Fertility transitions and induced abortion

1. Fertility transitions and induced abortion Dr Ernestina Coast e.coast@lse.ac.uk

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

3. Global scale 96 million unplanned pregnancies per year Unplanned ≠ unwanted 33 million estimated unintended pregnancies as a result of method failure or ineffective use

4. 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

5. Abortion and fertility TFR = TF × Cm × Ci × Ca × Cc TF = total fecundity Cm = index of marriage Ci = postpartum infecundability Ca = induced abortion Cc = contraception

6. Abortion and fertility TFR = TF × Cm × Ci × Ca × Cc TF = total fecundity Cm = index of marriage Ci = postpartum infecundability Ca = induced abortion Cc = contraception

7. 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

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

9. HIGH FERTILITY LOW FERTILITY WHO, 2008

10. 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

12. Contraception-abortion “paradox” Unmet need for contraception is high Contraceptive prevalence is low Less-effective contraceptive methods prevail

13. Abortion incidence Effective use of contraception Contraceptive prevalence rate

14. 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 (!)

15. Language and data: pregnancy Wanted vs. unwanted Intended vs. unintended Planned vs. unplanned

18. 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

20. 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

21. Center for Reproductive Rights, 2013

22. 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

23. Zambia: Legality vs. services

24. Total Fertility Rate (DHS 2010) (all women 15-49)

25. Total Fertility Rate (DHS 2010) (all women 15-49)

27. Current use of any modern method of contraception among married women in Zambia, 1992 Source: ICF International 2012. The DHS Program STATcompiler

28. Current use of any modern method of contraception among married women in Zambia, 2001-2 Source: ICF International 2012. The DHS Program STATcompiler

29. Current use of any modern method of contraception among married women in Zambia, 2007 Source: ICF International 2012. The DHS Program STATcompiler

31. 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)

35. Method use at time of terminated pregnancy Consistent use of paracetamol as post-exposure contraceptive

37. 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.

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

39. 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.

40. 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.

41. 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 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.

42. 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 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.

43. 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.

44. 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?”

45. Emergent policy issues

46. 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

47. 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)

48. ESRC Impact Maximisation Grant http://personal.lse.ac.uk/coast/ZambiaTOP.htm e.coast@lse.ac.uk