A mixed-methods study exploring women’s perceptions of terminology surrounding fertility and menstrual regulation in Côte d’Ivoire and Nigeria

Background Women use various terms when discussing the management of their fertility and menstrual irregularities and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology used to refer to abortion-like experiences (specifically menstrual regulation and pregnancy removal), and the specific scenarios that these practices encompass among women who reported doing something to bring back a late period or ending a pregnancy in Nigeria and Côte d’Ivoire. Methods Our analysis draws upon surveys with women in Nigeria (n = 1114) and Cote d’Ivoire (n = 352). We also draw upon qualitative in-depth interviews with a subset of survey respondents in Anambra and Kaduna States in Nigeria, and Abidjan, Cote d’Ivoire (n = 30 in both countries). We examine survey and interview questions that explored women’s knowledge of terminology pertaining to ending a pregnancy or bringing back a late period. Survey data were analyzed descriptively and weighted, and interview data were analyzed using inductive thematic analysis. Results We find that the majority (71% in Nigeria and 70% in Côte d’Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy. Conclusions Overall, menstrual regulation and pregnancy removal are seen as distinct experiences in both settings. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women’s reproductive health needs.

The confidante method to measure abortion: implementing a standardized comparative analysis approach across seven contexts.

Background: Obtaining representative abortion incidence estimates is challenging in restrictive contexts. While the confidante method has been increasingly used to collect this data in such settings, there are several biases commonly associated with this method. Further, there are significant variations in how researchers have implemented the method and assessed/adjusted for potential biases, limiting the comparability and interpretation of existing estimates. This study presents a standardized approach to analyzing confidante method data, generates comparable abortion incidence estimates from previously published studies and recommends standards for reporting bias assessments and adjustments for future confidante method studies.Methods: We used data from previous applications of the confidante method in Côte d’Ivoire, Ethiopia, Ghana, Java (Indonesia), Nigeria, Uganda, and Rajasthan (India). We estimated one-year induced abortion incidence rates for confidantes in each context, attempting to adjust for selection, reporting and transmission bias in a standardized manner.Findings: In each setting, majority of the foundational confidante method assumptions were violated. Adjusting for transmission bias using self-reported abortions consistently yielded the highest incidence estimates compared with other published approaches. Differences in analytic decisions and bias assessments resulted in the incidence estimates from our standardized analysis varying widely from originally published rates.Interpretation: We recommend that future studies clearly state which biases were assessed, if associated assumptions were violated, and how violations were adjusted for. This will improve the utility of confidante method estimates for national-level decision making and as inputs for global or regional model-based estimates of abortion.Funding: UK Aid from the UK Government

Reducing underreporting of abortion in surveys: Results from two test applications of the list experiment method in Malawi and Senegal

Background Accurately measuring abortion incidence poses many challenges. The list experiment is a method designed to increase the reporting of sensitive or stigmatized behaviors in surveys, but has only recently been applied to the measurement of abortion. To further test the utility of the list experiment for measuring abortion incidence, we conducted list experiments in two countries, over two time periods. Materials and methods The list experiment is an indirect method of measuring sensitive experiences that protects respondent confidentiality by hiding individual responses to a binary sensitive item (i.e., abortion) by combining this response with answers to other non-sensitive binary control items. Respondents report the number of list items that apply to them, not which ones. We conducted a list experiment to measure cumulative lifetime incidence of abortion in Malawi, and separately to measure cumulative five-year incidence of abortion in Senegal, among cisgender women of reproductive age. Results Among 810 eligible respondents in Malawi, list experiment results estimated a cumulative lifetime incidence of abortion of 0.9% (95%CI: 0.0, 7.6). Among 1016 eligible respondents in Senegal, list experiment estimates indicated a cumulative five-year incidence of abortion of 2.8% (95%CI: 0.0, 10.4) which, while lower than anticipated, is seven times the proportion estimated from a direct question on abortion (0.4%). Conclusions Two test applications of the list experiment to measure abortion experiences in Malawi and Senegal likely underestimated abortion incidence. Future efforts should include context-specific formative qualitative research for the development and selection of list items, enumerator training, and method delivery to assess if and how these changes can improve method performance.

An assessment of third-party reporting of close ties to measure sensitive behaviors: the Confidante Method to measure abortion incidence in Ethiopia and Uganda

Indirect estimation techniques are an important tool for measuring sensitive and stigmatized behaviors. This includes third-party reporting methods, which have become increasingly common in the field of abortion measurement, where direct survey approaches notoriously lead to underreporting. This paper provides the first in-depth assessment of one of the most widely used of these techniques in the field of abortion measurement: the Confidante Method. We outline six key assumptions behind the Confidante Method and describe how violations of these assumptions can bias resulting estimates. Using data from modules added to the nationally representative Performance Monitoring for Action (PMA) surveys in Uganda and Ethiopia in 2018, we compute one-year abortion incidence estimates using the Confidante Method. We also perform a validation check, using the method to estimate IUD and implant use. While our results reveal that the method performed differently in each country, there were implementation problems in both settings. Several of the method’s foundational assumptions were violated, and efforts to adjust for these violations either failed or only partially addressed the resulting bias. Our validation check also failed, resulting in a gross over-estimate of IUD and implant use. We identify substantial biases in both the numerator and denominator of our abortion estimates and challenge the continued use of this method to estimate abortion incidence. These results have implications more broadly for the potential biases that can be introduced in using third-party reporting of close ties to measure other sensitive or stigmatized behaviors.

Social network-based measurement of abortion incidence: promising findings from population-based surveys in Nigeria, Cote d’Ivoire, and Rajasthan, India

Background Monitoring abortion rates is highly relevant for demographic and public health considerations, yet its reliable estimation is fraught with uncertainty due to lack of complete national health facility service statistics and bias in self-reported survey data. In this study, we aim to test the confidante methodology for estimating abortion incidence rates in Nigeria, Cote d’Ivoire, and Rajasthan, India, and develop methods to adjust for violations of assumptions. Methods In population-based surveys in each setting, female respondents of reproductive age reported separately on their two closest confidantes’ experience with abortion, in addition to reporting about their own experiences. We used descriptive analyses and design-based F tests to test for violations of method assumptions. Using post hoc analytical techniques, we corrected for biases in the confidante sample to improve the validity and precision of the abortion incidence estimates produced from these data. Results Results indicate incomplete transmission of confidante abortion knowledge, a biased confidante sample, but reduced social desirability bias when reporting on confidantes' abortion incidences once adjust for assumption violations. The extent to which the assumptions were met differed across the three contexts. The respondent 1-year pregnancy removal rate was 18.7 (95% confidence interval (CI) 14.9–22.5) abortions per 1000 women of reproductive age in Nigeria, 18.8 (95% CI 11.8–25.8) in Cote d’Ivoire, and 7.0 (95% CI 4.6–9.5) in India. The 1-year adjusted abortion incidence rates for the first confidantes were 35.1 (95% CI 31.1–39.1) in Nigeria, 31.5 (95% CI 24.8–38.1) in Cote d’Ivoire, and 15.2 (95% CI 6.1–24.4) in Rajasthan, India. Confidante two’s rates were closer to confidante one incidences than respondent incidences. The adjusted confidante one and two incidence estimates were significantly higher than respondent incidences in all three countries. Conclusions Findings suggest that the confidante approach may present an opportunity to address some abortion-related data deficiencies but require modeling approaches to correct for biases due to violations of social network-based method assumptions. The performance of these methodologies varied based on geographical and social context, indicating that performance may be better in settings where abortion is legally and socially restricted.

Estimating the incidence of abortion: using the Abortion Incidence Complications Methodology in Ghana, 2017

IntroductionInduced abortion is legally permitted in Ghana under specific conditions, but access to services that meet guidelines approved by government is limited. As part of a larger project comparing five methodologies to estimate abortion incidence, we implemented an indirect estimation approach: the Abortion Incidence Complications Methodology (AICM), to understand the incidence of abortion in Ghana in 2017.MethodsWe drew a nationally representative, two-stage, stratified sample of health facilities. We used information from 539 responding facilities to estimate treated complications stemming from illegal induced abortions, and to estimate the number of legal abortions provided. We used information from 146 knowledgeable informants to generate zonal multipliers representing the inverse of the proportion of illegal induced abortions treated for complications in facilities in Ghana’s three ecological zones. We applied multipliers to estimates of treated complications from illegal abortions, and added legal abortions to obtain an annual estimate of all induced abortions.ResultsThe AICM approach suggests that approximately 200 000 abortions occurred in Ghana in 2017, corresponding to a national abortion rate of 26.8 (95% CI 21.7 to 31.9) per 1000 women 15–49. Abortion rates were lowest in the Northern zone (18.6) and highest in the Middle zone (30.4). Of all abortions, 71% were illegal.ConclusionDespite Ghana’s relatively liberal abortion law and efforts to expand access to safe abortion services, illegal induced abortion appears common. A concurrently published paper compares the AICM-derived estimates presented in this paper to those from other methodological approaches.