Pregnancy termination trajectories in Zambia: the socio-economic costs

Lead Research Organisation: London School of Economics & Pol Sci
Department Name: LSE Health and Social Care

Abstract

Abstracts are not currently available in GtR for all funded research. This is normally because the abstract was not required at the time of proposal submission, but may be because it included sensitive information such as personal details.
 
Description The mixed methods (quantitative and qualitative) research has produced:
- The first national estimates of the health system costs of abortion in Zambia, showing that unsafe abortion costs the Zambian health system up to $2.4 million more than if the pregnancies has been terminated safely and legally.
- Detailed description of the influences and pathways to seeking an abortion, highlighting: the roles played by men; the importance of knowing someone who works for the health sector; low levels of knowledge about the legality of abortion in Zambia; and, the risks that women will take in order to terminate an unsustainable pregnancy.
- Analyses of the determinants and economic consequences of abortion care-seeking reveal: Younger women are more likely to seek an unsafe abortion than older women; poorer women are more likely to seek an unsafe abortion, even though the costs of unsafe abortion for individual women are 27% higher than the costs associated with a safe abortion; the low levels of effective contraceptive access and use, particularly for adolescents and postpartum women.
In sum, the research shows that Zambia is not yet realising the substantial investment (legal and health services) it has made in safe abortion.

To date, 1 article is under review (Global Public Health), 2 are fully drafted (for Social Science & Medicine and Health, Policy & Planning) and a further 7 are in preparation. Research has been presented at a range of events with diverse audiences, including by invitation (Oxford University, IPPF), at international conferences and workshops (IUSSP, PAA), and in Zambia to policymakers, practitioners and journalists. Participation in international fora have led to a new research collaboration with American academics to develop a conceptual framework for the study of trajectories to abortion (in preparation).

Methodological innovation
The study used an innovative mixed methods interview which combined quantitative and qualitative techniques in one interview. This technique allowed us to capture both the individual fine-grained narratives, which are not easily captured in a questionnaire-type survey, especially on such a sensitive area, as well as survey data. Rather than conducting an in-depth qualitative interview and a survey, our method reduced the burden on the respondent, avoiding repetition of questions and reducing the time taken.

Considerable efforts were made to conduct qualitative longitudinal interviews, a novel technique in the study of abortion in low income countries. Despite multiple attempts to re-interview women (all of whom had given permission to be re-contacted), just three (out of a possible 104) re-interviews were achieved. These three interviews yielded high quality and additional information, and added additional insight to understanding women's abortion trajectories.

Additional funding
A linked Impact Maximisation Grant (on-going) was awarded by ESRC.
Exploitation Route See connected Maximising Research Impact Grant (on-going) [ES/L007827/1]
Sectors Healthcare,Government, Democracy and Justice

URL http://zambiatop.wordpress.com/
 
Description Findings are being written for publication in peer-reviewed journal articles. Findings have been presented at a range of international conferences and invited presentations with academic, policy and professional audiences. Impact of findings now being further developed in linked Impact Maximisation Grant [ES/L007827/1]
First Year Of Impact 2014
Sector Education,Healthcare
Impact Types Societal,Economic,Policy & public services

 
Description Contribution towards and acknowledgement of Co-I (Leone) in Countdown 2015 report
Geographic Reach Multiple continents/international 
Policy Influence Type Citation in other policy documents
URL http://www.countdown2015mnch.org/reports-and-articles/2014-report
 
Description ESRC DFID Impact Maximisation Grant
Amount £120,000 (GBP)
Funding ID ES/L007827/1 
Organisation Economic and Social Research Council 
Department ESRC-DFID Joint Fund
Sector Public
Country United Kingdom
Start 06/2014 
End 05/2015
 
Description LSE Research Investment Fund & LSE Research Committee Seed Fund (RIIF Seed Fund)
Amount £29,051 (GBP)
Funding ID RIIF-SF-2015-02 "Termination of pregnancy in rural Zambia" 
Organisation London School of Economics and Political Science (University of London) 
Sector Academic/University
Country United Kingdom
Start 06/2015 
End 02/2016
 
Description MRC/DFID Implementation research for adolescent health
Amount £513,000 (GBP)
Funding ID MR/P011454/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 01/2017 
End 12/2020
 
Title Feedback on research tools used by EVA-PMDUP 
Description Based on our experiences of generating data for the project, we provided detailed feedback on research tools (process of recruiting research assistants and potential candidates and guides for in-depth interviews with women) for an evaluation of the DFID funded Prevention of Maternal Deaths and Unwanted Pregnancies (PMDUP) Programme (EVA-PMDUP) being carried out by colleagues at the London School of Hygiene and Tropical Medicine, the Guttmacher Institute, and the Population Council. 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2014 
Provided To Others? Yes  
Impact Research assistants we suggested were eventually employed by the EVA-PMDUP team and our suggestions were incorporated into the data collection tool they used. 
 
Title Novel 2 interviewer method for simultaneous quantitative and qualitative data collection 
Description Novel 2 interviewer method for simultaneous quantitative and qualitative data collection from women who have had an abortion 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2016 
Provided To Others? Yes  
Impact Invitation (accepted) to work with a Mexican INGO to develop these approaches and tools for new (funded) research in Mexico City. Dr Coast will travel to Mexico in October 2016 to share and develop these approaches. 
 
Title Pregnancy termination trajectories in Zambia: research instruments 
Description In-depth interview guides, research data sheets, informed consent 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2013 
Provided To Others? Yes  
Impact Tools requested for inclusion in the international Abortion Research Consortium 
URL http://www.abortionresearchconsortium.org/
 
Title Qualitative dataset 
Description We generated qualitative data about women's trajectories to safe and unsafe abortion and the economic costs and consequences of this using in-depth interviews. Full translated transcripts of these interviews along with vignettes about each participant written by the Zambian research assistants who interviewed them have been anonymised and uploaded to the UK Data Service. 
Type Of Material Database/Collection of data 
Year Produced 2015 
Provided To Others? Yes  
Impact Not aware of any. TBC. 
 
Title Quantitative dataset 
Description We generated quantitative data about the costs of safe and unsafe abortion to women, their households and networks and to the Zambia healthcare system using closed-question interviews with women attending hospital for safe abortion or post-abortion care, interviews with key informants from the healthcare system and hospital records. The quantitative data from interviews with women have been anonymised and uploaded to the UK Data Service. 
Type Of Material Database/Collection of data 
Year Produced 2015 
Provided To Others? Yes  
Impact Not aware of any impacts yet. TBC. 
 
Description Conceptual framework for understanding trajectories to safe or unsafe abortion 
Organisation Guttmacher Institute
Country United States 
Sector Charity/Non Profit 
PI Contribution Developing a conceptual framework for the study of induced abortion
Collaborator Contribution Developing and writing of plenary presentation at IUSSP workshop, IUSSP working paper, and currently, a full paper for submission to peer-previewed journal.
Impact http://eprints.lse.ac.uk/58107/
Start Year 2014
 
Description Conceptual framework for understanding trajectories to safe or unsafe abortion 
Organisation Ohio State University
Country United States 
Sector Academic/University 
PI Contribution Developing a conceptual framework for the study of induced abortion
Collaborator Contribution Developing and writing of plenary presentation at IUSSP workshop, IUSSP working paper, and currently, a full paper for submission to peer-previewed journal.
Impact http://eprints.lse.ac.uk/58107/
Start Year 2014
 
Description Research approaches and methodologies for studying PAC 
Organisation Population Council
Country United States 
Sector Charity/Non Profit 
PI Contribution Sharing of research methods and approaches for the study of post-abortion care
Collaborator Contribution Convening and running a 3 day workshop in Mexico City
Impact Translation of research approaches to Spanish. Training.
Start Year 2016
 
Description 2013.03.07_Oxford Institute of Ageing Fertility Change Workshop: 'Unwanted' fertility and induced abortion' 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Presented paper along with colleague Dr Eleanor Hukin at the Oxford Institute of Population Ageing Workshop 'Fertility: Demographic Change in the South', 7 March 2013. The audience included leading demographers. The presentation sparked questions.

N/A
Year(s) Of Engagement Activity 2013
URL http://www.ageing.ox.ac.uk/news/2013/workshop-'fertility-demographic-change-south'
 
Description 2014.06.03_IUSSP presentation on pregnancy termination trajectories in Zambia 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Paper on findings from the 'Pregnancy Termination Trajectories' project presented at the International Union Scientific Study of population (IUSSP) Workshop on Decision-making Regarding Abortion, Nanyuki, Kenya, 3rd-5th June, 2014. The paper sparked questions and discussion afterwards and has since been published as an IUSSP working paper (available online to IUSSP members and to everyone via the LSE institutional repository). Presenting the paper led to being invited to develop a plenary presentation, subsequently developed into an IUSSP working paper, now under revisions for submission to peer-reviewed journal.

Invitation to develop a plenary presentation, subsequently developed into an IUSSP working paper, now under revisions for submission to peer-reviewed journal
Year(s) Of Engagement Activity 2014
URL http://iussp.org/en/international-seminar-decision-making-regarding-abortion%e2%80%94determinants-an...
 
Description 2014.09.24_Population@LSE Research Showcase 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Co-organised and participated in a reception showcasing the research carried out by Population Researchers at the LSE. It was attended by internal and external academics and those working outside of academia - including alumni. Dr Ernestina Coast (PI) presented work on the role of induced abortion in fertility transitions and the team presented a poster detailing both the research study and impact maximisation elements of this work on unsafe abortion in Zambia. Both sparked discussion of the work.

TBC
Year(s) Of Engagement Activity 2014
URL http://www.eventbrite.co.uk/e/population-research-lse-tickets-11871248223
 
Description 2014.10.29_Proposed session on abortion for the IUSSP 2017 Population Conference 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact We have proposed a session on abortion ("Induced abortion: trajectories and impacts") for the IUSSP 2017 International Population Conference. We expect to hear whether our submission was successful soon.

To be confirmed. If our submission is successful, the special session will take place in Cape Town, South Africa the week of 29 October 2017.
Year(s) Of Engagement Activity 2014
 
Description 2015.03.31_Presentation to Adolescent Health Technical Working Group with UNICEF_'Unsafe abortion in Zambia' 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact As part of our dissemination activities, in February 2015 the research team (Coast and Freeman) met with UNICEF's Adolescent Health Liaison Officer in his offices to discuss the research findings, how they could support work in this area and how they could be packaged and delivered in a way that would be most useful for policymakers. During the meeting, the current activities and debates of the national Technical Working Group (TWG) of Adolescent Health, of which the Adolescent Health Liaison Officer is a member, was discussed. This TWG, comprised of government (e.g. Ministries of Health and Community Development and Mother and Child Health) and non-government (e.g. UNICEF) stakeholders has a very strong influence in setting the sexual and reproductive health agenda for young people in Zambia and is currently revising the national 20114-2015 Adolescent Health Strategic Plan. Having our research presented at the TWG monthly meeting would allow participants in that meeting to use it to shape the agenda and inform their decision making. Subsequently, following the UNICEF Officer's request, the research team produced a PowerPoint presentation of the research findings, situated within targeted analyses of the publically-available Zambian Demographic and Health Survey data for delivery at the next national TWG meeting. These were presented at the meeting by the UNICEF Officer.

TBC
Year(s) Of Engagement Activity 2015
 
Description 2015.04.30_PAA Special Session on Abortion successfully proposed 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Along with Dr Ann Moore (Guttmacher Institute) we proposed a special session on abortion ("Induced abortion: determinants and consequences") at the Population Association of America Annual Conference, San Diego, CA 30 April- 2 May 2015. The proposal was successful and 3 special sessions on abortion have been timetabled ('Abortion', 'The Persistence of Unsafe Abortion', and 'Abortion in Transition'). Our colleague Dr Moore, being based in the USA, will lead organisation and attend the sessions.

Discussion of unsafe abortion is now on the programme at this large and very well-attended conference, widely regarded at the key place for knowledge transfer and ideational exchange for population research.
Year(s) Of Engagement Activity 2015
URL http://paa2015.princeton.edu/topics#1
 
Description 2015.06.24_Presentation to Ipas (NC, USA)_Conceptual framework 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact After presenting our research work at the Population Association of America (PAA) Annual Conference 2015, we were invited by Ipas to present it to their research and evaluation team at their headquarters in NC, USA in a dedicated meeting. Ipas is a global nongovernmental organisation dedicated to ending preventable deaths and disabilities from unsafe abortion. They fund Government provision of safe abortion services in Zambia and are a key stakeholder for our research.

Ipas delegates requested the paper in advance and came prepared to the talk to discuss it. The afternoon was spent discussing the research and how it could be used by Ipas.

TBC
Year(s) Of Engagement Activity 2015
 
Description 2016.03.17_Lessons from a Decade's Research on Poverty: Innovation, Engagement, and Impact Event 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Member of an expert panel on research uptake and impact at the ESRC-DFID Joint Fund for Poverty Alleviation Research 10 Year Lessons Learnt conference in Pretoria. The discussion and debate was lively, engaging the audience of DFID and ESRC representatives and other academics. A key area of discussion was who should set the research agenda and how that relates to impact.
Year(s) Of Engagement Activity 2016
 
Description Blog post: LSE Africa blog_ When legalising abortion isn't enough 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Blog post about the project hosted by Africa@LSE.

As of 02/02/2015, the blog has been Tweeted 16 times, shared by 22 Facebook users and elicited contact from two Zambia-focused academics we were not aware of. The blog as reposted on the Demographic blog 'Demotrends' where it attracted further readers (http://demotrends.wordpress.com/2013/05/15/research-spotlight-when-legalising-abortion-isnt-enough/).
Year(s) Of Engagement Activity 2013
URL http://blogs.lse.ac.uk/africaatlse/2013/05/13/when-legalising-abortion-isnt-enough/
 
Description Critical conjunctions: Abortion laws and policies in Malawi and Zambia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Coast, E. & E. Freeman (2016) "Critical conjunctions: Abortion laws and policies in Malawi and Zambia" Presented at Abortion research to policy conference, Addis Ababa, Ethiopia, 29th November - 2nd December 2016
Year(s) Of Engagement Activity 2016
URL http://eprints.lse.ac.uk/68554/
 
Description ESRC-DFID Impact Initiative: Research brief 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact A 2 page research brief developed in collaboration with the ESRC/DFID Impact Initiative and hosted on their website
Year(s) Of Engagement Activity 2018
URL https://opendocs.ids.ac.uk/opendocs/bitstream/handle/123456789/13868/ResearchImpact_Zambia_1.1_Onlin...
 
Description Interview with Children's Investment Fund - to inform their research agenda and strategy 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Conference call with Children's Investment Fund Foundation (CIFF) - arising out of work presented at ICFP in Kigali in 2018. Erin McCarthy followed up about the presentation and also about the project website. A conversation in order to give expert input to CIFF research agenda on abortion and young people in LMICs.
Year(s) Of Engagement Activity 2018
 
Description Ipas (NC) presentation: Abortion trajectories in Zambia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Third sector organisations
Results and Impact 28 Ipas staffers (global - many attended online) attended a presentation I gave on methodological and substantive insights from Zambia research.
Year(s) Of Engagement Activity 2018
 
Description Medical abortion self-use/management: reflections on words, meanings and evidence. Presentation at ICFP 2018, Kigali 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Invited participation in a panel at ICFP 2018 to global researcher audience. Let to follow ups for information from eg: Packard Foundation in India (and subsequent involvement of LSE student in consulting on Packard India's future research agenda)
Year(s) Of Engagement Activity 2018
URL http://eprints.lse.ac.uk/91482/
 
Description Medication abortion in Zambia: trajectories, costs and healthcare provider perspectives 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Coast, E., E. Freeman & T. Leone (2016) "Medication abortion in Zambia: trajectories, costs and healthcare provider perspectives" Paper presented at the International Seminar on Medication Abortion: Availability and use, and impact on safety and women's health" Dakar, Senegal, 6th-8th July, 2016
Year(s) Of Engagement Activity 2016
URL http://eprints.lse.ac.uk/68000/
 
Description Presentation (IUSSP seminar, Dakar) 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Presentation on medical abortion in Zambia. This led to questions and discussion, and an invitation from Population Council Mexico to work with them using our methodology. Trip to Mexico scheduled October 2016.
Year(s) Of Engagement Activity 2016
 
Description Press release: Lack of information and stigma associated with abortion are the main reasons why most women have unsafe abortion procedures 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Press release published on project website, used as the basis of SRH media and communications training with doctors and journalists and given to individual journalists.

Information contained in the brief, along with interviews given by the PI (Coast) and SRH training for journalists resulted in coverage of the research in Zambia and pan-African media.
Year(s) Of Engagement Activity 2014
URL https://zambiatop.files.wordpress.com/2014/09/trajectories-to-abortion-briefing-notes_website_24-11-...
 
Description Press release: Zambia could save 2.5 million Kwacha every year by providing access to legal safe abortion services - Study reveals 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Media (as a channel to the public)
Results and Impact Press release published on project website, used as the basis of SRH media and communications training with doctors and journalists and given to individual journalists.

Information contained in the brief, along with interviews given by the PI (Coast) and SRH training for journalists resulted in coverage of the research in Zambia and pan-African media.
Year(s) Of Engagement Activity 2014
URL https://zambiatop.files.wordpress.com/2014/09/costs-of-abortion-briefing-notes_website_24-11-2014.pd...
 
Description Project Twitter account and feed 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact We have opened a project Twitter account and now tweet information about our research work and findings, our impact activities and academic impact more broadly and news about reproductive and sexual health. It is primarily intended for other academic researchers and practitioners, as well as journalists, interested members of the public and policy makers.

Our Twitter account now has 85 followers who regularly re-tweet our tweets, spreading information about our project beyond our followers.
in addition, we have increased our own knowledge of research, events and ideas relevant to our research from following other Twitter users.
Year(s) Of Engagement Activity 2014,2015
URL https://twitter.com/zambiatop
 
Description Project website 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact We have produced a dedicated project website to share our research work and findings. It is primarily intended for journalists, interested members of the public, practitioners, policy makers, and other academic researchers. We have posted all our press releases, policy briefings and academic presentations on the site (and linked SlideShare.net account http://www.slideshare.net/ZambiaTOP/presentations), along with descriptions of the purpose of our research and resources that may be helpful for other researchers. We are continually updating the website with new content.


Our analytics show that our research outputs are being accessed. For example, our presentation slides have been downloaded 109 times as of February 2015.
Year(s) Of Engagement Activity 2014,2015
URL https://zambiatop.wordpress.com/
 
Description Saatchi Worldservice: Presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Industry/Business
Results and Impact Presentation to staff at Saatchi Worldservice HQ in London; audience composed of Saatchi communications and research experts.
Year(s) Of Engagement Activity 2018
 
Description Spotlight Magazine: Men's involvement in abortion 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Invited magazine article by Dr Emily Freeman
Year(s) Of Engagement Activity 2018
URL http://www.vidc.org/en/spotlight-online-magazine/
 
Description Understanding conscientious objection to abortion in Zambia 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Audience of approx. 50 researchers focused on abortion - which sparked questions and discussion afterwards.
Year(s) Of Engagement Activity 2017
URL http://ipc2017capetown.iussp.org/
 
Description Understanding conscientious objection to abortion in Zambia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Freeman, E., E. Coast & B. Vwalika (2016) "Understanding conscientious objection to abortion in Zambia" Presented at Abortion research to policy conference, Addis Ababa, Ethiopia, 29th November - 2nd December 2016
Year(s) Of Engagement Activity 2016
URL http://eprints.lse.ac.uk/68553/
 
Description Women's experiences of men's roles in their (un)safe abortion trajectories: evidence from urban Zambia 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Other audiences
Results and Impact Questions and discussion from audience
Year(s) Of Engagement Activity 2017
URL http://ipc2017capetown.iussp.org/