Respondent-Driven Sampling for Estimation of the Cumulative Lifetime Incidence of Abortion in Soweto, Johannesburg, South Africa: A Methodological Assessment.

Respondent-driven sampling (RDS) is a potential strategy for addressing challenges in accurate estimation of abortion incidence, but it relies on often untested assumptions. We conducted an RDS study to estimate the cumulative lifetime incidence of abortion in Soweto, Johannesburg, South Africa (April-December 2018), to evaluate whether RDS assumptions were met, and to compare RDS estimates of incidence with estimates adjusted for employment and age based on census data. A total of 849 participants were recruited from 11 seed participants between April and December 2018. The assumption that individuals can identify target population members and the assumption of approximation of sampling with replacement was met. There were minor violations of the assumptions of seed independence from the final sample and reciprocity of ties. Assumptions of accurate degree reporting and random recruitment were not met. Failure to meet assumptions yielded a study sample with different employment characteristics than those of the target population; this could not be resolved by standard RDS methods. The RDS estimate of cumulative lifetime abortion incidence was 12.1% (95% confidence interval: 9.8, 14.3), and the employment-adjusted estimate was 16.9% (95% confidence interval: 12.8, 22.1). We caution researchers in using RDS for representative estimates of abortion incidence. Use of postsurvey weights to adjust for differences in characteristics between the sample and the target population may yield more representative results.

Accounting for Misclassification and Selection Bias in Estimating Effectiveness of Self-managed Medication Abortion.

BACKGROUND: Studies on the effectiveness of self-managed medication abortion may suffer from misclassification and selection bias due to self-reported outcomes and loss of follow-up. Monte Carlo sensitivity analysis can estimate self-managed abortion effectiveness accounting for these potential biases. METHODS: We conducted a Monte Carlo sensitivity analysis based on data from the Studying Accompaniment model Feasibility and Effectiveness Study (the SAFE Study), to generate bias-adjusted estimates of the effectiveness of self-managed abortion with accompaniment group support. Between July 2019 and April 2020, we enrolled a total of 1051 callers who contacted accompaniment groups in Argentina and Nigeria for self-managed abortion information; 961 took abortion medications and completed at least one follow-up. Using these data, we calculated measures of effectiveness adjusted for ineligibility, misclassification, and selection bias across 50,000 simulations with bias parameters drawn from pre-specified Beta distributions in R. RESULTS: After accounting for the potential influence of various sources of bias, bias-adjusted estimates of effectiveness were similar to observed estimates, conditional on chosen bias parameters: 92.68% (95% simulation interval: 87.80%, 95.74%) for mifepristone in combination with misoprostol (versus 93.7% in the observed data) and 98.47% (95% simulation interval: 96.79%, 99.39%) for misoprostol alone (versus 99.3% in the observed data). CONCLUSIONS: After adjustment for multiple potential sources of bias, estimates of self-managed medication abortion effectiveness remain high. Monte Carlo sensitivity analysis may be useful in studies measuring an epidemiologic proportion (i.e., effectiveness, prevalence, cumulative incidence) while accounting for possible selection or misclassification bias.

Pregnancy and post-delivery maternal weight changes and overweight in preschool children.

OBJECTIVES: High maternal weight before and during pregnancy contributes to child obesity. To assess the additional role of weight change after delivery, we examined associations between pre- and post-pregnancy weight changes and preschooler overweight. SAMPLE: 4359 children from the Children and Young Adults of the 1979 National Longitudinal Survey of Youth (NLSY) born to 2816 NLSY mothers between 1979 and 2006 and followed to age 4-5years old. EXPOSURES: gestational weight gain (GWG) and post-delivery maternal weight change (PDWC). OUTCOME: child overweight (body mass index (BMI) ≥85th percentile). RESULTS: Adjusted models suggested that both increased GWG (OR: 1.08 per 5kg GWG, 95% CI: 1.01, 1.16) and excessive GWG (OR: 1.29 versus adequate GWG, 95% CI: 1.06, 1.56) were associated with preschooler overweight. Maternal weight change after delivery was also independently associated with child overweight (OR: 1.12 per 5kg PDWC, 95% CI: 1.04, 1.21). Associations were stronger among children with overweight or obese mothers. CONCLUSIONS: Increased maternal weight gain both during and after pregnancy predicted overweight in preschool children. Our results suggest that healthy post-pregnancy weight may join normal pre-pregnancy BMI and adequate GWG as a potentially modifiable risk factor for child overweight.

Do miscarriage care practice recommendations align with individuals' needs?: A scoping review.

OBJECTIVES: Miscarriage is a common occurrence; yet individuals often have negative experiences when receiving miscarriage care, signaling a gap in the quality of miscarriage care. We explore the literature on individuals' experiences with miscarriage care across a variety of dimensions and assess how these experiences align with practice recommendations. STUDY DESIGN: We conducted a scoping review of peer-reviewed studies in PubMed published in English through April 30, 2022, and focused on individuals' experiences with miscarriage care in healthcare settings and on practice recommendations for providing care in a variety of countries. The search returned 1812 studies; after screening, 41 studies were included in the analysis. RESULTS: Included studies reported on individuals' experiences with miscarriage care settings and accessibility, information provision, emotional support, decision-making and follow-up. Overall, individuals are often dissatisfied with their miscarriage care experiences. Practice recommendations are generally responsive to these issues. CONCLUSIONS: Individuals experiencing miscarriage are best served by care that is patient-centered, involves shared decision-making, and addresses individuals' informational and emotional needs. However, the prevalence of individuals' negative experiences with miscarriage care points to the need to address key gaps in and improve the implementation of practice recommendations. IMPLICATIONS: Future research should focus on documenting the miscarriage experiences of and developing relevant practice recommendations for communities that face the greatest barriers to care, generating evidence on the dimensions that constitute high-quality miscarriage care from patients' perspectives and assessing the barriers and facilitators to effectively implementing existing practice recommendations.

School environment and adolescent health: results from the HPTN 068 cohort.

PURPOSE: To assess the relationship between school environment and health and behavior outcomes. METHODS: Data are from baseline and first follow-up of the HIV Prevention Trials Network (HPTN) 068 longitudinal trial established in 2012 of adolescent girls and young women in rural Mpumalanga Province, South Africa. Data from 2,212 participants are included. We measured the association between four school environment domains: school resources, school safety, negative personal experiences, and school connectedness, and several health and behavior outcomes: depressive symptoms, low attendance, recent pregnancy, recent unprotected sex, transactional sex, and having an older romantic partner. We used a g-computation approach to estimate risk differences (RD) for the longitudinal relationship between the school environment (measured at the individual and school level) on individual health and behavior outcomes, controlling for baseline covariates. RESULTS: The mean age of participants at baseline was 15.4; mean age at first follow-up was 16.6. Individual baseline perceptions of an unsafe school environment (RD = 3.1%, 95% CI: 1.3% - 5.2%) and more frequent negative experiences (RD = 4.0%, 95% CI: 2.0% - 5.9%) were associated with higher absolute risk of depressive symptoms at follow-up. There was an overall trend toward higher risk of pregnancy, unprotected sex, and having an older partner among those who reported fewer school resources, lack of school safety, more negative personal experiences, and lack of school connectedness. CONCLUSIONS: Our findings provide evidence of an overall trend toward higher risk of depression, pregnancy, unprotected sex, and having an older partner among those reporting a worse school environment across four school environment domains.

Violence Related to Daily Water and Sanitation Needs in South Africa.

There is a critical lack of research on violence experienced by women when meeting their daily water and sanitation needs. This short report describes the cumulative lifetime incidence of exposure to violence when using the toilet or collecting water (water, sanitation, and hygiene [WASH]-related violence) and identifies associated health and behavioral risks. Data from 1,870 participants collected in 2013-2015 from a longitudinal cohort of young women in rural South Africa were included in this analysis. We found that exposure to WASH-related violence was high: 25.9% experienced violence when collecting water or when using the toilet. Those who experienced violence were more likely to report pregnancy, an older partner, unprotected sex, experience of intimate partner violence, engaging in transactional sex, depressive symptoms, and anxiety. Future research should investigate the location and type of violence experienced and examine how WASH-related violence is related to health outcomes to identify gender-centered WASH interventions that reduce violence exposure.

Self-managed medication abortion trajectories: results from a prospective observational study in Argentina, Nigeria and Southeast Asia.

OBJECTIVES: Time is a crucial factor in abortion-seeking because options for care change with pregnancy duration, and most people prefer to access abortion care early in pregnancy. We aimed to collect data on the timing of steps in accompanied self-managed abortion-seeking experiences in legally restrictive settings. METHODS: In this prospective, observational, cohort study we recruited callers from three abortion accompaniment groups in Argentina, Nigeria and a country in Southeast Asia. Participants completed a baseline survey before starting a self-managed medication abortion (SMA) and two follow-up surveys (approximately 1 and 3 weeks after taking medication). Primary outcomes of interest included: (1) time from abortion decision to contacting the hotline, (2) time from contacting the hotline to obtaining pills and (3) time from obtaining pills to taking the first dose. We explored relationships between participant characteristics and each of these outcomes and evaluated differences in overall abortion time using survival analyses. RESULTS: Between July 31, 2019 and October 01, 2020 we enrolled 1352 eligible callers; 1148 provided data for this analysis. After deciding to have an abortion, participants took 12.2 days on average (95% CI: 11.6, 12.9) to start medications for abortion. On average, participants at later pregnancy durations progressed through the SMA process more quickly (<4 weeks: 20.9 days, 4 weeks: 11 days, 5-6 weeks: 10.1 days, 7-9 weeks, 10.4 days, 10+ weeks: 9.1 days; p<0.001). CONCLUSIONS: Overall, participants accessed accompaniment group support and started abortion regimens quickly and at relatively early pregnancy durations. SMA with accompaniment provided a time-efficient route for obtaining abortions.

The impact of COVID-19 on safe abortion access in Africa: An analysis through a framework of reproductive justice and lens of structural violence.

The SARS-CoV-2 virus causing the coronavirus disease (COVID-19) global pandemic heightened restrictions on sexual and reproductive health and rights (SRHR), especially concerning safe abortion access. The African region has been particularly susceptible to the impact of COVID-19 on sexual and reproductive health services. Using a framework of reproductive justice, we interviewed key informants from the Mobilizing Action around Medication Abortion (MAMA) Network regarding the impacts of structural violence and COVID-19 on SRHR programming in Africa, particularly programming on self-managed abortion. We identified themes of lacking infrastructures of support, emergent marginality, and neocolonial funding environments as facets of structural violence within the context of the MAMA Network, as heightened by the COVID-19 global pandemic.

Incidence of and Experiences with Abortion Attempts in Soweto, South Africa: Respondent-Driven Sampling Study.

BACKGROUND: Estimation of abortion incidence, particularly in settings where most abortions occur outside of health facility settings, is critical for understanding information gaps and service delivery needs in different settings. However, the existing methods for measuring out-of-facility abortion incidence are plagued with methodological challenges. Respondent-driven sampling (RDS) may offer a methodological improvement in the estimation of abortion incidence. OBJECTIVE: In this study, we tested the feasibility of using RDS to recruit participants into a study about abortion and estimated the proportion of people who ever attempted abortion as well as 1-year and 5-year incidence of abortion (both in-facility and out-of-facility settings) among women of reproductive age in Soweto, South Africa. METHODS: Participants were eligible if they identified as a woman; were aged between 15 and 49 years; spoke English, Tswana, isiZulu, Sotho, or Xhosa; and lived in Soweto. Working with community partners, we identified 11 seeds who were provided with coupons to refer eligible peers to the study. Upon arrival at the study site, the recruits completed an interviewer-administered questionnaire that solicited information about demographic characteristics, social network composition, health behaviors, sexual history, pregnancy history, and experience with abortion; recruits also received 3 recruitment coupons. Recruitment was tracked using coupon numbering. We used the RDS-II estimator to estimate the population proportions of demographic characteristics and our primary outcome, the proportion of people who ever attempted abortion. RESULTS: Between April 4, 2018, and December 17, 2018, 849 eligible participants were recruited into the study. The estimated proportion of people who ever attempted abortion was 12.1% (95% CI 9.7%-14.4%). A total of 7.1% (95% CI 5.4%-8.9%) reported a facility-based abortion, and 4.4% (95% CI 3.0%-5.8%) reported an out-of-facility abortion. CONCLUSIONS: The estimated proportion of people who ever attempted abortion of 12% (102/849) in our study likely represents a substantial underestimation of the actual proportion of abortion attempts among this study population-representing a failure of the RDS method to generate more reliable estimates of abortion incidence in our study. We caution against the use of RDS to measure the incidence of abortion because of persistent concerns with underreporting but consider potential alternative applications of RDS with respect to the study of abortion.

Associations between WASH-related violence and depressive symptoms in adolescent girls and young women in South Africa (HPTN 068): a cross-sectional analysis.

OBJECTIVE: There is a lack of research on experiences of WASH-related violence. This study aims to quantify the association between experience or worry of violence when using the toilet or collecting water and depressive symptoms among a cohort of young women in South Africa. METHODS: Data are from visit 3 of the HPTN 068 cohort of adolescent girls in rural Mpumalanga Province, South Africa. Participants (n=1798) included in this analysis were aged 13-21 at baseline. Lifetime experience of violence or fear of violence when using the toilet and collecting water was collected by self-report; depressive symptoms in the past week were measured using the Center for Epidemiological Studies Depression Scale (CES-D). We used G-computation to calculate the prevalence difference (PD) and prevalence ratio of depression (CES-D score >15) associated with each domain of violence, controlling for baseline covariates. FINDINGS: A total of 15.1% of respondents reported experiencing violence when using the toilet; 17.1% reported experiencing violence when collecting water and 26.7% reported depression. In adjusted models, those who reported experiencing violence when using the toilet had an 18.1% higher prevalence of depression (95% CI: 11.6% to 24.4%) than those who did not experience violence when using the toilet. Adjusted prevalence of depression was also higher among those who reported violence when collecting water (PD 11.9%, 95% CI: 6.7% to 17.2%), and who worried about violence when using the toilet (PD 12.8%, 95% CI: 7.9% to 19.8%), as compared with those who did not report these experiences. Worrying about violence when collecting water was not associated with depression after adjusting for covariates. CONCLUSION: Experience of WASH-related violence is common among young women in rural South Africa, and experience or worry of experiencing violence is associated with higher prevalence of depressive symptoms. TRIAL REGISTRATION NUMBER: NCT01233531; Post-results.

Effect of a smartphone intervention on self-managed medication abortion experiences among safe-abortion hotline clients in Indonesia: A randomized controlled trial.

OBJECTIVE: To investigate the impact of a smartphone application (app) providing information and support for medication abortion (MA) on the primary outcomes of 'feelings of support' and 'preparedness' among clients of Samsara, a safe-abortion hotline in Indonesia. METHODS: In a parallel-arm, non-clinical, randomized controlled trial, women (ages ≥15) who contacted Samsara between February 2017- July 2018 seeking information on MA for pregnancies ≤13 weeks gestation were randomized to receive either an app with abortion information, or standard of care (high-quality comprehensive and empathic counseling on pregnancy options). Participants completed a questionnaire 24 days after enrollment; Fisher exact tests and risk differences were used to assess differences in self-reported feelings of preparedness and support throughout the process of self-managed MA. RESULTS: No differences in feelings of support or preparedness were detected between participants in the app arm versus the standard of care arm. CONCLUSION: This study represents the first-ever randomized control trial (and prospective study) among those who contacted a safe-abortion hotline for information about and support for self-managed abortion. Levels of preparedness, confidence, and feelings of support were all extremely high among both control and intervention arms-indicative of the high-quality, evidence-based information, comprehensive, and supportive abortion counseling that safe-abortion hotline clients receive.

Studying Accompaniment model Feasibility and Effectiveness (SAFE) Study: study protocol for a prospective observational cohort study of the effectiveness of self-managed medication abortion.

INTRODUCTION: A range of barriers deter or prevent people from accessing facility-based abortion care. As a result, people are obtaining and using abortifacient medications to end their pregnancies outside of the formal healthcare system, without clinical supervision. One model of self-managed abortion has come to be known as the 'accompaniment' model, in which grassroots organisations provide pregnant people with evidence-based counselling and support through the medication abortion process. Data are needed to understand the safety and effectiveness of this increasingly common model of abortion care. METHODS AND ANALYSIS: This is a large, prospective, observational study in Argentina and Nigeria. All people who contact one of two accompaniment groups seeking information for their own self-managed medication abortion, are ages 13 years and older, have no contraindications for medication abortion, are within the gestational range supported by the group (up to 12 weeks' gestation for the primary outcome) and are willing to be contacted for follow-up will be recruited. Participants will respond to an interviewer-administered baseline survey at enrolment, and 1-4 additional surveys over 6 weeks to ascertain whether they obtain medications for abortion, dosing and route of administration of medications, physical and emotional experience of medication abortion self-management, and effectiveness and safety outcomes. Analyses will include estimates of the primary outcome: the proportion of participants that report a complete abortion without surgical intervention at last recorded follow-up; as well as secondary outcomes including a pseudo-experimental test of non-inferiority of the effectiveness of self-managed medication abortion as compared with clinical medication abortion. ETHICS AND DISSEMINATION: We describe the ethical considerations and protections for this study, as well the creation of a study-specific Data Monitoring and Oversight Committee. We describe dissemination plans to ensure that study results are shared widely with all relevant audiences, particularly researchers, advocates, policymakers and clinicians. TRIAL REGISTRATION NUMBER: ISRCTN95769543.

Experiences of women who travel for abortion: A mixed methods systematic review.

OBJECTIVE: To systematically review the literature on women's experiences traveling for abortion and assess how this concept has been explored and operationalized, with a focus on travel distance, cost, delays, and other barriers to receiving services. BACKGROUND: Increasing limitations on abortion providers and access to care have increased the necessity of travel for abortion services around the world. No systematic examination of women's experiences traveling for abortion has been conducted; this mixed-methods review provides a summary of the qualitative and quantitative literature on this topic. METHODS: A systematic search was conducted using PubMed, Embase, Web of Science, Popline, and Google Scholar in July 2016 and updated in March 2017 (PROSPERO registration # CRD42016046007). We included original research studies that described women's experiences traveling for abortion. Two reviewers independently performed article screening, data extraction and determination of final inclusion for analysis. Critical appraisal was conducted using CASP, STROBE, and MMAT checklists. RESULTS: We included 59 publications: 46 quantitative studies, 12 qualitative studies, and 1 mixed-methods study. Most studies were published in the last five years, relied on data from the US, and discussed travel as a secondary outcome of interest. In quantitative studies, travel was primarily conceptualized and measured as road or straight-line distance to abortion provider, though some studies also incorporated measures of burdens related to travel, such as financial cost, childcare needs, and unwanted disclosure of their abortion status to others. Qualitative studies explored regional disparities in access to abortion care, with a focus on the burdens related to travel, the impact of travel on abortion method choice, and women's reasons for travel. Studies generally were of high quality, though many studies lacked information on participant recruitment or consideration of potential biases. CONCLUSIONS: Standardized measurements of travel, including burdens associated with travel and more nuanced considerations of travel costs, should be implemented in order to facilitate comparison across studies. More research is needed to explore and accurately capture different dimensions of the burden of travel for abortion services on women's lives.

Second-trimester medication abortion outside the clinic setting: an analysis of electronic client records from a safe abortion hotline in Indonesia.

INTRODUCTION: Unsafe abortion past the first trimester disproportionately accounts for the majority of global abortion-related morbidity and mortality; research that documents the safety, feasibility and acceptability of existing models for providing information and support to women who self-manage outside of formal clinic settings is needed. METHODS: This study is a retrospective analysis of anonymised electronic client records from callers to a safe abortion hotline in Indonesia. Between July 2012 and October 2016, a total of 96 women contacted the hotline for information on medication abortion beyond 12 weeks' gestation and are included in this study. Descriptive statistics were calculated regarding pregnancy termination status, client experience with warning signs of potential complications, and medical care seeking and treatment. RESULTS: Ninety-six women with pregnancies beyond the first trimester called the hotline for information on medication abortion; 91 women received counselling support from the hotline. Eighty-three women (91.2%) successfully terminated their pregnancies using medication and did not seek medical care. Five women exhibited warning signs of potential complications and sought medical care; one woman sought care after a failed abortion. Two women were lost to follow-up and the outcomes of their pregnancies are unknown. CONCLUSIONS: Evidence from our analysis suggests that a model of remote provision of support for abortions later in pregnancy by non-medically trained, skilled abortion counsellors could be a safe alternative for women in need of abortions beyond 12 weeks' gestation in a legally restrictive context. Further examination and documentation of the model is warranted.

Women's experiences with unplanned pregnancy and abortion in Kenya: A qualitative study.

BACKGROUND: Safe and legal abortions are rarely practiced in the public health sector in Kenya, and rates of maternal mortality and morbidity from unsafe abortion is high. Little is known about women's experiences seeking and accessing abortion in informal settlements in Nairobi, Kenya. METHODS: Seven focus group discussions were conducted with a total of 71 women and girls recruited from an informal settlement in Nairobi. The interview guide explored participants' perceptions of unplanned pregnancy, abortion, and access to sexual and reproductive health information in their community. Thematic analysis of the focus group transcripts was conducted using MAX QDA Release 12. RESULTS: Participants described a variety of factors that influence women's experiences with abortion in their communities. According to participants, limited knowledge of sexual and reproductive health information and lack of access to contraception led to unplanned pregnancy among women in their community. Participants cited stigma and loss of opportunities that women with unplanned pregnancies face as the primary reasons why women seek abortions. Participants articulated stigma as the predominant barrier women in their communities face to safe abortion. Other barriers, which were often interrelated to stigma, included lack of education about safe methods of abortion, perceived illegality of abortion, as well as limited access to services, fear of mistreatment, and mistrust of health providers and facilities. CONCLUSIONS: Women in informal settlements in Nairobi, Kenya face substantial barriers to regulating their fertility and lack access to safe abortion. Policy makers and reproductive health advocates should support programs that employ harm reduction strategies and increase women's knowledge of and access to medication abortion outside the formal healthcare system.