Abortion, contraception and associated social stigma : consequences and solutions in a low-resource setting in western Kenya

Abstract: Background: Complications of unsafe abortion is one of the top causes of maternal morbidity and mortality among women and adolescent girls globally. Stigmatising attitudes and behaviour seem to directly impact women’s and girls’ reproductive decision-making but are rarely explored. Enhanced understanding of the stigmatisation of abortion and contraceptive use is needed to reduce its impact on affected individuals and increase access to quality abortion care and contraceptive counselling and provision. Aim: The overall aim of this doctoral thesis was to increase knowledge on the constituents and consequences of, and solutions to, social stigma surrounding abortion and contraceptive use among women seeking post-abortion care, as well as secondary school students, in Kisumu, Kenya. Materials, Methods, and Findings: Study I was a qualitative study with individual, face- to-face interviews with nine women seeking post-abortion care. The objective was to analyse decision-making processes preceding abortion among women and adolescent girls with unwanted pregnancies. Method: Over all, 15 in-depth interviews using open-ended questions and a non-judgmental approach were conducted among women aged 19–32 years, with experienced induced abortion. All interviews were coded manually using inductive content analysis. Findings: The main findings showed poor social support and deviation from family- and gender-based norms determined abortion decision-making among women and girls. Strategic choices concerning whom to trust were made to avoid ignominy, which contributed to a culture of silence. The study found that abortion stigma hindered access to safe abortion services. Study II was a sub-study nested in a randomised, controlled trial on women seeking post- abortion care, focusing on pregnancy intentions in order to investigate contraceptive uptake and identify factors associated with unplanned pregnancy. Method: The analysis was based on follow-ups with 807 women and adolescent girls, aged 14–45 years, seven to ten days after their post-abortion care, preceding additional follow-ups with a subset of 472 women after three months. Descriptive statistics and binary logistic regression were used for the statistical analysis. Findings: Of the respondents (N = 807), 375 (46.3%) reported unplanned pregnancy, and 432 (53.3%) reported planned pregnancy. Regardless of reported pregnancy intention, most women started to use a contraceptive method after abortion: 273 (72.8%) of the unplanned pregnancy group and 338 (78.2%) of the planned pregnancy group, respectively (p = 0.072). Independent factors associated with unplanned pregnancy were young age (14-20 years) odds ratio (OR) 1.18; 95% confidence interval (CI), 1.05–2.82; p = 0.033; unmarried status OR 9.15; 95% CI, 5.72–14.64; p < 0.001; no previous children OR 1.97; 95% CI, 1.29–3.01; p = 0.002; hidden pregnancy OR 7.71; 95% CI, 3.30–18.01; p < 0.001; and the partner absent at the clinic visit OR 3.17; 95% CI, 2.21–4.55; p < 0.001. At the three-month follow-up, there was no difference in contraceptive use between those groups, unplanned (161; 77.4%) versus planned (193; 73.7%), p = 0.350, indicating that women seeking post-abortion care may hide their pregnancy intentions. Study III was a quasi-experimental study with pre- and post-tests, aiming to measure attitudes towards abortion and contraceptive use, and to evaluate a stigma-reduction intervention among secondary school students. Method: Two validated 5-point Likert scales were used for the data collection. The data was self-reported through classroom surveys at baseline, prior to initiation of the intervention, and at 1-month and 12-month post intervention. Findings: In total, 1,207 students (618 females and 582 males) 13–21 years old were included in the analysis at baseline. Abortion was considered sinful, bringing shame to the family and community, and contraceptive use was associated with immorality and promiscuity. However, male students displayed higher stigma scores: abortion stigma (57.7%) and contraceptive use stigma (58.5%), compared to female students (49.0%, p = 0.003 and 50.6%, p = 0.007, respectively). At 12-month follow-up, the decrease for the abortion stigma was 26.5% among the girls, and 29.8% among the boys. The stigma score regarding contraceptive use decreased with 25.2% among the girls, and with 28.8% among the boys. Hence, the intervention was considered effective to reduce stigma associated with abortion and contraception among both girls and boys. The overall stigma scores decreased significantly between baseline and 12-month; for abortion 28.2% (2.52±0.55, 1.81±0.54; p < 0.001) and for contraceptive use 27.2% (2.68±0.83, 1.95±0.70; p < 0.001). Conclusions: Stigma violates women’s and girls’ rights to sexual and reproductive education and services. Social stigma can manifest as negative stereotypes and discrimination, and it contributes to a culture of silence around abortion and unintended pregnancy, resulting in delayed health care and missed opportunities for contraceptive counselling. Women and girls might not disclose an unplanned pregnancy to avoid coercion from health-care providers. Girls associated with abortion and contraceptive use were highly stigmatised among their peers. A stigma-reduction programme within comprehensive sexuality education could be effective. However, to sustain the positive effect among students and to create a sociocultural environment where women and girls are empowered to make reproductive decisions, innovative strategies are required, including policy and community dialogues.