KAP Study On Abortion Among Ethiopian Health Workers

Introduction

Unsafe abortion is one of the major four causes of maternal mortality and morbidity in the developing countries, including Ethiopia. Generally, the underlying factors for UA are related to the patient, provider or /and the socio-economic situation. These factors are interrelated. This study addresses the provider's aspect of abortion in Ethiopia.

The knowledge, attitude and skill of the health care providers affect the quality of abortion services. The concern and perception of the providers especially where abortion is illegal need to be explored.  In Ethiopia, the knowledge, belief, attitude and skill in abortion as well as the knowledge and attitude towards the abortion law is not known. Therefore this study is designed to assess this knowledge gap.

Methods

A cross-sectional study using a self-administered questionnaire is used. Thirty hospitals & 56 referring centers were randomly selected. All HWs in these institutions were included in the study.

Result

There were 2636 respondents of which 71.4% & 93.7% were from hospitals & public institutions, respectively. Most of the HWs were nurses (49.9%) and HAs  (34.6%). Ten percent & 2.2% of them were also GPs & OBGYNS, respectively. Eighty percent (79.5%) of the HWs reported that their institutions provide abortion treatment.

Ninety-seven percent of the HWs had encountered incomplete abortion patients, 69.95 of them at "frequent/ sometimes" encounter. Ninety-eight percent (97.6%) of the HWs considered abortion related mortality & morbidity as a significant public health problem and 60% regarded the problem to be both in urban & rural settings.

The HWs description of unsafe abortion discloses various reasons for unwanted pregnancies, which force the victims to undertake high-risk measures. The stigmatization of some of these reasons  (e.g. extramarital) and abortion augments the unwanted ness of the pregnancies and leads to secrecy that makes abortion services unavailable & unsafe. The legal restriction also augments the complications of clandestine procedures. Safe abortion services are limited & coasty. Unsafe one is easily available & cheap. The available PAC services are inaccessible & of low quality.

Seventy-two percent of the HWs had abortion request by women with unwanted pregnancies; 33% being at "frequent /sometimes" encounter. HWs in the public sector (68.6%) reported fewer encounters than private practitioners (76.7%). Overall, 6.7% of the HWs provided the requested services more by the private (15.0%) than public (4.5%) practitioners.

Familiarity with the concept & practice of PAC was low (38.3%). About 51% of the HWs had heard or seen the MVA. Thirty-seven percent of the physicians & PHOs use the MVA in evacuating incomplete abortions & 80.1% graded the MVA to be "better/ much better" than E&C/ D&C. PAFP provision or advice to patients with incomplete abortions was given "frequently" by 62.9% of the HWs.

Only twenty nine percent of the health workers stated the correct provision of the penal code for termination of pregnancy. Obstetricians (39.6%) & PHOs (40.6%) had the highest correct knowledge (39.6%) while general practitioners had the least (16.8%). 18.2% of the HWs were able to provide or assist in termination of pregnancy on the basis of the legal provision. Generally, 34.7% of the physicians reported to do so. Specifically, 32.6% & 73.6% of the GPs & OBGYNs, respectively, were able to terminate pregnancies according to the provision. On the other hand, 34.5 % (49) of the private HWs had assisted in or provided legal abortion but 14.6% (257) of those in the government institutions did so (x2= 37, P-value=0.000) (Table 11). Twenty- three percent, 17.2% & 17.3% of the Moslems, Protestants & Orthodox were either able to provide or assist in abortion according to the current law. 28.1% of the remaining "other" believers stated so. 23.3% (112) of the HWs with correct knowledge of the penal code had provided legal abortion while 20.1 (237) of those with incorrect did so (X2=1.92, P-value=0.196).

18.2 % of all the health workers were able to provide or assist in the termination of pregnancy on the basis of the legal provision: 32.6 % of the general practitioners and 73.6 % of the Obstetricians. Having negative attitude towards abortion (55.6%) lack of skill and knowledge for termination  (26.0 %) & difficult legal procedural requirements (30%) were the commonest reasons for not providing legal abortion according to the current law. Higher proportion of HWs with incorrect abortion law knowledge  (23.3%) than those without correct knowledge  (20.3%) provided legal abortion. 

According to the 62.2% of the HWs, the effect of the current law would be "increased" unsafe abortion. Most of the OBGYNs (92.2%) had similar opinion. Fifty two percent of the HWs stated that the current law to be either "appropriate " or "too liberal while 48% stated it to be "too restrictive". Furthermore, 77.8% supported liberalization on certain circumstances. But, 23.1% only agreed on liberalization of the current law on request (unconditional termination). Maternal health, fetal abnormality, rape, incest, psychological reasons were accepted as indications for legal termination of pregnancy by more than 70% of the HWs. On the other hand, provision by doctors only (75.4%) and with in limited gestational age (66.9%) were accepted for restricting legal provision.

Discussion & Conclusion

This is the first study of its kind in Ethiopia addressing the abortion issue from the HWs point view and has a nationwide representation. Physicians, nurses & HAs who were expected to be involved in abortion patient care were included with adequate representation from all regions (with the exception of Benishangul & Afar) and institutions (public, private & NGO institutions).

About 98% of the health workers considered abortion related mortality & morbidity as an issue of public health significance and 97.1% of them had encountered patients with incomplete abortion. Almost 70% percent of these encounters were at a "frequent/ sometimes" level. Sixty percent of the HWs also considered abortion complications to be most significant in both urban & rural" settings. These findings show that most of the HWs considered abortion as a major health problem in both urban and rural Ethiopia. Besides, indirectly, they substantiate the public health significance of abortion that was revealed by other direct studies (2,9).

According to 49.7% & 13.1% of the HWs, the effect of the current law was to "increase" & "decrease" the number of unsafe abortions, respectively.  Most of the OBGYNs (92.2%), PHOs (84.4%) and GPs (78.0%) considered the effect would be to "increase" the number. 67.2% & 61.7% of HWs with correct & incorrect knowledge of the abortion law stated the effect to "increase" the number. The reasons for unsafe abortion described scenarios where by varied circumstances would lead to unwanted pregnancies that are rejected by the individual, family &/ or community. These scenarios lead to an environment filled with secrecy of the unwanted pregnancy & abortion. The secrecy surrounding abortion forces women to use any available method of abortion irrespective of its safety. The complications of the unsafe abortions are compounded by the legal restrictions. The implication on prevent of unsafe abortion by liberalization would be reduced as the stigma of abortion would pursue women with unwanted abortion to seek secret but unsafe abortion services.

Even though 97.1% of the respondents had encountered patients with incomplete abortion, abortion treatment was reported to be available in 79.5% of their working institutions. Private practitioners reported higher abortion patient encounter (97.1%) than HWs in public institutions (87.5%). And both of them had shortage in abortion treatment, private 86.1% & public 79%. The gap of abortion encounter to availability of abortion services is great among the rural & poor women who have no access to private services. Hence, programs should at least consider availing PAC at every HC & other diversified outlets including private & NGO institutions.

Besides, the shortage of abortion services, the study shows the compromised quality of PAC. Thirty eight percent (38.3%) of all the HWs claimed to be familiar with the concept & practice of PAC. Further, less than 63% of them identified one of the three components of PAC, PAFP being the most common identified element (62.7%). GPs reported 98.3% incomplete abortion encounter, of which 90.8% was at "frequent/ sometimes" exposure. But, 53.1% of them were familiar with PAC, 24.2% had formal training in PAC, and 81.3% used the E&C for abortion treatment. PAFP was identified by 83% of those who claimed to be familiar with PAC & 66.7% provided PAFP, frequently. Similarly, 96.4% of the nurses have encountered abortion patients, 69.2% at "sometimes/ frequent" level. But, 54.7% of them were familiar with PAC & among those who claimed to be familiar with PAC, 54.7% identified PAFP as a component of PAC. Only 56.4% of all the nurses reported to provide PAFP frequently. Hence, strengthening the training of GPs & nurses in PAC including MVA use (in & after school) is necessary because they take care of most of the abortion patients. The nurses' training in PAC should stress PAFP because they are the ones who are usually involved in these activities. The strategies include in-service training & updating the medical & nurse's curricula.

71.5% HWs had faced abortion requests by women with unwanted/ unplanned pregnancies, 33.0% being "sometimes/ frequent" requests. The highest request of "sometimes/ frequent" was reported by OBGYNs (83.6%) & GPs (68.8%). HWs in public institutions had "sometimes/ frequent" request (40.6%) than those in the private (27.8%). Unfortunately, 6.7% of the HWs were able to provide the requested abortion services. It is 12% of the physicians, who were expected to have the required knowledge & skill in safe termination of pregnancy, were able to do so. Most of the abortion providers (87.7%) were reported to be by unqualified personnel. Illegality of the procedure was the most common reason (51%) for not responding to client request of termination of unwanted/ unplanned pregnancies. Negative attitude & lack of knowledge & skill were also sited by 26.2% & 22.1% of the HWs. Hence, efforts in liberalizing the abortion law and expanding abortion care training will avert a substantial number of unsafe abortions. But, the negative attitude of HWs should also be addressed to maximize their impact.

Denials of abortion services were reported not only for requests of termination of unwanted / unplanned pregnancies, but, also for legally permitted terminations under the current law. The reasons for such denials included the negative attitude of the HWs towards abortion (55.6%), lack of knowledge or skill to perform abortion (36.0%) and the tiresome legal procedures to perform a legally permitted abortion (30.0%). Lack of interest of the HWs in providing such a service might also be a factor as shown by the significantly higher proportion of HWs in the private performing legal abortion (34.5%) than those in the public facilities (14.6%).

The lack of the correct knowledge of the abortion provision penal code is also another impediment observed in the denial of the legally allowable services. Twenty-nine percent of all the HW stated the correct provision of the penal code for termination of pregnancy, the lowest being among the physicians (22.6%). About forty percent & 16% of the OBGYNs & GPs, respectively, correctly identified the code. The lack of knowledge partly explains the low legal abortion assistance/ provision, 18.2% among all of the HWs. Specifically, only 32.6% & 73.6% of the GPs & OBGYNs, respectively, provided or assisted in termination of pregnancies according to the legal provision. Even though the difference was not statistically significant, a higher proportion of HWs with correct knowledge (23.3%) provided or assisted in legally permitted abortion service than those with incorrect knowledge (20.1%).

Almost half of the HWs considered that the current abortion law to be "too restrictive". The other half reported that the law is either "appropriate" or "too liberal". Eighty percent of the OBGYNs stated the law to be  “too restrictive”. Among those HWs with correct knowledge of the penal code provision for termination of pregnancies, 54.4% stated the law to be “too restrictive”. About 50% of the Orthodox Christians & Moslems also considered the law to be "too restrictive".

As to the extent of liberalization, the unconditional termination of pregnancy was not supported by most (73.9%) of the HWs. The majority (77.8%) of them considered liberalization of the law to accommodate termination of pregnancy on certain conditions. About 82% of the Moslems & Orthodox Christians agreed on legal abortion on certain conditions.

The reasons given for liberalization include the failure of FP services in preventing unwanted/ unplanned pregnancies & the current law to address the prevailing abortion needs. Liberalization was described to decrease unwanted /unplanned pregnancies & unsafe abortions. It was also perceived to decrease the maternal mortality & morbidity associated with abortion by the majority of the HWs (73.3%). Legal abortion prevents the problems of the unwanted child and economic burden of rearing large families. Liberalization was argued to minimize the cost related to treatment of unsafe abortion, to provide safe and high quality abortion services and expanding safe abortion services. It also addresses human right & empowers women. Nationally, liberalization was expected to bring economic, social & demographic harmony.

Among the nine provided possible conditions for legal termination of pregnancies, maternal health, fetal abnormality, rape, incest and psychological problems were accepted by more than 70% of all the HWs. Fifty to 69% of the HWs also accepted contraceptive failure and economical reasons for termination. The least support (about 50%) was seen in case of disruption of schooling & being sex –worker.

Seventy six percent (75.5%) of the HWs agreed on having conditions for restricting provision of legal abortions. Among those who agreed to have restrictions, 70% or more of the HWs agreed that 'the procedure be done by doctors only' and 'gestational age limitation' be implemented. 'Martial status' and 'age of the woman' were agreed upon by less then 20% of the HWs.

On the other hand, 22.2% of the HWs were against liberalization. Some of them argued that abortion was not a significant public health problem while others stated that the problem was not due to the law but its implementation. They also argued that liberalization would increase the number of abortions, premarital/ extramarital and unsafe sex. Seventy four percent (73.8%) & 40.6% of them also reported that it would increase the workload & cost on the health system, respectively. According to those who oppose liberalization, the country’s economy & health facilities were not prepared to provide legal abortion. Moreover, the moral, ethical, cultural & religious considerations were supposed to be against abortion.

In general, according to most of the HWs, abortion is a significant public health problem in both urban & rural Ethiopia. The most commonly identified factors underlying the problem were the compromised PAC Knowledge & services, the secrecy surrounding unwanted/ unplanned pregnancy & abortion and the restrictive abortion law. Liberalization of the current abortion law on certain conditions (maternal health, fetal abnormality, rape, incest psychological problems, contraceptive failure and economic reasons) and its provision by physicians with in a predetermined gestational age was supported by most of the HWs to decrease the complications of the prevailing unsafe abortions, even though, liberalization might increase the work load. To maximize the preventive effect of liberalization, expanding & diversifying the abortion service outlets & improving the quality of PAC with a strong FP services are essential. Liberalization should take into consideration of the providers' knowledge of the law, attitude towards abortion & knowledge & skill in performing abortion. Besides, the providers' motivation in performing such a service, which is full of controversy, should be considered. Tiresome & lengthy legal procedural requirements also hinder services and are used to legitimize denial of services.

Recommendation

Abortion is a major health problem both in urban and rural parts of Ethiopia. The abortion issue needs to be addressed appropriately and measures to decrease the occurrence as well as the consequences of abortion need to be undertaken.

1. Family planning services should be made accessible.

2. PAC services should be available at all levels of the health care system.

3. Health workers who at the forefront in managing abortion cases need to be trained in PAC as well as the use of MVA.

4. Abortion law needs to be liberalized to accommodate termination of pregnancy on certain circumstances like rape, contraceptive method failure, maternal indication and others. Efforts need to be strengthened to increase the knowledge of health workers about the existing law as well as functioning policies in the country regularly to improve the health care provision of abortion services within the existing law.

Full document available at the secretariat.