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Try out PMC Labs and tell us what you think. Learn More. The datasets generated and analysed as part of this study are not publicly available in order to maintain the confidentiality of the respondents. However, all transcripts are available from the corresponding author on reasonable request.

Unwanted pregnancies and unsafe abortions are prevalent in regions where women and adolescent girls have unmet contraceptive needs. Globally, about 25 million unsafe abortions take place every year. In countries with restrictive abortion laws, safe abortion care is not always accessible. In Kenya, the high unwanted pregnancy rate resulting in unsafe abortions is a serious public health issue. Decision-making is a fundamental factor for consideration when planning and implementing contraceptive services. This study explored decision-making processes preceding induced abortion among women with unwanted pregnancy in Kisumu, Kenya.

Individual face-to-face in-depth interviews were conducted with nine women aged 19—32 years old. In total, 15 in-depth interviews using open-ended questions were conducted. All interviews were tape-recorded, transcribed and coded manually using inductive content analysis. Respondents described their own experiences regarding decision-making preceding induced abortion. This study shows that the main reasons for induced abortion were socio-economic stress and a lack of support from the male partner. In addition, deviance from family expectations and gender-based norms highly influenced the decision to have an abortion among the interviewed women.

The principal decision maker was often the male partner who pressed for the termination of the pregnancy indirectly by declining his financial or social responsibilities or directly by demanding termination. Strategic choices regarding whom to confide in were employed as protection against abortion stigma.

This contributed to a culture of silence around abortion and unwanted pregnancy, a factor that made women more vulnerable to complications. Unwanted pregnancies and pregnancy termination are common in countries where women who want to prevent or delay childbearing have limited access to contraceptives. Around 25 million unsafe abortions take place worldwide each year. Recent evidence shows that nearly half a million induced abortions take place in Kenya every year. In this study, we used in-depth interviews to explore the decision-making processes preceding induced abortion among women with unwanted pregnancies in Kisumu, Kenya.

This study shows that the interviewed women decided to terminate their pregnancies for the following reasons: poverty, poor timing of the pregnancy and absence of support from male partners. The main decision maker was usually the male partner who pressed for the termination of the pregnancy indirectly by declining his financial or social responsibilities or directly by forcing his partner to terminate the pregnancy. Participants were affected by social stigma and carefully selected whom to talk to about the abortion.

This strategy was used as protection against humiliation and shame. This contributed to a culture of silence around abortion and unwanted pregnancy, a factor that made women vulnerable to complications. Where women and adolescent girls have unmet contraceptive needs, unwanted pregnancies and unsafe abortions are common.

Despite the availability of safe and effective interventions, unsafe abortions still contribute to maternal morbidity and mortality [ 2 ]. The majority of maternal deaths due to unsafe abortions occur in low-income settings where women experience low social status combined with legal and social restrictions to sexual and reproductive rights [ 3 ]. Women tend to opt for unsafe abortions where safe abortion services are not acceptable, accessible or affordable [ 4 ]. The of unsafe abortions tends to be higher among poor women because women with strong social or economic resources are more likely to access safe abortions, regardless of the legal context [ 5 ].

A recent study showed the disparity in abortion safety between low- and high-resource settings, indicating that in high-resource settings almost all abortions were safe, while only one in four abortions in Africa were safe [ 1 ]. The Agenda for Sustainable Development renewed the commitments by Member States of the United Nations to reduce global maternal mortality through universal access to sexual and reproductive health SRH services, education and information.

Modern contraceptives play an important role in reducing maternal deaths by preventing unwanted pregnancies and prolonging birth intervals [ 9 ]. Individual-level factors include marital status, education level, economic independency and whether the woman was a victim of rape or incest [ 15 ]. Interpersonal factors such as parental and partner support have also been found to influence decision-making [ 15 ], as have societal determinants like religion and social stigma and norms [ 13 ]. Relevant organisational factors include access to sexuality education [ 15 ] and the availability of facilities providing abortion services [ 14 ].

Kenyan women are economically dependent on men, and Kenyan cultures are largely patriarchal [ 17 ]. Marriage occurs comparatively early; among women aged 25—49 the median age at first marriage was A recent national study estimated that about , induced abortions occur in Kenya annually, with a national abortion rate of 48 abortions per women of reproductive age 15—49 years [ 19 ]. This figure is above the rate for all of sub-Saharan Africa SSA , which is 31 abortions per women of reproductive age [ 20 ]. It is estimated that the induced abortion rate in Kenya is highest in the Rift Valley region and the combined Nyanza and Western regions [ 19 ].

Until , abortion was only legally allowed to save the life of a pregnant woman. Thus far, the implementation of the constitution has been slow, and both knowledge and practice may differ throughout the country. The MMR in Kenya has remained almost constant since According to the Kenya Demographic Health Survey, the MMR is maternal deaths per , live births, and unsafe abortion is a major contributor [ 18 ].

Due to restrictive abortion legislation in Kenya [ 21 ], limited access to quality healthcare and stigma, most abortions occur outside authorised health care facilities and are classified as therefore considered unsafe [ 23 ]. Nyanza province, in which Kisumu is the principal city, has one of the highest MMRs in Kenya [ 24 ], and the total fertility rate for this province is 4. The aim of this study was to explore decision-making preceding induced abortion among women with unwanted pregnancies in Kisumu, western Kenya. At the time of the study, the two facilities treated approximately 80 women per month for abortion-related complications.

The authors recognise the ificance of reflexivity and transparency regarding researcher subjectivity in qualitative research. The research team consisted of five female researchers. The third author EF is a professor in Reproductive and Perinatal Health Care with broad experience conducting quantitative and qualitative research in Kenya and other low-income countries.

The final author MKA is a professor with a PhD in International Health who has extensive experience conducting research in low-resource settings using both quantitative and qualitative methods. Conducting and transcribing the interviews was physically and emotionally exhausting. During data collection and interview transcription the researchers ML and URL had daily contact and discussed their personal experiences. The deep emotional experience of conducting these interviews allowed them to empathise with participants and was used during analysis.

In total, 15 individual, in-depth interviews IDIs were conducted with nine women aged 19—32 years old. Follow-up interviews were conducted with six of the women. Purposive sampling was used to select women seeking care for abortion-related complications. Midwives at the two public hospitals in Kisumu identified possible interviewees between 1 January to 31 May by asking PAC-seeking women if they had tried to induce the abortion.

All women who met the inclusion criteria and were asked to participate agreed to be interviewed. Six women were interviewed face-to-face 7—10 days after receiving PAC, two were interviewed at the time of a three-month follow-up and one woman was approached while she was still admitted at the ward. In addition, a repeated interview was offered to all respondents approximately 2—5 weeks after the initial interview.

Five of the respondents were interviewed face-to-face a second time, while one respondent was interviewed over the phone due to distance. Three respondents declined the request for a repeat interview. The reason for conducting follow-up interviews was to further enhance understanding and enrich the material as trust and affinity were built between researcher and informant.

She was trained in qualitative methodologies and at the time of the study was a postgraduate student in Global Health. The fact that the interviewer was not a clinician and a non-Kenyan might have encouraged respondents to speak to her more openly about a sensitive subject.

During one interview the researcher used an interpreter to translate from Lou to English. The translator was an assistant from KMET. During the other interviews, the researcher was the only person in the room with the respondent. The interviews lasted on average 45 min. A semi-structured interview schedule, using open-ended questions and suggestions for probing, was developed by the research team.

The schedule was pilot tested and modified prior to initial data collection. Field notes were written directly after each interview to reflect on initial thoughts and reactions. With the written consent of the respondents, all interviews were tape-recorded and transcribed verbatim, including notations for nonverbal expressions, for analysis by the first and second authors URL and ML on an ongoing basis as data collection progressed. The interview with a translator was also transcribed in English. The research team met regularly to review progress and discuss interview techniques. Data collection continued until data saturation was reached [ 25 ].

Table 1 presents the characteristics of the respondents. The data were analysed by the first and second authors URL and ML using inductive content analysis, including open coding, category development and abstraction [ 25 , 26 ]. Inductive content analysis is a qualitative approach used to unconditionally analysing the data [ 27 ].

While analysis had already begun during interview transcription, open coding was conducted during the first reading of the transcripts. Thereafter, the transcripts were read through several times and coded manually. Meaning units were identified and transferred to Excel for classification into sub, generic and main . The process of analysis is presented in Fig.

Meaning units and were discussed and compared amongst all members of the research team in order to further improve the analysis and to maximise rigour [ 26 ]. Inductive content analysis process [ 27 ]. Inductive content analysis resulted in three main : 1 Reasons for induced abortion , 2 A culture of silence and 3 Choosing abortion despite risks and limited information.

The are presented according to these main together with their generic and citations from the interviews to clarify the findings. The abstraction process is illustrated in Fig. All women described their pregnancies as mistimed, unplanned or unwanted at the time of conception.

A lack of financial stability or support were described by most women as driving factors for the decision to terminate the pregnancy. In some cases, the woman was the main provider of the household, and the pregnancy jeopardised the stability of her income. The pregnancy might diminish her employment opportunities, as an employer could decide to let a woman go once it was evident she was pregnant. Therefore, pregnancy termination provided the respondents with the potential for continued employment and secured economic independence. And when you are [alone] at home, who will support you?

I have to work. Women who were still students and living with their parents indicated that their parents would not financially support their costs of living and studies as well as the costs of raising an additional child. The married respondents stressed that they had to prioritise resources and take care of the children they already had.

All women with children mentioned the importance of providing an education for them. High school fees were frequently cited. The respondents stated they could not afford to educate an additional child. Furthermore, financial constraints were perceived as a barrier to safe abortion. Women frequently cited not being able to afford to pay a professional to perform the abortion.

The unmarried respondents were concerned about the risk of negative views from family and community members if they continued the pregnancy at that particular time. Where you are staying, there are some people, those people like to gossip, people will definitely talk. Others explained that having would end a harmonious relationship with their parents. The need for a supportive social network, including a stable partnership, emerged as fundamental to avoid severe conflicts in the decision-making process.

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Decision-making preceding induced abortion: a qualitative study of women’s experiences in Kisumu, Kenya