A Data Base on Abortion Literature Review

A COMPILATION AND ANALYSIS OF AVAILABLE STUDIES IN ETHIOPIA

Executive Summary

Given the huge gap in abortion information, which has resulted in a lack of solid databased information for initiating and orienting programs, the need for well-designed quantitative and qualitative studies on abortion is crucial.  The abortion studies already conducted not only need to be replicated to validate information, but also need to be improved and methodologically strengthened.  More studies need to be conducted in both clinical settings as well as in communities.  Intervention and operations research that evaluate practical service delivery and clinical programmatic efforts should be encouraged in order to explore options for the future.

The following items have been identified during this literature review as being important areas for research and intervention.

Limited access to contraceptives for all groups of women has been clearly identified as a determinant of unwanted pregnancy and subsequently, induced and even spontaneous abortion in some studies.  The issues of accessibility and unmet demand for family planning services is felt more keenly, but is certainly not unique to special populations like adolescents or young unmarried women.  These studies also provide compelling evidence that, not only lack of access to reproductive health services but also lack of knowledge and misconceptions about contraceptive methods lead to unwanted pregnancy.  Drawing attention to the unmet demand for family planning methods among all groups is essential in reducing unwanted pregnancy and decreasing abortions.

In one review of maternal deaths conducted by a Maternal Mortality Review Committee, avoidable factors were found in 92% of the cases.  Many of these deaths were attributed to poor post-abortion and delivery management.  New studies of clinical management and procedural problems may cause us to review clinical protocols and case management of women suffering from incomplete abortions. Improvements in the clinical management of post-abortion complications can help develop nation-wide standards for a quality of care framework for the treatment of postabortion patients.

This literature review highlights problems particular to adolescents that can’t be ignored.  In one survey of 15-24 year-olds in Addis Ababa, half of the 976 young women interviewed reported having been pregnant and 76% of these women told interviewers that they had a spontaneous (2%) or an induced abortion (74%).   Another unpublished thesis proved this finding not uncommon, among 1663 young women interviewed; almost 70% responded that they had an abortion.  Another multi-year maternal mortality review conducted at a teaching hospital in Addis Ababa proved the grave outcomes among young women, 14% of the maternal deaths in that study were women under twenty.

Access to modern contraceptive methods is still sorely limited for adolescents, perhaps more importantly though, several cross-sectional studies reported inaccurate and low levels of knowledge about modern methods and relatively high levels of knowledge about methods for inducing an abortion.   Many of the studies recommended improved sexual health education or family life education and the wider availability of Youth Friendly family planning services in places where young men and women congregate.  The importance of these recommendations for the prevention of unwanted pregnancy cannot be overlooked, however, it is also necessary to address issues of legal and induced abortion among young people if we want to save lives.  Intervention research that tests the operational effectiveness of new community-based programs and learning instruments will become even more salient in the future.

The outcomes of spontaneous versus induced abortion have been analyzed in many of these studies and have lead to the conclusion that maternal deaths are more often outcomes of induced abortion. Even in studies where the majority of cases were presentations of spontaneous abortions, the majority of deaths were attributable to induced abortions.  In a record review of Addis Ababa maternal deaths 35 of 36 abortion-related deaths were induced abortion cases.  All of the studies showed more serious complications observed among induced abortion patients.  The attitudinal and organizational barriers that impede rapid and high quality abortion care, both from the clinician’s as well as the client’s perspective, should be explored further in order to have an impact on this outcome.

The issue of abortion is undeniably linked to maternal mortality.  These studies clearly indicate that the most common cause of maternal death is unsafe abortion.  Efforts to improve post-abortion care (PAC) and reduce the presentation of abortion will reduce maternal deaths.  National-level data, aggregated retrospective studies, and maternal mortality reviews, amongst other types of studies that can illuminate this correlation should be encouraged.

Abortion is linked to violence.  Only two of these studies attempted to correlate rape and abortion.   In each of these studies rape was cited as the reason for seeking an abortion in 20-25% of the cases.  We are left to guess at the actual occurrences of rape and violence that go unreported or do not end in a health institution as a pregnancy or an abortion.  Studies and interventions that address gender violence and rape need to elaborate on outcomes of unwanted pregnancy and abortion while attending to the psychosocial needs of the victims.  The social impacts of unsafe abortion as a consequence of abduction into marriage and rape need to be examined in our communities.

Abortion is common and it should be considered part of a broader reproductive health agenda.  Uterine evacuation is one of the most common surgical procedures worldwide.  In one cross-sectional study reported upon in this review, 21% of a random selection of married women reported a history of abortion.  Still, one 5-year review of maternal deaths in a teaching hospital pointed to the finding that 91% of those deaths occurred among un-booked mothers with no history of care before their obstetrical emergency treatment.  Interventions and studies that encourage an open and reliable exchange of information and attack the stigmatization of these women can save lives by encouraging early access to information and treatment of incomplete abortion.

According to the KAP studies included in this review, the majority of women with a history of abortion are not encountered in the formal health care system while terminating a pregnancy.  One KAP study reviewed here indicated that only 16% of women who reported to have had an abortion ever attended a health facility.  One study cited that 1/3 of women who confessed to having had an abortion bled for seven days or more.  Little work has been done to look at the issue of abortion through women’s eyes.  More qualitative research that builds a body of work from women’s own experiential perspectives is needed.  In addition, it is necessary to conduct more community-based descriptive studies that examine the true extent of the problem and the impact on the lives and livelihoods of women and men.

Only one urban-based study compared abortion outcomes between rural and urban women.  The findings indicated significantly higher hospital stays and higher case-fatality rates for rural compared to urban women.  While almost all levels of health facilities (staffed by all cadres of personnel) acknowledge that they have women presenting with incomplete abortions, the levels of training and preparedness between health facilities and health personnel for post-abortion care vary drastically.  Research on the training of mid-level providers and the equipping of lower level health facilities will help to improve women’s access to high quality abortion care in all parts of the country and at all levels of health care facilities.

Nearly all of the studies illustrated in this review have explored morbidity and mortality outcomes.  Post-abortion care is not only traumatic for women and men but also a costly and time-consuming endeavor for health care facilities, providers and families.  One hospital-based study reported an average stay of 4 days for abortion admissions, another 6 days for patients suffering from complications of induced abortion.  Studies that examine service delivery improvements and new technologies that have an impact on cost and time could promise to have a positive impact in resource-scarce environments.

In reading through this literature one can’t help but notice the emphasis on special populations such as adolescents.  While not undermining the importance of that finding it is still notable that many of these studies indicate significant numbers of married, older, and multiparous women presenting with an induced abortion.  Further studies that examine partner involvement in this decision-making process, access to health facilities, unmet need for contraception, and contraceptive failure may enlighten us as to why these women, who might seem to have other options, make this decision to induce an abortion.

The legal domain and the social impact of abortion-related issues have not been adequately explored.  While this was not a primary objective of this research it should not be overlooked that several of these studies indicated that a number of people feel that abortion should be a personal and private decision.  As the Government continues to redefine the penal code, practitioners, researchers and policymakers can work together to inform and evaluate studies on the legal aspects of population and reproductive health.  Researchers have a unique opportunity to propose and collaborate on more multi-sectoral research that truly addresses the breadth of this issue as it affects women and men in Ethiopia today.

This review illustrates that addressing unsafe abortion is essential in our efforts to reduce maternal mortality and improve reproductive health services for Ethiopians. Research, interventions, advocacy and capacity building that confront the enormity of the problem of unsafe abortion could offer information and solutions that could save thousands of lives.

Recommendations

1. Drawing attention to the unmet demand for family planning methods among all groups is essential in preventing unwanted pregnancy and decreasing abortions.

2. New studies of clinical management and procedural problems can help improve the standard and quality of care provided for women suffering from incomplete abortions.

3. Further intervention research that tests the operational effectiveness of new community-based programs and IEC strategies that will become even more salient in the future should be conducted.

4. The attitudinal and organizational barriers that impede rapid and high quality abortion care, both from the clinician’s as well as the client’s perspective, should be explored further in order to have an impact on the outcome.

5. National-level data, aggregated retrospective studies, and maternal mortality reviews, amongst other types of studies that can illuminate the correlation between improved postabortion care and reduction of maternal deaths should be encouraged.

6. Studies and interventions that address gender violence and rape need to elaborate on outcomes of unwanted pregnancy and abortion while attending to the psychosocial needs of the victims.

7. The social impacts of unsafe abortion as a consequence of abduction into marriage and rape need to be examined in our communities.

8. Interventions and studies that encourage an open and reliable exchange of information and attack the stigmatization of the women can save lives by encouraging early access to information and treatment of incomplete abortion.

9. More qualitative research that builds a body of work from women’s own experiential perspectives is needed. 

10. It is necessary to conduct more community-based descriptive studies that examine the true extent of the problem and its impact on the lives and livelihoods of women and men. 

11. Research on the training and capacity of mid-level providers and the equipping of lower level health facilities may help to improve women’s access to high quality abortion care in all parts of the country and at all levels of health care facilities.

12. Studies that examine service delivery improvements and new technologies that have an impact on cost and time could promise to have a positive impact in resource-scarce environments.  

13. Further studies that examine partner involvement in the decision-making process, access to health facilities, unmet need for contraception, and contraceptive failure may enlighten us as to why married women, who might seem to have other options, make the decision to induce an abortion. 

14. Studies addressing the legal aspects of sexuality and reproductive health rights of women are needed urgently.

List of  materials include for preparation of the document

Jeppsson A, Tesfu M. and Bohmer L.1999. Magnitude of abortion-related complications in Ethiopian health facilities: a national assessment. East Afr Med J 1999: 76 (10):547-551.

Ahmed Abdella . 1996.  Retrospective study on abortion admissions in Jimma Hospital, South West Ethiopia. Ethiop  J. Health Dev. 1996; 10(3): 167-170.

Kwast BE, Mekonen Bekele, SeyoumYoseph, Adane Gossa, L.Mehari & Frost O.1989. Confidential enquiries into maternal deaths in Addis Ababa, Ethiopia 1981- 1983. J. Obst. Gyn. East Cent. Afr. 1989; 8: 75-82.

Kwast B.E., Rochat R.W. and Widad Kidane Mariam. 1986.  Maternal mortality in Addis Ababa, Ethiopia. Studies in Family Planning, 1986; 17 (6/1): 288-301.

Seyoum Yoseph and Getahun Kifle. 1988. A six-year review of maternal mortality in a teaching hospital in Addis Ababa. Ethiop. Med. J. 1988;26: 115-20.

Tesfaye Genebo, Mebratu G/Hiwot, Rudolf K. and Donat H. 1987. Review of abortions at Gondar College of Medical Sciences Hospital.  Paper presented at the Gondar College of Medical Sciences Annual Conference.

Surafel Kebede. 2000. A survey of Illegal Abortion in Jimma Hospital, South Western Ethiopia. Ethiop. Med. J. 2000; 38:35-42.

Abebe G/Mariam, Sissay Wondimagegn, Sileshi Demissie and Aynalem Abrham.1989. A review of first pregnancy in Jimma Hospital. Paper from Jimma University.

Tesfaye Madebo and Tinbit G/Tsadik. 1993.  A six-month prospective study on different aspects of abortion. Ethiop. Med.  J. 1993; 31:165-72.

Yidnekachew W/Meskel and Assaye Chekol.1999.  Induced abortion and prevalence of sexually transmitted diseases and contraceptive behaviour in abortion cases. Ethiop. J. Hlth. Sci. 1999; 9 ( 2):77-83.

Yohannes Ali. 1994. Analysis of maternal deaths in Jimma Hospital, Southwestern Ethiopia. Ethiop. Med. J., 1994; 32: 125-29.

Gizie Worku and Solomon Kumbi. 1999.  A one-year analysis of abortion in Gondar College of Medical Sciences Hospital. Paper presented at the Gondar College of Medical Sciences Annual Conference.

Lukman Yusuf and Zein Ahmed Zein. 1986.  Abortion analysis at the Gondar College of Medical Sciences. Paper presented at the Gondar College of Medical Sciences Annual Conference.

Mesganaw Fentahun, Fekadu Chala and Mesfin Loha. 1995.  Knowledge, attitude and practice among senior high school students in North Gondar. Ethiop. Med. J. 1995;33:21-29.

Fortuna Hassen. 2000.  Analysis of factors for unwanted pregnancy among women in reproductive age group attending health institutions in Jimma town, South-western Ethiopia. Paper from Jimma University.

Seyoum Yoseph and Essayas Mulleta. 1996.  Report on a cross-sectional study of clients seeking reproductive health and family planning services. Paper from Marie Stopes International Ethiopia.

Haileyesus Getahun. 1999. Determinants of abortion in rural Ethiopia. Paper presented at EPHA X Annual Conference.

Eyob Tadesse, Abate Gudunfa and Genet Mengistu. 1996.   A survey of adolescent reproductive health in the city of Addis Ababa. Ethiop. J. Health Dev. 1996; 10(1): 35-39.

Seyoum Yoseph, Adane Gossa, Eyob Tadesse, et al. 1993. A survey of illegal abortion in Addis Ababa, Ethiopia. A report.

Lisane Mariam Tenkir, Abebe G/Mariam and Alemseged Janka. 1999. Induced abortion among Jimma comprehensive high school students: knowledge, attitude and practice. Ethiop. J. Hlth. Sci. 1999; 9 (1): 25-31.

Bohmer, Lisa. Documenting the magnitude of Unsafe Abortion in Ethiopia and Improving the Quality of Care: December 1994 to September 1995. Gandhi Memorial Hospital, Addis Ababa.

Lukman H.Y. and D. Pogharcan. 1996. Management of Incomplete Abortion with manual Vacuum Aspiration in Comparison to Sharp metallic Curettage in an Ethiopian Setting. East African Medical Journal. September 1996.

Abortion Related Literature

Zubeida Abdulahi 1992. The reproductive behavior of unmarried adolescent women in urban Ethiopia. A thesis submitted in fulfillment for the degree of MSC, CERTWID.

Konjit Kifetew 1998.  Some socio-demographic determinants and consequences of female adolescent sexual behaviour in Addis Ababa. A thesis submitted to school of graduate studies.  CERTWID.

Asnake Hailu 1991.  A community based survey of high-risk pregnancies and determinants of preeclampsia and gestational hypertension in Ada-A District Ethiopia. A thesis submitted to school of graduate studies.  Community Health Department, AAU.

FGAE 1996. Ethiopia: Illegal/Unsafe abortion. A review article published in African Journal of Fertility, Sexuality and Reproductive Health 1996;Vol.1, No.1: 68-71.

Solomon Mengiste 1995.  A community based study of health-related problems among adolescents in Awassa Zuria Woreda, Southern Ethiopia. A thesis submitted to school of graduate studies.  Community Health Department, AAU.

Agonafer Tekaligne 1988.  Barriers to access to modern contraceptives. A thesis submitted to school of graduate studies.  Community Health Department, AAU.

Filimona Bisrat 1992.  KAP study in Harar town high school students on family planning. A thesis submitted to school of graduate studies.  Community Health Department, AAU.

Rahel Zerihun 1992.  Purposes of legal provisions on abortion. A paper submitted in  fulfillment of the requirements of the degree of Bachelor of Laws, AAU.

Yalemzewd Bekele 1999. The legal regime governing reproductive health of women in Ethiopia.  A paper submitted in partial fulfillment of the requirements of bachelor of laws degree, AAU.

Assegid Gashaw 1984.  Abortion under the Ethiopian law. A paper submitted in partial fulfillment of the requirements of bachelor of laws degree, AAU.

Roba Megerssa 2000. Tripartite interest in abortion: The woman, the father and the fetus under Ethiopian law. A paper submitted in partial fulfillment of the requirements for the Degree of Bachelor of Laws (LLB) degree, AAU.

Akliledengel Getahun, Belayneh Dagnew, Cherinet Hirpo et al. 1997. The question of abortion in the Ethiopian context. Term paper presented the Department of Sociology, AAU

Wen Pin Chang. 1974. Population Studies in Ethiopia: Knowledge, Attitudes and Practice Surveys in Population and Health. The Journal of Ethiopian Studies. 1974; vol XII, No. 1.

Hanna Tsegaye 1998.  Socio-Economic and Demographic Determinants of Induced Abortion. A paper submitted in partial fulfillment of the requirements of the Degree of Bachelor of Arts in Sociology and Social Administration.

Bisrat F;  Pickering J: 1994   High school students' knowledge, attitude and practice of contraception in Harer town, eastern Ethiopia

Ethiop Med J; 32(3):151-9; 

Lukman   H.Y. and potts J. March 2000,  Monograph on Abortion.

The complete booklet is available form the secretariat