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Self-Managed Abortion in Urban Haiti: a Mixed-Methods Study

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Self-Managed Abortion in Urban Haiti: a Mixed-Methods Study BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2017-200009 on 31 May 2018. Downloaded from Research Self-managed abortion in urban Haiti: a mixed-methods study Erin Nicole Berry-Bibee,1 Clotilde Josamine St Jean,2 Nathan M Nickerson,2 Lisa B Haddad,1 Manuchca Marc Alcime,2 Eva H Lathrop1 1Department of Gynecology and ABSTRACT Key messages Obstetrics, Emory University, Objective Although illegal abortion is believed Atlanta, Georgia, USA 2 to be widely practised in Haiti, few data exist Konbit Sante Cap Haitien Health ► Healthcare providers and women in the Partnership, Portland, Maine, on such practices. We aimed to learn about community report that self-managed USA illegal abortion access, methods, and perceived abortion is widely practised in urban barriers to abortion-related care. Additionally, we Correspondence to Northern Haiti. aimed to identify the proportion of unscheduled Dr Erin Nicole Berry-Bibee, ► Misoprostol is often used with a Department of Gynecology and antepartum visits to a public hospital that were combination of other agents, some Obstetrics, Emory University, attributable to unsafe abortion in Cap Haitien, potentially harmful, for self-managed Atlanta, GA 30303, USA; Haiti. eberryb@ emory. edu abortion. Study design We conducted eight focus groups ► Men played key roles in abortion Received 23 October 2017 with women (n=62) and 13 interviews with decision-making and in accessing Revised 8 May 2018 women’s health providers and subsequently Accepted 9 May 2018 misoprostol. administered a survey to pregnant or recently Published Online First 31 May 2018 pregnant women (20 weeks of gestation or less) presenting to the hospital from May 2013 to Globally, approximately half of all abor- January 2014 (n=255). tions are unsafe; an increasing trend, Results Among the focus groups, there was most notably in areas where abortion widespread knowledge of misoprostol self- is illegal.2 Haemorrhage, sepsis, hyper- managed abortion. Women described use of tensive disorders and unsafe abortion multiple agents in combination with misoprostol. are the top four causes of maternal Men played key roles in abortion decision- deaths worldwide.1 Researching abor- http://jfprhc.bmj.com/ making and in accessing misoprostol. tion practices in regions where abor- Among the 255 pregnant or recently pregnant tion is restricted and abortion safety is women surveyed, 61.2% (n=150) reported the unknown can be crucial to inform efforts current pregnancy was unintended and 30% to reduce maternal mortality. (n=78) reported attempting an induced abortion. In Haiti, the maternal mortality rate is The majority of women used misoprostol either higher than in any other country in the alone or as a part of the medication/herb Western hemisphere.4 Haiti’s penal code on September 24, 2021 by guest. Protected copyright. regimen for their self-managed abortion (85.1%, forbids induced abortion in all cases with n=63). no explicit exceptions, making Haiti one Conclusions Awareness of methods to induce of the most restrictive countries in the abortion is high among women in urban Haiti world.5 6 In a review of global abortion and appears widely practised; yet knowledge laws, researchers state that the law in of the safest self-managed abortion options Haiti is interpreted with the legal prin- remains incomplete. Access to safer abortion ciple of ‘necessity’, which may provide a services could improve maternal health in Haiti. legal defence if an abortion is performed to save the life of the woman.5 Few data are available on abortion INTRODUCTION practices in Haiti. In the 2012 Demo- Unsafe abortion is a preventable public graphic and Health Survey, 4% of Haitian health crisis.1 2 Mortality from unsafe women reported ever having an induced To cite: Berry-Bibee EN, St 7 Jean CJ, Nickerson NM, et al. abortion ranges from 350 to 800 abortion, yet, anecdotal evidence from BMJ Sex Reprod Health times greater than from safe abortion, local practitioners and US Agency for 2018;44:193–199. depending on region of the world.1 3 International Development (USAID) Berry-Bibee EN, et al. BMJ Sex Reprod Health 2018;44:193–199. doi:10.1136/bmjsrh-2017-200009 193 BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2017-200009 on 31 May 2018. Downloaded from Research reports suggest that the abortion rate is significantly Qualitative analysis higher.1 8–10 Maternal morbidity and mortality from The research team developed general concepts through abortion in Haiti is unknown. In order to explore the review of notes. We developed a code book and two effect that unsafe abortion has on maternal health, individuals (EBB and EL) independently read the communities, and healthcare systems in Haiti we transcripts and analysed them using the techniques of performed a mixed-methods study. coding, memoing and sorting using Maxqda version 10 software (VERBI GmbH, Berlin). Discordance was resolved by re-review of transcripts (EBB and EL) and, METHODS if needed, review by a third person (LH). We used The study took place from 15 May 2013 to 31 January grounded theory to generate themes. 2014 at Justinian University Hospital (JUH), in Cap-Haitien, Haiti, in collaboration with Emory Quantitative methods and analysis University (Atlanta, USA) and a non-governmental Results from the qualitative phase informed the devel- organisation, Konbit Sante Cap-Haitien Health Part- opment of a cross-sectional survey. At JUH, all women nership (Maine, USA). Institutional review board who are currently pregnant (regardless of gestational approval for this study was obtained at both Emory age) or recently pregnant (approximately ≤6 weeks and JUH. Cap-Haitien, the second largest city in Haiti, after the end of a pregnancy) and with an obstetric has one 300-bed public hospital (JUH) and several or gynaecological complaint are seen on the maternity smaller health centres. Hospital Fort Saint Michel ward at JUH and not in the general emergency room. (FSM) is a small public health centre with a maternity We screened all women presenting to the JUH mater- unit that serves the poorest communal section in the nity ward over a 6-month period (July 2013 to Janurary city, Petite Anse. 2014) for eligibility. Women were eligible if they were (1) self-reported ≤20 weeks gestation or ≤6 weeks Qualitative methods post-pregnancy from a pregnancy ≤20 weeks gesta- Qualitative data collection consisted of in-depth tion; (2) ≥18 years of age; and (3) a Haitian Creole interviews with women’s healthcare informants and speaker. After obtaining verbal consent, research focus group discussions with women living in Petite nurses administered the survey verbally, recorded the Anse. Quantitative data collection consisted of a answers and later entered then into an online data- cross-sectional survey of pregnant women (29 July base (FeedbackServer 5.4.1). We analysed survey data 2013 to 31 January 2014) presenting to JUH maternity using SPSS version 22 (IBM, Armonk, NY, USA). Only ward for care. Before each phase of data collection, women who answered our primary research question, training sessions familiarised the research team with ‘Did you do or take anything to attempt an induced methodology, study guides and tools, and refreshed abortion in the current pregnancy?’, were included. the principles of ethical research conduct using vali- Current pregnancy is defined to include those within dated tools.11 6 weeks post-pregnancy for women presenting for http://jfprhc.bmj.com/ Interview and focus group discussion guides care after spontaneous or induced abortion. We cate- consisted of open-ended questions and scenarios gorised all variables, and Chi squares were calculated concerning pregnancy, contraception, and induced comparing characteristics among women reporting abortion. Community health workers based out of and not reporting a self-managed abortion. For signif- FSM used purposive and convenience sampling to icant variables with three or more categories P values recruit participants in Petite Anse (CJ). After verbal were calculated from odds ratios and 95% confidence consent, three female Haitian research nurses facil- intervals. on September 24, 2021 by guest. Protected copyright. itated focus group discussions in a private setting in each neighbourhood. Women at least 18 years of age, Patient involvement willing to participate, and able to speak Haitian Creole We sought feedback from women and healthcare were eligible. We audiotaped all discussions then tran- workers in Cap Haitien from the onset to assist in scribed and translated them into English. After each selection of methodologies most appropriate for this group, we reviewed notes and transcripts for accuracy sensitive topic, given women’s priorities and prefer- and discussed the themes that arose. We conducted ences. At a meeting in Cap Haitien (March 2014), we focus group discussions until thematic saturation was presented findings to stakeholders and members of the reached as determined by team consensus. public health community and collectively generated Purposive sampling identified key women’s health- integrated themes and conclusions. care informants which included community health workers, herbalists, traditional birth attendants, nurses RESULTS and physicians (CJ and NN). After written consent, the Qualitative overview primary author (EBB) conducted interviews in English We conducted eight focus group discussions with with a translator as needed. Interviews were recorded a total of 62 women (mean 7.8 per group; range and transcribed. 6–9). The mean age was 28 (range 20–50) years and 194 Berry-Bibee EN, et al. BMJ Sex Reprod Health 2018;44:193–199. doi:10.1136/bmjsrh-2017-200009 BMJ Sex Reprod Health: first published as 10.1136/bmjsrh-2017-200009 on 31 May 2018. Downloaded from Research discussions lasted a mean of 105 (range 76–137) min. what specific methods were being used, and denied We conducted 13 interviews with women’s healthcare providing education to women seeking abortion infor- informants; two gynaecologists, two gynaecology resi- mation or services.
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