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Table 4 Perceptions, practices, barriers, and facilitators to reporting termination of pregnancy in five EN-INDEPTH study sites

From: Termination of pregnancy data completeness and feasibility in population-based surveys: EN-INDEPTH study

  Woman Interviewer
Perceptions on reporting TOPs
 TOPs immoral and inhuman - Enquiring of a bad event is perceived unethical (Dabat, Ethiopia)
- TOP perceived as taking a life
Why did you abort the baby? Why did you kill a life? What would have been the problem if you had that child? Can’t you rear it up? If you think you cannot take care of it then you have [to] give it to someone for adoption! But why did you abort the baby? (Iganga-Mayuge, Uganda)
- Culture and religion consider TOP as immoral and inhuman
Also, in the Christian community, abortion is seen to be a bad thing, so it is very difficult to get responses to questions on abortion (Kintampo, Ghana)
Perceived TOP reporting practices
 Difficulty reporting TOPs - It is one’s secret and shameful to tell others
That one (abortion) is a secret so you won’t disclose it to people apart from telling your trusted friend. Maybe you didn’t know what to do and it was that friend who advised you on how to carry out the abortion. So, if you tell someone about it, the day the two of you will have arguments, the person will use it to insult you. It is shameful to tell people that you have aborted a pregnancy, so it is not possible to easily disclose it (Kintampo, Ghana)
- Pain of loss perceived to be self-afflicted, so one cannot openly grieve
In that case (TOP) there is no grievance. If she actually felt bad, then does she ever do such thing?…If I have to do that unwillingly, I will have to bear more sorrow (Matlab, Bangladesh)
- It is much more comfortable reporting livebirths.
If you ask the woman she does not want to talk about abortion, she only wants to talk about those children that she gave birth to (Bandim, Guinea-Bissau)
- Interviewers not being empathetic and patient
Sensitive questions must be asked systematically and with care so as not to remind the women of their loss. Being empathetic and patient with her can yield the right information. The problem is most data collectors are in a hurry and not conscious of the women’s grief, so they to ask directly about this sensitive issue. Consequently, the interview ends up with the wrong information (Dabat, Ethiopia)
- Young girls generally shy away from reporting TOPs
Then the other thing on the part of the girls, most of them were not open to disclose information about pregnancies. Some of them were shying away from telling us that they aborted…(Iganga-Mayuge, Uganda)
- TOPs reported as miscarriages instead
We are realizing this challenge of abortion that some women can’t tell you that this abortion was intended. This is a big problem to me. She can’t tell you that this was a miscarriage but when you reach here, she says no, so they hide the information. She says it was a miscarriage, but she fears to tell you that this was intended abortion (Iganga-Mayuge, Uganda)
Perceived barriers to reporting TOPs
 Interviewer unable to ask TOP questions or perceived as disrespectful - It is a taboo to ask a woman about TOP
If there is an abortion or other adverse events, another pregnancy will come soon as the woman is not lactating. Enquiring about such adverse events is really miserable, perceived as a taboo and as wanting to harm the woman (Dabat, Ethiopia)
- Interviewers who probe on TOP are perceived as disrespectful
The difficulty is when you ask a woman something, and she says, “is this what you are asking me, my son?” I say, “No auntie, ok, ok, we just want to know how many children, it is not like this, but we want to know how many abortions you have had”. If you don’t ask her in this way, the person becomes awkward and thinks you lack respect (lebsimente) because you seem keen to know about their life (Bandim, Guinea-Bissau)
- Interviewer’s fear to ask direct questions on TOP due to legal and religious reasons
There is a challenge though somehow not that serious that relates to issues of legal and religion…we hear that abortion is illegal and when it comes to the question that asks direct that “did you do anything to end this pregnancy?” this it requires you to be trained and less judgmental (Iganga-Mayuge, Uganda)
 Stigma associated with TOPs - TOPs are perceived to be linked to heredity and fear reoccurrence of the problem in the next pregnancy (Dabat, Ethiopia) - Younger females not willing to disclose TOPs
Some of them were shying away from telling us that they aborted (Iganga-Mauyge, Uganda)
- Persons who have done TOPs are stigmatised and perceived as murderers.
I think the perception the community has about abortion…how they stigmatize those who have done abortions... Sometimes you are seen as a murderer, so someone who has had an abortion would not like to open up (Kintampo, Ghana)
- Miscarriages easier reporting than TOPs as they are perceived as natural
For me personally getting information on miscarriages is not as difficult as that of abortion because they see the miscarriage as a natural occurrence (Kintampo, Ghana)
 Very uncomfortable reporting TOPs - Lots of women did not want to think about, more so talk about TOPs
God gave and God took it! (Dabat, Ethiopia)
- Some women are just uncomfortable disclosing TOPs
Some of them feel very uncomfortable giving you such details and also some of them find it difficult in giving you details about children that they have lost depending on the circumstance under which they lost the child (Kintampo, Ghana)
 Poor documentation of TOPs   - There are rarely records of TOPs as compared to livebirths, etc. so information solely depends on what the woman provides
There is a bit of records to get on the neonatal births and livebirths as compared to miscarriages and abortion. It also depends solely on the woman to give you all the details of since there are no records on it in the ANC so it all boils down to the kind of rapport and relationship you build with her (Kintampo, Ghana)
Perceived facilitators of TOP reporting
 Good interviewer techniques   - Making use of “expressions” that tacitly inquire about TOPs in place of explicit language
What makes it easier for us is instead of asking the woman how many times she has had an abortion; you ask her how many times she has ‘taken out her stomach’ (Bandim, Guinea-Bissau)
- Communicating with the husband or her mother is one way of getting reliable information (Dabat, Ethiopia)
- Or speaking to the woman after she recovers from her grief may be another alternative.
Interviewer must be able to gauge the right moment to ask questions
You have to also be careful not to directly go to the questionnaire. You must first get her attention and concentration by understanding her feelings, facial expressions, and readiness to share the information (Dabat, Ethiopia)
- TOPs are stigmatised and reasons for carrying them out are diverse, so interviewer’s craftiness facilitates disclosure
With the abortions, we have made it look like something that is really bad and scary. If someone has committed abortion, she is even afraid of saying it because she thinks she will be reported for the society to have a certain perception about her. There are different reasons why someone will have an abortion, some young girls are afraid of their parents so when they get pregnant, they will rather choose to abort it, some are also based on doctors’ advice. So, you have to be really careful when asking on the field (Kintampo, Ghana)
 A common language of interaction   - Speaking the language of the interviewee enhance disclosure
Apart from this consenting issue, sometimes the language also helps, especially when you speak their language (Kintampo, Ghana)
 Informed consent process is well done   - Providing detailed and enough information during the consenting process facilitates disclosure.
A good consenting process assures respondents of the use of information gathered to improve their and other’s outcomes.
Sometimes when the respondent has many of such incidence (TOP), when you consent her very well, she will have the mindset that the Ghana Health Service will implement policies that will help to reduce these things and they are willing to give you information (Kintampo, Ghana)
 Feeling justified or open-minded on TOP - Women are much more open when speaking about miscarriages, though still they hide some information. Abortions or miscarriages are perceived to be related to hereditary or uterine problems (Dabat, Ethiopia) - Some interviewees disclose TOPs as they feel justified in the reasons for doing it
I found a woman and when I asked that “ have you ever had a miscarriage?” she said that “not even miscarriage but I just aborted” and that the reason was that the rate of conception was high because when the child was only 3 months she could conceive and when she tried family planning she said that “ it was like I had loosen the tap because the bleeding was too much” (Iganga-Mayuge, Uganda)
- Some interviewees do not hide their experiences with TOP, they speak openly
I will say it is the personality, some people are outspoken, they are able to tell what they have gone through, sometimes I myself I get surprised when the women tell me that I aborted this pregnancy despite the difficulty in saying it, sometimes some people come out clear on that (Kintampo, Ghana)
 A sense of regret over TOP - Some disclose due to guilt they feel over their actions
They talk about it because…I have ever seen a woman who aborted and buried the fetus in the anthill. So, she spoilt her future because over time…she wanted to give birth to a child but in vain (Iganga-Mayuge, Uganda)
 Perception of speaking to a healthcare provider   - Interviewees feel secure speaking to interviewers they perceive to be health workers
Like the technique of her seeing you in the perspective of “musawo”, [doctor] so she does not want to deceive you, ahaa me, musawo the other husband, we separated, with my husband and that’s why I aborted these pregnancies but don’t let him know and the police will accuse me of this illegal abortions and for you accept to be called musawo but again when you say you are not a nurse, she will ask you why you have been asking her about that and she will say I have been talking with a wrong person (IgangaMayuge, Uganda)