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Background: Despite the increased availability of safe abortion methods in sub-Saharan Africa, women and girls continue to use unsafe abortion methods and procedures to terminate their unwanted pregnancies, resulting in severe complications, lifelong disabilities, and death. Barriers to safe abortion methods include restrictive laws, low awareness of safe abortion methods, poverty, and sociocultural and health system barriers. Nonetheless, there is a paucity of data on the decision-making around and use of abortion methods. This paper aims to provide answers to the following questions: Which abortion methods do women and girls use and why? Who and what influences their decisions? What can we learn from their decision-making process to enhance the uptake of safe abortion methods? We focus our in-depth analysis on the rationale behind the choice of abortion methods used by women and girls in Kilifi County in Kenya and Atlantique Department in Benin. Methods: We draw on data collected as part of an ethnographic study conducted between January and August 2021 on lived experiences, social determinants, and pathways to abortion. Data were collected using repeated in-depth interviews with 95 girls and women who had a recent abortion experience. Data from the interviews were supplemented using information from key informant interviews, focus group discussions, and participant observation. Data analysis was conducted through an inductive process. Results: Our findings reveal that women and girls use various methods to procure abortions, including herbs, high doses of pharmaceutical drugs, homemade concoctions, medical abortion drugs, and surgical abortion methods. Procedures may involve singular or multiple attempts, and sometimes, mixing several methods to achieve the goal of pregnancy termination. The use of various abortion methods is mainly driven by the pursuit of social safety (preservation of secrecy and social relationships, avoidance of shame and stigmatization) instead of medical safety (which implies technical safety and quality). Conclusion: Our findings reaffirm the need for comprehensive access to, and availability of, abortion-related information and services, especially safe abortion and post-abortion care services that emphasize both medical and social safety. Plain Language Summary: Despite the availability of safe abortion methods in sub-Saharan Africa, women and girls in the region continue to resort to unsafe methods, leading to severe complications, disabilities, and maternal death. This can be attributed to restrictive abortion laws, lack of awareness on safe abortion methods, poverty, and sociocultural and health system barriers. This paper uses data from a larger ethnographic study in Kilifi County, Kenya, and Atlantique Department, Benin, to understand which methods women and girls use, and why, to help improve the use of safe abortion methods. Data were collected through in-depth interviews with 95 girls and women who had recently undergone an abortion, as well as key informant interviews, focus group discussions, and participant observation. The findings reveal that women and girls use various methods to terminate their pregnancies, including herbs, high doses of pharmaceutical drugs, homemade concoctions, medical abortion drugs, and surgical methods. They often use these methods once, multiple times, or in combination to achieve their goal. The main reason for their choice of methods is not medical safety but social safety, including preserving social relationships and avoiding shame and stigma. We conclude that there is a pressing need for greater access to accurate, well-framed information about safe abortion methods. Abortion services should consider not only medical safety but also discretion to mitigate the social implications of having an abortion in a medical facility. By addressing these factors, it is possible to enhance the use of safe abortion methods and reduce the reliance on unsafe practices. [ABSTRACT FROM AUTHOR]

Despite political commitments to address maternal deaths due to abortion, women and girls in Burkina Faso still face impediments to accessing post-abortion care (PAC) services, including stigma, high costs, and negative patient-provider relationships. Based on a three-year ethnographic study in Ouagadougou, Burkina Faso (2011–2014), this paper provides an in-depth examination of the experiences and perceptions of patients and healthcare providers when seeking or delivering PAC. Extensive participant observation of PAC service delivery was carried out in five primary and three referral health facilities, as well as in-depth interviews with 13 healthcare providers and 39 patients. Data were analyzed using a thematic analysis approach and discussed using relevant literature. Patients and providers conceptualized PAC as literally "womb washing", vividly reflecting on the realities around health risks of abortion, procreation and role of health providers. Moreover, women described PAC as a life-saving intervention capable of averting infections and other complications, but also bears significant risks of disclosure depending on the uterine evacuation technology used (manual vacuum aspiration versus medical abortion). In delivering PAC services, healthcare providers agonize over the dilemmas they face, mainly derived from their conceptualization of PAC services and how they cope with discomfort using PAC technology options. Our findings present the intersection between patients' and providers' conceptions of PAC, and how these perceptions drive the choice of technology for uterine evacuation to mitigate stigma. We argue that these perceptions drive patient and healthcare provider practices around decision making to seek or deliver care, and patient-provider interactions in health facilities. These findings offer important guidance for interventions seeking to improve access and quality of PAC. • Analyses views of healthcare providers and post-abortion patients in Burkina Faso. • Shows how women navigate PAC service access in a legally-restrictive context. • Explains how care providers and patients cope with abortion-related stigma. • Illustrates how PAC technologies can mitigate or worsen obstetric violence. [ABSTRACT FROM AUTHOR]

A key obstacle to advocacy efforts to promote legal and policy reforms that ensure women's and girls' access to comprehensive abortion care (CAC) is the lack of relevant and timely evidence. This commentary outlines a research agenda-setting initiative that identified research priorities to support evidence-informed policy and advocacy for CAC access in sub-Saharan Africa (SSA). It involved three phases: 1) a landscape analysis; 2) research agenda co-creation with stakeholders, and 3) a validation exercise on research priorities. Overall, the priority evidence needs included 1) estimating the incidence and magnitude of unsafe abortion and related costs; 2) examining the role of abortion laws and policies in facilitating or inhibiting access to CAC; 3) developing and documenting successful approaches for addressing societal barriers to the provision of CAC, and fostering a more inclusive and liberal abortion environment, and 4) documenting practice-based evidence on the provision of legal abortion services as well as for advocating for CAC. Various stakeholders, including researchers, policymakers, civil society organizations, and funding agencies, will find the agenda useful as they engage, at different levels, for the full domestication and implementation of forward-looking commitments on access to CAC in SSA. [ABSTRACT FROM AUTHOR]