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Background: Sexual coercion is associated with sexually transmitted infections and unwanted pregnancies with consequential unsafe abortions and increased maternal morbidity and mortality. Current literature focuses mainly on its risk factors but less on its resultant deleterious health effects. We conducted a study to determine the prevalence of sexual coercion and its association with unwanted pregnancies among young pregnant women. Methods: In a cross-sectional study, four hundred and sixteen (416) consenting pregnant females aged 15-24 years attending antenatal clinics in Lubaga division Kampala district in Uganda were enrolled using systematic sampling. Quantitative and qualitative data on sexual coercion were collected by female interviewers. Adjusted Prevalence Proportion Ratios (Adj. PPRs) of unwanted pregnancy and associated 95 % confidence intervals were estimated by generalized linear models with log link function and Poisson family distribution using robust variance estimator. Quantitative data were analyzed using Stata version 10.0, while qualitative data were analyzed using manifest content analysis. Results: Prevalence of sexual coercion was 24 % and was higher among those who had non consensual sexual debut (29.0 %) compared with those who had consensual sexual debut (22.6 %). The prevalence of unwanted pregnancy was 18.3 % and was higher among participants who had been sexually coerced relative to their counterparts (p < 0.001). History of sexual coercion in the past 12 months and non consensual sexual debut were associated with unwanted pregnancy [adj.PPR = 2.23, 95 % CI: (1.49-3.32)] and 1.72, 95 % CI: (1.16- 2.54)] respectively. Qualitative results indicated that different forms/contexts of sexual coercion, such as deception, transactional sex and physical force influenced unwanted pregnancies. Discussion: This study highlights that a quarter of our participants in our quantitative study had experienced sexual coercion in the past twelve months and nearly a third of these, had history of non consensual sexual debut. Unwanted pregnancy was higher among the sexually coerced and those who had non consensual sexual debut. Conclusion: Sexual coercion among pregnant women aged 15-24 years in Kampala, Uganda is high and is significantly associated with unwanted pregnancy. Comprehensive sex education targeting young people (< 25 years), along with availability and access to youth friendly centers may be useful in addressing sexual coercion and its negative outcomes.
This study was conducted in Lubaga division one of the five administrative divisions in Kampala district, Uganda’s capital city. Lubaga was randomly selected out of the five using ballot papers. The division has 58 health facilities of which only 15 offer antenatal services. Nine health facilities with the highest antenatal attendances were purposively selected for inclusion in the study. These included: two public health facilities, two private not for profit hospitals and five private clinics. This study was conducted in antenatal clinics for pragmatic reasons and because of resource constraints. Nevertheless about 98 % of pregnant women in Kampala receive antenatal care from a skilled provider [21] hence we expected to get majority of the study population. We anticipated that young women who were attending antenatal clinics had decided to carry their pregnancies to term including those which were unwanted. From this reason, we were able to estimate the magnitude of unwanted pregnancies that may be resulting from sexual coercion which the young women had carried to term. This was a facility based cross-sectional study that employed both quantitative and qualitative methods of data collection. We combined both quantitative and qualitative methods of data collection because mixed methods would provide strengths to answer our research question. We aimed at assessing the relationship between sexual coercion and unwanted pregnancy so mixed methods was deemed suitable. The methods gave us a deeper understanding of the complex relationship. Quantitative surveys were administered to 416 young pregnant women aged 15–24 years. The sample size was determined using the Kish Leslie formula [36] a p of 0.36, power of 80 %, alpha of 0.05 and a non response rate of 15 % [22]. Probability proportionate to size sampling was used to select numbers needed at each health facility and systematic sampling to select the final respondent from each health facility. For qualitative data, eight in-depth interviews (IDIs) were conducted among young women who were purposively selected upon affirmation of a history of both sexual coercion and unwanted pregnancy at the time of conception of the current pregnancy in the quantitative study. Two of the in-depth interview participants had attained pre-secondary education; five had reached secondary while one was at the university. Three of the IDI participants were aged between 15–19 years, whereas five were aged between 20–24 years. Eight key informant interviews (KIIs) were also carried out. Key Informants were purposively selected and these comprised of heads of the youth friendly services selected from each of the eight health facilities except one which lacked any youth programs/youth friendly clinic. The Key Informants were selected because of their knowledge and their role of provision of youth friendly services. Seven of the key informant participants were females. Five of these participants were nurses while three were counselors. Quantitative and qualitative data were collected by one of the lead investigators (TS) and 4 trained research assistants from 2nd April to 24th May 2012. Female data collectors were used because of the sensitive nature of the subject matter. Prior to data collection, study tools were pretested for validation in an area outside the study site. A semi-structured questionnaire was used to measure: demographic characteristics, knowledge and use of contraceptives, sexual debut, partner characteristics, youth friendly service related factors, sexual coercion as well as experiences and circumstances surrounding first sex. The IDI’s explored the young women’s lived experience of sexual coercion, how they felt on discovering they were pregnant, their understanding of the causes of unwanted pregnancies and their thoughts about prevention approaches to sexual coercion and unwanted pregnancies. The KII’s were used to provide more understanding on the link between sexual coercion and unwanted pregnancies plus prevention approaches as obtained from their vast experience of working with young people. Qualitative interviews were conducted by TS. All interviews were tape recorded after obtaining consent from the participants. All IDIs were conducted in Luganda (local language) except one. Meanwhile, all KII’s were conducted in English. Each key Informant interview was conducted for about 45 minutes and IDI’s for about 90 minutes. No compensation was provided to participants. Unwanted pregnancy was our primary outcome and it was defined as a pregnancy that a participant reported of her own free will, as undesired by her [37]. “Unwanted pregnancy” was measured using the following statements in form of a question: “at the time of conception of this pregnancy, “did you want to get pregnant at that time” “did you want to get pregnant later in future” or “you did not want to get pregnant at all?” [38]. The responses included (1 = I did not want to get pregnant at all, (2) = I wanted to get pregnant at that time, (3) = I wanted to get pregnant later in future. Participants who answered that they did not want to get pregnant at all at the time of conception of the pregnancy were taken to have had an unwanted pregnancy. Sexual coercion was our secondary outcome and it was defined based on the definition by Heise et al. [39] as the act of forcing (or attempting to force) another individual through violence, threats, verbal insistence, deception or economic circumstances to engage in sexual behavior against the individual’s will. Accordingly, we measured sexual coercion using the following set of questions as applied with modification by Wagman et al. [11]. In the past twelve months has any of your sexual partners done the following to you? i) “Forced you to perform other sexual acts you did not want to”; ii) “Used verbal threats to force you to have sex when you did not want to”; iii) “Physically forced you to have sex when you did not want to”; iv) “Forced you to have sex by giving you money or gifts in exchange for sex”; v) “Forced you to have sex through promises the man did not intend to keep such as marriage or extravagant gifts”; If one responded “yes” to at least one of the above, the response was classified as sexual coercion in the past twelve months. This was defined as the first sexual intercourse reported by the respondent and the types (consensual and non consensual) were assessed as follows: the first time you had sex, were you forced to have sex? Did you both agree? Or did you force your partner to have sex? When a participant was forced to have sex, we defined the variable as non consensual or otherwise. Knowledge of contraception: was defined as; having ever heard about contraceptives, naming a source and at least one method of contraceptives. The variable was classified into; knowledgeable (when participants scored one or more), and no knowledge (when the participant scored zero) [40]. Ethical approval for the study was obtained from the Higher Degrees Research and Ethics Committee of Makerere University School of Public Health. The WHO ethical recommendations for conducting research on domestic violence against women were followed [41]. Female research assistants were trained on sexual coercion, the use of a non judgmental attitude while collecting data, how to recognize and respond to participants with emotional changes as well as to refer those who needed help. Prior to the study, health facilities were identified where participants who needed help could be referred. Interviews were conducted under confined rooms or restrained space to ensure confidentiality. All participants provided written informed consent. Females who were married or pregnant and below the age of 18 years were treated as emancipated minor according to the Uganda National guidelines for research involving humans as research participants [42]. Data were double entered into Epi-Info version 3.5.1 software, cleaned and then exported to Stata version 10.0 for analysis. Covariates were summarized using frequencies for categorical variables while means, standard deviations (SD), medians and inter-quartile range-(IQR) were used for continuous variables. The main outcome was unwanted pregnancy. Unadjusted and adjusted Prevalence Proportion Ratios (PPRs) of unwanted pregnancy and associated 95 % confidence intervals were estimated by generalized linear models with link (log) and family (Poisson) using robust variance estimator [43, 44]. This was done because the proportion of the outcome was greater than 10 % in which case odd ratios would provide biased estimates of associations [45]. Selection of covariates for inclusion in the multivariable model was based on variables found to be predictive of unwanted pregnancy at bivariate analyses at p < 0.15 and also using biological plausibility as well as evidence in the empirical literature. Logical model building was done by introducing one variable at a time in the model. Only those variables which retained their significance at p < 0.05 and potential confounders which included, knowledge of contraceptives, contraception use at the time of conception and level of education were retained in our final model. Qualitative analyses were done using manifest content analysis. Data were transcribed, read thoroughly line by line and coded using deductive coding. A coding framework was generated using an excel spread sheet. Data were analyzed for content guided by the objectives of the study. Corresponding data were summarized with supporting quotes and presented verbatim.
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