Reasons of women who undergone repeat induced abortion; in Wolaita Sodo town, Southern Ethiopia, 2021: A phenomenological qualitative study

doi:10.21203/rs.3.rs-1733847/v2

Download PDF

Research Article

Reasons of women who undergone repeat induced abortion; in Wolaita Sodo town, Southern Ethiopia, 2021: A phenomenological qualitative study

https://doi.org/10.21203/rs.3.rs-1733847/v2

This work is licensed under a CC BY 4.0 License

Version 2

posted

You are reading this latest preprint version

Background

Repeat induced abortion refers to a condition in which a woman has at least one previous history of induced pregnancy termination. It bound in a vicious cycle with repeat unintended or unplanned pregnancy and remains rising concern, particularly for developing countries.

Objectives

This study was aimed to explore reasons and lived experiences of women, who undergone repeat induced abortion; in Wolaita Sodo town, Southern Ethiopia.

Methods and Materials:

A phenomenological qualitative study approach was conducted from February 15-March 22, 2021 among women in Wolaita Sodo town. Twelve women between 17 and 35 years old, who had at least one previous abortion were selected using purposive sampling. In-depth interview using semi-structured interview guide was conducted. Data were audio recorded, transcribed verbatim and translated in to English and imported to ATLAS.ti8 software for coding. Code book development, peer debriefing, multiple coders and audit trials applied to maintain rigor of the data and analysis was done deductively.

Result

The study found reasons of repeat induced abortion among women at maternal, partner and family, healthcare and educational institution, community and policy level. It also looked into the effects of induced abortion from the standpoint of women. Economic issues, fears about contraceptive side effects, and a desire to limit the number of children were stated as reasons.

Conclusion

Study revealed multiple reasons for repeat induced abortion in holistic manner; and presented key emotional and physical effects of abortion and unintended pregnancy. Based on the findings, multiple interventions at individual, community and organizational levels; and strong law enforcement on criminals of rape are needed in order to avoid or minimize the reasons and negative consequences of repeat induced abortion.

Abortion

induced abortion

safe abortion

repeat induced abortion

Ethiopia

Induced abortion describes surgical or medical termination of a live fetus that has not reached viability (1). Repeat induced abortion refers to a condition in which a woman has at least one previous history of induced pregnancy termination (2). Repeat induced abortion is bound in a vicious cycle with repeat unintended or unplanned pregnancy (3).

It remains rising concern in the international community, particularly for developing countries. Its prevalence is high and ranges from 21.3% in China (4) to 43.7% in Finland (5). It signifies the highest problem of unplanned pregnancy (4). By contrast, greater than half of all women living in an underdeveloped nations are at risk of having one or more pregnancy that is unplanned in their lifetime (6).

Women with history of multiple abortion may have difficulty of how to use contraception properly and consistently, either undergoing abortion as a means of birth control method (4). Repeat induced abortion is frequently a consequence of inadequate contraception and/or nonuse of contraception (7). Nonuse of contraception may be related to unavailability of family planning service/too far (indicator of contraceptives unmet need), fear of side effect, religious prohibitions, inconvenience of available methods to use, husband and others opposition (8). With the exclusion of a few countries, access to have safe induced abortion in developing countries is limited to a very few circumstances (6).

Majority of young women are at high risk due to their inability to use contraceptives, which predisposes them for repeat induced abortion (4). One of the important parts of safe abortion care (SAC) services is integration of post abortion family planning (PAFP) in order to avoid repeat unwanted pregnancy and occurrence of induced abortion repeatedly as well (9). Most women reporting a previous one or more intentional ending of pregnancy also state their pregnancy was unplanned (10). Women who have a previous history of recent pregnancy termination are more likely to stop using contraceptives throughout follow up period of one year (3). Most of the time, women who had undergone induced abortion are at increased risk of pregnancy almost immediately after abortion (11). When women have multiple induced termination of pregnancy, in setups with limited access of safe induced abortion service, it can worsen health risks for women (10). It is linked to increased risk of adverse pregnancy outcomes in future pregnancies such as ectopic pregnancy, fetal loss, low birth weight babies and preterm delivery in future upcoming pregnancies (12).

Abortion especially induced abortion is a highly sensitive issue and pregnancy related maternal health concern. Even some studies done in Ethiopia, which shows the prevalence and associated factors for repeat induced abortion, but there is limitation of studies done on the reasons of women who undergone repeat induced abortion in the women's perspectives despite of having many options of preventing repeat unintended or unwanted pregnancy.

Study Design and Setting

A qualitative study by using phenomenological approach was conducted to explore the reasons and lived experience of women, who undergone repeat induced abortion. The study was conducted in two health centers that give safe abortion care service which were located in Wolaita Sodo town from February 15-March 22, 2021. Wolaita Sodo town is located in Wolaita zone, Southern Nations, Nationalities and Peoples Region (SNNPR) of Ethiopia, which is situated 330 km southwest of Addis Ababa city. Based on the 2018 population projection by the CSA, the town has a total population of 254,294, of whom 125,855 were men and 128,439 were women which made Wolaita Sodo most populous town in south region.

Study Participants and Sample size

Women who were having post abortion care service for induced abortion at the facilities during the study period and who fulfilled the inclusion criteria. The data was collected among twelve women who had at least one history of previous induced abortion. Number of participant was determined by information redundancy. To assure saturation, at the end of each day of interview, the data were checked for the occurrence of codes or categories and if the need for further interview in a preliminary fashion. Authors ensured interviews were no longer generating new information and new interview tend to be redundant of already collected data. Data saturation was assured after tenth interview and added two interview to ascertain that saturation have reached.

Purposive sampling method was used to select women who meet the inclusion criteria and provided detail information. During selection of participants, variation in age, marital status, economic status, residence, educational status and previous number of induced abortion was considered.

All women who had at least one induced abortion previously within the last 24 months and having post-abortion care for current abortion during the study period were included. The exclusion criteria were women who bled profusely, women who refused to give consent and women with known mental problems

Data Collection Tools and Procedures

In-depth interview (IDI) using semi-structured interview guide was conducted. Audio-tape recorder was used with the permission of the participants to record and capture the interview. Women were asked open-ended questions on one to one basis in a silent private room based on the semi-structured interview guide. The guide included topics and probing questions focusing on the demographic information of participants, reasons and predisposing condition to seek induced abortion service repeatedly.

The interview started with warm-up and general questions, and continuously modified throughout the data collection to include emerging issues and improve clarity of the interview questions. As central opening statement "Please, tell me about yourself?" was raised to the respective participant. In addition, in the middle of interview some minimal assisting questions such as "Can you tell me more?", "Don't you had other options?" and "What you mean when you say...?" was used. The interviews were audio recorded and field note was taken for all of participants. The audio taped interview ranged from 7–40 minutes.

Trustworthiness

Four techniques was considered to assure trustworthiness of findings. To establish credibility of the study, authors spent prolonged engagement and extended contact with study site and participants, use of peer debriefing and audio-recorder during interview. Dependability was assured by using audit trial, saving audio records of participants’ interview, notes taken during the interview and transcription verbatim and using code-recode method. Providing thick description about research context, methodology, participants and final report and purposive sampling used to ensure transferability. To establish conformability the researcher was reflected on, considered prior personal expectations and experiences to reduce bias and using participants' word from interview transcripts to confirm that the data interpretation reflect exact participants' own word.

Method of Data Analysis

Data analysis was done concurrently and began once first interview was conducted and emerging ideas and new questions was added in the subsequent interviews throughout the data collection process. Audio recordings was transcribed verbatim in the language of interview i.e. Amharic, then translated in to English and imported to ATLAS.ti8 software for coding process and data was coded line by line. Analysis was done deductively by using qualitative thematic analysis. The coding framework was updated continuously by developing code book to ensure coding consistency. Coding was carried out primarily by the investigator and another researcher also coded some of the translated data, and differences in the identified codes among the coders were resolved through discussion and coding with the investigator was revised and discussed to clarify the research findings. Identified 44 codes, according to similarities and differences, allocated into sub-themes. Similar sub-themes grouped into themes. Finally, the sub-themes and codes were determined as the expression of the latent meaning of the text.

Socio-demographic Characteristics of Participants

Participants were total of twelve women aged 17–35 years old who were receiving abortion care services in two health centers of Wolaita Sodo town. Most of the women had safe induced abortion and only one participant had unsafe abortion due to loss of information (Table 1).

Table 1

Background information of participants on reasons of women who undergone repeat induced abortion in Wolaita Sodo town, April 2021.
Socio-demographic Characteristics of Participants		Number
Age (Years)	17–24	7
Age (Years)	25–35	5
Marital Status	Single	7
Marital Status	Married	5
Educational status	Primary	2
	Secondary	5
	Diploma and above	5
Occupational status	Daily laborer	1
	House wives	3
	Government employee	1
	Students	6
	Commercial sex worker	1
Frequency of induced abortion	Second	7
	Third	3
	Fourth and above	2
Time gap between current and previous induced abortion	< 1 year	8
Time gap between current and previous induced abortion	< 2 years and ≥ 1 year	4
Types of previous induced abortion	Unsafe abortion	1
Types of previous induced abortion	Safe abortion	11

Emerged Themes

Reasons that has led study participants to undergone repeat induced abortion have been categorized in to five main themes; maternal related, partner and family related, healthcare & educational institution related, community related, and policy related reason. In addition effects of induced abortion was identified as an independent team. Within each themes further sub-themes were identified (Fig. 1).

Theme 1: Maternal Related Reasons

Four sub-themes of contraceptive related, future plans, fear of challenges/difficulties in life and risky sexual behaviors have been identified under this main theme.

Sub-theme 1: Contraceptive Related

Contraceptive discontinuation due to fear of side effects, contraceptive failure, fear of if families knowing about their contraceptive usage, lack of information and poor knowledge about contraceptives, rumors/myth and non-adherence to the contraceptive method were stated as a reason for having unwanted pregnancies that ended with repeat induced abortion.

Participants have stated fear of side effects for discontinuation of contraceptive use repeatedly as a reason for having unwanted pregnancy and repeat induced abortion. A 25 years old woman who had unwanted pregnancy due to contraceptives discontinuation stated she has used contraceptive methods and discontinued many times because she felt it was not suitable for her. A 26 years old commercial sex worker, stated that she knows that contraceptive methods are useful but not happy using it because she associated contraceptive with side effects that can affect her day to day life. She also stated irregular menstrual bleeeding makes sleeping with male customer very dificult and affecting her daily income.

Women stated that they fear contraceptive failure and claims as ineffective. A 26 years old, commercial sex worker has stated that as she lost trust on contraceptives because of the past history of contraceptive failure. Again, 24-year-old married women stated, “I don't want to use contraceptive method because I don't think they prevent pregnancy effectively.”

Intention to hide their contraceptive use from other family members and community was also stated as reason for not using that lead them to unwanted pregnancy. These particularly reported by adolescents living with their families and married women who were not currently living with their partners. For adolescents, parents will not approve contraceptive use and as sexual intercourse before marriage is considered as misbehavior by the community.

On the other hand, a 24-year-old women who is currently not living with her husband mentioned “I can't feel free to use birth control methods because of the peoples around me. Most methods are visible and someone can see them easily.” She has expressed a soceity associate using family planning while the husband is not around with cheating.

These women were not even want to be recognized by health professionals. She added “Once I tried to use and went to the family planning service center but there was our neighbor nurse in the center. Then I hide from her and returned home without receiving the service.”

Lack of information about where to get family planning services was another factor that resulted in unwanted pregnancy among adolescents. In line with this, an 18 years old adolescent girl who had a history of rape has stated:

“When it [Rape] happened, I don't have any information about what to do and how to prevent pregnancy. I had no idea of using emergency pills. I had no idea what to do”.

Not only about different contraceptive methods, adolescents has also explained as they do not have adequate information about menstural cycle and the specific time of the cycle in which they will be at risk of getting pregnant. A 17 years old adolescent explained this by saying “I do not know when it is the most risky time of getting pregnant. I don't know if it is safer or not to have sex before or after monthly bleeding. I don't even know how to count those days of the menstrual cycle exactly.”

Some participants especially youths had reported to have inadequate knowledge about types of family planning methods. Most of them had knowledge of only short acting contraceptive methods. A 17 years old participant said “I only know emergency pills and tablets but never used any type”. Another 22 years old participant added “I know oral tablets, emergency post pills and condom.”

Rumors about birth control methods is one factor that hinders using contraceptives and cause unwanted pregnancy. A 35 years old woman stated as she heard peoples talking about contraceptives by saying "Many people spoke contraceptives as not good and scratches uterus". This misleading information includes, contraceptives cause harm on uterus, infertility and weight loss due to these rumors participants had bad perception and fear to use. A 25 years old participant stated as "Some peoples say contraceptive methods are good and some says it is not good, it causes weight loss. They spoke if woman use any type of contraceptive method she will become infertile."

Other contraceptive related reason resulting in unwanted pregnancy and subsequent abortion is non-adherence to contraceptive methods to which they were using. An 18 years old adolescent girl mentioned "Most of the time I used emergency pills and sometimes oral tablets. Mostly I may miss one or two pill, once I missed, in the next day I stop taking the pill. I think that they may not help after missed."

Some participants expressed that they were using oral tablets as emergency pills. They took for few days after unprotected sex and didn't finish full 28 pills. A 22 years old participant stated "I used oral monthly tablets and post pills. I was taking oral tablets for six or seven days after unprotected sex. I stop taking pills mostly after one week."

Partner refusal to use condom during sexual intercourse also caused women to engage in unprotected sex and resulted in unwanted pregnancy.

It is perceived that only women are expected to use contraceptives to prevent unwanted pregnancy and men prefer unsafe sex. A 22 years old participant stated "Males only expect us to use contraceptive pills; they do not want to use condom, they prefer to have sex without condom."

She also stated that there was free condom supply in the university but males don't want to use and said as "There is free condom in the university but everyone can see you while taking the condom; they do not even feel comfortable taking the free condoms offered by the university clinic, it lacks privacy." A 21 years old woman stated "males prefer sex without condom and female don't use condom rather expect the male to have it"

Sub-theme 2: Future Plans

Respondents have mentioned desire to continue education, their future goal/ambitions to have better and improved life, need to limit and spacing children as their reason to seek repeat induced abortion. It was perceived that adolescents fear school dropout due to unwanted pregnancy. So girls who faced unwanted pregnancy seek abortion to continue their education and high level of fear of being mom while they are in school.

An 18 years old girl stated that her family especially her mom may accept her to give birth but she decided to terminate her pregnancy to continue her education. Another 22 years old girl added "I do not want dropping out of school due to child birth, I have to finish."

Participants expressed having a child may interfere with their future ambitions/goals and hopes to have improved life. They feel as not ready, not owning or being established with better life to have a child currently. A 26 years old commercial sex worker mentioned that she doesn't want to have child with her current life and work, she needs to improve her life before having child. She stated "Imagine if I had children and what they going to feel when they knew what I do for living. I think it harm their emotion. So, before having child I have to change my work, have better and stable income to afford at least my child’s basic needs."

Need to limit children among married women is another reason for seeking repeat induced abortion. Participants stated they preferred to have repeat induced abortion than to have more child. A 35 years old woman who already had seven children described "Even though my husband wanted to have more child, I decided not to have more child and aborted the pregnancy." She has also history of failed abortion attempt and added about difficulty of nurturing even available children.

Women need to space or stop child birth temporarily and terminate unwanted pregnancy to improve their profession/career. A 27 years old participant who had three children and decided to space birth in order to improve her educational status said "Even though I may have one or two child in the future, I want to pause giving birth temporarily. I have to complete my education to hold my degree so that I can improve my job, my income and I can give better life to my children."

Sub-theme 3: Economic Factors

As mentioned by most participants, economic problem was their major reason to seek repeat induced abortion service. Majority of women were dependent on family, sexual partner or someone else; this makes them to feel less capable of raising their unborn child. A 20 years old university student mentioned even if she wants to give birth, her boyfriend opposed because they both are dependent on their family. She said they cannot take responsibility of raising a child at this time and it is risky and difficult for them. A 25 years old woman who had two children stated as she preferred to have abortion rather than having more children. She said "I don't hate to give birth, but I don’t have myown income to raise the baby(...Crying...)." A 26 year old commercial sex worker also stated she will not have adequate income to provide even food for her new born. She mentioned as she can’t even feed herself. She stated "Within these two weeks, I didn't even have money to buy food for myself because I can't serve my customers due to this abortion." Another mother also stated as she prefered to have repeat induced abortion because she were worried and confused whether or not they can provide better life for their children.

Sub-theme 4: Maternal Risky Sexual Behavior

Youths, especially university students engage in abusing addictive substances due to lack of recreational places in the city where youths can spend their time; and low cost and easy access of addictive substances. After abusing, they practice unprotected sexual intercourse and having multiple sexual partners due to impaired decision-making ability and not considering risks related with multiple sexual partners. Respondents criticized concerned government or university bodies for not seriously enforcing rules and taking action to eradicate houses that provide addictive substances such as khat, shisha, alcohol and cigarettes.

A 21 years old university student explained how easy accessibility of these substances within and around the university compound had put her at risk of having unprotected sex, multiple unwanted pregnancies which ended with having repeat induced abortion. She said, "After using shisha and drinking alcohol I mostly engage in unprotected sex because it is less likely to think about the use of condom; even though I regret about my action the next morning." Another 17 years old adolescent girl said "After chewing khat and drinking alcohol, we had sex every time when he want without thinking about the risk...I never thought of getting pregnant but it happened." A participant also mentioned that because of the substances they used, their decision making ability hindered and because of these, they are less likely to use condom.

As described by participants, students who abuse addictive substances have multiple sexual partners. A 21 years old participant who has multiple sexual partners to get money for her expenses and addiction; and said "I have boyfriends with whom I goes to nightclub, I drunk different types of alcohols; I stayed longer until it gets so late and I slept together simply may be with eight or more boys in a single room." The girl mentioned that due to substances abused, she had sex with multiple boys and said "sex happens and it may be with more than one male in single night." She didn't know from whom she became pregnant. In line with this she said "I have three or more sexual partners: the one who give me money, the one who is romantic/can give good love and so on."

Substance use resulted in unprotected sex without considering the risks of unwanted pregnancy due to reduced cognitive ability to make rational decisions of using condom. Youths especially adolescents don't think of practicing safe sex and girls leave responsibility of using condom mostly for males. A 21 years old girl said "Mostly it is unprotected sex because it is less likely to think about the use of condom; in the next morning I ask myself and I regret after all."

Theme 2: Partner and Family Related Reasons

Under this theme four sub-themes were identified. These are abusive partner and family member, relationship status, risky sexual behavior of partner and family relation.

Sub-theme 1: Abusive Partner and Family Member

Study participants has listed experience of intimate partner violence, rape and pregnancy from family member/relative as a cause for seeking repeat induced abortion.

Women who experienced intimate partner violence seek repeat induced abortion. When their partner is abusive especially while they were pregnant, they perceived that giving birth to that pregnancy may worsen the violation. A 35 years old woman mentioned this by saying "I decided to have abortion because my husband became hard for me, and we had disagreement between us." Another 25 years old woman stated she had repeated abortion because her husband hits and insults her while she was pregnant because of her dependency on his income. She said "When he hits me, I become exasperated, irritated…I am even suffering a lot to raise two children...so, why should I give birth to that man's (abusive husband’s) baby?"

Participants mentioned that mostly women/young girls are abused, raped and impregnated by family members who were near to them or someone who was trusted and never expected as 'he never do this' or by their boyfriends. In line with this 24 years old married woman who is currently not living with her husband rather living with his families said "I got pregnant by my husbands' younger brother." She added that her husbands' brother insults, abuses and threatens her and said "He always scares me, abuses me. I had no choice, when I say no to have sex with him he starts beating and insulting me. He tells lies about me to his families." She perceived that girls are not trusted by the community, families, if they tell to someone about violence they faced; therefore she couldn't tell anyone to get help. Another 18 years old adolesecnt girl said:

"I was raped by my older brother's best friend. I couldn't tell to anyone because he is known like well-mannered person by our family and he is assumed family member or like brother."

A 17 years old adolescent girl stated that even if she was impregnated by her boyfriend, it was against her will to have sex. She thought that people may not perceive as a rape because they were couple almost for one year. She said "We were like couple for almost one year...It was rape, but people may not think it as a rape. Of course we were lovers but I want to stay. I have refused to have sex but it happened."

Sub-theme 2: Relationship Status

As participants stated, men are irresponsible, denying and reluctant to take responsibility after impregnating women. A 19 years old participant stated that her boyfriend left her and broke up after he knew about her pregnancy. In line with this another 17 years old adolescent girl mentioned that her boyfriend left her after the pregnancy and said "He said it is not mine, where did you get it? Go and search the father for your child." Another 22 years old participant stated:

"He blamed me for getting pregnant; he run away from me but during sex he always refuses using condom."

Sub-theme 3: Risky Sexual Behavior of Partner

Participants have mentioned knowing as their partners having multiple sexual partners as causes to have repeat induced abortion. As they described, their partners’ behavior of having multiple sexual partners puts their marriage or relationship insecure. Because of this, they preferred to have abortion than having child from doubtful relation or marriage. In line with this a 35 years old woman who had children mentioned "My husband is hard and not good for me. He sees another women." She stated, after she knew her hasband started of seeing another women, she perceived that her marriage is indanger and don't want to have another baby.

Sub-theme 4: Family Relation

Respondents mentioned that absence of good family relation, lack of having free and open discussion made them curios of their body changes during development of secondary sexual characteristics. Due to lack of good family relation, mostly adolescents are challenged by peer pressure. During adolescence period, body changes trigger to try and experiment everything around including early and unsafe premarital sex. These trials and engaging in sexual activity early without awareness of prevention way and its consequences made adolescents face unwanted pregnancies which ended with repeat induced abortions due to lack of discussion.

Participants perceived that don’t having good family relation, free and open discussion with family made them to have unwanted pregnancies in early age and made to seek repeat induced abortion. A 17 years old adolescent girl expressed "Not having habit of open discussion in my family about the risk of early, unsafe and premarital sex and how to abstain; put me to have unwanted pregnancy and subsequently abortion." She added that there should be open discussion between parents and their children about secondary sexual characteristics, risk of premarital sex and early pregnancies.

Theme 3: Healthcare and Educational Institution Related Reasons

Under this theme three sub-themes have been identified. These are schools and educational institutions services, healthcare institutions not providing post-abortion counseling and health care institutions provide ineffective post-abortion family planning (PAFP) counseling.

Sub-theme 1: Schools and Educational Institutions Services

Absence of education about sexuality, reproductive health and life skill; and not user friendly services by clinics in educational institutions was stated as a reason for having unprotected sex which resulted in unwanted pregnancy.

Participants mentioned that having sexuality and reproductive health related education in schools helps to avoid early sex and unplanned pregnancies. In contrast not having education about sexuality and reproductive health predisposed to have unplanned pregnancies which made participants to seek repeat induced abortion. A 17 years old adolescent girl said

"I had no information source about how to prevent unplanned pregnancy…If there was any education about sexual and reproductive health issues in our school, I may not got pregnant and seek abortion services repeatedly…"

Participants reported that clinics in higher educational institution/university provide health counseling and condom distribution but students don't feel comfortable because it is not user friendly and lacks privacy. A 21 years old woman who is university student stated "Condom distribution at university was available but I do not felt comfortable to use it; I was afraid because the place was not user friendly or suitable to seek the service; there were students who works there, they knew me…I got pregnant…" She added "I didn't want to be seen by my friends who work in the student clinic…"

Sub-theme 2: Unavailability of Post-abortion Family Planning Counseling

Participants expressed that most of the healthcare providers in abortion and family planning rooms were busy, exhausted and hard to approach. These are listed by participants as a reason for not receiving post-abortion family planning counseling service, had unplanned pregnancy and seek repeat induced abortion.

Regarding being busy, participants stated that they have observed staff shortage and the providers had no adequate time to provide post-abortion family planning counseling and services. An 18 years old adolescent girl expressed "When I got at the clinic, they had no time to talk and tell me about anything, they were too busy." A 19 years old participant added that she didn't received post-abortion family planning counseling and the healthcare providers simply sent her to home. She also stated as she didn't heard about post-abortion family planning counseling and that was the reason for her to seek repeat induced abortion.

In addition the participants stated that healthcare providers' approach made them not to receive post-abortion family planning counseling. According to the participants service providers were hard to approach and the way women were treated by staff affects women’s willingness to get post-abortion family planning counseling and services. It is perceived that healthcare providers should provide adequate informations about contraceptives. A 22 years old woman stated "I don't understand why healthcare professionals don't give adequate and appropriate information to women who had an abortion about family planning methods and other related issues and let us decide which type of contraceptive method to use." She added that healthcare providers judges women who seek abortion.

A 20 years old woman mentioned that providers were also unhappy and not friendly to counsel about contraceptives after abortion. Another 18 years old participant stated that healthcare providers didn't provide psychological support and even don't want to see unmarried girls who came for abortion and family planning services.

Sub-theme 3: Ineffective Post-Abortion Family Planning Services

Under this sub-theme participants listed contraceptives unavailability, family planning service not preference of women and poor family planning counseling by providers as causes for subsequent unwanted pregnancies and abortion.

It is mentioned that participants left the institution without receiving family planning services because of unavailability of suitable contraceptive.

A 26 years old woman stated "They [Healthcare providers] told me that contraceptives are not available at the health center and sent me to buy from private pharmacies. I had no money at that moment, I went home to buy another day then I got pregnant in between...” A 27 years old woman mentioned that she was unable to get family planning method at the health center. She said "I visited health center to use contraceptives, but there was no depo and they told me to return next week. I went to the health center after three weeks, then the nurse ordered me to have urine test and it was positive for pregnancy"

Another 35 years old woman mentioned even though she was advised to receive a family planning method, the available method in the health center was not the method of her choice.

A 27 years old participant said "after my previous pregnancy termination they offered me to use loop or implants but I didn't want to use these methods" A mother has also stated the level and quality of counseling was not adequete enough to convince her to use FP immidiatly after abortion. Another 17 years old adolescent girl mentioned that care providers only told to avoid sex but not how to prevent unintended pregnancy.

Theme 4: Community Related Reasons

Two sub-themes were identified under this theme. These are traditional gender norms of community and keeping pregnancy as secret due to fear of unacceptability and stigma.

Sub-theme 1: Traditional Gender Norms

According to participants, a lot of responsibilities community has assigned to women and should be carried out by them and unacceptability of unmarried and young women using contraceptives in the community are another reasons to seek induced abortion.

Participants have expressed as they decided to have repeat induced abortion because it is assumed that dealing with unwanted pregnancy was the role of women. It was also noted that men were reluctant to help women. A 20 years old woman stated women were solely blamed for getting pregnant. She said that men are not held accountable for their action. She mentioned "They [community members] don't understand there is somebody who is called 'man' and responsible for his action." Another 35 years old woman added that women are responsible to raise children and generating income by saying "Women are mostly responsible for raising children, getting income. If the partner is not willing to participate in the process of child growth." In addition it was mentioned by the participant that contraceptive use by unmarried women was not acceptable by the community.

Sub theme 2: Fear of Pregnancy Unacceptability and Stigma

Participants seek repeat induced abortion due to the reason that premarital pregnancy is not acceptable by community and fear of stigma.

A 19 years old participant stated that family don't agree with having pregnancy out of marriage and said "Families doesn't accept premarital pregnancy...it is taboo, so I aborted it. In our community becoming pregnant out of wedlock is taboo." A 22 years old woman added that she kept pregnany as secret "I do not want to be known about my pregnancy that is out of wedlock while studying in university."

Theme 5: Policy Related Reasons

One sub-theme of law enforcement was identified under this theme.

Sub-theme 1: Law Enforcement

Participants has listed ease of the law or not having exemplary punishment as a reason to be raped repetitively and seek repeat induced abortion. Women expressed that criminals are not taken to courts or left without appropriate punishment, this worsens the life of raped girls/women with repeated rape, violence, unwanted pregnancy and multiple abortions. A 17 years old adolescent girl stated "If a person who raped or had sex with a girl without her agreement was taken to court and imprisoned strictly, others may not do this…but it is not in such way; they don't care about the law or prison because it is not strict."

Theme 6: Effects of Induced Abortion

I is additional theme of post-abortion feelings, effects and complications women faced. Under this theme two sub-themes were identified. These are emotional feelings and physical pain and sufferings.

Sub-theme 1: Emotional Feelings

Participants stated that they had sense of guiltiness and hopelessness after they had abortion, missing of good oppurtunities in life that put them in current life.

A 20 years old woman stated "I do not feel free, it makes feel guilty." Another 25 years old participant added that abortion doesn't give good feelings even to seek the service. A 24 years old woman expressed that she left only with regrets due to abortion:

"Simply I left with only regrets. If I had studied my education seriously, I would probably have had better life" She added it is all about pretending.

A 27 years old participant mentioned that she considered herself as cruel for her family and and felt guilty for not avoiding unwanted pregnancy.

Participants mentioned that they had feeling of hopelessness after having induced abortion. An 18 years old participant who has history of rape said "I am moving with my pain hopping one day everything will be alright." She had suicidal thought and expressed as:

"I was just afraid, scared and I don't even know what I have to do when the nurse told me I was pregnant. At that time the only thing that I saw as a solution was suicide."

Sub-theme 2: Physical Pain and Sufferings

Participants stated bleeding and severe pain associated with abortion. An 18 years old girl mentioned "The nurse gave me pills to swallow but she doesn't explained detail...she simply told me that it would expel the pregnancy after few hours." She added that healthcare providers didn't provide detail about the procedures. Due to this most of women were scared. She said "I was a bit dizzy, almost fainted..."

Participants expressed that some peoples talk about abortion as it is easy but it is not true. A 17 years old participant stated "It was painful, scary, the room was also so scary." She added that care providers didn't gave analgesics to relief pain during procedure. A 21 years old woman stated as "you may finish the procedure in few minutes but the pain stays longer especially the emotional pain."

This qualitative study tried to explore reasons for repeat induced abortion among women in Wolaita Sodo town. Respondents narrated their reasons that predisposed them to have unwanted pregnancy on their day to day life and their reasons of seeking repeat induced abortion.

In this study maternal fear of side effects of contraceptives was noticeable contraceptive related reason for not using birth control methods. In addition, women with lack of adequate and appropriate information and poor knowledge about contraceptives tends not to use contraceptives. It is consistent with other studies in Switzerland, Tunisia and Ethiopia which reported close relationship of repeat induced abortion to not using contraceptives or using unreliable methods due to fear of side effects, lack of information about reproductive health and family planning services; and poor knowledge about contraceptives (13–16).

Fear of contraceptives failure due to previous experience of contraceptive failure and resulting in unwanted pregnancy was also reported in this study as reason not to use family planning methods. Women who lost trust in contraceptives tend to engage in unsafe sex, unwanted pregnancy and subsequent abortion. This result supports other finding in Ethiopia which reported some women had unwanted pregnancy while using contraceptives (15) and in Scotland which reported the absence of effective contraception was mentioned by women as reason for unintended conceptions and more than one termination of pregnancies (17).

Rumors/myths toward contraceptives also mentioned as an important non-motivating reason to use contraceptives. These rumors/myths regarding contraceptives spread out by families, friends or peoples/community members result in bad perception about birth control methods. Due to these bad perceptions women didn't want to use birth control methods and tend to had unwanted pregnancies. Studies conducted in Tunisia (Monastir) supports these findings that there is positive association between women with better attitude toward contraceptives and using contraceptive methods to avoid unwanted pregnancy and vice versa (16). In addition, non-adherence to contraceptive methods and not necessarily consistent use was also reported as a reason for multiple unintended conception (17).

Women reported that they also engaged in having repeat induced abortion due to their various future plans. Participants mentioned that they want to continue their education, don't want to dropout school and don't want to have baby while they are student were as a reason to seek repeat abortion. Women who are students tend to have multiple abortion because they want to continue their education to have better life. This finding is consistent with other studies done in Ethiopia and Scotland which reported still being student with full-time education is highly related with having more than one induced abortion (17, 18).

Women's desire to limit number of children was also reported as an important reason to undergo multiple termination of pregnancies. In this study, participants mentioned that if pregnancy occurred after they had decided to limit number of children, they seek induced abortion service. This result is consistent with other studies previously done in Ethiopia, Switzerland and USA which revealed close relationship of having living children and maximum number of pregnancies with multiple induced abortion (3, 13, 19).

Respondents in this study mentioned that ambitions, hopes and plans to achieve in life with children they have currently or not feeling ready to have child as a reason to seek multiple abortion. In line with this, women with unintended conception with current career or life don't want to have child and undergo termination of pregnancy. In addition, desire to space birth or stopping giving birth temporarily was also one reason of seeking multiple induced abortion. It supports finding done in Scotland which revealed that hopes/ambitions, career related factors and not ready to have another child at that time/at all as reason to seek more than one termination of pregnancies (17).

In this study, having repeat induced abortion was influenced by life challenges of women. Participants mentioned that economic problem, loss of their own income and being dependent on partner, boyfriend, family or someone else as main life challenges to have and raise child/children. Other studies conducted previously in Ethiopia were also found that women who had economic problem, unemployed and dependent on men are more likely to have induced abortion repeatedly (14, 18, 20).

Poor motherhood is also major life challenge that women faced in the process of having unwanted pregnancy. Participants mentioned that they had motherhood problem, can't be good mother and lack caring commitments due to being young aged, economically dependent and not having better income as reasons of having repeat induced abortion. This is in line with study done in Scotland that reported women are concerned about effect of pregnancy on care of children available now and family members, financial instability and unable to be committed mother as a reason multiple termination of pregnancy (17).

In this study women's sexual behavior is influenced by individual, partner and environmental related factors. They were not aware regarding the risks of risky sexual behaviors. Participants mentioned that availability of houses around university gates that provide addictive substances with low cost made them to abuse substances, engage in unsafe sex and unwanted pregnancy. In turn, women who use addictive substances tend to have multiple sexual partner, multiple unintended conception and pregnancy termination more than once. It is consistent with finding in other studies that revealed alcohol consumption and having multiple sexual partner has high risk of having multiple induced abortion (14, 16, 18). In addition, women whose partner's refuse to use condom is also related with having multiple unintended pregnancy and termination of pregnancy. It supports study done in England and Wales that reported repeat induced abortion implies repeated risky sexual and contraceptive behavior (21).

In this study experience of intimate partner violence was major family and partner related reason to seek multiple abortion. This finding is consistent with studies done previously which reported as women who experienced violence by their intimate partner have high chance of experiencing multiple termination of pregnancy (14, 16, 18). Participants also mentioned having pregnancy due to rape and abuse by their partner and friend; and pregnancy from incest were their reason to seek multiple induced abortion. This findings supports studies from Ethiopia and Tunisia which stated as women who had pregnancy due to rape and from incest have high probability of undergoing repeat induced abortion (14, 16, 18).

Irresponsible or denying partner also found to be a reason to seek multiple induced abortion. Having denying or irresponsible partner is more related with unstable relationship status and being unmarried. This finding is related with previous studies done in Kenya and Belgium which reported marital status is closely associated with repeat induced abortion; and unmarried women have increased risk of having multiple abortion (22, 23). Previous study conducted in Ethiopia and Tunisia also found that being unmarried and separated from husband (being single) are main reasons to undergo multiple termination of pregnancy (14, 16, 18).

In addition, not having better family relation and talking openly about sexual and reproductive health among families was reported as a reason to have multiple abortion. Due to bad family relation adolescents also don't use contraceptives because they fear if families aware of their use of contraceptives. Using contraceptives among community is related with starting sexual intercourse. Not talking openly is related with lack of awareness about sexuality, how to exercise safe sex by avoiding pregnancy and Sexual transmitted infections. Open discussion and getting family support during adolescence helps young girls to avoid early sex and pregnancy. This finding agrees with previous studies done in Uganda which reports lack of family support was one of perceived determinant for teenage pregnancy (24).

Participants mentioned that loss of continuous sexual, reproductive health and family planning trainings and education in schools and higher educational institutions as one reason for seeking multiple abortion. Unavailability of sexuality education and training is related with loss of accurate and appropriate information sources which supports study reported need of sensitization seminars and counseling for parents and girls to decrease prevalence of repeat teenage pregnancy and induced abortion (24). Universities having not user friendly services within their clinics was also one of reason not to use contraceptives which is similar with studies done in two Ethiopian universities (25).

Women who received post-abortion counseling didn't get contraceptive service due to unavailability, provision of not preferred method by mothers or poor counseling. These women sometimes linked to other health institution without any formal referral system. It supports studies which stated there is common problem of lack of regular, consistent, and adequate supplies of contraceptives (26).

Community unacceptability of premarital sex and using contraceptives among unmarried girls led to unwanted pregnancy. This premarital pregnancy was a reason to seek induced abortion repeatedly due to fear of stigma and to keep the pregnancy as secret. The finding is consistent with study which reported women with unwanted pregnancy who were isolated and stigmatized by families, friends and societies seek multiple induced abortion (27). Low social support is also associated with a twice increase of the incidence of induced abortion among young women (24).

Implications

The findings that emerged from the reasons of women who undergone repeat induced abortion indicates mainly there is a need to review health actions directed to contraceptives utilization, post-abortion family planning counseling services and addressing reproductive health service needs of women. Despite the decrements achieved in the last decades especially maternal death due to complications of induced abortion which undergone in as well as outside healthcare institutions, still there is need of improving reproductive health related services. Many women still become pregnant without planning and do not have the necessary family and community support to deal such an event. Once women faced unintended pregnancy and induced abortion, it should be corrected by providing strong post-abortion family planning counseling and provision.

Additionally, there should be rising of community awareness on traditional norms, gender equality and importance of women health and wellbeing by using different mechanisms such as media, community mobilization campaigns, and so on. There is need of community and family awareness rising and strict punishment for rape or gender based violence offenders which result in decreased occurrence of rape, intimate partner violence and gender based violence. This in turn result in decreased unintended pregnancy and repeat induced abortion occurrence. Healthcare institutions encouraged to hiring adequate staffs with better trainings on family planning counseling and rapport creation; and appropriate equipment to give reproductive health related services based on need of women. As suggested in the finding, university based clinics should hire healthcare professions rather than fellow students. There is need of school and university based additional intervention in cooperation with the health service already provided, which would show effective role to address the gap of limited information about sexuality and reproductive health.

This study revealed multiple reasons for repeat induced abortion in holistic manner; and presented key emotional and physical effects of abortion and unintended pregnancy. Different maternal, partner and family, institutional, community and policy related reasons were explored in the path of women who seek repeated induced abortion. Maternal reasons include contraceptive usage related, future plans, life challenges and maternal risky sexual behaviors. Reasons related to partner and family member were having abusive partner and family member, relationship status and risky sexual behavior of partner. Reasons of women who undergone repeated induced abortion is also related with healthcare and educational institutions.

Women's path of seeking repeat induced abortion is also affected by community perception and policy. Such complex problem need a strong effort to understand the reasons why women seek repeat induced abortion and effectively reduce its consequences on women's health, society and the country at large. Multiple interventions at individual, community and organizational levels; and strong law enforcement against rape offenders and abusers is needed from responsible bodies in order to avoid or minimize the reasons and negative consequences of repeat induced abortion in the area. Empowering women on income generation skills, developing self-esteem and confidence that help to overcome life challenges by themselves should be stressed.

This is the first study in Ethiopia, which explores the reasons and lived experiences of women who undergone repeat induced abortion in the women's perspectives. The study helped to explore respondents' reasons regarding repeat induced abortion in intrapersonal, interpersonal, institutional, community and policy levels based on their perspectives. The researcher tried to include participants purposively with different background to get diverse ideas and information saturation was assured. However, the views expressed are that of the participants and may not necessarily reflect the views held by every women who seek repeat induced abortion service in the area. Other women in the community might also have different experience or additional information. In addition, participants might have omitted some information about their reasons related experience of their personal issues due to social bias. The study also failed to include the experience of healthcare professionals that provide abortion service regarding reasons of the women.

FP - Family planning, IDI - In-Depth interview, IPV - Intimate partner violence, IUCD - Intrauterine contraceptive device, LARC - Long acting reversible contraceptives, PAC - Post abortion care, PAFP - Post abortion family planning, PI - Principal investigator, RIA - Repeat induced abortion, SAC - Safe abortion care, STIs – Sexually transmitted infections.

Ethical Approval and Consent to Participate

Ethical clearance and official letter requesting for cooperation were obtained from Institutional Review Board of Addis Ababa University, College of Health Sciences; School of nursing and midwifery postgraduate program and submitted to Wolaita Sodo town health office. The health office wrote letter of cooperation for the three health center in the town. The health center staffs were explained about the confidentiality of the data and the objective of study verbally. Each study participant was provided with written informed consent for willingness and confidentiality.

Consent for Publication:

All authors read the manuscript and gave consent for publication.

Data and materials availability statement

The data that support the findings in this study are available from the corresponding author upon reasonable request.

Competing Interests

The author(s) declared no potential financial and non-financial conflicts of interest with respect to the research, authorship and publication of this article.

Funding

This study received no specific grant from any funding agency in the public, commercial, or from any no-profit organizations.

Authors’ Contributions

Kibrework Bezabih carried out conceptualization of the study, methodology, data collection, analysis and preparing manuscript. Leul Deribe and Jembere Tesfaye participated in supervising the whole study and editing and reviewing manuscript. Sosina Workineh participated in data collection, analysis and developing manuscript. All authors read and approved the final manuscript.

Acknowledgement

We thankful to Addis Ababa University College of Health Sciences for its small financial support for data collection. We express our gratitude to all of the study participants for their time and willingness to be part of this study.

Dashe JS, Bloom SL, Spong CY, Hoffman BL. Williams obstetrics: McGraw Hill Professional; 2018.
Citernesi A, Dubini V, Uglietti A, Ricci E, Cipriani S, Parazzini F. Intimate partner violence and repeat induced abortion in Italy: A cross sectional study. The European journal of contraception & reproductive health care: the official journal of the European Society of Contraception. 2015;20(5):344–9.
Prata N, Holston M, Fraser A, Melkamu Y. Contraceptive use among women seeking repeat abortion in Addis Ababa, Ethiopia. African journal of reproductive health. 2013;17(4).
Guo C, Pang L, Wen X, Zheng X. Risky Sexual Behaviors and Repeat Induced Abortion Among Unmarried Young Women in China: Results from a Large, Nationwide, Population-Based Sample. Journal of women's health (2002). 2019;28(10):1442-9.
Pohjoranta E, Mentula M, Gissler M, Suhonen S, Heikinheimo O. Provision of intrauterine contraception in association with first trimester induced abortion reduces the need of repeat abortion: first-year results of a randomized controlled trial. Human reproduction (Oxford, England). 2015;30(11):2539–46.
Organization WH. Safe abortion: technical and policy guidance for health systems: World Health Organization; 2012.
Gemzell-Danielsson K, Kopp Kallner H, Faúndes A. Contraception following abortion and the treatment of incomplete abortion. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. 2014;126 Suppl 1:S52-5.
Asresie MB, Fekadu GA, Dagnew GW. Contraceptive use among women with no fertility intention in Ethiopia. PLoS One. 2020;15(6):e0234474.
Erko E, Abera M, Admassu B. Safe abortion care, utilization of post abortion contraception and associated factors, Jimma Ethiopia. J Women’s Health Care. 2016;4(4):5–9.
Kabiru CW, Ushie BA, Mutua MM, Izugbara CO. Previous induced abortion among young women seeking abortion-related care in Kenya: a cross-sectional analysis. BMC pregnancy and childbirth. 2016;16(1):104.
Planning HIPiF. Postabortion family planning: a critical component of postabortion care. 2019.
Bajos N, Prioux F, Moreau C. [Increase of repeat abortion in France: from contraceptive issues to postponement of childbearing age]. Revue d'epidemiologie et de sante publique. 2013;61(4):291–8.
Leeners B, Bieli S, Huang D, Tschudin S. Why prevention of repeat abortion is so challenging: psychosocial characteristics of women at risk. The European Journal of Contraception & Reproductive Health Care. 2017;22(1):38–44.
Alemayehu M, Yebyo H, Medhanyie AA, Bayray A, Fantahun M, Goba GK. Determinants of repeated abortion among women of reproductive age attending health facilities in Northern Ethiopia: a case-control study. BMC Public Health. 2017;17(1):188.
Alemu L, Ambelie YA, Azage M. Contraceptive use and associated factors among women seeking induced abortion in Debre Marko's town, Northwest Ethiopia: a cross-sectional study. Reproductive health. 2020;17(1):97.
El Mhamdi S, Ben Salah A, Bouanene I, Hlaiem I, Hadhri S, Maatouk W, et al. Obstetric and psychological characteristics of women seeking multiple abortions in the region of Monastir (Tunisia): results of a cross-sectional design. BMC women's health. 2015;15:40.
Purcell C, Riddell J, Brown A, Cameron ST, Melville C, Flett G, et al. Women's experiences of more than one termination of pregnancy within two years: a mixed-methods study. BJOG: an international journal of obstetrics and gynaecology. 2017;124(13):1983–92.
Behulu GK, Fenta EA, Aynalem GL. Repeat induced abortion and associated factors among reproductive age women who seek abortion services in Debre Berhan town health institutions, Central Ethiopia, 2019. BMC Res Notes. 2019;12(1):499.
Jones R, Jerman J, Ingerick M. Which abortion patients have had a prior abortion? Findings from the 2014 US abortion patient survey. Journal of Women's Health. 2018;27(1):58–63.
Waktola MI, Mekonen DG, Nigussie TS, Cherkose EA, Abate AT. Repeat induced abortion and associated factors among women seeking abortion care services at Debre Markos town health institutions, Amhara regional state, Ethiopia, 2017. BMC Research Notes. 2020;13(1):1–6.
Hoggart L, Newton VL, Bury L. ‘Repeat abortion’, a phrase to be avoided? Qualitative insights into labelling and stigma. Journal of Family Planning and Reproductive Health Care. 2017;43(1):26–30.
De Kort L, Wood J, Van de Velde S. What are the social correlates of subsequent abortions in Flanders, Belgium? The European Journal of Contraception & Reproductive Health Care. 2020;25(5):387–93.
Maina BW, Mutua MM, Sidze EM. Factors associated with repeat induced abortion in Kenya. BMC public health. 2015;15(1):1–8.
Hadley A. Teenage pregnancy: strategies for prevention. Obstetrics, Gynaecology & Reproductive Medicine. 2018;28(4):99–104.
Gebresllasie F, Tsadik M, Berhane E. Potential predictors of risk sexual behavior among private college students in Mekelle City, North Ethiopia. Pan African medical journal. 2017;28(1):122.
Thapa S, Neupane S. Risk factors for repeat abortion in Nepal. International Journal of Gynecology & Obstetrics. 2013;120(1):32–6.
Jayaweera RT, Ngui FM, Hall KS, Gerdts C. Women’s experiences with unplanned pregnancy and abortion in Kenya: A qualitative study. PloS one. 2018;13(1):e0191412.

No competing interests reported.

Download PDF

Version 2

posted

You are reading this latest preprint version

Reasons of women who undergone repeat induced abortion; in Wolaita Sodo town, Southern Ethiopia, 2021: A phenomenological qualitative study

Status:

Version 2

Abstract

Background

Objectives

Methods and Materials:

Result

Conclusion

Figures

Introduction

Method And Materials

Study Design and Setting

Study Participants and Sample size

Data Collection Tools and Procedures

Trustworthiness

Method of Data Analysis

Results

Socio-demographic Characteristics of Participants

Emerged Themes

Theme 1: Maternal Related Reasons

Sub-theme 1: Contraceptive Related

Sub-theme 2: Future Plans

Sub-theme 3: Economic Factors

Sub-theme 4: Maternal Risky Sexual Behavior

Theme 2: Partner and Family Related Reasons

Sub-theme 1: Abusive Partner and Family Member

Sub-theme 2: Relationship Status

Sub-theme 3: Risky Sexual Behavior of Partner

Sub-theme 4: Family Relation

Theme 3: Healthcare and Educational Institution Related Reasons

Sub-theme 1: Schools and Educational Institutions Services

Sub-theme 2: Unavailability of Post-abortion Family Planning Counseling

Sub-theme 3: Ineffective Post-Abortion Family Planning Services

Theme 4: Community Related Reasons

Sub-theme 1: Traditional Gender Norms

Sub theme 2: Fear of Pregnancy Unacceptability and Stigma

Theme 5: Policy Related Reasons

Sub-theme 1: Law Enforcement

Theme 6: Effects of Induced Abortion

Sub-theme 1: Emotional Feelings

Sub-theme 2: Physical Pain and Sufferings

Discussion

Implications

Conclusion

Strength And Limitation

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 2