Evidence – qualitative and quantitative – was generated from interviews with adolescents aged 10-19 years in Ethiopia, Malawi, and Zambia to understand how adolescent abortion-related care-seeking differs across a range of socio-legal national contexts. Our comparative study design includes countries with varying levels of restriction on access to abortion: Ethiopia (abortion is legal and services implemented); Zambia (legal, complex services with numerous barriers to implementations and provision of information); and Malawi (legally highly restricted). Most adolescents (98%) in Ethiopia obtained a medically safe abortion, with most adolescents (64%) in Zambia and almost all adolescents (94%) in Malawi obtaining a less medically safe abortion. A total of 313 facility-based interviews were carried out with adolescents aged 10-19 in 2018/19 in Ethiopia (n=99), Malawi (n=104), and Zambia (n=110). Adolescents were seeking public sector care for either safe abortion or post-abortion care for complications from an abortion initiated elsewhere. Adolescent recruitment was initiated by a study-trained senior nurse, who identified and invited eligible participants to participate in the study upon their readiness for discharge. Our research assistants (RAs) were all females in their twenties or early thirties and were recruited after the completion of intensive (two weeks) training from the project team that included role-playing and pilot interviews. We completed paid training for more RAs than the project required; performance during training and piloting were explicitly part of our RA recruitment process. Interviews with adolescents were conducted in a private setting in each facility by RAs fluent in all major local languages. Informed consent was obtained from adolescents aged 18 and above, while for those under 18, consent was sought from an accompanying parent or guardian with the respondent's assent. Unaccompanied respondents under 18 were considered emancipated minors, and their independent consent was obtained. Each adolescent in our study had one interview. A set of approaches were used to maximize the likelihood of disclosure of abortion-related behaviors, and to elicit the details, many of which were multiple attempts to end the pregnancy interwoven into a complex trajectory over weeks or months. For interviews where consent or assent was granted, they were recorded and subsequently transcribed (qualitative) and data entered (quantitative) by the RAs. In each interview, there were normally two RAs: one RA (Interviewer 1) conducted the interview in a conversational style to put the participant at ease and facilitate the narrative flow, whilst a second RA (Interviewer 2) completed the datasheet seated to the side of or behind Interviewer 1, so as not to influence or distract her from the conversation. Interviewer 2 was always positioned to be visible to the respondent [i.e.: not behind her]. As Interviewer 1 conducted the interview using a conversational style to follow and probe the responses, Interviewer 2 completed the datasheet (see below). Interviewer 1 did not write and was able to maintain eye contact and react to the adolescent’s body language, facial expressions, and emotions. Before closing the interview, Interviewer 1 re-introduced Interviewer 2 who would ask supplementary questions building on the conversation she had listened to. During training RAs had learnt and internalized the overall logic of the research project, so that when they were Interviewer 1 they knew the topics and questions that they needed to probe for. Our research project wanted to understand – in detail –adolescent abortion-related care-seeking. We wanted to generate quantitative and qualitative evidence quickly to minimize burden on respondents who may be feeling uneasy or uncomfortable after receiving abortion-related care. We needed a tool that would collect data quickly and facilitate disclosure. We refined a datasheet approach that had previously been used in a study of abortion care-seeking in Zambia (Coast and Murray 2016). Due to the number of closed questions, the datasheet shows superficial similarities to a survey questionnaire. Critically, however, the order of the questions was not pre-determined – RAs were able to decide which questions to ask depending on the conversation. Interviewer 2 added the information to the data sheet by following the flow of the conversation rather than a pre-determined order. The size of the datasheet (A3) allowed for notes on the tone or content of the discussion to be written on the margins or for detailed notes if consent to record was not given.

Topics: