Unsafe abortion in adolescents

Factors Influencing Abortion Decision-Making of Adolescents and Young Women: A Narrative Scoping Review

INTRODUCTION

Globally, about half of all induced abortions have been estimated to be unsafe, which results in 13% of maternal deaths yearly. Of these induced abortions, 41% of unsafe abortions have been reported in young women who are dependent on their parents for their livelihood. They are often left in a vulnerable position and may have difficulty in making a decision regarding abortion. This study aimed to (1) characterize and map factors that influence abortion decision-making of adolescents and young women, and (2) identify the care and support that they need in their decision-making process.

METHODS

We conducted a scoping review following the JBI method and PRISMA-ScR checklist. We comprehensively searched MEDLINE (PubMed), Embase, Cochrane Library, CINAHL, and PsycInfo, and hand searched publications in the Google Scholar database between November 2021 and October 2023. The search included all English language qualitative and mixed methods research articles published on the database up to October 2023 that included participants aged 10-24 years. The CASP checklist was used as a guide for the qualitative analysis. NVivo was used to synthesize the findings.

RESULTS

There were 18 studies from 14 countries (N = 1543 young women) that met the inclusion criteria. Three domains and eleven categories were included as follows: personal (desire for self-realization and unwanted pregnancy), interpersonal (parental impact, reaction of partner, roles of peers and friends, existence of own child, and lack of support), and social circumstances (sexual crime, financial problem, limitation of choice, and underutilized healthcare services). Decision-making factors regarding abortions were also found across all three domains.

CONCLUSION

The abortion decision-making of young women is influenced by various external factors regardless of country. Parents are especially influential and tend to force their daughters to make a decision. Young women experienced suffering, frustration, and lack of autonomy in making decisions based on their preference. This emphasizes the importance of autonomous decision-making. In this regard, healthcare services should be used. However, there are barriers to accessing these services. To improve such access, the following are required: staff training to provide adolescent and youth-friendly health services, counseling based on women's needs, counseling including the parents or guardians that is confidential and ethical, promotion of decision aids, and affordable accessible care.

Analysing the context and characteristics of legal abortion and comprehensive post-abortion care among adolescents aged 10-14 in a network of sentinel centres in Latin America: a retrospective cross-sectional study, 2016-2020

Pregnancy-related complications are a substantial source of morbidity and mortality among adolescents in low- and middle-income countries. While the youngest adolescents (those aged 10-14) are considered to be at particularly high risk of adverse outcomes, there is little empirical data available on their sexual and reproductive health. Using a unique dataset of clinical records drawn from a regional network of sentinel centres providing legal abortion and comprehensive post-abortion care in 12 Latin American and Caribbean countries, we described the population of adolescents aged 10-14 seeking legal abortion and post-abortion care and calculated institutional rates of complications, using older adolescents (aged 15-19) and young adults (aged 20-24) as comparator groups. We also assessed the quality of care provided as compared to WHO recommendations. Nearly 17% (89 out of 533) of young adolescents sought care when they were already at 15 or more weeks' gestation. Young adolescents were at higher risk of pre-procedure and intra-operative complications than older adolescents and young adults, though the trend is less clear for the most severe complications. In general, the quality of care provided by centres in the network was aligned with WHO recommendations for safe abortion and comprehensive post-abortion care. Taken together, these findings provide insight into the challenges facing the global health community in assuring the sexual and reproductive health and rights of the youngest adolescents, and outline avenues for future research, advocacy, and evidence-based policymaking.

Induced abortions among Chinese adolescent girls

BACKGROUND

Induced abortion among adolescent girls is a global public health issue and a serious challenge in China, but still remains under-examined. We aimed to examine the overall trend and characteristics of induced abortions among Chinese adolescent girls and to investigate the factors associated with induced abortion.

STUDY DESIGN

Based on the 2017 China Fertility Survey, this study examined the trend and characteristics of induced abortions among adolescent girls with statistical analysis and multiple indicators of descriptive statistics from period and cohort perspectives, including induced abortion proportion and rate, age-specific cumulative proportion, and age-specific cumulative number of induced abortions in adolescent girls.

RESULTS

Between 1996 and 2016, the proportion and rate of adolescent induced abortions first increased and then decreased, and the mean age at the time of induced abortions among adolescent girls declined. The cumulative proportion of women who had experienced induced abortion at the age of 15-19 in a cohort is less than 2.5% but shows an upward trend. Over 70% of all adolescent induced abortions are premarital. The proportion of women with unintended pregnancy experiences increased and is higher among rural, less educated, and ethnic minority women. Similarly, the prevalence of induced abortion is higher among adolescent girls who live in rural areas, are less educated, and come from ethnic minorities. The cumulative number of induced abortions and premarital abortions increased with later cohorts.

CONCLUSIONS

This study shows an upward trend in adolescent-induced abortion and a decline in the age at the time of the induced abortion. Women in later birth cohort have a higher proportion of having experienced adolescent induced abortion. Adolescent girls who live in rural areas, who are less educated, or who are from ethnic minorities, are more likely to undergo induced abortions at the age of 15-19. More appropriate educational efforts and interventions are urgently needed to reduce the incidence of adolescent induced abortions.

"I was waiting for my period": Understanding pregnancy recognition among adolescents seeking abortions in Ethiopia, Malawi, and Zambia

OBJECTIVES

For a person seeking an abortion, the ability to recognize a pregnancy is a critical first step. Pregnancy recognition is complex and shaped by numerous factors. This paper explores the experiences of pregnancy recognition among adolescents in Ethiopia, Malawi, and Zambia.

STUDY DESIGN

The final sample included 313 adolescents aged 10 to 19 who had sought abortion-related care at urban public facilities in Ethiopia (N = 99), Malawi (N = 104), and Zambia (N = 110). Researchers collected mixed-method data on how adolescents came to recognize that they were pregnant and thematically analyzed qualitative data alongside descriptive statistics from quantitative data.

RESULTS

Most adolescents reported that their main mode of recognizing a pregnancy was medical pregnancy tests or late menstruation. Reasons for not recognizing a pregnancy included irregular menses or recent menarche and attribution of signs and symptoms to other medical conditions. Psychological barriers to pregnancy recognition were important, including the refusal to accept a pregnancy and denial of a pregnancy. Timing of recognition shaped the abortion care available for adolescents and the affordability of care. For some adolescents, their capacity to recognize their pregnancy led to involuntary or voluntary disclosure, which decreased their reproductive autonomy.

CONCLUSIONS

Adolescent experiences of pregnancy recognition complement existing evidence, illustrating critical barriers across age and context. Interrogating pregnancy recognition among adolescents exposed the critical implications for the availability, accessibility, affordability, and autonomy of their abortion trajectory.

IMPLICATIONS

Pregnancy recognition is complex and can influence adolescents' ability to exercise their reproductive rights and access abortion care of their choosing. Programmes to improve awareness of the signs of a pregnancy, increasing the provision of affordable and accessible pregnancy testing and further research on pregnancy recognition are necessary to support adolescents' reproductive autonomy.

Gaps in available published data on abortion in Uganda and the missed opportunity to inform policy and practice

Globally, 25% of pregnancies end up in induced abortion, the majority of which are unsafe. Abortion is safe when conducted according to WHO recommendations. The objective of the present study was to identify gaps in the data published on abortion and make recommendations to the Ministry of Health, Uganda. The search strategy included PubMed, Google Scholar articles (from October 2020 to May 2021) on unsafe abortion in Uganda, reviewed data from the Association of Obstetricians and Gynecologists of Uganda (AOGU) members' baseline survey (2019), Health Management Information System (HMIS) summary data (2015-2016 to 2019-2020), and the Uganda Demographic and Heath Survey (DHS) report (2011, 2016). From the 200 articles and national health surveys identified, 37 articles and two national representative surveys met our criteria: prevalence, factors, estimating cost of induced abortion, and complications associated with safe and unsafe abortion in both low- and high-income countries. There are many unsafe abortions in restrictive environments. Abortion is one of the leading causes of maternal and morbidity. Physicians favor dilatation and curettage over manual vacuum aspiration and medical methods for the evacuation of retained products. Several gaps still exist in the published articles, HMIS data, and DHS data, leading to missed opportunities for data to inform policy and practice.

Integrating child rights standards in contraceptive and abortion care for minors in Africa

Minor girls in Africa face challenges in accessing high-quality contraceptive and abortion services because laws and policies are not child-friendly. Many countries maintain restrictive laws, policies, or hospital practices that make it difficult for minors to access contraception and safe abortion even when the pregnancy would risk their life or health. Further, the clinical guidelines on contraceptive and abortion care are silent, vague, or ambiguous regarding minors' consent. African states should remedy the situation by ensuring that clinical guidelines integrate child rights principles and standards articulated in child rights treaties to enable health providers to facilitate full, unencumbered access to contraceptive and abortion care for minor girls. A sample of clinical guidelines is analyzed to demonstrate the importance of explicit, consistent, and unambiguous language about children's consent to ensure that healthcare workers provide sexual and reproductive health care in a manner that respects child rights.

Recent trend and correlates of induced abortion in China: evidence from the 2017 China Fertility Survey

BACKGROUND

Although there are more than 10 million induced abortions per year in China, there are few comprehensive, systematic, and characteristic-based data on induced abortions among Chinese women. This study aims to examine the overall trend in induced abortions in China and to analyze the correlation between induced abortions and some socio-economic factors.

METHODS

Drawing from the 2017 China Fertility Survey, this study analyzed induced abortions using multiple indicators from period and cohort perspectives on a sample of 240,957 women. The indicators include the abortion rate and proportion, average age at the time of induced abortion, age-specific cumulative proportions, and the number of induced abortions by cohort. The analysis also differentiated based on residency, ethnicity, education level, and marital status. A binomial logistic regression model was used to examine the association between induced abortions and socio-economic factors.

RESULTS

Between 2006 and 2016, among women aged 15-49, there was an increase in the induced abortion rate and the average age of women who had induced abortions, but a decline in the proportion of abortions. The proportion of induced abortion was higher among premarital than post-marital pregnancies, among unintended than planned pregnancies. Women with induced abortion experiences accounted for less than 30% of all cohorts, and the cumulative number of induced abortions per woman in each cohort was less than 0.45. These indicators varied with birth cohort, residence, ethnicity, education level, and marital status. The results of binomial logistic regression confirmed the association between induced abortion and these socio-economic variables. Sex-selective abortions of female fetuses still exist, despite the government's considerable efforts to eliminate them.

CONCLUSION

The practice of induced abortions differs by cohort and socio-economic characteristics. The profile of women who resort to abortions in China has shifted from well-educated urban women to rural, less-educated women. More effective measures should be taken by the government to reduce the number of induced abortions among women with higher abortion risks.

Utilization of abortion services from an unsafe provider and associated factors among women with history of induced abortion in Ghana

BACKGROUND

In sub-Saharan Africa (SSA), numerous studies have examined women's choice of abortion methods and services using hospital-based data, community-based surveys and nationally representative data. Little research focuses on the factors influencing a woman's choice of abortion provider. This study sought to identify factors that are associated with why a woman seeks abortion care services from an unsafe provider in Ghana.

METHODS

We used nationally representative data of women from the 2017 Ghana Maternal Health Survey (GMHS). Data analysis was restricted to women aged 15-49 with a recent history of induced abortion. Analyses focused on a weighted sample of 1,880. Descriptive analysis and the chi-square test were used to examine the proportion of women utilizing abortion services from unsafe providers. Factors hypothesized to affect the utilization of abortion services from unsafe providers were examined using both bivariable and multivariable logistic regression analyses.

RESULTS

The proportion of survey respondents who reported that they utilize abortion service from unsafe providers were 57.5%. After adjusting for confounders, those who have knowledge of abortion legality [aOR: 0.381 (0.271-0.541)] and those who have attained secondary or higher education [aOR: 0.613 (0.411-0.914)] were less likely to use abortion services from unsafe providers. On the other hand, women belonging to the Ewe ethnic group [aOR: 0.696 (0.508-0.953)], those residing in the middle belt zone [aOR: 1.743 (1.113-2.728)], younger women aged 15-29 years [aOR: 2.037 (1.234-3.362)] were more likely to use abortion services from unsafe abortion providers.

CONCLUSIONS

This research suggests that increasing the knowledge of women on the legal status of abortion through public education and encouraging more women to pursue secondary or higher education can contribute to reducing the use of abortion services from unsafe providers. These interventions should be targeted among younger women and those who reside in the middle belt zones of Ghana.

Three Delays Model applied to prevention of unsafe abortion in Ghana: a qualitative study

BACKGROUND

Unsafe abortion is an important public health problem in Ghana, making significant contributions to the morbidity and mortality of reproductive-aged women. Although mostly used in explaining mortality associated with perinatal care, recent calls for research on induced abortion in Africa suggest that the Three Delays Model could be used to enhance understanding of women's experiences and access to induced abortion care.

METHODS

We conducted 47 face-to-face interviews with women who had experienced unsafe abortions, with formal abortion providers (abortion providers in hospitals) and with informal and non-legal abortion providers (pharmacy workers and herb sellers). Study participants were recruited from selected hospitals, community pharmacies and markets within the Ashanti region of Ghana. We drew on phenomenology to analyse the data.

FINDINGS

The first delay (in seeking care) occurred because of women's poor knowledge of pregnancy, the influence of religion, and as a result of women underestimating the seriousness of abortion complications. Factors including cost, provider attitudes, stigma, and the proximity of pharmacies to women's homes delayed their access to safe abortion and resulted in their experience of the second delay (in reaching a healthcare facility). The third delay (in receiving appropriate care) was a result of hospitals' non-prioritisation of abortion complications and a shortage of equipment, resulting in long hospital waiting times before treatment.

CONCLUSION

This study has shown the value of the Three Delays Model in illustrating women's experiences of unsafe abortions and ways of preventing the first, second and third delays in their access to care.

Understanding women's provider choice for induced abortion in Turkey

In Turkey, women gained free access to induced abortion from public facilities through the legalization of abortion in 1983. However, due to unmet need and abortion stigma, women use predominantly private services. The political discourse on anti-abortion in the past decade has triggered a diminishing trend in public provision. This runs against both the 1983 Law and the healthcare reforms initiated in 2003, which aimed at universal access to health services. This study investigates the socioeconomic characteristics of women affecting the utilization of public services for induced abortion. Using "Turkey Demographic and Health Survey 2013", the results of Probit models indicate that women who were young, unmarried, wealthier and whose abortion decisions were made by themselves or their spouses were less likely to choose the public services for induced abortion. Regional differences in the utilization of public sector were also observed. Findings indicate a need to ensure and widen women's access to abortion nationwide; both at the hospital and outpatient level. Health education programs including family planning should give special emphasis to young, single and socioeconomically disadvantaged women who are more prone to apply for unsafe abortion when access to public and/or private sector is limited. A transparent referral system should be designed to timely direct women to abortion services.

Framing Contraceptive Use Motivations Among Adolescents and Young Adults Living in Informal Settlements in Kira Municipality, Wakiso District, Uganda

Introduction: The use of contraceptives among adolescents and young adults is one of the most cost-effective strategies to address many sexual and reproductive health (SRH) challenges, including unintended pregnancies, early marriages, and sexually transmitted infections. Despite a high burden of SRH challenges, uptake and unmet needs of modern contraceptives remain low in Uganda, especially among adolescents and young adults in informal settlement settings. This study aimed to explore the motivations of adolescents and young people to use modern contraceptives (or not). Methods: We analysed qualitative data from eight focus group discussions with 88 adolescents and young people aged 18-24 years residing in informal settlements of urban communities in Kira Municipality of Wakiso district, Uganda. Results: Motivations for use (or not) of modern contraceptives were framed by two interrelated constructs, sources of information on contraception and the unacceptable use of contraceptives among adolescents widespread in the community. These two, in turn, formed the scope of knowledge upon which adolescents and young people based their decision on whether or not to access and use modern contraceptives. Conclusion: To be more effective, sexual and reproductive health programs and interventions that aim to motivate the use of modern contraceptives among adolescents and young people in informal settings should be more comprehensive and focused on alleviating individual, health systems, social, religious factors that reinforce negative health-seeking behaviours towards contraceptive use. In addition, there is a need to support adolescents and young people with socio-economic empowering strategies that equip them with sufficient resources to choose contraceptives of their choice.

Prevalence of first adolescent pregnancy and its associated factors in sub-Saharan Africa: A multi-country analysis

INTRODUCTION

In low-and middle-income countries, pregnancy-related complications are major causes of death for young women. This study aimed to determine the prevalence of first adolescent pregnancy and its associated factors in sub-Saharan Africa.

METHODS

We undertook a secondary analysis of cross-sectional data from Demographic and Health Surveys conducted in 32 sub-Saharan African countries between 2010 and 2018. We calculated the prevalence of first adolescent (aged 15 to 19 years) pregnancy in each country and examined associations between individual and contextual level factors and first adolescent pregnancy.

RESULTS

Among all adolescents, Congo experienced the highest prevalence of first adolescent pregnancy (44.3%) and Rwanda the lowest (7.2%). However, among adolescents who had ever had sex, the prevalence ranged from 36.5% in Rwanda to 75.6% in Chad. The odds of first adolescent pregnancy was higher with increasing age, working, being married/cohabiting, having primary education only, early sexual initiation, knowledge of contraceptives, no unmet need for contraception and poorest wealth quintile. By contrast, adolescents who lived in rural areas and in the West African sub-region had lower odds of first adolescent pregnancy.

CONCLUSION

The prevalence of adolescent pregnancy in sub-Saharan African countries is high. Understanding the predictors of first adolescent pregnancy can facilitate the development of effective social policies such as family planning and comprehensive sex and relationship education in sub-Saharan Africa and can help ensure healthy lives and promotion of well-being for adolescents and their families and communities.

Exploring media framing of abortion content on Kenyan television: a qualitative study protocol

BACKGROUND

Media framing of abortion messages is an emerging field of research. However, little is known about how the news media frames abortion messages aimed at influencing adolescents' reproductive health choices. This study therefore seeks to investigate the framing of abortion in TV news items on three leading Kenyan TV outlets over a period of 3 years, understand Kenyan journalists' perceptions and experiences with abortion coverage, and to examine adolescents' perceptions and experiences with abortion coverage on Kenyan televised news media.

METHODS

This qualitative study which will be conducted in two sites-Nairobi and Uasin Gishu counties-in Kenya will purposively sample abortion news items from three leading media outlets aired between January 2016 to December 2019, for content analysis. Additionally, 12 journalists (9 reporters, 3 news editors) will be purposively sampled for Key Informant Interviews (KIIs) on journalist framing of abortion messages. Finally, convenience sampling will be used to select approximately 48 university-going adolescents for four Focus Group Discussions (FGDs)-2 female, 2 male- aimed at examining adolescents' perceptions and experiences with abortion coverage in the broadcast news media. The KIIs and FGDs will be audio-recorded, transcribed and translated. These data will be analyzed thematically.

DISCUSSION

This study moves beyond interrogating only media items to further exploring framing from the perspectives of media consumers and investigations in the process behind production of abortion messages. The study interrogates abortion messages aimed at younger demographics such as adolescents as well as the gendered differences of the effects of these abortion messages, an area barely explored. The study findings will be informative to those who wish to develop media that could be used to promote safe abortion as well as advocate for sexual reproductive health rights, especially among adolescents.

Abortion care pathways and service provision for adolescents in high-income countries: A qualitative synthesis of the evidence

Limited research in high-income countries (HICs) examines adolescent abortion care-seeking pathways. This review aims to examine the pathways and experiences of adolescents when seeking abortion care, and service delivery processes in provision of such care. We undertook a systematic search of the literature to identify relevant studies in HICs (2000–2020). A directed content analysis of qualitative and quantitative studies was conducted. Findings were organised to one or more of three domains of an a priori conceptual framework: context, components of abortion care and access pathway. Thirty-five studies were included. Themes classified to the Context domain included adolescent-specific and restrictive abortion legislation, mostly focused on the United States. Components of abortion care themes included confidentiality, comprehensive care, and abortion procedure. Access pathway themes included delays to access, abortion procedure information, decision-making, clinic operation and environments, and financial and transportation barriers. This review highlights issues affecting access to abortion that are particularly salient for adolescents, including additional legal barriers and challenges receiving care due to their age. Opportunities to enhance abortion access include removing legal barriers, provision of comprehensive care, enhancing the quality of information, and harnessing innovative delivery approaches offered by medical abortion.

Spatial distribution and determinants of abortion among reproductive age women in Ethiopia, evidence from Ethiopian Demographic and Health Survey 2016 data: Spatial and mixed-effect analysis

BACKGROUND

Unsafe abortion remains a global public health concern and it is the leading cause of maternal mortality and morbidity. Despite the efforts made to improve maternal health care service utilization, unsafe abortion yet constitutes the highest maternal mortality in Sub-Saharan Africa (SSA) including Ethiopia. Although abortion among reproductive-age women is a common problem in Ethiopia, there is limited evidence about the spatial distribution and determinants of abortion. Therefore, this study aimed to investigate the spatial distribution and determinants of abortion among reproductive-age women in Ethiopia.

METHODS

A secondary data analysis was conducted using the 2016 Ethiopian Demographic and Health Survey (EDHS) data. A total of 12378 reproductive-age women were included in this study. The Bernoulli model was fitted using SaTScan version 9.6 statistical software to identify significant hotspot areas of abortion and ArcGIS version 10.6 statistical software was used to explore the spatial distributions of abortion. For the determinant factors, a mixed effect logistic regression model was fitted to take into account the hierarchical nature of the EDHS data. Deviance (-2LL), AIC, BIC, and ICC were used for model comparison. The AOR with a 95% CI was estimated for the potential determinants of abortion.

RESULTS

The overall prevalence of abortion in Ethiopia was 8.9% ranging from 4.5% in Benishangul to 11.3% in Tigray regions. The spatial analysis revealed that abortion was significantly varied across the country. The SaTScan analysis identified a total of 60 significant clusters, of these 19 clusters were primary clusters. The primary clusters were located in the northern part of the Tigray region (LLR = 26.6, p<0.01; RR = 2.63). In the multivariable mixed-effect logistic regression analysis; primary education [AOR = 1.36; 95% CI: 1.13, 1.64], rural residence [AOR = 4.96; 95% CI: 3.42, 7.18], protestant religion follower [AOR = 0.56; 95% CI: 0.42, 0.75], richest wealth status [AOR = 1.72; 95% CI: 1.24, 2.40], maternal age 45-49 years [AOR = 3.12; 95% CI: 1.52, 6.44], listening radio [AOR = 1.27; 1.01, 1.60], and watching television [AOR = 1.45; 1.04, 2.01] were significant determinants of abortion.

CONCLUSIONS

The prevalence of abortion remains unacceptably high in Ethiopia. The spatial distribution of abortion has been significantly varied across regions in Ethiopia. Having primary education, being rural, having media exposure, and being from the richest household were significantly associated with higher odds of abortion whereas being protestant religious followers were associated with lower odds of abortion. Therefore, the government should design public health programs targeting the identified hotspot areas of abortion and should scale up maternal health programs in rural areas, to reduce maternal morbidity and mortality.

Healthcare Providers' Knowledge and Attitude Towards Abortions in Thailand: A Pre-Post Evaluation of Trainings on Safe Abortion

Although physicians in Thailand can carry out abortions legally, unsafe abortion rates remain high and have serious consequences for women's health. Training programs for healthcare providers on the 'Care of unplanned and adolescent pregnancies for the prevention of unsafe abortions' have been implemented in Thailand with the aim of providing information and challenging negative attitudes about abortions. This study investigated the participants of the training courses in order to: (i) evaluate their knowledge and attitudes towards safe abortions; and (ii) investigate the factors that determine their knowledge and attitudes. A pre-post study design was applied. Descriptive statistics were calculated to provide an overview of the data. Bivariate analysis, a Wilcoxon signed rank test and a multivariable analysis using multiple linear regression were applied to determine the changes in attitudes and assess the likelihood of behaviour change towards adolescents and women experiencing unplanned pregnancy and abortions, according to demographic and professional characteristics. Having had the training, healthcare providers' change in attitudes towards adolescents and women experiencing unplanned pregnancies and abortions were found to be 0.67 points for the nine responses of attitudes and 0.79 points for the 14 responses on various abortion scenarios. Changes in attitude were significantly different among the varying health professional types, with non-doctors increasing by 0.53 points, non-obstetricians and non-gynaecologists increasing by 0.46 points and obstetricians and gynaecologists (OBGYN) increasing by 0.32 points. Positive attitudes towards unplanned pregnancies and unsafe abortions and attitudes towards abortion scenarios significantly increased. The career type of the health professional was a significant factor in improving attitudes. The training program was more effective among non-doctor healthcare providers. Therefore, non-doctors could be the target population for training in the future.

Estimating abortion incidence and unintended pregnancy among adolescents in Zimbabwe, 2016: a cross-sectional study

OBJECTIVE

To estimate age-specific abortion incidence and unintended pregnancy in Zimbabwe, and to examine differences among adolescents by marital status and residence.

DESIGN

We used a variant of the Abortion Incidence Complications Methodology, an indirect estimation approach, to estimate age-specific abortion incidence. We used three surveys: the Health Facility Survey, a census of 227 facilities that provide postabortion care (PAC); the Health Professional Survey, a purposive sample of key informants knowledgeable about abortion (n=118) and the Prospective Morbidity Survey of PAC patients (n=1002).

SETTING

PAC-providing health facilities in Zimbabwe.

PARTICIPANTS

Healthcare providers in PAC-providing facilities and women presenting to facilities with postabortion complications.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was abortion incidence (in rates and ratios). The secondary outcome measure was the proportion of unintended pregnancies that end in abortion.

RESULTS

Adolescent women aged 15-19 years had the lowest abortion rate at five abortions per 1000 women aged 15-19 years compared with other age groups. Adolescents living in urban areas had a higher abortion ratio compared with adolescents in rural areas, and unmarried adolescent women had a higher abortion ratio compared with married adolescents. Unintended pregnancy levels were similar across age groups, and adolescent women had the lowest proportion of unintended pregnancies that ended in induced abortion (9%) compared with other age groups.

CONCLUSIONS

This paper provides the first estimates of age-specific abortion and unintended pregnancy in Zimbabwe. Despite similar levels of unintended pregnancy across age groups, these findings suggest that adolescent women have abortions at lower rates and carry a higher proportion of unintended pregnancies to term than older women. Adolescent women are also not a homogeneous group, and youth-focused reproductive health programmes should consider the differences in experiences and barriers to care among young people that affect their ability to decide whether and when to parent.

Predictors of Unsafe Induced Abortion among Women in Ghana

Background

Unsafe induced abortion is a major contributor to maternal morbidity and mortality in Ghana.

Objective

This study aimed to explore the predictors of unsafe induced abortion among women in Ghana.

Methods

The study used data from the 2017 Ghana Maternal Health Survey. The association between women's sociodemographic, obstetric characteristics, and unsafe induced abortion was explored using logistic regression. The analysis involved a weighted sample of 1880 women aged 15-49 years who induced abortion in the period 2012-2017. Analysis was carried out using STATA/IC version 15.0. Statistical significance was set at p <0.05.

Results

Of the 1880 women, 64.1% (CI: 60.97-67.05) had an unsafe induced abortion. At the univariate level, older women (35-49 years) (odds ratio=0.50, 95% CI: 0.28-0.89) and married women (odds ratio=0.61, 95% CI:0.44-0.85) were less likely to have an unsafe induced abortion while women who did not pay for abortion service (odds ratio=4.44, 95% CI: 2.24-8.80), who had no correct knowledge of the fertile period (odds ratio =1.47, 95% CI: 1.10-1.95), who did not know the legal status of abortion in Ghana (odds ratio =2.50, 95% CI: 1.68-3.72) and who had no media exposure (odds ratio =1.34, 95% CI: 1.04-1.73) had increased odds for an unsafe induced abortion. At the multivariable level, woman's age, payment for abortion services, and knowledge of the legal status of abortion in Ghana were predictors of unsafe induced abortion.

Conclusion

Induced abortion is a universal practice among women. However, unsafe abortion rate in Ghana is high and remains an issue of public health concern. We recommend that contraceptives and safe abortion services should be made available and easily accessible to women who need these services to reduce unwanted pregnancies and unsafe abortion rates, respectively, in the context of women's health. Also, awareness has to be intensified on abortion legislation in Ghana to reduce the stigma associated with abortion care seeking.

Contraception and abortion knowledge, attitudes and practices among adolescents from low and middle-income countries: a systematic review

Background

Adolescents face significant barriers to contraception access and utilization that result in adverse health effects of early pregnancy and childbirth. Unsafe abortions continue to occur partly due to failure to prevent pregnancies, with Sub-Saharan Africa contributing the most significant burden of all unsafe abortions among young people globally, of which a quarter occurs in those aged 15–19 years. We aimed to conduct a systematic review of the contraceptive and abortion knowledge, attitudes and practices of adolescents in low and middle-income countries to increase the understanding of the sexual and reproductive health dynamics that they face.

Methods

Literature searches from 6 databases; PubMed, Science Direct, Google Scholar, BioMed Central, CINAHL, MEDLINE, were conducted, covering the period from 1970 to 2016 and concerning the adolescents aged 15–19 years and 21 studies were read and analyzed using thematic analysis.

Results

Limited knowledge about sexual and reproductive health among adolescents was a significant cause of reduced access to contraception and safe abortion services, especially among unmarried adolescents. Reduced access to reproductive health services for some resulted in extreme methods of contraception and abortion such as the use of battery acid and crushed bottles. Despite all adolescents having limited access to information and services, girls faced more consequences such as being blamed for pregnancy or dealing with the effects of unsafe abortions. Parents, health workers, and teachers were cited as trusted sources of information but often received the most information from peers and other family members instead, and the girls mostly confided in their aunties, cousins and peers while the boys resorted to peers, media and even pornography.

Conclusion

The reported observations suggest severe limitations in the access to safe and effective methods of contraception and safe abortion services. There is a need for an urgent response in reducing the “unmet needs” for contraception and to improve access to contraception, abortion information, and services in this group. Interventions which target the involvement of parents and teachers should be considered, to carry one wholesome message to the adolescents.

Should condoms be available in secondary schools? Discourse and policy dilemma for safeguarding adolescent reproductive and sexual health in Rwanda

Introduction

As a response to challenges associated with adolescent reproductive and sexual health, policy makers in Rwanda have instituted preventive measures against risky sexual behaviours among adolescents. There is an ongoing debate on whether condoms should be made available in secondary schools to minimise risks related to unprotected sex in the context of a growing number of unintended pregnancies among school girls. This paper aims to examine the proposal of condom provision in Rwandan secondary schools through the analysis of policy narratives and the claims-making process.

Methods

A narrative policy analysis was used to understand the claims and counter claims surrounding the debate on the provision of condoms in secondary schools. Documents that were consulted include: the national reproductive health policy, the girls' education policy, the national behaviour change and communication policy for the health sector, the Rwanda national policy on condoms, the adolescent sexual reproductive health and rights policy and the Rwanda family planning policy.

Results

Social and cultural norms in the Rwandan context consider adolescent sexual practices as immoral and thus reject the idea of providing condoms in secondary schools. However, some stakeholders promoting reproductive health suggest that ignoring that some adolescents are sexually active will prevent them from accessing appropriate reproductive and sexual health protective programmes. Consequently, adolescents will be exposed to risky sexual behaviours, a situation which may be counter productive to the overarching goal of safeguarding adolescent sexual health which might impact their long-term education goals.

Conclusion

Making condoms available in secondary schools evokes different meanings among the debaters, underscoring the complex nature of the condom provision debate in Rwanda. This paper calls for a revision of policies related to adolescent reproductive and sexual health in order to answer to the issues of risky sexual behaviours among secondary school students.

Estimating abortion incidence among adolescents and differences in postabortion care by age: a cross-sectional study of postabortion care patients in Uganda

Objectives:

To provide the first estimate of adolescents’ abortion incidence in Uganda and to assess differences in the abortion experiences and morbidities of adolescent and nonadolescent postabortion care (PAC) patients.

Study design:

We used the age-specific Abortion Incidence Complications Method, drawing from three surveys conducted in Uganda in 2013: a nationally representative Health Facilities Survey (n=418), a Health Professionals Survey (n=147) and a Prospective Morbidity Survey of PAC patients (n=2169). Multivariable logistic and Cox proportional hazard models were used to compare adolescent and nonadolescent PAC patients on dimensions including pregnancy intention, gestational age, abortion safety, delays to care, severity of complications and receipt of postabortion family planning. We included an interaction term between adolescents and marital status to assess heterogeneity among adolescents.

Results:

Adolescent women have the lowest abortion rate among women less than 35 years of age (28.4 abortions per 1000 women 15–19) but the highest rate among recently sexually active women (76.1 abortions per 1000 women 15–19). We do not find that adolescents face greater disadvantages in their abortion care experiences as compared to older women. However, unmarried PAC patients, both adolescent and nonadolescent, have higher odds of experiencing severe complications than nonadolescent married women.

Conclusions:

The high abortion rate among sexually active adolescents highlights the critical need to improve adolescent family planning in Uganda. Interventions to prevent unintended pregnancy and to reduce unsafe abortion may be particularly important for unmarried adolescents. Rather than treating adolescents as a homogenous group, we need to understand how marriage and other social factors shape reproductive health outcomes.

Implications:

This paper provides the first estimate of the adolescent abortion rate in Uganda. Studies of adolescent abortion and reproductive health must account for sexual activity and marital status. Further, interventions to address unintended pregnancy and unsafe abortion among unmarried women of all ages in Africa should be a priority.

Medical abortions among university students in Ghana: implications for reproductive health education and management

Purpose

In Ghana, unsafe abortion is a major cause of maternal mortality. Even though pharmaceutical drugs seem to be a key means of unsafe abortion, a paucity of evidence exists on the issue among adolescents, students, and other groups at risk. This study therefore explores the abortion experiences of Ghanaian university students with particular reference to pharmaceutical drugs to fill the knowledge gap and enrich the evidence base for reproductive health education, policies, and interventions on abortions among students.

Patients and methods

Undergraduate students from the University of Ghana were randomly selected and interviewed. The interviews was recorded, transcribed, and analyzed thematically using the framework analysis.

Results

Students were aware of safe medical abortion services but were reluctant to use them because of cost, stigma, and proximity. Generally, medical abortions were more likely to be self-induced among students with misoprostol-based drugs administered orally or vaginally. However, students also used various over-the-counter drugs, contraceptives, and prescription drugs singly, in series, or in combinations to induce abortion. Yet students had relatively little knowledge on the inherent risks and long-term implications of unsafe medical abortions and were more likely to have repeat abortions through unsafe medical methods.

Conclusion

Students’ knowledge and awareness of safe medical abortion avenues have not influenced their propensity to use them because of stigma, cost, and other factors. Rather, several methods of unsafe medical abortions are used increasingly with dire long-term effects on students. Serious knowledge gaps exist among students on the methods and risks of medical abortion. Consequently, there is an urgent need to revise current abortion management approaches and redirect attention toward reducing stigma and financial and social costs of safe abortion services, and increasing the proactive engagement, counseling, and management of medical abortions among students.

Delays in access to care for abortion-related complications: the experience of women in Northeast Brazil

Around 18 million unsafe abortions occur in low and middle-income countries and are associated with numerous adverse consequences to women's health. The time taken by women with complications to reach facilities where they can receive appropriate post-abortion care can influence the risk of death and the extent of further complications. All women aged 18+ admitted for abortion complications to public-sector hospitals in three capital cities in the Northeastern Brazil between August-December 2010 were interviewed; medical records were extracted (N = 2,804). Nearly all women (94%) went straight to a health facility, mainly to a hospital (76.6%); the rest had various care-seeking paths, with a quarter visiting 3+ hospitals. Women waited 10 hours on average before deciding to seek care. 29% reported difficulties in starting to seek care, including facing challenges in organizing childcare, a companion or transport (17%) and fear/stigma (11%); a few did not initially recognize they needed care (0.4%). The median time taken to arrive at the ultimate facility was 36 hours. Over a quarter of women reported experiencing difficulties being admitted to a hospital, including long waits (15%), only being attended after pregnant women (8.9%) and waiting for a bed (7.4%). Almost all women (90%) arrived in good condition, but those with longer delays were more likely to have (mild or severe) complications. In Brazil, where access to induced abortion is restricted, women face numerous difficulties receiving post-abortion care, which contribute to delay and influence the severity of post-abortion complications.

Playing it Safe: Legal and Clandestine Abortions Among Adolescents in Ethiopia

PURPOSE

The 2005 expansion of the Ethiopian abortion law provided minors access to legal abortions, yet little is known about abortion among adolescents. This paper estimates the incidence of legal and clandestine abortions and the severity of abortion-related complications among adolescent and nonadolescent women in Ethiopia in 2014.

METHODS

This paper uses data from three surveys: a Health Facility Survey (n = 822) to collect data on legal abortions and postabortion complications, a Health Professionals Survey (n = 82) to estimate the share of clandestine abortions that resulted in treated complications, and a Prospective Data Survey (n = 5,604) to collect data on abortion care clients. An age-specific variant of the Abortion Incidence Complications Method was used to estimate abortions by age-group.

RESULTS

Adolescents have the lowest abortion rate among all women below age 35 (19.6 per 1,000 women). After adjusting for lower levels of sexual activity among adolescents however, we find that adolescents have the highest abortion rate among all age-groups. Adolescents also have the highest proportion (64%) of legal abortions compared with other age-groups. We find no differences in the severity of abortion-related complications between adolescent and nonadolescent women.

CONCLUSIONS

We find no evidence that adolescents are more likely than older women to have clandestine abortions. However, the higher abortion and pregnancy rates among sexually active adolescents suggest that they face barriers in access to and use of contraceptive services. Further work is needed to address the persistence of clandestine abortions among adolescents in a context where safe and legal abortion is available.

Sexual behavior of adolescent students in Chandigarh and their perceptions regarding family life education

Background:

With rapidly changing lifestyle and exposure to the Internet and mass media, lifestyle and sexual behavior of adolescent students are also changing rapidly.

Objectives:

To investigate the sexual behavior of adolescent students and to study misconceptions prevailing among them.

Methods:

A cross-sectional survey of 1022 adolescent students aged 14–19 years as a part of an Indian Council of Medical Research sponsored survey. Sexual behavior explored by interview method. Logistic regression analysis for finding correlates.

Results:

Intimate friendship was reported by 19.2% respondents. The sexual behavior included 89% exposure to sex-related material, 74.7% were aware of sexual intercourse. Awareness regarding at least one contraceptive was found among 95.5% (94.5% of condoms and 67.2% of emergency contraception). About 6% respondents reported some sex-related problems and 2.5% of all respondents consulted some doctors for these problems. Awareness of HIV/AIDS was quite high (about 99%), and 96.4% of them were of the opinion that it is spread through sexual intercourse. Knowledge regarding transmission of sexually transmitted infections (STIs) through sexual contact was found among 89.2% respondents. Avoidance/abstinence from sex (84.7%), faithful to one partner (81.7), and use of barrier methods (90.3%) was main reported preventive measures for STI's. About 33% want that the discussion about sex should be open and frank, and 69.4% showed the need of sex education in the schools mostly by doctors.

Conclusions:

Sexual behavior of adolescent students is changing, and awareness about sex acts is also increasing. There is likelihood of indulging in risky behavior by adolescents. Family life education was felt necessary mainly by qualified medical staff.

[Abortion practices in high school students in Yamoussoukro, Côte d'Ivoire]

INTRODUCTION

Induced abortion is illegal in Cote d'Ivoire, except when the mother's life is in danger. The primary objective of this study was to describe abortion practices among Yamoussoukro high school students. More specifically, this study estimated the prevalence of induced abortion, described the pathway and the methods used for abortion and determined any abortion-related complications.

MATERIAL AND METHODS

This cross-sectional study was conducted in July 2011 on 312 randomly selected girls attending the Lycée Jeunes Filles in Yamoussoukro.

RESULTS

These girls had a mean age (SD) of 16.1 (4.7) years; 258 (82.7%) of them had already had sexual intercourse and 81 (31.4%) had already been pregnant. Fifty (61.7% [56.3-67.1%]) of these 81 girls had already had an abortion. The abortion pathway was as follows: the main method was self-prescribed medication (70%) as first attempt, followed, in case of failure, by traditional healers (56.4%). Healthcare practitioners were usually consulted at the third attempt (85.7%). The most commonly used methods of abortion were drugs (91.9%), ingestion of plants/beverages (68.5%) and introduction of devices into the uterine cavity (62.3%). Twenty-two (44%) out of 50 induced abortions resulted in complications, mostly infectious complications (81.8%), and bleeding (68.2%). Complications were significantly associated with self-induced abortions or abortions performed by traditional healers (p < 0.001).

CONCLUSION

More intensive sexual education, access to modern methods of contraception, awareness campaigns concerning the risks related to unwanted pregnancies and abortions performed by non-medical personnel need to be implemented to prevent school abortions. The quality and accessibility of post-abortion services also need to be reinforced.

Opportunities, challenges and systems requirements for developing post-abortion family planning services: Perceptions of service stakeholders in China

Post-abortion family planning (PAFP) has been proposed as a key strategy to decrease unintended pregnancy and repeat induced abortions. However, the accessibility and quality of PAFP services remain a challenge in many countries including China where more than 10 million unintended pregnancies occur each year. Most of these unwanted pregnancies end in repeated induced abortions. This paper aims to explore service providers' perceptions of the current situation regarding family planning and abortion service needs, provision, utilization, and the feasibility and acceptability of high quality PAFP in the future. Qualitative methods, including in-depth interviews and focus group discussions, were used with family planning policy makers, health managers, and service providers. Three provinces-Zhejiang, Hubei and Yunnan-were purposively selected, representing high, medium and relatively undeveloped areas of China. A total of fifty-three in-depth interviews and ten focus-group discussions were conducted and analysed thematically. Increased numbers of abortions among young, unmarried women were perceived as a major reason for high numbers of abortions. Participants attributed this to increasing socio-cultural acceptability of premarital sex, and simultaneously, lack of understanding or awareness of contraception among young people. The majority of service stakeholders acknowledged that free family planning services were neither targeted at, nor accessible to unmarried people. The extent of PAFP provision is variable and limited. However, service providers expressed willingness and enthusiasm towards providing PAFP services in the future. Three main considerations were expressed regarding the feasibility of developing and implementing PAFP services: policy support, human resources, and financial resources. The study indicated that key service stakeholders show demand for and perceive considerable opportunities to develop PAFP in China. However, changes are needed to enable the systematic development of high quality PAFP, including actively targeting young and unmarried people in service provision, obtaining policy support and increasing the investment of human and financial resources.

What can obstetrician/gynecologists do to support abortion access?

Unsafe abortion causes approximately 13% of all maternal deaths worldwide, with higher rates in areas where abortion access is restricted. Because safe abortion is so low risk, if all women who needed an abortion could access safe care, this rate would drop dramatically. As women's health providers and advocates, obstetrician/gynecologists can support abortion access. By delivering high-quality, evidence-based care ourselves, supporting other providers who perform abortion, helping women who access abortion in the community, providing second-trimester care, and improving contraceptive uptake, we can decrease morbidity and mortality from unsafe abortion.

The Women'S Perceptions About Unwanted Pregnancy: A Qualitative Study in Iran

Background:

Unwanted pregnancy has affected different aspects of our life. Researchers point out if a child’s birth is unwanted, an increase in maternal issues can be observed. The aim of this study was to describe the women’s viewpoints regarding unwanted pregnancy.

Method:

This qualitative study using content analysis was employed in Shiraz University in 2013-2014. 20 women with unwanted pregnancy were chosen using purposeful sampling. Data were gathered through semi-structured interviews and trustworthiness of them was evaluated.

Results:

Findings of this study, according to the participants’ experience, revealed maternal emotions like embarrassment for getting pregnant, mother’s own negative affection, concerns about missing family and other children, and terminating the pregnancy through illegal abortion, the husband’s disagreement about the termination, blaming themselves for thinking about abortion or illegal abortion, and concern about their guilt feeling. Another finding was family problems like husband’s behavior and his negative outlook towards his child and fetus. The next category belonged to anxiety about the future of their child, including economic, social and relational problems, and suppression of the children’s logical expectations. The last finding was the lack of maternal emotional support.

Conclusions:

Unwanted pregnancy’s effects on the mothers and infants’ health are considerable. A closer observation by family and health care providers for unwanted pregnancies and its results is recommended; therefore, they should be taken care of as high risk pregnancies, requiring family support.

Peer Influences on Sexual Activity among Adolescents in Ghana

Little is known about the influences of peers on the sexual activity of adolescents in sub-Saharan Africa. Better understanding of these issues could lead to more effective sexual and reproductive health interventions. Using two waves of survey data from 1,275 adolescents in two southeastern Ghanaian towns, we examine age, sex, and community differences in peer group characteristics. We also examine prospective associations between peer group characteristics and self-reported sexual initiation and multiple partnerships during a 20-month follow-up period. Sex differences in peer-context variables were small. Affiliation with antisocial peers and perceived peer norms favoring sex increased the odds of transition to first sex. Having more friends increased the odds among younger respondents of acquiring multiple new sexual partners. Among males, perceived peer norms favoring sex increased the odds of acquiring multiple partners. We discuss the implications of these findings for adolescent sexual and reproductive health intervention strategies in sub-Saharan Africa, and conclude that peer-based interventions may be best suited to the needs of at-risk adolescent boys.

Knowledge about complications and practice of abortion among female undergraduates in the university of ibadan, Nigeria

Background:

Unwanted pregnancies and unsafe abortion pose major health risks to women in the reproductive age group. Female undergraduates are particularly exposed to these risks. This study was carried out to assess the knowledge about complications and practice of abortion among female undergraduates of the University of Ibadan.

Methods:

A cross-sectional study was conducted using structured, self-administered questionnaires, to collect data on respondents’ socio-demographic characteristics, sexual behaviour, knowledge about various complications of abortion and practice of abortion. Data was analyzed using SPSS version 14.

Results:

A total of 425 students were interviewed, mean age of the undergraduates was 21.5± 2.8 years. Overall, 122 (29%) of the respondents had ever had sexual intercourse. Twenty five percent of those who were sexually active had ever been pregnant and 90% had terminated the pregnancy. The most common reason given for termination was that pregnancy was unplanned for. Most of the respondents 354 (83.3%) had a good knowledge about complications of abortion and mean knowledge score was 4.01±1.58 (range 0-5).

Conclusion:

This group of students were aware of the risks associated with unsafe abortion; however, the abortion rate was still high. Sexual reproductive health interventions are needed on campus in order to equip female undergraduates with comprehensive knowledge and skills to reduce the likelihood of unplanned pregnancies

Post-abortion care services for youth and adult clients in Kenya: a comparison of services, client satisfaction and provider attitudes

Unsafe abortion accounts for 35% of maternal mortality in Kenya. Post-abortion care (PAC) reduces maternal death and provides an opportunity to prevent unwanted pregnancies. Few studies have documented how the receipt of PAC services varies by client age. In this study, descriptive data were collected from clients, providers and eight health facilities in Kenya's Central and Nairobi provinces to examine receipt of PAC services by client age, client satisfaction and provider attitudes. Delivery of PAC treatment, pain management, HIV and STI services and violence screening did not vary by age. However, fewer youth between the ages of 15 and 24 received a contraceptive method compared with adult clients (35% versus 48%; p=0.02). Forty-nine per cent of youth reported not using a family planning method due to fears of infertility, side-effects or lack of knowledge compared with 22% of adults. Additional efforts are needed in Kenya to bolster the family planning services that young PAC clients receive and increase the uptake of contraception.

Meeting the need: youth and family planning in sub-Saharan Africa

BACKGROUND

The need for a concerted effort to address the gaps in family planning services for youth in sub-Saharan Africa has been underreported and underexplored.

STUDY DESIGN

Trends in fertility, childbearing, unmet need for family planning options and contraceptive prevalence (CP) among youth are described with data from six African countries with four consecutive Demographic and Health Surveys. Estimates of exposure to risk of pregnancy and number of new contraceptives users needed to maintain and double CP in 2015 are calculated using current CP and projected youth population size in six African countries.

RESULTS

The youth population is expected to range from approximately 3 to 35 million in six African countries by 2015. Accounting for population growth and current estimates of sexual activity among youth, family planning services will need to absorb more than 800,000 and 11.3 million new contraceptive users total to maintain and double CP, respectively, in 2015 in those six African countries alone.

CONCLUSION

Our findings support existing literature that calls for a reorientation of family planning policies and programs, especially improved access to modern contraceptive methods among African youth.

Obstetric outcomes of booked teenage pregnancies at University of Calabar Teaching Hospital, Nigeria

Background

Teenage pregnancy is high-risk and associated with complications due to adverse physiological, anatomical, and socioeconomic factors. The purpose of this study was to determine the patterns and obstetric outcomes of booked teenage pregnancies at the University of Calabar Teaching Hospital (UCTH) in Nigeria.

Methods

A retrospective comparative analysis of teenage pregnancies and mature mothers at UCTH was carried out from January 2011 to December 2011. A total of 82 teenage pregnancies and 72 mature pregnancies were compared.

Results

There were 145 teenage deliveries from a total of 2313 deliveries, ie, 6.3% of total deliveries. There was no statistically significant difference in the mode of delivery (cesarean section, spontaneous vaginal delivery, instrumental delivery) between the groups of mothers. There was also no difference in risk of complications, including obstructed labor, retained placenta, uterine atony, pre-eclampsia/eclampsia, and antepartum hemorrhage. However, teenage mothers had more perineal lacerations (P = 0.02) and more preterm labor (P = 0.05), and delivered more low-birth-weight babies (P = 0.02).

Conclusion

Supervised teenage pregnancy may not be as hazardous as previously thought.

Bowel perforation secondary to illegally induced abortion: a tertiary hospital experience in Tanzania

BACKGROUND

Bowel perforation though rarely reported is a serious complication of induced abortion, which is often performed illegally by persons without any medical training in developing countries. A sudden increase in the number of patients in our centre in recent years prompted the authors to analyze this problem. The study was conducted to describe our own experiences in the surgical management of these patients.

METHODS

This was a retrospective study involving patients who were jointly managed by the surgical and gynecological teams at Bugando Medical Centre (BMC) for bowel perforation secondary to illegally induced abortion from January 2002 to December 2011. The statistical analysis was performed using SPSS version 17.0.

RESULTS

A total of 68 patients (representing 4.2% of cases) were enrolled in the study. Their ages ranged from 14 to 45 years with a median age of 21 years. Majority of patients were, secondary school students/leavers (70.6%), unmarried (88.2%), nulliparous (80.9%), unemployed (82.4%) and most of them were dependent member of the family. Previous history of contraceptive use was reported in only 14.7% of cases. The majority of patients (79.4%) had procured the abortion in the 2nd trimester. Dilatation and curettage (82.4%) was the most common reported method used in procuring abortion. The interval from termination of pregnancy to presentation in hospital ranged from 1 to 14 days (median 6 days ). The ileum (51.5%) and sigmoid colon (22.1%) was the most common portions of the bowel affected. Resection and anastomosis with uterine repair was the most common (86.8%) surgical procedure performed. Complication and mortality rates were 47.1% and 10.3% respectively. According to multivariate logistic regression analysis, gestational age at termination of pregnancy, delayed presentation, delayed surgical treatment and presence of complications were significantly associated with mortality (P<0.001). The overall median length of hospital stay (LOS) was 18 days (1day to 128 days ). Patients who developed complications stayed longer in the hospital, and this was statistically significant (P=0.012).

CONCLUSION

Bowel perforation following illegally induced abortion is still rampant in our environment and constitutes significantly to high maternal morbidity and mortality. Early recognition of the diagnosis, aggressive resuscitation and early institution of surgical management is of paramount importance if morbidity and mortality associated with bowel perforation are to be avoided.

A minimally invasive approach to an iatrogenic pelvic mass

A case report describing an unusual complication following a 17-week elective termination of pregnancy in a pediatric patient that was managed laparoscopically.

Married men's first time experiences of early childbearing and their role in sexual and reproductive decision making: a qualitative study from rural Vietnam

Male partners' involvement in women's sexual and reproductive health has been increasingly emphasised in international health. A qualitative approach with open-ended qualitative interviews was used to explore young, married men's first time experiences of early childbearing, their sexual and reproductive decision making and the meanings they make of their role as husbands and fathers. The results offer a nuanced picture of the men's vulnerability in becoming young fathers and having to assume their role as family decision-makers, while still being inexperienced in matters related to the health of their wives and newborn child. Constraints to gender equality and traditional norms and values continue to pose barriers to both young men and women making independent decisions in relation to marriage and childbearing. Men's involvement is necessary in healthcare programmes designed to improve women's sexual and reproductive health and the health of the newborn. Young, first-time fathers, in particular, need support and empowerment.

Meeting the needs of adolescent post-abortion care patients in the Dominican Republic

Counselling on contraception and contraceptive method provision are key components of post-abortion care (PAC). Some studies have suggested that adolescent PAC patients receive worse care than older women seeking these services. This study aimed to evaluate an intervention whose goal was to improve the counselling and contraceptive uptake of PAC patients, with special attention given to the needs of adolescent patients, in the four public hospitals in the Dominican Republic where PAC services were not being routinely offered. The counselling intervention effort included provider training and the development of adolescent-friendly information, education and communication (IEC) materials. Eighty-eight providers were interviewed at baseline and 6 months after the intervention was implemented. Six months after providers were trained, 140 adolescent PAC patients (< or = 19 years of age) and 134 older PAC patients (20-35 years) were interviewed about the contraceptive counselling messages and contraceptive methods they received before they were discharged from hospital. The adolescent and older PAC patients were matched on study hospital and time of arrival. Significant improvements were noted in provider knowledge and attitudes. No changes were noted in provider-reported PAC counselling behaviours, with close to 70% of providers reporting they routinely assess patients' fertility intentions, discuss contraception, assess STI/HIV risk and discuss post-abortion complications. Adolescent and older PAC patients reported receiving PAC counselling messages at similar rates. Forty per cent of adolescent PAC patients and 45% of older PAC patients who wanted to delay pregnancy were discharged with a contraceptive method. Adolescents were more likely to receive an injectable contraceptive method whereas older women were discharged with a variety of methods. The PAC counselling intervention increased provider knowledge and improved their attitudes and benefited both adolescent and older patients.

Adolescent sexual behavior and reproductive outcomes in Central America: trends over the past two decades

CONTEXT

Compared with the Latin American average, adolescent fertility is high in El Salvador, Guatemala, Honduras and Nicaragua, countries that also have high poverty levels and poor access to reproductive health care.

METHODS

For each country, data were drawn from four national health surveys conducted between 1987 and 2007, and analysis focused on trends in sexual and reproductive behavior among adolescent females aged 15-19. Event history analysis examined transitions to first sexual intercourse, first union and first live birth across survey years; Cox hazard and logistic regression analyses assessed associations between selected demographic characteristics and these outcomes, as well as ever-use of a modern contraceptive method.

RESULTS

The likelihood that adolescent females have initiated sexual intercourse has increased over time in El Salvador, Honduras and Nicaragua, and has remained stable in Guatemala. Meanwhile, the odds of having entered their first union have declined in Nicaragua and risen in El Salvador, but have not changed in Honduras or Guatemala. Notably, the likelihood that adolescents have ever used a modern contraceptive method has increased in all four countries over the survey years. Nicaraguan adolescents became significantly less likely to have had their first live birth over the study period. Finally, urban residence, education level and socioeconomic status were important predictors of adolescents' sexual and reproductive outcomes.

CONCLUSIONS

Programmatic and policy initiatives should focus on improving adolescents' education and socio- economic prospects, and efforts are especially needed to help adolescents delay the age at which they become sexually active and enter their first union.

Who is excluded when abortion access is restricted to twelve weeks? Evidence from Maputo, Mozambique

In Mozambique, since 1985, induced abortion services up to 12 weeks of pregnancy are performed in the interest of protecting women's health. We asked whether any women were being adversely affected by the 12-week limit. A retrospective record review of all 1,734 pregnant women requesting termination of pregnancy in five public hospitals in Maputo in 2005-2006 revealed that it tended to be those who were younger and poorer, with lower levels of education, literacy and formal employment who were coming for abortions after 12 weeks. Countries such as Mozambique that endeavor to enhance equality, equity and social justice must consider the detrimental effect of narrow gestational limits on its most vulnerable citizens and include second trimester abortions. We believe the 12-week restriction works against efforts to reduce maternal deaths due to unsafe abortion in the country.

Perinatal outcome of primiparous teenagers in northern Namibia

Internationally, teenagers are at risk for pregnancy-related morbidity and mortality. We assessed the obstetric and perinatal outcomes of teenage pregnancies compared with their older counterparts in northern Namibia. We made a retrospective study using birth records from February 2002 to August 2002. The data collected included perinatal mortality, delivery mode, birth weight, in-hospital days and frequency of antenatal care (ANC) attendance. They were compared with primiparous women in different age groups (n = 612). No differences were found in obstetric and perinatal outcomes between the three different age groups. Overall ANC attendance was high. The perinatal outcome for pregnant teenagers was comparable with their older counterparts in northern Namibia. In this region, ANC succeeds in reaching pregnant teenagers and teenage pregnancies are not at an increased risk for obstetric complications.

OPINIONS OF MIDWIFERY STUDENTS ON ADOLESCENT SEXUALITY AND REPRODUCTIVE HEALTH IN TURKEY

The purpose of this study was to evaluate how midwifery students feel about adolescent sexuality, the use of contraceptive methods, and abortion. A total of 55 students in the second year of a midwifery course were included in the sampling. Data were evaluated by percentage distribution and McNamara's Test. An evaluation of the students' thoughts on sexuality showed that 87.3% believed a girl should be a virgin when she married, that 50.9% believed abortion was morally wrong and that 23.6% believed only married couples should be informed of contraceptive methods. The study showed that students were influenced in their attitudes by social-value judgments about adolescent sexual and reproductive health.

Respecting adolescents' confidentiality and reproductive and sexual choices

Adolescents, defined as between 10 and 19 years old, present a growing challenge to reproductive health. Adolescent sexual intercourse contributes to worldwide burdens of unplanned pregnancy, abortion, spread of sexually transmitted infections (STIs), including HIV, and maternal mortality and morbidity. A barrier to contraceptive care and termination of adolescent pregnancy is the belief that in law minors intellectually mature enough to give consent also require consent of, or at least prior information to, their parental guardians. Adolescents may avoid parental disclosure by forgoing desirable reproductive health care. Recent judicial decisions, however, give effect to internationally established human rights to confidentiality, for instance under the Convention on the Rights of the Child, which apply without a minimum age. These judgments contribute to modern legal recognition that sufficiently mature adolescents can decide not only to request care for contraception, abortion and STIs, but also whether and when their parents should be informed.

Adolescência e contracepção de emergência: Fórum 2005

OBJETIVO: Relatar os resultados do Fórum "Adolescência e Contracepção de Emergência", que teve como proposta trazer maiores esclarecimentos sobre a contracepção de emergência (CE), além de apoio ético e técnico para sua prescrição, a partir da análise de três vertentes principais de discussão: o perfil da clientela adolescente; as questões éticas que envolvem a CE; a eficácia e o risco do método. FONTES DE DADOS: Discussão dos temas propostos a partir da literatura atual sobre o tema do Fórum organizado em 2005, que envolveu a participação de pediatras, ginecologistas, profissionais ligados a Comissões de Bioética, ao Conselho Federal de Medicina e ao Ministério da Saúde, advogados e juízes. SÍNTESEDOS DADOS: A adolescência caracteriza-se por mudanças, transformações e experimentações que vinculam essa fase da vida à vulnerabilidade e risco. Alguns desses riscos estão relacionados ao exercício inadvertido ou impensado da sexualidade, cujas conseqüências são bem conhecidas: gravidez precoce, aborto e doenças sexualmente transmissíveis, entre as quais HPV e AIDS. É fundamental, portanto, que a assistência a essa faixa etária inclua o enfoque de prevenção, na qual a educação sexual seja vista como um processo do qual é parte relevante a orientação anticoncepcional, incluindo-se nesta a contracepção em situações de emergência. CONCLUSÕES: O artigo apresenta as conclusões resultantes das discussões realizadas durante esse evento. Seu principal desdobramento foi a Resolução do Conselho Federal de Medicina: a CE não é abortiva e pode ser usada em qualquer etapa da vida reprodutiva.

Ethics of justice and ethics of care

Adolescent's sexuality and related reproductive health and rights problems are sensitive issues in Vietnam. Globalisation has had an impact on the lifestyles of young people, and rising numbers of abortion and STI/HIV risks among youth are posing major health concerns in the country. These problems need to be addressed. Midwives belong to a key category of health personnel in Vietnam, whose task it is to promote adolescents' sexual and reproductive health and prevent reproductive ill health. It is important to understand future midwives' perceptions and attitudes in order to improve their education and training programmes.

AIM

The aim of this study was to investigate Vietnamese midwifery students' values and attitudes towards adolescent sexuality, abortion and contraception and their views on professional preparation.

METHODS

A quantitative survey including 235 midwifery students from four different secondary medical colleges in northern Vietnam was carried out in 2003. A qualitative study addressing similar questions was performed and 18 midwifery students were individually interviewed.

FINDINGS

Findings revealed a general disapproval of adolescent pre-marital sexual relations and abortion-'an ethics of justice'-but also an empathic attitude and willingness to support young women, who bear the consequences of unwanted pregnancies and social condemnation-'an ethics of care'. Gender-based imbalance in sexual relationships, limited knowledge about reproductive health issues among youth, and negative societal attitudes were concerns expressed by the students. The students saw their future tasks mainly related to childbearing and less to other reproductive health issues, such as abortion and prevention of STI/HIV.

CONCLUSION

Midwifery education in Vietnam should encourage value-reflective thinking around gender inequality and ethical dilemmas, in order to prepare midwives to address adolescents' reproductive health needs.