Social network-based measurement of abortion incidence: promising findings from population-based surveys in Nigeria, Cote d'Ivoire, and Rajasthan, India

Direct and indirect estimation of adolescent sexual intercourse and contraceptive use in Rajasthan India: an application of the best friend methodology

BACKGROUND

Existing estimates of adolescent sexual and reproductive health (ASRH) behaviors may be a gross undercount given the sensitivity of this behavior in Indian culture. The objective of this study was to estimate ASRH behaviors in Rajasthan, India using direct questions and the best friend approach that seeks to reduce social desirability bias.

METHODS

We used population-based data of adolescents aged 15-19 in Rajasthan collected between September and December 2022. Data include whether the respondent and her closest female friend ever had a partner, ever had sex, ever used contraception, and were currently using contraception. We estimated respondent and best friend ASRH outcomes separately, overall and among unmarried adolescents for whom we anticipate social desirability bias is greatest.

RESULTS

The best friend approach performed well, with method assumptions largely met even before adjustments. Respondent and best friend estimates were similar among all adolescents except for current contraceptive use, which was higher for friends (though not significantly so). However, we observed large differences in ASRH behaviors between unmarried respondents and friends, with a significantly higher percentage of friends who ever had a partner (4.3% respondents, 11.6% friends), and a slightly higher percentage who ever had sex (2.4%, 3.8%) and who were currently using contraception (17.0%, 19.7% among those in need of contraception).

CONCLUSIONS

We observed potential benefits of using the best friend methodology in estimating premarital sexual activity, but further work is needed to refine social network-based measures of sensitive adolescent behaviors in larger study samples to better understand ASRH needs.

The confidante method to measure abortion: implementing a standardized comparative analysis approach across seven contexts

BACKGROUND

Obtaining representative abortion incidence estimates is challenging in restrictive contexts. While the confidante method has been increasingly used to collect this data in such settings, there are several biases commonly associated with this method. Further, there are significant variations in how researchers have implemented the method and assessed/adjusted for potential biases, limiting the comparability and interpretation of existing estimates. This study presents a standardized approach to analyzing confidante method data, generates comparable abortion incidence estimates from previously published studies and recommends standards for reporting bias assessments and adjustments for future confidante method studies.

METHODS

We used data from previous applications of the confidante method in Côte d'Ivoire, Ethiopia, Ghana, Java (Indonesia), Nigeria, Uganda, and Rajasthan (India). We estimated one-year induced abortion incidence rates for confidantes in each context, attempting to adjust for selection, reporting and transmission bias in a standardized manner.

FINDINGS

In each setting, majority of the foundational confidante method assumptions were violated. Adjusting for transmission bias using self-reported abortions consistently yielded the highest incidence estimates compared with other published approaches. Differences in analytic decisions and bias assessments resulted in the incidence estimates from our standardized analysis varying widely from originally published rates.

INTERPRETATION

We recommend that future studies clearly state which biases were assessed, if associated assumptions were violated, and how violations were adjusted for. This will improve the utility of confidante method estimates for national-level decision making and as inputs for global or regional model-based estimates of abortion.

Menstrual regulation: examining the incidence, methods, and sources of care of this understudied health practice in three settings using cross-sectional population-based surveys

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.

Improving abortion underreporting in the USA: a cognitive interview study

Abortion is a difficult-to-measure behaviour with extensive underreporting in surveys, which compromises the ability to study and monitor it. We aimed to improve understanding of how women interpret and respond to survey items asking if they have had an abortion. We developed new questions hypothesised to improve abortion reporting, using approaches that aim to clarify which experiences to report; reduce the stigma and sensitivity of abortion; reduce the sense of intrusiveness of asking about abortion; and increase respondent motivation to report. We conducted cognitive interviews with cisgender women aged 18-49 in two US states (N = 64) to assess these new approaches and questions for improving abortion reporting. Our findings suggest that including abortion as part of a list of other sexual and reproductive health services, asking a yes/no question about lifetime experience of abortion instead of asking about number of abortions, and developing an improved introduction to abortion questions may help to elicit more accurate survey reports. Opportunities exist to improve survey measurement of abortion. Reducing the underreporting of abortion in surveys has the potential to improve sexual and reproductive health research that relies on pregnancy histories.

Describing the safety of abortion at the population level using network-based survey approaches

BACKGROUND

Despite the negative impact of unsafe abortions on women's health and rights, the degree of abortion safety remains strikingly undocumented for a large share of abortions globally. Data on how women induce abortions (method, setting, provider) are central to the measurement of abortion safety. However, health-facility statistics and direct questioning in population surveys do not yield representative data on abortion care seeking pathways in settings where access to abortion services is highly restricted. Recent developments in survey methodologies to study stigmatized / illegal behaviour and hidden populations rely on the fact that such information circulates within social networks; however, such efforts have yet to give convincing results for unsafe abortions.

OBJECTIVE

This article presents the protocol of a study whose purpose is to apply and develop further two network-based methods to contribute to the generation of reliable population-level information on the safety of abortions in contexts where access to legal abortion services is highly restricted.

METHODS

This study plans to obtain population-level data on abortion care seeking in two Health and Demographic Surveillance Systems in urban Kenya and rural Burkina Faso by applying two methods: Anonymous Third-Party Reporting (ATPR) (also known as confidantes' method) and Respondent Driven Sampling (RDS). We will conduct a mixed methods formative study to determine whether these network-based approaches are pertinent in the study contexts. The ATPR will be refined notably by incorporating elements of the Network Scale-Up Method (NSUM) to correct or account for certain of its biases (transmission, barrier, social desirability, selection). The RDS will provide reliable alternative estimates of abortion safety if large samples and equilibrium can be reached; an RDS multiplex variant (also including social referents) will be tested.

DISCUSSION

This study aims at documenting abortion safety in two local sites using ATPR and RDS. If successful, it will provide data on the safety profiles of abortion seekers across sociodemographic categories in two contrasted settings in sub-Saharan Africa. It will advance the formative research needed to determine whether ATPR and RDS are applicable or not in a given context. It will improve the questionnaire and correcting factors for the ATPR, improve the capacity of RDS to produce quasi-representative data on abortion safety, and advance the validation of both methods.

Induced abortion incidence and safety in Burkina Faso in 2020: Results from a population-based survey using direct and social network-based estimation approaches

This study aims to estimate induced abortion incidence and safety in Burkina Faso using direct and indirect methods, overall and by women's background characteristics. Data come from a nationally representative survey of reproductive aged women (n = 6,388). To address social desirability bias in abortion reporting, we asked about respondents' closest female friends' experience with abortion. The one-year abortion incidence in 2020 for respondents was 4.0 (95% CI 2.2-5.9) per 1,000 women aged 15-49 while the adjusted friend incidence was 22.9 (95% CI 15.8-30.0). Although not significant, abortion incidence was higher for adolescents, unmarried women, those with higher education, and those in urban areas among both respondents and their friends. Approximately nine out of ten abortions were unsafe (90% respondents, 95% friends), with respondent and friend findings suggesting higher risk of unsafe abortion among older women, less educated women, and women residing in rural areas. Despite recent increases in contraceptive use and continued legal restrictions, abortion remains common in Burkina Faso and is largely unsafe, with evidence of potential disparities.

Interviewer effects on abortion reporting: a multilevel analysis of household survey responses in Côte d'Ivoire, Nigeria and Rajasthan, India

OBJECTIVES

The analysis aimed to assess the scale of interviewer effects on abortion survey responses, to compare interviewer effects between different question wordings and between direct and indirect approaches, and to identify interviewer and interview characteristics that explain interviewer effects on abortion reporting.

SETTING

2018 Performance Monitoring for Action nationally representative household surveys from Côte d'Ivoire, Nigeria and Rajasthan, India.

PARTICIPANTS

Survey data from 20 016 interviews with reproductive age (15-49) women, selected using multistage stratified cluster sampling. Data from self-administered interviewer surveys and from a sample of health service delivery points that serve the female survey participants were also included.

PRIMARY OUTCOME MEASURES

Outcomes were the respondent's own experience of ever 'removing a pregnancy', their closest confidante's experience of pregnancy removal and the respondent's own experience of period regulation.

RESULTS

Substantial interviewer effects were observed, ranging from 7% in Côte d'Ivoire to 24% in Nigeria for pregnancy removal. Interviewer effects for survey questions that were designed to ask about abortion in a less stigmatising way were either similar to (9%-26% for confidante-reporting) or higher than (17%-32% for a question about period regulation) the pregnancy removal question. Interviewer and interview characteristics associated with abortion reporting included respondent-interviewer familiarity, the language of interview and the interviewer's comfort asking questions about abortion.

CONCLUSION

This study highlights that questions designed to be less stigmatising may increase interviewer effects due to lower comprehension among respondents. Further work is needed to assess question wordings for different contexts. Selecting and training interviewers to ensure comfort asking questions about abortion is important for reproductive health surveys. Challenges for the use of 'insider' interviewers and the management of surveys in countries with high linguistic diversity are also identified.

An Assessment of Third-Party Reporting of Close Ties to Measure Sensitive Behaviors: The Confidante Method to Measure Abortion Incidence in Ethiopia and Uganda

Indirect estimation techniques are important tools for measuring sensitive and stigmatized behaviors. This includes third‐party reporting methods, which have become increasingly common in the field of abortion measurement, where direct survey approaches notoriously lead to underreporting. This paper provides the first in‐depth assessment of one of the most widely used of these techniques in the field of abortion measurement: the confidante method. We outline six key assumptions behind the confidante method and describe how violations of these assumptions can bias resulting estimates. Using data from modules added to the performance monitoring for action surveys in Uganda and Ethiopia in 2018, we compute one‐year abortion incidence estimates using the confidante method. We also perform a validation check, using the method to estimate intrauterine device /implant use. Our results revealed implementation problems in both settings. Several of the method's foundational assumptions were violated, and efforts to adjust for these violations either failed or only partially addressed the resulting bias. Our validation check also failed, resulting in a gross overestimate of intrauterine device/implant use. These results have implications more broadly for the potential biases that can be introduced in using third‐party reporting of close ties to measure other sensitive or stigmatized behaviors.

Postabortion care availability, facility readiness and accessibility in Nigeria and Côte d'Ivoire

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.

Induced Abortion Incidence and Safety in Rajasthan, India: Evidence that Expansion of Services is Needed

Despite induced abortion being broadly legal in India, up-to-date information on its frequency and safety is not readily available. Using direct and indirect methodological approaches, this study measures the one-year incidence and safety of induced abortions among women in the state of Rajasthan. The analysis utilizes data from a population-based survey of 5,832 reproductive aged women who reported on the abortion experiences of their closest female confidante in addition to themselves. We separately assess correlates of having a recent and most unsafe abortion using multivariable regression models. The confidante approach produced a one-year abortion incidence estimate of 23 per 1,000 women, whereas the respondent estimate is 9.5 per 1,000 women. Based on the confidante estimate, approximately 441,000 abortions occurred in Rajasthan over a year. Overall, 25 and 29 percent of respondent and confidante reported abortions were classified as most unsafe. Results suggest that abortion remains an integral component of women's fertility regulation, and that a liberal law alone is insufficient to guarantee access to safe abortion services. Existing policies on abortion in India need updating to permit task sharing in line with current recommendations to expand service delivery so that demand is met through provision of safe and accessible services.