Estimating abortion incidence using the network scale-up method

Background: A major challenge in abortion research is accurately measuring the incidence of induced abortion, particularly in restrictive settings. This study tests the network scale-up method (NSUM) to measure abortion incidence, which uses respondent social network data to estimates the size of hidden populations. Methods: Using NSUM modules added to the Ethiopia and Uganda 2018 Performance Monitoring for Action (PMA) community-based surveys, we compute NSUM abortion incidence ratios, and adjust these ratios to account for transmission bias. We conduct internal validity checks to assess the NSUM performance. Results: The unadjusted NSUM abortion ratios were likely underestimates (Uganda: 15.3 per 100 births, Ethiopia: 3.6 per 100 births). However, the transmission bias-adjusted NSUM abortion ratios grossly overestimated abortion (Uganda: 151.4 per 100 births, Ethiopia: 73.9 per 100 births), which was likely due to selection bias, question wording, and the use of lifetime abortions to measure transmission bias. Internal validity checks revealed problems with the NSUM application in Ethiopia. Unadjusted NSUM estimates of intrauterine device/implant use performed well compared to established external estimates, but adjusting for transmission bias again resulted in overestimation. Conclusions: The NSUM resulted in overestimates of abortion incidence in Ethiopia and Uganda. We discuss several modifications that may improve future applications of the NSUM for measuring abortion. Contribution: This is the first test of the NSUM to estimate national abortion incidence. Our findings highlight the critical need to assess the validity of abortion estimates, a key feature of the NSUM that is lacking in most other indirect abortion measurement methods

Investigating the early impact of the Trump Administration's Global Gag Rule on sexual and reproductive health service delivery in Uganda.

BACKGROUND:The Global Gag Rule (GGR), reinstated by President Trump in January 2017, makes non-U.S. non-governmental organizations ineligible for U.S. foreign assistance if they provide access to or information about abortion. While evidence suggests previous iterations of the GGR negatively impacted sexual and reproductive health outcomes, no studies have quantitatively assessed the impacts of the Trump administration's GGR. METHODS:We constructed a panel dataset of facilities (76% public) using 2017/2018 Performance Monitoring and Accountability 2020 service delivery point (SDP) surveys in Uganda. Based on information from stakeholder meetings, we classified districts as more or less exposed to the GGR; 45% (N = 34) of study districts were classified as "more exposed", which corresponded to 145 "more exposed" and 142 "less exposed" health facilities in our sample. We assessed changes in provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, engagement with community health workers (CHWs), service integration, and quality of care from 2017 (pre-GGR) to 2018 (post-GGR). Multivariable regression models were estimated, and difference-in-differences impact estimators were determined by calculating predicted probabilities from interaction terms for exposure and survey round. FINDINGS:We observed no immediate impact of the GGR on the provision of long-acting reversible contraceptives, contraceptive stock-outs, mobile outreach services, service integration, or quality of care. We did observe a significant impact of the policy on the average number of CHWs, with "more exposed" facilities engaging 3.8 fewer CHWs post-GGR (95% CI:-7.31,-0.32). CONCLUSIONS:The reduction in CHWs could reduce contraceptive use and increase unintended pregnancies in Uganda. The lack of other significant findings may not be surprising given the short post-GGR observation window. Rapid organizational responses and stopgap funding from foreign governments may have mitigated any immediate impacts on service delivery in the short term. The true impact may not be felt for many years, as stopgap funding potentially ebbs and service providers adapt to new funding environments

Youth relationships in the era of COVID-19: A mixed-methods study among adolescent girls and young women in Kenya

Background: Measures to mitigate COVID-19\u27s impact may inhibit development of healthy youth relationships, affecting partnership quality and sexual and reproductive health (SRH) outcomes. Methods: We conducted a mixed-methods study to understand how COVID-19 affected girls\u27 and young women\u27s relationships in Kenya. Bivariate and multivariate logistic regression examined factors associated with relationship quality dynamics and SRH outcomes among 756 partnered adolescents aged 15–24 years. Qualitative data from in-depth interviews were analyzed using inductive thematic analysis to explore youth perceptions of how intimate relationships changed during COVID-19. Results: Nearly three-quarters of youth described changes in relationship quality since COVID-19 began, with 24% reporting worsening. Reduced time with partners was the strongest predictor of changed relationship quality. Youth experiencing complete or partial COVID-19-related household income loss had heightened risk of deteriorating partnerships (relative risk ratio = 2.43 and 2.02; p \u3c .05); those whose relationships worsened were more likely to experience recent intimate partner violence, relative to no relationship change (20.8% vs. 3.5%; p \u3c .001). Qualitative analysis revealed how COVID-19 mitigation measures hindered intimate relationships, school closures accelerated marriage timelines, and economic hardships strained relationships, while increasing early pregnancy risk and girls\u27 financial dependency on their partners. Conclusions: COVID-19 disrupted adolescent girls\u27 and young women\u27s romantic relationships, depriving some of partner emotional support and exposing others to sexual violence, early pregnancy, and economically motivated transactional relationships. Increased social support systems, including access to psychosocial services, are needed in low-income communities in Kilifi, Kisumu, and Nairobi, in particular the informal settlement areas, to mitigate COVID-19\u27s consequences on girls\u27 SRH