Reducing underreporting of stigmatized pregnancy outcomes: Results from a mixed-methods study of self-managed abortion in Texas using the list-experiment method

Abstract

Background: Accurately 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. Methods: We 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. Results: Results 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. Conclusion: The 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.