Community perceptions of the impact of war on unintended pregnancy and induced abortion in Protection of Civilian sites in Juba, South Sudan

ABSTRACT

Conflict and mass displacement into Protection of Civilian (POCs) sites in South Sudan led to the breakdown of community and family structures, increasing women and girls’ vulnerability to gender-based violence and exacerbating already poor sexual and reproductive health outcomes. As one component of a study on post-abortion care, this study explores community perceptions of unintended pregnancy and abortion in a POC in Juba. Four focus group discussions were conducted with 36 women and married men aged 18–45 living in the POC. Although initial reactions to induced abortion were generally negative, participants discussed that unintended pregnancy and induced abortion appeared to have increased during the current conflict. Their discussion of abortion became less condemnatory as they described changes in people’s situation due to war, including instability and poverty, transactional sex, disruption of marital norms, rape, and low contraceptive use. This is one of the first studies to investigate community perceptions and practices related to unintended pregnancy and abortion in South Sudan. Despite the beliefs that these are taboo topics, the discussions provide an opening to reduce abortion stigma. To ensure lasting stigma reduction, investment in women and girls to improve gender equity is needed.

KEYWORDS:

• South Sudan
• unintended pregnancy
• abortion
• conflict
• internally displaced people (IDP)

Introduction

Globally, nearly 80 million people were forcibly displaced by the end of 2019; recent crises in South Sudan were responsible for large numbers of the displaced (UNHCR, 2020). Women and girls in humanitarian crises experience many challenges in addition to their need for food, water and shelter, including higher risks of pregnancy-related morbidity and mortality, unintended pregnancy, complications from unsafe abortion and increased sexual violence (Austin et al., 2008). Despite their inclusion in international humanitarian standards (Myers et al., 2018), sexual and reproductive health services are often limited in humanitarian settings (Casey et al., 2015). A global evaluation of sexual and reproductive health in humanitarian settings by the Inter-Agency Working Group on Reproductive Health in Crises in 2014 found that abortion, including post-abortion care, was rarely provided or mentioned in funding proposals (Casey et al., 2015; Chynoweth, 2015; Tanabe et al., 2015). Contraceptive service availability, which reduces the need for abortion, was also limited. In addition, the weakness of health systems in conflict is often associated with distrust in available health services and providers, often compounded for services that may be stigmatised such as clinical management of rape, contraceptive or abortion-related services (Casey et al., 2015; Gele et al., 2017; Makleff et al., 2019; Shellenberg et al., 2011). Although unintended pregnancy is a problem everywhere, including in humanitarian settings, data on the prevalence of unsafe abortion, as well as knowledge, attitudes and practices related to abortion are lacking in these settings (Erhardt-Ohren & Lewinger, 2020; McGinn & Casey, 2016).

South Sudan context

Following decades of civil war (1955–1972 and 1983–2005), South Sudan gained independence from Sudan in 2011. However, independence did not bring an end to conflict, as civil war broke out less than three years later in 2013 (Blanchard, 2016). What started out as a political dispute in the governing Sudan People’s Liberation Movement (SPLM) exacerbated longstanding traditional tensions between the two largest ethnic groups, the Dinka and Nuer (Rolandsen, 2015). The conflict led to the forced displacement of 4 million people, of which 2.5 million took refuge in neighbouring countries and an estimated 200,000 people fled to six UN Protection of Civilian (POC) sites across the country (Human Rights Watch, 2019).

In Juba, around 30,000 civilians, mostly Nuer, fled the city and sought refuge at the nearby United Nations Mission in South Sudan (UNMISS) base (Stern, 2015). In response, UNMISS created POC sites within and adjacent to its bases where the internally displaced people (IDP) could take shelter from the violence. These sites were not designed to be humanitarian camps or to accommodate large numbers of people over a long period of time. Living conditions were poor with many sites prone to flooding, and the POCs were ill-equipped to provide adequate food, water, sanitation, and medical care. Over the years, humanitarian non-governmental organizations (NGOs) and UNMISS have worked to improve conditions; however many of the POCs still do not meet international standards (Stern, 2015).

The mass displacement of the population caused a significant breakdown of community structures and separation of families. Nearly half of partnered women living in the Juba POCs were living without their husbands because of the crisis (Ellsberg et al., 2020). The rise in levels of frustration, trauma and limited economic activity among IDPs over the years, combined with the overall lack of adequate shelter, facilities, food, and poor lighting in POCs have increased women and girls’ vulnerability (Green, 2014; South Sudan Protection Cluster, 2015). Prevalence of sexual violence is high with 35% of women in the Juba POCs having experienced non-partner sexual violence and 54% reporting violence by an intimate partner (Ellsberg et al., 2020). The sharing of shelters with strangers, as well as poorly lit water and sanitation facilities, have increased women’s exposure to violence (South Sudan Protection Cluster, 2015). Women who left the POCs in search of basic necessities, such as food and firewood, reported being harassed, attacked, raped or gang raped by members of the armed forces and other groups (South Sudan Protection Cluster, 2015; United Nations, 2014). Conflict-related sexual violence has been widespread since the start of the civil war, with rape used as a political tool and a weapon of war as a means of repression, terror and control (United Nations, 2014).

The conflict has further normalised gender inequality, with women and girls experiencing other forms of violence as coping strategies, such as early and forced marriage and transactional sex. South Sudan has the seventh highest prevalence of child marriage in the world, with 52% of girls marrying before their 18th birthday and 9% marrying before the age of 15 (Madut, 2019; Ministry of Health et al., 2010). Traditionally, girls were seen as ready for marriage once they began menstruating rather than based on age (Madut, 2019). Marriage was seen as a business transaction between two families, with the exchange of a dowry or payment of a bride price to the woman’s family (Luedke & Logan, 2017; Onyango & Mott, 2011; Sommers & Schwartz, 2011). When an unmarried girl became pregnant, the families usually negotiated marriage and an appropriate dowry, often money or cattle (Pillsbury et al., 2011); otherwise, she was viewed as spoiled and would bring in a reduced dowry (Murphy et al., 2019). Early and forced marriages have continued during the current conflict with families driven to marry off girls as a survival tactic in order to relieve economic burden and food insecurity by receiving a dowry or reducing the number of mouths to feed, or as a means of protecting their daughters (Girls Not Brides, n.d.; Martin, 2014; South Sudan Protection Cluster, 2015).

Improvements in health, and more specifically sexual and reproductive health (SRH), have lagged in South Sudan (Republic of South Sudan Ministry of Health, 2019a). Unsafe abortion is likely a major contributor to South Sudan’s high maternal mortality ratio of 789 deaths per 100,000 live births, the fifth highest in the world (Palmer & Storeng, 2016; Republic of South Sudan Ministry of Health, 2019a; World Health Organization, 2018). Safe abortion in South Sudan is permitted, according to the 2008 Penal Code, only to save the life of the mother; an unmarried woman who terminates a pregnancy to avoid shame may receive a reduced sentence (Ministry Legal Affairs and Constitutional Development, South Sudan, 2009). In addition to high maternal mortality, South Sudan also has very low modern contraceptive prevalence (3.9%) (FP2020, 2019). Traditionally, contraception and abortion were seen as taboo and unacceptable in South Sudan (Mkandawire et al., 2019; Palmer & Storeng, 2016). This is described as due, in part, to the social pressure to produce children, or to the need to ‘replace’ those lost in the conflict, produce more fighters or increase their ethnic group’s population (Elmusharaf et al., 2017; Luedke & Logan, 2017; Mkandawire et al., 2019; Onyango & Mott, 2011; Sommers & Schwartz, 2011). The Government of South Sudan, however, recently made a new commitment to improve SRH with their Reproductive Health Policy of 2019–2029 and the Reproductive Health Strategic Plan of 2019–2023 (Republic of South Sudan Ministry of Health, 2019a, 2019b). These efforts identify contraception and post-abortion care as key pillars to reduce maternal mortality, and emphasise the need to engage with all stakeholders including community-based organisations, national and international NGOs, line ministries and communities. However, the escalating conflict and political strife combined with the lack of government funding and MOH leadership in SRH means these strategies have not yet been put into practice (Republic of South Sudan Ministry of Health, 2019a).

Since 1994, International Medical Corps (IMC) has worked to deliver health services and training through integrated interventions to strengthen the capacity of the health system in South Sudan. At the time of this study, IMC was working with the Ministry of Health to support three nursing and midwifery schools and 14 health facilities to provide primary healthcare, including services and programming to improve health, SRH, nutrition, and protection against GBV. In the POCs in Juba, IMC supported two health centres in the Juba POCs, including one that provided inpatient and 24-hour emergency care. In 2018, IMC, in collaboration with the Reproductive Health Access, Information and Services in Emergencies (RAISE) Initiative at Columbia University, conducted a mixed methods study to identify the factors that influence access to, use and provision of post-abortion care services at IMC-supported health facilities in two Juba POCs and two refugee camps in Maban. This manuscript reports on community perceptions in the Juba POCs of how the current conflict has contributed to changing attitudes and practices concerning unintended pregnancy and induced abortion.

Methods

We conducted a mixed methods study on post-abortion care among IDPs in the POCs in Juba and refugees in camps in Maban that included focus group discussions (FGDs), indepth interviews with post-abortion care clients, health facility assessments and register reviews. This manuscript, focusing on community perceptions of war and abortion, includes data from four FGDs conducted with 36 women and married men aged 18–45 from communities in the largest POC in Juba, recruited by IMC staff in collaboration with community leaders: women aged 18–24 (n = 9), women aged 25–45 (n = 9), men aged 18–29 (n = 9) and men aged 30–45 (n = 9). Participants may or may not have used IMC’s services. We replaced the older male group participants when the group that was originally convened decided not to participate due to the lack of compensation.

Semi-structured discussion guides were adapted from tools used by the authors in other countries (supplementary material 1). IMC recruited two female and two male interviewers who were residents in the POCs, spoke Nuer, had at least secondary education and prior experience conducting qualitative research, and were comfortable discussing reproductive health topics. Interviewers completed a five-day training on qualitative data collection methods and research ethics. They then conducted all discussions in Nuer, with female interviewers conducting the female FGDs and male interviewers conducting the male FGDs. No compensation was provided to participants. All FGDs were audio-recorded, transcribed in Nuer and translated into English for analysis. US and South Sudanese researchers performed an initial review of transcripts to check quality and requested clarification when needed. FGDs lasted 1–2 h. The first two FGDs were conducted in August 2018. Violence erupted in the POCs that day and continued for several weeks, delaying the last two FGDs until late September 2018.

Analysis

Three US researchers read the transcripts and created a codebook with the major themes, which were discussed with the South Sudanese research team member. After the codebook was finalised, the transcripts and codebook were uploaded to Nvivo (v11), and all transcripts were coded independently by two researchers; a third researcher coded a subset of the transcripts. When discrepancies arose, they were discussed and resolved until the inter-rater agreement was in the 80th percentile range. US, South Sudanese and Congolese team members used thematic content analysis to identify the main themes that arose.

Ethical considerations

To protect confidentiality, all discussions were held in a private space and no names were included in transcripts. Verbal informed consent was obtained from all participants. Only members of the research team had access to the recordings and transcripts. Ethical approvals for the study were obtained from the Institutional Review Board of Columbia University and the Ethical Committee of the Ministry of Health for the Republic of South Sudan.

Results

Although initial reactions to induced abortion and women who had them were generally negative in the FGDs, participants in all groups discussed that unintended pregnancy and induced abortion appeared to have increased during the current conflict (the one that drove them into the POCs). Participants attributed these increases to changes in people’s situation due to the war. In discussing the reasons why women had abortions now, their discussion of abortion became more nuanced and less condemnatory. Participants, especially in the male groups, mentioned that unintended pregnancy was handled in their community one way ‘before the war’ and another way now. While women referred more to the instability and additional difficulties women faced now, men talked more about transactional sex that women in the POCs engaged in. Participants described women using ‘medicines’ to induce abortion, often obtaining these themselves or with the help of a partner or friends. Participants did not name the medicines used, so it is unclear how effective they were.

Discussion of how the war has changed the perceptions of abortion to become more pragmatic are grouped into several themes: instability and related poverty, transactional sex, disruption of norms around marriage, and sexual violence. Additional discussion focused on contraception and unintended pregnancy.

Instability and related poverty due to displacement

Participants referred to concerns about the instability of their current living situation, including the lack of access to food for a woman and her children as reasons why women or couples may choose to have an abortion. Women, in particular, recognised that pregnant women and those with newborns required additional resources including better nutrition which were largely not available in the POC.

The termination of pregnancies has affected women too … because many women aren’t together with their husband or he doesn’t have a job to support the family. If she gives birth three times and she gets pregnant [again], she will decide to remove the pregnancy because no one will take care [of her] because people are not in the same standard of economic [status as before]. (Woman aged 25–45)

In many cases, participants referred to the frequent separation of families in the POCs as a reason women decide to have an abortion. Women and children may be in the camps while the husbands remained home or were away fighting, or family members were separated when they fled home. For example, adolescent girls who were separated from their families may have an abortion because they had no one to support them or a child.

There are so many people who do abortion. … Before, maybe she is a wife of somebody and now her husband is away. If she is pregnant … but she doesn’t want her husband to know because it can bring shame or he will divorce her. She will do abortion. (Man aged 18–29)

Girls who end their pregnancy, nobody is helping them … She will think of ending her pregnancy because … if she gives birth, who will be with her or support her? The only easy decision to take is to end her pregnancy in order to reduce her problems … If she has someone to support [her], she would not end her pregnancy … ‘I have nothing, and if I give birth there will be more problems ahead’, that is the reason which makes girls end their pregnancy. (Woman aged 25–45)

There are children who don’t have someone to take care of them. … Many girls are orphans, their parents died. They will end their pregnancy because no one will be responsible for that child. (Woman aged 25–45)

Increases in transactional sex due to conflict and displacement

Because of this poverty and instability, participants reported increases in transactional sex in the POCs. As mentioned, many men were away fighting or tending to their fields or cattle, while their wives and children lived in the POCs with little support. Therefore, a woman may resort to selling sex to gain support for herself and her children. If she became pregnant, she would terminate the pregnancy out of fear her husband would find out or to maintain the transactional relationship.

Women terminated their pregnancy because most of them were impregnated when they were not ready and by wrong people … Many people have no support in the camp, so women look for men to support them with their children, women whose husbands are not in the camp … These reasons contribute a lot to unplanned pregnancy and increases the abortion rate at the same time. (Man aged 30–45)

Someone might be starving, and she will use her body to get food … She is coming from another region because there is crisis, because she doesn’t have a ration card, someone will deceive her until she gets pregnant. When she gets pregnant, the man will stop giving her money, and she will think of where to go … She thinks if I end my pregnancy, I will get another man to support me. Because she has children at home who are suffering … she will end her pregnancy and face the consequences. (Woman aged 25–45)

Participants in all groups highlighted that unmarried girls who were separated from their families due to the conflict were particularly vulnerable. These girls engaged in sex with older men or peers, often for money or food, so they could survive. If the girls became pregnant, they would terminate the pregnancy on the assumption that the men could not or would not support them and their child.

The rate of abortion is very high due to the crisis, these crises have separated many children from their parents. You find girls here without [their families] … Some of them ran for their safety, when they arrived, they found out their parents were not there. … Then she will live an unstable [life] when she shares a place with a man and conceives. If she realizes that guy will not support the baby, then she [will] induce abortion. (Man aged 30–45)

Girls are mostly affected by unwanted pregnancy as we lack most of the basic services in POCs. So girls may decide to have male friends who are economically somehow stable. During the friendship, a man demands to have sex with a girl in order to share his income which puts the girl in a dilemma: if she refuses to be used by the man, she will not have part of that resource; if she accepts, maybe the man is not her choice. … If she accepts to be used by the man as his girlfriend, once she ends up with an unwanted pregnancy, she may either plan to abort it or look for poison to kill herself. That has happened many times. (Woman aged 18–24)

Several groups referred to men who had sex with multiple women or girls because they had money. Women in the older age group commented on these men who had sex with many girls, and then sent them off to terminate a resulting pregnancy without caring if ‘these girls are going to die’ (rather than negotiate for marriage as is traditional).

Disruption of norms around marriage since the conflict and displacement

In addition to unaccompanied girls inducing abortion, participants also described that the traditional practice of bride price, where the man pays a dowry to the woman’s family, may encourage girls to have an abortion in the POCs. They described this as a change from the way an unmarried girl’s unintended pregnancy used to be handled: previously, the families of the boy and the girl would negotiate an appropriate dowry and marriage would be arranged. However, the poverty of many in the POCs made appropriate dowries difficult for many men to provide.

What I have experienced as a major cause of abortion is because we as Nuer people, we used to pay cattle as dowry for the marriage arrangement. … Many people used money as dowry; after these crises it led to a lack of both cattle and money for the marriage arrangement. While it is unacceptable for many families to give their daughter to an empty-handed person, then the easy way is to force the girl to terminate the pregnancy. (Man aged 30–45)

Participants described that if an unmarried girl became pregnant in the POC, her family may decide together that she should have or pressure her to have an abortion if the partner could not provide a sufficient dowry or if the parents decided the partner was unsuitable for some reason.

[Induced] abortion is common in the POCs, especially girls are highly affected. For example, when a young girl who is not yet married is friends with a boy, if the girl gets pregnant and she comes to her boy to inform him about the pregnancy, the boy says ‘I did not impregnate you’. So if she insists and tries to involve the family of the boy, the family of the boy will refuse her because they haven’t any cattle to marry her. From there the girl will be in the middle without a stable relationship … as she has been chased by her parents because she will no longer motivate a dowry while her present in-law family gave no dowry. She will feel that she is alone without anyone to support her and no comfortable place for delivery. Then an induced abortion would be a means for survival. (Man aged 30–45)

These are very important issues right now because some girls usually terminate pregnancy with the knowledge of their parents, especially nowadays. And these cases happen when a girl becomes pregnant by her boyfriend or anyone else whom she loves, but her parent hates that person. … Most say to their daughter ‘we don’t want to have any kind of relationship with that family so you have to terminate the pregnancy’. Maybe the parents of the girl refuse the man because they don’t have enough cattle to pay as dowry for the marriage, as in our culture if a girl gets pregnant and delivers in their home she does not attract many cattle for dowry. (Woman aged 18–24)

Given the difficult economic situation of most families in the POCs, participants suggested that the girl may feel pressured to bring resources to her family through marriage. If she gets pregnant and the man lacks cattle for a dowry, she may terminate the pregnancy before her family finds out. Participants in several groups mentioned the girl may choose to do this in part out of fear that she or her partner may be killed by her family members.

But girls fear to inform their parents about their pregnancy when they get pregnant. They know that he is empty-handed and they think their parents will kill them because they were impregnated by a [man that is] jobless or has no cattle to marry her. Then the last option should be removal of the pregnancy. (Man aged 30–45)

Some girls accept abortion when she is the only girl in the family with many brothers. Once she is pregnant, she may think ‘Now I am the only girl in the family and all my brothers are looking to get some cattle when I am officially married … ’ If she thinks there is no alternative, she may decide to terminate the pregnancy as she feels when her brothers know that she is pregnant they may denounce her to people that she is not our sister from this moment or they will kill one of them, either the girl or the man who got her pregnant. (Woman aged 18–24)

Sexual violence in displacement

Participants in all groups mentioned that women in the POCs terminated pregnancies due to rape. They said that women experienced sexual assault in or near the camps, and were at risk of rape when they left the POC to run errands. Perpetrators included community members in the POCs, men living near the camps and security forces. Women who were raped would terminate the pregnancy to keep the rape secret from their husband or family out of fear she may be rejected and to avoid social stigma or being associated with the perpetrator long-term. Young girls in particular would find their future marriage prospects ruined if people knew she had been raped.

One of the major causes of [induced] abortion are unavoidable rapes that women encounter since this civil war in the country. Many women in the POCs have been raped on their way to town by security personnel. And most of them fear to reveal they have been raped because she may think she will be rejected by her husband or in-laws. Therefore, if she becomes pregnant, she doesn’t tell her husband or see health personnel for a check-up, so she may go secretly to buy drugs and terminate the pregnancy. (Man aged 30–45)

If a girl has been raped, she was forced to have sex and maybe she got pregnant and she will think [her chances of] getting married as a maiden in the future is not good. It is good to end the pregnancy and stay as a girl. She will go and end her pregnancy if she doesn’t know the man. She was just forced to have sex. (Man aged 18–29)

In some cases, the woman feared that her husband and other male family members would engage with the perpetrator of the rape and be killed or injured, and that she would be blamed in the community for those deaths.

Some girls induce abortion when they have a pregnancy after rape. … If the girl is raped by someone within the community she may refuse to reveal it to people that ‘he is the one who raped me’ because she fears the shame that will be in the community, plus she doesn’t love or doesn’t want to get married to him. … She may only reveal that she was raped by someone. If her parents will force her to show them the one who raped her, they will try to kill him [rapist] or they will fight with his family which will result in death, and her name will be spread in the entire community that many people lost their lives because of her. (Woman aged 18–24)

Participants specifically referred to rape by men from the opposing ethic group (Dinka) which was viewed as even worse for the woman than rape by someone from their community. It was also seen as an even stronger reason for termination of the pregnancy.

There are girls and women who are pregnant by a Dinka outside [the POC]. Maybe they don’t want to bring a child whose father is Dinka inside the camp here. And it should not be accepted by her parents. So Dinka killed us and she knows she is pregnant by a Dinka. … And she can end her pregnancy in that way also. (Man aged 18–29)

Contraceptive use to reduce unintended pregnancy

A few participants mentioned the use of contraceptives to reduce unintended pregnancy and therefore prevent abortion. Positive mentions of contraception came up far more often in the women’s groups, especially the older group. Correct knowledge of contraception, however, was limited; and in a few groups, contraceptives were incorrectly described as abortifacients.

The word abortion becomes a big problem in the UN camp right now because women are practicing it. To stop termination of pregnancies, you need to provide contraceptives that prevent women from getting pregnant for three years or more. (Woman aged 25–45)

But nowadays it’s not difficult to have unwanted pregnancy because if you don’t want to carry it you can remove it by using contraceptives. It’s very easy to use modern contraceptives today because even health personnel can help you with using contraceptives if you want to abort the pregnancy. (Woman aged 18–24)

Discussion

Little evidence is available about abortion in South Sudan, even less is known among displaced populations. This is one of the first studies to investigate community perceptions and practices related to unintended pregnancy and induced abortion among IDPs in South Sudan. The findings reveal instances where a shift in attitudes and behaviours when considering the increased vulnerability of women and girls can be seen. Previous studies have found similar changes in perceptions from negative to nuanced as people consider the circumstances under which women seek abortions (Casey et al., 2019; Ushie et al., 2019). If abortion is more common, it’s most likely unsafe given the restrictive legal status, and suggests an increased need for post-abortion care in the POCs (Palmer & Storeng, 2016). Several participants, especially men, referred to how things were done ‘before the war’ compared to now, suggesting that the conflict contributed to some changing perceptions and attitudes on abortion. Although it is unclear what is different about the current conflict that produced these changes, it is possible that people used the term ‘before’ to indicate a general sense of change in society, similar to findings in a 2013 study in three South Sudanese communities (LeRoux-Rutledge, 2020). Participants recognised that abortion was more justifiable, or perhaps even necessary, given the current situation in the POCs due to the war. The consequences of an extramarital pregnancy for a married or unmarried woman were perceived to be severe, and participants suggested that abortion may now be an acceptable option. Men talked more about transactional sex, dowries and rape while women expressed more empathy for the stresses and difficulties women face in displacement. Change in social norms in war is not uncommon, as seen in other places, for example, with changing marital practices or gender roles (Ritchie, 2017; Schlecht et al., 2013). The changing attitudes toward abortion here may be a pragmatic decision made in the face of war, intense poverty and lack of economic opportunity, separation of families, increased transactional sex, disrupted marital norms, increased sexual violence, and low contraceptive use.

One potential contributor to the changing view of what to do about unintended pregnancy is related to the social contract in South Sudan regarding marriage which is seen as an exchange: the wife produces children and the husband is the breadwinner to support them (Luedke & Logan, 2017; Mkandawire et al., 2019). The conflict has broken this contract for many couples as the husband was away or unable to provide for his family. Many women suddenly became the heads of their household when their husbands and sons were killed during the conflict or recruited to fight. Similarly, adolescent girls became the main breadwinners for their families when they lost their parents in the violence (Martin, 2014). This has led to more women and girls engaging in transactional sex, where they trade sex to obtain income, food, water, services or safety (Martin, 2014; South Sudan Protection Cluster, 2015; Stern, 2015). As a result, women and girls across POCs have faced increasing rates of unintended pregnancies, leading to induced abortion or the abandonment of their newborns (South Sudan Protection Cluster, 2015). One way to address this is by increasing livelihood options for women and girls so they have more options to support themselves and their families beyond transactional sex. Providing women and girls the means to earn a living enhances women’s autonomy and contributes to social norm change (Grabska, 2013).

As mentioned earlier, marriage in South Sudan is seen as a business transaction between two families with the exchange of a dowry (Luedke & Logan, 2017; Sommers & Schwartz, 2011). Prior to the conflict, the families of a boy and girl who became pregnant would come together to negotiate an appropriate dowry. However now, the girl’s parents may deem the boy an unsuitable partner due to his family’s inability to pay an adequate dowry, leading them to push her to terminate the pregnancy to preserve her marital prospects and ‘value’. This may be particularly salient for girls who are in school as educated girls may be viewed as commanding a higher bride price (LeRoux-Rutledge, 2020). Given the reduced economic prospects, it may be more difficult for men to pay a bride price for a first or additional wives; 38% of women in the POCs reported being in polygamous marriages (Ellsberg et al., 2020). Participants in several groups referred to the girl’s parents pushing her to have an abortion, reinforcing the expectation that girls bring income into the family through marriage. Young women discussed this pressure, in addition to suggesting that a girl may have an abortion to prevent her family members from confronting the man who impregnated her or his family. Violence is not uncommon and can flare up easily in the POCs, given the elevated inter-personal and community tension (Munive, 2019; Rhoads & Sutton, 2020), and the girl would not want to be responsible for deaths in her community. Participants also voiced fears that family members may harm their own daughter or sister who had an unintended pregnancy. A recent study in the POCs found that marriage due to abduction, pregnancy or rape or for economic reasons and marriage where a bride price was paid were all associated with increased odds of experiencing intimate partner violence (Ellsberg et al., 2020). The use of abortion to prevent such marriages may contribute to reduced lifetime intimate partner violence.

The recent conflict has been characterised by reported increases in sexual violence (Ellsberg et al., 2020; Guterres, 2019; Hove & Ndawana, 2017; OHCHR and UNMISS, 2017; Rhoads & Sutton, 2020). Participants here, as documented elsewhere, said that women risked rape when they left the POC to gather firewood or go into town, particularly by soldiers or police (Ellsberg et al., 2020; Murphy et al., 2019; OHCHR and UNMISS, 2017). While traditional practice in cases of rape was for the families to negotiate marriage between the perpetrator and the woman, the prevalence of sexual violence by perpetrators of the opposing tribe in the current conflict may have contributed to changing practice. Participants suggested that abortion was preferable to delivering a baby of another tribe or to forced marriage outside the tribe, particularly when referring to the perpetrators of the violence that forced them into the POCs. Many also said the woman would terminate a pregnancy from rape to avoid the strong social stigma, shame and rejection she could face from her community (Murphy et al., 2017; Tankink, 2013). This suggests a need for emergency contraception to prevent pregnancy after rape which should be made available in the POCs, particularly through informal support networks. Information on how it works, that it may be used by a woman after any unprotected intercourse to prevent pregnancy, and where to find it should be widely disseminated. Increased availability and use of emergency contraception would help women to reduce or avoid disclosure of sexual assault and the related stigma. While 48% of women in the Juba POCs who experienced non-partner sexual violence told someone, only 30% sought support services (Murphy et al., 2020). However, women who experienced conflict-related sexual violence were more likely to disclose their experience and seek help. These findings support the need for good quality confidential support services for survivors as well as emergency contraception.

The increasingly nuanced perspectives on abortion, as participants discussed women’s motivations to seek abortion, suggest an opportunity to engage community members in constructive conversations with a view to shift community norms and reduce abortion-related stigma. Such stigma can lead women to avoid seeking post-abortion care for complications (Kumar et al., 2009; Tagoe-Darko, 2013). The sharing of experiences and concerns of a stigmatised group via scenarios is a component of many stigma reduction interventions, although this does not suggest that women must claim stigmatised identities publicly (Cockrill et al., 2013; Nayar et al., 2014; Stangl et al., 2013). Although evidence-based interventions to reduce abortion stigma are limited (Hanschmidt et al., 2016), critical elements to address stigma include increasing recognition of the stigma, improving knowledge of the stigmatised topic, providing safe opportunities to discuss the values and beliefs that contribute to the stigma (Cockrill et al., 2013; Nayar et al., 2014; Stangl et al., 2013). Effective strategies intervene on multiple levels, working with individuals, communities, and health workers, and ideally address broader social norms like gender inequality to ensure lasting change (Ipas, 2018; Nayar et al., 2014). Some humanitarian NGOs avoid addressing abortion due to political concerns; it is necessary to address the topic respectfully with the community in ways that do not incite harm to individuals so that women can safely access lifesaving post-abortion care (Lehmann, 2002; McGinn & Casey, 2016; Palmer & Storeng, 2016). It is important to recognise that attitudes towards abortion are complex; the conversation should not end with the initial negative reaction (Casey et al., 2019; Ushie et al., 2019).

Many of the reasons participants gave to justify abortion were related to unintended pregnancy, suggesting a clear opening to improve access to and use of contraception in this community especially because abortion is highly restricted. As mentioned previously, contraceptive knowledge and use in South Sudan are low and may be viewed as against cultural norms (Casey et al., 2015; FP2020, 2019; McGinn et al., 2011; Palmer & Storeng, 2016). The availability of contraceptives is limited in the POCs: both IMC-supported health centres had necessary supplies to provide injectables, condoms and emergency contraception, but only one had implants and oral contraceptives, and none had IUDs (International Medical Corps and RAISE Initiative, 2020). Participants in all focus groups mentioned contraception as a way to prevent abortion, more often by the women, suggesting that it may be less taboo than assumed; further research exploring this is needed. However contraceptive knowledge was limited, and in some cases, participants conflated contraceptives with abortifacients. South Sudan committed in 2017 to increase contraceptive prevalence to 10% by 2020 (Government of South Sudan, 2017), and reducing unmet need for contraception is a specific objective in its 2019–2029 Reproductive Health Policy. One way to frame the discussion, as recommended in a 2011 study in South Sudan (Pillsbury et al., 2011) and by South Sudanese colleagues during the authors’ dissemination of these results in Juba, is with the positive effect of birth spacing on women’s and children’s health and survival, an appropriate strategy in places where contraception may be sensitive (Duclos et al., 2019; Kane et al., 2016; Post, n.d.), or where post-partum sexual abstinence is traditionally practiced (Pillsbury et al., 2011). It is important that a range of short- and long-acting contraceptive methods be made available at no cost and provided by well-trained staff in a private location. In the close confines of the POCs, confidentiality is critical. Correct and clear information on contraception must be provided to women, men and adolescents. Further, community mobilisation must address rumours and misconceptions about contraception, particularly to dispel confusion that contraceptives are abortifacients. In addition, it will be important to engage men specifically as they are seen as particularly opposed to contraceptive use (Elmusharaf et al., 2017; Kane et al., 2016; Mkandawire et al., 2019).

Limitations

It is important to consider the limitations of our study. Only four FGDs were conducted in one POC in Juba (others were conducted in refugee camps in Maban as part of the larger study). This limits how well our study reflects the perspectives of diverse groups in the POCs. Further research on this topic with a larger sample is needed. A delay of several weeks occurred between the first two and last two FGDs due to violence that erupted in the POCs; it is unclear how the interim violence may have affected the discussions in the last two FGDs.

Conclusion

Despite beliefs that abortion and contraception are taboo topics in South Sudan, the increasingly nuanced discussions of abortion provide an opening to encourage dialogue around abortion and reduce abortion-related stigma. Our findings suggest some community recognition of the need for contraception to reduce unintended pregnancy although correct knowledge was limited. Increased use of unsafe abortion suggests increased need for confidential post-abortion care services, as well as access to emergency contraception. To ensure lasting stigma reduction, investment in women and girls to improve gender equity and reduce the power imbalance faced by women and girls in this society is needed. While these findings are specific to the Juba POCs in South Sudan, the recommendations may be relevant for other conflict-affected populations where women and girls experience heightened SRH needs and protection risks. The impact of war and forced displacement can have a devastating effect on the lives of women and girls; however, addressing the stigma related to abortion and contraception can significantly contribute to reductions in maternal morbidity and mortality.

Author contributions

SEC participated in the study conception and design; SEC, GPI, EIM, SMP implemented the study; SEC, MMG, MJK participated in analysis of the data with input from all authors; SEC and SMP drafted the manuscript with input from all authors. All authors reviewed and approved the final manuscript.

Acknowledgments

The authors would like to acknowledge the interviewers, transcribers/translators, Deepak Kumar and other International Medical Corps staff in Juba that helped make this study possible. The team thanks Columbia University MPH student Devin Nagle for her help with the article outline. The authors also acknowledge the South Sudan Ministry of Health staff for their collaboration and feedback on the research findings. The authors would also like to thank POC residents that participated in this important study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Enhancing Learning and Research for Humanitarian Assistance (Elrha) Research for Health in Humanitarian Crises (R2HC) Programme under [grant number: 28375]. The R2HC programme aims to improve health outcomes by strengthening the evidence base for public health interventions in humanitarian crises. R2HC is funded by the UK Department for International Development (DFID), Wellcome, and the UK National Institute for Health Research (NIHR). The funder had no role in study design, data collection, analysis, interpretation or writing.