Methodologies for Estimating Abortion Incidence and Abortion-Related Morbidity

217 Pages·2010·4.36 MB·English

by  Guttmacher Institute

Methodologies for Estimating
Abortion Incidence and Abortion-Related
Morbidity: A Review
EDITORS
SUSHEELA SINGH
LISA REMEZ
ALYSSA TARTAGLIONE
2010
Guttmacher Institute • International Union for the Scientific Study of Population
Methodologies for Estimating
Abortion Incidence and Abortion-Related
Morbidity: A Review
Editors
SuSheela Singh
liSa Remez
alySSa TaRTaglione
2010 • Guttmacher Institute • International Union for the Scientific Study of Population
Acknowledgments
Methodologies for Estimating Abortion Incidence and The panel was chaired by Susheela Singh and included
Abortion-Related Morbidity: A Review was edited by the following members: Sandra G. Garcia, Hailemichael
Susheela Singh, of the Guttmacher Institute; Lisa Remez, Gebreselassie, Agnes Guillaume, Ali Mohammad Mir and
independent consultant; and Alyssa Tartaglione, of the Friday Okonofua. The seminar was supported by funds
Guttmacher Institute. Kathleen Randall supervised produc- provided by the UNFPA, the IUSSP, the Centre Population
tion and Judith Rothman was responsible for the layout. et Développement (CEPED, France), the Centre de
The publishers of this review gratefully acknowledge Recherche et de Documentation sur l’Amérique Latine
the financial support of the United Nations Population (CREDAL, France) and the Population Council, Mexico.
Fund (UNFPA), the Consortium for Research on Unsafe We are deeply grateful to the panel members for their
Abortion in Africa and the Guttmacher Institute, which contributions to this volume, which included commenting
made production of this volume possible. on the papers presented at the seminar; reviewing sub-
The volume is based on the International Seminar sequent versions of presented papers as well as chapters
on Measurement of Abortion Incidence, Abortion- written especially for this volume; and coordinating rounds
Related Morbidity and Mortality, which took place in of revisions by authors. We also acknowledge the contri-
Paris, France, in November of 2007. The seminar was butions of all seminar participants whose discussions at
convened by the International Union for the Scientific the seminar helped authors improve their papers.
Study of Population (IUSSP) Scientific Panel on Abortion.
ISBN: 978-1-934387-07-8
© Guttmacher Institute, 2010
Suggested citation: Singh S, Remez L and Tartaglione A,
eds., Methodologies for Estimating Abortion Incidence
and Abortion-Related Morbidity: A Review, New York:
Guttmacher Institute; and Paris: International Union for
the Scientific Study of Population, 2010.
To order this report or download an electronic copy, go to
www.guttmacher.org
Table of Contents
List of Contributors...................................................................................................................................................................................................4
IUSSP Scientific Panel on Abortion....................................................................................................................................................................4
Abbreviations............................................................................................................................................................................................................5
INTRODUCTION........................................................................................................................................................................................................7
CHAPTER 1: . Generating National Unsafe Abortion Estimates: Challenges and Choices
. Elisabeth.Ahman.and.Iqbal.H..Shah...........................................................................................................................................................13
CHAPTER 2: . Measuring the Incidence of Abortion in Countries with Liberal Laws
. Gilda.Sedgh.and.Stanley.Henshaw............................................................................................................................................................23
CHAPTER 3: . Three Approaches to Improving the Use of Face-to-Face Interviews to Measure Abortion
. Heidi.Bart.Johnston,.Jeffrey.Edmeades,.Laura.Nyblade,.Erin.Pearson,.Florina.Serbanescu.and.Paul.Stupp.
. (Contributor:.Stephanie.McMurtrie;.Coordinator:.Sandra.G..Garcia)................................................................................................35
CHAPTER 4: . Examples of Model-Based Approaches to Estimating Abortion
. Heidi.Bart.Johnston.and.Charles.Westoff.(Coordinator:.Lisa.Remez).............................................................................................49
CHAPTER 5: . Examples of Methods to Address Underreporting of Induced Abortion:
Preceding Birth Technique and Randomized Response Technique
. Elizabeth.Oliveras.and.Gobopamang.Letamo.(Contributor:.Diana.Lara;.Coordinator:.Agnes.Guillaume).............................63
CHAPTER 6: . The Abortion Incidence Complications Method: A Quantitative Technique
. Susheela.Singh,.Elena.Prada.and.Fatima.Juarez..................................................................................................................................71
CHAPTER 7: . Measuring Abortion with the Anonymous Third Party Reporting Method
. Clementine.Rossier.........................................................................................................................................................................................99
CHAPTER 8: . The Sealed Envelope Method of Estimating Induced Abortion: How Much of an Improvement?
. Fatima.Juarez,.Josefina.Cabigon.and.Susheela.Singh......................................................................................................................107
CHAPTER 9: . Data Triangulation: Using Multiple Methods to Estimate and Validate Abortion
Incidence and Prevalence
. Heidi.Bart.Johnston,.Diana.Lara,.Silvia.Mario.and.Edith.Pantelides.(Coordinators:.Diana.Lara,.Sandra.G..Garcia)............125
CHAPTER 10: . Prospective Approach to Measuring Abortion-Related Morbidity: Individual-Level Data
On Postabortion Patients
. Tamara.Fetters...............................................................................................................................................................................................135
CHAPTER 11: . Use of Health System Data to Study Morbidity Related to Pregnancy Loss
. Raffaela.Schiavon,.Erika.Troncoso.and.Gerardo.Polo........................................................................................................................147
CHAPTER 12: . Quantitative Measures of Self-Reported Data on Abortion Morbidity: A Case Study
In Madhya Pradesh, India
. Laura.Nyblade,.Jeffrey.Edmeades,.Erin.Pearson.and.Janna.McDougall....................................................................................165
CHAPTER 13: . Self-Reported Data on Abortion Morbidity: Using Qualitative Techniques with Community-Based Samples
. Ann.M..Moore.and.Elena.Prada...............................................................................................................................................................175
CHAPTER 14: . Misoprostol Use and Its Impact on Measuring Abortion Incidence and Morbidity
. Katherine.S..Wilson,.Sandra.G..Garcia.and.Diana.Lara.....................................................................................................................191
3
List of Contributors
Name and affiliation at the time of writing
Elisabeth Ahman, World Health Organization, Switzerland
Josefina Cabigon, University of the Philippines, Population Institute, Philippines
Jeffrey Edmeades, International Center for Research on Women, USA
Tamara Fetters, Ipas, USA
Sandra G. Garcia, Population Council, Mexico
Agnes Guillaume, Institut de Recherche pour le Développement, France
Stanley Henshaw, Guttmacher Institute, USA
Fatima Juarez, Guttmacher Institute, USA and El Colegio de México, Mexico
Diana Lara, Ibis Reproductive Health, USA
Gobopamang Letamo, University of Botswana, Botswana
Silvia Mario, Instituto de Investigaciones Gino Germani, Universidad de Buenos Aires, Argentina
Janna McDougall, International Center for Research on Women, USA
Stephanie McMurtrie, Population Council, Mexico, Consultant
Ann M. Moore, Guttmacher Institute, USA
Laura Nyblade, International Center for Research on Women, USA
Elizabeth Oliveras, International Centre for Diarrhoeal Disease Research, Bangladesh
Edith Pantelides, Centro de Estudios de Población, Argentina
Erin Pearson, International Center for Research on Women, USA
Elena Prada, Guttmacher Institute, USA
Gerardo Polo, Ipas, Mexico, Consultant
Heidi Bart Johnston, International Centre for Diarrhoeal Disease Research, Bangladesh
Lisa Remez, Independent Consultant, USA
Clementine Rossier, Institut National d’Études Démographiques, France
Raffaela Schiavon, Ipas, Mexico
Gilda Sedgh, Guttmacher Institute, USA
Florina Serbanescu, Centers for Disease Control and Prevention, USA
Iqbal H. Shah, World Health Organization, Switzerland
Susheela Singh, Guttmacher Institute, USA
Paul Stupp, Centers for Disease Control and Prevention, USA
Alyssa Tartaglione, Guttmacher Institute, USA
Erika Troncoso, Ipas, Mexico
Charles Westoff, Princeton University, USA
Katherine S. Wilson, Population Council, Mexico
IUSSP Scientific Panel on Abortion
Sandra G. Garcia, Population Council, Mexico
Hailemichael Gebreselassie, Ipas Africa Alliance, Kenya
Agnes Guillaume, Institut de Recherche pour le Développement, France
Ali Mohammad Mir, Population Council, Pakistan
Friday Okonofua, Women’s Health and Research Action Centre, Nigeria
Susheela Singh, Guttmacher Institute, USA
4 Guttmacher Institute/IUSSP
Abbreviations
ACASI Audio Computer-Assisted Self-Interview
AFS Abortion Frequency Survey
AICM Abortion Incidence Complications Method
ATPR Anonymous Third Party Reporting
CAMS Community Abortion Morbidity Study
CBS Community-Based Survey of Women
CDC Centers for Disease Control and Prevention, USA
CIHI Canadian Institute for Health Information
CEPED Centre Population et Développement, France
CONAPO Consejo Nacional de Población, Mexico
CREDAL Centre de Recherche et de Documentation sur l’Amérique Latine, France
D&C Dilation and Curettage
DALY Disability Adjusted Life Year
DHS Demographic and Health Survey
DSS Demographic Surveillance System
ENNyS Encuesta Nacional de Nutrición y Salud, Argentina
FGD Focus Group Discussion
FLASOG Federación Latinoamericana de Sociedades de Obstetricia y Ginecología
HFS Health Facilities Survey
HPS Health Professionals Survey
ICDDR,B International Centre for Diarrhoeal Disease Research, Bangladesh
ICD International Classification of Diseases
ICRW International Center for Research on Women, USA
IDI In-depth Interview
IMSS-O Instituto Mexicano del Seguro Social-Oportunidades
IMSS-RO Instituto Mexicano del Seguro Social-Regimen Ordinario
ISSSTE Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico
IUSSP International Union for the Scientific Study of Population
MCH–FP Maternal Child Health–Family Planning
MDHS Matlab DHS, Bangladesh
MoH Ministry of Health
MOLAP Multi-Dimensional Online Analytical Processing
MMR Maternal Mortality Ratio
MR Menstrual Regulation
MTP Medical Termination of Pregnancy
MVA Manual Vacuum Aspiration
NFHS National Family Health Survey, India
NSFG National Survey of Family Growth, USA
PAC Postabortion Care
PBT Preceding Birth Technique
PEMEX Petróleos Mexicanos, Mexico
PMM Prospective Morbidity Methodology
RHS Reproductive Health Survey
RKS Record Keeping System
RRT Randomized Response Technique
SAEH Sistema Automatizado de Egresos Hospitalarios, Mexico
SEDENA Secretaría de la Defensa Nacional, Mexico
SEM Sealed Envelope Method
SEMAR Secretaría de Marina, Mexico
SSa Secretaría de Salud, Mexico
TAR Total Abortion Rate
TF Total Fecundity Rate
TFR Total Fertility Rate
UNDP United Nations Development Programme
UNFPA United Nations Population Fund
WHO World Health Organization
Guttmacher Institute/IUSSP 55
6 Guttmacher Institute/IUSSP
Introduction
Lisa Remez, Susheela Singh and Alyssa Tartaglione
The social and political sensitivity surrounding induced are valuable in documenting the health consequences of
abortion makes it very difficult to conduct high-quality unsafe abortion and the medical care provided, but they
research to measure its incidence. This is particularly true do not represent morbidity from abortion among women
where abortion is illegal, but occurs in countries where who suffer complications but do not obtain treatment at a
abortion is broadly legal as well. These same factors also facility.
constrain research on morbidity resulting from unsafe The objective of the following chapters is to contrib-
abortion. As a result, there are large evidence gaps in the ute to addressing these data-quality issues by improving
documentation of abortion incidence and abortion-related research on the measurement of abortion incidence and
morbidity. One major problem in carrying out research abortion-related morbidity. To do so, they provide over-
on abortion is the generally high level of underreporting. views of existing methods of and approaches to estimat-
For example, with surveys of women, a high proportion ing abortion incidence and morbidity. The volume supplies
of respondents will not report their abortion experience detailed descriptions and examples of key methods. Its
because of the strong stigma against abortion. In addi- goal is to provide a clear understanding of the relative
tion, data on abortion from such surveys are likely to be merits of available study designs to quantify abortion
nonrepresentative of all women, because underreporting incidence and abortion-related morbidity. Information on
typically varies according to women’s characteristics. As methodologies will greatly assist researchers worldwide
a result, measures of abortion incidence, prevalence and in carrying out studies on these topics, particularly in set-
morbidity from face-to-face surveys of women are likely to tings where abortion is legally restricted.
be both underreported and biased. This volume is primarily based on papers presented
Surveys of providers are also problematic for a number at a seminar titled Measurement of Abortion Incidence,
of reasons. Such surveys may not be possible in countries Abortion-Related Morbidity and Mortality, which took
where the procedure is illegal for obvious reasons (fear of place in Paris, France, in November of 2007. The semi-
prosecution), and even if they are conducted, underreport- nar was convened by the International Union for the
ing will likely be high. Where abortion is legal under broad Scientific Study of Population’s (IUSSP) Scientific Panel
indications, the numbers of official abortions may be low on Abortion, in collaboration with the Centre Population
because private-sector providers may not be required to et Développement (CEPED) and the Centre de Recherche
report to government statistical bodies; because public et de Documentation sur l’Amérique Latine (CREDAL).
stigma affects providers’ willingness to openly acknowl- The goal of the meeting was to stimulate and advance
edge that they perform abortions; because providers who research on the measurement of abortion incidence and
do not meet all requirements to do the procedure may its morbidity by bringing together researchers who had
be reluctant to participate in surveys; and because others developed and applied different methodologies and ap-
may not want to have this source of income recognized proaches. Key papers from the seminar were selected to
by authorities. be revised for inclusion in the report. In addition, a few
In summary, the quality of data on abortion incidence chapters were added on notable methods and topics that
or prevalence is problematic both when women and pro- were not covered by the papers presented at the seminar.
viders serve as data sources, regardless of the legal status The following chapters present a comprehensive ap-
of abortion. Thus, data-quality issues persist in countries praisal of the state of abortion estimation methodology
where abortion is legally permitted under broad criteria, as today. Many estimation approaches of both incidence and
well as in countries where it is permitted only under very morbidity have been developed for use in contexts where
restricted circumstances, such as to save the life of the abortion is legally restricted, some are used mainly where
pregnant woman. In the case of morbidity, data collected abortion is legally permitted under broad circumstances,
from facilities that provide postabortion care can be of and some are relevant in both contexts. As such, the vol-
reasonably high completeness and quality. These data ume is relevant for research in a wide range of contexts in
GGuuttttmmaacchheerr IInnssttiittuuttee/IUSSP 77
both developed and developing countries. Wherever pos- methods. The second section (Chapters 10 through 14)
sible, the chapters provide a way to validate the approach covers methodologies for estimating and examining
in question to assess how well it works to accurately morbidity resulting from unsafe abortion, a research area
quantify abortions or their morbidity. that is somewhat less developed. All chapters provide
Methods measuring the incidence of induced abortion detailed descriptions and discussions of how the method-
generally fit into two categories. In the first, direct meth- ologies have been applied and indicate their strengths and
ods, women are directly interviewed about their abortion limitations. We anticipate that this volume will be helpful
experience through surveys that can use community- to researchers and students conducting abortion studies,
based, convenience or random samples. The degree of and to advocates, program managers, service providers
underreporting in a direct survey will vary by country and and others who use the studies’ results for policy change,
is associated with each society’s cultural and religious program development and public health interventions.
framing of abortion. Societies that are tolerant of abortion Below we give a brief summary of the material covered in
will have less underreporting, and the stronger the stigma each chapter.
surrounding abortion, the more likely women will not
report their abortions in a direct, personal interview. CHAPTER 1. Generating National Unsafe Abortion Esti-
Because of the sensitivity of the topic and the tenden- mates: Challenges and Choices highlights the need for
cy for abortion to be heavily underreported, women who more national-level estimates of unsafe abortion in coun-
self-report an abortion tend be a highly selective group, tries that legally restrict the procedure. The authors stress
which automatically introduces bias into the resulting the importance of measuring the magnitude of unsafe
measures of abortion incidence, prevalence or morbid- abortion at the country level to inform national strategies
ity. The volume provides information on approaches to to improve women’s reproductive health. Country-level
remove some of that bias through approaches that shield data on the scope of unsafe abortion are not only essential
women’s identities from interviewers or that use qualita- for local advocacy and intervention but are useful for build-
tive techniques to build rapport to lessen reluctance to ing an accurate knowledge base on which to design and
report an abortion. One of the greatest strengths of direct implement solutions. The chapter describes the method-
methods is that they can obtain information on women’s ology used by the World Health Organization (WHO) to
characteristics (such as demographic, social and economic make regional and global estimates of unsafe abortion and
characteristics) that help to better understand the barri- outlines how country-level assessments of unsafe abor-
ers women face in accessing safe abortion and treatment tion can be developed by drawing on existing data. The
for unsafe abortions. Direct surveys also yield invaluable chapter identifies regions where country-level data are
details about the process of seeking an abortion and most needed, underlines the importance of using existing
whether women were practicing contraception (and, if so, and often untapped data sources, and draws attention to
which method they were using) when they conceived the lesser-known aspects of incidence research.
pregnancy that ended in an abortion.
Approaches in the second major category, indirect CHAPTER 2. Measuring the Incidence of Abortion in
methods, are often most useful when measuring abortion Countries with Liberal Laws reviews and discusses data-
incidence and related morbidity in settings where abortion quality issues affecting a range of sources of data on legal
is highly stigmatized, and thus illegal and unsafe. These abortion. These include central government agencies,
methods rely on retrospective hospital records, prospec- surveys of abortion providers, surveys of women, insur-
tive health facility data, and retrospective surveys of ance reimbursement reports and hospital statistics. The
health professionals and facilities. Other indirect methods chapter describes in detail the data collection systems of
interview third parties about others’ abortions, and several eight countries (Australia, Canada, China, Finland, India,
integrate elements from both direct and indirect approach- the Russian Federation, the United States and Vietnam).
es to assure the most complete—and most accurate— It provides examples of existing data collection efforts for
reporting possible. countries whose abortion laws have been newly liberal-
This volume presents many examples of direct and ized and whose systems are still being put into place, and
indirect methods of estimating abortion. It is divided into where improvements in established data collection pro-
two main sections. The first section (Chapters 1 through cedures are needed. The chapter details the importance
9) covers fundamental methods and approaches to esti- of using population data to convert numbers of abortions
mating abortion incidence, including those that have been into uniform measures of annual rates (per 1,000 women
used for decades as well as new and less well-known of reproductive age) and ratios (per 100 live births) for
8 Guttmacher Institute/IUSSP
cross-country and regional comparisons. It also discusses Part II, A Regression Equation Approach to the
issues that remain to be solved to achieve more complete Estimation of Abortion Rates, is premised on the very
reporting of abortion in settings where the procedure is high correlation between modern contraceptive use and
legal and available. abortion in 44 countries (most of which are developed
countries). From this observation, the author assumes that
CHAPTER 3. Three Approaches to Improving the Use of widely available contraception and fertility information can
Face-to-Face Interviews to Measure Abortion presents serve as input data in a regression equation to predict total
modifications to standard approaches toward interviewing abortion rates (TARs). TARs from a first equation using
women about abortion. Two incorporate a qualitative data both traditional and modern method use are presented for
component. The first, a protocol known as the Abortion 34 countries, and regression-derived TARs for broad inter-
Frequency Survey, was applied and validated in Matlab, national regions are compared with TARs estimated by the
Bangladesh. It used a semistructured questionnaire with WHO and the Guttmacher Institute. Part II also provides
both open- and closed-ended questions to elicit better re- results of a modified regression equation using modern
porting of abortions by taking into account the underlying contraceptive use only to predict abortion.
cultural context of abortion. The second, a two-day, “nar-
rative” survey technique was applied in Madhya Pradesh, CHAPTER 5. Examples of Methods to Address Under-
India. That technique started out with qualitative questions reporting of Induced Abortion: Preceding Birth Technique
to build rapport with women before asking them to report and Randomized Response Technique evaluates two
their abortion experiences as part of the broader story of indirect methods that specifically address underreporting
their lives. The third approach involved the addition of a of abortion in contexts where abortion is illegal or access
special abortion module to standard Reproductive Health is highly restricted. The Preceding Birth Technique (PBT)
Surveys conducted in Eastern Europe. In these former was employed in a study in Ghana and the Randomized
communist countries, stigma against abortion has been Response Technique (RRT) was used in a study in Mexico.
relatively weak and, as a result, women rarely under- Applying the PBT to abortion research involves adapting
report their abortions. Government reporting systems, a method that was used to collect stigma-free informa-
however, have increasingly become more inefficient and tion on previous births to instead collect data on previous
incomplete, so in this environment, direct questioning of abortions. With RRT, women (who can be semi-literate or
women using a specialized module is assumed to produce illiterate) are asked to privately respond yes or no to one
more complete and more reliable measures of abortion of two questions that the interviewer is unaware of, on a
incidence. The authors also point out that while the true form that is separate from other questions. One question
abortion rate is unknown, different survey designs affect has a known probability and the other asks the sensitive
completeness within the same country; as a result, there question about abortion. The prevalence of abortion can
is need for further work to improve measurement of inci- then be calculated from the responses. These two meth-
dence in Eastern Europe. ods collect only data on whether women have ever had an
abortion (prevalence) and, given the data collection design,
CHAPTER 4. Examples of Model-Based Approaches to cannot identify the characteristics of such women.
Estimating Abortion introduces the attractive concept of
not having to gather new data on the highly sensitive topic CHAPTER 6. The Abortion Incidence Complications
of abortion. Instead, its incidence is indirectly deduced Method: A Quantitative Technique describes this indirect
through existing relationships with other fertility determi- approach that builds on the number of women treated in
nants. The chapter is divided into two parts. Part I, The health facilities for abortion complications to estimate the
Residual Technique, discusses how Bongaarts’s model of total number of induced abortions. The AICM first yields
the main proximate determinants of fertility—for which data on numbers and rates of women receiving treatment
standard reproductive health surveys readily supply three for complications of induced abortion, either through na-
of the four main determinants—can be rearranged to yield tional hospital discharge data or a nationally representative
an abortion index, which is then converted into abortion Health Facilities Survey. Then, respondents to a Health
rates. The residual technique is applied with data for Professionals Survey are asked three sets of questions
Matlab, Bangladesh, and its validity is assessed through that are used to calculate a multiplier by which to inflate
comparison with abortion data collected from a direct the morbidity data to take into account those women who
Abortion Frequency Survey and results from an application do not develop complications or who do not get formal
of the indirect Abortion Incidence Complications Method treatment. (These questions ask about the distribution of
(AICM). abortions by type/provider, the probability of complications
Guttmacher Institute/IUSSP 9