Marital status and abortion among young women in Rupandehi, Nepal

Individual and community-level factors of abortion in East Africa: a multilevel analysis

Background

Abortion is one of the top five causes of maternal mortality in low and middle-income countries. It is associated with a complication related to pregnancy and childbirth. Despite this, there was limited evidence on the prevalence and associated factors of abortion in East African countries. Therefore, this study aimed to investigate the prevalence and associated factors of abortion among reproductive-aged women in East African countries.

Methods

The Demographic and Health Surveys (DHS) data of 12 East African countries was used. A total weighted sample of 431,518 reproductive-age women was included in the analysis. Due to the hierarchical nature of the DHS data, a multilevel binary logistic regression model was applied. Both crude and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) was calculated for potential associated factors of abortion in East Africa. In the final model, variables with a p value < 0.05 were declared as statistically significant factors of abortion.

Results

Around 5.96% (95%CI: 4.69, 7.22) of reproductive-aged women in East Africa had a history of abortion. Alcohol use, tobacco or cigarette smoking, being single, poorer wealth index, currently working, traditional family planning methods, and media exposure were associated with a higher risk of abortion. However, higher parity, having optimum birth intervals, and modern contraceptive uses were associated with lower odds of abortion.

Conclusions

The prevalence of abortion among reproductive-aged women in East Africa was high. Abortion was affected by various socio-economic and obstetrical factors. Therefore, it is better to consider the high-risk groups during the intervention to prevent the burdens associated with abortion.

The effects of stillbirth and abortion on the next pregnancy: a longitudinal study

BACKGROUND

Abortion and stillbirths are the common obstetrics condition in Ethiopia and their effect on the next pregnancy was not well identified in resource limited settings. The aim of the study was to assess the effect of stillbirth and abortion on the next pregnancy.

METHODS

A prospective cohort study design was implemented. The study was conducted in Mecha demographic surveillance and field research center catchment areas. The data were collected from January 2015 to March 2019. Epi-info software was used to calculate the sample size. The systematic random sampling technique was used to select stillbirth and abortion women. Poison regression was used to identify the predictors of MCH service utilization; descriptive statistics were used to identify the prevalence of blood borne pathogens. The Kaplan Meier survival curve was used to estimate survival to pregnancy and pregnancy related medical disorders.

RESULTS

1091 stillbirth and 3,026 abortion women were followed. Hepatitis B was present in 6% of abortion and 3.2% of stillbirth women. Hepatitis C was diagnosed in 4.7% of abortion and 0.3% of stillbirth women. HIV was detected in 3% of abortion and 0.8% of stillbirth women. MCH service utilization was determined by knowledge of contraceptives [IRR 1.29, 95% CI 1.18-1.42], tertiary education [IRR 4.29, 95% CI 3.72-4.96], secondary education. [IRR 3.14, 95% CI 2.73-3.61], married women [IRR 2.08, 95% CI 1.84-2.34], family size [IRR 0.67, 95% CI 1.001-1.01], the median time of pregnancy after stillbirth and abortion were 12 months. Ante-partum hemorrhage was observed in 23.1% of pregnant mothers with a past history of abortion cases and post-partum hemorrhage was observed in 25.6% of pregnant mothers with a past history of abortion. PREGNANCY INDUCED DIABETES MELLITUS was observed 14.3% of pregnant mothers with a past history of stillbirth and pregnancy-induced hypertension were observed in 9.2% of mothers with a past history of stillbirth.

CONCLUSION

Obstetric hemorrhage was the common complications of abortion women while Pregnancy-induced diabetic Mellitus and pregnancy-induced hypertension were the most common complications of stillbirth for the next pregnancy.

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.

Prevalence and correlates of sex-selective abortions and missing girls in Nepal: evidence from the 2011 Population Census and 2016 Demographic and Health Survey

OBJECTIVES

These were to: (1) produce national and subnational estimates of the sex ratio at birth (SRB) and number of missing girl births in Nepal and (2) understand the socioeconomic correlates of these phenomena.

DESIGN

Observational secondary data analysis of (1) the 2011 population census of Nepal and (2) the Nepal Demographic and Health Survey (DHS) 2006, 2011 and 2016.

SETTING

Nepal.

PARTICIPANTS

(1) 2 567 963 children age 0-4 in the 2011 population census and (2) 27 329 births recorded in DHSs.

PRIMARY AND SECONDARY OUTCOMES

We estimate the SRB, and number and proportion of missing girls in the year and 5 years before the census by district. We also calculate conditional sex ratios (the SRB dependant on parity and sex of previous children) by province, time, education and wealth.

RESULTS

We find that 11 districts have significantly skewed sex ratios at birth in the 2011 population census, with the highest SRBs observed in Arghakhanchi (SRB=127) and Bhaktapur (SRB=123). 22 540 girl births were missing in the 5 years before the 2011 population census. Sex-selective abortion is geographically concentrated, especially in the Kathmandu Valley and Lumbini Province, with 53% of missing girls found in only 11 out of 75 districts.DHS data confirm this, with elevated conditional sex ratios observed in Bagmati and Lumbini Provinces; conditional sex ratios where previous births were all female also became more skewed over time. Skewed sex ratios are concentrated among wealthier more educated groups.

CONCLUSIONS

It is clear that sex selection will persist and develop in Nepal unless a coordinated effort is made to address both the demand for and supply of this service. Policies should be holistic and encompass economic and legal gender equity, and strengthen monitoring mechanisms to prevent technology misuse, without jeopardising the right to safe, free and legal abortion.

Medical abortion kit dispensing practices of community pharmacies in Pokhara Metropolitan, Nepal

Background

Medical abortion (MA) refers to the use of medicines to terminate the pregnancy. There is an urgent need to spread safe abortion services in the community. This study assessed the MA kit dispensing practices of community pharmacies in Pokhara Valley, Nepal.

Methods

A cross-sectional descriptive study was conducted in Pokhara Valley, Nepal from December 2017 to November 2018. Among the community pharmacies of Pokhara Valley, 115 community pharmacies were selected using a consecutive sampling method. A semi-structured questionnaire was used to collect data. MA kit and related information were requested by simulated male clients visiting the community pharmacies. The information obtained from the pharmacy workers was recorded in the data collection sheet.

Results

Nine brands of MA kit from eight manufacturing companies were found in practice in Pokhara Valley, out of those only five (56%) were registered in Nepal. Seven brands were sold at more than the labeled price. The pharmacy workers asked about the gestational age and confirmation of pregnancy in all the cases. Most of them counseled the clients on the frequency, duration, and direction of use. Dispensing practice and level of counseling were found to be significantly correlated (r = 0.40, p value = 0.01).

Conclusion

Despite the awareness of the pharmacy workers on the MA kit, most of them provided limited information to the clients. Nearly half unregistered MA kits were found in practice at the community pharmacies. Thus, the Department of Drugs Administration and other concerned authorities must provide relevant training and awareness programs to the pharmacy workers of the community pharmacies for preventing the malpractice of MA kit. The Government of Nepal must restrict the illegal entry of unregistered brands and assure the standards of MA kit by regulating drug acts and policies effectively.

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.

Assessment of knowledge on abortion law and factors affecting it among regular undergraduate female students of Ambo University, Oromia Region, Ethiopia, 2018: a cross sectional study

BACKGROUND

Knowledge of abortion law is a key determinant of the utilization of safe abortion services. Neglecting it can lead to high social and economic costs, both immediately and in the future. One of the major reasons for not utilizing the safe abortion by the youth female is inadequate knowledge about the abortion law. Therefore the aim of this study was to assess knowledge on abortion law and associated factors among female regular undergraduate students of Ambo University.

METHODOLOGY

Institutional-based cross-sectional study was conducted on 795 randomly selected undergraduate female students of Ambo University using structured and pre-tested questionnaire from March, 28-May, 18, 2018.The result of the analysis was presented by tables using descriptive frequency percentage and odd ratios. The result was presented using tables. Bivariate and multivariate logistic regression was done between dependent and independent variables at 95% confident interval and P value < 0.05.

RESULT

Majority (79%) of the study participants were not able to identify all the conditions under which abortion is legally available in Ethiopia. In this study receiving health education on abortion law (AOR = 7.382, 95% CI: (1.118-48.761), knowing where safe abortion can be performed (AOR = 3.116, 95% CI: (1.854-5.239)) and being member of health club in the university (AOR = 2.092, 95% CI:1.256-3.484) were the predictors of abortion law knowlwdge .

CONCLUSION

The study concluded that knowledge of female student's on abortion law is low in the study area. In this study, participates who received health education on abortion law and having involving in the health club at university were found to be the predictors of knowledge on abortion law .

What has women's reproductive health decision-making capacity and other factors got to do with pregnancy termination in sub-Saharan Africa? evidence from 27 cross-sectional surveys

Introduction

Pregnancy termination is one of the key issues that require urgent attention in achieving the third Sustainable Development Goal (SDG) of ensuring healthy lives and promoting well-being for all at all ages. The reproductive health decision-making (RHDM) capacity of women plays a key role in their reproductive health outcomes, including pregnancy termination. Based on this premise, we examined RHDM capacity and pregnancy termination among women of reproductive age in sub-Saharan Africa (SSA).

Materials and methods

We pooled data from the women’s files of the most recent Demographic and Health Surveys (DHS) of 27 countries in SSA, which are part of the DHS programme. The total sample was 240,489 women aged 15 to 49. We calculated the overall prevalence of pregnancy termination in the 27 countries as well as the prevalence in each individual country. We also examined the association between RHDM capacity, socio-demographic characteristics and pregnancy termination. RHDM was generated from two variables: decision-making on sexual intercourse and decision-making on condom use. Binary logistic regression analysis was conducted and presented as Crude Odds Ratios (COR) and Adjusted Odds Ratios (AOR) with their corresponding 95% confidence intervals (CI). Statistical significance was declared p<0.05.

Results

The prevalence of pregnancy termination ranged from 7.5% in Benin to 39.5% in Gabon with an average of 16.5%. Women who were capable of taking reproductive health decisions had higher odds of terminating a pregnancy than those who were incapable (AOR = 1.20, 95% CI = 1.17–1.24). We also found that women aged 45–49 (AOR = 5.54, 95% CI = 5.11–6.01), women with primary level of education (AOR = 1.14, 95% CI = 1.20–1.17), those cohabiting (AOR = 1.08, 95% CI = 1.04–1.11), those in the richest wealth quintile (AOR = 1.06, 95% CI = 1.02–1.11) and women employed in the services sector (AOR = 1.35, 95% CI = 1.27–1.44) were more likely to terminate pregnancies. Relatedly, women who did not intend to use contraceptive (AOR = 1.47, 95% CI = 1.39–1.56), those who knew only folkloric contraceptive method (AOR = 1.25, 95% CI = 1.18–1.32), women who watched television almost every day (AOR = 1.16, 95% CI = 1.20–1.24) and those who listened to radio almost every day (AOR = 1.11, 95% CI = 1.04–1.18) had higher odds of terminating a pregnancy. However, women with four or more children had the lowest odds (AOR = 0.5, 95% CI = 0.54–0.60) of terminating a pregnancy.

Conclusion

We found that women who are capable of taking reproductive health decisions are more likely to terminate pregnancies. Our findings also suggest that age, level of education, contraceptive use and intention, place of residence, and parity are associated with pregnancy termination. Our findings call for the implementation of policies or the strengthening of existing ones to empower women about RHDM capacity. Such empowerment could have a positive impact on their uptake of safe abortions. Achieving this will not only accelerate progress towards the achievement of maternal health-related SDGs but would also immensely reduce the number of women who die as a result of pregnancy termination in SSA.

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.

Expansion of Safe Abortion Services in Nepal Through Auxiliary Nurse-Midwife Provision of Medical Abortion, 2011-2013

Introduction

The termination of unwanted pregnancies up to 12 weeks’ gestation became legal in Nepal in 2002. Many interventions have taken place to expand access to comprehensive abortion care services. However, comprehensive abortion care services remain out of reach for women in rural and remote areas. This article describes a training and support strategy to train auxiliary nurse‐midwives (ANMs), already certified as skilled birth attendants, as medical abortion providers and expand geographic access to safe abortion care to the community level in Nepal.

Methods

This was a descriptive program evaluation. Sites and trainees were selected using standardized assessment tools to determine minimum facility requirements and willingness to provide medical abortion after training. Training was evaluated via posttests and observational checklists. Service statistics were collected through the government's facility logbook for safe abortion services (HMIS‐11).

Results

By the end of June 2014, medical abortion service had been expanded to 25 districts through 463 listed ANMs at 290 listed primary‐level facilities and served 25,187 women. Providers report a high level of confidence in their medical abortion skills and considerable clinical knowledge and capacity in medical abortion.

Discussion

The Nepali experience demonstrates that safe induced abortion care can be provided by ANMs, even in remote primary‐level health facilities. Post‐training support for providers is critical in helping ANMs handle potential barriers to medical abortion service provision and build lasting capacity in medical abortion.