elizabeth Larson
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Zimmerman LA, Karp C, Thiongo M, Gichangi P, Guiella G, Gemmill A, Moreau C, Bell SO. Stability and change in fertility intentions in response to the COVID-19 pandemic in Kenya. PLOS Glob Public Health 2022; 2:e0000147. [PMID: 36962268 PMCID: PMC10021581 DOI: 10.1371/journal.pgph.0000147] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 01/19/2022] [Indexed: 12/20/2022]
Abstract
Fertility intentions are expected to decline due to the COVID-19 pandemic but limited empirical research on this topic has been conducted in sub-Saharan Africa. Longitudinal data from Kenya, with baseline (November 2019) and follow-up (June 2020) data, were used to 1) assess the extent to which individual-level fertility intentions changed, and 2) examine how security, specifically economic and health security, affected fertility intentions. The final sample included 3,095 women. The primary outcomes were change in quantum and timing. Exploratory analyses described overall changes within the sample and logistic regression models assessed sociodemographic and COVID-19 related correlates of change, specifically income loss at the household level, food insecurity, and ability to socially distance. Approximately 85% of women reported consistent fertility intentions related to both the number and timing of childbearing. No COVID-19-related factors were related to changing quantum intentions. Women who reported chronic food insecurity had 4.78 times the odds of accelerating their desired timing to next birth compared to those who reported no food insecurity (95% CI: 1.53-14.93), with a significant interaction by wealth. The COVID-19 pandemic did not lead to widespread changes in fertility intentions in Kenya, though the most vulnerable women may have accelerated their childbearing intentions.
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Affiliation(s)
- Linnea A Zimmerman
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Celia Karp
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Mary Thiongo
- International Centre for Reproductive Health Kenya (ICRH-K), Mombasa, Kenya
| | - Peter Gichangi
- International Centre for Reproductive Health Kenya (ICRH-K), Mombasa, Kenya
- Technical University of Mombasa, Mombasa, Kenya
- Faculty of Medicine and Health Sciences, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP/University of Ouagadougou), Ouagadougou, Burkina Faso
| | - Alison Gemmill
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Caroline Moreau
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France
| | - Suzanne O Bell
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Sheehy G, Omoluabi E, OlaOlorun FM, Mosso R, Bazié F, Moreau C, Bell SO. A mixed-methods study exploring women's perceptions of terminology surrounding fertility and menstrual regulation in Côte d'Ivoire and Nigeria. Reprod Health 2021; 18:251. [PMID: 34930322 PMCID: PMC8686364 DOI: 10.1186/s12978-021-01306-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
Background Women use various terms when discussing the management of their fertility and menstrual irregularities and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology used to refer to abortion-like experiences (specifically menstrual regulation and pregnancy removal), and the specific scenarios that these practices encompass among women who reported doing something to bring back a late period or ending a pregnancy in Nigeria and Côte d’Ivoire. Methods Our analysis draws upon surveys with women in Nigeria (n = 1114) and Cote d’Ivoire (n = 352). We also draw upon qualitative in-depth interviews with a subset of survey respondents in Anambra and Kaduna States in Nigeria, and Abidjan, Cote d’Ivoire (n = 30 in both countries). We examine survey and interview questions that explored women’s knowledge of terminology pertaining to ending a pregnancy or bringing back a late period. Survey data were analyzed descriptively and weighted, and interview data were analyzed using inductive thematic analysis. Results We find that the majority (71% in Nigeria and 70% in Côte d’Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy. Conclusions Overall, menstrual regulation and pregnancy removal are seen as distinct experiences in both settings. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women’s reproductive health needs. Supplementary Information The online version contains supplementary material available at 10.1186/s12978-021-01306-5. Women use various words and phrases to describe their experiences managing their fertility and menstrual irregularities, and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology women use to refer to abortion-like experiences (specifically menstrual regulation, which refers to actions taken to regulate a menstrual cycle, and pregnancy removal), and the specific scenarios that these practices encompass among women who reported having had an abortion in Côte d’Ivoire and Nigeria. Our analysis draws upon data from surveys and qualitative interviews conducted in both countries. We find that the majority (71% in Nigeria and 70% in Côte d’Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women’s reproductive health needs.
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Affiliation(s)
- Grace Sheehy
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, 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
| | | | - Rosine Mosso
- École Nationale Supérieure de Statistique et d'Économie Appliquée d'Abidjan (ENSEA), Abidjan, Côte d'Ivoire
| | - Fiacre Bazié
- Institut Supérieur des Sciences de la Population, Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., Baltimore, MD, 21205, USA
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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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Karp C, Wood SN, Guiella G, Gichangi P, Bell SO, Anglewicz P, Larson E, Zimmerman L, Moreau C. Contraceptive dynamics during COVID-19 in sub-Saharan Africa: longitudinal evidence from Burkina Faso and Kenya. BMJ Sex Reprod Health 2021; 47:252-260. [PMID: 33579717 PMCID: PMC7886665 DOI: 10.1136/bmjsrh-2020-200944] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/17/2021] [Accepted: 01/19/2021] [Indexed: 05/07/2023]
Abstract
INTRODUCTION Evidence from health emergencies suggests COVID-19 will disrupt women's sexual and reproductive health (SRH). In sub-Saharan Africa, which experiences the highest rates of unintended pregnancy and unsafe abortion globally, COVID-19 is projected to slow recent progress toward universal access to contraceptive services. METHODS We used longitudinal data collected from women at risk of unintended pregnancy in Burkina Faso (n=1186) and Kenya (n=2784) before (November 2019-February 2020) and during (May-July 2020) COVID-19 to quantify contraceptive dynamics during COVID-19; examine sociodemographic factors and COVID-19 experiences related to contraceptive dynamics; and assess COVID-19-related reasons for contraceptive non-use. Bivariate and multivariate logistic regressions were used to examine correlates of contraceptive dynamics amid COVID-19. RESULTS Most women did not change their contraceptive status during COVID-19 (68.6% in Burkina Faso and 81.6% in Kenya) and those who did were more likely to adopt a method (25.4% and 13.1%, respectively) than to discontinue (6.0% and 5.3%, respectively). Most women who switched contraceptives were using methods as or more effective than their pre-pandemic contraception. Economic instability related to COVID-19 was associated with increased contraceptive protection in Burkina Faso but not in Kenya. Altogether, 14.4% of non-contraceptive users in Kenya and 3.8% in Burkina Faso identified COVID-19-related reasons for non-use. CONCLUSIONS The vast majority of women at risk of unintended pregnancy did not change their contraceptive status during COVID-19, and more women adopted than discontinued methods. A minority of women reported COVID-19-related reasons for non-use, underscoring the importance of expanding safe modes of service delivery during health crises.
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Affiliation(s)
- Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP)/University of Ouagadougou, Ouagadougou, Centre, Burkina Faso
| | - Peter Gichangi
- International Centre for Reproductive Health Kenya (ICRH-K), Mombasa, Kenya
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Philip Anglewicz
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Larson
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Linnea Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018 INSERM, Villejuif, France
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Bell SO, Shankar M, Ahmed S, OlaOlorun F, Omoluabi E, Guiella G, Moreau C. Postabortion care availability, facility readiness and accessibility in Nigeria and Côte d'Ivoire. Health Policy Plan 2021; 36:1077-1089. [PMID: 34131700 PMCID: PMC8359750 DOI: 10.1093/heapol/czab068] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 06/17/2020] [Revised: 05/25/2021] [Accepted: 06/07/2021] [Indexed: 11/24/2022] Open
Abstract
Postabortion care (PAC) is an essential component of emergency obstetric care (EmOC) and is necessary to prevent unsafe abortion-related maternal mortality, but we know little regarding the preparedness of facilities to provide PAC services, the distribution of these services and disparities in their accessibility in low-resource settings. To address this knowledge gap, this study aims to describe PAC service availability, evaluate PAC readiness and measure inequities in access to PAC services in seven states of Nigeria and nationally in Côte d’Ivoire. We used survey data from reproductive-age women and the health facilities that serve the areas where they live. We linked facility readiness information, including PAC-specific signal functions, to female data using geospatial information. Findings revealed less than half of facilities provide basic PAC services in Nigeria (48.4%) but greater PAC availability in Côte d’Ivoire (70.5%). Only 33.5% and 36.9% of facilities with the capacity to provide basic PAC and only 23.9% and 37.5% of facilities with the capacity to provide comprehensive PAC had all the corresponding signal functions in Nigeria and Côte d’Ivoire, respectively. With regard to access, while ∼8 out of 10 women of reproductive age in Nigeria (81.3%) and Côte d’Ivoire (79.9%) lived within 10 km of a facility providing any PAC services, significantly lower levels of the population lived <10 km from a facility with all basic or comprehensive PAC signal functions, and we observed significant inequities in access for poor, rural and less educated women. Addressing facilities’ service readiness will improve the quality of PAC provided and ensure postabortion complications can be treated in a timely and effective manner, while expanding the availability of services to additional primary-level facilities would increase access—both of which could help to reduce avoidable abortion-related maternal morbidity and mortality and associated inequities.
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 62501, USA
| | - Mridula Shankar
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 62501, USA
| | - Saifuddin Ahmed
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 62501, USA
| | - Funmilola OlaOlorun
- College of Medicine, University of Ibadan, Queen Elizabeth II Road, Agodi, Ibadan, Nigeria
| | - Elizabeth Omoluabi
- Center for Research, Evaluation Resources and Development, Flat 16, Ajanaku Estate Ife-Ibadon Road, Opp RCCG Rehoboth Mega Cathedral, Ile-Ife Osun State, Nigeria.,Department of Statistics and Population Studies, University of the Western Cape, Robert Sobukwe Road, P/Bag X17, Bellville, 7530 Cape Town, South Africa
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP), Université of Ouagadougou, 03 BP 7118, Blvd Charles De Gaulle, Ouagadougou, Burkina Faso
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 62501, USA.,Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Bat 15/16 16 av PV Couturier, 94807 Villejuif Cedex, France
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Polis CB, Otupiri E, Hindin M, Chiu DW, Keogh SC, Aidoo C, Larsen-Reindorf R, Bell SO. Prevalence and Correlates of Perceived Infertility in Ghana. Stud Fam Plann 2021; 51:207-224. [PMID: 32964426 PMCID: PMC7539950 DOI: 10.1111/sifp.12136] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Perceived infertility is an understudied phenomenon in low‐ and middle‐income countries, where biomedical infertility can have severe consequences, particularly for women. We conducted a nationally representative survey of Ghanaian women, estimated the prevalence of and reasons for perceived infertility, and assessed factors associated with higher levels of perceived infertility using a partial proportional odds model. Among 4,070 women, 13 percent believed they were “very likely” to have difficulty getting pregnant when they wanted to, 21 percent believed this was “somewhat likely,” and 66 percent believed this was “not at all likely.” Reasons for perceived infertility varied by whether the respondent was currently seeking pregnancy. In multivariable analysis, several factors were associated with higher levels of perceived infertility, while unexpectedly, women who reported ever using contraception were less likely to report perceived infertility. Acknowledging the need to address infertility globally and understanding the role of perceived infertility are important components in supporting people's ability to decide whether and when to have children.
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Affiliation(s)
- Chelsea B Polis
- Chelsea B. Polis, Guttmacher Institute, New York, NY.,Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Easmon Otupiri
- Doris W. Chiu, Sarah C. Keogh, Guttmacher Institute, New York, NY
| | - Michelle Hindin
- Suzanne O. Bell, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Easmon Otupiri, Cara Aidoo, Roderick Larsen-Reindorf, School of Public Health, Kwame Nkrumah University of Science and Technology, Ghana. Michelle Hindin, Population Council, New York, NY
| | - Doris W Chiu
- Chelsea B. Polis, Guttmacher Institute, New York, NY
| | - Sarah C Keogh
- Chelsea B. Polis, Guttmacher Institute, New York, NY
| | - Cara Aidoo
- Doris W. Chiu, Sarah C. Keogh, Guttmacher Institute, New York, NY
| | | | - Suzanne O Bell
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Bell SO, Shankar M, Ahmed S, OlaOlorun F, Omoluabi E, Guiella G, Moreau C. Erratum to: postabortion care availability, facility readiness, and accessibility in Nigeria and Cote d'Ivoire. Health Policy Plan 2021; 36:1357. [PMID: 34245269 PMCID: PMC8428293 DOI: 10.1093/heapol/czab082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Polis CB, Otupiri E, Bell SO, Larsen-Reindorf R. Use of Fertility Awareness-Based Methods for Pregnancy Prevention Among Ghanaian Women: A Nationally Representative Cross-Sectional Survey. Glob Health Sci Pract 2021; 9:318-331. [PMID: 34234024 PMCID: PMC8324203 DOI: 10.9745/ghsp-d-20-00601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 05/11/2021] [Indexed: 01/21/2023]
Abstract
Few studies in low- and middle-income countries have examined the use of fertility awareness-based methods (FABMs) for pregnancy prevention. Understanding the prevalence of FABM use among Ghanaian contraceptors and the characteristics and practices of users is essential. Our 2018 nationally representative survey of Ghanaian women included detailed questions on the use of rhythm and Standard Days Method/Cycle Beads (SDM). After considering multimethod use patterns, we estimated likely FABM prevalence among contraceptors, identified characteristics associated with current use of an FABM (vs. current use of a hormonal method/intrauterine device [IUD]), and described how women report using FABMs. At least 18% of contracepting Ghanaian women likely use an FABM, though this may be underreported. Among FABM users, 57% reported current use of an FABM alone; the remainder reported concurrent use of other methods. Women who were older, richer, more educated, and had fewer children had higher odds of current FABM use versus IUD/hormonal method. Although FABM users were more likely than other contraceptors to correctly identify the approximate fertile time, only 50% of FABM users did so correctly. Most (92%) rhythm users were interested in making their method use more effective. While 72% had heard of SDM, less than 25% had heard of various other ways to make the rhythm method more effective. Only 17% of rhythm users had ever discussed the method with a health professional. Rhythm users indicated substantial willingness to track additional biomarkers (e.g., daily temperature or cervical mucus) or to use a phone to enhance the effectiveness of their method, and most indicated no substantial difficulty getting partners to abstain or withdraw on fertile days. A nontrivial proportion of reproductive age Ghanaian women are using an FABM, nearly all of whom are interested in learning how to improve its effectiveness. The family planning field should better address these women's contraceptive needs in commitment to reproductive autonomy and choice.
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Affiliation(s)
- Chelsea B Polis
- Guttmacher Institute, New York, New York, USA. .,Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Easmon Otupiri
- School of Public Health, Kwame Nkrumah University of Science and Technology, Ghana
| | - Suzanne O Bell
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Bell SO, Bishai D. Can you repeat the question? Paradata as a lens to understand respondent experience answering cognitively demanding, sensitive questions. PLoS One 2021; 16:e0252512. [PMID: 34097702 PMCID: PMC8183984 DOI: 10.1371/journal.pone.0252512] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 05/17/2021] [Indexed: 11/18/2022] Open
Abstract
Survey researchers hope that respondents will provide high-quality data, but evidence suggests that social desirability bias may be commonplace. Social desirability can lead to significant underreporting or overreporting of sensitive behaviors. With better understanding of the cognitive processes that respondents use to prepare and deliver their responses, survey designers could hope to minimize social desirability bias or at least detect settings that lessen its impact. The primary objective of this study was to use survey paradata to understand the psychology of responding to certain types of survey questions. More specifically, we sought to determine how emotional triggering can alter response latencies to cognitively demanding and sensitive survey questions on induced abortion, which is underreported. We hypothesize that having had a prior abortion might lengthen response times to an indirect question about abortion among respondents who have experienced this sensitive reproductive outcome as they hesitate in deciding whether and how to respond to the question. Data come from a representative survey of 6,035 reproductive age women in Rajasthan, India. We used list experiment question active screen time paradata in conjunction with responses from direct questions on abortion to assess our hypothesis. Our final model was a multivariate linear regression with random effects at the level of the interviewer, including adjustments for respondent, community, and interviewer characteristics to estimate within-respondent effects. Results suggest that women who reported an abortion on the direct abortion questions took 5.11 (95% CI 0.21, 10.00) seconds longer to respond to the list experiment treatment list compared to the control list in comparison to women who did not report an abortion on the direct abortion questions. This study demonstrates the additional insights gained when focusing on response latencies to cognitively demanding questions involved in the measurement of sensitive behaviors.
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Affiliation(s)
- Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- * E-mail:
| | - David Bishai
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
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Keogh SC, Otupiri E, Castillo PW, Chiu DW, Polis CB, Nakua EK, Bell SO. Hormonal contraceptive use in Ghana: The role of method attributes and side effects in method choice and continuation. Contraception 2021; 104:235-245. [PMID: 33992609 DOI: 10.1016/j.contraception.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 11/13/2020] [Revised: 05/04/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To understand the barriers and facilitators of hormonal contraceptive use among Ghanaian women, in order to help improve contraceptive counseling and reduce the high rates of unintended pregnancy. STUDY DESIGN We conducted a nationally representative community-based survey of 4143 women aged 15-49 in 2018, and used descriptive statistics and logistic regression to examine correlates of current hormonal method use, preferred method attributes and their association with method choice, and the role of side effects in hormonal method discontinuation. RESULTS Hormonal method use (vs. contraceptive non-use) was associated with younger age, higher parity and education, but not with union status, wealth or residence. Preferences for key method attributes were associated with choosing particular methods. Most valued attributes were effectiveness at preventing pregnancy, and low risks of harming health and future fertility. These last 2 concerns are echoed in the second most common reason for discontinuation (health concerns). While menstrual changes were a common concern, leading some respondents to discontinue hormonal contraceptives, many were willing to endure these effects. In contrast, having experienced long-term health issues as a perceived result of hormonal method use more than halved the odds of current use. Contraceptive counseling on menstrual changes, other side effects, and impacts on future fertility had not been universally provided. CONCLUSIONS Ghanaian women value hormonal methods for their effectiveness against pregnancy. However, concerns about side effects (particularly bleeding changes), future fertility impairment, and long-term health issues led some women to discontinue hormonal methods. Counseling on these issues was reportedly inadequate. IMPLICATIONS Identifying barriers to, and facilitators of, hormonal contraceptive use, as well as method attributes important to Ghanaian women, can help to better tailor contraceptive counseling to individual needs, in order to ensure that all women can access the method that suits them best, and decide whether and how to manage side effects, switch methods or discontinue.
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Affiliation(s)
| | - Easmon Otupiri
- Department of Population, Family and Reproductive Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | | | - Doris W Chiu
- Guttmacher Institute, New York, NY, United States.
| | - Chelsea B Polis
- Guttmacher Institute, New York, NY, United States; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
| | - Emmanuel K Nakua
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.
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Abstract
Background In Côte d’Ivoire, induced abortion is legally restricted unless a pregnancy threatens a woman’s life. Yet the limited available evidence suggests abortion is common and that unsafe abortion is contributing to the country’s high maternal mortality. Our study aimed to estimate the one-year incidence of induced abortion in Côte d’Ivoire using both direct and indirect methodologies, determine the safety of reported abortions, and identify the women most likely to experience a recent induced abortion or an unsafe abortion. Methods In 2018, we conducted a nationally representative, population-based survey of women age 15 to 49 in Côte d’Ivoire. Women reported their own abortion experiences and those of their closest female confidante. We estimated the one-year incidence of induced abortion, and the safety of the abortions women experienced. Using bivariate and multivariate regression, we separately assessed sociodemographic characteristics associated with having had a recent abortion or an unsafe abortion. Results Overall, 2,738 women participated in the survey, approximately two-thirds of whom reported on the abortion experiences of their closest female friend. Based on respondent data, the one-year incidence of induced abortion was 27.9 (95% CI 18.6–37.1) per 1,000 women of reproductive age, while the confidante incidence was higher at 40.7 (95% CI 33.3–48.1) per 1,000. Among respondents, 62.4% of abortions were most unsafe, while 78.5% of confidante abortions were most unsafe. Adolescents, less educated women, and the poorest women had the most unsafe abortions. Conclusion This study provides the first national estimates of induced abortion incidence and safety in Côte d’Ivoire, using a population-based approach to explore social determinants of abortion and unsafe abortion. Consistent with other research, our results suggest that legal restrictions on abortion in Côte d’Ivoire are not preventing women from having abortions, but rather pushing women to use unsafe, potentially dangerous abortion methods. Efforts to reduce the harms of unsafe abortion are urgently needed.
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Affiliation(s)
- Suzanne O. Bell
- Department of Population, Family and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Grace Sheehy
- Department of Population, Family and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP), Université of Ouagadougou, Ouagadougou, Burkina Faso
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, France
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Polis CB, Castillo PW, Otupiri E, Keogh SC, Hussain R, Nakua EK, Larsen-Reindorf R, Bell SO. Estimating the incidence of abortion: using the Abortion Incidence Complications Methodology in Ghana, 2017. BMJ Glob Health 2020; 5:e002130. [PMID: 32337086 PMCID: PMC7170428 DOI: 10.1136/bmjgh-2019-002130] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 10/30/2019] [Revised: 02/20/2020] [Accepted: 02/28/2020] [Indexed: 01/02/2023] Open
Abstract
Introduction Induced abortion is legally permitted in Ghana under specific conditions, but access to services that meet guidelines approved by government is limited. As part of a larger project comparing five methodologies to estimate abortion incidence, we implemented an indirect estimation approach: the Abortion Incidence Complications Methodology (AICM), to understand the incidence of abortion in Ghana in 2017. Methods We drew a nationally representative, two-stage, stratified sample of health facilities. We used information from 539 responding facilities to estimate treated complications stemming from illegal induced abortions, and to estimate the number of legal abortions provided. We used information from 146 knowledgeable informants to generate zonal multipliers representing the inverse of the proportion of illegal induced abortions treated for complications in facilities in Ghana’s three ecological zones. We applied multipliers to estimates of treated complications from illegal abortions, and added legal abortions to obtain an annual estimate of all induced abortions. Results The AICM approach suggests that approximately 200 000 abortions occurred in Ghana in 2017, corresponding to a national abortion rate of 26.8 (95% CI 21.7 to 31.9) per 1000 women 15–49. Abortion rates were lowest in the Northern zone (18.6) and highest in the Middle zone (30.4). Of all abortions, 71% were illegal. Conclusion Despite Ghana’s relatively liberal abortion law and efforts to expand access to safe abortion services, illegal induced abortion appears common. A concurrently published paper compares the AICM-derived estimates presented in this paper to those from other methodological approaches.
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Affiliation(s)
- Chelsea B Polis
- Guttmacher Institute, Manhattan, New York, USA.,Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Easmon Otupiri
- Department of Population, Family and Reproductive Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | | | - Emmanuel K Nakua
- Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Roderick Larsen-Reindorf
- Department of Obstetrics & Gynaecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Keogh SC, Otupiri E, Chiu DW, Polis CB, Hussain R, Bell SO, Nakua EK, Larsen-Reindorf R. Estimating the incidence of abortion: a comparison of five approaches in Ghana. BMJ Glob Health 2020. [PMCID: PMC7245387 DOI: 10.1136/bmjgh-2019-002129] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Introduction Induced abortion estimates are critical for reproductive health programming. In countries like Ghana where abortion is somewhat legally restricted and highly stigmatised, official records are incomplete and different approaches are needed to measure abortion incidence. We conducted a study in Ghana to test five methodologies for estimating incidence: direct reporting, the list experiment, the confidante method, the Abortion Incidence Complications Method (AICM) and a modified AICM. Methods The direct reporting, list experiment and confidante method were implemented through a nationally representative community-based survey (CBS) of 4722 women. The AICM used data from a nationally representative health facilities survey (HFS) and a knowledgeable informant survey. The modified AICM combined CBS and HFS data. For each approach, we calculated abortion incidence nationally and for Ghana’s three ecological zones and conducted checks to determine the most internally valid approaches. Results National incidence estimates ranged from 27 per 1000 (AICM) to 61 (confidante method). The Northern zone displayed lower rates than the other two zones for all approaches. Validity and reliability checks found that the list experiment was invalid. The approaches that stood up to the internal validity checks and were most reliable were the direct reporting, confidante method and modified AICM. These approaches provide lower and upper bound estimates for the abortion rate, and the mean of the estimates from the three approaches yields a final abortion rate of 44 per 1000 and an unintended pregnancy rate of 103 per 1000. Conclusions Comparing five approaches to estimating abortion enabled cross-validation of findings and highlighted strengths, pitfalls and requirements of each approach that can inform abortion estimation in other settings.
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Affiliation(s)
| | - Easmon Otupiri
- Department of Population, Family and Reproductive Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Chelsea B Polis
- Guttmacher Institute, New York, New York, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emmanuel K Nakua
- Department of Epidemiology and Biostatistics, Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti, Ghana
| | - Roderick Larsen-Reindorf
- Department of Population, Family and Reproductive Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Bell SO, Omoluabi E, OlaOlorun F, Shankar M, Moreau C. Inequities in the incidence and safety of abortion in Nigeria. BMJ Glob Health 2020; 5:e001814. [PMID: 32133166 PMCID: PMC7042592 DOI: 10.1136/bmjgh-2019-001814] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 07/02/2019] [Revised: 10/14/2019] [Accepted: 11/10/2019] [Indexed: 11/21/2022] Open
Abstract
Background We know little about the frequency, correlates and conditions under which women induce abortions in Nigeria. This study seeks to estimate the 1-year induced abortion incidence and proportion of abortions that are unsafe overall and by women’s background characteristics using direct and indirect methodologies. Methods Data for this study come from a population-based, nationally representative survey of reproductive age women (15–49) in Nigeria. Interviewers asked women to report on the abortion experiences of their closest female confidante and themselves. We adjusted for potential biases in the confidante data. Analyses include estimation of 1-year induced abortion incidence and unsafe abortion, as well as bivariate and multivariate assessment of their correlates. Results A total of 11 106 women of reproductive age completed the female survey; they reported on 5772 confidantes. The 1-year abortion incidence for respondents was 29.0 (95% CI 23.3 to 34.8) per 1000 women aged 15–49 while the confidante incidence was 45.8 (95% CI 41.0-50.6). The respondent and confidante abortion incidences revealed similar correlates, with women in their 20s, women with secondary or higher education and women in urban areas being the most likely to have had an abortion in the prior year. The majority of respondent and confidante abortions were the most unsafe (63.4% and 68.6%, respectively). Women aged 15–19, women who had never attended school and the poorest women were significantly more likely to have had the most unsafe abortions. Conclusion Results indicate that abortion in Nigeria is a public health concern and an issue of social inequity. Efforts to expand the legal conditions for abortion in Nigeria are critical. Simultaneously, efforts to increase awareness of the availability of medication abortion drugs to more safely self-induce can help mitigate the toll of unsafe abortion-related morbidity and mortality.
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Affiliation(s)
- Suzanne O Bell
- Population Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Elizabeth Omoluabi
- Centre for Research, Evaluation Resources and Development, Ile-Ife, Nigeria
| | - Funmilola OlaOlorun
- Department of Community Medicine, University of Ibadan, Ibadan, Oyo, Nigeria
| | - Mridula Shankar
- Population Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Caroline Moreau
- Population Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Bell SO, OlaOlorun F, Shankar M, Ahmad D, Guiella G, Omoluabi E, Khanna A, Kouakou Hyacinthe A, Moreau C. Measurement of abortion safety using community-based surveys: Findings from three countries. PLoS One 2019; 14:e0223146. [PMID: 31697696 PMCID: PMC6837422 DOI: 10.1371/journal.pone.0223146] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 09/13/2019] [Indexed: 01/23/2023] Open
Abstract
This study aimed to measure abortion safety in Nigeria, Cote d’Ivoire, and Rajasthan, India using population-based abortion data from representative samples of reproductive age women. Interviewers asked women separately about their experience with “pregnancy removal” and “period regulation at a time when you were worried you were pregnant”, and collected details on method(s) and source(s) of abortion. We operationalized safety along two dimensions: 1) whether the method(s) used were non-recommended and put the woman at potentially high risk of abortion related morbidity and mortality (i.e. methods other than surgery and medication abortion drugs); and 2) whether the source(s) used involved a non-clinical (or no) provider(s). We combined source and method information to categorize a woman’s abortion into one of four safety categories. In Nigeria (n = 1,800), 29.1% of abortions involved a recommended method and clinical provider, 5.4% involved a recommended method and non-clinical provider, 2.1% involved a non-recommended method and clinical provider, and 63.4% involved a non-recommended method and non-clinical provider. The corresponding estimates were 32.7%, 3.0%, 1.9%, and 62.4% in Cote d’Ivoire (n = 645) and 39.7%, 25.5%, 3.4%, and 31.4% in Rajasthan (n = 454). Results demonstrate that abortion safety, as measured by abortion related process data, is generally low but varies significantly by legal context. The policy and programmatic strategies employed to improve abortion safety and quality of care are likely to differ for women in different abortion safety categories.
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Affiliation(s)
- Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- * E-mail:
| | | | - Mridula Shankar
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Danish Ahmad
- Indian Institute of Health Management Research, Jaipur, India
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP), Université de Ouagadougou, Ouagadougou, Burkina Faso
| | - Elizabeth Omoluabi
- Center for Research, Evaluation Resources and Development, Ile-Ife, Nigeria
| | - Anoop Khanna
- Indian Institute of Health Management Research, Jaipur, India
| | | | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Gender, Sexual and Reproductive Health, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France
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Zimmerman LA, Bell SO, Li Q, Morzenti A, Anglewicz P, Tsui AO. Individual, community and service environment factors associated with modern contraceptive use in five Sub-Saharan African countries: A multilevel, multinomial analysis using geographically linked data from PMA2020. PLoS One 2019; 14:e0218157. [PMID: 31220114 PMCID: PMC6586288 DOI: 10.1371/journal.pone.0218157] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/27/2019] [Indexed: 11/18/2022] Open
Abstract
The importance of the family planning service environment and community-level factors on contraceptive use has long been studied. Few studies, however, have been able to link individual and health facility data from surveys that are nationally representative, concurrently fielded, and geographically linked. Data from Performance Monitoring and Accountability 2020 address these limitations. To assess the relative influences of the service delivery environment and community, household, and individual factors on a woman's likelihood of using a modern contraceptive in five geographically and culturally diverse sub-Saharan African countries. Nationally representative, cross-sectional data from PMA2020 were linked at the household and service delivery level. Country-specific and pooled multilevel multinomial logistic models, comparing non-users, short- and long-acting method users were used. The variables elected for inclusion in our multivariate analyses were guided by the conceptual framework to profile the different levels of influences on individual use of modern contraception. Average marginal effects were calculated to improve interpretability. We find that the effect of contextual factors varies widely but that being visited by a health worker who spoke about family planning in the past 12 months was consistently and positively associated with individual use of short-acting and long-acting contraception. Characteristics of the nearest health facility did not generally exercise their own independent influences on a woman's use of contraception, except in the case of Burkina Faso, where the average distance between individuals and the nearest family planning provider was significantly greater than other countries. Inclusion of country fixed effects in the pooled models and the relevance of covariates at different levels in the country-specific models demonstrate that there is significant variation across countries in how community, individual, and service delivery environment factors influence contraceptive use and method choice. Context must be taken into account when designing family planning programs.
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Affiliation(s)
- Linnea A. Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Qingfeng Li
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Antonia Morzenti
- Center for Communication Programs, Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Philip Anglewicz
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | - Amy O. Tsui
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Abstract
Although induced abortion is common, measurement issues have long made this area of research challenging. The current analysis applies an indirect method known as the list experiment to try to improve survey‐based measurement of induced abortion. We added a double list experiment to a population‐based survey of reproductive age women in Rajasthan, India and compared resulting abortion estimates to those we obtained via direct questioning in the same sample. We then evaluated list experiment assumptions. The final sample completing the survey consisted of 6,035 women. Overall, 1.8 percent of the women reported a past abortion via the list experiment questions, whereas 3.5 percent reported an abortion via the direct questions, and this difference was statistically significant. As such, the list experiment failed to produce more valid estimates of this sensitive behavior on a population‐based survey of reproductive age women in Rajasthan, India. One explanation for the poor list experiment performance is our finding that key assumptions of the methodology were violated. Women may have mentally enumerated the treatment list items differently from the way they enumerated control list items. Further research is required to determine whether researchers can learn enough about how the list experiment performs in different contexts to effectively and consistently leverage its potential benefits to improve measurement of induced abortion.
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Bell SO, Bishai D. The Impact of Respondent-Interviewer Familiarity and Repeated Survey Participation on Abortion Reporting: Evidence from Rajasthan, India. Int Perspect Sex Reprod Health 2018; 44:147-156. [PMID: 31294696 DOI: 10.1363/44e7018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
CONTEXT Researchers have long assumed that familiarity between an interviewer and a survey participant reduces the validity of responses, especially for such sensitive behaviors as abortion. However, little empirical evidence exists on this issue. METHODS Data on 6,041 women aged 15-49 and 133 interviewers who took part in the second (2017) round of the Performance Monitoring and Accountability 2020 survey in Rajasthan, India, were used to examine the effect of interviewer-respondent acquaintance and participation in the prior survey round on women's reporting of induced abortion. Associations were identified using multivariate, multilevel models that adjusted for respondent, interviewer and community characteristics, and that included interviewer random effects. RESULTS On average, interviewers completed interviews with 41 respondents from their assigned cluster; they reported that they were acquainted with 61% of respondents and that 13% of respondents had participated in the prior survey round. Four percent of women reported having had an abortion. Neither interviewer-respondent acquaintance nor participation in the previous survey round was associated with abortion reporting in any of the multivariate models or in additional sensitivity analyses. CONCLUSIONS The findings do not support the hypothesis that respondent familiarity with the interviewer or the survey process is associated with lower reporting of sensitive behaviors, like abortion. Future studies should further explore these and other design features to identify those that provide statistically significant improvements in the reporting of abortion and other sensitive behaviors.
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Affiliation(s)
- Suzanne O Bell
- Assistant scientist, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA,
| | - David Bishai
- Professor, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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Bell SO, Zimmerman L, Choi Y, Hindin MJ. Legal but limited? Abortion service availability and readiness assessment in Nepal. Health Policy Plan 2018; 33:99-106. [PMID: 29136148 DOI: 10.1093/heapol/czx149] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2017] [Indexed: 11/13/2022] Open
Abstract
The government of Nepal revised its law in 2002 to allow women to terminate a pregnancy up to 12 weeks gestation for any indication on request, and up to 18 weeks if certain conditions are met. We evaluated the readiness of facilities in Nepal to provide three abortion services, manual vacuum aspiration (MVA), medication abortion (MA) and post-abortion care (PAC), using the service availability and readiness assessment (SARA) framework. The framework consists broadly of three domains; service availability, general service readiness and service readiness specific to individual services (i.e. service-specific readiness). We applied the framework to data from the Nepal Health Facility Survey 2015, a nationally representative survey of 992 health facilities. Overall, we find that access to safe abortion remains limited in Nepal. Of the facilities that reported offering delivery services and were thus eligible to provide safe abortion services, 44.5, 36.0 and 25.6% had provided any MVA, MA or PAC services, respectively, in the 3 months prior to the survey, and <2% were 'ready' to provide any abortion service based on our application of the SARA criteria for service-specific readiness. Among only the facilities that reported providing an abortion service in the 3 months prior to the survey, 3.2% of facilities that provided MVA, 1.5% of facilities that provided MA and 1.1% of the facilities that provided PAC had all the components of care required. Although the private sector conducted approximately half of all abortion services provided in the 3 months prior to the survey, no private sector facilities had all the abortion service-specific readiness components. Results suggest that accessing safe abortion services remains a significant challenge for Nepalese women, despite a set of permissive laws.
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Affiliation(s)
- Suzanne O Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Ste W4041, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Linnea Zimmerman
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Ste W4041, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Yoonjoung Choi
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Ste W4041, 615 N. Wolfe Street, Baltimore, MD 21205, USA
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