STUDY DESIGN & RESEARCH METHODS
A 3 country (Ethiopia, Malawi, Zambia) comparative study design of contraception and abortion services for adolescents. In each country, two contrasting public health study sites (tertiary hospital and designated adolescent sexual and reproductive health services [ASRHS]). We focus on evidence from adolescents who are either seeking post-abortion care from an abortion initiated elsewhere (at home, unregulated sector, etc.) or who are seeking an abortion. Ethical review was sought and approved in Ethiopia, Malawi, Zambia and the UK.
1. Comparative policy and legal analyses
We identified current laws and policies relating to adolescent SRH – with a specific focus on contraception and abortion care – in each country. Where they exist (Ethiopia and Zambia), guidelines that operationalise the law on safe abortion were also included. We analysed relevant regional instruments relevant to UHC and adolescent SRH. We included AU instruments to situate contemporary state-level laws and policies and to identify – if any – contradictions between regional commitments and state-level laws and policies. We developed frameworks informed by documents on rights-based and adolescent-focused SRH to extract information on the content of salient laws and policies in each country.
2. Interviews with adolescents: Facility-based recruitment of adolescents seeking either SA or PAC following an abortion initiated elsewhere. In each country, adolescents seeking care at two public sector facilities were recruited. We focus on the public sector because it is where most vulnerable or marginalised adolescents seek care. Adolescents identified as having sought either SA or PAC by a study-trained senior nurse were invited to participate once ready for discharge. We included adolescents who received treatment as out-patients and those hospitalised for severe complications. Interviewers worked across a range of shifts (Mon-Fri vs weekend; early morning vs. early evening) to maximise the range of adolescents seeking care. Research instruments were tested with attention to inter-country comparability. The research instruments (see below) generate evidence on: detailed care seeking pathways (and their influences and influencers); barriers to care-seeking (eg: knowledge, confidentiality, cost, transport, unofficial provider payments, perceived quality of care); sociodemographic status; contraceptive (non-)use; direct service costs (for example, fees per procedure or intervention); indirect costs (e.g.: travel, food, lost productivity); resources used to pay costs (e.g.: credit, asset sale, borrowing, loss of wages); knowledge of the law, including understanding of adolescent rights to services; barriers and facilitators to care-seeking. To improve the quality of reports of abortion methods, we developed novel country-specific visual aids for respondents to identify non-facility abortion methods. Interviews were conducted in private by female research assistants (RA) fluent in all major local languages in each country. RAs were trained in research ethics, informed consent and interviewing techniques. An established two-interviewer approach was be used: one RA led the interview in a conversational style to put the participant at ease and facilitate the narrative flow, whilst a second RA completed the research instrument. Towards the end of the interview the second RA asked supplementary questions not covered by the first RA to ensure completeness. Treatment records were accessed, with permission, to validate individual reports of abortion care received and morbidity symptoms as a result of unsafe abortion procedures or attempts.
Analyses: Verbatim translation and transcription of recorded interviews. Preliminary content analysis of a sub-set of purposively selected transcripts for the development of a codebook which was iterated and used by the team analysing the transcripts meaning that a combination of deductive and inductive themes were included.
3: In-depth interviews with key informants: Key informants (n≈20 per country) involved in the implementation of contraception and abortion services for adolescents, purposively sampled for a range of perspectives (nurse-midwives, doctors, administrators, pharmacists decision-makers, funders, donors, civil society [including faith-based organisations]), and reflect the comparative (standard vs. ASRHS) design of interviews with adolescents. Key informant interviews (KIIs) focused on a range of topics, including: funding for SRH in general and ASRHS in particular; training in ASRH for health professionals; levels of awareness of ASRH policies; capacity in planning, implementing and monitoring ASRH activities at national and sub-national level; objection to abortion service provision (in general, and for adolescents in particular); and, attitudes towards ASRHS. Recorded interviews (with consent) were be transcribed.
Analyses: Thematic analyses of verbatim transcripts of interviews.
4: In-depth “interviewing the interviewers”: We interviewed the Research Assistants that worked on the study in order to better understand the issues involved in not only generating evidence from adolescents who have sought abortion-related care, but also the meanings for and experiences of RAs doing abortion-related interviewing.
Improving adolescent access to contraception and safe abortion in sub-Saharan Africa: health system pathways 