DOI: https://doi.org/10.21203/rs.2.10385/v1
The World Health Organization (WHO) defines unsafe abortion as “a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both”.[1] According to the WHO estimation, there were about 55.7 million abortions worldwide each year from 2010-14 and about 45% of them were unsafe abortion. This indicates about 25 million abortions occurred each year between 2010 and 2014 were unsafe, and about 97% of them occurred in developing countries.[2]
Unsafe induced abortion is a major public health problem that affects not only mother’s life but also the people around her. Abortion related complication such as anemia, genital tract infection, shock, peritonitis, incomplete evacuation, renal failure accounts for increased maternal morbidity and mortality.[3] Women who had unsafe induced abortion should have to get post abortion care to prevent severity of complications. Post-abortion care is treatment given to women who present at hospital or health center with complications due to an incomplete abortion or miscarriage. Ethiopian women are suffering from increased risk of abortion related complication, due to various reasons such as unmet contraceptive need, rape, early sexual practice etc.[4, 5] The top three causes of maternal deaths are post-abortion complication (29%), eclampsia (21%) and ruptured uterus (16%).[6] Women who had experience of unsafe induced abortion may suffer from emotional side effects like regret, feeling of guilty, and shame. [7] In addition, unsafe induced abortion has negative impact on maternity service and subsequent pregnancy.[8]
To reduce unsafe induced abortion, Ethiopia has permitted abortion in specific legal circumstances when the conception of the fetus is caused by rape, incest, when continuation of pregnancy endanger the mother’s life ,if the fetus has incurable deformity or if the mother doesn’t fit to give birth mentally or physically.[9, 10]
According to reports by different literature; socio-economic, educational level, lack of contraceptive methods, and contraceptive failure are mainly associated to unsafe induced abortion.[1, 11-14] Women who have low income are more likely to experience unsafe abortion than women who are financially stable.[12-16]
Nowadays, availability and accessibility of modern contraceptives are increasing in many countries including Ethiopia, although it varies according to the types of contraceptives. For instance, in Ghana the availability of male condom and combination of oral contraceptive were high in health facilities. [17] However, people use inappropriately due to different factors such as insufficient awareness, community’s sociocultural, and fear of side effect.[18-20] In appropriate use of contraceptives lead to unintended pregnancy which result in unsafe abortion.[21] Unintended pregnancies are pregnancies that are mistimed, unplanned or unwanted at the time of conception.
Even if, there is an increasing modern contraceptive use, Ethiopian women still have unmet contraceptive need especially in unmarried and young women.[4] Contraceptive methods failure and low access for contraceptives was the main reason for unintended pregnancy in Ethiopia. [4, 5, 22] Unsafe abortion is one of the major causes of maternal mortality in Ethiopia. [23] Ethiopia has the 5th largest maternal mortality, where unsafe abortion accounts for 32% of it. [24]
Nowadays, unsafe abortion is increasing in developing countries. However, there are not plenty of data on unsafe induced abortion and related issues in Ethiopia. The aim of this study was to describe the determinants of unsafe induced abortions in the study area that enables to deal with unwanted pregnancy, contributes bases for reduction of maternal mortality, and clarifies how much unsafe induced abortion is prevalent in the study area. It can be used as a base line to the public health organizations and other organizations to explore the way to reduce risks of unsafe induced abortion.
Methods
Study Design and Sampling Technique
Institutional based cross-sectional interview questionnaire survey was conducted. This study was conducted among all women who received post abortion care service in Fitche hospital from November 30, 2017 up to May 30, 2018. Proportion of people presenting for post-abortion care approximately 1100 per year. Fitche Hospital is located at Fitche town which is the capital town of North shoa administrative zone. The town is located at a distance of 112km from Addis Ababa to the North part of Ethiopia along the way to Gojam main asphalt road.
The required sample size was estimated using a single population proportion formula with 95% CI, 5% margin of error, and 50% population proportion was taken to increase sample size. Though this true for larger population, the minimum sample size required was determined by using the correctional formula. Five percent was also added to account for non-response rate. Accordingly, the required sample size calculated was 308 and the data was collected using systematic random sampling technique.
Study Design and Sampling Technique
Institutional based cross-sectional interview questionnaire survey was conducted. This study was conducted among all women who received post abortion care service in Fitche hospital from November 30, 2017 up to May 30, 2018. Proportion of people presenting for post-abortion care approximately 1100 per year. Fitche Hospital is located at Fitche town which is the capital town of North shoa administrative zone. The town is located at a distance of 112km from Addis Ababa to the North part of Ethiopia along the way to Gojam main asphalt road.
The required sample size was estimated using a single population proportion formula with 95% CI, 5% margin of error, and 50% population proportion was taken to increase sample size. Though this true for larger population, the minimum sample size required was determined by using the correctional formula. Five percent was also added to account for non-response rate. Accordingly, the required sample size calculated was 308 and the data was collected using systematic random sampling technique.
Inclusion and exclusion criteria
All women who received post abortion care service in Fitche hospital during the study period were included.
Women who were seriously ill and unable to talk, and women who had mental problem were not included in this survey. This is because it was not possible to collect data and get an appropriate response from this group of patients.
Data collection procedures
The data were collected using structured questions which was adopted from study done in Guaraghe zone, Ethiopia in 2014.[4] The questionnaire had three parts: Socio-demographic characteristics, contraceptive practice, and abortion related questions. An interview questionnaire was used after explaining the aim of the study to the participant. The data collector was given a proper training about the study on the prior week. All information regarding socio-demographic characteristics was acquired from the direct information of participant response.
Data quality control
A questionnaire was prepared in English and translated into Amharic and back to English in order to avoid any language barrier (information bias). To keep the quality of data completeness, each questionnaire was checked for completeness. After checking the data for completeness, the questionnaire was coded and the data entered to a computer. The coded questionnaire was rechecked to avoid any error during coding and entrance. Finally, the response of each participant was entered based on the coded questionnaire.
Data analysis and processing
The completed data were entered into EpiData 3.1 and analyzed using statistical package for social sciences (SPSS) version 24. Descriptive statistics were done to determine the socio-demographic characteristics of respondents and their practice toward unsafe induced abortion. Results were presented in the form of figures, tables, and text. Multivariate logistic regression analysis was conducted. The odds ratio (OR), 95% confidence intervals and chi-square test were computed to assess the magnitude and association between predictors (socio-demographic, contraceptive practice, and abortion related questions) and outcome (unsafe induced abortion). P- value of < 0.05 was used as a cut off value to detect statistical significance.
Socio demographic characteristics
Three hundred eight respondents (100% response rate) with mean age of 30 ± 9 years were participated in this study from which 65% respondents were aged between 15-34 years. From women participated in the study, 19% unable to read and write whereas 81% able to read and write, and had different level of education. According to this study, most of the participants (48%) were married and 46% of the respondents had monthly income < 1500 ETB as shown in Table 1.
Contraceptive knowledge, practice, and history of its failure
Respondents were asked whether they know about different contraceptive methods such as condom, OCP, injectable, calendar rhythm, implant, and IUCD. About 75% of respondents had mentioned that they had history of using one or more contraceptive methods to prevent pregnancy. From the total respondents, 14% had history of contraceptive failure, of which 46% reported OCP failure and 24% reported calendar rhythm contraceptive failure (Table 2).
Place of abortion, method used and its complication
Among respondents, 46% reported they had induced abortion, of which 45% of the induced abortion was unsafe. Regarding place of induced abortion, 27% of women reported that abortion was performed at traditional birth attendants’ house, while 18% of respondents reported that abortion was performed in patients’ house. About 66% of respondents reported that abortion was initiated by medication, and more than 46% induced abortion performed without health professional. It was induced by traditional birth attendants (27%) and patients themselves (18%). Among respondents, 55% knew the complication of induced abortion and 63% of the respondents have reported feeling of unwellness after the procedure as shown in table 3.
Figure 1 illustrates the common reasons of induced abortion. Socio-economic problem was mentioned as the most common cause of induced abortion and followed by health problems, contraceptive failure, school/class, rape, and peer pressure.
Figure 2 illustrates the complication of unsafe induced abortion reported by respondents. Fever and heavy bleeding were the most common complications of unsafe induced abortion and followed by sweating, chilling, and foul vaginal discharge.
Associations between unsafe induced abortion and its predictors
Logistic regression analysis identified significantly associated factors of unsafe induced abortion. According to logistic regression analysis result, single women were more likely practice unsafe induced abortion than widowed women [OR: 9.71; 95%CI (1.30 – 72.42)]. Women who had monthly income less than 1500ETB were more likely practice unsafe abortion than counterparts [OR: 6.72; 95%CI (2.15 - 20.97)]. Regarding occupation, house wife women were more likely practice unsafe induced abortion than counterparts [OR: 12.29; 95%CI (1.70 - 88.63)]. Age of women, education level, religion, number of pregnancies, and number of children were not identified as significant associated factors with unsafe induced abortion in our study as shown in table 4.
According to Chi-square test, failure of contraceptive methods (𝜒2: 38.95; P < 0.001), place of interference (𝜒2: 85.61; P < 0.001), method used to interference (𝜒2: 48.17; P < 0.001), a person who induced the abortion (𝜒2: 38.95; P < 0.001), knowledge about complication of induced abortion (𝜒2: 11.20; P < 0.001), condition after procedure (𝜒2: 42.49; P < 0.001), and reasons to induce abortion (𝜒2: 29.08; P < 0.001) were identified as association factors of unsafe induced abortion as shown in table 5.