Fertility transitions and induced abortion

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Fertility transitions and induced abortion

• Dr Ernestina Coast
• e.coast_at_lse.ac.uk

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Two objectives

• Macro relationships
• Abortion and fertility
• Contraception-abortion paradox
• Language and data
• Micro perspectives
• Pregnancy termination trajectories in Zambia

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Global scale

• 96 million unplanned pregnancies per year
• Unplanned ? unwanted
• 33 million estimated unintended pregnancies as a
  result of method failure or ineffective use

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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

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Abortion and fertility

• TFR TF Cm Ci Ca Cc
• TF total fecundity
• Cm index of marriage
• Ci postpartum infecundability
• Ca induced abortion
• Cc contraception

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Abortion and fertility

• TFR TF Cm Ci Ca Cc
• TF total fecundity
• Cm index of marriage
• Ci postpartum infecundability
• Ca induced abortion
• Cc contraception

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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

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• How, and to what extent, are rates of induced
  abortion and contraception related?

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HIGH FERTILITY
LOW FERTILITY
WHO, 2008
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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

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Contraception-abortion paradox

• Unmet need for contraception is high
• Contraceptive prevalence is low
• Less-effective contraceptive methods prevail

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Abortion incidence
Effective use of contraception
Contraceptive prevalence rate
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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 (!)

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Language and data pregnancy

• Wanted vs. unwanted
• Intended vs. unintended
• Planned vs. unplanned

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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

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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

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Center for Reproductive Rights, 2013
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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

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Zambia Legality vs. services
Adequate Medium Poor
Legality of safe abortion v
Access to safe abortion v
Access to postabortion care v
Access to contraceptive services v
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Total Fertility Rate (DHS 2010) (all women 15-49)
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Total Fertility Rate (DHS 2010) (all women 15-49)
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Current use of any modern method of contraception
among married women in Zambia, 1992
Source ICF International 2012. The DHS Program
STATcompiler
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Current use of any modern method of contraception
among married women in Zambia, 2001-2
Source ICF International 2012. The DHS Program
STATcompiler
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Current use of any modern method of contraception
among married women in Zambia, 2007
Source ICF International 2012. The DHS Program
STATcompiler
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Multi-method approach

• Quantitative survey combined with in-depth
  interview (n112)
• Refusal 13
• Key informant interviews
• Health system costing analyses
• Medical notes analyses and data extraction (n81)

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Characteristics Percent distribution
Age group (range 15-43 years) 15-19 20-24 25-29 30-34 gt35 25.0 27.9 14.4 17.3 13.5
Highest school level completed Nursery/kindergarten Primary Secondary Higher 12.5 34.6 33.7 16.3
Religion Catholic Protestant Muslim Seventh Day Adventist Other 27.9 9.6 1.0 14.5 45.3
Main occupation / activity Work for pay (f-t / p-t) Housewife Student Runs own business Unemployed and seeking work 25.9 10.6 25.9 17.3 5.8
Using contraception at the time of terminated pregnancy 51.0
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Method use at time of terminated pregnancy
Consistent use of paracetamol as post-exposure
contraceptive
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Procedure (n112)
Safe abortion at hospital 59.8
(Un)safe abortion medical abortion initiated elsewhere 14.7
Unsafe abortion any other method 25.5
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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.

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Vignettes

• Written by Research Assistants immediately after
  interview, and before translating and
  transcribing an interview.
• NOT for analyses
• Framework analyses of verbatim transcripts

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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.

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Poor post-partum FP

• 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.

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Diffusion of SA knowledge

• A 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 cant afford to raise a child. The
  boyfriend responsible doesnt 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.

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Male involvement

• After agreeing with the boyfriend to remove the
  pregnancy, they went together to a Clinic where
  they were seen by a friend of her boyfriends.
  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.

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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.

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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?

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Emergent policy issues
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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

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• 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)

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• ESRC Impact Maximisation Grant
• http//personal.lse.ac.uk/coast/ZambiaTOP.htm
• e.coast_at_lse.ac.uk