An assessment of third-party reporting of close ties to measure sensitive behaviors: the Confidante Method to measure abortion incidence in Ethiopia and Uganda

Abstract

Indirect estimation techniques are an important tool for measuring sensitive and stigmatized behaviors. This includes third-party reporting methods, which have become increasingly common in the field of abortion measurement, where direct survey approaches notoriously lead to underreporting. This paper provides the first in-depth assessment of one of the most widely used of these techniques in the field of abortion measurement: the Confidante Method. We outline six key assumptions behind the Confidante Method and describe how violations of these assumptions can bias resulting estimates. Using data from modules added to the nationally representative Performance Monitoring for Action (PMA) surveys in Uganda and Ethiopia in 2018, we compute one-year abortion incidence estimates using the Confidante Method. We also perform a validation check, using the method to estimate IUD and implant use. While our results reveal that the method performed differently in each country, there were implementation problems in both settings. Several of the method’s foundational assumptions were violated, and efforts to adjust for these violations either failed or only partially addressed the resulting bias. Our validation check also failed, resulting in a gross over-estimate of IUD and implant use. We identify substantial biases in both the numerator and denominator of our abortion estimates and challenge the continued use of this method to estimate abortion incidence. These results have implications more broadly for the potential biases that can be introduced in using third-party reporting of close ties to measure other sensitive or stigmatized behaviors.

The confidante method to measure abortion: implementing a standardized comparative analysis approach across seven contexts.

“…Another limitation of this analysis was our inability to perform validation tests of the con dante method as was done in the Giorgio and Sully paper using long-acting contraceptive method prevalence rates. 10 Future con dante studies should explore suitable indicators of hidden reproductive behavior to use in validity checks.…”

“…Out of 40 published studies, we identi ed seven applications of the con dante method in: Côte d'Ivoire, Ethiopia, Ghana, the island of Java-in Indonesia, Nigeria, Uganda, and Rajasthan state in India. [9][10][11][12] Five of the seven studies were elded on the Performance Monitoring for Action (PMA) survey platform. 13 All surveys were cross-sectional and elded in 2018.…”

“…[9][10][11][12] Despite the growing popularity of the con dante method, research has shown that the method is subject to several potential sources of bias, likely affecting the accuracy of induced abortion incidence estimates. 10 In addition, published papers on the con dante method detail signi cant variations in how the method was applied and how the analyses were conducted. [9][10][11][12] These variations impact the presence of potential biases in the resulting abortion incidence estimates, and limit the comparability of indicators across contexts.…”

“…[6][7][8] Thus far, the con dante method has been recently elded in multiple settings, with published descriptions of study results in Ethiopia, Ghana, India, Indonesia, Côte d'Ivoire, Nigeria and Uganda. [9][10][11][12] Despite the growing popularity of the con dante method, research has shown that the method is subject to several potential sources of bias, likely affecting the accuracy of induced abortion incidence estimates. 10 In addition, published papers on the con dante method detail signi cant variations in how the method was applied and how the analyses were conducted.…”

“…10 In addition, published papers on the con dante method detail signi cant variations in how the method was applied and how the analyses were conducted. [9][10][11][12] These variations impact the presence of potential biases in the resulting abortion incidence estimates, and limit the comparability of indicators across contexts. For nationally representative estimates of abortion incidence to be used as inputs for global models of pregnancy and abortion, 2 potential sources of bias in the application of this method must be addressed in a comparable way.…”