Person:

Bartels, Susan

Background: Sexual violence is prevalent in eastern Democratic Republic of Congo (DRC), and has resulted in sexual violence-related pregnancies (SVRPs). Despite restrictive laws, women may seek to terminate SVRPs; however, there are limited data on termination of SVRPs. Methods: A mixed methods study was conducted in 2012 in Bukavu, DRC. Adult women who self-reported an SVRP and termination of that SVRP were recruited using respondent-driven sampling (RDS). Trained female interviewers verbally administered a quantitative survey to all participants and a semi-structured qualitative survey to a subset. Quantitative data on characteristics and complications of pregnancy termination, including mental health outcomes, were analyzed using SAS. Results: In total, 86 women completed quantitative surveys. Most SVRPs (93 %) involved two or more assailants; 73 % occurred while in captivity. Most women (82 %) terminated the SVRPs at 3 months gestation or earlier; 79 % reported one attempt at pregnancy termination and 21 % more than one attempt. The most common methods of termination were an oral medicine (55 %) or herb (35 %); cimpokolo (31 %) and quinine (18 %) were most frequently reported. These methods were accessed through friends (37 %), healthcare providers (18 %), family (16 %), or self-obtained (12 %). Following the termination, 79 % of women reported subsequent physical symptoms, including abdominal pain (74 %), bleeding (47 %), vaginal discharge (35 %) and fever (18 %); 44 % sought medical care for their symptoms. Varied emotional responses to the termination were reported and included relief (34 %), anxiety (21 %), anger (19 %), guilt (19 %), and regret (10 %). At the time of the study, many women met symptom criteria for post-traumatic stress disorder (57 %), depression (50 %), and generalized anxiety disorder (33 %). Conclusion: Most women terminated SVRPs using medications or herbs not recognized as evidence-based methods of pregnancy termination and sought these methods outside of the formal healthcare sector. These data suggest that access to safe abortion methods is needed for women with SVRPs in DRC. Physical symptoms and emotional reactions related to the termination varied. While it is not possible to differentiate the impacts of sexual violence, SVRP, and pregnancy termination on mental health outcomes, the findings highlight the complex needs of women with SVRPs and opportunities for integrative health services.

Background: Sexual violence has been prevalent throughout the armed conflict in eastern Democratic Republic of Congo (DRC). Research on sexual violence-related pregnancies (SVRPs) and pregnancy termination in eastern DRC, a context with high prevalence of sexual violence, high maternal mortality, and restrictive abortion laws, is scant but crucial to improving the overall health of women in the DRC. Understanding women’s perceptions and experiences related to an SVRP, and in particular to pregnancy termination in this context, is critical for developing effective, targeted programming. Methods: Respondent-driven sampling (RDS) was used to recruit two subgroups of women reporting SVRPs, 1) women raising a child from an SVRP (parenting group) and 2) women who had terminated an SVRP (termination group), in Bukavu, DRC in 2012. Semi-structured qualitative interviews on pregnancy history and outcomes were conducted with a systematically selected sub-group of women recruited through RDS methodology. Interview responses were translated, transcribed and uploaded to the qualitative data analysis software Dedoose. Thematic content analysis, complemented by the constant comparative technique from grounded theory, was subsequently used as the analytic approach for data analysis. Results: Fifty-five qualitative interviews (38 parenting group and 17 termination group) were completed. The majority of women in the termination group reported using traditional herbs to terminate the SVRP, which they often obtained on their own or through family, friends and traditional healers; whereas women in the parenting group reported ongoing pregnancies after attempting pregnancy termination with herbal medications. Three women in the termination group reported accessing services in a health center. Almost half of the women in the parenting group cited fear of death from termination as a reason for continuing the pregnancy. Other women in the parenting group contemplated pregnancy termination, but did not know where to access services. Potential legal ramifications and religious beliefs also influenced access to services. Conclusions: Women in this study had limited access to evidence-based safe abortion care and faced potential consequences from unsafe abortion, including increased morbidity and mortality. Increased access to reproductive health services, particularly safe, evidence-based abortion services, is paramount for women with SVRPs in eastern DRC and other conflict-affected regions.