This is the foremost study in the Republic of Congo to explore the prevalence of abortion, median years to abortion after sexual debut and the prognostic factors of time to first abortion. The findings showed that about 60% of women had history of abortion. This is higher than 38.8% previously reported from the country (9) and pooled prevalence for Africa (3.9%) (37). Similarly, higher than the prevalence of abortion in Nigeria (11%) (11), Ethiopia (53%) (38), Mozambique (9%) and Ghana (25%) (29), Benin (7.5%), Gabon (39.5%) and Democratic Republic of Congo (18.5%) (9) respectively. This high prevalence of abortion in the Republic of Congo could be due to women’s influence of reproductive health decision-making capacity on pregnancy termination. Clearly, over 60% of the women had at least secondary education. As such, it is expected that their decision-making ability is sufficient to decide about their health and pregnancy respectively. Educational attainment will aid a woman to identify pregnancy-related danger signs and what to do with it. In a previous study, education was identified as a key factor to explain not only an induced abortion decision but also having a repeated or a second trimester induced abortion (39). Pregnancy termination is one of the key issues that require urgent attention to achieve the third SDG of ensuring healthy lives and promoting wellbeing for all at all ages (7). The reproductive health decision-making capacity of women plays a key role in their reproductive health outcomes, including pregnancy termination. Unsafe abortion is unavoidable in a society where laws, culture, religion amongst others prohibit the practice thereby leading to restrictions on access to safe and legal abortion (5).
There are numerous reasons why women undertake abortion. In line with the findings of this study, women gave reasons such as wrong timing, which encompassed a sense of not being ready for motherhood and the desire not to disrupt education, work, or life plans and because of health problems as also reported from a previous study (40). Other reasons for seeking abortion-related to life circumstances, including cost, readiness, not wanting any more children, marital issues or relationship instability, and being too young in line with results from a previous study (41). In addition, being too young to be a mother is an aspect of being unready for motherhood. This is consistent with the findings from previous studies (41,42). Prominently, husband/partner not needing a child contributed to reasons for abortion in our study. This could be either by his absence or because the relationship was troubled, unstable, too new, or not being in a relationship at all, the partner’s immaturity, his unreliability, his reluctance to be a father, the women’s reluctance to have him as her baby’s father, his unfaithfulness, drinking, physical abuse, and problems with paternity (such as the partner’s denial of paternity or pregnancy to someone other than the partner). Furthermore, women’s financial problems and very short preceding birth interval were part of the major reasons that contributed to women’s sense that they would be unable to care adequately for a child and that abortion was the most responsible action to take unfortunately. These findings are similar to report from a previous study which stated the most frequently cited reasons for having an abortion in most countries were socioeconomic concerns or limiting childbearing (43).
Overall, the median years between sexual debut and first abortion was 9.0. However, there were differences in years between sexual debut and first abortion across women’s characteristics. For example, the adolescent women (15-19 years) and those aged 20-24 years had the lowest median years to first abortion respectively, when compared with older women. This finding is consistent with the results of a previous study (44). In that study, the difference between age at first intercourse and age at onset of first pregnancy was 1.3 years among adolescents compared to 4.8 years for older women. Also, the study confirmed that young women were more at risk of an unwanted pregnancy soon after menarche (44). It is common that societal, social, family and career pressure will make the young women to opt for abortion from unwanted pregnancy. Furthermore, women of high educational attainment and household wealth quintiles had lower median years between sexual debut and first abortion. As reported by the women, some reasons for abortion were to keep with schooling or working. Consequently, education and wealth will enhance the decision to opt for abortion in the advent of unwanted pregnancy.
In this study, the geographical region was a significant factor of first abortion. In addition, older women and those who were married had a reduction in the risk of first abortion. Furthermore, women from higher households wealth quintiles, educated, those who had ever used anything or tried to delay or avoid getting pregnant, had their first birth before age 20 years and having higher total lifetime number of sex partners had higher risk of abortion among Congolese women. Although, there was no previous study identified anywhere in the world that examined the prognostic factors of time to first abortion, however, these findings are comparable with the results from previous studies that examined the factors associated with history of abortion (9,11,29–31). Women of higher socioeconomic status will usually weigh the options on whether to keep a pregnancy or not, as such could have higher risk of first abortion. The pursuit of career such as schooling or working, can make a woman take a decision to terminate a pregnancy. On the other hand, women in high socioeconomic status would have the knowledge and economic empowerment to afford abortion services. In addition, women with high total lifetime number of sex partners are more likely to be sexually active over time, and if effective contraceptive method is not utilized, more unwanted pregnancies can occur which could lead to higher risk of abortion.
Conversely, our finding on older women having reduction in the risk of first abortion, was inconsistent with the result from previous studies where older women had increased odds of pregnancy termination history (9,11,29). Notably, our outcome variable of time to first sex after sexual debut is somewhat different from the outcome variable (history of abortion) of the previous studies used for comparison. Based on our findings, it is correct to say that the older women would have more awareness of the methods to delay getting pregnant after sexual debut. Moreover, women who were married/living with partner would have less risk of first abortion because unlike the single women, the married counterparts are able to keep pregnancy for the need of the family. Furthermore, early childbearing especially beginning from adolescence would mean that a woman would have large number of children long before the menopause stage. The implication is that the woman may now resort to the use of contraceptive methods or terminating further pregnancies especially in the advent of economic hardship or limited resources. Consequently, such women will have higher risk of abortion. The risk of abortion was higher among women who ever used anything or tried to delay or avoid getting pregnant. The issue is prominently hinged on the type of contraceptive methods. Moreover, it is possible that contraceptive use was introduced to the women during post-abortion care service or as a lesson learned. Sexually active women who do not use modern contraceptive methods are more likely to have unwanted pregnancy and consequently have higher risk of abortion. This is consistent with the findings of a previous study where women who had unintended pregnancy were more likely to terminate pregnancy (11). It is not sufficient to use any contraceptive methods, the emphasis should be using effective contraceptive methods.
Strengths and limitations
A major strength of this study was the use of nationally representative data and the findings are generalisable for the women of reproductive age. In addition, relevant variables were available in the datasets for the estimation of time to first abortion after sexual debut. Nonetheless, the study captured the life time experience of women on abortion, the occurrence of recall bias is very likely as highly multigravida women could have lost track of certain sexual and reproductive events, thereby leading to underestimation of abortion.