Exploring pregnancy termination experiences and needs among Malaysian women: a qualitative study

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).

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

Background

Health care for stigmatized reproductive practices in low- and middle-income countries (LMICs) often remains illegal; when legal, it is often inadequate, difficult to find and / or stigmatizing, which results in women deferring care or turning to informal information sources and providers. Women seeking an induced abortion in LMICs often face obstacles of this kind, leading to unsafe abortions. A growing number of studies have shown that abortion seekers confide in social network members when searching for formal or informal care. However, results have been inconsistent; in some LMICs with restricted access to abortion services (restrictive LMICs), disclosure appears to be limited.

Main body

This systematic review aims to identify the degree of disclosure to social networks members in restrictive LMICs, and to explore the differences between women obtaining an informal medical abortion and other abortion seekers. This knowledge is potentially useful for designing interventions to improve information on safe abortion or for developing network-based data collection strategies. We searched Pubmed, POPLINE, AIMS, LILACS, IMSEAR, and WPRIM databases for peer-reviewed articles, published in any language from 2000 to 2018, concerning abortion information seeking, communication, networking and access to services in LMICs with restricted access to abortion services. We categorized settings into four types by possibility of anonymous access to abortion services and local abortion stigma: (1) anonymous access possible, hyper stigma (2) anonymous access possible, high stigma (3) non-anonymous access, high stigma (4) non-anonymous access, hyper stigma. We screened 4101 references, yielding 79 articles with data from 33 countries for data extraction. We found a few countries (or groups within countries) exemplifying the first and second types of setting, while most studies corresponded to the third type. The share of abortion seekers disclosing to network members increased across setting types, with no women disclosing to network members beyond their intimate circle in Type 1 sites, a minority in Type 2 and a majority in Type 3. The informal use of medical abortion did not consistently modify disclosure to others.

Conclusion

Abortion-seeking women exhibit widely different levels of disclosure to their larger social network members across settings/social groups in restrictive LMICs depending on the availability of anonymous access to abortion information and services, and the level of stigma.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01165-0.

Women seeking an induced abortion in LMICs often face inexistent or inadequate, difficult to find and/ or stigmatizing legal services, leading to the use of informal methods and providers, and unsafe abortions. A growing number of studies have shown that abortion seekers contact social network members beyond their intimate circle when seeking care. However, results have been inconsistent. We searched Pubmed, POPLINE, AIMS, LILACS, IMSEAR, and WPRIM databases for peer-reviewed articles published in any language from 2000 to 2018, concerning abortion information seeking, communication, networking and access to services in restrictive LMICs. We screened 4101 references, yielding 79 articles with data from 33 countries for extraction. We grouped countries (or social groups within countries) into four types of settings: (1) anonymous access possible, hyper stigma; (2) anonymous access possible, high stigma; (3) non-anonymous access, high stigma; (4) non-anonymous access, hyper stigma. Most studies fitted Type 3. Disclosing to network members increased across setting types: no women confided in network members in Type 1 settings, a minority in Type 2 and a majority in Type 3. No setting fitted Type 4. The informal use of medical abortion did not modify disclosure to others. Abortion seekers in restrictive LMICs frequently contact their social network in some settings/groups but less frequently in others, depending on the availability of anonymous access to abortion care and the level of stigma. This knowledge is useful for designing interventions to improve information on safe abortion and for developing network-based data collection strategies.

Migrant Women's Access to Sexual and Reproductive Health Services in Malaysia: A Qualitative Study

Providing sexual and reproductive health (SRH) services to migrant workers is key to fulfilling sustainable developmental goals. This study aims to explore key informants’ views on the provision of SRH services for migrant women in Malaysia, exploring the provision of SRH education, contraception, abortion, antenatal and delivery, as well as the management of gender-based violence. In-depth interviews of 44 stakeholders were conducted from July 2018 to July 2019. Data were thematically analysed. Migrant workers that fall pregnant are unable to work legally and are subject to deportation. Despite this, we found that insufficient SRH information and contraceptive access are provided, as these are seen to encourage promiscuity. Pregnancy, rather than sexually transmitted infection prevention, is a core concern among migrant women, the latter of which is not adequately addressed by private providers. Abortions are often seen as the only option for pregnant migrants. Unsafe abortions occur which are linked to financial constraints and cultural disapproval, despite surgical abortions being legal in Malaysia. Pregnant migrants often delay care-seeking, and this may explain poor obstetric outcomes. Although health facilities for gender-based violence are available, non-citizen women face additional barriers in terms of discrimination and scrutiny by authorities. Migrant women face extremely limited options for SRH services in Malaysia and these should be expanded.

Contradictions in womxn's experiences of pre-abortion counselling in South Africa: Implications for client-centred practice

Pre-abortion counselling may play a key role in abortion seekers' understanding of their decision to terminate a pregnancy and the subsequent emotions that they feel. In this paper, we report on a study conducted in the Eastern Cape province of South Africa concerning womxn's experiences of the pre-abortion counselling offered as part of the implementation of the Choice of Termination Act that governs the provision of legal abortion in the country. Using a narrative-discursive lens, the analysis revealed four micro-narratives in which participants appreciated non-directive and empathic counselling, as well as being provided with information. They also indicated that the counselling was upsetting and hurtful, particularly when providers drew on the awfulisation of abortion discourse to suggest that abortion leads to terrible consequences, and foetal personhood discourse to intimate that terminating the pregnancy is wrong and other alternatives (adoption, parenting) are better. The connection between these broadly positive and negative responses may lie in the dominance of anti-abortion discourses coupled with the powerful positioning of healthcare providers as experts. The attendant disempowerment of clients within the health clinic setting may constrain pregnant people's ability to question such 'expert' information. The implications for feminist client-centred pre-abortion counselling are discussed.

Pragmatics of everyday life: A qualitative study of induced abortion among Tibetan women in Lhasa

Many abortions are performed annually in the People's Republic of China, where the practice is legal, largely safe, and readily available. In this article we present a qualitative study exploring the experiences and perceptions of sixteen Tibetan women who had undergone induced abortions, and five healthcare workers from hospitals in Lhasa in which abortions are carried out. Our findings in this first study of abortion in the Tibet Autonomous Region suggest that despite the availability and medical safety of abortion services, Tibetan women must deal with various social, ethical, and religious challenges related to the practice, as well as limited knowledge and availability of contraceptives.

Medical students' knowledge and perception toward family planning services: A preliminary intervention study

INTRODUCTION

Family planning and contraception is the effective strategy to reduce maternal mortality, child mortality, abortion, and unwanted pregnancies. Since the medical students are the future doctors, it is important to have proper knowledge and training on family planning services. This study aimed to explore the effect of teaching-learning process at maternal and child health (MCH) clinics on the students' knowledge, perceptions toward contraception methods, and family planning counselling.

METHODS

This quasi-experimental study was conducted in the private medical institution in Malaysia. The same questionnaire was used to administer twice, before and after the posting. Moreover, a qualitative question on the issues related to family planning and contraception utilizations in Malaysia was added to the after posting survey. The quantitative data were analyzed using IBM SPSS (version 20) and qualitative data by RQDA software.

RESULTS

A total of 146 participants were recruited in this study. Knowledge on contraception method before posting was 5.11 (standard deviation [SD] ±1.36) and after posting was 6.35 (SD ± 1.38) (P < 0.001). Thematic analysis of the students' answer revealed four salient themes, which were as follows: (1) cultural barrier, (2) misconception, (3) inadequate knowledge, and (4) improvement for the health-care services.

CONCLUSIONS

The teaching-learning process at the MCH posting has an influence on their perception and upgraded their knowledge. It also reflects the role of primary health-care clinics on medical students' clinical exposure and training on family planning services during their postings.

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

OBJECTIVE

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

STUDY DESIGN

A quantitative, community-based cross-sectional survey.

METHODS

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

RESULTS

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

CONCLUSION

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

Male Partners' Involvement in Abortion Care: A Mixed-Methods Systematic Review

CONTEXT

Although some women may desire the involvement of their partners when obtaining abortion care, male partners are not routinely included in the abortion process. A review of the literature on how male involvement relates to women's abortion experiences may help guide facilities that are considering incorporating male partners in abortion care.

METHODS

PubMed, PsycINFO (Ovid), the Cumulative Index to Nursing and Allied Health Literature, the Latin American and Caribbean Health Sciences Literature database, and the Cochrane Library were systematically searched without restrictions through September 23, 2015, to identify qualitative and quantitative primary studies investigating male partner accompaniment during the abortion process in noncoercive situations. Analysis focused on identifying different types of male involvement and their associations with women's abortion experiences.

RESULTS

Some 1,316 unique articles were reviewed; 15 were analyzed. These studies were conducted in six countries and published between 1985 and 2012, primarily with observational designs. Four types of male partner involvement emerged: presence in the medical facility, participation in preabortion counseling, presence in the room during the surgical abortion procedure or while the woman is experiencing the effects of abortifacient medications, and participation in postabortion care. Studies explored relationships between type of involvement and women's access to abortion care and their emotional and physical well-being. Most findings suggested that male involvement was positively associated with women's well-being and their assessment of the experience; no negative associations were found.

CONCLUSION

In noncoercive circumstances, women who include their male partners in the abortion process may find this involvement beneficial.

Aborto e estigma: uma análise da produção científica sobre a temática

Resumo O artigo objetiva analisar a produção científica sobre aborto e estigma social e o potencial da categoria estigma para estudos sobre a assistência ao abortamento no Brasil. Utilizou-se o método de revisão integrativa de publicações das bases científicas, optando por não estabelecer limite temporal. Analisou-se 65 publicações com as representações sociais de mulheres que abortam e de profissionais que as atendem; exploram os obstáculos para a implementação das leis do aborto e dos protocolos e normas que facilitariam o acesso a serviços de qualidade. À relevância conceitual de Erving Goffman somou-se a compreensão sobre a transgressão dos estereótipos de gênero, o imperativo da maternidade, a pureza sexual, que marca as mulheres que abortam como seres inferiores, deteriorados: promíscuas, pecadoras, assassinas. Identificaram-se grupos mais afetados pela estigmatização: mulheres em abortamento, profissionais de saúde. O conflito feminino pela dualidade ocultar/revelar seus abortamentos, a objeção de consciência de profissionais e os obstáculos na implementação de políticas públicas emergiram dos trabalhos. A reflexão sobre o papel do estigma pode interferir no ciclo do aborto clandestino e contribuir para o (re) desenho de intervenções que apoiem a redução de danos à saúde sexual e reprodutiva das mulheres.

Decision making on unsafe abortions in Sri Lanka: a case-control study

BACKGROUND

Following an unintended pregnancy, not every woman would invariably choose to undergo an unsafe abortion. It suggests that in the decision making process, women face both 'push' factors that favour abortion and 'pull' factors that work against it. This study assessed the circumstances that surrounded a woman's decision to undergo an unsafe abortion, compared to a decision to continue, when faced with an unintended pregnancy in Sri Lanka.

METHODS

An unmatched case-control study was conducted among 171 women admitted to nine hospitals in eight districts following an unsafe abortion (Cases) and 600 women admitted to the same hospitals for delivery of an unintended term pregnancy (Controls). Interviewer-administered-questionnaires and in-depth interviews assessed women's characteristics, decision making process and underlying reasons for their decision. The risk of abortion related to their decision making was assessed using odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Compared to controls, the cases were significantly less-educated, employed, unmarried and primi-gravid (p < 0.05). All knew the 'illegal' status of abortion, mainly through media (65.5% cases versus 80% controls). When making a decision, the risk of undergoing an unsafe abortion was significant among those who sought assistance (44% versus 32%; OR = 1.7 (95% CI = 1.2-2.4)), with more reliance placed on non-medical sources such as spouse/partner, friend, neighbour and family/relation. Speaking to women with past experience of induced abortions (31% versus 21.5%; OR = 1.6 (1.1-2.4) and failure in making the final decision with partners also imparted a significant risk for abortion (64% versus 34%; OR = 3.4; 2.4-4.8). A decision favouring unsafe abortion was predominantly based on their economic instability (29.5%) and poor support by partners (14%), whereas a decision against it was based on ethical considerations (44% religious beliefs: 12% social stigma) over its legal implications (4%). Most abortions were performed by unqualified persons (36.1% self proclaimed abortionists; 26.2% not revealed their qualifications) for a wide range of payment in non-sterile environments (45.9% unknown place) using septic procedures (38.5% trans-vaginal insertions; 24.6% unaware of the procedure).

CONCLUSIONS

Women's risk of unsafe abortion was associated with unreliable sources of information during decision making that led to poor knowledge and positive attitudes on its safety; poor access to affordable abortion services; and their economic instability.

Access to safe legal abortion in Malaysia: women's insights and health sector response

Malaysia has an abortion law, which permits termination of pregnancy to save a woman's life and to preserve her physical and mental health (Penal Code Section 312, amended in 1989). However, lack of clear interpretation and understanding of the law results in women facing difficulties in accessing abortion information and services. Some health care providers were unaware of the legalities of abortion in Malaysia and influenced by their personal beliefs with regard to provision of abortion services. Accessibility to safer abortion techniques is also an issue. The development of the 2012 Guidelines on Termination of Pregnancy and Guidelines for Management of Sexual and Reproductive Health among Adolescents in Health Clinics by the Ministry of Health, Malaysia, is a step forward toward increasing women's accessibility to safe abortion services in Malaysia. This article provides an account of women's accessibility to abortion in Malaysia and the health sector response in addressing the barriers.