The ethnographic study was carried out between January and August 2021 in both Kilifi county in Kenya and the Atlantique department in Benin. The study aimed at exploring the lived experiences, social determinants, and pathways to un/safe abortion of adolescent girls and young women (21)(22). Data was obtained using participant observation, in-depth interviews (IDI), key informant interviews (KII), and focus group discussions (FGD).
Study setting
The study was conducted in Kilifi county in the coastal region of Kenya and the Atlantique department in Benin. Kilifi county has a high rate of adolescent pregnancy and unsafe abortion. According to the 2014 Kenya Demographic and Health Survey (2014), 22% of 15 to 19-year-old girls in Kilifi were pregnant with their first child or had already given birth compared to the national rate of 18% of the same age bracket. According to the same survey, Kilifi county also records a low use of modern contraceptives with 33% compared to the average national rate of 53% (23). Kilifi county is divided into seven sub-counties comprising rural, peri-urban, and urban areas. For this study, data were collected in two sub-counties, Kilifi North which is more urbanized, Kaloleni which is rural and areas in between which are peri-urban. The Atlantique department on the other hand has a high rate of post-abortion care (PAC) and an unmet need for contraception. The 2016 statistical yearbook of health indicates that 1921 women used PAC services, of whom more than 50% were aged 15 to 24 years (5). Additionally, only 14% of women in the department use modern contraceptive methods. The Atlantique department is composed of eight communes, five of which are purely rural. For this study, data was collected from two communes: Allada which is rural, and Abomey Calavi which is more urban. Data collection was focused on health facilities that had reported a high number of PAC cases in the preceding year and the neighboring communities.
Approach and study population
In both study settings, a team of young female research assistants with backgrounds in Anthropology and Sociology was recruited to collect data. In Kenya, four research assistants were based in Kilifi County with two in Kilifi north and the remaining two in Kaloleni while in Benin, two researchers were based in Allada and the remaining two in Abomey Calavi. Through their constant presence in the health facilities and the community, the research assistants were able to gain the support of healthcare providers, community health volunteers, and youth advocates in identifying adolescents and young women who had experienced abortion. A total of 95 adolescents and young women were recruited for the study, 54 in Kenya, and 41 in Benin. Their socio-demographic characteristics are described in Table 1. Informal exchanges, in-depth interviews, and follow-up interviews were conducted mainly in Swahili, sometimes mixed with English in Kenya while in Benin they were mainly conducted in Fon, Aïzo, and a few times in French. The constant interaction of the research assistants with the participants through home visits, outings to places of entertainment, offer of moral support, and referrals to services helped to build relationships of trust that allowed the participants to share their lived experiences. Twenty-nine (29) IDIs in Kenya and 21 IDIs in Benin were also conducted with other actors including male partners, aunties, mothers, fathers, uncles, sisters, friends, grandmothers, and grandfathers. The interviews aimed at documenting their perspectives on the woman’s abortion pathways, including the practices around pregnancy prevention, their reaction to the pregnancy, and their role in the decision-making process, as well as the care-seeking pathways. We also conducted KIIs (29 in Kenya and 40 in Benin) with community health volunteers, community leaders, health providers (private/public), pharmacists and drug vendors, traditional birth attendants, and policymakers. The observations, interviews, and informal discussions with those actors aimed at understanding their role in abortion and post-abortion services provisions in the county, including their rationale, challenges encountered, policies and guidelines in abortion services provision, training, and equipment in health facilities, among others. Additionally, 12 FGDs with mixed groups of young men and women aged 18–24, with mothers as well as with fathers of adolescents aged 30–55 were conducted in Kenya, and 15 FGDs in Benin. The youth groups were divided into male and female one. The FGDs covered topics including the social and cultural dynamics in which abortion is embedded, the transition to adulthood, perceptions of adolescent pregnancies and single motherhood in the community, parents-adolescents communication, reproductive decision-making, and induced abortion.
Insert Table 1 here
Table 1
Sociodemographic characteristics of girls and young women interviewed.
Characteristics
|
Frequency (N = 95)
|
|
Benin (N = 41)
|
Kenya (N = 54)
|
Age (Years)
|
14–19
|
11
|
12
|
20–24
|
19
|
38
|
25–30
|
5
|
5
|
31–40
|
7
|
0
|
Highest Level of Education
|
No Formal education
|
7
|
1
|
Primary school
|
7
|
18
|
High school
|
21
|
28
|
College
|
6
|
7
|
Area of Residence
|
Urban
|
10
|
12
|
Peri-urban
|
8
|
16
|
Rural
|
23
|
26
|
Marital Status
|
Married
|
8
|
3
|
Separated
|
5
|
4
|
Never Married
|
28
|
47
|
Occupation
|
Student
|
17
|
19
|
Employed/informal laborer*
|
22
|
19
|
Unemployed/housewife
|
2
|
12
|
Sex worker**
|
0
|
4
|
*hairdressers, housegirls, bartenders, shopkeepers, waitresses, tailors, a casual worker at the cereals board plant
**Unique to participants in Kenya
|
Data Analysis
All audio recordings from FGDs, IDIs, and KIIs were transcribed verbatim and translated into English and French. As an initial analysis step, a coding scheme was developed jointly by the research team based on the initial thematic proposal and emerging themes from the data. An inductive method was employed to identify patterns and relationships to build on the main themes (24). The data was coded using Dedoose software by seven full-time coders, all except one coder had been involved in the research before the coding started. The team then met weekly (virtually) to discuss the consistency and duplications of the codes to enable further analysis in a more nuanced qualitative way. Finally, the findings were presented using verbatim quotes from interviews with participants using pseudonyms to protect their identity.
Ethical approval and informed consent
Before going to the field, ethical approval and research permits were obtained. The African Population and Health Research Center (APHRC) ethics review committee approved the study protocol for scientific soundness. In Kenya, further ethical approval was obtained from the AMREF Health Africa's Ethics and Scientific Review Committee (ESRC), and research clearance was obtained from the National Commission for Science, Technology, and Innovation (NACOSTI). In Benin, ethical approval was obtained from the ethics and research committee of the institute of applied Biomedical Sciences (ISBA) and authorization from the ministry of health. In both countries, further approval and permits were obtained from local administrative and health authorities including county directors of education and health in Kenya, health facilities administrators, chiefs and assistant chiefs, and village elders. Before the commencement of each interview, research assistants obtained informed consent from participants by first explaining to them the objectives of the study, the procedure, the risks, and the benefits. For participants below the age of 18, we did not seek parental consent given the sensitivity of the issue and the fact that the study represented a minimal risk to them. We sought and obtained a waiver from the ethics committees in both countries.
Findings
In this section, we present the emerging themes from our analysis of the interviews in Benin and Kenya. We begin by describing the array of methods used by the participants to terminate pregnancies and then the motivations for the specific methods women ultimately used to terminate pregnancies. We present the motivations for various abortion methods including; a) The pursuit of social safety, b) the Influence of partners, friends, and relatives, c) Knowledge, and awareness of different methods of abortion, d) Healthcare barriers, and e) Affordability and costs.
Abortion methods
Analysis of participant interviews revealed a variety of methods used by women in Benin and Kenya to terminate unintended pregnancies as summarised in Table 2 below.
Table 2
Summary of different abortion methods used by women
Abortion Methods
|
Benin
|
Kenya
|
Herbs
|
Castor seeds, Kodô, Tisanes (Herbal tea), hyssop leaves.
|
Shubiri, Mjaji, Mkilifi, Mwarubaini, Aloe vera
|
Home remedies/concoctions
|
Concentrated lime juice, Sodabi, a mixture of Guinness and Moca, Seven up, fresh coconut water, La Pottasse (Potash).
|
Boiled coca cola drink, concentrated quencher drink.
|
pharmaceutical/unknown drugs
|
Sédaspir, Nivaquine, Paracetamol
|
Unnamed hormonal drugs
|
Insertion of sharp objects
|
Wooden straw
|
-
|
Surgical abortion
|
Curettage, Manual Vacuum Aspiration (MVA)
|
Manual Vacuum Aspiration (MVA)
|
Medical abortion
|
Mifepristone and Misoprostol
|
Mifepristone and Misoprostol
|
As highlighted in the table above, the methods ranged from homemade concoctions using local herbs, high doses of pharmaceutical drugs, medical abortion drugs, and surgical abortion. In Kenya, women mentioned bitter herbs useful for the termination of pregnancies such as Shubiri, Mkilifi, and Mjaji (These are different types of succulent plants used to make medicinal or herbal medicines) while in Benin, they cited castor seeds, Kodô (caïlcédrat tree bark or roots known to be bitter and used to treat different medical conditions), concentrated lime juice or Sodabi, hyssop leaves and fresh coconut water. Apart from surgical abortion, (MVA or curettage which is mostly used by quack doctors) and sometimes medical abortion methods which were administered in health facilities or at medical providers' homes, all other methods were administered by the women themselves, usually through drinking or inserting in the vagina. In both contexts, participants mentioned obtaining the herbs in their local surroundings, from street vendors, traditional healers, or through friends/relatives/confidants as illustrated in the quotes below;
(…) There was my friend who removed it (pregnancy), so when I was pregnant, I did not tell her I was the one, I asked what she used because there was someone who wanted to remove it. Then she told me she used leaves from theMkilifitree. So I went back home and boiled the leaves ofMkilifiand drank it, then I started bleeding. (17-year-old, single, primary school student, urban Kilifi)
I went to a lady who sells bush medicines and explained my case to her. She then sold me some[...]When I took the medicine there, I went to my little sister's house and I started to prepare and drink Kodô. (32-year-old, Widowed, Businesswoman, Urban Benin)
In some cases, participants also explained that they depended on herbs that they normally use for other reasons, such as for treating ulcers. As described by a young girl in Kenya, she was not sure Shubiri would work because she normally only use it for stomach problems, yet, she still used it;
I usedShubiri, I normally take it when I have stomach problems (Ulcers). I wasn't sure it would work. I was just trying ( 22-year-old, Single girl, College student, Rural Kilifi)
Some of the participants also reported the use of high dosages of pharmaceutical drugs to terminate pregnancies. Often, these would be over-the-counter drugs contraindicated in pregnancy. In Benin for instance, participants reported commonly using Nivaquine and Sédaspir. Nivaquine is an over-the-counter drug containing chloroquine used to treat malaria while Sédaspir is used to treat conditions like apnea of prematurity, rheumatic arthritis, fever, and pain among others. Both drugs are ill-advised during pregnancy. Participants would usually mix it with herbs or take it in high doses. In Kenya, some participants also reported using drugs used for the treatment of other reproductive issues like hormonal imbalance. As such, there was no guidance or recommendation on the dosage of the pharmaceutical drugs and women would take as much as possible until they induced abortion. This is illustrated in the quotes below.
I bought Sedaspir first and I went to the lady and I told her that I did not get my period today, tomorrow it may not come. The lady told me to buy Kodô and to go and prepare to drink it warm with the Sedaspir tablets ….. I said ok and I started but the Sedaspir that she sold me is not of good quality because it breaks into pieces by itself. I took a lot without any results. I understood that it was not effective because I did not get the expected results. I felt nothing in my belly but there was still something moving. So when I went to Houègbo I looked for where they sell Sedaspir there. A lady sold the three tablets at 500 fcfa, and I bought Kodô in addition and I looked again for a leaf that looks red. (40-year-old, divorced, Businesswoman, Urban Benin).
In Benin and Kenya, homemade concoctions were common, especially among school-going adolescents given that they are easily accessible and inexpensive. Some of the common concoctions reported by participants in Kenya included boiled soft drinks such as coca cola and concentrated quencher orange juice. In Benin, participants indicated a mixture of alcoholic and soft drinks such as Guinness and Moca, SevenUp, and la potasse (caustic substance) as common concoctions used to terminate pregnancies, as illustrated in the quotes below;
One of my friends told me I could drink concentrated juice since I didn’t have money. I went to the shop and bought the quencher (processed orange juice usually diluted with water before consumption), the small one. I went to my friend's house and drank one glass. Immediately after drinking, I had a lot of pain, I was also bleeding a lot. It was very painful. I bled a lot for one week. (24-year-old, Single girl, College, Urban Kilifi)
In our neighborhood, I had heard that a lady had an abortion but they said she used Seven-up with something you call, "akango" (la potasse in French which refers to calcium chloride)......And besides that, they said others use leaves, and medicines that they prepare. That is why I tried the same. (19-year-old, single girl, student, urban Benin)
Albeit few, some participants used medical abortion and surgical abortion as the first methods of pregnancy termination. During our interviews, participants who used medical abortion described the method using the route of administration indicating “ one drug is inserted in the vagina and another one under the tongue.” The specific names of the drugs were unknown to them. A few participants reported having used surgical methods of abortion;
I didn't go far. It's just here in the neighborhood, I went and told the doctor the situation I was in, and that I was begging for his help. Then he said, now that I had decided, he would help me. So he put one drug in me, down there (the vagina) and I then swallowed another one. (21-year-old, single, waitress, semi-urban Kilifi)
In the end after the ultrasound, the doctor told me that the stage at which the thing (pregnancy) is that it is better to do, I do not know… (What they call it) aspiration or curettage or I do not know what. (23-year-old, Single, Student, Rural Benin)
The above excerpts show that medical and surgical abortion was chosen when the participants sought services at (private) health facilities, and pharmacies and met with providers willing to help them, or they went to health workers they knew who offered abortion services from their homes.
Some participants ultimately used multiple methods to achieve their pregnancy termination. A few citations above already reveal that many women went for mixed methods to terminate a pregnancy or tried out different ones (multiple methods) subsequently when they thought one method would not work effectively.
Women would use the same abortion method multiple times, or different methods sequentially or simultaneously. On occasions where women went for multiple or mixed methods, we observed herbs, pharmaceutical drugs, or homemade concoctions to be the first and most sought method. Women would then reach out for medical or surgical methods by going to the hospital for post-abortion care once they experienced complications from their self-administered methods. The table below highlights some of the mixed and multiple methods used by women.
Table 3
Examples of the use of multiple and mixed methods
Age (Years)
|
Country
|
Residence
|
Multiple/Mixed Methods used
|
22
|
Benin
|
Rural
|
Sedaspir together with Kodô
|
40
|
Benin
|
Peri-urban
|
First attempt: Sedaspir and alcohol, followed by Sedaspir with Kodo.
Second attempt: Kodô + Sedaspir Ibuprofen, Kodô+ Sedaspir herbs
|
23
|
Benin
|
Urban
|
First attempt: Two different herbal plants + consultation with a traditional healer
Second attempt: surgical abortion.
|
23
|
Benin
|
Urban
|
Guinness + tisanes + paracétamol.
|
19
|
Benin
|
Peri-urban
|
First attempt: salt water, Nivaquine + contraceptive pills
Second attempt: surgical abortion
|
26
|
Benin
|
peri-urban
|
Nivaquine + Café
|
22
|
Benin
|
Rural
|
Nivaquine (5 times) + lemon juice
|
24
|
Benin
|
Urban
|
First attempt: Cytotec
Second attempt: Guinness
Third attempt: Unknown medicine
|
17
|
Kenya
|
Urban
|
Mixed Method: MJaji + Mkilifi
|
22
|
Kenya
|
Rural
|
Mixed Method: Mjaji (herbal tree), Mwarubaini
(neem tree) and Shubiri (herbal tree)
|
15
|
Kenya
|
Rural
|
Mixed Method: Shubiri and Mwarubaini (neem tree)
|
29
|
Kenya
|
Rural
|
Abortion pills- 4 attempts + MVA
|
18
|
Kenya
|
Urban
|
One method multiple times: Abortion pills twice
|
24
|
Kenya
|
Urban
|
Mixed Method: Mix of traditional herbs and tea leaves
|
21
|
Kenya
|
Urban
|
First attempt: Shubiri tree (Unsuccessful)
Second attempt: Abortion pills (Unsuccessful)
Third attempt: MVA (successful)
|
22
|
Kenya
|
Urban
|
Multiple Methods: Aloe vera + Shubiri (Unsuccessful), Medical Abortion
|
16
|
Kenya
|
Urban
|
Multiple Methods: Medical abortion, MVA
|
Women in Benin and Kenya shared great similarities about their first choice of abortion method; in rural areas, herbs and homemade concoctions were predominantly used, although in Kenya, in rural areas medical abortion was also common. In Kenya, medical abortion pills were far more commonly used in general whereas in Benin the use of medical abortion was less common. While we had a higher number of participants using high doses of pharmaceutical drugs like Sédaspir, Nivaquiné and Paracetamol mixed with traditional herbs in Benin, our participants in Kenya hardly used high doses of pharmaceutical drugs. Additionally, the use of homemade concoctions differed in Benin from Kenya. In Benin participants often mixed alcoholic and soft drinks to come up with drinkable potions. In Kenya, participants reported drinking soft drinks either in concentrated form or boiled on high heat before consumption. While homemade concoctions in Benin were used by participants of varying ages, we observed homemade concoctions to be used by mostly school-going adolescents in Kenya. Only one participant in Benin used a sharp object. The Kenya field researchers attributed the absence of the use of sharp objects to the wide availability of abortive herbs growing in the environment of Kilifi, as compared to some other regions in Kenya where they identified more common use of sharp objects when carrying out a different research project.
Motivations toward different choices of abortion methods
The pursuit of social safety
Our participants chose methods that would conceal their abortion experience from people in the community (friends, parents, and neighbors). This avoidance of exposure was not only limited to the girl, but also the girl's boyfriend or partner, or husband. The partner or the girl would therefore facilitate access to a method that guarantees privacy and confidentiality of the abortion process. As explained by a community health volunteer in Kenya, people avoided going to health facilities to seek abortion services because a visit to the health facility risked them being seen by people they know.
Yes, if they want it to be a secret, if they go to a hospital, it will be known that so and so has gone to the hospital, to do what? So if that boy does not want to be known. And in most cases, the reason they go to those traditional healers is that it is a secret between him and the girl. (Community Health Volunteer, Urban Kilifi)
The pursuit of secrecy was linked to efforts to preserve social relationships and avoid shame. As one of the participants noted, she had been dating a married man and if her pregnancy or abortion was known, she would be shamed, so she went for Shubiri because it is often used for the treatment of many other ailments and no one will know why she is taking it;
I used Shubiri, I normally take it when I have stomach problems (Ulcers). I wasn't sure it would work. I was just trying……No one could find out about it because they would shame me for dating a married man but I did not know he was married until I got pregnant. ( 22-year- old, Single girl, College student, Rural Kilifi)
In both countries, parents (especially mothers) and grandmothers were also seen to be pursuing secrecy. Mothers were reported to be taking part in the search for abortion methods for their daughters, to keep people (including their husbands and inlaws) from knowing about the abortion, and to avoid insults from community members. As narrated by a girl in Kilifi, her grandmother provided Mkilifi herbs to her to terminate a pregnancy after her boyfriend denied the pregnancy, and it was going to be shameful if others heard about it, as illustrated in the quotes below;
The mother is often afraid of insults from her husband or the family so she quickly looks for the person who can help her without anyone knowing. She and her daughter go to the person. So it's only mum and daughter who know the secret. Even now there is a similar situation. Sometimes the mother was also confronted with insults from members of her in-laws because of some of her behavior. So running away from comments and insults again she quickly finds people who can help her daughter to get rid of the pregnancy. ( FGD, women, Urban Benin)
When I told my boyfriend, he said that pregnancy is not his, he did not make me pregnant. I have never been with another man. I told my grandmother that the man had denied the pregnancy. She thought it would be shameful if others heard about it. She then took Mkilifi, boiled it, and gave it to me to drink. I drank and kept drinking many cups of water, then I started bleeding. The concoction was very bitter, it was painful. Up to now, I am feeling dizzy when I stand and walk. I still bleed a lot up to now. When I walk and carry water, if I stop, I just feel a lot of blood coming out. (21-year-old, single girl, manual worker, urban Kilifi)
Social safety motivated girls, their partners, and female parents or guardians in an attempt to evade the stigma and discrimination associated with abortion.
Influence of partners, friends, and relatives
The findings in both countries show that girls' decision on which method to use was in some instances influenced by their relatives (aunties, siblings, acquaintances who are health providers, parents, grandparents) as well as their partners. These actors helped by advising, choosing, and at times being the providers of the abortion methods. These networks were mainly motivated by social safety (pursuit of discreteness on their abortion experience to maintain their social dignity and respect) of the women procuring the abortion, availability of resources and knowledge on the availability of abortion services, exposure, and where to find the abortion services. The quote below shows an example of a young woman who reaches out to her aunt who is her confidant and she provides her with abortion drugs.
My Aunt is like my confidant. She knew that I had a boyfriend. So when I told her, she told me to go to her place and that she can help me. She told me to come with 6000 Kenyan shillings. I told my boyfriend and he sent her the money directly. So when I arrived there, she gave me a drug that I took, it was only one tablet. After taking it, I started bleeding and had a lot of cramps. It was so painful. (23-year-old, Single girl, Unemployed, Urban Kilifi)
Participants reported that parents especially mothers, were important decision-makers in the abortion experience and in directing which abortion method was to be used. Occasionally, women would refer their daughters to a private practitioner; afraid of the consequences of traditional methods. The mother of Gbéta (pseudonym), 18 years old in rural Benin told us about a conversation with her son who asked her how she would handle the daughters’ abortion: “I told him I don't know anything traditional and if I did something traditional and killed my child, I would have lost it…” The mother was able to use the money from a savings group to pay for her daughter's abortion in a private clinic.
Male partners played varied and significant roles in the choice of abortion methods used by their partners in procuring an abortion. While some directed their women towards the use of safe abortion methods, for some it was the contrary. The excerpts below illustrate the two opposite scenarios.
He (Her partner) took me to that old woman, it was scary. The woman said that I have to accept to either die or live because there are different pregnancies, others are difficult, and others are easy. (21-year-old, single, house help, Urban Kilifi)
We were together and then I told him (the partner) that I am pregnant. At first, he was shocked, so I asked him what we were going to do. My mother, I don't know how to tell her. He then told me "then let us remove it." He then looked for a doctor for me, and I then went and removed that pregnancy. But then the pregnancy was big, there is…The doctor told me if I insert these drugs it won't come out because that wants like a month-old pregnancy. I had reached three months. He had to use the other method, that of 'kuvuta mtoto ile na ile chuma' (pulling the baby, that one with a metal). I felt a lot of pain until I said…then lost a lot of blood. That thing is very risky. (18-year-old, single, student, semi-urban Kilifi)
Partners of the women choose the methods of abortion and accompanied them for the services. However, the choice of method was unsafe as partners were motivated by their need to keep the pregnancy a secret and preserve their social status, sometimes the safety of the girl, and the nature of the relationship they had. The nature of partners' involvement tended to be mostly financial, which, at times, enhanced access to certain types of abortion methods. In some cases, partners were helpful with information on abortion methods, and where possible, they would seek advice from health providers within their circle, as reported in Benin.
At the moment, if I find some money, I send them. I consulted someone in my family, who is a doctor in Sèmè so the doctor came to speak with her, she explained the situation to the doctor and she told the doctor that she was thinking of having an abortion. (Male partner to a 19-year-old, Urban Benin)
The influence of social actors in abortion methods however does not simply come as a process of negotiation and discussion, for some this is through coercion or deceit to terminate a pregnancy. In these instances, women have little or no opinion on the method used for the termination of their pregnancy. Telling of this case is the story of Lucrece, a 19-year-old in Benin, whose parents decided she should have an abortion. While she and her boyfriend were willing to keep the baby, she had also told her parents she would accept their decision. One morning without explaining anything, her father drove her to a clinique where he left her for abortion and recovery on her own for days without money for food. The father was out to punish her and said very ugly things to her.
My dad [was] saying that I can die, that it's none of his business, that I can die…The doctor asked me if I was brave [to undergo the abortion procedure without crying ] [...] I said yes. And my daddy told him I'm a demon [...] [that] I'm never going to shout that I'm too stubborn[...] [then] my dad took his motorbike and left. And that left me and the doctor alone there. And my dad refused to give me any money. (19-years-old, single girl, student, Urban Benin)
In the case of Lucrece, her father was abusive and she showed herself submissive to his choices, while he brought her to a doctor that insulted her on her father's behalf before treating her. On other occasions, boyfriends gave their pregnant girlfriend medication without their knowledge or coerced them to take it, as described in the case of one girl in Kenya.
When I was going to school, I was taken by two people, a man and a woman on a motorbike. They forced me to go with them, so when they took me, I was not comprehending anything. (...) They gave me some medicine. But I refused to take it. So, they put it in water, held me down, and forcefully gave me. (15-years-old, Single, Primary School Student, Rural setting).
In the case of this girl, the individuals who kidnapped her were the boyfriend's sister and a man acting on the behalf of the boyfriend who was studying in the country's capital city Nairobi. In those situations, the girls did not decide to have an abortion, nor which method to use. The decision was solely made by their partners (or people acting on their behalf) who managed to get the abortion drug and get them taken by the girls.
Knowledge And Awareness Of Different Abortion Methods
The choice of some of the abortion methods described above depended on the knowledge that women had. Before contemplating an abortion, most women did not have sufficient information on the different abortion methods that exist. They often had heard of specific herbs that would work, or of 'abortion pills, which are sometimes confused with emergency contraceptive pills. Abortion is a very taboo topic among these communities, and accessibility to appropriate and comprehensive information on abortion methods remains a challenge. The quotes below illustrate this;
Before my own experience, I had not heard about how people end pregnancy nor knew of anyone who had done it. (18-year-old single girl, apprentice, rural Atlantique)
It was one month. Because I started feeling unwell and wondered what was wrong with me. That's when I tested and saw two lines. Then I started asking around what people do when they get into such situations and people told me different things. After they told me that I should start with the Shubiri. (24-year-old, single girl, Bar waitress, Rural Kilifi)
As described above, before the pregnancy, the young women were unaware of ways to terminate the pregnancy. The information they had was vague and based on hearsay. In Benin and Kenya, the only thing many young women knew, was that one could die as a consequence of abortion, as they witnessed this in their community or heard about it from their mothers. In addition, knowledge about safe abortion methods like medical and surgical abortion is very limited for example in the case of the 21-year-old girl in Kilifi below;
I did not think of going to the hospital because I hadn't sat down with anyone to give me a hint of how they abort pregnancies at the hospital. I didn't know what they used; drugs or something else. So when I heard that Shubiri can work I thought to try it because I hadn't heard anyone else's experience of how they do it at the hospital. (21-year-old, single girl, student, Kilifi Urban)
What I knew about abortion is what I learned in the pharmaceutical field. I didn't know if there are traditional things that are used for abortion. I just knew that there are abortion drugs. But I was afraid to take them because they can cause death. (26-year-old, sells drugs at a pharmacy, Urban Benin)
In seeking information and methods to terminate their pregnancy, our data show that it is rare for women to seek multiple sources of information before deciding which abortion method to use. The secrecy surrounding unwanted pregnancy and the stigma of abortion would prevent a thorough search for information and careful evaluation of options. Women would rather go for the only advice they can obtain from that one person they trust enough to ask for information. In such situations, girls would ideally try to confide in someone they know to have procured an abortion because they won't judge them and they would advise them on a 'safe' effective abortion method.
I believed the girl because it's something that she experienced so according to the way I was thinking, they were four tablets, two you swallow, two you put down there so I saw that these are the ones people talk about and they didn't reveal more. Also, she was someone close, and it's as if she's also a relative so I said she can't want this thing to harm me so if it works it works if it won't then okay. I had decided if I take them it's either it saves me or I die. I was ready for anything. ( 22-year-old, student, single, rural Kilifi)
Our participants hardly mentioned the use of the internet and helplines as resourceful sites for information on abortion. One participant in Kenya tried to use a helpline but did not get the help needed because no one picked up the call despite numerous attempts. Only two participants in Benin mentioned having obtained information on abortion methods on the internet, one, after her partner had described the surgical abortion method to her as something painful and she felt she needed more information on the procedure while the second case the partner used the internet to find information on general topics but in the end relies majorly on his friends within the healthcare profession for guidance.
I went on the internet, looked up the different abortion methods that exist, um drugs that could induce abortion, which ones you could get without a prescription and I found in my research that everything that could do the job was necessarily under prescription. I found in my research that anything that could do the job was necessarily prescribed, Cytotec in particular. (28-year-old, married, facilitator, Urban Benin)
The internet told me when it's in the beginning, I think, up to two months, some medications make it go away… the internet informs me a lot but at the moment, I have a lot of friends in medicine [child cries] I have a lot, a lot, a lot, a lot, so when I have a little situation, I call them, Hello! I have such and such a problem, how is it managed? (male partner, 36-year-old, Technical officer, Rural Benin)
In both cases above, trustworthy information was found about safe methods (suction, and MA) by educated young people. On the other hand, the internet may refer one to unsafe methods such as herbs and concoctions as these are widely promoted online on Benin Facebook pages for example, or underneath YouTube videos from the Benin abortion law reforms. On both sites, phone numbers are included.
Ultimately, then, the large majority of girls and young women end up depending on their peers and female relatives or vendors and friends for advice on medication, often referring them to traditional methods/ pharmaceuticals and/or homemade concoctions. These people might also know individuals that can help in acquiring abortion methods, including pills, and even in procuring the abortion through surgical methods. Many participants cite their peers and friends as their sources of information. However, information from friends and relatives is highly diverse and fragmented based on their own experience and knowledge of other women, making it highly heterogeneous and different from medical standards.
We observed that young women's final choice of abortion method was shaped by their initial sources of information. In both rural and urban settings of Benin and Kenya for example, most women reported using herbs as an abortion method because they learned about them from peers and older women in the community. Younger girls in Kenya reported using homemade concoctions as they learned about them from their peers.
Healthcare Barriers
Interviews revealed how abortion is perceived as a criminal act, and girls and women known to have procured an abortion face the risk of arrest and prosecution. By presenting at health facilities with abortion-related complications, health providers often threatened to call the police on some girls. Additionally, girls would get harsh judgment and maltreatment from healthcare providers when they presented any abortion-related issues. The quote below illustrates this.
Yes. I had gone to pay. I went downstairs to pay. When I was down there paying they saw what the paper explained and they said, “You school children come here after abortion and come here for blood transfusion. Wait here we call the police.” When they were about to call, there was another mother who said, “Don’t do that. She is paying the money. (Mother of an 18-year-old, primary school student, Rural Kilifi)
If I go to a hospital, I will be told I am a murderer, they will tell me a lot of bad things, ( 20-year-old, Single girl, Manual worker, Urban Benin)
However, legal restrictions on abortion are not only limited to women but also to healthcare providers. Healthcare providers in some cases decline to offer pregnancy termination services for fear of persecution. Additionally, religious and personal beliefs also influenced healthcare workers' attitudes toward abortion patients. Some healthcare providers displayed negative attitudes towards abortion patients and declined to offer abortion services such as manual vacuum aspiration (MVA), saying it is a "dirty job" and that their religious beliefs do not allow them to perform abortion procedures. Participants also showed how some health care providers (especially in Kenya) discriminated against patients seeking abortion services (e.g., uterine evacuation using MVA after an unsuccessful abortion attempt) and gave priority to other patients seeking other health services. Interviews and observations with providers also indicated that most of the time they conduct painful procedures such as MVA with no effort to manage the pain for patients. These are illustrated in the quotes below.
I do not offer [...] abortion services because my faith does not allow it. ( KII, Health care provider, Public facility, Urban Kilifi)
That thing (MVA) is very painful, we do it as if it is not painful but it is very painful. I don’t like those dirty jobs…….the blood that comes out of there is dirty, you know as doctors, we like clean blood, fresh blood. But those come out as clots. I don’t like that. ( KII, health care provider, Public facility, Urban Kilifi)
Moreover, girls and young women especially in Kenya associated health facilities with unsafe abortion methods based on stories they heard of other women who died getting an abortion from a health facility. This situation could be explained by insufficient training of health care providers to perform an abortion in the past. Despite the changes and reforms in the medical sector women remain unaware of safe abortion methods offered in health facilities.
Affordability And Costs
Affordability and costs are also crucial determinants of the choice of abortion method used by women in Benin and Kenya. Due to the legal restrictions in both counties, most abortion services were clandestine. Therefore, the prices could not be regulated and were often raised by abortion providers and clinics depending on how desperate girls and young women seeking abortion services were. The costs of medical and surgical abortion in both Benin and Kenya were relatively high for most women as mentioned by our participants. In Benin, most participants reported using between 25,000 and 100,000 Francs (USD 40–160) to get either medical or surgical abortion, while in Kenya participants needed between Kenyan shillings 3000–20000 (USD 25–160). Herbs, on the other hand, were cheaper, Benin participants used between 300–1000 Francs (USD 0.5–1.6), and in Kenya, between Kenyan shillings 50–100 (USD 0.4–0.8) or they would find them for free around their homes. Most of the women in our study reported that they resorted to homemade concoctions and traditional herbs because they were cheaper compared to medical and surgical abortion. Additionally, often women depended on their partners to cover the costs of abortion and therefore their choice of abortion method was limited to the amount of money given by their partners.
If I had my own money, I would have gone to the hospital. But he took me to that old woman, it was scary. The woman said that I have to accept to either die or live because there are different pregnancies, others are difficult, and others are easy. (21-year-old, single, house help, Urban Kilifi)
no! When I bought the test and I did it and the lady said that I am pregnant and I said what am I going to do now, and the lady said; first of all, the lady said that she is going to take me to a guy but I am going to have to find 2000f first and I said that I don't have any money and if it is so that I have 1000f like that and I handed that to the lady. But when I gave it to the lady, she didn't take me to the guy anymore, she made me the tea and I drank. (18-year-old, single, student, rural Benin)
Further, they were a lot of misinformation and discrepancies on the standard costs of medical and surgical abortion methods. Our participants reported having been deceived by healthcare providers and social actors within their network to give more money than they should to get an abortion. On other occasions, some girls took too long to raise money to visit a health facility without success and ended up using unsafe abortion methods that were cheaper- which may lead to unsuccessful and repeat attempts as illustrated in the quote below.
…the first doctor I used three thousand, the second I used one thousand, five hundred and the third one I used three thousand, later added one thousand, five hundred shillings… So in total, I used nine thousand, two hundred and fifty shillings. I just felt bad when I remembered the cost I had incurred without success. ( 29-year-old, single, unemployed, Rural Kilifi)