Knowledge, Attitude and Associated Factors towards Safe Abortion among Private College Female Students of Gondar town, northwest Ethiopia: A cross sectional study

Background: Unwanted pregnancies in youths and complications of induced abortions are an important health problem. Inadequate knowledge, unfavorable attitude towards safe abortion results in unsafe abortion. Most women die because of complications arising from unsafe abortion in developing countries are likely to have had little knowledge. Studies on knowledge, attitude and associated factors towards safe abortion among private college students are limited. Therefore, the aim of this study was to assess knowledge, attitude and associated factors towards safe abortion among private college female students in Gondar town, northwest Ethiopia Methods: An institution based cross-sectional study was conducted from April 30, 2019 to May 30, 2019 among private college students in Gondar town. Data were collected from 633female students using self-administered questionnaires by simple random sampling technique. Bivariable and multivariable logistic regression analysis was performed to identify association of dependent and independent variables using SPSS version 20. Result: A total of 633 respondents participated in this study with the response rate of 97.7%. Regarding the overall knowledge, 433(68.4%) of students had good knowledge towards safe abortion. Age (AOR= 2.81, 95% CI: 1.13, 7.47), residence (AOR=2.33, 95% CI: 1.22, 4.46), family education (AOR=3.29, 95% CI: 1.22, 6.46) and ever heard about safe abortion, (AOR=4.31, 95% CI: 1.79, 10.33) were factors associated with knowledge of students on safe abortion. Regarding attitude, 361 (57%) of students had favorable attitude towards safe abortion. Age (AOR=2.62, 95% CI: 1.70, 4.04) and residents (AOR=1.50, 95% CI: 1.04, 2.17) were factors signicantly associated with attitude towards safe abortion. Conclusion: have good knowledge and attitude towards abortion still students and attitude. Information,


Background
Abortion is the termination of pregnancy before fetal viability which can occur spontaneously due to complications during pregnancy or can be induced (1). Abortion is safe when performed by persons with the necessary training and skills, and in an environment meeting minimal medical standards or it can be de ned as the termination of pregnancy before 28 weeks of gestational age by quali ed and skilled persons using correct techniques in sanitary conditions (2).
Unwanted pregnancies in youths and complications of induced abortions are an important health problem in the world; in which each year, approximately 20 million abortions are performed worldwide, 95% of them in developing countries (3). Out of 4.2 million pregnancies, an estimated 420,000 induced abortions occurred in Ethiopia in 2016, with an annual abortion rate of 28 per 1,000 women aged 15-49 (4).
In the world daily 192 reproductive age women died because of complications arising from unsafe abortion, majority of this occurred in developing countries. Those women are likely to have poor knowledge towards safe abortion. Many of them are young age, maybe in their teens. Some of them may be raped, and others have exposed to unintended pregnancy due to failure of the contraceptive method they were using or the incorrect or inconsistent way they used it. Some of them lacked knowledge of methods to prevent unintended pregnancy or did not have the access for the service (5).
As evidences indicate in Ethiopia, about half of all pregnancies end with unsafe abortion as a result of inadequate information, unfavorable attitude towards safe abortion. A study conducted in Ethiopia revealed that the rate of abortion among students was found to be 65 per 1000 women, making it three fold the national rate of abortion for Ethiopia (23/1000 women aged ; almost all of the abortions (96.9%) were induced and only 16% were reported to be safe abortion (6). Similar study at other regions of Ethiopia showed that the knowledge and attitude in relation to safe abortion are limited among women (7). In previous studies so far conducted in Ethiopia tried to identify factors associated with knowledge and attitude of students toward safe abortion. Marital status, family income and educational status of the parents were associated with knowledge of safe abortion among University students whereas previous residence was associated with attitude (7,8).
Safe abortion is an essential component of reproductive health care, which entails a range of medical and related health services, including counseling, contraception, and referrals to other reproductive healthcare services as appropriate (9,10).However, access to safe abortion continues to depend on several factors such as, women's awareness of the law, shortage of safe abortion services provision and sociocultural pressures(6, 11,12).
College students are vulnerable to unplanned and unintended early sexual encounters which lead to unwanted pregnancies. They are therefore exposed to seek for induced abortion and candidates to suffer its complications (13). The students who undergo an induced abortion expose themselves to serious health risks such as hemorrhage, genital injuries, sepsis and death (14). These study participants were chosen, because young women in the college environment are away from home for the rst time and become free to experiment sex without any parental supervision, especially in the study area students in private college are non-dormitories. There is limited information on knowledge, attitude and associated factors towards safe abortion among private college students. Therefore, the aim of this study was to assess knowledge, attitude and associated factors towards safe abortion among private college female students in Gondar town, northwest Ethiopia. Thus, this study may help to give an attention for the development of guideline and resources regarding information, education and communications (IEC) programs on youth reproductive health for college students. Methods 2.1 Study Design, Setting, period and participants An institutional based cross-sectional study was conducted from April 30, 2019 to May 30, 2019 among private college students in Gondar town. This town is located in Amhara Regional State of northwest Ethiopia. During the study period there were four private colleges in the town. The total students enrolled in a regular program, during the study period, was 5,448. Out of these, 3756 were female students. Randomly selected female students in private college in Gondar town were included in the study.
Students incapable to ll the questionnaire were excluded from the study.

Sample size determination
The sample size was determined using single population proportions formula with the assumption of 95 % con dence interval, 5 % margin of error, 74.17% of students who had positive attitude towards safe abortion was taken from previous study (15), and non-response rate of 10% was considered. Design effect of 2 was used to account for the strati ed sampling involved. The nal sample size was determined to be 648.

Sampling technique
To obtain the required sample size, strati ed random sampling was applied to select study participants from the source population. First students were strati ed by their department. Then, sample size was proportionally allocated to all the departments in the institutions based on the number of female students in each department. Sample was collected from all departments by computer generated simple random sampling method from list of female students obtained from the principal o ce.

Data collection method
The data was collected by using structured and self-administered questionnaires that was designed by reviewing from previous similar studies (7,8,12,15,16). The questionnaire was prepared in English. The questionnaire consists of all the variables that can meet the objectives of the study which is related to sociodemographic characteristics, knowledge and attitude towards safe abortion. Data collectors were selected from health professionals of University of Gondar comprehensive specialized hospital. Data collectors were given training before actual data collection was commenced. The data was collected while students were in class rooms. The completed questionnaires were checked for completeness by the investigators.

Study Variables and Measurements
The study assessed the knowledge and attitude of participants towards safe abortion. Students' knowledge regarding safe abortion score was calculated out of the 21 knowledge speci c questions. Each correct response earned one point and zero for the incorrect one based on the respondent's response. Finally, the respondent who scored greater than or equal to the mean score were considered as having 'good knowledge' and respondents who scored less than the mean score were considered as having 'poor knowledge'.
Students' attitude towards safe abortion score was calculated out of 11 speci c questions. The respondents who scored greater than or equals to the mean score were considered as having 'favorable attitude' and those who scored less than the mean score was considered as having 'unfavorable attitude'. The independent variables were: age, sex, religion, marital status, place of previous resident (either urban or rural), year of study and income from family.

Data quality control
A pre-test of the data collection tool was carried out. Training was given to the data collectors before the data collection on objectives of the study, procedure of data collection, ethical consideration, data quality control and other related issue like con dentiality. Before the beginning, the respondents were told about the objective of the study and their importance to participate voluntarily in the study. The collected data were checked for completeness and consistency, on daily basis. Data was kept in the form of le in a private secured place and con dentiality was insured by not recording names or any personal identity.

Data processing and analysis
Data were coded, entered and cleaned using EPI-INFO version 3.5.3 and then transported to SPSS version 20 for further statistical analysis. Frequencies, percentages and mean were computed to describe the key variables of the study. Bivariable and multivariable analysis were used to determine the association between different factors and the outcome variables. Forward model building procedure was used to select variables. Those variables having p-value <0.2 in the bivariable analysis were included in multivariable analysis and variables having p-value <0.05 in the multivariable were considered as statically signi cant. Odds ratio and the respective 95% con dence intervals were used to assess the strength of association between the variables.

Socio-demographic characteristics of respondents
A total of 633 respondents participated in this study making the response rate of 97.7%. The mean age was 21.8 years (SD ± 2.99). Regarding to ethnicity, 588 (92.9%) of participants were Amhara. Majority, 425 (67.2%) of the students were Orthodox religion followers. Four hundred ninety-ve (78.2%) of students reported that they were living in urban area before they joined to the college. Nearly two third, 389 (61.5%) of students were single never been in relationship. Concerning family education, 338(53.4%) of them were from both illiterate parents. The monthly incomes send from the family of the 71.6% students were less than 600 Birr (Table-1).

Knowledge of respondents on safe abortion
The overall knowledge of students regarding safe abortion was 433(68.4%).Among respondents, 609 (96.2%) had ever heard about safe abortion, from those 483(79.3%) got information from health institutions( Figure 1).Unsafe abortion as a major health problem of Ethiopia was considered by 598 (80.3%) of the participants. From the total participants, 452(71.4%) responded that Ethiopia has abortion law. Nearly half, 315 (49.9%) of the respondents mentioned the place where safe abortion performed was in hospital. Among respondents, 376 (59.4%) said less than 3 months of pregnancy is the preferable time to perform safe abortion. The students were asked to answer why abortion is legal in Ethiopia; 516(81.5%) mentioned when the pregnancy is extra marital and 492(77.7%) if she is nancially unable to rise the child ( Table 2).

Attitudes of respondents on safe abortion
Among the study participants, 361 (57%) of respondent had positive attitude towards safe abortion. Majority, 531(83.9%) of the respondents disagreed that elective abortion should be legal & accessible under any circumstance. Majority, 461(72.8%) of respondents were disagreed with legalization of safe and voluntary abortion. Majority, 435(68.7%) of them agreed as abortion services should be available at health center &hospital. The nding also showed that 406(64.1%) of the respondents agreed that male/husbands should have in uences in decision of abortion. More than half, 348(55%) of the respondents agreed that adolescent students use induced abortions to terminate pregnancies (Table 3).

Factors affecting students' knowledge towards safe abortion
In the bivariate analysis, the factors that found to have an association with knowledge towards safe abortion among students were age, marital status, residence, family education, year of study and ever heard about abortion with a p-value< 0.2. In the multivariate analysis age, family education, residence and ever heard about abortion had association with knowledge towards safe abortion.
Students who found in the age group of 25-30 were 2.81 times more likely to have good knowledge on safe abortion compared to those whose age found in 18-24 (AOR = 2.81, 95% CI: 1.13, 7.47). Those respondents who came from urban area were 2.33 times more knowledgeable as compared to those living in rural areas (AOR = 2.33, 95% CI: 1.22, 4.46).Respondents with both parent literates were 3.29 times more likely to have good knowledge on safe abortion compared to their counter parts (AOR = 3.29, 95% CI: 1.22, 6.46). Students who ever heard about safe abortion were 4.31 times more likely to have good knowledge compared with those who did not heard about safe abortion (AOR = 4.31, 95% CI: 1.79, 10.33)( Table 4).

Factors affecting students' attitude towards safe abortion
Regarding attitude, age, religion, family education, residence and marital status had association with attitude towards safe abortion in bivariable analysis. All explanatory variables which were considered in the bivariate analyses were included in the multivariable logistic regression. Accordingly, age of respondents and place of residence were remained to be signi cantly associated with attitude of students towards safe abortion. Students who found in the age group of 25-30 were 2.62 times more likely to have favorable attitude towards safe abortion compared to those whose age found in 18-24 (AOR = 2.62, 95% CI: 1.70, 4.04). Those students from urban residents were 1.5 more likely to have favorable attitude towards safe abortion compared to rural residents (AOR = 1.50, 95% CI: 1.04, 2.17) ( Table 5).

Discussion
Assessment of knowledge, attitude and associated factors towards safe abortion among students is important to minimize the burdens associated with unsafe abortion. This study revealed that the overall knowledge of students regarding to safe abortion was 68.4% (95% CI: 64.8, 72.4). This nding is consistent with other study done in in Kampala, Uganda (12)which documented 72.4% of students had good knowledge towards safe abortion. However, this nding was higher than studies conducted in Mekelle University, Northern Ethiopia (7),WolaitaSodo University, Southwest Ethiopia(17) and in Puducherry, India (18) where the knowledge of students was reported as 44.1%, 38.8% and 36% respectively. The reason for this variation might be due to difference in study participants, only rst year students were included in these studies, where as in this study participants includes were rst year and above. It is fact that as the year of study increases the level of knowledge of students also increased (19). Moreover, the variation might be occurred due to difference in access to health information in different settings.As the study conducted in Mizan-Tepi University, South West Ethiopia, among Female Students 90.52% had adequate knowledge regarding safe abortion (15); which is higher than this nding.
In the present study, students who found in the age group of 25-30 were 2.62 more likely to have adequate knowledge regarding safe abortion as compared to those whose age found in 18-20.This nding is in line with a cross sectional study conducted in Kampala, Uganda (12). The possible explanation might be the fact that as age increases student's exposure to information regarding safe abortion could also increase.
This study also showed that students who came from urban area were more knowledgeable as compared to those living in rural areas.This may be because of the fact that urban dwellers have an opportunity to access information and educational media. Respondents with both parent literates were more than three times more likely to have good knowledge on safe abortion compared to their counter parts. This nding was supported by studies done in Mekelle University, Northern Ethiopia(7) and University of Buenos Aires, Argentina(20). This is may be due to the fact that parents having higher educational background let their children know additional and important lesson beside the academic program.
This study revealed that students who ever heard about safe abortion were more likely to have good knowledge compared with those who did not hear about safe abortion. This nding is in agreement with other studies conducted in Mizan-Tepi University, Ethiopia (15) and South Africa (21). The explanation for this might be that students, who have different information regarding health problems of unsafe abortion, could have increased awareness related to major obstacles for their education and other health related problems. Further, students are becoming more accessed to different mass media and getting more information about the problem, may have expected good knowledge regarding safe abortion. In addition to this youth friendly service and youth center are limited to the urban area, which can increase the access for the reproductive information and service.
In this study 57% (95% CI: 52.6, 60.8) of students had positive attitude towards safe abortion. This result is supported by a study done in Mekelle University, Ethiopia which showed nearly half of the students 52.8% have positive attitude towards safe abortion (7). This nding is lower than other cross-sectional studies conducted in Mizan-Tepi University (15)and South Africa (21)which reported as 74.17% and 70%of students had positive attitude towards safe abortion, respectively. This result is higher than a cross sectional study conducted in Somali Region, Ethiopia that revealed 40.7% of students had favorite attitude towards safe abortion (16). The reason for this variation may be due to cultural beliefs and socioeconomic status.
According to this study, students who found in the age group of 25-30 were 2.62 times more likely to have favorable attitude towards safe abortion compared to those whose age found in 18-24. This nding is supported by previous study conducted among medical school students in South Africa(21).
This study also showed that students from urban residents before joining to college were more likely to have favorable attitude towards safe abortion as compared to rural residents. This nding is in agreement with a cross sectional study conducted Somali Region(16), Mekelle University (7); Ethiopia and Kampala, Uganda (12).
This study has some limitations; it was assessed both health science and non-health science students together without separating by department, and even the study touches sensitive issues qualitative study was not done. The other limitation the study is it does not include governmental owned college and university students, and sociocultural factors were not assessed.

Conclusion
In conclusion, this study revealed that more than two-third of participants had good knowledge and more than half of the participants had favorable attitude regarding to safe abortion. But, still signi cant proportion of students had poor knowledge and unfavorable attitude towards safe abortion. Moreover, age of students, residence, family education, and ever heard about abortion were factors that associated with knowledge on safe abortion. Age of students and residence had an association with attitude towards abortion. Therefore, information, education and communications programs on youth reproductive health should be provided to address topics on safe abortion for all College students. Forums and panel discussions on safe abortion need to be undertaken especially, among youths and students who came from rural area. Youth friend service has to expand to the rural part of Ethiopia.  Source of information about safe abortion among private college students in Gondar town, northwest Ethiopia, 2019