This study aimed to determine the knowledge, attitude, and practice towards induced abortion among adolescent girls in a selected secondary school in Moshi municipal. This study has shown that almost half of the respondents have a poor knowledge of induced abortion. This observation is contrary to similar studies done in Nigeria , and Goma , in which 88.3% and 61.3% respectively of respondents had good knowledge of induced abortion. A similar result of poor knowledge of induced abortion was observed in a study among female students in different settings in Ethiopia [13, 15]. The observed variations might be explained because of methodological differences in the categorization of the knowledge scores used in each study. Therefore the role of misclassification bias could not be excluded. An alternative explanation could be the difference in the source's information about induced abortion information in different study settings [11, 13, 14]. In the current study, respondents who were living in a hostel were more likely to have good knowledge of induced abortion compared to those who stay at home. This observation corroborates with the study finding that most respondents first heard about abortion from their friends . Respondents who reside at the hostel may have more time together and share more health information, including induced abortion. Future intervention to increase the level of knowledge of induced abortion in this setting should emphasize on the standard definition of an induced abortion according to the WHO [1, 2], and target female students who are residing at home.
More than half of the respondents in this study had a negative attitude towards induced abortion. This proportion is lower than what was reported in different studies done in Ethiopia [13, 15], in which the majority of respondents had a negative attitude towards induced abortion. The most important explanatory factor to the current observation could be explained by religious belief. The majority of respondents in this study agreed that induced abortion was a sin against God. Most respondents in this study were either Christians or Muslims-both doctrines do not advocate abortion [11, 13, 14]. This observation, however, should be taken with caution, because there was no statistically significant association between the religion of respondents and their attitude towards induced abortion. However, it is well documented in behavior studies that religion and cultural factors have a very strong influence on an individual's attitude .
Although this study did not ask about the legalization of abortion in the country, which is a key determinant in the reduction of the burden associated with unsafe abortion [1, 2]. low proportions of study respondents agreed that unwanted pregnancies should be aborted, or whether they would abort if pregnant, or encourage their friends to have an abortion if pregnant. Similar findings were reported from similar studies in other settings in Africa [11, 14, 15]. Countries such as Tanzania, with restive abortion law [5, 6, 8, 9], need to integrate and develop national strategies, and programs, such as Adolescent Sexual and Reproductive Health (ASRH) interventions, which will empower adolescents to universal access for family planning, reproductive health information and education in secondary schools in Tanzania [12, 17].
In this study, the prevalence of induced abortion was very low (5.5%). This result concurs with findings from a study in Brazil , but high compared to findings reported in Ethiopia (2.5%), and Nigeria (2%), respectively [11, 13]. However, the current finding is very low compared to studies done in Uganda , Nigeria (Cadmus and Owoaje 2011), and Ethiopia , reporting high abortion rates among adolescents. Religious and cultural factors, restrictive laws on induced abortion, awareness campaigns on risk of induced abortion, abstinence and condom use among adolescents may explain the observed low prevalence of unwanted pregnancies in these settings [11, 13, 14]. Given the fact that a significant number of the adolescent in this study reported being sexually experienced, with low use of contraception, it is important to undertake community-based qualitative studies to explore abortion experiences among female students in this study setting.
Most respondents reported their first abortion at a young age (16 years or above), although the majority, had aborted only once. This alarming observation highlights the presence of induced abortion from unwanted pregnancy among female students in secondary schools in this study setting. Unsurprisingly, this study revealed that most of the induced abortions were done by health professionals working in private for-profit health facilities. Very few respondents attended a traditional healer for induced abortion. This observation concurs with findings from studies done in SSA countries [7, 13]. The health system in Tanzania is categorized as public (government-owned), private (not-for-profit owned/or private for-profit owed). Government-owned health facilities are supervised directly by the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), and follows government regulations, including the restive abortion law, making difficult for adolescent girls with unwanted pregnancy accessing PAC. Hence, the only option for adolescent girls to undergo an induced abortion is the private-for-profit health facilities [5–7].
Based on the above observation, this study showed that most respondents who undergone an induced abortion, surgical instruments, or modern medicines were used. This observation concurs with a finding reported from a similar study conducted in Zanzibar, where adolescent girls, used blend of herbs, and modern drugs to ensure that the induced abortion does not fail .
In this study, the two main reasons mentioned by most respondents who undergone induced abortion was to finish their education and fear of parents' reactions. These results concur with findings from a study conducted in Ethiopia [13, 22]. This observation may be attributable to the restive laws on unwanted pregnancy among female students, which lead to termination from the education system [5, 6]. To avoid having their educational aspirations terminated, most female students opt for induced abortion [14, 22]. To reduce the problem of induced abortion because of fear of termination from the education system, it is imperative to have supportive intervention in this setting, which will enroll female students with unwanted pregnancies to continue with their studies after delivery.
Fear of parents' reactions arises from the fact that in most African societies, it is a taboo, and a sign of disrespect to discuss sexual matters with parents. Also, based on religious belief, becoming pregnant before marriage, or induce abortion is seen as an abomination . In this study setting, interventionists of ASRH programs need to integrate religious leaders and parents in the design, and implementation of effective interventions to reduce unwanted pregnancy among adolescent girls in secondary schools. According to Babalola et al. parents’ awareness of their adolescents' social networks contributes to influencing their attitudes about sexual behavior, such as abstinence .
Finally, the most common complication post-abortion mentioned by respondents who had undergone induced abortion was excessive bleeding, followed by abdominal pains. This observation corroborates with the high proportion of respondents in the current study who mention excessive bleeding among the leading complication associated with induced abortion. This finding concurs with results from studies conducted in different settings in Africa [10, 11, 19, 20, 22]. It is a well documented in the peer-reviewed literature regarding induced abortion, that excessive bleeding is the main cause of both morbidity and mortality, which impact on the health of adolescent girls with unwanted pregnancies worldwide [1, 2, 8].
The study limitations that should be taken into consideration include the following.
First, this is cross-sectional study design, hence it is unable to demonstrate the causal-effect relationships reported in this study. Second, the generalizability of the study findings is limited to the study setting only. Third, the study respondents were asked very sensitive issues such as their practices of induced abortion, which is illegal in Tanzania hence the possibility of response bias can not be excluded and may influence the low proportion of induced abortion reported in this study. Finally, the validity of the study findings may be affected by the moderate internal reliability of the scales used to assess the level of knowledge (α = .61) and attitude (α = .62) towards induced abortion.