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Two objectives
Macro relationships Abortion and fertility Contraception-abortion paradox Language and data
Micro perspectives Pregnancy termination trajectories in Zambia
Global scale
96 million unplanned pregnancies per year Unplanned ≠ unwanted
33 million estimated unintended pregnancies as a result of method failure or ineffective use
Abortion: end point of a set of events
sex
contraceptive use (non-use/ineffective use/failure)
a pregnancy
a decision to terminate
access to abortion (safe/unsafe/legal/illegal)
abortion
morbidity / mortality
Abortion and fertility
TFR = TF × Cm × Ci × Ca × Cc
TF = total fecundity
Cm = index of marriage
Ci = postpartum infecundability
Ca = induced abortion
Cc = contraception
Abortion and fertility
TFR = TF × Cm × Ci × Ca × Cc
TF = total fecundity
Cm = index of marriage
Ci = postpartum infecundability
Ca = induced abortion
Cc = contraception
Induced abortion: data Much Demographic & Health Survey data
unusable: “Did you have any miscarriages, abortions or
stillbirths that ended before 2002?”
Few reliable national estimates globally
Rare and non-representative
Few data of use to policymakers
How, and to what extent, are rates of induced abortion and contraception related?
HIGH FERTILITY LOW FERTILITY
WHO, 2008
Abortion & unmet need Abortion as an outcome of unmet
need for effective contraception? People are motivated to regulate their
fertilityusing behavioural methodssupplied contraception
Inaccessibleand/or
Inconsistently or incorrectly used
Contraception-abortion “paradox” Unmet need for contraception is high Contraceptive prevalence is low Less-effective contraceptive methods
prevail
Abortion incidence
Contraceptive prevalence
rate
Effective use of contraception
Intra-country variation
Urban-rural differentials in Fertility Unmet need Effective contraceptive use (and access)
Likely to be echoed in Urban-rural differentials in abortion rates Data (!)
Language and data: pregnancy
Wanted vs. unwanted
Intended vs. unintended
Planned vs. unplanned
Data on (un)wanted / mistimed /(un)intended pregnancy
Survey data – posthoc rationalisation of “wantedness” (and then whether mistimed etc.) retrospective
Our Zambian data collected from women at the time of pregnancy termination Unwanted at that point in time
Zambia: case study
Comparative study design - comparing the experiences of girls and women who seek
Safe abortion (SA) services
or
Post-abortion care (PAC) following an unsafe induced abortion
Center for Reproductive Rights, 2013
Legality: Zambia (Category IV) Abortion is legally permitted
– To save the life of a woman– To preserve physical health– To preserve mental health– Foetal impairment– Socio-economic grounds
Gestational age limits apply
Zambia: Legality vs. services
Adequate Medium Poor
Legality of safe abortion
√
Access to safe abortion
√
Access to postabortion care
√
Access to contraceptive services
√
Total Fertility Rate (DHS 2010) (all women 15-49)
Total Fertility Rate (DHS 2010) (all women 15-49)
Current use of any modern method of contraception among married women in Zambia, 1992
Source: ICF International 2012. The DHS Program STATcompiler
Current use of any modern method of contraception among married women in Zambia, 2001-2
Source: ICF International 2012. The DHS Program STATcompiler
Current use of any modern method of contraception among married women in Zambia, 2007
Source: ICF International 2012. The DHS Program STATcompiler
Multi-method approach
Quantitative survey combined with in-depth interview (n=112)Refusal 13%
Key informant interviewsHealth system costing analysesMedical notes analyses and data
extraction (n=81)
Characteristics Percent distribution
Age group (range 15-43 years) 15-1920-2425-2930-34
>35
25.027.914.417.313.5
Highest school level completed Nursery/kindergartenPrimary
SecondaryHigher
12.534.633.716.3
Religion CatholicProtestant
MuslimSeventh Day Adventist
Other
27.99.61.0
14.545.3
Main occupation / activity Work for pay (f-t / p-t)Housewife
StudentRuns own business
Unemployed and seeking work
25.910.625.917.35.8
Using contraception at the time of terminated pregnancy 51.0
% distribution of sample (n=112) by ToP type and age group
0
2
4
6
8
10
12
14
16
18
15-19 20-24 25-29 30-34 >34
Hospital ToP Unsafe
% distribution of sample by ToP type and highest level of completed education
0
5
10
15
20
25
30
Nursery 1ary 2ary 3ary
%
Hospital ToP Unsafe
Method use at time of terminated pregnancy
Consistent use of paracetamol as post-exposure contraceptive
Procedure % (n=112)
Safe abortion at hospital 59.8
(Un)safe abortion: medical abortion
initiated elsewhere
14.7
Unsafe abortion: any other method
25.5
Trajectories
• Once the decision to terminate has occurred, the question is “How”?
• Can be complex and iterative
• Individuals navigate complex private and public health systems as well as unqualified “providers” in order to achieve their pregnancy termination.
• Of those seeking PAC in our study, 15% had tried at least two different unsafe/unregulated methods before reaching the hospital for PAC.
Vignettes
• Written by Research Assistants immediately after interview, and before translating and transcribing an interview.
• NOT for analyses– Framework analyses of verbatim transcripts
Contraception:
• A 32 year old woman who is married with four children. She is a very poor woman who is struggling with the up keep of her four children. The husband does not work and only depends on piece work to feed them. She does some piece work like washing of clothes just to earn some money for food. She was surprised to find out that she was pregnant because she was on a three months injectable contraceptive which was provided for free. The reason for attempting to terminate the pregnancy was because the cost of raising children is very expensive and already she was unable to send her four children to school. She had no money to even feed the family and so why would she have another child? The husband is not aware that she was pregnant and she intends to keep it that way.
She is a 26 year old married woman with three children, the youngest of which is 7 months old. She runs a small business, baking scones which she sells in her shop. She went to the clinic to start her family planning pill but she was told to come back when her periods start, and was not given any contraceptive supplies. Getting pregnant came as a surprise to her, and she self-induced an abortion using unspecified pills. She intends to have a normal life when she goes home and wants to start her family planning pills.
Poor post-partum FP
Diffusion of SA knowledgeA 20 year old school leaver who lives with her “Aunty” in
Lusaka in order to help out with childcare. She comes from a poor family and decided to have a ToP because her mother is a widow and can’t afford to raise a child. The boyfriend responsible doesn’t know anything about her being pregnant and he is no longer answering his phone. When she told her Aunty that she was pregnant, it was the Aunty who arranged with a Doctor for her to have a TOP and made a down payment of k100 against the k300 demanded by the doctor. The Doctor refused to complete treatment without full payment in advance, so the Aunty had to raise the balance and make a return visit, after which the respondent was treated and given a medical abortion.
• After agreeing with the boyfriend to remove the pregnancy, they went together to a Clinic where they were seen by a friend of her boyfriend’s. She knew that her boyfriend had paid for this consultation, but did not know how much. She was given three tablets and told to insert them at home. After four days, the bleeding stopped. After two weeks she bled again and after another two weeks, clots started coming out. She went to visit her mother who noticed that she was pale and weak and that she had blood on her leg. She told her mother about what had happened and her mother took her to another clinic where they gave her injections and the bleeding stopped. After two weeks, she had stomach pains, came to a hospital, and was admitted for three nights. Scans revealed retained products in her uterus and severe infection.
Male involvement
Whose unwanted pregnancy?• She is a 20 year old school girl, who comes from a poor family
and both her parents are dead. She lives with her widowed step-mother and some siblings. Her step-mother made her a herbal mix liquid and forced her to drink it in order to induce an abortion. The step-mother told her that if she did not terminate the pregnancy, she would be forced to leave the house. The respondent reported that the liquid gave her terrible stomach pains. It was a school friend who told her about the services available at the hospital, and she arrived at the hospital with no money. Once at the hospital she was provided with a medical abortion, and the standard registration fee for a medical card was waived because she was unable to pay for it. When she goes home, she thinks her step-mother will shout at her because she said she had gone to school, and she came to the hospital secretly. However, she said she will tell her step-mother about removing the pregnancy so that she stops forcing her to drink herbal drugs.
Pregnancy “wantedness”
I: Feel free. You can tell me. Did you want to keep? How did you feel after finding out that you are pregnant?
R: Yes, I wanted to keep it.I: You wanted to keep it. So what then happened next?R: I was told that there was no way that I would take
care of this child.I: Who said that to you?R: My mother and my father.I: Okay R: I was asked “How I would care for that child? Where
would I find clothes and how I would finish school?”
Emergent policy issues
Safe vs unsafe
• Is this dichotomy less useful given wife availability of medical abortion drugs?
• Substantial proportions of girls and women procure a less-risky “unsafe” medical abortion
• Lower risk unsafe abortion– Initiate termination using MA drugs
Zambia Project Team:
Dr Ernestina Coast (P.I.) Dr Tiziana Leone Dr Divya Parmar Dr Ellie Hukin Dr Emily Freeman Dr Susan Murray (KCL) Dr Bellington Vwalika (UTH/UNZA) Dr Bornwell Sikateyo (UTH/UNZA) Erica Chifumpu (RA) Victoria Saina (RA) Taza Mwense (RA) Doreen George (RA)
ESRC Impact Maximisation Grant
http://personal.lse.ac.uk/coast/ZambiaTOP.htm
