How, when and where? A systematic review on abortion decision making in legally restricted settings in sub-Saharan Africa, Latin America, and the Caribbean

Abstract

Background With increasing global availability of medication abortion drugs, a safer option exists for many women to terminate a pregnancy even in legally restrictive settings. However, more than 22,000 women die each year from unsafe abortion, most often in developing countries where abortion is highly legally restricted. We conducted a systematic review to compile existing evidence regarding factors that influence women’s abortion-related decision making in countries where abortion is highly legally restricted. Methods We searched ten databases in two languages (English and Spanish) for relevant literature published between 2000 and 2019 that address women’s decision-making regarding when, where and how to terminate a pregnancy in sub-Saharan African, Latin American and the Caribbean countries where abortion is highly legally restricted. Results We identified 46 articles that met the review’s inclusion criteria. We found four primary factors that influenced women’s abortion-related decision-making processes: (1) the role of knowledge, including of laws, methods and sources; (2) the role of safety, including medical, legal and social safety; (3) the role of social networks and the internet, and; (4) cost affordability and convenience. Conclusions The choices women make after deciding to terminate a pregnancy are shaped by myriad factors, particularly in contexts where abortion is highly legally restricted. Our review catalogued the predominant influences on these decisions of when, where and how to abort. More research is needed to better understand how these factors work in concert to best meet women’s abortion needs to the full limit of the law and within a harm reduction framework for abortions outside of legal indications.

Abortion information-seeking experiences among women who obtained abortions in Kinshasa, DRC: Results from a qualitative study

“…One of the ways women seek information while avoiding public exposure is to involve their partners who do not face the same risk of social shame. As suggested in other studies conducted in legally restricted abortion settings [ 12 , 28 ], we found male partners take on much responsibility in women’s abortion trajectories, often connecting their pregnant partners directly to healthcare providers. However, in doing so, our results indicate some partners infringed on women’s reproductive autonomy, making decisions without sharing information.…”

“…Understanding how women obtain information about where to access abortion in a setting characterized by limited abortion-related knowledge and access to care is essential in reducing morbidity and mortality due to unsafe abortion. Lack of knowledge about abortion methods and sources, which often depends on an individual’s residence, age, and education, presents an initial obstacle to accessing safe abortion care [ 12 ]. This extends to knowledge of medication abortion specifically, which has been found to be higher among younger women [ 13 ].…”

“…Fear of stigmatization may be greater in a highly Catholic country like the DRC given the church’s prominent role in society and its opposition to abortion. Women who decide to engage others in their abortion care trajectories generally rely on few informants from their communities who often provide incomplete information [ 18 ], exposing them to potential negative health consequences [ 12 , 19 , 20 ].…”

The Relationship Between Access to Abortion and Mental Health in Women of Childbearing Age: Analyses of Data From the Global Burden of Disease Studies

“…While these explanations are plausible, it is also significant that after adjusting for confounding factors, this relationship was not significant; instead, the prevalence of depression in women in this age group was associated with lower levels of gender development and higher rates of intimate partner violence. Therefore, the most likely conclusion is that the link between abortion access and depression in older women of childbearing age is indirect, and is more directly related to women’s rights and social status in both the personal and political spheres [ 58 , 59 ]. This is supported by the additional analyses presented in this study, which show that abortion access is strongly and negatively associated with measures of gender inequality and intimate partner violence, and positively associated with a measure of gender development.…”

Mobile Apps for Sexual and Reproductive Health Education: a Systematic Review and Quality Assessment

“…Even though some apps might include abortion as a topic no SRH-app could be identified that focused on abortion care. As an SRH issue with a high mortality, health apps dealing with said topic could be a potential aid when it comes to the decision-making process or to reducing the stigma still attached to abortion [93,94]. Social-structural factors were rarely the primary aim of the apps although they are highly relevant for the way we deal with SRH [20].…”