RESUMO
Background: About 45.1% of all induced abortions are unsafe and 97% of these occur in low- and middle-income countries (LMICs). Women's abortion decisions may be complex and are influenced by various factors. We aimed to delineate women's abortion decision-making trajectories and their determinants in LMICs. Methods: We searched Medline, EMBASE, PsychInfo, Global Health, Web of Science, Scopus, IBSS, CINAHL, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest, and Google Scholar for primary studies and reports published between January 1, 2000, and February 16, 2021 (updated on June 06, 2022), on induced abortion decision-making trajectories and/or their determinants in LMICs. We excluded studies on spontaneous abortion. Two independent reviewers extracted and assessed quality of each paper. We used "best fit" framework synthesis to synthesise abortion decision-making trajectories and thematic synthesis to synthesise their determinants. We analysed quantitative findings using random effects model. The study protocol is registered with PROSPERO number CRD42021224719. Findings: Of the 6960 articles identified, we included 79 in the systematic review and 14 in the meta-analysis. We identified nine abortion decision-making trajectories: pregnancy awareness, self-reflection, initial abortion decision, disclosure and seeking support, negotiations, final decision, access and information, abortion procedure, and post-abortion experience and care. Determinants of trajectories included three major themes of autonomy in decision-making, access and choice. A meta-analysis of data from 7737 women showed that the proportion of the overall women's involvement in abortion decision-making was 0.86 (95% CI:0.73-0.95, I2 = 99.5%) and overall partner involvement was 0.48 (95% CI:0.29-0.68, I2 = 99.6%). Interpretation: Policies and strategies should address women's perceptions of safe abortion socially, legally, and economically, and where appropriate, involvement of male partners in abortion decision-making processes to facilitate safe abortion. Clinical heterogeneity, in which various studies defined "the final decision-maker" differentially, was a limitation of our study. Funding: Nuffield Department of Population Health DPhil Scholarship for PL, University of Oxford, and the Medical Research Council Career Development Award for MN (Grant Ref: MR/P022030/1).
RESUMO
INTRODUCTION: Globally, about half of all pregnancies are unintended and/or unwanted and three-fifths of these end in induced abortion. When faced with a choice to terminate pregnancy, women's abortion decision-making processes are often complex and multiphasic and maybe amplified in low- and middle-income countries (LMICs) which bear the major burden of abortion-related morbidity and mortality. Our review aims to (1) describe abortion decision-making trajectories for women in LMICs and (2) investigate factors influencing the choice of abortion decision-making trajectories in LMICs. METHODS AND ANALYSIS: We will search and retrieve published and unpublished qualitative, quantitative and mixed-methods, community and/or hospital-based studies conducted in LMICs from 1 January 2000 up to 16 February 2021. We will search Ovid Medline, Ovid EMBASE, Ovid PsycInfo, Ovid Global Health, Web of Science (including Social Science Citation Index), Scopus, IBSS, CINAHL via EBSCO, WHO Global Index Medicus, the Cochrane Library, WHO website, ProQuest and Google Scholar. We will search reference lists of eligible studies and contact experts for additional data/information, if required. We will extract all relevant data to answer our research questions and assess study quality using the appropriate appraisal tools. Depending on the extracted data, our analysis will use sequential or convergent synthesis methods proposed by Hong et al. For qualitative studies, we will synthesise evidence using thematic synthesis, meta-ethnography or 'best-fit' framework synthesis; and for quantitative findings, we will provide a narrative synthesis and/or meta-analysis. We will do sensitivity analyses and assess confidence in our findings using Grades of Recommendation, Assessment, and Evaluation -Confidence in Evidence from Reviews of Qualitative Research (GRADE-CERQUal) for qualitative findings and Grades of Recommednation, Assessment, and Evaluation (GRADE) for quantitative findings. ETHICS AND DISSEMINATION: We did not require ethics approval for this systematic review. We will publish our findings in an open-access peer-reviewed journal with global and maternal health readership. We will also present our findings at national and international scientific conferences.
