1. Fertility transitions and
induced abortion
Dr Ernestina Coast
http://personal.lse.ac.uk/coast/
Presentation at Pop@LSE Reseatch Day
24th Sept 2014

2. http://zambiatop.wordpress.com/
//twitter.com/ZambiaToP
@ZambiaToP

3. Two objectives
• Macro relationships
– Abortion and fertility
– Contraception-abortion paradox
• Micro perspectives
– Contraception and abortion in Zambia
– Pregnancy “(un)wantedness”

4. 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?

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

6. Abortion: an end point

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

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

9. 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

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

11. HIGH FERTILITY LOW FERTILITY
WHO, 2008

12. 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

14. Contraception-abortion “paradox”
• Unmet need for contraception is high
• Contraceptive prevalence is low
• Less-effective contraceptive methods prevail
• Poor contraceptive service access and
provision

15. Abortion
incidence
Contraceptive
prevalence
rate
Effective use
of
contraception

16. ZAMBIA CASE STUDY

17. Center for Reproductive Rights, 2013

18. 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

19. Zambia: Legality vs. services
Adequate Medium Poor
Legality of safe
abortion
√
Access to safe abortion √
Access to postabortion
care
√
Access to
contraceptive services
√

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

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

23. 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)

24. Characteristics Percent
distribution
Age group (range 15-43 years) 15-19
20-24
25-29
30-34
>35
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

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

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

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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

33. 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)

34. Get in touch
e.coast@lse.ac.uk
http://zambiatop.wordpress.com/
//twitter.com/ZambiaToP @ZambiaToP