Abstract
BackgroundAccurately measuring stigmatized experiences is a challenge across reproductive health research. In this study, we tested a novel method – the list experiment – that aims to reduce underreporting of sensitive events by asking participants to report how many of a list of experiences they have had, not which ones. We applied the list experiment to measure “self-managed abortion” - any attempt by a person to end a pregnancy on one’s own, outside of a clinical setting – a phenomenon that may be underreported in surveys due to a desire to avoid judgement.MethodsWe administered a double list experiment on self-managed abortion to a Texas-wide representative sample of 790 women of reproductive age in 2015. Participants were asked how many of a list of health experiences they had experienced; self-managed abortion was randomly added as an item to half of the lists. A difference in the average number of items reported by participants between lists with and without self-managed abortion provided a population level estimate of self-managed abortion. In 2017, we conducted cognitive interviews with women of reproductive age in four states to understand how women (1) interpreted the list experiment question format, and (2) interpreted the list item on prior experiences attempting to self-manage an abortion.ResultsResults from this list experiment estimated that 8% of women of reproductive age in Texas have ever self-managed an abortion. This number was higher than expected, thus, the researchers conducted cognitive interviews to better understand how people interpreted the list experiment on self-managed abortion. Some women interpreted “on your own” to mean “without the knowledge of friends or family”, as opposed to “without medical assistance”, as intended.ConclusionThe list experiment may have reduced under-reporting of self-managed abortion; however, the specific phrasing of the list item may also have unintentionally increased reporting of abortion experiences not considered “self-managed.” High participation in and comprehension of the list experiment, however, suggests that this method is worthy of further exploration as tool for measuring stigmatized experiences.
Highlights
Measuring stigmatized experiences is a challenge across reproductive health research
Twelve percent of subjects disclosed a prior abortion, more than half had attended at least some college (60%), and 22% of participants completed the survey in Spanish
Of the four item variants, the most preferred phrasing read: “Have you ever taken or done something to try and end an unwanted pregnancy on your own, without medical assistance?” The main difference between this question and the prior phrasing was that adding “without medical assistance” seemed to change the abortion experiences that could be included in this category
Summary
Measuring stigmatized experiences is a challenge across reproductive health research. We applied the list experiment to measure “self-managed abortion” - any attempt by a person to end a pregnancy on one’s own, outside of a clinical setting – a phenomenon that may be underreported in surveys due to a desire to avoid judgement. Current measures of the prevalence of self-managed abortion, are almost certainly limited by underreporting due to legal and privacy concerns, as well as stigma [5,6,7]. We know this to be true for measures of abortion in clinical settings. For self-managed abortion in particular, fear of legal prosecution may be salient as numerous women have been arrested or prosecuted for allegations of self-managed abortion in the United States [11]
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