Ernestina Coast

Whether, how, and when a person comes to recognise they may be pregnant can have significant implications for their health and wellbeing. Little theoretical or empirical work has interrogated the time-bound, varied processes that lead to pregnancy recognition. We develop a novel conceptual framework, using an inductive saturation approach to review literature published between 2000 and 2023 and workshops with multi-disciplinary researchers and experts. Our framework comprises three overlapping domains: assessing the possibility of becoming pregnant; interpreting signs and symptoms of a (potential) pregnancy; and opportunities for pregnancy confirmation. The framework includes an individual’s trajectory to recognising a pregnancy, recognising there is no pregnancy following suspicion there may be, and not recognising a pregnancy that could be recognised through other means (e.g. using biomedical testing). It is inclusive of diverse conceptualisations of what constitutes a pregnancy. Within these intersecting domains, we map factors influencing trajectories operating at micro, meso, and macro levels, identifying the connections between individuals, communities, policies, health systems and institutional structures. While pregnancy duration is linear, time manifests in different ways across an individual’s trajectory. Individuals might experience one or all the domains of pregnancy recognition, different factors within those domains, and may encounter them in differing order. Individuals may move between states of recognition and non-recognition, and experience liminal states in between them. A better understanding of pregnancy recognition provides policy and care practitioners with new insights into care-seeking related to pregnancy.

The experiences and timings of pregnancy recognition trajectories have significant impacts on pregnancy-related care. Understanding individuals' contextually informed trajectories is crucial to their reproductive rights and service delivery needs. While many studies take pregnancy recognition as a starting point, capturing the complexities and nuances of these trajectories has received much less attention. This paper critically reflects on new approaches to capturing pregnancy recognition trajectories in two studies conducted between 2018-19, one in Nigeria with women aged 18 and over (n=394), and a three-country study with adolescents aged 10-19 in Ethiopia, Malawi, and Zambia (n=313). Pregnancy recognition trajectories were complex and involved multiple physical, material, and psychological recognition factors. Adolescents in the three-country study cited predominantly between two and four factors that led to their pregnancy recognition, with a range of one to seven factors. In the Nigeria study, 43.4% of respondents named two factors that led them to recognise they were pregnant, with a range of one to five factors. As pregnancy recognition is the starting point for many public health actions and interventions, it is imperative that future survey tools better capture this complex and poorly understood process. Our analyses suggest that questions should include response categories that capture physical, material, and psychological contributors to pregnancy recognition including open-ended responses to capture heretofore unidentified aspects of this process. Questions on the duration of time between recognition factors would be beneficial, as well as an understanding of what factors were most important to an individual when recognising a pregnancy.

Emergency contraceptive pills (ECP) are an essential and unique postcoital method of preventing pregnancy. Trends in supply data show that sales of ECP are increasing at faster rates globally than many other contraceptives. Yet nationally representative survey data suggest that ECP use has remained relatively static overtime, suggesting significant measure and reporting issues. Accurate measurement of ECP use is critical for informing policies and programs that provide people the choice and freedom to exercise their reproductive rights. There is an urgent need for a revision of ECP measurement to better capture the realities of people's contraceptive needs and desires. In this commentary, we outline the key reasons why surveys may be underreporting and misreporting ECP. We focus on issues around current method‐specific measurements, definition issues around “use” and problems with survey questions and prompt phraseology. We illustrate the importance of recognizing other postcoital methods and strategies that people use when trying to prevent a pregnancy, and the implications this has for ECP measurement. As ECP use evolves, we offer recommendations for survey revisions and further research that can ensure that ECP measurement is robust and able to provide accurate reporting in the future.

Since the International Conference on Population and Development in 1994, global policies, and agenda‐setting milestones have emphasized that universal sexual and reproductive health and rights (SRHR) are unattainable without the meaningful engagement and inclusion of men. Despite this, the field of SRHR continues to struggle with how and in what ways men can and should be included in research, programs, and policies. In this commentary, we argue that the programmatic focus of SRHR limits the capacity to produce the data and evidence needed to inform gender transformational change. For men to be meaningfully engaged with by SRHR, researchers need an analytic lens that can capture the manifestations and outcomes of gender and power. We consider the conceptual complementarities between two theoretical frameworks: hegemonic masculinities and Reproductive Justice. We contend that bringing together these conceptual approaches to men and SRHR offers an analytic framework to iterate and innovate approaches to research. Such changes will allow for a greater interrogation of gender and power and the production of data and evidence necessary to grapple with the ongoing injustices that curtail people's sexual and reproductive freedoms.

Lack of access to safe abortions continues to be a major sexual and reproductive health concern. Adolescents can face barriers to safe abortions due to the unique implications of their age. Understanding adolescent abortion experiences and care trajectories is critical. Qualitative and quantitative evidence is analysed from interviews with 313 adolescents aged 10–19 years who sought abortion-related care in public health facilities in Addis Ababa (Ethiopia), Lilongwe (Malawi), and Lusaka (Zambia) between April 2018 and September 2019. The trajectories framework is used to understand how adolescent abortion-related care-seeking differs across a range of socio-legal national contexts. A comparative study design incorporates varying levels of restriction on access to abortion: Ethiopia (legal on broad social or economic grounds, services implemented); Zambia (legal on broad social or economic grounds, complex services with barriers to implementation and information provision); and Malawi (legally highly restricted). Most adolescents (n = 97, 98%) in Ethiopia obtained a medically safe abortion, and most adolescents (n = 70, 64%) in Zambia and almost all adolescents (n = 94, 94%) in Malawi obtained a less medically safe abortion. There is a significant association between country and whether an adolescent tried to end a pregnancy before coming to the facility, X²(2, N = 313) = 135.93, p < 0.001. In Malawi 97% (n = 101) of adolescents had sought to end the pregnancy before coming to the facility, compared to 18% (n = 18) in Ethiopia. Cross-country variations in the relative safety of the abortion and type of care sought by adolescents reflect national laws, policies and service availability. The most facility-based abortions were recorded where care is most accessible (Ethiopia), and most non-facility-based and least safe abortions were recorded where care is the most restricted (Malawi). Across all countries, adolescents experienced delays to their care-seeking; 39% (n = 39), 71% (n = 74), and 66% (n = 73) in Ethiopia, Malawi, and Zambia respectively. Adolescents reported high levels of respectful treatment across countries, with a minority reporting negative experiences. A minority of adolescents in each country reported that unofficial money was paid to facility staff. There were different experiences of post-abortion contraception in the three countries, including an absence of choice. Adolescents’ trajectories – particularly those involving multiple attempts and barriers to achieving abortion care – require tenacity and determination. Our analyses show that less restrictive abortion policies and accessible abortion services improve adolescent chances to access abortion care.

Activism for abortion rights and access in Africa is a vibrant and diverse movement that has become more prominent in recent years. Drawing on qualitative data from interviews with members and allies of the MAMA network (an African transnational pro-abortion activist network), this article explores the evolving landscape of feminist abortion rights activism in Africa, examining how activists navigate and reshape this complex terrain influenced by enduring historical, socio-cultural and political legacies. Employing the concept of the palimpsest as a lens, we examine how feminist organising for abortion rights and access unfolds in a context where historic scripts that limit African womens'-and African feminists'-agency have been imperfectly erased. We argue that activists record their experiences, strategies, successes and challenges on the societal landscape, creating a cumulative and evolving record, similar to a palimpsest, in which each contribution builds upon and reinterprets the layers that precede it. By foregrounding the interconnectedness of past and present struggles, the article contributes to deeper understanding of the complexities of feminist abortion activism in Africa, showing how these efforts contribute to broader struggles for gender and reproductive justice across the continent.