Chiweshe, Malvern Tatenda

Coast, Ernestina

Fetters, Tamara

Strong, Joe

English

LSE Research Online

Adolescent abortion decision-making in Ethiopia, Malawi, and Zambia: a supportability frameworkMalvern Tatenda Chiweshe, Joe Strong, Ernestina Coast, & Tamara Fettershttps://abortioninafrica.wordpress.com/@SRHRadoelscentPAA 2023Our teamSelamawit AbebeDr Malede BiraraTracy ChasimaErica ChifumpuRuth ChipoyaDr Grace ChiudzuDr Malvern ChiwesheDr Patrick DjemoProf Ernestina CoastLisa EckersbergerTamara FettersGertrude FinyizaDr HailemichaelGebreselassieAbrham GetachewSena GetenetRisa GriffinDr Godfrey KangaudeChimwemwe KanyinjiDr Tiziana LeoneProf Nyovani MadiseSalim MapilaNomsa MategulaHanna MershaChikwanka MubangaCharlotte MulagaIsikanda MulasikwandaNamonje MutamboDoreen MwanzaBlain RezeneDr Chrispine SibandeLaura SochasJoe StrongEbbie TembenuJessica TemboLuke TemboProf Bellington VwalikaFitsum WorkinehShewit WeldegebirealSamuel WolelawYetnayet Nathan YosephNana ZuluMethods Facility-based recruitment of adolescents 10–19 years old seeking either safe abortion (SA) or post-abortion care (PAC): 313 interviews in 2018-19All adolescents identified as having sought either SA or PAC by a study-trained senior nurse were invited to participate once ready for discharge. Nurses were not involved in research consent procedures.  Trained research assistants completed informed consent with potential participants – processes dependent on age (<>18 years). Quantitative and qualitative interviewing techniques using an established two interviewer techniqueVerbatim translation and transcription of recorded interviews. Qualitative data were coded and content analysed in Dedoose by a team of five using a combination of deductive and inductive themes. Coding was developed collaboratively, including blind coding by all five team members of 10 cases to check for intercoder variability and understandings. Nearly half (49%) of the interviews were coded by two members of the team blinded to the other coder to check for internal consistency; the remaining interviews were single coded.  Ethical review was obtained in Ethiopia, Malawi, Zambia and the UK.For details on methods and research instruments: https://abortioninafrica.wordpress.com/• Highlights the complex interweaving individual, micro, meso and macro-level contexts involved in abortion decision-making • Supportability is conceptualized as the capacity [or desire] of a woman to carry a pregnancy in such a way that she experiences positive health and welfare, which is dynamic, multifaceted, and intersectional • Pregnancies viewed as biologically, emotionally, cognitively and/or psychologically supportable or unsupportable (or unevenly supportable and unsupportable). • Continuum 1) 'unsupportable           supportable' and 2)' unsupported            supported', 4Our readings of interview transcripts:• Highlighted how adolescent bodies are contested by parents, relatives, strangers, partners and healthcare workers; adolescent reproductive preferences and desires are often minimised, ignored or overridden.• Within a single abortion trajectory there could be multiple experiences of coercion or control involving different perpetrators and power dynamics.• Could be cumulative and / or concurrent from sex to ending a pregnancy [time]Power x Control → Reduced AutonomyCurtailed educational prospects: “I am a student, and I am just being sponsored by my aunt, so I thought it was just disturbing in terms of education and I was thinking uhm that maybe the guy won’t be responsible, but I just never had intentions of getting pregnant or being interfered when it comes to education. I do not want to rely on anyone and disappointing my family.  (Zambia, Age 19)“The decision came when I started thinking about my future. I thought that the pregnancy will disturb me…A girl needs to be educated so if I would have kept the pregnancy it means I would have had to drop out of school……. after finishing school, I would start a good job….” (Malawi, Age 19)Constrained resources“I want to go back to school and continue my studies. I do not want to take care of a child who has no father. No one is around to support me in childcare, so that I work and get money to run my life. …. My mother is sick she can't help me with childcare…I do not want to give birth. ” (Ethiopia, age 18)“I cried because if I had money, I would have given birth. I wasn’t happy since I got pregnant. I thought of raising the child, but I couldn’t afford. ”  (Ethiopia, age 18)Protecting the family name from shame and stigma“All my siblings and relatives are educated, one works… one is a journalist… the other is doing school… so I was embarrassed that all my relatives are educated, and I will be the only one with a baby.. .”(Malawi, age 15)“Firstly, if my parents heard about it, they would be disappointed. No one knew about my pregnancy other than us but if my parents heard about it they would be irritated even they would not want to meet me. Because of this, I did not tell anyone, and I decided to terminate the pregnancy by myself.” (Ethiopia, Age 17)Too young for motherhood9“He [partner] is still with me, but he doesn’t want the baby because he thinks that we are such young people to have a baby and we just have to change our selves by working hard then the baby will come after that.” (Ethiopia age 18)“The women started saying that I should go to my boyfriend’s home, but my father refused. My father said that I am still young, I can’t get married and that my boyfriend is still young too.” (Malawi age 16)Masculine providers and conjugalised fatherhood10“We used to love each other. But he has a child from his ex-girlfriend. And the child lives with his mother. So, because of that, he doesn't have a plan to marry and live with me. When I told him about the pregnancy, he didn't want it. He told me to remove it saying he couldn't afford to raise a second child.” (Ethiopia age 19)“He [doctor] then asked me where my man was and I told him my man was refusing and acting funny like he is doubting, he was scared of the parents, and you know it is not ok to raise a child without a father.” (Zambia age 19)“My friends might talk about my pregnancy. They might say she got pregnant without getting married. Such kind of thing is very bad when it is heard in our village. In our culture, it is not allowed for a girl to get pregnant before getting married. Her father or a brother could kill her if she got pregnant before marriage…...It is dangerous in our area to get pregnant before marriage. They send you away from home. They chase you to live on the roadside…. I cannot keep the pregnancy, that is why I terminated (Ethiopia, Age 18). Violence and coercion“Even, my parents asked me to give birth rather than terminating the pregnancy, but I did not agree with them because I did not know the man who raped me, so I did not want to give birth.” (Ethiopia, Age 18).“I went there [partner’s house] but he was mistreating me. He liked to beat me and do other bad things. So, I was tired and did not want the marriage anymore, then we separated…..My parents had chased me from home. My father beat me…. Yes. They beat me to the extent that my, my hands were swollen, my legs were swollen and up to now I still feel the pain….” (Malawi, Age 17).Our analytic journey: Applying a supportability framework…Anticipation of the circumstances surrounding how pregnancy  conception would mean that they would not be supported by their family or the broader community+Stigma and shame of pregnancies and protecting one’s family important+the calculus of available resources played a significant part in their abortion+adolescents active participants in getting an abortion+gendered dimensions - males as boyfriends, deniers of fatherhood and sexual partners, sexual abusers, and employers and as fathers threatening violence  Why a supportability framework?• illuminates how abortion decision-making for adolescents happens across different contexts• allows a move away from individual cognitions in understanding abortion decision-making by foregrounding the social and structural dynamics than makes pregnancies unsupportable and unsupported• the framework has allowed us to show the intersection of individual factors (cognitions, emotions, behavior), micro-level factors (partners, family, healthcare providers and macro-level factors (policy, cultural patterns)• efforts to liberalize abortion laws alone will not be enough without paying attention to the subtle, contemporary, and often taken-for-granted ways in which gender assumptions and power dynamics are discursively taken up.Thank youBroader project• https://abortioninafrica.wordpress.com/• Chiweshe, M. T., Fetters, T., & Coast, E. (2021). Whose bodies are they? Conceptualising reproductive violence against adolescents in Ethiopia, Malawi and Zambia. Agenda, 35(3), 12-23.• Kangaude, G., E. Coast & T. Fetters (2020) “Adolescent sexual and reproductive health and universal health coverage: a comparative policy and legal analysis of Ethiopia, Malawi and Zambia”. Sexual and Reproductive Health Matters. 28(2)• Strong, J., Coast, E., Fetters, T., Chiweshe, M., Getachew, A., Griffin, R., & Tembo, L. (2023). “I was waiting for my period”: understanding pregnancy recognition among adolescents seeking abortions in Ethiopia, Malawi, and Zambia. Contraception, 110006.• Animations + comics based on our research: https://positivenegatives.org/story/safer-abortion/

Adolescent abortion decision-making in Ethiopia, Malawi, and Zambia: a supportability framework

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Adolescent abortion decision-making in Ethiopia, Malawi, and Zambia: a supportability framework

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