Study design, setting, sampling and data collection
This was a cross-sectional survey that analyzed secondary data from the 2018 Mongolian Social Indicators Sample Survey (MSISS) . Mongolia has a population of approximately 2.8 million, with nearly 69% of its population occupying the capital, Ulaanbaatar. .. The MSISS complements previous Multiple Indicator Surveys (MCIS) conducted every five years since 1996. The MSISS was first introduced in 2013 with support from the United Nations Children’s Fund (UNICEF) and the United Nations Population Fund (UNFPA). A total of 14,500 households were sampled. All women aged 15-49 from the sampled provinces were eligible to participate in the survey. A total of 11,737 women were interviewed. In the present study, participants with complete information on all selected variables were analyzed (n = 8373).
Information on MSISS design, methodology and sampling techniques has been detailed elsewhere. . Briefly, the MSISS is a household survey whose final sampling units are the individuals of each enrolled household. The MSISS 2018 was designed to cover more indicators than other previous surveys. The 2018 survey covered five geographical regions (East, West, Central, Khangai and Ulaanbaatar) both in rural and urban areas aiming to provide a large number of estimates of indicators on the situation of women, children and men. The sample selection for the survey was based on a two-stage stratified cluster sampling technique, using the 2017 Population and Household Database sampling frame. A total of 8 Target provinces/districts were selected from the five regions (Bayan-Ulgii, Bay ankhongor, Gobi-Altai, Zavkhan, Umnugovi, Khuvsgul, Bayanzurkh and Nalaikh) from which the samples were taken.
Data was collected by completing questionnaires using computer-assisted personal interviews. Paper-and-pencil interviews were used in the pre-tests, which led to changes in the wording and consistency of some items in the questionnaire. Everyone involved in data collection has undergone rigorous training in interview techniques, questionnaire content and other essentials. The MSISS questionnaire was designed to collect data on the characteristics of households, women, men and children. The data used in this study included self-reported responses. The questionnaire had several sections, including socio-demographic information on women, contraceptive use, unmet need for contraception, access to mass and social media and/or technology, fertility, miscarriages, stillbirths and abortion, maternal and newborn health, attitudes towards domestic violence, adult function and much more. The data extracted for this study was obtained from the sections socio-demographic information of women, use of contraception and miscarriage, stillbirth and abortion.
The outcome variable was current contraceptive use by women of childbearing age (15 to 49 years). Contraceptive methods were defined as devices, drugs, or methods used to prevent pregnancy . First, we assessed overall contraceptive use (i.e. whether the participant reported using a contraceptive method (yes/no)). The women were asked the following question:Are you currently doing anything or using any method to delay or avoid getting pregnant?”. Second, we assessed the use of a specific contraceptive method. Participants were asked to indicate the type of contraceptive method using the following question “wWhat type of method do you use?”. It was a “yes/no” question. Participants reported using different types of contraceptive methods (i.e. permanent non-reversible methods [male and female sterilization]long-acting reversible contraception (LARC) [IUD or Implants]any other modern contraceptive method [i.e., injections, pills, male or female condoms, foam/jelly]and traditional or natural methods [lactational amenorrhea method (LAM), periodic abstinence/rhythm/calendar, withdrawal] or any other method) they were using at the time of the interview. We created a variable “use of a specific contraceptive method” with nine mutually exclusive categories (ie pills, ‘6’ male condom, ‘7’ female condom, ‘8’ abstinence). Although the question regarding contraceptive use may have been affected by the potential for social desirability bias (in which women may have wanted to report contraceptive use when they did not, resulting in a overestimation of contraceptive use), data collectors were well trained to assure participants of the confidentiality of their responses to ensure that participants provided accurate information.
Primary independent variable
Our main independent variable was abortion history (yes or no). During the survey, women of childbearing age were asked if they had ever experienced a case where their pregnancy ended in miscarriage, stillbirth, missed abortion or abortion. . Responses were self-reported based on the total number of abortion histories in the respondent’s lifetime. The variable was coded “Yes” (for those with a history of abortion) and “No” (for those without a history of abortion).
Variables considered as covariates were selected and classified as individual or community factors based on the literature [30, 31]. Based on our outcome of interest, abortion history, missing cases of each of the covariates used in this study were removed. Age of women (15–19, 20–24, 25–34, 35+), their marital status (married, formerly married/divorced, never married), highest level of education (high school[lower/upper], professional or training center and university/institute/collective), age at first marriage (10–19, 20–29, 30+), currently pregnant (yes/no), already given birth (yes/no), consumption of alcohol (yes/no), age at first alcohol consumption (10–19, 20–29, 30+, Never), total number of children (Less than or equal to 2, Less than or equal to 4, Equal or greater than 5, None) and husband’s age (15-24, 25-34, 35+) were the socio-demographic and individual factors included in this study. Community factors included were area of residence (rural/urban), area of origin (Khangai, Central, East, Ulaanbaatar, West), ethnicity (Khalkh, Kazakh, Other), religion (Buddhist, Islam, Other, No religion), and wealth index score (richest, fourth, middle, second, poorest).
The chi-square test was used to examine the distribution of study characteristics by history of abortion and contraceptive use, respectively. We used binary logistic regression to account for the association between outcome and independent variables. The variables assessed in the current analysis were selected based on their importance in the literature [30, 31]. Univariate models were constructed and variables with a p 0.1 indicating the absence of multicollinearity problems in our models. Additionally, we used Receiver Operating Characteristics (ROC) analysis to compare and assess the accuracy of the four statistical models used. [33, 34]. The higher the AUC value or the larger the area under the curve, the better the performance of the model. The strength of the association was reported as the adjusted odds ratio (AOR) and their 95% confidence intervals. Statistical significance was set at p
The MSISS was approved by ONS President’s Order Number A/67 2018 in 2018. Order A/67 2018 contained details regarding potential risks and their mitigation throughout the lifecycle of the investigation under its protection protocol. Informed consent was obtained prior to the start of the survey from each participant or their legal guardian. Participants were assured of the confidentiality and anonymity of any information they provided. The investigation was conducted in accordance with approved guidelines and regulations.