Understanding abortion seeking care outside of formal health care settings in Cape Town, South Africa: a qualitative study

Factors influencing abortion care-seeking outside of formal healthcare settings: lived experiences from Rwandan young women

BACKGROUND

Informal abortions, commonly known as unsafe abortions, refer to all induced abortions that occur outside of formal healthcare settings conducted without the assistance of a licensed, trained healthcare provider. Despite the legalization of safe induced abortion care services, informal abortions continue to be among the major causes of maternal mortality and morbidity among young women in Rwanda living in rural areas with limited or no access to safe abortion care services. The purpose of this qualitative study was to gain an in-depth understanding of the lived experience of seeking informal abortions from the perspective of young women in rural Rwanda and to identify the underlying factors for these women seeking abortion care services outside of the formal healthcare setting.

METHODS

This qualitative study was guided by a descriptive phenomenology in rural Rwanda, specifically in a selected district located in the Northern Province of Rwanda. Ten young women between 18 and 24 years of age, who had the experience of seeking informal abortion services from informal providers within the last eight years participated in audio-recorded, in-depth, face-to-face interviews. Collected data were analyzed using Colaizzi's (1978) seven steps of the phenomenological method.

RESULTS

The study found that young Rwandan women still seek unregulated abortions to end their unintended pregnancies due to limited access to or utilization of sexual reproductive health and rights services. Among the reasons for seeking abortion care services outside of the formal healthcare setting in Rwanda were sociocultural and economic factors and the stigma associated with terminating unintended pregnancies before marriage.

CONCLUSION

In light of the findings of this study, the authors recommend the Ministry of Health and its stakeholders to expand access to comprehensive adolescent and youth-friendly reproductive health and reproductive rights while addressing the sociocultural stigma through public awareness and economic factors that play a big role in unregulated abortions rather than safe abortion care services.

The association of experiences of medical mistrust and mistreatment and ever considering self-managing an abortion

OBJECTIVE

To assess the prevalence of ever considering self-managing an abortion (SMA) and its associations with experiences of medical mistrust and mistreatment in a nationally representative sample.

STUDY DESIGN

In 2021-22, we conducted a national, cross-sectional, online probability-based survey of US people assigned female at birth ages 15-49. Among those who had ever been pregnant, we ran weighted multivariable logistic regressions to examine whether having had difficulty trusting medical providers and/or experiencing medical mistreatment was associated with SMA consideration.

RESULTS

Of 4260 participants who had ever been pregnant, 5.2% (95% CI, 4.3%-6.3%) ever considered SMA. Additionally, 38.8% (95% CI, 36.8%-40.9%) reported prior moderate medical mistrust; 17.0% (15.4%-18.6%) experienced neglect of symptoms only, and 22.2% (20.6%-24.0%) experienced ridicule or humiliation in a previous healthcare encounter. In multivariable analyses, those who reported prior high medical mistrust had increased odds of considering SMA (aOR=5.2, [95% CI, 2.9-9.2]), compared to those who had no prior medical mistrust. Those who had experienced ridicule or humiliation by healthcare providers had increased odds of considering SMA (aOR=3.8, [95% CI, 2.3-6.1]), compared to those without such experiences. Participants who believed others perceived them as Black or Arab/Middle Eastern, were poor in their youth, or identified as Lesbian, Gay, Bisexual, Transgender, Queer, and other had higher proportions of considering SMA (p-values<0.01).

CONCLUSIONS

Experiences of medical mistrust and mistreatment are common and are associated with increased likelihood of considering SMA. Those who identified with a structurally minoritized group were more likely to consider SMA, and those whose "street race" was Arab/Middle Eastern had the highest likelihood.

IMPLICATIONS

If restrictions on abortion continue to increase, individuals may further consider SMA. Our findings suggest a need to create healthcare environments that foster trust and respect, as well as to ensure people have access to safe options for SMA.

[Women's rescuers network: Community support for self-managed abortion in Argentina]

The availability of medications to induce abortion, especially in contexts of restricted access, has transformed practices and allowed women and/or their community organizations to assist other women in obtaining abortions, whether or not they interact with the healthcare system. This study recovers the experience of a feminist community organization that, from the province of Neuquén, extends throughout the country, creating a network of community care. An exploratory descriptive study with a qualitative approach was conducted to analyze the experiences of women who facilitate access to permitted abortion in Argentina. Through in-depth interviews with three leaders of the feminist collective La Revuelta and semi-structured interviews with 33 members of the socorrista groups, conducted between November 2019 and December 2020, we describe their history and processes of work and growth; we explore their motivations and feelings and characterize the interactions of these organizations with public and private health systems. The results of this work align with the international conversation and bibliographic production about these organizations and their particularities, and with the need to incorporate these forms of care into institutional health systems.

Perspectives about social support among unmarried pregnant university students in South Africa

BACKGROUND

Pregnant young women in an academic environment are susceptible to stressors associated with unintended pregnancy and academic demands of universities. The challenges they face may be exacerbated by lack of social support, putting them at risk of psychological disorders such as depression. Women who receive social support during pregnancy and postpartum experience less emotional distress and report greater maternal satisfaction. However, very little is known about the perspectives about social support among unmarried pregnant students in tertiary institutions.

METHODS

Participants were purposively selected among unmarried pregnant students and those in the puerperal period at the time of the study. We conducted semi-structured qualitative interviews to explore the perspectives of unmarried pregnant students on the type of support that they need during pregnancy and the puerperium and the period when most support is needed. The data were audio-recorded and transcribed verbatim, then analysed using thematic analysis.

RESULTS

The findings show that social supports (emotional, instrumental, informational, and financial) were highlighted as important resources to cope with stressors during pregnancy and post-birth. Emotional support from male partners was the most important type of support needed as it entailed a sense of being loved and cared for. Social support was identified as important throughout the different phases of pregnancy and post birth, with different support needs expressed at each of these phases.

CONCLUSION

This study identified support needs of unmarried pregnant university students in their transition to motherhood. Given the several challenges that they are faced with, unmarried pregnant students need social support, including male partner support to enhance wellbeing as they try to cope with academic and pregnancy-related stressors.

Incidence of and Experiences with Abortion Attempts in Soweto, South Africa: Respondent-Driven Sampling Study

BACKGROUND

Estimation of abortion incidence, particularly in settings where most abortions occur outside of health facility settings, is critical for understanding information gaps and service delivery needs in different settings. However, the existing methods for measuring out-of-facility abortion incidence are plagued with methodological challenges. Respondent-driven sampling (RDS) may offer a methodological improvement in the estimation of abortion incidence.

OBJECTIVE

In this study, we tested the feasibility of using RDS to recruit participants into a study about abortion and estimated the proportion of people who ever attempted abortion as well as 1-year and 5-year incidence of abortion (both in-facility and out-of-facility settings) among women of reproductive age in Soweto, South Africa.

METHODS

Participants were eligible if they identified as a woman; were aged between 15 and 49 years; spoke English, Tswana, isiZulu, Sotho, or Xhosa; and lived in Soweto. Working with community partners, we identified 11 seeds who were provided with coupons to refer eligible peers to the study. Upon arrival at the study site, the recruits completed an interviewer-administered questionnaire that solicited information about demographic characteristics, social network composition, health behaviors, sexual history, pregnancy history, and experience with abortion; recruits also received 3 recruitment coupons. Recruitment was tracked using coupon numbering. We used the RDS-II estimator to estimate the population proportions of demographic characteristics and our primary outcome, the proportion of people who ever attempted abortion.

RESULTS

Between April 4, 2018, and December 17, 2018, 849 eligible participants were recruited into the study. The estimated proportion of people who ever attempted abortion was 12.1% (95% CI 9.7%-14.4%). A total of 7.1% (95% CI 5.4%-8.9%) reported a facility-based abortion, and 4.4% (95% CI 3.0%-5.8%) reported an out-of-facility abortion.

CONCLUSIONS

The estimated proportion of people who ever attempted abortion of 12% (102/849) in our study likely represents a substantial underestimation of the actual proportion of abortion attempts among this study population-representing a failure of the RDS method to generate more reliable estimates of abortion incidence in our study. We caution against the use of RDS to measure the incidence of abortion because of persistent concerns with underreporting but consider potential alternative applications of RDS with respect to the study of abortion.

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).