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Do Perceived Contraceptive Attitudes Influence Abortion Stigma? Evidence from Luanda, Angola

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Do Perceived Contraceptive Attitudes Influence Abortion Stigma? Evidence from Luanda, Angola THE INFLUENCE OF CONTRACEPTIVE ATTITUDES ON ABORTION STIGMA IN LUANDA, ANGOLA 1 Do Perceived Contraceptive Attitudes Influence Abortion Stigma? Evidence from Luanda, Angola Madeline Blodgett*, Benjamin Andrade-Nieto**, Ndola Prata* Paper prepared for The Population Association of America meeting 2016 *University of California, Berkeley, **Population Services International - Angola Corresponding author: Ndola Prata, MD, MSc THE INFLUENCE OF CONTRACEPTIVE ATTITUDES ON ABORTION STIGMA IN LUANDA, ANGOLA 2 Abstract Abortion stigma is influenced by a range of factors. Previous research has documented a range of contributors to stigma, but the influence of perceived social norms about contraception has not been significantly investigated. This study assesses the influence of perceived social norms about contraceptive on abortion stigma among women of reproductive age in Luanda, Angola. This analysis uses data from the 2012 Angolan Community Family Planning Survey that employed a multi-stage random sampling to collect demographic, social, and reproductive information from a representative sample of Luandan women aged 15-49. We analyzed responses from 1469 women of reproductive age that completed the survey using bivariate and multivariate logistic regression. Analysis assessed women’s perceptions of how their partners, friends, communities, and the media perceived contraception, and examined associations between those perceptions and respondents’ abortion stigma. Stigma was examined by responses to questions assessing the likelihood to help someone get an abortion; likelihood to help someone who needed medical attention after an abortion; and likelihood to avoid disclosing abortion experiences. Preliminary results show that friends’ encouragement of family planning use was associated with an increase in likelihood to conceal abortion experiences. Community acceptance of family planning and exposure to media discussion of family planning were associated with a decrease in likelihood to help someone receive an abortion. Higher levels of partner engagement in family planning discussion were associated with increased stigma on two of the three stigma measures, while higher levels of partner support of family planning were associated with decreased stigma. These results suggest that increasing partner support of family planning may be one strategy to help reduce abortion stigma. Results also suggest that some abortion stigma in Angola stems not from abortion itself, but rather from judgment about socially unacceptable pregnancies. THE INFLUENCE OF CONTRACEPTIVE ATTITUDES ON ABORTION STIGMA IN LUANDA, ANGOLA 3 Introduction Globally, unsafe abortion kills an estimated 47,000 women annually (WHO, 2011). Research is increasingly identifying abortion stigma as a contributor to this mortality. Abortion stigma puts abortion patients’ mental and physical health at risk by silencing their ability to speak about their experiences (Kimport, Foster, & Weitz, 2011, Goyaux, Yacé-Soumah, Welffens-Ekra, & Thonneau, 1999). Stigma also reduces access to safe abortion, driving providers away from providing services and rendering abortion a clandestine service accessed through word of mouth, if at all (Bingham et al., 2011, Freedman, Landy, Darney, & Steinauer, 2010). This research assesses how perceived social attitudes towards contraception affect abortion stigma. We analyzed recent survey data gathered in Luanda Province, Angola from women of reproductive age, which asked women how they thought their partners, friends, and communities feel about contraception. The same women were also asked questions to assess their level of abortion stigma, as measured by willingness to help someone get an abortion, willingness to help someone who was sick after an abortion, and desire to not talk about abortion experiences. This research originates in the practice assumption that while interventions that explicitly aim to reduce abortion stigma are unlikely to be accepted by all members of a community, interventions that influence contraceptive attitudes have much higher acceptability. Thus, if perceived contraceptive attitudes are shown to influence abortion stigma, family planning-focused interventions could be implemented to obliquely shift abortion attitudes as well as addressing family planning needs. Background Abortion in Angola Little is known about abortion in Angola. The country spent nearly three decades ravaged by a violent civil war which—though it officially ended in 2002—has had ongoing devastating effects on health record-keeping and health systems infrastructure (Bloemen, 2010). In the years since the end of the war, Angolan authorities have been working to rebuild systems to support the health of all Angolans. Vital to this mission is facilitating reproductive health services that can reduce the country’s dangerously high maternal mortality rates. Already, the efforts of Angolan health leadership is having a positive effect: the maternal mortality ratio has decreased from an estimated 750 deaths per 100,000 live births in 2005 to 460 deaths per 100,000 live births in 2013 (WHO, 2014). It’s difficult to ascertain the influence of unsafe abortion on Angola’s maternal mortality ratio. Globally, an estimated 21.6 million unsafe abortions took place in 2008, 18.5 million of which took place in developing countries (WHO, 2011). An estimated 930,000 abortions took place in Middle Africa, equivalent to an abortion rate of approximately 36 unsafe abortions per 1000 15- 44-year-old women. Abortion is illegal in Angola, with a practical exception for saving the life of the pregnant woman (Population Division, n.d.). Imprisonment for performing an abortion can range from 2- 8 years (Harvard School of Public Health, 2014). Angola’s strict penal code reflects the country’s religious composition: though estimates vary, Angola’s population is at least 55% THE INFLUENCE OF CONTRACEPTIVE ATTITUDES ON ABORTION STIGMA IN LUANDA, ANGOLA 4 Catholic (Department Of State, 2009). In 2009, Pope Benedict XVI inveighed against abortion in a speech to nearly a million Angolan Catholics, calling abortion a strain on the traditional African family (Simpson, 2009). Angolan bishops have expressed similar attitudes, fervently opposing efforts to shift abortion laws (Baklinski, 2012). In contrast to this internal opposition, recommendations from international human rights organizations have targeted mortality rates from unsafe abortion as a key priority for Angola. Angola’s criminalization of abortion has been identified as an area of concern hindering implementation of the International Covenant on Civil and Political Rights (Human Rights Committee, 2013). Angola has ratified the African Union’s Protocol to the Charter on People’s and Human Rights on the Rights of Women in Africa, also known as the Maputo Protocol, which affirms women’s rights to control their fertility and advocates for abortion in several circumstances (Maiga, 2012). Despite internal opposition, Angolan government has been making efforts to address unsafe abortion in Angola. Angola’s legislature has been considering legislation to decriminalize abortion for gestations under 16 weeks, though this effort has been contested by various groups within the country (Baklinski, 2012). In recent years, NGOs, in collaboration with the Ministry of Health, have implemented post-abortion care (PAC) interventions to improve access to and management of cases of incomplete abortion and miscarriage, including the introduction of misoprostol to manage uncomplicated cases in peripheral health centers (Venture Strategies Innovations, 2013). Conceptualizing abortion stigma No one universal definition of stigma has been adopted across the plurality of fields which seek to understand stigma. Many definitions and discussions of stigma build off Erving Goffman’s characterization of stigma as “an attribute that is deeply discrediting” which transforms a “whole and usual” person into a “tainted, discounted” one (1963). Goffman argues for the understanding of this discrediting attribute in a social context: stigma is socially contingent, and comprehensible only in a “language of relationships.” Sociologists Link and Phelan build on and respond to this definition, arguing that stigma is the convergence of several components (2001). First, people note and name differences between individuals, labeling people as members of social groups based on difference. Second, cultural beliefs link these differences to negative stereotypes, connecting labeled individuals to characteristics linked to stereotypes. Third, social labels create categories of “us” vs. “them,” defining in- and out-groups. These groups lead to status loss and discrimination against the out-group. All these processes are dependent on access to power, which facilitates the creation of differentness and its attendant negative consequences. Abortion stigma presents an interesting case for these theories, as Kumar et al discuss in their examination of the phenomenon (Kumar, Hessini, & Mitchell, 2009). As safe abortion experiences are transient and leave no “enduring stigmata” that differentiate women who have had abortions from those who have not, abortion can be a relatively invisible experience and many women can choose whether to publically identify as having had an abortion. This under- reporting of abortion, as well as misclassification of abortion, creates the perception that abortion is rare and exceptional, hence establishing women who have abortions as deviant. This perceived
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