IntroductionInduced abortion estimates are critical for reproductive health programming. In countries like Ghana where abortion is somewhat legally restricted and highly stigmatised, official records are incomplete and different approaches are needed to measure abortion incidence. We conducted a study in Ghana to test five methodologies for estimating incidence: direct reporting, the list experiment, the confidante method, the Abortion Incidence Complications Method (AICM) and a modified AICM.MethodsThe direct reporting, list experiment and confidante method were implemented through a nationally representative community-based survey (CBS) of 4722 women. The AICM used data from a nationally representative health facilities survey (HFS) and a knowledgeable informant survey. The modified AICM combined CBS and HFS data. For each approach, we calculated abortion incidence nationally and for Ghana’s three ecological zones and conducted checks to determine the most internally valid approaches.ResultsNational incidence estimates ranged from 27 per 1000 (AICM) to 61 (confidante method). The Northern zone displayed lower rates than the other two zones for all approaches. Validity and reliability checks found that the list experiment was invalid. The approaches that stood up to the internal validity checks and were most reliable were the direct reporting, confidante method and modified AICM. These approaches provide lower and upper bound estimates for the abortion rate, and the mean of the estimates from the three approaches yields a final abortion rate of 44 per 1000 and an unintended pregnancy rate of 103 per 1000.ConclusionsComparing five approaches to estimating abortion enabled cross-validation of findings and highlighted strengths, pitfalls and requirements of each approach that can inform abortion estimation in other settings.

Indirect estimation techniques are important tools for measuring sensitive and stigmatized behaviors. This includes third-party reporting methods, which have become increasingly common in the field of abortion measurement, where direct survey approaches notoriously lead to underreporting. This paper provides the first in-depth assessment of one of the most widely used of these techniques in the field of abortion measurement: the confidante method. We outline six key assumptions behind the confidante method and describe how violations of these assumptions can bias resulting estimates. Using data from modules added to the performance monitoring for action surveys in Uganda and Ethiopia in , we compute one-year abortion incidence estimates using the confidante method. We also perform a validation check, using the method to estimate intrauterine device /implant use. Our results revealed implementation problems in both settings. Several of the method's foundational assumptions were violated, and efforts to adjust for these violations either failed or only partially addressed the resulting bias. Our validation check also failed, resulting in a gross overestimate of intrauterine device/implant use. These results have implications more broadly for the potential biases that can be introduced in using third-party reporting of close ties to measure other sensitive or stigmatized behaviors.

Objective: To understand the barriers and facilitators of hormonal contraceptive use among Ghanaian women, in order to help improve contraceptive counseling and reduce the high rates of unintended pregnancy. Study design: We conducted a nationally representative community-based survey of 4143 women aged 15-49 in 2018, and used descriptive statistics and logistic regression to examine correlates of current hormonal method use, preferred method attributes and their association with method choice, and the role of side effects in hormonal method discontinuation. Results: Hormonal method use (vs. contraceptive non-use) was associated with younger age, higher parity and education, but not with union status, wealth or residence. Preferences for key method attributes were associated with choosing particular methods. Most valued attributes were effectiveness at preventing pregnancy, and low risks of harming health and future fertility. These last 2 concerns are echoed in the second most common reason for discontinuation (health concerns). While menstrual changes were a common concern, leading some respondents to discontinue hormonal contraceptives, many were willing to endure these effects. In contrast, having experienced long-term health issues as a perceived result of hormonal method use more than halved the odds of current use. Contraceptive counseling on menstrual changes, other side effects, and impacts on future fertility had not been universally provided. Conclusions: Ghanaian women value hormonal methods for their effectiveness against pregnancy. However, concerns about side effects (particularly bleeding changes), future fertility impairment, and longterm health issues led some women to discontinue hormonal methods. Counseling on these issues was reportedly inadequate. Implications: Identifying barriers to, and facilitators of, hormonal contraceptive use, as well as method attributes important to Ghanaian women, can help to better tailor contraceptive counseling to individual needs, in order to ensure that all women can access the method that suits them best, and decide whether and how to manage side effects, switch methods or discontinue.

Perceived infertility is an understudied phenomenon in low‐ and middle‐income countries, where biomedical infertility can have severe consequences, particularly for women. We conducted a nationally representative survey of Ghanaian women, estimated the prevalence of and reasons for perceived infertility, and assessed factors associated with higher levels of perceived infertility using a partial proportional odds model. Among 4,070 women, 13 percent believed they were “very likely” to have difficulty getting pregnant when they wanted to, 21 percent believed this was “somewhat likely,” and 66 percent believed this was “not at all likely.” Reasons for perceived infertility varied by whether the respondent was currently seeking pregnancy. In multivariable analysis, several factors were associated with higher levels of perceived infertility, while unexpectedly, women who reported ever using contraception were less likely to report perceived infertility. Acknowledging the need to address infertility globally and understanding the role of perceived infertility are important components in supporting people's ability to decide whether and when to have children.

Background As a result of the June 2022 decision of the United States (US) Supreme Court, as many as 24 states have, or are expected to, ban or severely restrict abortion. We provide baseline information about abortion patients living in different state environments prior to this decision. Methods We obtained surveys from 6674 women, transgender men, and other pregnancy capable individuals accessing abortion care at 56 facilities across the US between June 2021 and July 2022. The final analytic sample uses information from 5930 abortion patients to compare the demographic and situational profiles of those living in the 24 states likely to ban abortion (restricted) to those living in states where it is likely to remain legal (protected). Results Compared to respondents who lived in protected states, abortion patients in restricted states were more likely to be Black (39% vs. 30%) or white (35% vs. 28%) and less likely to be Latinx (18% vs. 32%). Respondents in restricted states were more likely to be paying out‐of‐pocket for care (87% vs. 42%), be relying on financial assistance (22% vs. 11%), and indicate that it was difficult to pay for the abortion (54% vs. 28%). Twelve percent of respondents who lived in a restricted state crossed state lines for care and the majority (59%) was going to another restricted state. Discussion Prior to June 2022, abortion patients in restricted states encountered more situational and financial barriers compared to those in protected states. These barriers have undoubtedly been exacerbated by abortion bans.