Pregnancy termination trajectories in Zambia: the socio-economic costs
We aim to establish how investment in abortion services impacts on the socio-economic conditions of women and their households, and the implications of this for policy-making and service provision in Zambia.
Our
objective is to understand
the role that socio-economic circumstances play in the seeking of abortion and
abortion-related services in Zambia.
Our work has enabled us to:
We are committed to disseminating our findings to a wide range of audiences.
Our work answers the following research questions:
What are the indirect and direct socio-economic costs of safe abortion compared to hospital-based post-abortion care following an unsafe abortion for women and their households?
What role does poverty play in termination of pregnancy trajectories?
What are the social benefits and costs of using formal safe abortion services compared to informal unsafe abortion methods?
Why is the investment in safe abortion services in Zambia not fully used by women seeking to terminate a pregnancy?
Unsafe abortion is a significant, but preventable, cause of maternal mortality and morbidity and is both a cause and a consequence of poverty.
Zambia’s maternal mortality ratio is 591 deaths per 100,000 live births. A significant proportion of these are likely to be due to unsafe abortion, but there are no nationally representative data available. Pregnancies reported as unplanned are common: 16% of births are reported as unwanted, and 26% are reported as being mistimed. Unmet need for effective contraception among married women (an underestimate of the unmet need for women overall) is 27%, and it is estimated that if all married women with an unmet need for contraception were to use a method, the contraceptive prevalence rate would rise to 67% from 41%.
Unsafe abortion is the most easily prevented cause of maternal death. Post-abortion care (PAC) is a strategy to address the problem of the outcomes of unsafe abortion. The majority of women seeking abortion-related care in Zambia do so for PAC following an unsafe abortion, and have not accessed legal safe abortion services available. This demands better understanding and analysis.
The microeconomic impact of out-of-pocket health expenditure for reproductive health and abortion care for women and their households has until now received little attention. The data available for sub-Saharan Africa are particularly scanty and poor quality. Our research addresses this knowledge gap.
Zambia's relatively liberal legal context and provision of PAC facilitates research on issues related to abortion which can have broader lessons for developments elsewhere in the region.
Zambia has one of the most liberal abortion policies in sub-Saharan Africa. There is evidence that requests for, and provision of, abortion is increasing as a result of the HIV pandemic (RHM, 1993). Despite the legal provisions, death rates from unsafe abortion are high. On the basis of a community-based study in western Zambia, Koster-Oyekan et al. (1998) estimated that one in one hundred girls of school age dies from abortion-related complications each year. Despite the policy context of abortion in Zambia, it is known that in many parts of the country the administrative barriers (requirement for three registered medical practitioners to certify, one of whom must be a specialist) and service constraints (limited number of hospitals registered to perform abortions) combine to limit the number of women seeking safe, legal abortions (Kaseba et al, 1998; Mtonga & Ndhlovu, 2001). The Zambian government has expressed concern about the continuing high incidence of unsafe abortion in Zambia, but efforts to reduce these have so far had little effect (Likwa et al, 2009).
Women who obtain an illegal, unsafe abortion not only risk their well-being, but also seven years’ imprisonment, yet for every woman having a safe abortion, 85 women were admitted to hospitals with abortion-related complications (including complications from spontaneous abortions), accounting for just over one third of all gynaecologic admissions (Likwa, 2009). The capital city, Lusaka, has the best gynaecology provision in the country, but of women attending the Gynaecological Emergency Admission Ward of University Teaching Hospital (UTH) for abortion-related care, just 20% have attend for safe abortion (SA) services, and 80% require post abortion care many of these following unsafe procedures carried out elsewhere (Kaseba, Pers. Comm.).
The reasons for setting this research in Lusaka, Zambia are twofold. Firstly, the relatively liberal legal context, and the existence of PAC provision facilitates research on issues related to abortion which can have broader lessons for developments elsewhere in the region. The continuing high levels of unsafe abortion highlight that efforts beyond legal context need to be sustained, although the legal context remains an important first step. Secondly, Lusaka offers the optimal in current scenarios - it has a typical urban concentration of gynaecologists and established abortion services in government facilities. Yet we know that still the majority of women seeking abortion-related care at Lusaka’s main hospital do so for PAC following an unsafe abortion, and have not accessed safe abortion services. This demands better understanding and analysis.
Our approach is multi-disciplinary (health economics, policy analysis, sociology, anthropological demography, medical practitioner, statistics), necessitating a rigorously integrated multi-method strategy incorporating primary data collection of both qualitative and quantitative data.
Our research strategy is one of a comparative case study (women seeking safe abortion compared to women seeking post-abortion care) using mixed methods. It therefore balances the need to assemble detailed understandings of individual contexts and complexities with the necessity of producing results that can be generalised to other contexts.
The research process was designed to be iterative and interpretative, with a continuous interplay between collection and analysis. Three strands of primary data collection were carried out: a quantitative survey of women who had received hospital-based abortion-related services; qualitative in-depth interviews with women who had received hospital-based abortion-related services; and qualitative interviews with policymakers.
Our research instruments are included in the resources of the Consortium for Research on Unsafe Abortion in Africa.
Our research has been carried out in five stages, each building on the preceding one:
Stage One: Pilot Study
Prior to the main data collection phase, a pilot study was carried out. This enabled us to conduct a detailed audit of hospital case notes to inform sampling and interview guides; develop, translate and rigorously test the qualitative question guide and quantitative questionnaire; and refine interviewer skills.
Stage Two: Quantitative survey
This aimed to establish the distribution of out-of-pocket expenses for women and their households incurred using hospital-based safe abortion and PAC services.
Over 4 months all women that were identified as having undergone either a safe abortion or having received PAC were approached for inclusion in the quantitative survey. The survey questionnaire, that aimed to determine key characteristics of women that undergo either safe or unsafe abortion as well as the costs incurred, was based on questionnaires used elsewhere and produced in English (the language of the formal education system), Nyanja and Bemba (the most commonly used languages in Lusaka).
Treatment records were accessed, with permission, in order to validate individual reports of direct hospital costs. Interviews were conducted privately with women prior to discharge and after any prescriptions etc. had been given.
Analysis: Comparative (safe abortion versus PAC) quantitative analysis of costs (indirect and direct) for women and their households. Key socio-demographic determinants of the two groups will be studied using logistic regression. Analyses will make allowance for uncertainty in the estimates of costs and consequences, and non-market items (e.g.: opportunity costs) will be imputed using nationally-available secondary datasets in order to produce a range of estimates. Loss of productivity due unsafe abortion-related complications will be estimated also using disability adjusted life-years. Analysis of treatment records will allow for classification of the degree of seriousness of post-abortion complication, and will measure the economic impact of different levels of PAC. Moreover, access to treatment record will allow to perform a simple cost-effectiveness analysis of SA versus PAC. Data on unsafe abortion mortality will be imputed using national estimates.
Stage 3: In-depth qualitative interviews (QL1)
This aimed to establish the range of reasons why women sought abortion, and why they used or did not use safe abortion services, and to explore the social costs and benefits of their trajectories, and the policy implications.
Individual fine-grained narratives are not easily captured in a questionnaire-type survey, especially on such a sensitive area. Subsequently, in-depth qualitative interviews were conducted with a sub-sample of 40 women, drawn from the quantitative sample. This sub-sample was drawn to maximize heterogeneity in sociodemographic characteristics, including age, marital status, ethnic group, education, employment status, residence, in financial circumstances, and in clinical intervention and outcomes. Permission was sought to audio-record the interviews. Interviews were conducted in a private room within the hospital in the language of the interviewee’s choice.
Analysis: Data were organised using NVivo software. Preliminary content analysis of transcripts was carried out independently by the lead researchers and interviewers and then discussed in a team analysis workshop. This informed the coding basis for second cycle thematic analysis for a narrative summary on socio-economic issues surrounding abortion-related services.
Stage 4: Follow up in-depth qualitative interviews (QL2)
Stage 4 aimed to examine the ongoing socio-economic trajectories in a sub-group of interviewees.
Where permission was given, and follow-up was possible, we re-interviewed as many of women as possible at around 6 months after their discharge from hospital. The location of these re-interviews was determined by the women themselves, but where possible, linked to a return visit to the hospital or family planning clinic.
In order to build on existing rapport, these interviews were carried out by the same interviewer as the first interview (Stage 3). Again, interviews were in-depth and audio-recorded with permission. These follow-up interviews produced important data in a situation where very little indeed is known about what happens to women post-abortion in this context and about their coping strategies to deal with the socioeconomic costs over time.
Analysis: The analysis will use a longitudinal qualitative analysis summary matrix to capture change and continuity over time. Qualitative longitudinal research is emerging as an important tool for sociological investigation into change and transition, but is still rarely used in health research in low income country settings. It has yet to be employed specifically for examining post-abortion experiences.
Stage 5: Policymaker interviews and feedback
Policy maker interviews aimed to improve the quality of the research interpretation and findings, and the likelihood of policymaker impact.
Recorded in-depth interviews were carried out using a pre-tested interview guide, and were audio-recorded with permission and transcribed. Policymakers were recruited purposively to represent a range of (inter)national perspectives and approaches, including government, NGO and civil society.
Analysis: Thematic analysis of interviews using the policy triangle (context, content, actors, processes) framework will be conducted to provide retrospective and prospective profiles of and for policy. Findings will be integrated iteratively into the research findings and policy briefs.
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Principal Investigator Senior Lecturer in Population Studies London School of Economics & Political Science |
Dr Bellington Vwalika Co-Investigator University Teaching Hospital Lusaka, Zambia
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Co-Investigator Senior Research Fellow & Lecturer in Demography London School of Economics & Political Science |
Co-Investigator Research Officer London School of Economics & Political Science
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Co-Investigator Reader in International Healthcare King's College London Visiting Senior Fellow, LSE Health
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Dr Bornwell Sikateyo Post-doctoral Research Fellow Department of Public Health University of Zambia |
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Post-doctoral Research Officer London School of Economics & Political Science
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Dr Ellie Hukin (2012/2013) Post-doctoral Research Officer London School of Economics & Political Science |
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Lusaka-based Research Assistants Erica Chifumpu Taza Mwense Doreen Mwanza Victoria Saina |
The project is funded by the Economic & Social Research Council (UK) / DFID (UK)
The grant is held at London School of Economics and the grant number is RES-167-25-0626
Here are some presentations and papers about the research. If you are interested in our outcomes please do check back as we update this list.
Leone, T., E. Coast, D. Parmar & S. Murray (forthcoming) "The socio-economic burden of unsafe abortion for women and households in Zambia" Paper presentation at BSPS Annual Conference, University of Winchester, 8-10 September, 2014
Coast, E. (forthcoming) "The role of induced abortions in fertility transitions" Paper presentation at BSPS Annual Conference, University of Winchester, 8-10 September, 2014
Coast, E. & E. Freeman (forthcoming) "Research uptake and impact activities on unsafe abortion in Zambia" Presentation at ESRC DFID Poverty Alleviation Conference, London, 9th September 2014
Coast, E. (2014) "Pregnancy termination trajectories and costs in Zambia" Presentation to IPAS Media workshop, Lusaka, 21st-22nd August, 2014.
Vwalika, B. (2014) "Costs and consequences of induced abortion in Zambia" Presentation to the Zambia Medical Association AGM, 8-9 August, 2014, Livingstone, Zambia.
Coast, E. & S. Murray (2014) "Pregnancy termination trajectories in Zambia" Presentation at the Maternal and Neonatal health Group Seminar, LSHTM, 3rd July 2014
Coast, E., A. Norris, A. Moore & E. Freeman (2014) "Trajectories to abortion and abortion-related care: a conceptual framework" IUSSP Working Paper Presentation at the IUSSP workshop on Decision-making regarding abortion, Nanyuki, Kenya, 3rd-5th June, 2014.
Coast, E. & S. Murray (2014) "Pregnancy termination trajectories in Zambia" Presentation at the IUSSP workshop on Decision-making regarding abortion, Nanyuki, Kenya, 3rd-5th June, 2014.
Coast, E. (2014) "The role of induced abortions in fertility transitions" Invited Keynote at "The fertility transition in the South" St Anne's College Oxford, 23rd-25th April 2014
Parmar, D., T. Leone, E. Coast, S. Murray, E. Hukin, B. Vwalika (2014) "A comparative study of health systems costs of safe abortion and post abortion care in Zambia" Presentation at the Third International Conference of the African Health Economics and Policy Association (AfHEA). Nairobi, 11th-13th March, 2014.
Coast (2014) "Pregnancy termination trajectories in Zambia" Presentation at the LSE Dept. of Social Policy research seminar. 19th January 2014.
Coast, E. & E. Hukin (2013) Unwanted fertility: induced abortion in Zambia. Invited presentation at IPPF, London, 22nd May 2013.
Coast, E. (2013) ""Unwanted" fertility and induced abortion" Invited presentation at the Oxford Institute of Population Ageing. Workshop on Fertility change in the South. Oxford University, 7th March 2013
"When legalising abortion isn't enough" Africa at LSE Blog
Coast, E. (2012) Project poster
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We will shortly be hosting an eConference to share our findings and encourage debate. We will post details here.
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Please contact Dr Ernestina Coast: e.coast@lse.ac.uk