Timing, quality of care, & agency: women’s abortion trajectories & outcomes

Nandagiri, Rishita ORCID: 0000-0003-4424-769X (2018) Timing, quality of care, & agency: women’s abortion trajectories & outcomes. In: International Union for the Scientific Study of Population Seminar on Incidence and Safety of Abortion: New Evidence and Improvements in Measurements, 2018-12-03 - 2018-12-05, Watamu, Kenya, KEN.

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Abstract

This paper reflects on current understandings and classifications of abortion safety and suggests expanding existing approaches by linking it to women’s needs, their contexts of abortion-seeking and treatment, and their experiences of navigating care.   Definitions of abortion safety have shifted from a binary understanding to a continuum traversing the spectrum of risk (Ganatra et al., 2014). The spectrum accounts for (i) the conditions in which an abortion is obtained, and (ii) the outcome of the procedure, offering potential for safety classifications (Sedgh et al., 2016). Medical abortion and recommendations to expand some abortion services to trained, non-specialist health workers have also shifted conceptualisations of abortion safety (Kapp et al., 2018).   Abortion legality has a large impact on the accessibility and safety of abortion, but liberal abortion laws alone do not ensure access to abortion services. India, for instance, passed the Medical Termination of Pregnancy Act (MTP) in 1971, enabling women to seek abortion under a range of conditions. Yet, of the 15.6 million abortions that occurred in 2015, 73% (11.5 million) were medical abortions conducted outside health facilities, and 5% (0.8 million) were conducted outside health facilities using other, probably unsafe, methods (Singh et al., 2018).   Understanding women’s abortion care-seeking trajectories- the reasons, the number of attempts, the methods used or resorted to, and the providers or practitioners consulted- is underpinned by gendered economic, cultural, political, and social factors. This paper draws on existing conceptual work around women’s reasons for abortion-seeking (Bankole et al., 1998), women’s abortion care-seeking pathways (Banerjee et al., 2012; Banerjee and Andersen, 2012) and women’s abortion-related care-seeking trajectories and decision-making (Coast et al., 2018). Investigating women’s trajectories to care and the interactions between and amongst the domains highlights the different risk profiles and determinants that affect women’s abortions and its safety. It also centres women’s experiences, negotiations, and understandings of abortion-related care, allowing for an exploration of what, for them, constitutes safety in abortion access, care, and outcomes. This can potentially expand conceptualisations of abortion safety beyond clinical and biomedical outcomes to account for the broader conditions that women experience and negotiate in seeking safe(r) abortion care.   Using in-depth, semi-structured interviews (n=31) conducted in two rural districts in Karnataka, India in 2017, I investigate women’s trajectories to care, management of abortion, abortion outcomes, and experience of morbidities. Data collected on abortion-related morbidities were not verified against clinical classifications but relied on women’s descriptions of adverse impacts on their daily lives. I map these experiences onto Sedgh et al.’s (2016) suggested abortion safety classifications. I focus on three themes relating to notions of safety that shape women’s care trajectories: delays in abortion access, quality of care, and abortion management. Data are presented as anonymised case studies and illustrative quotes.   Respondents experienced delays in accessing abortion, managing issues and attempting to circumvent barriers at the individual and interpersonal levels, as well as in their interactions with the health system. This was especially evident for women who obtained an abortion through the formal health systems, as they were managing both the interpersonal and the larger health system contexts. Women who self-managed their abortion negotiated their interpersonal relationships and individual contexts but were able to circumvent the health system, allowing them to access an abortion with fewer barriers; allowing them greater control over their privacy and secrecy.   Quality of abortion care has been highlighted as an important aspect of care-seeking that has important implications for abortion outcomes, but agreement on understanding of quality of care or indicators for its assessment have been difficult to establish (Dennis et al., 2017). Respondents in this sample valued their privacy and confidentiality, going to great lengths to ensure this in their interactions with the health system. Their fears shaped their trajectories, and their overall abortion experiences. The quality of care they received may impact whether they seek care for complications from abortion or not.   Women’s management of abortion involves considering a number of factors including access, secrecy, trust, “honour”, and their own autonomies. Thus, women’s notions of what constitutes “safety” in abortion can be markedly different to current understandings of abortion safety. Self-managed abortions, in particular, saw the least amount of disruption to women’s lives, generally did not involve travel or excess cost, and allowed them to set the conditions under which their abortion occurred.   Trajectories to care centre women’s experiences, underscoring that their ideas of and priorities for what constitutes safety affects their care-seeking in way that differ from current understandings. In order to truly capture the range of issues affecting abortion safety and where an abortion lies on a gradient of safety, women’s experiences must be centred. This may mean considering three key domains influencing women’s access to care, the type(s) of procedure(s) they opt for, and the eventual outcomes: (i) delays (or timeliness), (ii) quality of care, and (iii)abortion management. Centring women’s experiences and needs raises questions around who is considered a provider, what constitutes ‘trained’ and what the ‘minimum standards’ are for an environment; disrupting how we currently understand un/safe abortion.

Item Type:	Conference or Workshop Item (Other)
Official URL:	https://iussp.org/en/iussp-seminar-incidence-and-s...
Additional Information:	© 2018 The Author
Divisions:	Social Policy
Subjects:	H Social Sciences > HQ The family. Marriage. Woman R Medicine > RG Gynecology and obstetrics
Date Deposited:	18 Dec 2018 14:26
Last Modified:	13 Sep 2024 14:16
URI:	http://eprints.lse.ac.uk/id/eprint/91318

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