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Ouedraogo R, Wanjiru S, Zan ML, Rossier C, Owolabi O, Athero S, Oduor C, Bangha M. "I always know she cannot betray me." Disclosure of abortion and methods of abortion used in informal settlements in Nairobi, Kenya. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003252. [PMID: 39018278 PMCID: PMC11253939 DOI: 10.1371/journal.pgph.0003252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 06/11/2024] [Indexed: 07/19/2024]
Abstract
Despite abortion being stigmatized and legally restricted in Kenya, women still disclose their abortions within their network. Evidence has shown how stigma can influence and regulate individual abortion disclosure decisions and behaviors. This paper seeks to understand why and how women make the decisions to disclose their abortion and the associated methods used. The data are from a qualitative formative study and a respondent-driven sampling survey conducted between 2020 and 2021 in two informal settlements in Nairobi, Kenya. The data were analyzed using a descriptive analysis approach for the quantitative data, and thematic analysis for the qualitative data. Our findings reveal that information sharing about abortion is enclosed in a social dynamic of secrecy. This dynamic contributes to making abortion a secret that respondents decided to share with confidants in 81% of the abortion cases. These confidants include intimate relationships such as trusted friends (62%), followed by female relatives. Information was shared in many cases either to get support (i.e. method to use), or because participants had close ties with the confidants. Regarding the methods used, unidentified pills were the most used regardless of the confidant; followed by traditional methods especially among those who sought help with their mothers/aunts/grandmothers (33%), while Medical Abortion and Manual Vacuum Aspiration were rarely used, mostly by those who confided in friends or sisters/cousins. Our findings show that the disclosure of abortion is a complex process embedded in existing codes regarding the circulation of information on sensitive issues and "help" seeking. Our findings show that the need for information on safe abortion and lack of financial resources frequently empowers them to overcome the fear of stigma and disclose their abortion. However, this often resulted in use of unsafe procedures. The findings suggest the need for strengthening the circulation of information on safe methods within communities, using community champions and intermediaries to increase the likelihood of women being directed through safe methods to enhance their use.
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Affiliation(s)
| | - Shelmith Wanjiru
- Graduate Institute of International and Development Studies, Geneva, Switzerland
| | - Moussa L. Zan
- Institut Supérieur des Sciences de la Population, Ouagadougou, Burkina Faso
| | | | - Onikepe Owolabi
- Guttmacher Institute, New York, New York, United States of America
| | - Sherine Athero
- African Population and Health Research Center, Nairobi, Kenya
| | - Clement Oduor
- African Population and Health Research Center, Nairobi, Kenya
| | - Martin Bangha
- African Population and Health Research Center, Nairobi, Kenya
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Bell SO, Ahmad D, Khanna A, Thomas HL, Moreau C. Direct and indirect estimation of adolescent sexual intercourse and contraceptive use in Rajasthan India: an application of the best friend methodology. BMC Womens Health 2024; 24:373. [PMID: 38926696 PMCID: PMC11210037 DOI: 10.1186/s12905-024-03209-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
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.
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Affiliation(s)
- Suzanne O Bell
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Danish Ahmad
- Indian Institute of Health Management Research, Rajasthan, India
| | - Anoop Khanna
- Indian Institute of Health Management Research, Rajasthan, India
| | - Haley L Thomas
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Caroline Moreau
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, F-94805, France
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Ngondo D, Karp C, Kayembe D, Basile KS, Moreau C, Akilimali P, Bell SO. Abortion information-seeking experiences among women who obtained abortions in Kinshasa, DRC: Results from a qualitative study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002383. [PMID: 38381761 PMCID: PMC10880974 DOI: 10.1371/journal.pgph.0002383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/22/2023] [Indexed: 02/23/2024]
Abstract
Little is known about the process of seeking information related to abortion care options among women in the Democratic Republic of Congo (DRC). Understanding how women obtain information can help identify opportunities for intervention to increase awareness and use of safe pregnancy termination options. Using qualitative data collected from women in Kinshasa, DRC who reported having an abortion in the last 10 years, this study aims to determine how women navigate obtaining information about their options for abortion and the role of their social network in their information-seeking processes. Data for this analysis come from a mixed-method study of abortion in Kinshasa conducted from December 2021 to April 2022. Fifty-two qualitative interviews followed a structured interview guide, including open-ended questions and probes, developed by a multidisciplinary team of researchers in Kinshasa and the United States. Inductive thematic analysis was conducted using Atlas.ti, and a thematic analysis matrix was used to describe the major themes and subthemes. Thematic analysis revealed two main themes with nested subthemes. The first and most salient theme highlighted the highly selective and narrow information search process women engaged in, involving no others or very few individuals (e.g., partners, women in one's community, or providers) that the pregnant woman chose strategically. The second theme revealed the heterogeneous and often stigmatizing nature of these interactions, including attempts at deterrence from many sources and information of varying completeness and accuracy. While the recent liberalization of the abortion law in the DRC is essential to improve access to safe abortion, public health gains will not materialize unless they are accompanied by community-level actions to raise awareness about the legality and availability of safe abortions services, including medication abortion pills for safe self-managed abortion.
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Affiliation(s)
- Denise Ngondo
- Department of Biostatistical Epidemiology, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Dynah Kayembe
- Department of Biostatistical Epidemiology, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Kisulu Samyonga Basile
- Department of Biostatistical Epidemiology, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, Villejuif, France
| | - Pierre Akilimali
- Department of Nutrition, Patrick Kayembe Research Center, Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Willis B, Church K, Perttu E, Thompson H, Weerasinghe S, Macias-Konstantopoulos W. The preventable burden of mortality from unsafe abortion among female sex workers: a Community Knowledge Approach survey among peer networks in eight countries. Sex Reprod Health Matters 2023; 31:2250618. [PMID: 37712508 PMCID: PMC10506426 DOI: 10.1080/26410397.2023.2250618] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023] Open
Abstract
Previous studies have found high levels of unintended pregnancy among female sex workers (FSW), but less attention has been paid to their abortion practices and outcomes. This study is the first to investigate abortion-related mortality among FSW across eight countries: Angola, Brazil, Democratic Republic of Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa. The Community Knowledge Approach (CKA) was used to survey a convenience sample of FSW (n = 1280). Participants reported on the deaths of peer FSW in their social networks during group meetings convened by non-governmental organisations (n = 165 groups, conducted across 24 cities in 2019). Details on any peer FSW deaths in the preceding five years were recorded. The circumstances of abortion-related deaths are reported here. Of the 1320 maternal deaths reported, 750 (56.8%) were due to unsafe abortion. The number of abortion-related deaths reported was highest in DRC (304 deaths reported by 270 participants), Kenya (188 deaths reported by 175 participants), and Nigeria (216 deaths reported by 312 participants). Among the abortion-related deaths, mean gestational age was 4.6 months and 75% occurred outside hospital. Unsafe abortion methods varied by country, but consumption of traditional or unknown medicines was most common (37.9% and 29.9%, respectively). The 750 abortion-related deaths led to 1207 children being left motherless. The CKA successfully recorded a stigmatised practice among a marginalised population, identifying very high levels of abortion-related mortality. Urgent action is now needed to deliver comprehensive sexual and reproductive healthcare to this vulnerable population, including contraption, safe abortion, and post-abortion care.
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Affiliation(s)
- Brian Willis
- Director, Global Health Promise, Portland, OR, USA
| | - Kathryn Church
- Independent Consultant, London, UK; Honorary Assistant Professor, Department of Epidemiology & Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Emily Perttu
- Director of Data Analysis, Global Health Promise, Portland, OR, USA
| | - Heather Thompson
- Maternal Health Advisor, Global Health Promise, Portland, OR, USA; Adjunct Professor, Schulich School of Medicine, McMaster Faculty of Medicine; & Obstetrician/Gynecologist, Grey Bruce Health Services, Hamilton, Ontario, Canada
| | - Swarna Weerasinghe
- Biostatistician, Global Health Promise, Portland, OR, USA; Associate Professor, Department of Community Health and Epidemiology, Dalhousie University, Faculty of Medicine, Halifax, Nova Scotia, Canada
| | - Wendy Macias-Konstantopoulos
- Global Policy Advisor, Global Health Promise, Portland, OR, USA; Director, Center for Social Justice and Health Equity, Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Giorgio M, Makumbi F, Kibira SPS, Shiferaw S, Seme A, Bell SO, Sully E. Self-reported abortion experiences in Ethiopia and Uganda, new evidence from cross-sectional community-based surveys. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002340. [PMID: 37682781 PMCID: PMC10490852 DOI: 10.1371/journal.pgph.0002340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 08/08/2023] [Indexed: 09/10/2023]
Abstract
Unsafe abortion is a major contributor to maternal morbidity and mortality. To gain insight into the ways in which abortion restrictions and stigma may shape reproductive health outcomes, we present self-reported data on abortions in Ethiopia and Uganda and compare these findings across the two varying legal contexts. W investigate differences in sociodemographic characteristics by whether or not a woman self-reported an abortion, and we describe the characteristics of women's most recent self-reported abortion. In Ethiopia only, we classified abortions as being either safe, less safe, or least safe. Finally, we estimate minimum one-year induced abortion incidence rates using the Network Scale-Up Method (NSUM). We find that women who self-reported abortions were more commonly older, formerly married, or had any children compared to women who did not report an abortion. While three-quarters of women in both settings accessed their abortion in a health facility, women in Ethiopia more commonly used public facilities as compared to in Uganda (23.0% vs 12.6%). In Ethiopia, 62.4% of self-reported abortions were classified as safe, and treated complications were more commonly reported among least and less safe abortions compared to safe abortions (21.4% and 23.1% vs. 12.4%, respectively). Self-reported postabortion complications were more common in Uganda (37.2% vs 16.0%). The NSUM estimate for the minimum one-year abortion incidence rate was 4.7 per 1000 in Ethiopia (95% CI 3.9-5.6) and 19.4 per 1000 in Uganda (95% C 16.2-22.8). The frequency of abortions and low levels of contraception use at the time women became pregnant suggest a need for increased investments in family planning services in both settings. Further, it is likely that the broadly accessible nature of abortion in Ethiopia has made abortions safer and less likely to result in complications in Ethiopia as compared to Uganda.
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Affiliation(s)
| | - Fredrick Makumbi
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Assefa Seme
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Suzanne O. Bell
- Johns Hopkins Bloomberg School of Public Health, Department of Population, Family, and Reproductive Health, Baltimore, MD, United States of America
| | - Elizabeth Sully
- Guttmacher Institute, New York, NY, United States of America
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Ouma OJ, Ngoga EO, Odongo I, Sigu BS, Akol A. Pathways to medical abortion self-use (MASU): results from a cross-sectional survey of women's experiences in Kenya and Uganda. BMC Womens Health 2023; 23:412. [PMID: 37542313 PMCID: PMC10403870 DOI: 10.1186/s12905-023-02570-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 07/25/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND In Kenya and Uganda, unsafe abortions are a leading cause of maternal mortality. The new WHO policy guidelines on the safe termination of pregnancies up to 9 weeks lack information on women's experiences with self-administered medical abortion (MA), impeding the development of interventions to increase MA use. This study aimed to comprehend women's experiences with MA in Kenyan and Ugandan pharmacies. METHODS A cross-sectional mixed-methods survey utilized data from medical registers in 71 purposefully identified pharmacies and clinics dispensing MA drugs between September and October 2021. Forty women who were MA users participated in focus group discussions. The main outcome variables were: sources of MA information, costs of MA services, complications from MA, pain management, follow-up rates, and use of post-MA contraception. Quantitative data were analyzed using Stata 15, while qualitative thematic analysis was conducted using Dedoose qualitative analysis software. RESULTS 73.6% of 2,366 women got an MA, both in Kenya (79%) and Uganda (21%). Most (59.1%) were walk-in clients. Kenya had significantly more women referred for MA (49.9%) than Uganda (10.1%) (p 0.05). Friends and family members were the main sources of MA information. The median cost of MA was USD 18 (IQR 10-60.5) in Kenya and USD 4.2 (IQR 2-12) in Uganda. Most MA clients received pain management (89.6%), were followed up (81%), and received post-MA contraception (97.6%). Qualitative results indicated a lack of medicines, high costs of MA, complications, stigma, and inadequate training of providers as barriers to MA use. CONCLUSIONS AND RECOMMENDATIONS Communities are a valuable information resource for MA, but only if they have access to the right information. A relatively weak health referral system in Uganda highlights the importance of pharmacies and clinicians collaborating to support clients' abortion needs and contraceptive use after medical abortion (MA). Low client follow-up rates show how important it is to make sure pharmacy technicians know how to give MA correctly. Finally, it is crucial to strengthen the supply chain for MA products in order to eliminate cost barriers to access.
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Affiliation(s)
- Ogol Japheth Ouma
- Ipas Africa Alliance, Research and Learning Advisor, P.O. Box 1192-00200, City Square, Nairobi, Kenya.
| | - Edward O Ngoga
- Ipas Africa Alliance, Quality of Care Manager, P.O. Box 1192-00200, City Square, Nairobi, Kenya
| | - Isaac Odongo
- Ipas Africa Alliance, Quality of Care Manager, Uganda, P.O. Box 1192-00200, City Square, Nairobi, Kenya
| | - Biko Steve Sigu
- Ipas Africa Alliance, Quality of Care Advisor-UCD, P.O. Box 1192-00200, City Square, Nairobi, Kenya
| | - Angela Akol
- Ipas Africa Alliance, P.O. Box 1192-00200, City Square, Nairobi, Kenya
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Magalona S, Thomas HL, Akilimali PZ, Kayembe D, Moreau C, Bell SO. Abortion care availability, readiness, and access: linking population and health facility data in Kinshasa and Kongo Central, DRC. BMC Health Serv Res 2023; 23:658. [PMID: 37340470 PMCID: PMC10283295 DOI: 10.1186/s12913-023-09647-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 06/05/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND The Democratic Republic of Congo (DRC) legalized abortion in 2018 to preserve health and pledged to provide quality postabortion care (PAC), yet little is known about the availability of abortion care services and if facilities are prepared to provide them; even less is known about the accessibility of these services. Using facility and population-based data in Kinshasa and Kongo Central, this study examined the availability of abortion services, readiness of facilities to provide them, and inequities in access. METHODS Data on 153 facilities from the 2017-2018 DRC Demographic and Health Survey Service Provision Assessment (SPA) were used to examine signal functions and readiness of facilities to provide services across three abortion care domains (termination of pregnancy, basic treatment of abortion complications, and comprehensive treatment of abortion complications). To examine PAC and medication abortion provision before and after abortion decriminalization, we compared estimates from the 2017-2018 SPA facilities to estimates from the Performance Monitoring for Action (PMA) data collected in 2021 (n = 388). Lastly, we assessed proximity to PAC and medication abortion using PMA by geospatially linking facilities to representative samples of 2,326 and 1,856 women in Kinshasa and Kongo Central, respectively. RESULTS Few facilities had all the signal functions under each abortion care domain, but most facilities had many of the signal functions: overall readiness scores were > 60% for each domain. In general, readiness was higher among referral facilities compared to primary facilities. The main barriers to facility readiness were stock shortages of misoprostol, injectable antibiotics, and contraception. Overall, provision of services was higher post-decriminalization. Access to facilities providing PAC and medication abortion was almost universal in urban Kinshasa, but patterns in rural Kongo Central showed a positive association with education attainment and wealth. CONCLUSION Most facilities had many of the necessary signal functions to provide abortion services, but the majority experienced challenges with commodity availability. Inequities in accessibility of services also existed. Interventions that address supply chain challenges may improve facility readiness to provide abortion care services, and further efforts are needed to narrow the gap in accessibility, especially among poor women from rural settings.
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Affiliation(s)
- Sophia Magalona
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Haley L Thomas
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Pierre Z Akilimali
- Department of Biostatistics and Epidemiology, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Dynah Kayembe
- Performance Monitoring for Action DRC, Kinshasa, Democratic Republic of Congo
| | - Caroline Moreau
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Centre for Research in Epidemiology and Population Health, Institut National de la Santé et de la Recherche Médicale, Villejuif, France
| | - Suzanne O Bell
- Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Biggs MA, Driver M, Kaller S, Ralph LJ. Unwanted abortion disclosure and social support in the abortion decision and mental health symptoms: A cross-sectional survey. Contraception 2023; 119:109905. [PMID: 36415007 DOI: 10.1016/j.contraception.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the extent of unwanted abortion disclosure and levels of social support in the abortion decision and their association with depression, anxiety, and stress. STUDY DESIGN From January to June 2019, we surveyed people presenting for abortion at four clinics in California, New Mexico, and Illinois regarding their experiences accessing abortion. We used multivariable regression to examine associations between unwanted abortion disclosure and social support in the abortion decision, and symptoms of depression, anxiety and stress. RESULTS Among 1092 people approached, 784 (72% response rate) eligible individuals initiated the survey, and 746 responded to the unwanted abortion disclosure item and were included in analyses. Over one-quarter (27%) told someone they would have preferred not to tell about their decision, mostly due to obstacles getting to the appointment-time to appointment (46%), travel distance (33%), and costs (32%). Three-quarters (74%, n=546) had at least one person in their life who supported the abortion decision "very much"; 20% had someone who supported the decision "not at all." In adjusted analyses, unwanted abortion disclosure was associated with more symptoms of depression (B = 0.62, 95% confidence interval: 0.28, 0.95), anxiety (B = 1.79; 95% CI: 0.76, 2.82) and stress (B = 1.80, 95% CI: 0.64, 1.72). People also had more symptoms of depression and stress when one or more person (B = 0.64; 95% CI: 0.27, 1.02 and B = 0.75, 95% CI: 0.15, 1.35, respectively) or the man involved in the pregnancy (B = 0.67, 95% CI: 0.16, 1.18 and B = 0.96, 95% CI: 0.13, 1.78, respectively) supported their decision "not at all" (vs "very much" support). CONCLUSION Being forced to disclose the abortion decision due to logistical and cost constraints may be harmful to people's mental health. IMPLICATIONS Logistical burdens such as travel, time to access care, and costs needed to access abortion may force people seeking abortion to involve others who are unsupportive in the abortion decision having negative implications for their mental health.
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Affiliation(s)
- M Antonia Biggs
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States.
| | - Matthew Driver
- University of Washington, School of Public Health, Department of Epidemiology, Seattle, WA, United States
| | - Shelly Kaller
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Lauren J Ralph
- Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA, United States
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Rossier C, Owolabi O, Kouanda S, Bangha M, Kim CR, Ganatra B, Feehan D, Breen C, Zan M, Compaoré R, Baguiya A, Ouédraogo R, Oduor C, Bagnoa V, Athero S. Describing the safety of abortion at the population level using network-based survey approaches. Reprod Health 2022; 19:231. [PMID: 36575489 PMCID: PMC9795788 DOI: 10.1186/s12978-022-01518-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 10/21/2022] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Clémentine Rossier
- Institute of Demography and Socioeconomics, University of Geneva, 40 Bd du Pont d'Arve, 1211, Geneva, Switzerland. .,Institut National d'Etudes Démographiques, Paris, France.
| | - Onikepe Owolabi
- grid.417837.e0000 0001 1019 058XGuttmacher Institute, New York, USA
| | - Seni Kouanda
- grid.457337.10000 0004 0564 0509IRSS, Ouagadougou, Burkina Faso
| | - Martin Bangha
- grid.413355.50000 0001 2221 4219APHRC, Nairobi, Kenya
| | - Caron R. Kim
- grid.3575.40000000121633745UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Bela Ganatra
- grid.3575.40000000121633745UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Dennis Feehan
- grid.47840.3f0000 0001 2181 7878University of California, Berkeley, Berkeley USA
| | - Casey Breen
- grid.47840.3f0000 0001 2181 7878University of California, Berkeley, Berkeley USA
| | - Moussa Zan
- grid.8591.50000 0001 2322 4988Institute of Demography and Socioeconomics, University of Geneva, 40 Bd du Pont d’Arve, 1211 Geneva, Switzerland
| | | | - Adama Baguiya
- grid.457337.10000 0004 0564 0509IRSS, Ouagadougou, Burkina Faso
| | | | - Clement Oduor
- grid.413355.50000 0001 2221 4219APHRC, Nairobi, Kenya
| | - Vincent Bagnoa
- grid.457337.10000 0004 0564 0509IRSS, Ouagadougou, Burkina Faso
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Bell SO, Guiella G, Byrne ME, Bazie F, Onadja Y, Thomas HL, Moreau C. Induced abortion incidence and safety in Burkina Faso in 2020: Results from a population-based survey using direct and social network-based estimation approaches. PLoS One 2022; 17:e0278168. [PMID: 36449473 PMCID: PMC9710743 DOI: 10.1371/journal.pone.0278168] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/10/2022] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Suzanne O. Bell
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Georges Guiella
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Meagan E. Byrne
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Fiacre Bazie
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Yentéma Onadja
- Institut Supérieur des Sciences de la Population (ISSP), Université Joseph Ki-Zerbo, Ouagadougou, Burkina Faso
| | - Haley L. Thomas
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Soins Primaires et Prévention, CESP Centre for Research in Epidemiology and Population Health, U1018, Inserm, Villejuif, France
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Christianson M, Lehn S, Velandia M. The advancement of a gender ethics protocol to uncover gender ethical dilemmas in midwifery: a preliminary theory model. Reprod Health 2022; 19:211. [DOI: 10.1186/s12978-022-01515-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 10/13/2022] [Indexed: 11/20/2022] Open
Abstract
Abstract
Objectives
Ethical dilemmas at both the individual and structural level are part of the daily work of midwives and gender inequality and injustice can affect women’s sexual and reproductive health. Mainstream bioethical theory has been criticized for neglecting women’s issues. To ensure women’s experiences are addressed, a gender lens on ethics is crucial.
Aim
This study develops a theory model by exploring ethical dilemmas related to gender in the context of maternity care from the perspective of midwifery science and feminist ethics.
Methods
The research strategy followed a coherent stepwise approach: literature search, thematic analysis, elaboration of a gender ethics protocol, and the integration of various components into a preliminary gender ethics model for midwifery.
Findings
A literature search was performed using Scopus and Web of Science to identify ethical dilemmas in maternity care linked to gender and power. The search of articles published between 1996 and 2019 returned 61 abstracts. These abstracts were screened and assigned one of the following themes: The Midwifery Profession, The Rights of the Woman, Fetal Rights Dominate, and Medicalization of Pregnancy and Childbirth. A tentative gender ethics frame was developed and tested on two articles on abortion, one from Denmark and one from Japan. The protocol facilitated the gender analysis of ethical dilemmas related to abortion, which were related to the imbalance of power relations in health care. In the final step, we synthesized the dimensions of gender and power in a gender ethics model for midwifery.
Discussion
The gender ethics protocol developed revealed gendered dimensions of ethical dilemmas in midwifery. This gender analysis adds to the understanding of the “do no harm” principle by revealing assumptions and stereotypes that promote unequal power relations. The gender ethics model is an innovative approach that envisions and exposes power imbalance at the micro, meso, and macro levels.
Conclusions
The protocol could improve gender competence among researchers, midwives/professionals, and midwifery students throughout the world.
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Mehrtash H, Kim CR, Ganatra B, Tuncalp Ö. What's needed to improve safety and quality of abortion care: reflections from WHO/HRP Multi-Country Study on Abortion across the sub-Saharan Africa and Latin America and Caribbean regions. BMJ Glob Health 2021; 6:bmjgh-2021-007226. [PMID: 34465583 PMCID: PMC8407209 DOI: 10.1136/bmjgh-2021-007226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 12/21/2022] Open
Affiliation(s)
- Hedieh Mehrtash
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Caron Rahn Kim
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Bela Ganatra
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Özge Tuncalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and ResearchTraining in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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