Repeated Induced Abortion and Trends of Contraceptive Utilization

Worldwide more than 227 million women become pregnant each year, and roughly two-thirds of them deliver live infants. The remaining one-third of pregnancies end in miscarriage, stillbirth, or induced abortion. Following this fact, abortion is a sensitive and public health concern with religious, moral, cultural, and political dimensions. According to the World Health Organization (WHO) Newsroom report, from 2015 to 2019, an average of 73.3 million induced (safe and unsafe) abortions occurred worldwide each year and approximately 45% of all abortions worldwide were unsafe. There were 39 induced abortions per 1000 women aged between 15–49 years. Risk is greater for women in areas of high fertility because they are pregnant more often and therefore face the risks of pregnancy more often than women in areas of low fertility. Of all the regions in the world, Africa has the highest number of abortion-related deaths, estimated at more than 15,000 in 2017, accounting for 7% of pregnancy-related deaths.

Worldwide more than 227 million women become pregnant each year, and roughly two-thirds of them deliver live infants. The remaining one-third of pregnancies end in miscarriage, stillbirth, or induced abortion[1]. Following this fact, abortion is a sensitive and public health concern with religious, moral, cultural, and political dimensions [1, 2]. According to the World Health Organization (WHO) Newsroom report, from 2015 to 2019, an average of 73.3 million induced (safe and unsafe) abortions occurred worldwide each year and approximately 45% of all abortions worldwide were unsafe. There were 39 induced abortions per 1000 women aged between 15–49 years [3]. Risk is greater for women in areas of high fertility because they are pregnant more often and therefore face the risks of pregnancy more often than women in areas of low fertility  [1, 4-6]. Of all the regions in the world, Africa has the highest number of abortion-related deaths, estimated at more than 15,000 in 2017, accounting for 7% of pregnancy-related deaths [1].

The prevalence of repeated induced abortion varies across the world with different causative factors; 43.1-65.2% % in Northwest China, 30.1% in Switzerland, 70% in Georgia, 50% in France [2, 4, 7, 8]. The magnitude of a repeated abortion ranges from 20.3% to 33.5

Study period, design, and area

Quantitative institution-based cross-sectional study design was applied. The study was conducted from September 1st, 2022 to May 30th, 2023 in Mizan Tepi University Teaching Hospital (MTUTH). It is located 561 km away from Addis Ababa, the center of Ethiopia.

Source population: All females who utilize public health institutions in Bench-Sheko Zone for abortion services.

Study population: All females who utilize MTUTH for abortion services during the study period.

Sample size calculation and sampling technique

Sample size calculation: the sample size was determined by using a single population proportion formula using a basic assumption of 95% confidence level, 5% margin of error, and proportion (P=20.3%), which was the proportion of repeated abortion in Central Ethiopia(Debre Birhan) [9]. Using the formula

Where: n = Sample size= 373, Z = Confidence level which is 95%, P = Proportion= 41.44%, d = the margin of error taken as 5%, But, since the catchment areas population is,10,000 the adjusted sample size will be the final sample size(nf);

,     ,  addig five percent non-response = 221

This was taken as the final minimum sample size. The sample sizes calculated for the second objective (factors associated with repeated abortion in the previous studies) yielded smaller sample sizes. 

Sampling technique and Data collection procedure

A consecutive sampling technique was used to select the study subjects. Two BSc midwives from two health centers (outside of the study area) were assigned for the data collection after having two days of training on how to collect the data and research ethics. The data was collected using a pre-tested interviewer-administered structured questionnaire from a total of 211 mothers who were coming for abortion service utilization from September 1st, 2022 to May 30th, 2023 in Mizan Tepi University Teaching Hospital (MTUTH). The interview was implemented after informing the participants all about the ethical issues and gaining informed consent. The questionnaire was adopted and modified from different works of pieces of literature addressing the socio-demographics, the pregnancy and abortion history, and the trends of contraceptive use.

Operational definitions

Abortion: is the termination of pregnancy before viability of the fetus

Safe abortion: when the abortion is carried out by a person with the necessary skills, using a WHO-recommended method appropriate to the pregnancy duration

Unsafe abortion: when it is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards or both.

Repeated induced abortion: if the woman has more than one induced abortion.

Data processing and analysis

The entire collected data have been checked for completeness and clarity, cleaned manually, coded, and entered into Epi Data 3.02 then transferred to SPSS version 21 statistical package to be cleaned, edited, and analyzed by the principal investigator for further analysis. Frequencies and percentages have been used to summarize descriptive statistics, tables and charts are also used for data presentation. Bivariate logistic regression has been done to determine the association between each independent variable with the dependent variable. Variables with a p-value less than 0.05 were considered as statistically significant and AOR with 95% CI has been used to control for possible confounders and to interpret the result.

Socio-demographic characteristics

Among the total of 211 females with a 96% response rate who were in the health institution at the comprehensive abortion care unit seeking abortion care, most of them were in the age group of 21 to 34 years old with a mean age of 24.24 years old. The majority of the participants 120(56.9%) were urban dwellers, 64.9 % are the Bench ethnicity, 84939.8) were students, 148(70.1) have low income, and 59(28%) have completed a college diploma and above.

Table 1: The distribution of socio-demographic characteristics of females who have an abortion in Mizan Tepi University Teaching Hospital (MTUTH), 2022/23 (N=211).

The pregnancy and abortion history

The majority of participant females 101(47.9) have a history of pregnancy, 71(62.8) have last pregnancy of less than one year. Of all the participants, 96(45.5%) have an abortion history with one to three times frequently in their lifetime. Among females with an abortion history, most of them 34(35.4%) reasoned out for the reason for their abortion was being single.

Table 2: Pregnancy and Abortion related history of the women seeking an abortion in Mizan Tepi University Teaching Hospital (MTUTH), 2022/23 (N=211).

The trends of contraceptive use

Even if the whole participants had a piece of information about modern family planning methods of contraceptives, 4.3% of the participants didn’t use modern contraceptives. However, 48(22.7%) of the participants didn’t hear about emergency contraceptives and 167(79.1%) didn’t use emergency contraceptives in their experience of contraceptive use because the majority of respondents 94(56.3%) fear sterility.

Table 3: The trends of contraceptive use of women seeking an abortion in Mizan Tepi University Teaching Hospital (MTUTH), 2022/23 (N=211).

The magnitude of repeated abortion

Among 211 of all the participants, 96(45.5%) have an abortion history with one to three times in their lifetime experience with the mean range of 38.9% to 52.1%.

Factors associated with repeated abortion

In this study, from the variables entered to bivariate analysis; Educational status, Marital status, types of contraceptives used, duration of FP use, the occurrence of the pregnancy, and ever use of emergency contraceptives were associated with repeated abortion. After transferring to multivariable analysis; Educational status, types of contraceptives used, duration of FP use, the way pregnancy occurred, and ever use of emergency contraceptives were associated with repeated abortion was statistically significant. Repeated abortion was nearly five times AOR=4.767 (1.159-19.603) likely to be done within females with the academic status of those able to read and write than that of females with a college diploma and above. Besides, participants those used implants AOR=0.007(0.001-0.89) and other contraceptives like calendar method and cultural methods AOR=0.0030(0.004-0.2160) are more protected from committing repeated abortion than those used oral contraceptive pills. The participants who use family planning contraceptives less than one-year duration are six-folds AOR= 5.771(1.418-23.478) prone to commit or practice repeated abortion as compared to those used beyond two years. The same was true for those participants who have a practice of using emergency contraceptives; participants who have a history of using emergency contraceptive pills have more chance of committing repeated abortion AOR= 0.088(0.23-0.338).

Table 4: The logistic regression analysis of factors associated with repeated abortion among women seeking an abortion in Mizan Tepi University Teaching Hospital (MTUTH), 2022/23 (N=211).

NB: *= significant at P-Value< 0 COR =crud xss=removed CI=Confidence xss=removed>Other contraceptive = traditional methods like calendar method and herbals

This study tried to emanate with the magnitude and causative environs of repeated abortion among females who came for seeking an abortion at Comprehensive Abortion Care (CAC) unit in public health institutions in Bench-Sheko Zone, South West Ethiopia.

The magnitude of repeated abortion in this study area was very high when compared to most of the studies conducted in different countries: 0.8% among unmarried women in China, 23.4% in the Grampian region of Scotland and the Uk, 24% in Swedish, 30.1% in Switzerland, 33% in Alsace [6, 14, 18-20]. On the contrary, the magnitude is lower than the studies conducted in Northwest China (56.6%), in 30 provinces of China (65.2%), in Georgia 70%) [7, 8, 21]. But, this finding was in line with the magnitudes of repeated abortion found in Aquitaine France (41.3%), and a systematic analysis finding among Chinese women (43.1%) [4, 22]. 

The magnitude found in this study was the highest magnitude among the studies conducted in Ethiopia in different parts of the country; 20.3% in central Ethiopia (Debrebirhan Town), 33.6% in Addis Ababa at Marie Stops Clinic, and 29.93% with the findings of systematic analysis [9-11]. This variation may be due to regional disparities and tendencies of contraceptive use.

The educational background females at the level of reading and writing are five times more likely to commit repeated abortion than those of females with an educational background of college diploma and above. This finding is supported by the study conducted in Addis Ababa at Marie Stops International Clinic in Ethiopia [10], a systematic and meta-analysis conducted in Ethiopia [11], another systematic and meta-analysis conducted among Chinese females [4], and in Northwestern China [7]. This may be due to the reason that literacy is a key for having awareness towards appropriate utilization of different types of contraceptives. It is also known that both Ethiopia and China are amongst high fertility rates and highly populated countries. Females with a history of contraceptive use like implants and traditional methods like calendar method and herbals have a negative association with repeated abortion. This finding is similar to the study conducted in the Grampian region of Scotland, the UK stated that females who use implants were safer than those who didn’t use them [14]. 

Participants who used contraceptives for less than one year of duration are nearly six times more prone to have repeated abortion than those females who used contraceptives for three and more than three years. This may be due to the reason that most of the participants have no the trend to use long-acting family planning contraceptives. Instead, most of the participants (38.4%) used oral contraceptive pills. 

Those females who have the practice and utilization of emergency contraceptives have likely history of repeated abortion than those who have no history of emergency contraceptive use. This may be due to the reason that those women have the trend of using other methods of contraceptives and most of them didn’t use it for the complaining of side effects like infertility. Besides those who are using contraceptives responded that they have used it correctly, but their appropriate use of contraceptives was not measured except their response during the interview.

Limitations of the study
Repeated abortion is rare and somehow sensitive for social and cultural aspects, and this makes it difficult to accommodate a large sample size. To have a large nationwide sample size, it needs a fundraise and this study was not funded. Because of the small sample size, the cross-tabulation of the regression table has a value of fewer than five frequencies and this may make the regression to be affected. Therefore, it needs another research with a large sample size to be conducted. It is also better if we have included more than one referral hospital for generalization. 

The magnitude of repeated abortion was high and the trends of emergency contraceptive utilization were too low for the claim of infertility. The females with college diplomas and above, those who used implants and other contraceptives like calendar method and cultural methods are more protected from committing repeated abortion than those who used oral contraceptive pills. The participants who use family planning contraceptives less than one-year duration and those with the practice of using emergency contraceptives are prone to commit or practice repeated abortion.

The trends of contraceptive usage should be a focus of intervention for the ideal tackling of this highly prevalent practice of repeated abortion. There should be a tough intervention regarding the repeated abortion and utilization of contraceptives, especially the attitude towards emergency contraceptives.

AOR: Adjusted Odd Ratio, BSc: Bachelor Science, COR: Crude odd ratio, ETB: Ethiopian Birr, FHB/R, FP: Family Planning, MTUTH: Mizan-Tepi University Teaching Hospital, SNNPR: South Nations, Nationalities and peoples Region, SPSS: Statistical Package for Social Science, UK: the United Kingdom, WHO: World Health Organization

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest statement: The author declares no conflict of interest in preparing this article.

Author’s contributions: STW conceptualized the study, drafted the manuscript, and analyzed the data.

Acknowledgment: I profoundly thank Mizan-Tepi University (MTU) for the proof of ethical review. Also, I would like to thank the MTUTH Chief executive director's office. Eventually, I would like to give a great thank you to all our friends who were around me while I was in the duty of this study.