Understanding abortion-related stigma and incidence of unsafe abortion: experiences from community members in Machakos and Trans Nzoia counties Kenya

Abstract

IntroductionThe rate of unsafe abortions in Kenya has increased from 32 per 1000 women of reproductive age in 2002 to 48 per 1000 women in 2012. This is one of the highest in Sub-Saharan Africa. In 2010, Kenya changed its Constitution to include a more enabling provision regarding the provision of abortion services. Abortion-related stigma has been identified as a key driver in silencing women's ability to reproductive choice leading to seeking to unsafe abortion. We sought to explore abortion-related stigma at the community level as a barrier to women realizing their rights to a safe, legal abortion and compare manifestations of abortion stigma at two communities from regions with high and low incidence of unsafe abortion.MethodsA qualitative study using 26 focus group discussions with general community members in Machakos and Trans Nzoia Counties. We used thematic and content analysis to analyze and compare community member's responses regarding abortion-related stigma.ResultsAlthough abortion is recognized as being very common within communities, community members expressed various ways that stigmatize women seeking an abortion. This included being labeled as killers and are perceived to be a bad influence for women especially young women. Women reported that they were poorly treated by health providers in health facilities for seeking abortion especially young unmarried women. Institutionalization of stigma especially when Ministry of Health withdrew of standards and guidelines only heightened how stigma presents at the facilities and drives women seeking an abortion to traditional birth attendants who offer unsafe abortions leading to increased morbidity and mortality as a result of abortion-related complications.ConclusionCommunity members located in counties in regions with high incidence of unsafe abortion also reported higher levels of how they would stigmatize a woman seeking an abortion compared to community members from counties in low incidence region. Young unmarried women bore the brunt of being stigmatized. They reported a lack of a supportive environment that provides guidance on correct information on how to prevent unwanted pregnancy and where to get help. Abortion-related stigma plays a major role in women's decision on whether to have a safe or unsafe abortion.

Exploring stigma and social norms in women’s abortion experiences and their expectations of care

“…For example, one woman shared: "I was afraid of whether someone would scold me [ (India, age 28). Similarly, another woman said she felt "shy to come back to that place [the clinic]" if she became pregnant after they provided her with contraceptives (India, focus group participant, aged [24][25][26][27][28].…”

“…4,17 In 2013, the Kenyan Ministry of Medical Services withdrew the previously published national "Standards and Guidelines for Reducing Morbidity and Mortality from Unsafe Abortion in Kenya" without explanation and warned health providers against participating in abortion training. 23,24 These actions, possibly in response to pressure from anti-abortion groups, resulted in confusion among service providers and people seeking care with regards to the legality of abortion service provision. 23 The withdrawal of the guidelines and the confusion about the law have been found to contribute to abortion stigma, which can hinder access to care and result in women seeking unsafe abortion.…”

“…23 The withdrawal of the guidelines and the confusion about the law have been found to contribute to abortion stigma, which can hinder access to care and result in women seeking unsafe abortion. 24,25 High levels of abortion stigma have been linked to high incidence of unsafe abortion, particularly impacting young and unmarried women who may experience more acute abortion stigma when seeking the service in Kenya. 24 Younger women in Kenya are among those who most commonly experience severe complications from unsafe abortion.…”

“…24,25 High levels of abortion stigma have been linked to high incidence of unsafe abortion, particularly impacting young and unmarried women who may experience more acute abortion stigma when seeking the service in Kenya. 24 Younger women in Kenya are among those who most commonly experience severe complications from unsafe abortion. 26 In India, abortion is legal and accessible up to 20 weeks of gestation under a wide range of indications.…”

Making Abortion Safer in Rwanda: Operationalization of the Penal Code of 2012 to Expand Legal Exemptions and Challenges

“…This compound stigma is a powerful inhibiting force leading to severe consequences for women, including death, further abuse of victims, and poor quality of care 19 . Similarly, a study from Kenya also highlighted abortion related stigma as a key driver in silencing women's ability to seek help, and suggested that in communities where abortion stigma is higher, women are more likely to resort to unsafe abortion, even when legal options are available 20 . While this evaluation was not designed as a before/after study, and monitoring data was collected in the midst of ongoing initiatives to address unsafe abortions, it is important to highlight some of the differences observed between the two data collection periods to demonstrate the trajectory in the two and a half years.…”