RELIGIOSITY AND ABORTION PERCEPTIONS IN THREE ZAMBIAN PROVINCES by Meghan C. Gallagher A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland June 2018 © 2018 Meghan Gallagher All Rights Reserved DISSERTATION ABSTRACT Background: Access to safe abortion is critical to the health of women. In Zambia, where abortion laws are among the least restrictive in sub-Saharan Africa, an estimated 30% of the annual 398 maternal deaths per 100,000 live births are due to unsafe abortion, which is higher than many neighboring countries. Zambia is also a notably Christian country, with 98% of the population ascribing to Protestant or Catholic denominations; further, Evangelicals comprise an estimated 25% of the overall population. These religious denominations tend to view abortion as a sin within their doctrine and Zambia is a country where negative attitudes toward abortion are common, often prompting women to access clandestine, and often unsafe, abortion services to avoid the perception of stigma that would potentially result from disclosure. Objectives: The objectives of this study were to first construct measures of personal abortion attitudes, support for Zambian abortion laws, and individual religiosity. Next, individual and community factors that influence individuals’ abortion perceptions (abortion attitudes and support for Zambian abortion law) were investigated. Finally, the role that religion and stigma play in women’s understanding of abortion and how it informs their perceptions, decision-making, and social experiences with abortion were explored. Methods: This study was based on secondary analysis of a cross-sectional household sample of women of reproductive age (15-44) living within three Zambian provinces and in-depth interviews at two time points with 51 women who had terminated a pregnancy. Exploratory and confirmatory ii factor analyses were conducted to validate the Duke University Religion Index (DUREL) as well as an abortion attitude scale. Multivariate logistic regression models were employed to measure the association between individual religiosity and perceptions of abortion as well as the influence of community religiosity and community abortion attitudes on individual abortion perceptions. Finally, a directed content analysis approach was applied to semi-structured in-depth interviews with woman conducted immediately after they had terminated a pregnancy and again 3-4 months later. Results: The DUREL showed good internal consistency; however, the results of the EFA and CFA suggest that DUREL cannot be used as a scale to measure religiosity within this population, as the subscales of the DUREL are not explained by a common underlying construct, as evidenced by goodness of fit statistics. The findings support the validity of the three-item subscale measuring intrinsic religiosity. The validity assessment of the DUREL supports that the DUREL be analyzed as three independent subscales and not an aggregate measure of religiosity. Within this female Zambian population, the five survey questions pertaining to abortion attitudes do not function together as a valid scale. The multivariate analyses do not find associations between religiosity and abortion perceptions at an individual level but find associations between religiosity at a community level and individual abortion perceptions. iii The analysis of the in-depth interviews found that many of the women interviewed viewed abortion is a sin in their religion. Though most believed that praying for forgiveness would lead to absolution, many women still noted feelings of guilt and shame. Several respondents felt that abortion is perceived as non-normative and unacceptable within their religious communities, which can lead to difficulty reintegrating. Conclusion: Although this is the first study of its kind, this research suggests that religiosity at a community level may play a role in perpetuating abortion stigma and influencing abortion perceptions for women. The qualitative research suggests that women perceive that they are being judged by their communities, notably their religious communities, even in situations where their abortion is unknown. This study provides initial evidence that community religiosity and attitudes may motivate abortion stigma. Further research is need to in sub-Saharan Africa to confirm these findings and better understand this important social dynamic. iv COMMITTEE OF FINAL THESIS READERS Committee Members: Amy O. Tsui, PhD Professor, Johns Hopkins Bloomberg School of Public Health Department of Population, Family and Reproductive Health Mary Elizabeth Hughes, PhD Associate Scientist, Johns Hopkins Bloomberg School of Public Health Department of Population, Family and Reproductive Health Anne E. Burke, MD, MPH Associate Professor, Johns Hopkins University School of Medicine Department of Gynecology and Obstetrics Associate Professor, Johns Hopkins Bloomberg School of Public Health Department of Population, Family and Reproductive Health Carol R. Underwood, PhD Assistant Professor, Johns Hopkins Bloomberg School of Public Health Department of Health, Behavior and Society Alternate Committee Members: Caitlin E. Kennedy, PhD, MPH Associate Professor, Johns Hopkins Bloomberg School of Public Health Department of International Health Joint Appointment in Department of Health, Behavior and Society Caroline Moreau, MD, PhD Associate Professor, Johns Hopkins Bloomberg School of Public Health Department of Population, Family and Reproductive Health v ACKNOWLEDGEMENTS I would like to express my gratitude for my wonderful advising duo. Drs. Amy Tsui and M.E. Hughes have been wildly supportive throughout my doctoral journey and accompanying demographic events. Their support, advice, encouragement, and humor were always appreciated and will be remembered fondly. I am grateful to my committee members, Drs. Anne Burke and Carol Underwood, who took the time to read my work and provide constructive feedback during my preliminary and final examinations. I am also grateful to Dr. Caroline Moreau who provided insightful thoughts over the years and served on my departmental examination and as an alternate for my final defense. I appreciate the thoughtful feedback from Dr. Terri Powell who participated in my departmental and preliminary examinations. Thanks to Drs. Caitlin Kennedy and Stephane Helleringer who kindly committed to participate as alternate members of my committees. I was fortunate to be a part of the Department of Population, Family, and Reproductive Health. I am very grateful for faculty that I had the opportunity to work with and learn from, especially Drs. Bill Mosher and Anne Riley. I am grateful for the ongoing support and assistance of Lauren Black. I am thankful for the funding I received toward my doctoral education, notably from the Laurie Schwab Zabin Award, the Carl Swan Shultz Fellowship, the Fellowship in Family Planning and Reproductive Health, the Edward J. Dehne Award, and the US Policy Communication Training Program from the Population Reference Bureau. Without Ann Moore at the Guttmacher Institute and Jenny Cresswell and Veronique Filippi at the London School of Hygiene and Tropical Medicine, I would not have had such rich and informative data. Sara Casey and Therese McGinn laid the groundwork for my enthusiasm for research and I am grateful to have had the opportunity to work with them at Columbia University for many years. I am fortunate to currently have wonderful colleagues at Save the Children who tirelessly work toward expanding access to reproductive health services in humanitarian settings. My community of fellow students has been a beacon of support, humor, and calm throughout the doctoral process. I am especially grateful to my GSD accountability group comprised of Amanda Gatewood, Lauren Okano, and Nomi Weiss-Laxer. Sara Riese was my first friend on day one of my public health journey and I am honored to continue on this path with her. Hannah Lantos, Michelle Hawks Cuellar, Suzanne Bell, Amanda Kalamar, Sahnah Lim, Sarah Peitzmeier and many others in the Pop Fam community were gracious with their time, humor, and grounding. Nicole Armstrong has been a source of inspiration and laughs since our two-week intensive course in life tables. The road to my PhD has involved a wedding, a birth, and a full-time job. I am grateful to the village that has made this accomplishment possible. My community of longtime friends in Brooklyn and beyond have provided perspective, distraction, and ongoing love and support. Gillian Collymore has been a remarkable caregiver to my son. I am grateful for my large and vi wonderful extended family who have no idea what I’m doing with my life, but love me all the same. My sister is the funniest person I know and a phenomenal individual who has lent a hand or shared a laugh on more occasions than I can count. My parents instilled in me a desire for learning and a commitment to social justice that has carried me thorough life as well as the doctoral process. Roger and James keep me going every day and are my heart. Finally, I am grateful to all the brave women in Zambia and beyond who give their time and tell their stories so that we can learn from them in hopes of better understanding pathways for improving the health and well-being of all women and families throughout the world. These are trying and complicated times and I am inspired by those who continue to push forward. vii TABLE OF CONTENTS DISSERTATION