Decisionmaking Regarding Unwanted Pregnancy among Adolescents in Mexico City: A Qualitative Study

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

About 45.1% of all induced abortions are unsafe and 97% of these occur in low- and middle-income countries (LMICs). Women's abortion decisions may be complex and are influenced by various factors. We aimed to delineate women's abortion decision-making trajectories and their determinants in LMICs.

Methods

We searched Medline, EMBASE, PsychInfo, Global Health, Web of Science, Scopus, IBSS, CINAHL, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest, and Google Scholar for primary studies and reports published between January 1, 2000, and February 16, 2021 (updated on June 06, 2022), on induced abortion decision-making trajectories and/or their determinants in LMICs. We excluded studies on spontaneous abortion. Two independent reviewers extracted and assessed quality of each paper. We used "best fit" framework synthesis to synthesise abortion decision-making trajectories and thematic synthesis to synthesise their determinants. We analysed quantitative findings using random effects model. The study protocol is registered with PROSPERO number CRD42021224719.

Findings

Of the 6960 articles identified, we included 79 in the systematic review and 14 in the meta-analysis. We identified nine abortion decision-making trajectories: pregnancy awareness, self-reflection, initial abortion decision, disclosure and seeking support, negotiations, final decision, access and information, abortion procedure, and post-abortion experience and care. Determinants of trajectories included three major themes of autonomy in decision-making, access and choice. A meta-analysis of data from 7737 women showed that the proportion of the overall women's involvement in abortion decision-making was 0.86 (95% CI:0.73-0.95, I2 = 99.5%) and overall partner involvement was 0.48 (95% CI:0.29-0.68, I2 = 99.6%).

Interpretation

Policies and strategies should address women's perceptions of safe abortion socially, legally, and economically, and where appropriate, involvement of male partners in abortion decision-making processes to facilitate safe abortion. Clinical heterogeneity, in which various studies defined "the final decision-maker" differentially, was a limitation of our study.

Funding

Nuffield Department of Population Health DPhil Scholarship for PL, University of Oxford, and the Medical Research Council Career Development Award for MN (Grant Ref: MR/P022030/1).

Adolescent experiences of pregnancy in low-and middle-income countries: a meta-synthesis of qualitative studies

Background

Fertility rates among adolescents have fallen globally, yet the greatest incidence remains in low-and middle-income countries (LMICs). Gaining insight into adolescents needs and experiences of pregnancy will help identify if context specific services meet their needs and how to optimise pregnancy experiences. A meta-synthesis of qualitative studies considering adolescent experiences of pregnancy in LMICs has not yet been published.

Aim

To synthesise available qualitative evidence to provide greater understanding of the needs and experiences of adolescents who become pregnant in low-and middle-income countries.

Methods

An extensive search utilised six databases and citations searching. Studies were included if they were of a qualitative or mixed methods design. Participants lived in LMICs and were adolescents who were pregnant, had experienced pregnancy during adolescence or were an adolescent male partner. Relevant studies were assessed for quality to determine suitability for inclusion. A meta-ethnography approach was used to generate themes and a final line of argument.

Results

After screening and quality assessment 21 studies were included. The meta-ethnography generated four themes, A wealth of emotions, I am not ready, Impactful relationships and Respectful and disrespectful care. Unplanned, unwanted and unacceptable pregnancies were a source of shame, with subsequent challenging personal relationships and frequently a lack of needed support. Even when pregnancy was wanted, adolescents faced the internal conflict of their desires not always aligning with socio-cultural, religious and family expectations. Access, utilisation and experiences of care were significantly impacted by adolescents’ relationships with others, the level of respectful care experienced, and engagement with adolescent friendly services.

Conclusions

Adolescents who experience pregnancy in LMICs deserve support to meet their personal and pregnancy needs; efforts are needed to tailor the support provided. A lack of a health care provider knowledge and skills is an obstacle to optimal support, with more and better training integral to increasing the availability of adolescent friendly and respectful care. Adolescents should be involved in the planning of health care services and supported to make decisions about their care. The diversity across countries mean policy makers and other stakeholders need to consider how these implications can be realised in each context.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05022-1.

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

Men’s involvement in abortion is significant, intersecting across the individual, community and macro factors that shape abortion-related care pathways. This scoping review maps the evidence from low- and middle-income countries relating to male involvement in abortion trajectories. Five databases were searched, using search terms, to yield 7493 items published in English between 01.01.2010 and 20.12.2019. 37 items met the inclusion criteria for items relating to male involvement in women’s abortion trajectories and were synthesised using an abortion-related care-seeking framework. The majority of studies were conducted in sub-Saharan Africa and were qualitative. Evidence indicated that male involvement was significant, shaping the ability for a woman or girl to disclose her pregnancy or abortion decision. Men as partners were particularly influential, controlling resources necessary for abortion access and providing or withdrawing support for abortions. Denial or rejection of paternity was a critical juncture in many women’s abortion trajectories. Men’s involvement in abortion trajectories can be both direct and indirect. Contextual realities can make involving men in abortions a necessity, rather than a choice. The impact of male (lack of) involvement undermines the autonomy of a woman or girl to seek an abortion and shapes the conditions under which abortion-seekers are able to access care. This scoping review demonstrates the need for better understanding of the mechanisms, causes and intensions behind male involvement, centring the abortion seeker within this.

Relationship Between Abortion at First Pregnancy and Live Births by Young Adulthood: A Population-Based Study Among Mexican Women

STUDY OBJECTIVE

To identify factors associated with having an abortion (spontaneous or induced) at the time of first pregnancy, and to test the association between abortion in the first pregnancy and the number of live births among young women 20-24 years of age.

DESIGN

Cross-sectional study.

SETTING

We used a nationally representative survey of Mexican women 20-24 years of age with data at time of survey and retrospective measures of exposures in adolescence. We include 1913 women who reported ever having a pregnancy.

MAIN OUTCOMES

Our outcomes were history of abortion (spontaneous or induced) and number of live births by 20-24 years of age. We used multivariable logistic regression models to estimate the association between sociodemographic factors at the time of pregnancy and abortion history, and between abortion history and number of live births.

RESULTS

Among women 20-24 years of age who ever had a pregnancy, 15.5% reported an abortion in the first pregnancy, and 84.4% never had an abortion. Among women who had an abortion in the first pregnancy, 62.3% did not report any live birth by age 20-24 years. Young women living with their parents (adjusted odds ratio [AOR] = 1.87; confidence interval [CI] = 1.16-3.02) or with a partner with a higher educational level (AOR = 4.64; CI = 1.05-20.44) had greater odds of having an abortion in the first pregnancy. Compared with women who never had an abortion, women who reported an abortion in the first pregnancy had lower odds (AOR = 0.02; CI = 0.01-0.03) of having 1 or more children by the age of 20-24 years.

CONCLUSION

Young women who reported abortion in the first pregnancy had fewer live births at ages 20-24 years compared to women with no history of abortion.

Mandatory pre-abortion counseling is a barrier to accessing safe abortion services

Empirical research showcases that pre-abortion counseling scarcely reverses the woman’s decision either to terminate a pregnancy or not. Growing evidence regarding the high levels of decisional certainty among women seeking abortions renders a careful rethink of the place of mandatory pre-abortion counseling packages. Mandatory counseling packages, when inscribed in the laws, at times contain false information that can deter women from going in for safe abortions. Mandatory waiting times indirectly label opting for an abortion as not being the right thing to do. In areas where abortion stigma from health care providers and communities remains highly prevalent, women are forced to incur extra expenses by travelling to other countries. I argue that pre-abortion counseling on opting-in grounds is ethically sound (enhances the woman’s reproductive autonomy), since most clients in need of abortions are certain on their decisions before the abortion care provider and do not regret these decisions after the process. Regrets are prone to be more prevalent in areas with high unsafe abortion practices, generally due to complications from excessive bleeding, pain, and post abortion infections. Allowing systematic mandatory pre-abortion counseling practice as the rule in a competent adult is unjustified ethically and empirically, is time consuming and presents the legality of abortions in most settings an oxymoron.

Reproductive autonomy and pregnancy decision-making among young Ghanaian women

Decision-making regarding the outcome of a pregnancy may include participation of the woman herself, her sexual partner, parents, family, and/or community. This paper examines who had the most say in the outcome of young Ghanaian women's last pregnancy and whether this correlated with her level of reproductive autonomy (RA). We analysed cross-sectional data from 380 previously pregnant young women in urban Ghana. We measured communication and decision-making RA using modified scales ranging from 3 (low RA) to 12 (high RA). We tested unadjusted associations between the RA sub-scales and who made the pregnancy decision (self, partner, both together, or someone else) and used multinomial regression models to understand these associations when controlling for sociodemographic, reproductive history, and social context variables. In final models, a one-point increase in decision-making RA was associated with an adjusted relative risk ratio of 0.79 (95% CI: 0.66-0.93; p = 0.006) of partner having the most say as compared to the woman having the most say. The communication RA scale was not associated. Programmes that increase RA may be effective in increasing women's rights to execute decisions about reproductive health and outcomes. Future research should explore this notion and the role of pregnancy disclosure in this relationship.

Beyond the discourse of reproductive choice: narratives of pregnancy resolution among Latina/o teenage parents

Despite the fact that the US teenage birth rate has declined dramatically in recent years, teen births among Latinas are higher than any other racial/ethnic group. Most studies focus on the causes and consequences of early motherhood among Latina teenagers, neglecting other important dimensions of the issue. This study examines how Latina/o teenage parents living in California narrate their experiences with unintended pregnancy resolution. Qualitative analysis reveals three central themes. First, participants expressed shock upon learning they or their partner was pregnant, followed by acceptance about their impending parenthood. Second, participants' views of abortion and adoption largely foreclosed these options as pathways by which to resolve their unintended pregnancies. Third, participants recounted numerous stories of the messages they received from parents, other family members and male partners that were frequently directive regarding how to resolve their pregnancies. These findings have implications for young people's reproductive health and rights, and for reproductive justice more broadly.

Social networks and the communication of norms about prenatal care in rural Mexico

Many normative beliefs are shared and learned through interpersonal communication, yet research on norms typically focuses on their effects rather than the communication that shapes them. This study focused on interpersonal communication during pregnancy to uncover (a) the nature of pregnancy-related communication and (b) normative information transmitted through such communication. Results from interviews with pregnant women living in rural Mexico revealed limited social networks; often, only a woman's mother or the baby's father were consulted about prenatal care decisions. However, women also indicated that communication with others during pregnancy provided important normative information regarding prenatal care. First, most referents believed that women should receive prenatal care (injunctive norm), which was conceptualized by participants as biomedical, nonmedical, or a blend of both. Second, family members often received prenatal care, whereas friends did not (descriptive norms). These findings highlight the key role of personal and social networks in shaping personal pregnancy-related beliefs and behaviors.