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How, and in what ways, are rates of contraceptive use and induced abortion linked? What reasons do women give for contraceptive (non-)use for a terminated pregnancy?
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Fertility transitions and induced abortion
Dr Ernestina Coast
http://zambiatop.wordpress.com///twitter.com/ZambiaToP
Presentation at BSPS Annual Conference, University of Winchester, 10th Sept 2014
Two objectives• Macro relationships
– Abortion and fertility– Contraception-abortion paradox– Language and data
• Micro perspectives– Contraception and abortion in Zambia– Pregnancy “(un)wantedness”
Two questions• How, and in what ways, are rates of
contraceptive use and induced abortion linked?
• What reasons do women give for contraceptive (non-)use for a terminated pregnancy?
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: an end point
Abortion and fertility
TFR = TF × Cm × Ci × Ca × Cc
TF = total fecundityCm = index of marriageCi = postpartum infecundabilityCa = induced abortionCc = contraception
Abortion and fertility
TFR = TF × Cm × Ci × Ca × Cc
TF = total fecundityCm = index of marriageCi = postpartum infecundabilityCa = induced abortionCc = contraception
Induced abortion: data
• Much Demographic & Health Survey data unusable:
– “Did you have any miscarriages, abortions or stillbirths that ended before 2010?”
• 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 fertility
– using behavioural methods
– supplied contraception
× Inaccessible; and/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
ZAMBIA CASE STUDY
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. servicesAdequate Medium Poor
Legality of safe abortion √
Access to safe abortion √
Access to postabortion care √
Access to contraceptive services √
Total Fertility Rate (all women 15-49)(DHS 2010)
Current use of any modern method of contraception among married women in Zambia
Source: ICF International 2012. The DHS Program STATcompiler
Multi-method approach
• Quantitative survey combined with in-depth interview (n=112)
– Refusal 13%
• Key informant interviews
• Health system costing analyses
• Medical 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
Method use at time of terminated pregnancy
Consistent use of paracetamol as post-exposure contraceptive
Vignettes
• Written by Research Assistants immediately after interview, and before translating and transcribing an interview.
• NOT for analyses– Framework analyses of verbatim transcripts
Contraceptive failure(?)
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.
Contraceptive knowledge
• She is a 22 years old and doing an accountancy degree. She has been in a relationship for 4 years and she got pregnant during the time she was cleansing her body, as she put it. She said that she was on the 3 months injectable contraceptive, after it expired she wanted to stay off any contraceptive to allow her body to cleanse and during that time she was drinking an after morning pill every time she had sex but somehow she got pregnant. She came to [hospital] today in the company of her boyfriend, who made all the financial arrangements with the doctor and of which she is not aware of how much they were charged.
Poor post-partum services
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.
Contraceptive non-use
She is married with seven children. She said that she was surprised when she found out that she was pregnant as she never expected that to happen at her age. She had the ToP because they already have problems paying school fees for the seven children. She said that the husband was also not happy about the pregnancy because she is old and always had complications with past pregnancies.
Contraceptive non-use
She is 25 years old and has three children, and moved to Lusaka three months ago to follow her husband for work. Her husband abandoned her and the children soon after they arrived. She said that after giving birth to her youngest she was not attending [menstruating] and so was very certain that she would not get pregnant being in such a condition. She has used contraceptive pills before, just for a month, but had stopped because she felt like she was drinking medicine.
Induced abortion as
• An endpoint after a series of events, including contraceptive– Non-use– Never-use– Failure– Ineffective use
• An outcome of a pregnancy that is not sustainable at that point in time
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)
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?”
Whose unwanted pregnancy?• She is a school girl who 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.
