This document summarizes a presentation on fertility transitions, induced abortion, and contraception. It discusses: 1) Relationships between abortion and fertility rates, as well as the contraception-abortion paradox where contraceptive use is low but abortion rates are high. 2) A case study from Zambia analyzing pregnancy termination trajectories and characteristics of women who seek safe abortion services versus post-abortion care. 3) Issues with data on induced abortion and ways language around wanted/unwanted pregnancies can impact data collection.

1. Fertility transitions and
induced abortion
Dr Ernestina Coast (London School of Economics)
e.coast@lse.ac.uk
Presentation to ‘Fertility Transition in the South’, Collen
Programme Conference, Oxford, 23-25 April 2014

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)

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
Contraceptive
prevalence
rate
Effective use
of
contraception

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
Adequate Medium Poor
Legality of safe
abortion
√
Access to safe abortion √
Access to postabortion
care
√
Access to contraceptive
services
√

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

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

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)

32. 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

33. 0
2
4
6
8
10
12
14
16
18
15-19 20-24 25-29 30-34 >34
Hospital ToP Unsafe
% distribution of sample (n=112) by ToP type
and age group

34. 0
5
10
15
20
25
30
Nursery 1ary 2ary 3ary
%
Hospital ToP Unsafe
% distribution of sample by ToP type and highest level
of completed education

35. Method use at time of terminated pregnancy
0
5
10
15
20
25
30
35
40
45
%ofwomenusingcontraceptives
Consistent use of paracetamol
as post-exposure
contraceptive

36. Procedure % (n=112)
Safe abortion at hospital 59.8
(Un)safe abortion: medical abortion
initiated elsewhere
14.7
Unsafe abortion: any other method 25.5

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. Acknowledgements and further
details
ESRC Impact Maximisation Grant
http://personal.lse.ac.uk/coast/ZambiaTOP.htm
e.coast@lse.ac.uk