Factors associated with abortion-seeking and obtaining a safe abortion in Ghana

'We had that abortion together': abortion networks and access to il/legal abortions in Turkey

Abortion was legalised in Turkey in 1983 with a 10-week limit, restrictions on who could provide abortions, and spousal or parental consent requirements. Currently, although abortion is legal, because of structural barriers, access is restricted (O'Neil, Altuntaş, and Keskin 2020). This study aimed to investigate how women strategically mobilise their social networks to overcome such restrictions to abortion care. Drawing from 25 in-depth interviews with urban-educated cis-women aged 24-30, I identify three groups within abortion networks: included, excluded and ambiguous. While included groups comprised largely of female family and friends, excluded groups were male family members and organisations, and the ambiguous category included health professionals and partners. Supporting findings in other contexts, individuals initially utilise their abortion networks to access the provider, they then build abortion solidarity networks to act as buffers against groups they wish to exclude during the abortion experience. Additionally, I show that excluded and ambiguous networks also impact abortion access, decision-making, and experience, even pushing individuals to follow through with illegal or semi-legal abortion procedures. Findings draw attention to the structural boundaries surrounding abortion laws, how patriarchal institutions make access to abortion care and abortion networks challenging, and how social networks may be utilised to alleviate such obstacles.

« Éloigne cette honte de moi! »: une étude qualitative des normes sociales entourant les expériences d’avortement chez les adolescentes et jeunes femmes au Bénin

In Africa, the rights of adolescent girls and young women in terms of sexual and reproductive health are strongly influenced by social norms. This article delves into the pivotal role these norms play in the abortion decisions and experiences of young women aged 15-24 in Benin. An ethnographic approach was adopted for data collection among young women who have undergone abortion, their confidants, and other community members. The findings reveal that these young women face a threefold normative burden in their social environment. They juggle contradictory norms that simultaneously stigmatise early pregnancies, hinder proper sexual education, and strongly condemn abortion. These normative pressures often drive their resort to abortions, typically carried out under unsafe conditions. The study also highlights the significant role parents play in the abortion decisions and processes of teenagers under 20. When men are involved in seeking care for abortion, adolescents and young women usually access safer procedures. However, their access to aftercare and contraception following an abortion is hindered by the social norms of healthcare professionals. In addition to broadening the conditions of access to abortion in Benin in October 2021, it is imperative to implement interventions centred on value clarification, raising awareness of adolescents' rights, combating obstetric violence, and social stigmatisation. These measures are crucial to alleviate the weight of social norms bearing down on these young women. DOI: 10.1080/26410397.2023.2294793.

Pregnancy termination and determinant factors among women of reproductive age in Kenya, evidence from Kenyan Demographic and Health Survey 2022: Multilevel analysis

BACKGROUND

Pregnancy termination is one of the common causes of maternal mortality, particularly in developing countries, and remains a global public health concern despite the efforts made to enhance maternal healthcare services. Maternal mortality is still the highest in sub-Saharan Africa, including Kenya, due to pregnancy termination.

OBJECTIVES

This study aimed to investigate the current burden of pregnancy termination and its determinants among reproductive-age women in Kenya.

DESIGN

A cross-sectional study design with multilevel analysis.

METHODS

The total weighted samples of 19,530 women of reproductive age were included in this study. The data were taken from the Kenyan Demographic and Health Survey 2022. A multilevel multivariable logistic regression model was used to identify the determinant factors of pregnancy termination. In the multivariable multilevel analysis, the adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to declare significant determinants of pregnancy termination among women of reproductive age.

RESULTS

The overall prevalence of pregnancy termination among women of reproductive age in Kenya was 14.19%. The determinant factors associated with pregnancy termination were the age of the women; as age increased, the risk of pregnancy termination increased, 25-29 years (AOR = 2.23; 95 CI (1.08-4.60)), 30-34 years (AOR = 2.98; 95% CI (1.43-6.18)), 35-39 years (AOR = 3.24; 95% CI (1.55-6.76)), 40-44 years (AOR = 4.57; 95% CI (2.16-9.68)), 45- 49 years (AOR = 5.16; 95% CI (2.33-9.98)); marital status: married (AOR = 5.63; 95% CI (3.08-10.29)), ever married (AOR = 5.05; 95% CI (2.74-9.33)); wealth index: richest (AOR = 1.32; 95% CI (1.05-1.63)); employment status: employed (AOR = 1.23; 95% CI (1.09-1.38)); preceding birth interval: greater than 24 months (AOR = 1.21; 95% CI (1.06-1.38)); urban residence (AOR = 1.25; 95% CI (1.06-1.46)); and Islamic followers (AOR = 1.64; 95% CI (1.31-2.06)).

CONCLUSION

Pregnancy termination among women of reproductive age in Kenya has become an important public health concern. Policymakers and other stakeholders should focus on maternal healthcare service programs to prevent the termination of pregnancy. The determinant factors are an important input to developing strategies to improve the accessibility of maternal healthcare services in the country.

Lived experiences and drivers of induced abortion among women in central Uganda

Although unsafe abortions are preventable, they are one of the leading causes of maternal mortality and morbidity. Despite the serious potential health consequences, there is limited published information about drivers and challenges of obtaining abortions in restrictive settings such as Uganda. This limits efforts to improve programing for preventing unsafe abortion and providing comprehensive post abortion care. This study sought to understand the drivers and explain the lived abortion experiences among women from central Uganda, in an effort to promote greater access to safe reproductive healthcare services, and reduce unsafe abortions. This qualitative study included 40 purposely selected women who self-reported an abortion, living in Kampala and greater Rakai district, Uganda. They were part of a larger survey using respondent driven sampling, where seed participants were recruited from selected facilities offering post-abortion care, or through social referrals. Data were collected from May to September 2021 through in-depth interviews. Audio data were transcribed, managed using Atlas.ti 9, and analyzed thematically. The findings show that the underlying drivers stemmed from partners who were unsupportive, denied responsibility, or had raped/defiled women. Career and education decisions, stigma and fear to disappoint family also contributed. Women had feelings of confusion, neglect, betrayal, or shame after conception. Abortion and post-abortion experiences were mixed with physical and emotional pain including stigma, even when the conditions for safe abortion in the guidelines were satisfied. Although most women sought care from health facilities judged to provide safe and quality care, there was barely any counselling in these venues. Confidantes and health providers informed the choice of abortion methods, although the cost ultimately mattered most. The mental health of women whose partners are unsupportive or who conceive unintendedly need consideration. Abortion provided psychological relief from more complicated consequences of having an unplanned birth for women.

Abortion incidence and safety in Niger in 2021: Findings from a nationally representative cross-sectional survey of reproductive-aged women using direct and indirect measurement approaches

Niger is a country in which legal restrictions and a dearth of research has long limited our understanding of the extent and safety of induced abortion. The current study is the first national study of induced abortion in Niger. It uses direct (self-report) and indirect (best friend method) to provide nationally representative estimates of induced abortion incidence and safety and evaluates the performance of the indirect measurement approach. We used cross-sectional, representative survey data on women aged 15-49 in Niger collected between January and May 2022; final sample included 3,696 women. The survey included questions on respondents' and their closest female friends' experience with abortion, including methods and sources used. We calculated one-year abortion incidence and the proportion of abortions involving non-recommended methods and/or sources to determine safety separately for respondents and friends, overall and by background characteristics. The fully adjusted one-year friend abortion rate was 6.7 abortions per 1,000 women in 2021, which was substantially higher than the corresponding respondent rate of 0.4 per 1,000 women. Confidence intervals were wide, but friend estimates suggest higher abortion rates among women in their 20s, those with secondary or higher education, and those with no children. Nearly all abortions were unsafe (97% respondents, 100% friends), involving non-recommended methods and/or sources. While abortion numbers were small, unsafe abortion appeared more common among older women, married women, those with children, and those residing in rural areas. Our findings indicate that, despite legal restrictions, some women undergo abortions in Niger at great risk to their physical safety. Ensuring adequate access to quality voluntary family planning services to prevent unintended pregnancy and postabortion care to treat complications is essential to reducing the risk of unsafe abortion in the country.

Association of alcohol consumption with abortion among ever-married reproductive age women in Ethiopia: A multilevel analysis

Background

A miscarriage or a spontaneous loss of a pregnancy that occurs before the 20th week is an abortion. Even though numerous recommendations state that pregnant women should abstain from alcohol at all stages of pregnancy, alcohol intake among pregnant women is common. However, there are few papers addressing the effect of alcohol use on miscarriage using nationally representative data. Moreover, the association of alcohol use with abortion and its mechanisms is not well studied in the Ethiopian region. Therefore, the objective of the current study was to estimate the association of alcohol use with abortion rates among reproductive age (15-49) women in Ethiopia.

Methods

Using the most recent findings of the Ethiopian Demographic and Health Survey (EDHS), secondary data analysis was performed among pregnant women in Ethiopia. A total of 11,396 women between the ages of 15 and 49 years who were of reproductive age were included in the research. To characterize the study population, descriptive statistics were used. The variability was considered using the multilevel binary logistic regression model. A multilevel binary logistic model was used to determine the effect of alcohol intake on abortion while controlling for potential confounders. In the multivariable analysis, variables with a P-value of less than 0.05 were considered statistically significant for the response variable.

Results

The proportion of women who had an abortion was 10.46% with a 95% CI of 9.92-11.03. In the final model of the multilevel analysis, age group [adjusted odds ratio (AOR) = 6.13; 95% CI: 3.86-9.73], education level (AOR = 1.29; 95 and CI: 1.10-1.51), alcohol consumption (AOR = 1.38; 95% CI: 1.18-1.61), age at first sex (AOR = 1.20; 95% CI: 1.03-1.39), media exposure (AOR = 1.28, CI: 1.10-1.48), contraceptive use (AOR = 1.34, CI: 1.16-1.56), and occupation of respondent (AOR = 1.21, CI: 1.06-1.38) were identified to be significant determinants of abortion in Ethiopia.

Conclusion

Sexual and reproductive health education and family planning programs should target older women in the reproductive age group, women with primary educational status, working women, and those who initiated sexual intercourse at a younger age considering it could reduce abortion and unintended pregnancy. Furthermore, as part of sexual and reproductive health education, the adverse effect of alcohol consumption on abortion should be emphasized.

Saving more lives on time: Strategic policy implementation and financial inclusion for safe abortion in Indonesia during COVID-19 and beyond

Abortion is common in Indonesia, with 79% being unsafe. Unsafe abortion is one of the top five causes of maternal deaths globally. Meanwhile, in Indonesia, the maternal mortality rate (MMR) is still high, with up to 30% of it being related to unsafe abortion. In the COVID-19 pandemic, the number of unsafe abortions is expected to increase along with a 15-30% increase in unintended pregnancies. This will add to the number of maternal deaths on top of direct deaths caused by COVID-19. In Indonesia, access to safe abortion is still limited based on grounds. There are also gaps in implementation and in the financing mechanism of legal safe abortion, especially in the era of the national health insurance scheme (Jaminan Kesehatan Nasional/JKN). This brief aims to guide how to equitably implement and inclusively finance safe abortion in Indonesia-in and beyond the COVID-19 pandemic-to gain maximum socioeconomic benefit and leave no one behind.

Examining the rural-urban divide in predisposing, enabling, and need factors of unsafe abortion in India using Andersen's behavioral model

BACKGROUND

The prevalence of unsafe abortions significantly varies with geography; therefore, more research is needed to understand the rural-urban differences in unsafe abortion practices in India. The present study aims to explore the rural-urban differences in predisposing, enabling, and need factors of unsafe abortion in India.

METHODS

The present study used the fourth round of the National Family Health Survey (2015-16) and included the women aged 15-49 who terminated pregnancies by induced abortion during the 5 years prior to the survey (N = 9113) as the study sample. Descriptive statistics, bivariate chi-square significance test and multivariate logistic regression model were used to accomplish the study objectives.

RESULTS

The findings revealed that almost one-third of pregnancies were terminated through unsafe measures with sharp rural-urban contrast. The likelihood of unsafe abortions increases with decreasing women's age and spousal level of education. Younger women in urban settings were more vulnerable to unsafe abortion practices. In rural settings, women with an uneducated spouse are more likely to have unsafe abortions (OR: 1.92). Poor households were more likely to undergo unsafe abortions, which were more common in rural settings (OR: 1.26). The unmet need for family planning was revealed to be a significant need factor for unsafe abortion, particularly in rural settings.

CONCLUSION

Although abortion is legal, India's high estimated frequency of unsafe abortions reveals a serious public health issue. Due to socio-economic vulnerability, unmet family planning needs, and a lack of awareness, significant numbers of women still practice unsafe abortions in India.

Multilevel analysis of factors associated with pregnancy termination in Ethiopia

Background

Pregnancy termination is a major public health issue that affects maternal mortality around the world. So the study aimed to identify factors that are associated with pregnancy termination in Ethiopia.

Methods

Community-based crossectional data came from Ethiopia's Mini Demographic and Health Survey 2019. The current study's sample included women who had their pregnancy terminated (aged 15–49) and had complete information on all factors of interest (N = 8885). The binary logistic regression model investigated the factors that contribute to pregnancy termination in Ethiopia and multilevel logistic regression were used to identify regional variation in Ethiopia.

Results

The current study showed that the prevalence of pregnancy termination in Ethiopia was 8.6%. The likelihood of pregnancy termination in uneducated women was 1.5 times (AOR = 1.479, 95% CI = 1.205–1.816) lower than in women who attended elementary school, 1.5 (AOR = 1.476, 95% CI = 1.107–1.969) lower than Secondary attended women and 1.8 times (AOR = 1.755, 95% CI = 1.270–2.427) lower than Higher school attended women. The likelihood of pregnancy termination in rural women was 0.8 times (AOR = 0.753, 95% CI = 0.573–0.990) higher than in urban women.

Conclusion

The current study showed that there was regional Variation among women in Ethiopia to terminate the pregnancy. The characteristics of education level, place of residency, marital status and contraceptive knowledge are significant and differ between regions of the country. As a result, increasing contraception use and enhancing women's knowledge are the most effective ways to avert the problem.

•

Pregnancy termination is a major public health issue that affects maternal mortality around the world.

•The study aimed to identify factors that are associated with pregnancy termination in Ethiopia.

•Community-based crossectional data came from Ethiopia's Mini Demographic and Health Survey 2019.

•The current study showed that the prevalence of pregnancy termination in Ethiopia was 8.6%.

•The current study showed that there was regional Variation among women in Ethiopia to terminate the pregnancy.

•As a result, increasing contraception use and enhancing women's knowledge are the most effective ways to avert the problem.

Unintended pregnancy resolution among parous women in twelve low- and middle-income countries

Around 40% of pregnancies worldwide are unintended and a half of those are terminated. Yet, few international comparisons of unintended pregnancy resolution (choosing birth or abortion) exist. This study analysed how parous women's pregnancy intentions and abortion decisions are associated with their reproductive histories and country contexts using twelve Demographic and Health Surveys representing four context groups: post-Soviet/communist and Asian countries with liberal abortion legislation, and Asian and Latin American countries with restrictive abortion legislation. Similarities were found across contexts: preference to have children of both sexes, space births, stop childbearing after reaching desired family size and an increased likelihood of unintended pregnancy when using less-effective contraceptive methods versus none. Contextual factors most clearly associated with reports of unintended pregnancy resolution were type of abortion legislation and living in post-Soviet/communist contexts. Women's propensity to report abortions and unintended pregnancy varied by context and the decision-making processes for pregnancy versus fertility management were different.

Women's post-abortion contraceptive use: Are predictors the same for immediate and future uptake of contraception? Evidence from Ghana

This study seeks to identify the socio-demographic, reproductive, partner-related, and facility-level characteristics associated with women’s immediate and subsequent use of post-abortion contraception in Ghana. Secondary data from the 2017 Ghana Maternal Health Survey were utilized in this study. The weighted data comprised 1,880 women who had ever had an abortion within the five years preceding the survey. Binary logistic regression analyses were performed to examine the associations between the predictor and outcome variables. Health provider and women’s socio-demographic characteristics were significantly associated with women’s use of post-abortion contraception. Health provider’s counselling on family planning prior to or after abortion and place of residence were associated with both immediate and subsequent post-abortion uptake of contraception. Among subsequent post-abortion contraceptive users, older women (35–49), women in a union, and women who had used contraception prior to becoming pregnant were strong predictors. Partner-related and reproductive variables did not predict immediate and subsequent use of contraception following abortion. Individual and structural/institutional level characteristics are important in increasing women’s acceptance and use of contraception post abortion. Improving and intensifying family planning counselling services at the health facility is critical in increasing contraceptive prevalence among abortion seekers.

Methods women use for induced abortion and sources of services: insights from poor urban settlements of Accra, Ghana

Background

Increasing access to safe abortion methods is crucial for improving women’s health. Understanding patterns of service use is important for identifying areas for improvement. Limited evidence is available in Ghana on factors associated with the type of method used to induce abortion. This paper examined the methods and sources of services used for abortion by women living in poor urban settings of Accra.

Methods

Data are from a survey that was conducted in 2018 among 1233 women aged 16–44 years who reported ever having had an induced abortion. We estimated a multinomial logistic regression model to examine factors associated with the type of abortion methods women used. We further generated descriptive statistics for the source of abortion services.

Results

About 50% women used surgical procedures for their last abortion, 28% used medication abortion (MA), 12% used other pills, 3% used injection, and 7% used non-medical methods. However, nearly half (46%) of the women who terminated a pregnancy within the year preceding the survey used medication abortion (MA), 32% used surgical procedures, while 5% used non-medical methods. Women who terminated a pregnancy within three years preceding the survey had a 60% lower chance of using surgical procedures if they did not use MA compared to those who terminated a pregnancy more than 3 years before the survey (Relative Risk Ratio [RRR] 0.4; 95% CI 0.3–0.5). The vast majority (74%) of women who used MA obtained services from pharmacies.

Conclusions

The use of MA pills to terminate pregnancies has increased in recent years in Ghana and these pills are mostly accessed from pharmacies. This suggests a need for a review of the national guidelines to include pharmacists and chemists in the provision of MA services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01444-9.

Predictors of Pregnancy Termination among Young Women in Ghana: Empirical Evidence from the 2014 Demographic and Health Survey Data

Pregnancy termination remains a delicate and contentious reproductive health issue because of a variety of political, economic, religious, and social reasons. The present study examined the associations between demographic and socio-economic factors and pregnancy termination among young Ghanaian women. This study used data from the 2014 Demographic and Health Survey of Ghana. A sample size of 2114 young women (15-24 years) was considered for the study. Both descriptive (frequency, percentages, and chi-square tests) and inferential (binary logistic regression) analyses were carried out in this study. Statistical significance was pegged at p < 0.05. Young women aged 20-24 were more likely to have a pregnancy terminated compared to those aged 15-19 (AOR = 3.81, CI = 2.62-5.54). The likelihood of having a pregnancy terminated was high among young women who were working compared to those who were not working (AOR = 1.60, CI = 1.19-2.14). Young women who had their first sex at the age of 20-24 (AOR = 0.19, CI = 0.10-0.39) and those whose first sex occurred at first union (AOR = 0.57, CI = 0.34-0.96) had lower odds of having a pregnancy terminated compared to those whose first sex happened when they were less than 15 years. Young women with parity of three or more had the lowest odds of having a pregnancy terminated compared to those with no births (AOR = 0.39, CI = 0.21-0.75). The likelihood of pregnancy termination was lower among young women who lived in rural areas (AOR = 0.65, CI = 0.46-0.92) and those in the Upper East region (AOR = 0.18, CI = 0.08-0.39). The findings indicate the importance of socio-demographic factors in pregnancy termination among young women in Ghana. Government and non-governmental organizations in Ghana should help develop programs (e.g., sexuality education) and strategies (e.g., regular sensitization programs) that reduce unintended pregnancies which often result in pregnancy termination. These programs and strategies should include easy access to contraceptives and comprehensive sexual and reproductive health education. These interventions should be designed considering the socio-demographic characteristics of young women. Such interventions will help to achieve Sustainable Development Goal 3.1 that seeks to reduce the global maternal mortality ratio to fewer than 70 per 100,000 live births by 2030.

Experiences of women seeking post-abortion care services in a Regional Hospital in Ghana

Introduction

Abortions remain one of the highest contributors to maternal deaths in Ghana. In 2003, a policy on post-abortion care was introduced to help reduce abortion-related mortality and morbidity. However, depending on the method of pregnancy termination; women encounter varying experiences. This study examines the experiences of women seeking post-abortion care services in a Regional Hospital in Ghana.

Materials and methods

In-depth interview technique was used to collect data from 20 purposively selected post-abortion care clients at the Volta Regional Hospital. Data were analysed manually using a qualitative content analysis technique.

Results

The study found that medical abortion was the main method of pregnancy termination used by women who participated in the study to induce abortion. Spontaneous abortion, however, was attributed mainly to engaging in activities that required the use of excessive energy and travelling on bad roads by pregnant women. The study also revealed that, women do not seek early post-abortion care services due to stigma and poverty.

Conclusions

We found that severity of pain from complications, stigma and financial constraints were factors that influenced women’s decision to seek post-abortion care services. Our findings also suggest that women who experienced spontaneous abortion mainly received financial and emotional support from partners and other family members. To encourage women to seek early post-abortion care services, the Ministry of Health and the Ghana Health Service should take pragmatic steps to educate women on the dangers associated with delay in seeking post-abortion care services and the factors that expose women to spontaneous abortions.

Intimate Partner Violence and Pregnancy Termination in Armenia: Evidence from Nationally-Representative Survey Data

Intimate partner violence has been associated with numerous consequences for women, including pregnancy termination. This study examined the association between predictive capacity of intimate partner violence and pregnancy termination among women in Armenia. The study analyzed the 2015-16 Armenia Demographic and Health Survey (ADHS) data on women aged 15-49 (Mean: 31.49; Standard Deviation, SD: 9.51). Marital control exercised by husbands, ever experienced physical violence, sexual violence, and emotional violence by husbands were the four indicators of intimate partner violence used in this study. To assess the association between intimate partner violence and pregnancy termination, a binary logistic regression model was fitted. After controlling for confounders, we found that women whose husbands exercised marital control were 26% more likely to experience pregnancy termination, compared to women whose husbands did not exercise marital control (adjusted odds ratio (aOR): 1.26, 95% Confidence interval (CI): 1.03-1.53). Women who ever experienced sexual violence were about 10 times likely to experience pregnancy termination than women who did not experience sexual violence (aOR: 9.76, 95% CI: 1.91-49.96). Both ever experienced physical violence and emotional violence did not have any significant associations with pregnancy termination. Forms of intimate partner violence are associated with pregnancy termination. The findings of this study provide evidence for government and policymakers to formulate, modify, and implement policies and program that target both men and women regarding the prevailing intimate partner violence and its consequences. Strengthening the policy implementation will ensure that women are empowered to make decisions about their reproductive health. Making husbands and their family members aware of the basics and consequences of intimate partner violence and focusing on child cognitive development which can be hampered due to the prevalence violence in families are recommended.

Contraceptive method use, discontinuation and failure rates among women aged 15-49 years: evidence from selected low income settings in Kumasi, Ghana

BACKGROUND

This paper provides estimates of contraceptive discontinuation and failure rates in a poor urban setting in Ghana. Contraceptive use is for the purposes of preventing unintended or mistimed pregnancies. Unfortunately, evidence abounds in many parts of the world where there is considerable levels of contraceptive failure and high levels of discontinuation resulting in unintended pregnancies.

METHODS

We estimated discontinuation rates during a 12-month period since starting use by applying single and multiple decrement life table methods to the contraceptive calendar data collected in a survey of women in reproductive age of 15-49 years.

RESULTS

Modern contraceptive method use was estimated to be 13.7% at the time of the survey. The results show that contraceptive method discontinuation vary markedly by type of contraceptive method but are high for almost all methods, except for implants (23.7%). Discontinuation rate for emergency contraception was estimated at 88.5%, withdrawal 87.6%, and male condom use 80.9%. However, discontinuation rates were moderately high for rhythm (63.6%), pills (65.6%) and injectables (56%). In terms of failure rates, overall contraceptive failure for all methods was estimated at 7.9%. The factors significantly associated with method failure include being within age bracket 40-44 years (OR = 0.3, p < 0.05), having secondary/higher education (OR = 0.4, p < 0.01), belonging to the richest household wealth scale (OR = 3.3, p < 0.01), currently in union with a partner (OR = 2.2, p < 0.01), and using contraceptive methods such as rhythm (OR = 5.6, p < 0.01) and withdrawal (OR = 3.7, p < 0.01). On the flip side, the odds for method discontinuation were significantly higher for women in their 20s and mid 30s, formerly in union (OR = 1.9, p < 0.05) and use of withdrawal method (OR = 1.4, p < 0.05) and lower for women formerly in union (OR = 0.4, p < 0.01) and use of implants (OR = 0.2, p < 0.01) and injectables (OR = 0.6, p < 0.01).

CONCLUSION

While contraceptives use is low, both discontinuation and failure rates are high and variable among different methods. Failure and discontinuation rates are lowest for long-acting methods such as implants while higher failure rates are more prevalent among women who rely on withdrawal and the rhythm methods.

Exploring the roles of men and masculinities in abortion and emergency contraception pathways, Ghana: a mobile phone-based mixed-methods study protocol

INTRODUCTION

Global commitments have established goals of achieving universal sexual and reproductive health and rights (SRHR) access, but critical obstacles remain. Emergency contraception and induced abortion are overlooked in policy and research. Men's roles in the SRHR of others are significant, particularly as obstacles to universal SRHR. Evidence on gender, masculinities and SRHR is essential to understand and reduce the barriers faced by individuals seeking to avoid the conception or continuation of a pregnancy.

METHODS AND ANALYSIS

This study aims to understand men's masculinities and their relationships with emergency contraception and abortion. The protocol presents a multimethod study of men aged over 18 years in James Town, Accra, Ghana. In response to the COVID-19 pandemic, the research will use two mobile-based methods: a survey and in-depth interviews. Using respondent-driven sampling, an estimated 789 men will be recruited to participate in the survey, asking questions on their knowledge, attitude, behaviours and roles in emergency contraception and abortion. In-depth interviews focused on constructions of masculinity will be conducted with a purposive sample of men who participated in the survey. Data will be analysed concurrently using multiple regression analyses of quantitative data and abductive analysis of qualitative data.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the London School of Economics and Political Science and the Ghana Health Service. The findings in this study will: engage with emerging research on masculinities and SRHR in Ghana and elsewhere; offer methodological insight for future research; and provide evidence to inform interventions to reduce obstacles for emergency contraception and abortion care seekers. Dissemination will occur at all levels-policy, academic, community-including multiple academic articles, policy briefs, workshops and presentations, conference papers, and theatre/radio-based performances of key messages.

Induced abortion in Ghana: prevalence and associated factors

The termination of unwanted pregnancies is a growing health-related issue around the world. This study used the 2017 Ghana Maternal Health Survey to examine the factors associated with the prevalence of induced abortion in Ghana. The study sample included 18,116 women of reproductive age who had a pregnancy in the 5 years preceding the survey. A multivariate logistic regression technique was applied. The prevalence of induced abortion was higher among women aged 25-34 years, those who had secondary-level education, those living in urban areas and in the Ashanti region, those of Akan ethnicity and those belonging to non-Catholic Christian denominations. Moreover, the prevalence was higher among single women, those who had no children, those who started sexual intercourse before the age of 18, those who were currently using a contraceptive, those exposed to media and those who knew about the legality of abortion. The multivariate analysis found that education, place and region of residence, marital status, ethnicity, current contraceptive use, religion, age at sexual debut, media exposure and knowledge about abortion legality were all significant predictors of induced abortion among women in Ghana. The study findings support a call for action to strengthen family planning services and educational programmes on induced abortion in Ghana to reach the target groups identified.

Overview and factors associated with pregnancies and abortions occurring in sex workers in Benin

Background

Behavioural and structural factors related to sex work, place female sex workers (FSWs) at high risk of maternal mortality and morbidity (MMM), with a large portion due to unintended pregnancies and abortions. In the African context where MMM is the highest in the world, understanding the frequency and determinants of pregnancy and abortion among FSWs is important in order to meet their sexual and reproductive health needs.

Methods

Data from two Beninese cross-sectional surveys among FSWs aged 18+ (2013, N = 450; 2016, N = 504) were merged. We first performed exploratory univariate analyses to identify factors associated with pregnancy and abortion (p < 0.20) using Generalized Estimating Equations with Poisson regression and robust variance. Multivariate analyses first included all variables identified in the univariate models and backward selection (p ≤ 0.05) was used to generate the final models.

Results

Median age was 39 years (N = 866). The proportion of FSWs reporting at least one pregnancy during sex work practice was 16.4%, of whom 42.3% had more than one. Most pregnancies ended with an abortion (67.6%). In multivariate analyses, younger age, longer duration in sex work, previous HIV testing, having a boyfriend and not using condoms with him were significantly (p < 0.05) associated with more pregnancies.

Conclusion

One FSW out of five had at least one pregnancy during her sex work practice. Most of those pregnancies, regardless of their origin, ended with an abortion. Improving access to various forms of contraception and safe abortion is the key to reducing unintended pregnancies and consequently, MMM among FSWs in Benin.

Abortion knowledge and experiences among young women and men in Accra, Ghana

Background : Despite the presence of legal abortion services in Ghana, unsafe abortion remains common, particularly among young women. Little is understood about what young people know about safe and legal abortion, and if and how they are utilizing it. Methods : To characterize abortion use and address gaps in safe access, from September-December 2013, we conducted a cross-sectional survey with 100 men and 250 women aged 18-24 in Accra, Ghana. Participants were asked about abortion experiences, including prior services, providers, methods, satisfaction, perceived support, and knowledge of laws. Descriptive statistics, Fisher's exact tests, and chi-square tests were performed. Results : Among surveyed youth, most (87% of women, 64% of men) thought abortion was illegal or did not know the law. In total, 30% of women and 14% of men ever had an abortion and partner who had an abortion, respectively. Among women's most recent abortions, medication abortion (61%), surgical methods (26%), and unsafe methods categorized "least safe" (14%) were the initial or only methods used. Most women who accessed medication abortion initially or as their only method saw a pharmacist (40%) or no one (33%). Nearly one-quarter of women (n=16, 24%) who initially took tablets used more than one method. Conclusions : Despite experiences with abortion, most young people in this study were unaware of its legality and unsafe abortions occurred. More needs to be done to ensure young people understand the law and have access to safe methods, and that pharmacists are trained to provide appropriate doses and formulations of medication abortion.

Factors associated with induced abortion among women of reproductive age attending selected health facilities in Addis Ababa, Ethiopia: a case control study

Background

There has been a significant reduction of abortion rates in high-income countries, while the rates remain unchanged in low- and middle-income countries. In Ethiopia, for example, the number of women of reproductive age seeking an induced abortion is increasing. However, there is limited information concerning the reasons why the occurrence of this procedure is increasing. Thus, this study aimed to identify factors associated with having induced abortion in Addis Ababa, Ethiopia.

Methods

An unmatched case-control study was conducted using a semi-structured, interviewer-administered questionnaire from October to December 2017. The cases were 147 women of reproductive age who underwent abortion in a health facility or presented with complications due to induced abortion conducted outside the health facility. The controls were 295 women who came for antenatal care and who reported never having had an induced abortion. The cases were selected by consecutive sampling from nine health facilities, whereas the controls were selected by systematic sampling from the same health facilities. Bivariate and multivariate logistic regression models were employed using STATA version 14 to identify factors associated with induced abortion.

Results

The mean age of cases was 26.5 ± 5.7 years, while for the controls it was 28.1 ± 4.8 years. Being unmarried (AOR = 9.6; 95% CI: 1.5–61.7), having primary (AOR = 5.3; 95% CI: 1.5–18.3) and tertiary (AOR = 5.7; 95% CI: 1.6–21.1) education, earning monthly income 100–300 USD (AOR = 0.2; 95% CI: 0.1–0.4) and >  300 USD (AOR = 0.1; 95% CI: 0.0–0.2), initiating first intercourse between ages of 15 and 19 (AOR = 4.7; 95% CI: 1.4–15.6), marrying before the age of 18 (AOR = 2.9; 95% CI: 1.3–6.7), and having two children (AOR = 4.7; 95% CI: 1.8–12.7) were independent predictors of induced abortion.

Conclusion

Family planning programs hoping to reduce the occurrence of induced abortion should specifically target unmarried women, low income, and those who have two children. The government should also work on preventing early marriage and providing sexual and reproductive health education to help adolescents delay age at first sexual experience.

Contraceptive use among women with a history of induced abortion: findings from a national sample of sexually active, non-pregnant women in Ghana

OBJECTIVE

The aim of the study was to examine the relationship between a history of induced abortion and current use of contraception among reproductive-aged women in Ghana.

METHODS

The analysed data were a weighted sample of 6544 sexually active, non-pregnant women aged 15-49 years, obtained from the 2014 Ghana Demographic and Health Survey. Survey logistic regression analysis was used to estimate the odds of currently using any contraception and of using a modern method of contraception, given a history of induced abortion in the period 2009-2014.

RESULTS

A history of induced abortion between 2009 and 2014 was reported by 17.4% of women (95% CI 16.0%, 18.9%); 28.7% (95% CI 26.9%, 30.6%) were currently using a method of contraception and 23.0% (95% CI 21.4%, 24.7%) were currently using a modern method of contraception. The majority (80.1%) of current contraceptive users were using a modern method. The adjusted analysis revealed no statistically significant association between a history of induced abortion and current contraceptive behaviour. Other factors were associated with modern contraceptive use.

CONCLUSION

Overall, the use of contraception among sexually active women in Ghana was found to be low. Our findings showed that women's experience of induced abortion was unlikely to influence their current use of modern contraception.

Postpartum and post-abortion contraceptive use among unmarried young women in Ghana

Pregnancy outcomes impact subsequent contraceptive behaviour. The purpose of this study was to assess the relationship between previous pregnancy outcomes and subsequent contraceptive behaviours among unmarried young women intending to delay childbearing. Using data from the 2014 Ghana Demographic and Health Survey, among 1118 sexually experienced, fecund and non-pregnant unmarried women aged 15-24 years, the study assessed how childbirth and abortion are related to sexual abstinence and use of modern contraception. While about 70% of unmarried young women were nulligravid, approximately 11% had had an abortion and 18.2% were postpartum. The majority of respondents were sexually abstinent while 21% and 27% were using and not using contraception, respectively. Postpartum women were more likely than nulligravid and post-abortion women to use contraceptives. Post-abortion women were least likely to be sexually abstinent. Number of years since the respondent's sexual debut was positively associated with the likelihood of using modern contraception, particularly among postpartum women, and negatively associated with sexual abstinence among those who had aborted. The findings show that prior pregnancy outcomes have significant implications for secondary abstinence and contraceptive use among unmarried young women in Ghana. Post-abortion women are more likely than postpartum women to be sexually active but less likely to use contraceptives. Efforts must be strengthened towards increasing access to modern contraceptives for young women who present for abortion in Ghana.

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.

Inequities in the incidence and safety of abortion in Nigeria

Background

We know little about the frequency, correlates and conditions under which women induce abortions in Nigeria. This study seeks to estimate the 1-year induced abortion incidence and proportion of abortions that are unsafe overall and by women’s background characteristics using direct and indirect methodologies.

Methods

Data for this study come from a population-based, nationally representative survey of reproductive age women (15–49) in Nigeria. Interviewers asked women to report on the abortion experiences of their closest female confidante and themselves. We adjusted for potential biases in the confidante data. Analyses include estimation of 1-year induced abortion incidence and unsafe abortion, as well as bivariate and multivariate assessment of their correlates.

Results

A total of 11 106 women of reproductive age completed the female survey; they reported on 5772 confidantes. The 1-year abortion incidence for respondents was 29.0 (95% CI 23.3 to 34.8) per 1000 women aged 15–49 while the confidante incidence was 45.8 (95% CI 41.0-50.6). The respondent and confidante abortion incidences revealed similar correlates, with women in their 20s, women with secondary or higher education and women in urban areas being the most likely to have had an abortion in the prior year. The majority of respondent and confidante abortions were the most unsafe (63.4% and 68.6%, respectively). Women aged 15–19, women who had never attended school and the poorest women were significantly more likely to have had the most unsafe abortions.

Conclusion

Results indicate that abortion in Nigeria is a public health concern and an issue of social inequity. Efforts to expand the legal conditions for abortion in Nigeria are critical. Simultaneously, efforts to increase awareness of the availability of medication abortion drugs to more safely self-induce can help mitigate the toll of unsafe abortion-related morbidity and mortality.

Reproductive autonomy and pregnancy decision-making among young Ghanaian women

Decision-making regarding the outcome of a pregnancy may include participation of the woman herself, her sexual partner, parents, family, and/or community. This paper examines who had the most say in the outcome of young Ghanaian women's last pregnancy and whether this correlated with her level of reproductive autonomy (RA). We analysed cross-sectional data from 380 previously pregnant young women in urban Ghana. We measured communication and decision-making RA using modified scales ranging from 3 (low RA) to 12 (high RA). We tested unadjusted associations between the RA sub-scales and who made the pregnancy decision (self, partner, both together, or someone else) and used multinomial regression models to understand these associations when controlling for sociodemographic, reproductive history, and social context variables. In final models, a one-point increase in decision-making RA was associated with an adjusted relative risk ratio of 0.79 (95% CI: 0.66-0.93; p = 0.006) of partner having the most say as compared to the woman having the most say. The communication RA scale was not associated. Programmes that increase RA may be effective in increasing women's rights to execute decisions about reproductive health and outcomes. Future research should explore this notion and the role of pregnancy disclosure in this relationship.

Is abortion justified to save the life or health of a woman? Evidence of public opinion from Accra, Ghana

OBJECTIVE

In this study, we sought to determine to what extent the abortion law in Ghana is reflective of public opinion.

METHODS

In a cross-sectional, community-based survey, individuals in two fishing communities in Accra were interviewed about their beliefs on abortion between May and July 2016, and sociodemographic, attitudinal, and experience data were collected. Factors associated with the outcome variable (abortion is justified to save the life/health of the woman: Yes/No) were entered into a multivariate logistic regression.

RESULTS

A total of 508 participants completed the survey. Thirty-nine percent (n=198) of the sample agreed that abortion was justified to save the life/health of the woman, with no significant differences in this finding when controlling for understanding of the law, gender, marital status, or personal experience of abortion in multivariate analysis. Higher education (odds ratio [OR] 1.64 [P<0.001]) and older age (OR 1.28 [P<0.001]) are positively associated with abortion being justified to save life/health, while those who have had an experience of unwanted sex are less likely to believe that (OR 0.60 [P=0.029]).

CONCLUSION

The participants held conservative views about the justification of abortion to save a woman's life and/or health. Improving access to safe abortion services will require acknowledgment of the broader social and cultural context that may make accessing such services difficult.

Abortion experience and self-efficacy: exploring socioeconomic profiles of GHANAIAN women

Background

Unsafe abortions remain a major global public health concern and despite its prevalence, unsafe abortions remain one of the most neglected global health challenges. The proportion of women in Ghana who have experienced unsafe abortions has increased from 45% in 2007 to 62% in 2017. Given the noted consequences of (unsafe) abortions on women health, it is important to explore factors correlated with women’s abortion decisions and why they opt for safe or unsafe methods. The study also examines determinants of over 6,000 Ghanaian women’s self-efficacy in abortion decision-making, given that this is likely to affect the likelihood of future abortions.

Methods

Using cluster-level Geographic Information System data from the 2017 Ghana Maternal Health Survey, the study provides a hot spot analysis of the incidence of abortion in the country. The study also makes use of Probit multivariate analyses also show the correlates of abortion with socio-economic factors.

Results

Results suggest that abortion among women is positively correlated with the absence of partners, low education levels, higher household wealth, lower parity and family size, polygyny and Christian religious background.

Conclusion

It is observed that the groups of women with higher abortion self-efficacy are the same groups of women who are more likely to opt for safer abortion methods, indicating some correlation, albeit indirect, between abortion self-efficacy and women’s abortion behaviors in Ghana. Relevant policy applications are adduced from these research findings.

Abortion among adolescents in Africa: A review of practices, consequences, and control strategies

BACKGROUND

Developing countries register 98% of unsafe abortion annually, 41% of which occur among women aged between 15 and 25 years. Additionally, 70% of hospitalizations due to unsafe abortion are among girls below 20 years of age.

PURPOSE

This study unveils abortion practices in Africa, its consequences, and control strategies among adolescents.

METHODS

Online databases that provided relevant information on the topic were searched. A Google Scholar search yielded 623 000 results, PubMed yielded 1134 results, African Journals Online yielded 110 results, and PsycINFO yielded eight results. A total of 25 studies published from 2000 to 2018 that met the Critical Appraisal Skills Programme (CASP) standard were thematically reviewed.

FINDINGS

These studies indicated that abortion is a neglected problem in health care in developing countries, and yet decreasingly safe abortion practices dominate those settings. Adolescents who have unintended pregnancies may resort to unsafe abortion practices due to socio-economic factors and the cultural implications of being pregnant before marriage and the legal status of abortion. Adolescents clandestinely use self-prescribed drugs or beverages, insert sharps in the genitals, and most often consult traditional service providers. Abortion results in morbidities such as sepsis, severe anaemia, disabilities, and, in some instances, infertility and death. Such events can be controlled by the widening availability of and accessibility to contraceptives among adolescents, advocacy, and comprehensive sexuality education and counselling.

CONCLUSION

Adolescents are more likely to use clandestine methods of abortion whose consequences are devastating, lifelong, or even fatal. Awareness and utilization of youth-friendly services would minimize the problem.

Abortion knowledge and experiences among young women and men in Accra, Ghana

Background : Despite the presence of legal abortion services in Ghana, unsafe abortion remains common, particularly among young women. Little is understood about what young people know about safe and legal abortion, and if and how they are utilizing it. Methods : To characterize abortion use and address gaps in safe access, from September-December 2013, we conducted a cross-sectional survey with 100 men and 250 women aged 18-24 in Accra, Ghana. Participants were asked about abortion experiences, including prior services, providers, methods, satisfaction, perceived support, and knowledge of laws. Descriptive statistics, Fisher's exact tests, and chi-square tests were performed. Results : Among surveyed youth, most (87% of women, 64% of men) thought abortion was illegal or did not know the law. In total, 30% of women and 14% of men ever had an abortion and partner who had an abortion, respectively. Among women's most recent abortions, medication abortion (61%), surgical methods (26%), and unsafe methods categorized "least safe" (14%) were the initial or only methods used. Most women who accessed medication abortion initially or as their only method saw a pharmacist (40%) or no one (33%). Nearly one-quarter of women (n=16, 24%) who initially took tablets used more than one method. Conclusions : Despite experiences with abortion, most young people in this study were unaware of its legality and unsafe abortions occurred. More needs to be done to ensure young people understand the law and have access to safe methods, and that pharmacists are trained to provide appropriate doses and formulations of medication abortion.

Factors associated with induced abortion in Nepal: data from a nationally representative population-based cross-sectional survey

Background

Despite the legalization of abortion services in 2002, unsafe abortion (abortion services conducted by persons lacking necessary skill or in substandard settings or both) continues to be a public health concern in Nepal. There is a lack of national research exploring the characteristics of women who choose to have an abortion. This study assessed abortion in Nepal and its correlates using data from a nationally representative population-based cross-sectional survey.

Methods

We employed data from the Nepal Demographic and Health Survey 2016. Sample selection was based on stratified two-stage cluster sampling in rural areas and three-stage sampling in urban areas. The primary outcome is report of induced abortion in the 5 years preceding the survey, as recorded in the pregnancy history. All values were weighted by sample weights to provide population-level estimates. Bivariate and multivariate logistic regressions were performed using STATA 14 considering cluster sampling design.

Results

A total of 12,862 women of reproductive age (15–49 years) were interviewed. Overall, 4% (95% CI: 3.41–4.29) reported an abortion within the last 5 years (and less than 1% had had more than one abortion during that time). A higher proportion of women aged 20–34 years (5.7%), women with primary education (5.1%), women aware of abortion legalization (5.5%), and women in the richest wealth quintile (5.4%) had an abortion in the past 5 years. Compared to women aged < 20 years, women aged 20–34 years had higher odds (AOR: 5.54; 95% CI: 2.87–10.72) of having had an abortion in the past 5 years. Women with three or more living children had greater odds (AOR: 2.24; 95% CI: 1.51–3.31) of having had an abortion than women with no living children. The odds of having an abortion in the past 5 years increased with each wealth quintile, with the richest wealth quintile having almost three-fold greater odds of having had an abortion. No significant association was observed between having an abortion and the ecological zone and place of residence.

Conclusion

This nationally representative study shows that abortion is associated with women’s age, knowledge of abortion legality, wealth status, number of living children, and caste/ethnicity. Targeted interventions to young women, those in the poorest wealth quintile, women from Terai caste groups, and those who reside in Province 2 would be instrumental to address disproportional access to abortion services. Overall, strengthening contraceptive provision and abortion education programs would be cornerstone to improving the health of women and girls in Nepal.

Contributing factors to unsafe abortion practices among women of reproductive age at selected district hospitals in the Ashanti region of Ghana

BACKGROUND

Despite the existence of an abortion law and a safe abortion policy in Ghana, the Ghana Statistical Service found that 15% of all women in the reproductive age group (15-49 years) have practiced unsafe abortions. The objective of this study was to explore factors that contribute to the high incidence of unsafe abortion practices in the Ashanti Region of Ghana.

METHODS

A qualitative descriptive study design was used to assess factors that contribute to unsafe abortion practices. Purposive sampling technique was employed in selecting participants. Data were collected through key informant interviews and focus group discussions. One hundred and eleven participants were involved in the study. Data analysis was carried out through qualitative content analysis.

RESULTS

Seven thematic categories were elicited from data collected. The categories are: a) Lack of knowledge of safe abortion services; b) Socio-economic conditions as a perceived influence for unsafe abortion practices; c) Safe abortion as a perceived religious and cultural taboo in Ghana; d) Stigma of unplanned pregnancy; e) A desire to bear children only after marriage; f) Avoiding parental/guardian disappointment and resentment; g) A desire to pursue education.

CONCLUSIONS

Evidence available in this study suggests that several factors are responsible for unsafe abortion practices in Ghana. Lack of knowledge on safe abortion services, poor socio-economic conditions, cultural and religious beliefs, a stigma of unplanned pregnancy, a desire to bear children only after marriage, attempts to avoid parental/guardian disappointment and resentment, and a desire to pursue education were cited by participants as situations that contributed to unsafe abortion practices. Measures such as Aunty Jane, Ms. Rose and Women Help Women programmes can be publicised to reduce maternal morbidity and mortality that occur as a result of unsafe abortions in Ghana. Improvement in family planning education in educational institutions needs to be considered in order to reduce the rate of unwanted pregnancies among young women in school.

The relationship between sociodemographic factors and reporting having terminated a pregnancy among Ghanaian women: a population-based study

Background

Pregnancy termination is an illegal medical procedure in Ghana and 88% of induced abortions are performed in unsafe conditions, thus recipients face an elevated risk of abortion-related complications. This study aims to explore the associations between sociodemographic factors and reporting having terminated a pregnancy among Ghanaian women.

Methods

Logistic regression models were estimated using data from the 2014 Ghana Demographic and Health Survey (n=9396). ORs were computed for the associations between reporting pregnancy termination and select demographic and socio-economic factors.

Results

Education level, employment status, financial status and marital status of women are significantly associated with reporting having terminated a pregnancy.

Conclusions

Women who are employed, cohabit with a partner and are considered middle class or wealthy are more likely than their counterparts to report having terminated a pregnancy. Ghanaian women with intermediate levels of education are more likely than both their more- and less-educated counterparts to report having terminated a pregnancy. These findings highlight the need for the development of policies aimed at reducing unsafe abortions associated with unintended pregnancies. Specific recommendations include providing family planning education and outreach to high-risk groups to reduce unintended pregnancies and improving working conditions for expectant mothers, including provisions for paid maternity leave and job protection.

Global Contraceptive Failure Rates: Who Is Most at Risk?

Contraceptive failure is a major contributor to unintended pregnancy worldwide. DHS retrospective calendars, which are the most widely used data source for estimating contraceptive failure in low-income countries, vary in quality across countries and surveys. We identified surveys with the most reliable calendar data and analyzed 105,322 episodes of contraceptive use from 15 DHSs conducted between 1992 and 2014. We estimate contraceptive method-specific 12-month failure rates. We also examined how failure rates vary by age, education, socioeconomic status, contraceptive intention, residence, and marital status using multilevel piecewise exponential hazard models. Our failure rate estimates are significantly lower than results from the United States and slightly higher than previous studies that included more DHS surveys, including some with lower-quality data. We estimate age-specific global contraceptive failure rates and find strong, consistent age patterns with the youngest users experiencing failure rates up to ten times higher than older women for certain methods. Failure also varies by socioeconomic status, with the poorest, and youngest, women at highest risk of experiencing unintended pregnancy due to failure.

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.

Men's and women's roles in decision making about abortion in the context of HIV

OBJECTIVE

Mother-to-child transmission of HIV is a matter of global concern but is particularly serious in Zimbabwe. A number of strategies have been identified to limit the risk of mother-to-child transmission, including abortion. The aim of the current study was to assess men's and women's roles in decision making about abortion in a setting with a high prevalence of HIV.

METHODS

Qualitative research based on eight focus group discussions was conducted among adult men and women in Gokwe North District, Zimbabwe.

RESULTS

Both men and women expressed strong, negative attitudes towards abortion. Often, HIV-infected women considered carrying their pregnancy to term so as to fulfil societal and cultural expectations of childbirth after marriage. Termination of pregnancy by HIV-infected women was discouraged due to the availability of highly active antiretroviral drugs. Fear of giving birth to a sick and HIV-infected child, however, remained high. Also, the restricted legal environment appeared to complicate HIV-positive women's decisions to abort. Male involvement in decision making about abortion was relatively limited; if women opted for termination of pregnancy they were likely to do so secretly without obtaining their partner's consent.

CONCLUSIONS

In the context of HIV, it is important for prevention programmes to target both men and women in order to reduce the risk of mother-to-child transmission.

Abortion care in Haiti: A secondary analysis of demographic and health data

Background

Abortion-related mortality accounts for 8% of all global maternal deaths and 97% of the estimated 25 million unsafe abortions performed each year occur in low- and middle-income countries. Haiti has the highest rate of maternal mortality in the western hemisphere and to further understand the circumstances of induced abortion in Haiti, the current work uses data from the 2012 Demographic and Health Survey (DHS) to describe the methods of induced abortion in Haiti between 2007–2012 and to identify potential factors associated with use of different abortion methods.

Methods

This is a secondary analysis of nationally representative cross-sectional data from the 2012 Haitian DHS, a two-stage cluster randomized household survey. Analysis included descriptive statistics on participant demographics, methods of abortion, and location of / assistant for the abortion. Multivariate regression was conducted to determine if demographic characteristics were associated with: 1) increased or decreased odds of having an abortion; or 2) increased or decreased odds of reporting an evidence based or non-evidence based method of abortion.

Results

Among the 14,287 women of childbearing age who completed the 2012 Haiti DHS survey, 289 women reported having an induced abortion in the previous five years. Recommended methods, manual vacuum aspiration (MVA) or misoprostol alone, were used in 26.6% of the abortions (n = 77). Additionally, 13.8% (n = 40) of abortions used these recommended methods in combination with a non-evidenced based method such as injections, plants or tablets. A total of 92 women had a dilation and curettage (D&C) abortion, either alone (n = 77) or in combination with another method (n = 15) and over a quarter (n = 80) of reported abortions were conducted by non-evidence based methods (n = 80). A majority of abortions using a recommended method were assisted by a relative/friend (n = 28) or were unassisted (n = 34). Most abortions occurred in private homes (n = 174) with hospitals/clinics being the second most common location (n = 84). Women in the middle (OR = 3.3, 95% CI = 2.0–5.6) and highest (OR = 7.4, 95% CI = 4.4–12.3) wealth brackets were more likely to have had an abortion in comparison to women in the lowest wealth bracket. Women who had ever been in a marital union were more likely to have had an abortion than those who had not. The only demographic factor predictive of aborting using a recommended method was living in an urban area, with urban-dwelling women being less likely to use a recommended abortion method (OR = 0.4, 95% CI = 0.2–0.9) in comparison with women living in rural settings.

Conclusion

In a nationally representative survey in Haiti, 2% of women of childbearing age reported having an abortion in the five years prior to the survey. A large proportion of these abortions were carried out using non-evidence based methods and over half occurred outside of the formal health care system. Understanding women’s attitudes, knowledge and barriers around abortion is paramount to improving knowledge and access to evidence-based abortion care in an effort to decrease maternal morbidity and mortality in Haiti.

Prevalence and factors associated with abortion and unsafe abortion in Nepal: a nationwide cross-sectional study

BACKGROUND

Abortion is one of the leading causes of maternal death in low- and middle-income countries. In Nepal, abortion is reported to be the third leading cause of maternal death. We aimed to investigate the prevalence and factors associated with abortion and unsafe abortion in Nepal.

METHODS

This study is based on a nationally representative sample of the Nepal Demographic and Health Survey 2011. Women who had ever had a terminated pregnancy (n = 2395) were studied. The survey elicited information on the most recent abortion. Unsafe abortion was defined according to the providers of abortion services. Binary logistic regression was used to calculate odds ratios (ORs) and 95% Confidence Intervals (CIs) of abortions and unsafe abortions due to demographic, socio-economic and lifestyle-related characteristics. The interaction of the reason for abortion with age and educational status in predicting unsafe abortion was calculated using the predictive margins and their 95% CI.

RESULTS

The five-year prevalence of abortion was 21.1% among women of reproductive age who ever had a terminated pregnancy and 16.0% of total abortions were unsafe. Women of Buddhist religion (OR 2.15; 95% CI 1.04, 4.44), those who were literate (secondary level education OR 1.69; 95% CI 1.22, 2.34), those who knew about legal abortion (OR 1.88; 95% CI 1.41, 2.52) and those who were aware of safe places for abortion services (OR 4.96; 95% CI 3.04, 8.09) were more likely to undergo an abortion. Likewise, women in age group 25-34 years (OR 0.43; 95% CI 0.19, 0.97) and those who were in the richest wealth quintile (OR 0.10; 95% CI 0.04, 0.25) were less likely to undergo an unsafe abortion. Educated women of 25-34 years reporting "health risk" as the reason for abortion had a decidedly lower probability (< 10.0%) than the others of going through the unsafe abortion.

CONCLUSIONS

The prevalence of abortion in Nepal remains high. Education, religion, age, knowledge about legal abortion and safe places to undergo abortion were the major decisive factors associated with abortion. Young, poorest and uneducated women were more likely to undergo unsafe abortions. Therefore, intervention studies among these target groups are warranted.

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.

Correlates of sexual inactivity and met need for contraceptives among young women in Ghana

Background

Young women in sub-Saharan Africa continue to experience unintended pregnancies despite effective contraceptive methods being more readily available than ever. This study sought to determine the correlates of met need for contraceptives and sexual inactivity among young women in Ghana who want to postpone childbearing. We examine this among all women and then separately by marital status.

Methods

Using data from 1532 females aged 15–24 years from the 2014 Ghana Demographic and Health Survey, we conducted descriptive and multinomial logistic regression analyses to assess sociodemographic, economic and obstetric determinants of the type of family planning method (current abstinence, modern contraceptive method) used by married and unmarried young women.

Results

A higher proportion (~ 44%) of the respondents was currently abstinent compared to those with met need (~ 25%). Abstinence was higher among single young women while unmet and met need were higher among the married. Having at least senior high school education was significantly associated with the likelihood of current abstinence (especially among single women) and with met need. Being in the middle and rich categories, on the other hand, was associated with lower likelihood of current abstinence and a met need. Compared with multiparous women, those with one or no surviving child had a lower likelihood of being abstinent and having a met need. Other correlates of both current abstinence and met need are region of residence and ethnicity, while previous pregnancy termination and age were associated with abstinence and contraceptive use, respectively.

Conclusions

Unmet need is high among young women but abstinence is an option they are using. As reproductive health programmes target the at-risk groups, the secondary and higher educational levels must be attained by most women as this is associated with use of abstinence and met need.

Socio - economic determinants of abortion among women in Mozambique and Ghana: evidence from demographic and health survey

Background

Despite the variances in abortion laws accounting for differences in incidence of abortion among African countries, it appears there is absence of literature on other factors that may also account for the differences in incidence of abortion. Specifically, there is paucity of information on how socio-demographic factors account for the disparities in prevalence of pregnancy termination among women of reproductive age in sub-Saharan Africa. In view of this, this paper examined how socio-demographic factors influence pregnancy termination among women in reproductive age in Mozambique and Ghana.

Methods

The study made use of data from the 2014 Ghana and 2011 Mozambique Demographic and Health Survey for the study. For the purpose of this study a sample of 9375 and 13,660 made up of women in their reproductive ages (15–49) in Ghana and Mozambique respectively was used. The results on the analysis of the association between socio-demographic factors and pregnancy termination are presented as odds ratio (OR) with 95% confidence intervals (CI).

Results

The results revealed that about 25% of the respondents in Ghana and 9% of the respondents in Mozambique reported ever had a pregnancy terminated. In both countries, the odds of pregnancy termination were high among women with primary education, those in the older age groups, women who were Christians and women who were employed. Similarly, higher odds of pregnancy termination were found among ever married women, those who less than four births or more and those who have had access to social media (radio and television).

Conclusion

To reduce unintended pregnancies that could lead to pregnancy termination, there is a need for regular integrated community-based outreach programs targeted at generating community responsiveness of effective contraception and prevention of unintended pregnancy.

Responsiveness of Health Professionals to Postabortion Care at a Regional Level Hospital in Ghana: A Qualitative Study of Patients' Self-Reports

Background

The responsiveness of health professionals to patients in the provision of abortion services is essential to influencing patients' perceptions and expectations regarding the quality of medical care to be received and their general satisfaction. This, in turn, determines if patients will revisit a particular health facility to access abortion services. In this study, we examine the responsiveness of health professionals in providing postabortion care at a regional level health facility in Ghana.

Methods

Qualitative data collected from 20 female patients who assessed abortion services at a regional level health facility in Ghana were used. The sample was achieved through saturation while a systematic qualitative orientated text analysis was adopted in analysing the data.

Results

Health professionals were responsive to postabortion care at the facility. Most women who sought postabortion care at the facility were referred from other health facilities which could not handle such cases. Other reasons include satisfaction with services received on previous visits to the hospital. We also realized, however, that postabortion services were not covered by the National Health Insurance Scheme.

Conclusions

All hospitals across the country should be equipped with the basic equipment and personnel to conduct and manage abortions. This would reduce not only referrals but also possible maternal deaths. Abortion services should also be added to the services covered by the country's National Health Insurance Scheme.

The Severity and Management of Complications Among Postabortion Patients Treated in Kinshasa Health Facilities

CONTEXT

Unsafe abortion is common in Kinshasa, which contributes to high rates of maternal morbidity and mortality. Little is known about the complications and treatment experienced by women seeking postabortion care at health facilities in the city.

METHODS

Data from 867 women admitted to a sample of health facilities providing postabortion care in Kinshasa in 2016 were drawn from a Prospective Morbidity Survey. A measure of severity of postabortion complications was developed on the basis of information from these women and their primary care provider. Generalized ordered logistic regression analyses were used to examine associations between the characteristics of postabortion care patients and complication severity.

RESULTS

Nearly three-fourths (72%) of postabortion care patients were classified as certainly having had an induced abortion, and another 16% as probably having had one. Sixteen percent of postabortion care patients experienced severe complications, 46% moderate complications and 33% mild complications; 5% had no evidence of complications. Severity of complications was associated with certain patient characteristics: For example, poor patients and those who had never been married had elevated odds of having experienced severe or moderate complications rather than mild or no complications (odds ratios, 1.8-1.9). Patients' complications were most commonly treated with such outdated methods as dilation and curettage and digital curettage (49% and 23%, respectively); only 11% of patients received medication for pain.

CONCLUSIONS

Policies and programs promoting contraceptive use and safe legal abortion are needed in Kinshasa to reduce women's recourse to unsafe abortion. Improved quality postabortion care provision is also needed, including World Health Organization-recommended methods.

Trajectories of women's abortion-related care: A conceptual framework

We present a new conceptual framework for studying trajectories to obtaining abortion-related care. It assembles for the first time all of the known factors influencing a trajectory and encourages readers to consider the ways these macro- and micro-level factors operate in multiple and sometimes conflicting ways. Based on presentation to and feedback from abortion experts (researchers, providers, funders, policymakers and advisors, advocates) (n = 325) between 03/06/2014 and 22/08/2015, and a systematic mapping of peer-reviewed literature (n = 424) published between 01/01/2011 and 30/10/2017, our framework synthesises the factors shaping abortion trajectories, grouped into three domains: abortion-specific experiences, individual contexts, and (inter)national and sub-national contexts. Our framework includes time-dependent processes involved in an individual trajectory, starting with timing of pregnancy awareness. This framework can be used to guide testable hypotheses about enabling and inhibiting influences on care-seeking behaviour and consideration about how abortion trajectories might be influenced by policy or practice. Research based on understanding of trajectories has the potential to improve women's experiences and outcomes of abortion-related care.

Is a woman's first pregnancy outcome related to her years of schooling? An assessment of women's adolescent pregnancy outcomes and subsequent educational attainment in Ghana

Background

Adolescent pregnancy and childbearing pose challenges to young women’s educational attainment. Studies show that while adolescent childbearing reduces educational attainment, not becoming pregnant and resorting to induced abortion when pregnant increases women’s educational levels. This study examined relationships between adolescents’ resolution of their first pregnancies and subsequent educational outcomes, for all women ages 20–49 years and across three age cohorts: 20–29, 30–39 and 40–49 year olds.

Methods

Using the 2007 Ghana Maternal Health Survey (GMHS) dataset, we conducted ANOVA, bivariate and multivariate linear regression analyses on 8186 women ages 20–49 years. Women’s first adolescent pregnancy outcomes were measured as live births, induced abortions, spontaneous abortions or no pregnancy, while educational attainment constituted their years of schooling.

Results

Findings showed years of schooling was highest for women who had induced abortions, and lowest for those who experienced live births. Women with live births as teenagers experienced significantly fewer years of schooling compared to their counterparts who terminated their pregnancies. Also, women with miscarriages and stillbirths exhibited levels similar to those who gave birth. Although women with no teenage births had higher educational levels than their childbearing counterparts, controlling for age at first pregnancy resulted in similar years of schooling compared to those who gave birth. Finally, the 30 to 39 year olds were the only age group whose results contradicted those of all women. These findings may be due to the socio-economic and political events that affected women’s educational attainment at the time.

Conclusions

Childbearing during adolescence does impact women’s educational attainment levels. Therefore, in addition to encouraging young mothers to continue schooling, all other interventions to help keep young girls in school must focus on preventing and/or delaying their adolescent pregnancies.

Characteristics of women obtaining induced abortions in selected low- and middle-income countries

BACKGROUND

In 2010-2014, approximately 86% of abortions took place in low- and middle-income countries (LMICs). Although abortion incidence varies minimally across geographical regions, it varies widely by subregion and within countries by subgroups of women. Differential abortion levels stem from variation in the level of unintended pregnancies and in the likelihood that women with unintended pregnancies obtain abortions.

OBJECTIVES

To examine the characteristics of women obtaining induced abortions in LMICs.

METHODS

We use data from official statistics, population-based surveys, and abortion patient surveys to examine variation in the percentage distribution of abortions and abortion rates by age at abortion, marital status, parity, wealth, education, and residence. We analyze data from five countries in Africa, 13 in Asia, eight in Europe, and two in Latin America and the Caribbean (LAC).

RESULTS

Women across all sociodemographic subgroups obtain abortions. In most countries, women aged 20-29 obtained the highest proportion of abortions, and while adolescents obtained a substantial fraction of abortions, they do not make up a disproportionate share. Region-specific patterns were observed in the distribution of abortions by parity. In many countries, a higher fraction of abortions occurred among women of high socioeconomic status, as measured by wealth status, educational attainment, and urban residence. Due to limited data on marital status, it is unknown whether married or unmarried women make up a larger share of abortions.

CONCLUSIONS

These findings help to identify subgroups of women with disproportionate levels of abortion, and can inform policies and programs to reduce the incidence of unintended pregnancies; and in LMICs that have restrictive abortion laws, these findings can also inform policies to minimize the consequences of unsafe abortion and motivate liberalization of abortion laws. Program planners, policymakers, and advocates can use this information to improve access to safe abortion services, postabortion care, and contraceptive services.

"My friend who bought it for me, she has had an abortion before." The influence of Ghanaian women's social networks in determining the pathway to induced abortion

BACKGROUND

Even given the liberal abortion law in Ghana, abortion complications are a large contributor to maternal morbidity and mortality. This study sought to understand why young women seeking an abortion in a legally enabling environment chose to do this outside the formal healthcare system.

METHODS

Women being treated for complications arising from a self-induced abortion as well as for elective abortions at three hospitals in Ghana were interviewed. Community-based focus groups were held with women as well as men, separately. Interviews and focus group discussions were conducted until saturation was reached.

RESULTS

A total of 18 women seeking care for complications from a self-induced abortion and 11 seeking care for an elective abortion interviewed. The women ranged in age from 13 to 35 years. There were eight focus groups; two with men and six with women. The reasons women self-induce are: (1) abortion is illegal; (2) attitudes of the healthcare workers; (3) keeping the pregnancy a secret; and (4) social network influence. The meta-theme of normalisation of self-inducing' an abortion was identified.

DISCUSSION

When women are faced with an unplanned and unwanted pregnancy, they consult individuals in their social network whom they know have dealt with a similar situation. Misoprostol is widely available in Ghanaian cities and is successful at inducing an abortion for many women. In this way, self-inducing abortions using medication procured from pharmacists and chemical sellers has become normalised for women in Kumasi, Ghana.