I haven’t, but I would be interested to read more. Is there a reason to suppose it is more effective than standard contraception/sex ed-promoting interventions?
Hey Calum—yes these CE charities (Layifa, FEM and perhaps others) have great evidence behind them to support that their methods are far more effective than standard contraception/sex ed-promoting mechanisms. Would recommend checking them out.
Thanks for this. I have had an (admittedly short) scout around, and would be grateful for a bit more direction if possible. Both Lafiya and FEM seem to take women reached and contraceptive prevalence as their primary measured outcome—but this doesn’t get us what we need, since contraceptive prevalence can have both positive and negative effects on the abortion rate (due to risk compensation). Do you know if either have an RCT where they measure pregnancies (or, even better, abortions) as an outcome? If so, do you know where I could find this?
There’s likely not going to be a RCT looking at abortions as an outcome, due to ethical reasons.
Could you explain what those reasons are? It’s fine to have death, cancer progression, miscarriage and other bad things as endpoints, so I don’t see why abortion would not be an ethically permitted endpoint? In my experience most of the ethical concerns have been around the intervention you are permitted to vary, not the endpoint. Gathering data might be hard, but that seems like a practical limitation, not an ethical one.
In most African countries at least, most forms of abortion are illegal and carry a lot of social stigma. It’s not about the outcome just being bad life your other examples.
The only way to gather this data would be to ask people in in a survey, which (I could be wrong) I doubt you would get through a local ethics board both because of the stigma and the illegality.
And yes practicality would also be very difficult as people are very unlikely to admit to having had abortions anyway due to above reasons.
I’m a little bit locally focused though, there may well be parts of the world where this is possible and has been done, but I’m sure it wouldn’t be easy both ethically and practically anywhere in the world.
There are ways to survey about illegal/taboo topics. Researchers studying GiveDirectly use them when asking if people spent the money on drugs, for example.
One common technique is list randomization, which allows surveyors to collect statistically meaningful results without respondents having to admit to anything in particular.
There are lots of survey-based studies on abortion in countries where abortion is illegal—the problem is not so much getting it through an ethics board as the reliability of the results. You could alternatively measure using hospitalisations for incomplete abortion as a proxy—you won’t be able to identify the exact magnitude of the problem or the change since an unknown proportion of these are from miscarriages (some have tried to estimate the ‘natural’ miscarriage presentation rate, but I think these estimates are obviously unreliable), but you could see if there is a change and whether it is a big or small change, since the miscarriage rate should remain relatively constant. It would need a big enough sample size though.
Hey Callum practically wise on the ground here I would be like 70 percent sure that it would be impossible to meaningfully assess abortion reduction and a study endpoint
An anonymous survey based study is a lot easier ethics wise than a big RCT, I think it would be a struggle to get through ethics approval in Uganda here—again I have a bit of experience with ethics board but could be wrong. For better or worse (I think worse) ethics boards are understandably often tighter on RCTs than other study forms.
Yes, Marston and Cleland’s paper is helpful, I think. But I think developing countries are generally most likely to have risk compensation, since they tend to be more conservative sexually and thus have more capacity for increased risky sex. The countries where abortion and contraception are inversely correlated tend to be those which have already been through a kind of sexual revolution, and were using abortion as birth control (i.e. generally the Soviet bloc in the latter 20th century). But neither of those are true in most developing countries today.
I believe the charities have been incubated based on health economic evidence showing that they reduce negative health outcomes associated from unplanned pregnancies, presumably by preventing them, which should also reduce abortions.
Characteristics of the specific programs (setting, baseline effects, low-cost approaches etc) might make them more cost-effective than the average contraception / sex-ed program. Also, programs may be cost-effective despite small effects on abortion rates due to low costs.
I haven’t, but I would be interested to read more. Is there a reason to suppose it is more effective than standard contraception/sex ed-promoting interventions?
Hey Calum—yes these CE charities (Layifa, FEM and perhaps others) have great evidence behind them to support that their methods are far more effective than standard contraception/sex ed-promoting mechanisms. Would recommend checking them out.
Thanks for this. I have had an (admittedly short) scout around, and would be grateful for a bit more direction if possible. Both Lafiya and FEM seem to take women reached and contraceptive prevalence as their primary measured outcome—but this doesn’t get us what we need, since contraceptive prevalence can have both positive and negative effects on the abortion rate (due to risk compensation). Do you know if either have an RCT where they measure pregnancies (or, even better, abortions) as an outcome? If so, do you know where I could find this?
That’s an interesting question. You are right that contraceptive prevalence can have both positive and negative effects on the abortion rate
https://www.guttmacher.org/journals/ipsrh/2003/03/relationships-between-contraception-and-abortion-review-evidence
But I hard to plausibly see how in developing countries contraceptive use could ever do anything other than reduce abortions, but I could be wrong.
In terms of reducing pregnancies.
Here’s one RCT showing a 40% reduction in pregnancies after a family planning intervention in Malawi
https://pubmed.ncbi.nlm.nih.gov/35609202/#:~:text=Studies%20have%20suggested%20that%20improving,and%20birth%20spacing%20is%20lacking.
There’s likely not going to be a RCT looking at abortions as an outcome, due to ethical reasons.
Could you explain what those reasons are? It’s fine to have death, cancer progression, miscarriage and other bad things as endpoints, so I don’t see why abortion would not be an ethically permitted endpoint? In my experience most of the ethical concerns have been around the intervention you are permitted to vary, not the endpoint. Gathering data might be hard, but that seems like a practical limitation, not an ethical one.
In most African countries at least, most forms of abortion are illegal and carry a lot of social stigma. It’s not about the outcome just being bad life your other examples.
The only way to gather this data would be to ask people in in a survey, which (I could be wrong) I doubt you would get through a local ethics board both because of the stigma and the illegality.
And yes practicality would also be very difficult as people are very unlikely to admit to having had abortions anyway due to above reasons.
I’m a little bit locally focused though, there may well be parts of the world where this is possible and has been done, but I’m sure it wouldn’t be easy both ethically and practically anywhere in the world.
There are ways to survey about illegal/taboo topics. Researchers studying GiveDirectly use them when asking if people spent the money on drugs, for example.
One common technique is list randomization, which allows surveyors to collect statistically meaningful results without respondents having to admit to anything in particular.
There are lots of survey-based studies on abortion in countries where abortion is illegal—the problem is not so much getting it through an ethics board as the reliability of the results. You could alternatively measure using hospitalisations for incomplete abortion as a proxy—you won’t be able to identify the exact magnitude of the problem or the change since an unknown proportion of these are from miscarriages (some have tried to estimate the ‘natural’ miscarriage presentation rate, but I think these estimates are obviously unreliable), but you could see if there is a change and whether it is a big or small change, since the miscarriage rate should remain relatively constant. It would need a big enough sample size though.
Hey Callum practically wise on the ground here I would be like 70 percent sure that it would be impossible to meaningfully assess abortion reduction and a study endpoint
An anonymous survey based study is a lot easier ethics wise than a big RCT, I think it would be a struggle to get through ethics approval in Uganda here—again I have a bit of experience with ethics board but could be wrong. For better or worse (I think worse) ethics boards are understandably often tighter on RCTs than other study forms.
Thanks Nick. I have come across quite a lot of abortion surveys in countries with restrictive laws. Here is one from Uganda: https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0002340#sec007 I agree entirely that the results are likely not to be very reliable, but I think that is the bigger problem; less so the lack of ethics approval.
Yes, Marston and Cleland’s paper is helpful, I think. But I think developing countries are generally most likely to have risk compensation, since they tend to be more conservative sexually and thus have more capacity for increased risky sex. The countries where abortion and contraception are inversely correlated tend to be those which have already been through a kind of sexual revolution, and were using abortion as birth control (i.e. generally the Soviet bloc in the latter 20th century). But neither of those are true in most developing countries today.
I believe the charities have been incubated based on health economic evidence showing that they reduce negative health outcomes associated from unplanned pregnancies, presumably by preventing them, which should also reduce abortions.
Characteristics of the specific programs (setting, baseline effects, low-cost approaches etc) might make them more cost-effective than the average contraception / sex-ed program. Also, programs may be cost-effective despite small effects on abortion rates due to low costs.