Building the nation's body: The contested role of abortion and family planning in post-war South Sudan

Using Vignettes to Gain Insights Into Social Norms Related to Voluntary Family Planning and Gender-Based Violence in South Sudan

Social norms are the shared expectations about behaviors that are held within collective groups. These differ from attitudes and beliefs, which are individually held. In South Sudan, social norms can affect the use of voluntary family planning and reproductive health (FP/RH); some of these norms even present risks for women seeking FP/RH care and their FP/RH providers. This cross-sectional, descriptive study conducted in 5 counties in South Sudan used vignettes as a qualitative method to explore social norms related to FP/RH and decisions related to contraceptive use and gender-based violence. Participants were asked to respond to vignettes about a fictional couple during various life stages of care-seeking. Vignettes allow respondents to share their opinions and feelings without directly speaking about their own experiences. Respondents included community members, FP/RH providers, and key influencers (e.g., religious leaders, traditional leaders, elders). The study identified restrictive social norms related to FP/RH, including entrenched, dominant gender roles (i.e., requiring male consent to use contraceptives) and risk for the woman and her provider if she accesses FP/RH services. Of note, supportive social norms are gaining acceptance regarding women's voice and agency; it was found that some women can negotiate their reproductive choice with their partners and participate in planning their families, which has not always been a widely accepted norm. The use of vignettes can lead to a better understanding of the challenges and provide insights on effective implementation approaches. It is essential for programs working to promote the use of FP/RH services in South Sudan to consider the challenges presented by social norms. Findings from this study were shared with stakeholders and communities to codesign interventions aimed at increasing the use of FP/RH services. Additionally, the dialogue stimulated by this study should lead to an organic transformation toward supportive social norms through collective agency.

Maternal Health in Crisis: A Scoping Review of Barriers and Facilitators to Safe Abortion Care in Humanitarian Crises

During humanitarian crises, women are particularly vulnerable to unwanted pregnancy. Unsafe abortion is among the five leading causes of maternal mortality and it is the only one which is entirely preventable. This study aimed to identify the barriers and facilitators to the provision of safe abortion care by humanitarian organisations. We performed a scoping review of the literature in July 2020, covering the years 2010-2020, on the following databases: Medline, Global Health, CINAHL Plus and ReliefWeb. We critically appraised all included articles and we conducted a narrative synthesis of the findings. We retrieved 881 articles. After removing duplicates and excluding articles that did not meet the inclusion criteria, twenty-four articles published between 2015 and 2020 were included in the review. Nine of the included papers were non-research practise items. The findings revealed five main themes: legal environment; context; stigma; economic factors; and service delivery. Restrictive laws, stigma, and lack of funding were reported as the main barriers to safe abortion, while the main facilitators were the fact that abortion is permitted under some circumstances in most countries, humanitarian actors' ability to inform healthcare policies at the onset of a humanitarian crisis, and community engagement. This scoping review revealed a dearth of published research. Increased dissemination of studies on Termination of Pregnancy (ToP) could increase the visibility of unsafe abortion and the need to provide ToP in humanitarian settings. Moreover, humanitarian organisations need to have a clear protocol on safe abortion and an in-depth understanding of relevant legislation, including the International Humanitarian Law, in order to provide this service to the full extent of the law.

Community perceptions of the impact of war on unintended pregnancy and induced abortion in Protection of Civilian sites in Juba, South Sudan

Conflict and mass displacement into Protection of Civilian (POCs) sites in South Sudan led to the breakdown of community and family structures, increasing women and girls' vulnerability to gender-based violence and exacerbating already poor sexual and reproductive health outcomes. As one component of a study on post-abortion care, this study explores community perceptions of unintended pregnancy and abortion in a POC in Juba. Four focus group discussions were conducted with 36 women and married men aged 18-45 living in the POC. Although initial reactions to induced abortion were generally negative, participants discussed that unintended pregnancy and induced abortion appeared to have increased during the current conflict. Their discussion of abortion became less condemnatory as they described changes in people's situation due to war, including instability and poverty, transactional sex, disruption of marital norms, rape, and low contraceptive use. This is one of the first studies to investigate community perceptions and practices related to unintended pregnancy and abortion in South Sudan. Despite the beliefs that these are taboo topics, the discussions provide an opening to reduce abortion stigma. To ensure lasting stigma reduction, investment in women and girls to improve gender equity is needed.

Analysing the intersection between health emergencies and abortion during Zika in Brazil, El Salvador and Colombia

The Zika outbreak of 2015-7 is a lens to analyse the positioning of abortion within in global health security. The sequelae of the virus almost exclusively affected newborn children, manifested through Congenital Zika Syndrome (CZS), and a focus on women at risk of, planning or being pregnant. At the global level, debate considered whether Zika would provide impetus for regulatory change for reproductive rights in Latin America, a region with some of the most restrictive abortion regulation in the world. However, regulatory change for abortion did not occur. We analyse why the Zika health emergency did not lead to any changes in abortion regulation through multi-method analysis of the intersection between Zika, health emergencies and abortion in Brazil, Colombia and El Salvador. These case study countries were purposefully selected; each had Zika infected women (albeit with differing incidence) yet represent diverse regulatory environments for abortion. Our comparative research is multi-method: framework analysis of key informant interviews (n = 49); content analysis of women's enquiries to a medical abortion telemedicine provider; and, policy analysis of (inter)national-level Zika response and abortion policies. We consider this within literature on global health security, and the prioritisation of a particular approach to epidemic control. Within this securitized landscape, despite increased public debate about abortion regulatory change, no meaningful change occurred, due to a dominant epidemiological approach to the Zika health emergency in all three countries and prominent conservative forces in government and within anti-abortion rights movements. Simultaneously, we demonstrate that regulation did not deter all women from seeking such service clandestinely.

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Zika affected reproductive decision making, but did not impact abortion regulation.

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Epidemiological framing ignored reproductive dimensions of emergency responses.

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Conservative forces instrumentalized disability concerns to oppose abortion rights.

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Women sought abortions clandestinely, citing Zika as a justification.

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Abortion provision must form part of health emergency planning and response.

Exposure to Armed Conflict and Fertility in Sub-Saharan Africa

Changes in fertility patterns are hypothesized to be among the many second-order consequences of armed conflict, but expectations about the direction of such effects are theoretically ambiguous. Prior research, from a range of contexts, has also yielded inconsistent results. We contribute to this debate by using harmonized data and methods to examine the effects of exposure to conflict on preferred and observed fertility outcomes across a spatially and temporally extensive population. We use high-resolution georeferenced data from 25 sub-Saharan African countries, combining records of violent events from the Armed Conflict Location and Event Data Project (ACLED) with data on fertility goals and outcomes from the Demographic and Health Surveys (n = 368,765 women aged 15-49 years). We estimate a series of linear and logistic regression models to assess the effects of exposure to conflict events on ideal family size and the probability of childbearing within the 12 months prior to the interview. We find that, on average, exposure to armed conflict leads to modest reductions in both respondents' preferred family size and their probability of recent childbearing. Many of these effects are heterogeneous between demographic groups and across contexts, which suggests systematic differences in women's vulnerability or preferred responses to armed conflict. Additional analyses suggest that conflict-related fertility declines may be driven by delays or reductions in marriage. These results contribute new evidence about the demographic effects of conflict and their underlying mechanisms, and broadly underline the importance of studying the second-order effects of organized violence on vulnerable populations.

Health policy mapping and system gaps impeding the implementation of reproductive, maternal, neonatal, child, and adolescent health programs in South Sudan: a scoping review

BACKGROUND

Pregnant women, neonates, children, and adolescents are at higher risk of dying in fragile and conflict-affected settings. Strengthening the healthcare system is a key strategy for the implementation of effective policies and ultimately the improvement of health outcomes. South Sudan is a fragile country that faces challenges in implementing its reproductive, maternal, neonatal, child, and adolescent health (RMNCAH) policies. In this paper, we map the key RMNCAH policies and describe the current status of the WHO health system building blocks that impede the implementation of RMNCAH policies in South Sudan.

METHODS

We conducted a scoping review (39 documents) and individual interviews (n = 8) with staff from the national Ministry of Health (MoH) and implementing partners. We organized a workshop to discuss and validate the findings with the MoH and implementing partner staff. We synthesized and analyzed the data according to the WHO health system building blocks.

RESULTS

The significant number of policies and healthcare strategic plans focused on pregnant women, neonates, children, and adolescents evidence the political will of the MoH to improve the health of members of these categories of the population. The gap in the implementation of policies is mainly due to the weaknesses identified in different health system building blocks. A critical shortage of human resources across the blocks and levels of the health system, a lack of medicines and supplies, and low national funding are the main identified bottlenecks. The upstream factors explaining these bottlenecks are the 2012 suspension of oil production, ongoing conflict, weak governance, a lack of accountability, and a low human resource capacity. The combined effects of all these factors have led to poor-quality provision and thus a low use of RMNCAH services.

CONCLUSION

The implementation of RMNCAH policies should be accomplished through innovative and challenging approaches to building the capacities of the MoH, establishing governance and accountability mechanisms, and increasing the health budget of the national government.

Setting the research agenda for induced abortion in Africa and Asia

Provision of safe abortion is widely recognized as vital to addressing the health and wellbeing of populations. Research on abortion is essential to meet the UN Sustainable Development Goals. Researchers in population health from university, policy, and practitioner contexts working on two multidisciplinary projects on family planning and safe abortion in Africa and Asia were brought together for a workshop to discuss the future research agenda on induced abortion. Research on care-seeking behavior, supply of abortion care services, and the global and national policy context will help improve access to and experiences of safe abortion services. A number of areas have potential in designing intervention strategies, including clinical innovations, quality improvement mechanisms, community involvement, and task sharing. Research on specific groups, including adolescents and young people, men, populations affected by conflict, marginalized groups, and providers could increase understanding of provision, access to and experiences of induced abortion. Methodological and conceptual advances, for example in the measurement of induced abortion incidence, complications, and client satisfaction, conceptualizations of induced abortion access and care, and methods for follow-up of patients who have induced abortions, will improve the accuracy of measurements of induced abortion, and add to understanding of women's experiences of induced abortions and abortion care.

Behind the scenes: International NGOs' influence on reproductive health policy in Malawi and South Sudan

Global health donors increasingly embrace international non-governmental organisations (INGOs) as partners, often relying on them to conduct political advocacy in recipient countries, especially in controversial policy domains like reproductive health. Although INGOs are the primary recipients of donor funding, they are expected to work through national affiliates or counterparts to enable 'locally-led' change. Using prospective policy analysis and ethnographic evidence, this paper examines how donor-funded INGOs have influenced the restrictive policy environments for safe abortion and family planning in South Sudan and Malawi. While external actors themselves emphasise the technical nature of their involvement, the paper analyses them as instrumental political actors who strategically broker alliances and resources to shape policy, often working 'behind the scenes' to manage the challenging circumstances they operate under. Consequently, their agency and power are hidden through various practices of effacement or concealment. These practices may be necessary to rationalise the tensions inherent in delivering a global programme with the goal of inducing locally-led change in a highly controversial policy domain, but they also risk inciting suspicion and foreign-national tensions.

Trajectories of women's abortion-related care: A conceptual framework

We present a new conceptual framework for studying trajectories to obtaining abortion-related care. It assembles for the first time all of the known factors influencing a trajectory and encourages readers to consider the ways these macro- and micro-level factors operate in multiple and sometimes conflicting ways. Based on presentation to and feedback from abortion experts (researchers, providers, funders, policymakers and advisors, advocates) (n = 325) between 03/06/2014 and 22/08/2015, and a systematic mapping of peer-reviewed literature (n = 424) published between 01/01/2011 and 30/10/2017, our framework synthesises the factors shaping abortion trajectories, grouped into three domains: abortion-specific experiences, individual contexts, and (inter)national and sub-national contexts. Our framework includes time-dependent processes involved in an individual trajectory, starting with timing of pregnancy awareness. This framework can be used to guide testable hypotheses about enabling and inhibiting influences on care-seeking behaviour and consideration about how abortion trajectories might be influenced by policy or practice. Research based on understanding of trajectories has the potential to improve women's experiences and outcomes of abortion-related care.

Accounting for abortion: Accomplishing transnational reproductive governance through post-abortion care in Senegal

Reproductive governance operates through calculating demographic statistics that offer selective truths about reproductive practices, bodies, and subjectivities. Post-abortion care, a global reproductive health intervention, represents a transnational reproductive regime that establishes motherhood as women's primary legitimate reproductive status. Drawing on ethnographic fieldwork conducted in Senegal between 2010 and 2011, I illustrate how post-abortion care accomplishes reproductive governance in a context where abortion is prohibited altogether and the US is the primary bilateral donor of population aid. Reproductive governance unfolds in hospital gynecological wards and the national health information system through the mobilization and interpretation of post-abortion care data. Although health workers search women's bodies and behavior for signs of illegal abortion, they minimize police intervention in the hospital by classifying most post-abortion care cases as miscarriage. Health authorities deploy this account of post-abortion care to align the intervention with national and global maternal health policies that valorize motherhood. Although post-abortion care offers life-saving care to women with complications of illegal abortion, it institutionalizes abortion stigma by scrutinizing women's bodies and masking induced abortion within and beyond the hospital. Post-abortion care reinforces reproductive inequities by withholding safe, affordable obstetric care from women until after they have resorted to unsafe abortion.