title: Sexual violence-related pregnancies in eastern Democratic Republic of Congo: a qualitative analysis of access to pregnancy termination services.
abstract: 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.
authors.affiliation: Harvard Humanitarian Initiative, Cambridge, MA USA ; Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, MA USA.
authors.forename: Gillian
authors.initials: G
authors.lastname: Burkhardt
authors.affiliation: Harvard Humanitarian Initiative, Cambridge, MA USA ; Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA USA ; Brigham and Women's Hospital, Division of Women's Health, Boston, MA USA ; Harvard Medical School, Boston, MA USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Scott
authors.affiliation: Department of Global Health, Boston University School of Public Health, Boston, MA USA.
authors.forename: Monica Adhiambo
authors.initials: MA
authors.lastname: Onyango
authors.affiliation: Harvard Humanitarian Initiative, Cambridge, MA USA ; Harvard Medical School, Boston, MA USA ; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA USA.
authors.forename: Shada
authors.initials: S
authors.lastname: Rouhani
authors.affiliation: Department of Obstetrics and Gynecology, University of Illinois, Chicago, IL USA.
authors.forename: Sadia
authors.initials: S
authors.lastname: Haider
authors.affiliation: Harvard Humanitarian Initiative, Cambridge, MA USA ; Harvard Medical School, Boston, MA USA ; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA.
authors.forename: Ashley
authors.initials: A
authors.lastname: Greiner
authors.affiliation: Harvard Humanitarian Initiative, Cambridge, MA USA ; Harvard Medical School, Boston, MA USA ; Department of Surgery, Massachusetts General Hospital, Boston, MA USA.
authors.forename: Katherine
authors.initials: K
authors.lastname: Albutt
authors.affiliation: Harvard Humanitarian Initiative, Cambridge, MA USA ; Harvard Medical School, Boston, MA USA ; Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA USA ; Harvard School of Public Health, Boston, MA USA.
authors.forename: Michael
authors.initials: M
authors.lastname: VanRooyen
authors.affiliation: Harvard Humanitarian Initiative, Cambridge, MA USA ; Harvard Medical School, Boston, MA USA ; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA USA ; Department of Emergency Medicine, Queen's University, Kingston, ON Canada.
authors.forename: Susan
authors.initials: S
authors.lastname: Bartels
keywords: Democratic Republic of Congo; Pregnancy termination; Sexual violence; Sexual violence-related pregnancy; Unsafe abortion