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Unsafe abortion and associated factors among reproductive aged women in Sub-Saharan Africa: a protocol for a systematic review and meta-analysis

• Merhawi Gebremedhin 1 ,
• Agumasie Semahegn 1 , 3 ,
• Tofik Usmael 2 &
• Gezahegn Tesfaye 1  

Systematic Reviews volume  7 , Article number:  130 ( 2018 ) Cite this article

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Unsafe abortion is a neglected public health problem contributing for 13% of maternal death worldwide. In Africa, 99% of abortions are unsafe resulting in one maternal death per 150 cases. The prevalence of unsafe abortion is associated with restricted abortion law, poor quality of health service, and low community awareness. Hence, the aim of this systematic review and meta-analysis is to identify and summarize the available evidence to generate an abridged evidence on the prevalence of unsafe abortion and its associated factors in Sub-Saharan Africa.

The development of the systematic review methodology has followed the procedural guideline depicted in the preferred reporting items for systematic review and meta-analysis protocol statement. Observational studies that have been conducted from January 1, 1994, up to December 31, 2017, in Sub-Saharan African countries will be included in the systematic review and meta-analysis. MEDLINE (via PubMed), EMBASE, CINAHL, and PopLine will be searched to retrieve available studies. Relevant studies will be retrieved using the search strings applied to different sources. The Joanna Briggs Institute quality assessment tool will be used to critically appraise the methodological robustness and validity of the finding to avoid erroneous data due to confounded or biased statistics. Data extraction template will be prepared to record abstracted information from selected studies. The selection of relevant studies, data extraction, and quality assessment of studies will be carried out by two authors. Meta-analysis using Mantel–Haenszel random effects model will be carried out. The presence of heterogeneity between studies will be checked using the I 2 value.

Unsafe abortion is not yet reduced significantly in Sub-Saharan Africa, and maternal death rate due to unsafe abortion remains high. Currently, there is a gap in availability of abridged evidence on unsafe abortion and this negatively influenced the current service delivery. This finding will help stakeholders to design appropriate strategy. The finding of this systematic review and meta-analysis will be helpful to inform policy-makers, programmers, planners, clinician’s decision making, researchers, and women clients at large.

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PROSPERO 2017: CRD42017081437 .

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Unsafe abortion is entirely preventable. However, it remains pandemic and serious public health issue worldwide [ 1 , 2 , 3 , 4 ]. The World Health Organization (WHO) defines unsafe abortion as a procedure of pregnancy termination either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards or both [ 5 ]. Unsafe abortion is a neglected problem of health care in developing countries [ 4 ]. Despite technological advancements in health care, unsafe abortion remained essentially unchanged worldwide [ 6 ]. Unsafe abortion is identified as one of the major cause of maternal morbidity and mortality [ 7 ]. In Sub-Saharan Africa (SSA), abortion is more common and it tends to be clandestine and unsafe that has a substantially contribution to maternal mortality [ 8 ].

Worldwide, 210 million women become pregnant each year. Of these, 80 million pregnancies are unplanned. Out of these, 46 million pregnancies terminated each year, and 19 million ends with unsafe abortion [ 1 , 2 , 3 , 4 ]. More than 97% of unsafe abortions take place in developing countries [ 2 , 4 , 9 , 10 ]. Globally, unsafe abortion increased from 44% in 1995 to 49% in 2008 [ 2 , 10 ]. In 2000, the WHO estimates that one in ten pregnancies end up with unsafe abortion, giving one unsafe abortion to seven live births ratio. Likewise, 68,000 women die due to unsafe abortion each year, and the risk of maternal death is high in developing countries (1 in 270 unsafe abortion) [ 4 ].

The maternal death associated with unsafe abortion was 37 deaths per 100,000 live births in SSA, 23 per 100,000 in Latin America and the Caribbean, and 12 per 100,000 in South Asia [ 1 ]. The WHO (2008) estimates that unsafe abortion contributes for 13% of maternal death, worldwide. However, in Africa, the contribution of unsafe abortion is too high which is 2.4 million unsafe abortions occurred in eastern Africa in 2008. Globally, 40% of reproductive aged women live in countries with highly restrictive abortion law [ 11 ]. In Africa, over 4 million unsafe abortions are carried out yearly; mostly on poor, rural, and young women lacking information on availability of safe abortion care. About 99% of all abortions carried out in Africa are unsafe, and the risk of maternal death from an unsafe abortion is one in every 150 procedures which is the highest in the world [ 12 , 13 ].

The prevalence of unsafe abortion is attributable to poverty, social inequity, and denial of women’s human rights [ 1 ]. Countries with restricted abortion or where abortions are clandestine and unsafe, its consequences to women’s health are harmful, particularly for young, poor, and low-education women [ 3 , 14 ]. Unsafe abortion is practiced using different methods such as use of oral and injectable items, vaginal preparations, intrauterine foreign bodies, and trauma to the abdomen [ 13 ]. Significant proportion of women (20–50%) with unsafe abortion develop complications that lead to hospital admission. These complications include hemorrhage, sepsis, peritonitis, and trauma to the cervix, vagina, uterus, and abdominal organs [ 2 ]. The Sustainable Development Goals (SDG) aim to reduce global maternal mortality ratio from 216 to 70 per 100, 000 live births by 2030. Therefore, in order to contribute to this goal, developing countries need to legalize abortion and improve health care system to reduce abortion-related maternal deaths [ 2 , 15 ]. Hence, the main purpose of this systematic review and meta-analysis is to identify and summarize the available evidence to determine prevalence of unsafe abortion among women in the reproductive age and associated factors in SSA.

Development review protocol and registration

The development of the review methodology has followed the procedural guideline that was endorsed by the preferred reporting items for systematic review and meta-analysis protocol (PRISMA-P) statement [ 16 ], and all of the items in the checklist were completed (see Additional file  1 ). The review protocol has been registered in international prospective register of systematic reviews (PROSPERO) with trial registration number (CRD42017081437).

Data source and searching strategies

The search of studies will be carried out by (MG and GT). Published and unpublished studies written in English will be retrieved and included into the review process. Databases such as MEDLINE (via PubMed), EMBASE, CINAHL, and POPLINE will be searched for studies that had been conducted since January 1, 1994. Relevant sources such as Google search engine, Google scholar, and WHO websites will be searched. In addition, experts on the field will be consulted to retrieve unpublished studies. The year 1994 was chosen because the international community recognized the pressing need to address unsafe abortion at the International Conference on Population and Development (ICPD) in the year 1994 [ 17 ] and many African countries endorsed semi-restricted abortion law since 1994 [ 18 ]. The search strings will emerge from the following keywords (unsafe abortion, induced abortion, abortion, Sub-Saharan Africa, or African South of Sahara). Depending on the specific requirement of the database, the search string will be modified, and relevant studies using search strings will be identified. The combinations of free keywords and MeSH (medical sub-headings) will be extensively used in the search process. The reference lists of relevant studies will also be reviewed for sources that may have been missed in the database search. The search strategy developed for selected database is attached (see Additional file  2 ).

Eligibility criteria

All observational studies (cross-sectional, case-control, and cohort) and survey reports will be included in the systematic review. However, case reports, case series, commentaries, and editorials will be excluded from the review. All studies with primary objective to determine the prevalence of unsafe abortion and/or its associated factors among reproductive aged women in Sub-Saharan Africa will be considered [ 8 ].

We will consider studies that defined unsafe abortion based on WHO definition [ 19 ]; WHO defines unsafe abortion as a procedure of pregnancy termination either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards or both. We will also include community or facility-based studies that used either primary or secondary data. We will include studies that had mainly reported prevalence of unsafe abortion and its associated factors. However, as far as our primary aim is to determine the prevalence of unsafe abortion, studies that reported only prevalence of unsafe abortion but not associated factors will be included. In addition, studies that at least had test statistics that measured association between predictor variables with unsafe abortion will be considered to identify the associated factors. The studies should have a crosstab showing difference in prevalence of unsafe abortion in the categories of the exposure variables. We will exclude studies that only investigated unsafe abortion with qualitative approach. If we come across studies that have both quantitative and qualitative study finding, we will only consider the quantitative findings.

Selection of studies

We will export all retrieved studies into the Endnote citation management software [ 20 ]. Initially, duplicated studies will be removed from the citation manger. The two authors (MG and AS) will independently screen the studies based on information contained in the titles and abstract based on the inclusion criteria. Studies that clearly mentioned unsafe abortion among reproductive aged women will be selected for the next step of evaluation. Consequently, studies that have been eligible based on their title and abstract will be further screened by GT and TU. Based on title and abstract assessment, the studies will be classified as included, excluded, and undecided studies. For studies that will be categorized as included and undecided, we will further examine and evaluate full texts of the studies for eligibility. The full-text screening will be carried out by GT and AS. Studies that will not be eligible based on the full-text assessment will be excluded and reasons will be described for their exclusion. Studies that will pass through this selection process will be included in qualitative and quantitative synthesis. During screening of the studies, any disagreement among reviewers will be resolved by discussion and reach common understanding. The study selection process flow diagram is adapted from PRISMA guideline [ 16 ] (see Additional file  3 ).

Quality assessment

Studies will be critically evaluated for their validity of the findings. To determine the methodological robustness and validity of the findings of the studies, we will use the JBI (Joanna Briggs Institute) tool for assessing the quality of evidence. Particular attention will be given to clear statement of the objective of the study, sampling techniques, precision of measurement of outcomes of interest and exposure variables, as well as documentation of sources of bias or confounding. The two review authors (GT and AS) will check the scientific quality of the studies independently using quality assessment tool mentioned above. In case of uncertainties, it will be resolved by joint discussion between them.

Data extraction

Data extraction template will be constructed on Microsoft Excel (2013). The two authors (MG and TU) will extract data systematically and stored using data extraction form. Piloting of the data extraction form will be carried out before the beginning of the actual data extraction. Study description tables will be used to record the type of study design, aim, sample size, primary outcomes of interest (prevalence of unsafe abortion), and secondary outcome (associated factors). Numerical data (frequency) will also be extracted and recorded in Microsoft Excel sheet. The systematic review and meta-analysis working group will contact authors of the studies to request for details through email in case of missing data, incomplete report, or any uncertainties.

Data synthesis and statistical analysis

The data will first be presented using narrative synthesis of the included studies. A summary table will be prepared to describe characteristics (author-date, country, design, aim, sampling method, sample size, response rate, and key findings) of the included studies. The presence of statistical heterogeneity will be checked by using the Cochran Q test. The level of heterogeneity among the studies will be quantified using the I 2 statistics where substantial heterogeneity will be assumed if the I 2 value is ≥ 60%. We will also check the presence of publication bias using funnel plot if more than ten studies are included. We will also do Egger’s and Beggar’s test to check publication bias [ 21 ]. To pool prevalence of unsafe abortion, we will conduct meta-analysis using Comprehensive Meta-analysis software [ 22 ]. We will use the random effects model and the raw numerical data (number of unsafe abortions ( n ) and total sample size ( N )) from each study. We hypothesize that the legal and illegal status of abortion influences the magnitude of unsafe abortion. Therefore, we will conduct sub-group analysis of the prevalence of unsafe abortion based on countries abortion legal status. Moreover, we will use adjusted, and if none available unadjusted, odds ratios to assess the association between risk factors and unsafe abortion.

The aim of this systematic review and meta-analysis is to synthesis research findings on the prevalence of unsafe abortion and its associated factor in SSA. Even though evidence [ 23 ] indicates that unsafe abortion is not showing reduction in SSA, there is no systematically reviewed evidence that show the overall prevalence of unsafe abortion and influencing factors in the region. Moreover, currently, there is a gap in the availability of complete data on unsafe abortion and this can negatively influence the prevailing service delivery [ 24 ]. Establishing reliable evidence on the magnitude of unsafe abortion are generally challenging especially in countries where access to abortion is legally restricted. Whether legal or illegal, induced abortion is usually stigmatized and frequently censured by political, religious, or other cultural issues. Hence, under-reporting is routine even in countries where abortion is legally available [ 25 ].

The magnitude of unsafe abortion can be measured using different approaches namely absolute numbers, incidence ratio, incidence rate, mortality ratio, and case fatality rate. However, absolute number of unsafe abortions cannot be used to compare the magnitude in different regions or sub-regions because of difference in population size. In our analysis, ratios and rates will be used to allow inter or intra comparisons of nation(s) [ 4 ]. Worldwide report indicates that the rate of unsafe abortion is not decreased at the same pace with that of safe abortion. Unsafe abortions changed very little: from 19.9 million in 1995 to 19.7 million in 2003 [ 26 ]. But there is no specific data that indicates the prevalence of unsafe abortion to support the current initiative to reduce the rate of unsafe abortion in the region.

Evidence indicates that maternal mortality ratio secondary to unsafe abortion is 950 times higher in SSA (520) than in the USA (0.6) per 100,000 live births, respectively. The burdens of unsafe abortion and its associated maternal mortality are disproportionately higher for women in Africa than in any other developing region [ 27 ]. Its share of global unsafe abortions was 29%, and more seriously, 62% of all deaths related to unsafe abortion occurred in Africa in 2008 [ 28 ]. In places where laws and policies allow abortion under broad indications, the incidence of and mortality from unsafe abortion are reduced to a minimum [ 28 ].

Meanwhile, unsafe abortion affects the health of millions of women predominantly the poor, illiterate, and those living in rural areas, and hence, knowing the prevailing situation of unsafe abortion could help develop appropriate programs that potentially circumvent its occurrence. Experts proposed that expanding effective modern contraceptive methods, making abortion legal with accessible safe abortion services, and improving the quality of post abortion care would reduce the magnitude of unsafe abortion, its associated maternal mortality and morbidity, and cost of post abortion services [ 26 , 29 ]. Systematic review conducted in SSA showed that care givers in general were uncertain about the legal status of abortion in their countries, with majority of them having negative feeling towards induced abortion and only some of the health care providers perceived the legalization of abortion as a positive step [ 1 ].

Subsequently, it remains important to assess the magnitude of unsafe abortion and its associated factors in SSA so as to inform the development of appropriate programs and policy that would have an impact in reducing maternal morbidity and mortality in the region. The finding from this systematic review will be important for national governments and nongovernmental organizations in the health sector of the individual countries of the region to give emphasis on the main factors that drive unsafe abortion. Moreover, this finding will also help governments and other health development partners to expand and improve family planning services, to further advocate for legalization of abortion and increase accessibility and availability of abortion services in order to improve women’s health and well-being [ 4 ]. Therefore, the finding of this systematic review and meta-analysis will be used to inform policy-makers, health programmers, clinicians’ decision making, researchers, human right activist, and women clients at large.

Abbreviations

International Conference on Population and Development

Joanna Briggs Institute

Preferred reporting items for systematic review and meta-analysis

Sustainable Development Goals

• Sub-Saharan Africa

World Health Organization

Rehnström Loi U, Gemzell-Danielsson K, Faxelid E, Klingberg-Allvin M. Health care providers’ perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data. BMC Public Health. 2015. https://doi.org/10.1186/s12889-015-1502-2 .

Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, Shah IH. Unsafe abortion: the preventable pandemic. Sex Reprod Health. 2006. https://doi.org/10.1016/S0140-6736(06)69481-6 .

CLB F. Unsafe abortion: a serious public health issue in a poverty stricken population. Reprod Clim. 2013;2(8):2–9.

WHO. Unsafe abortion: global and regional estimates of the incidence of unsafe abortionand associated mortality. Geneva: World Health Organization; 2004. ISBN 92 4 159180 3

Google Scholar  

WHO. HRP annual report; WHO Department of Reproductive Health and Research. Geneva: World Health Organization; 2016. WHO/RHR/HRP/17.06

WHO. Interagency list of priority medical devices for essential interventions for reproductive, maternal newborn and child health. Geneva: World Health Organization; 2016.

Benson J, Nicholson LA, Gaffucin L, Kinoti SN. Complications of unsafe abortion in sub-Saharan Africa: a review. Health Policy Plan. 1996;11(2):117–31.

Kulczycki A.The imperative to expand provision, access and use of misoprostol for post-abortion care in sub-Saharan Africa. 2016.

Facts on induced abortion worldwide. http://www.who.int/reproductivehealth/publications/unsafe_abortion/abortion_facts/en/ . Accessed 23 Dec 2017.

Shah IH, Åhman E. Unsafe abortion differentials in 2008 by age and developing country region: high burden among young women; 2012. https://doi.org/10.1016/S0968-8080(12)39598-0 .

Book   Google Scholar  

Rasch V, Sørensen PH, Wang AR, Tibazarwa F, Jäger AK. Unsafe abortion in rural Tanzania – the use of traditional medicine from a patient and a provider perspective. BMC Pregnancy Childbirth. 2014;14:419.

Article   PubMed   PubMed Central   Google Scholar  

Abortion law reform in Sub-Saharan Africa: no turning back: an international journal on sexual and reproductive health and rights, 2005. https://doi.org/10.1016/S0968-8080(04)24026-5 .

Guttmacher Institute. Abortion and unintended pregnancy in Kenya. 2012: No. 2.

Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, Shah IH. Unsafe abortion: the preventable pandemic. Lancet. 2006;368:1908–19.

HEARD. Unsafe abortion in South Africa: country factsheet. Durban: Health Economics and HIV/AIDS Research Division/ University of KwaZuluNatal; 2006.

Moher D, Liberati A, Tetzlaff J, Altman D. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PloS Med. 2009;6(7)

McIntosh CA, Finkle JL. The Cairo conference on population and development: a new paradigm? Popul Dev Rev. 1995:223–60.

Brookman-Amissah E, Moyo JB. Abortion law reform in sub-Saharan Africa: no turning back. Reprod Health Matters. 2004;12(24):227–34.

Article   PubMed   Google Scholar  

WHO. Unsafe abortion: global and regional estimates of the incidence of unsafe and associated mortality. Geneva: World Health Orgnzaiation; 2008.

Reuters T. Cite While You Write TM Patented technology U.S patent number 8,092,24119888-2015. inventorEndNote X 7.3.1 (BId 8614). 2015.

Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58. https://doi.org/10.1002/sim.1186 .

Borenstein M, Hedges L, Higgins J, Rothstein H. Comprehensive meta analysis (CMA) version 2.0. 2004.

WHO. Safe abortion: technical and policy Guidance for health system. Geneva: World Health Organization; 2012. ISBN 978 92 4 154843 4

WHO. Countdown to 2015 decade report (2000–2010): taking stock of maternal, newborn and child survival. Geneva: World Health Organization; 2010. ISBN 978 92 4 159957 3

Unsafe abortion: the preventable pandemic. pulisher, Lancet online. 2006. https://doi.org/10.1016/S0140-6736(06)69481-6 .

S Singh, et, al. Abortion worldewide: a decade of uneven progress. [Online] 2003.

Shah I, Ahman E. Unsafe abortion: global and regional incidence, trends, consequences and challenges. J Obstet Gynaecol Can. 2009:1149–58.

WHO. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. Geneva: WHO; 2011.

GUTT AMACHER INSTITUTE. Facts on induced abortion worldwide. 2012.

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Acknowledgements

We would like to thank Haramaya University, College Health and Medical Sciences, for the office arrangement and free internet access.

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Merhawi Gebremedhin, Agumasie Semahegn & Gezahegn Tesfaye

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Tofik Usmael

School of Public Health, College of Health Science, University of Ghana, Legon, Accra, Ghana

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Contributions

MG, AS, TU, and GT conceived and designed the systematic review and meta-analysis. MG, AS, and GT drafted the protocol manuscript, and MG is the guarantor of the review. MG and GT developed the search strings. MG, AS, GT, and TU extensively reviewed and incorporated intellectual inputs in the protocol manuscript development. All authors read and approved the final version of the protocol manuscript.

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Correspondence to Merhawi Gebremedhin .

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Additional files

Additional file 1:.

PRISMA-P checklist. (DOC 84 kb)

Additional file 2:

Sample search strategy using search strings. (PDF 19 kb)

Additional file 3:

Diagramatic presentation of the studies selection process for systematic review. (DOCX 36 kb)

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Gebremedhin, M., Semahegn, A., Usmael, T. et al. Unsafe abortion and associated factors among reproductive aged women in Sub-Saharan Africa: a protocol for a systematic review and meta-analysis. Syst Rev 7 , 130 (2018). https://doi.org/10.1186/s13643-018-0775-9

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Systematic Reviews

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Decision-making preceding induced abortion: a qualitative study of women’s experiences in Kisumu, Kenya

• Ulrika Rehnström Loi   ORCID: orcid.org/0000-0002-3455-8606 1 ,
• Matilda Lindgren 1 ,
• Elisabeth Faxelid 1 ,
• Monica Oguttu 2 , 3 &
• Marie Klingberg-Allvin 4 , 5  

Reproductive Health volume  15 , Article number:  166 ( 2018 ) Cite this article

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Unwanted pregnancies and unsafe abortions are prevalent in regions where women and adolescent girls have unmet contraceptive needs. Globally, about 25 million unsafe abortions take place every year. In countries with restrictive abortion laws, safe abortion care is not always accessible. In Kenya, the high unwanted pregnancy rate resulting in unsafe abortions is a serious public health issue. Gaps exist in knowledge regarding women’s decision-making processes in relation to induced abortions in Kenya. Decision-making is a fundamental factor for consideration when planning and implementing contraceptive services. This study explored decision-making processes preceding induced abortion among women with unwanted pregnancy in Kisumu, Kenya.

Individual face-to-face in-depth interviews were conducted with nine women aged 19–32 years old. Women who had experienced induced abortion were recruited after receiving post-abortion care at the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) or Kisumu East District Hospital (KDH) in Kisumu, Kenya. In total, 15 in-depth interviews using open-ended questions were conducted. All interviews were tape-recorded, transcribed and coded manually using inductive content analysis.

Respondents described their own experiences regarding decision-making preceding induced abortion. This study shows that the main reasons for induced abortion were socio-economic stress and a lack of support from the male partner. In addition, deviance from family expectations and gender-based norms highly influenced the decision to have an abortion among the interviewed women. The principal decision maker was often the male partner who pressed for the termination of the pregnancy indirectly by declining his financial or social responsibilities or directly by demanding termination. In some cases, the male partner controlled decision-making by arranging an unsafe abortion without the woman’s consent. Strategic choices regarding whom to confide in were employed as protection against abortion stigma. This contributed to a culture of silence around abortion and unwanted pregnancy, a factor that made women more vulnerable to complications.

Conclusions

The findings suggest that financial, social and gender-based dependencies influence women’s agency and perceived options in decision-making regarding abortion.

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Plain English summary

Unwanted pregnancies and pregnancy termination are common in countries where women who want to prevent or delay childbearing have limited access to contraceptives. Around 25 million unsafe abortions take place worldwide each year. Recent evidence shows that nearly half a million induced abortions take place in Kenya every year. In this study, we used in-depth interviews to explore the decision-making processes preceding induced abortion among women with unwanted pregnancies in Kisumu, Kenya.

This study shows that the interviewed women decided to terminate their pregnancies for the following reasons: poverty, poor timing of the pregnancy and absence of support from male partners. The main decision maker was usually the male partner who pressed for the termination of the pregnancy indirectly by declining his financial or social responsibilities or directly by forcing his partner to terminate the pregnancy. In some cases, the male partner arranged an unsafe abortion without the woman’s knowledge or consent. Participants were affected by social stigma and carefully selected whom to talk to about the abortion. This strategy was used as protection against humiliation and shame. This contributed to a culture of silence around abortion and unwanted pregnancy, a factor that made women vulnerable to complications.

Where women and adolescent girls have unmet contraceptive needs, unwanted pregnancies and unsafe abortions are common. About 25 million unsafe abortions (45% of all induced abortions) occur globally, most of them (97%) in low resource settings [ 1 ]. Despite the availability of safe and effective interventions, unsafe abortions still contribute to maternal morbidity and mortality [ 2 ]. The majority of maternal deaths due to unsafe abortions occur in low-income settings where women experience low social status combined with legal and social restrictions to sexual and reproductive rights [ 3 ]. Women tend to opt for unsafe abortions where safe abortion services are not acceptable, accessible or affordable [ 4 ]. The number of unsafe abortions tends to be higher among poor women because women with strong social or economic resources are more likely to access safe abortions, regardless of the legal context [ 5 ].

The World Health Organization (WHO) defines unsafe abortion as “ the termination of an unwanted pregnancy by persons lacking the necessary skills, or in an environment lacking minimal medical standards, or both” [ 6 ], while also emphasising the impact of the social and legal context on abortion safety [ 7 ]. A recent study showed the disparity in abortion safety between low- and high-resource settings, indicating that in high-resource settings almost all abortions were safe, while only one in four abortions in Africa were safe [ 1 ].

The 2030 Agenda for Sustainable Development renewed the commitments by 193 Member States of the United Nations to reduce global maternal mortality through universal access to sexual and reproductive health (SRH) services, education and information. Moreover, sexual and reproductive health and rights (SRHR), ensuring the ability to make decisions about one’s contraceptive and own health, is core to the post-2015 goals because of its remarkable potential to contribute to sustainable development [ 8 ].

Contraceptives allow women/couples to decide if and when to become pregnant. Modern contraceptives play an important role in reducing maternal deaths by preventing unwanted pregnancies and prolonging birth intervals [ 9 ]. Contraceptives are, however, underutilised in many low-resource settings [ 10 , 11 ], largely as a result of limited availability of a range of contraceptive methods, including to modern long-acting reversible contraceptive methods [ 11 ], and social stigma surrounding young women’s contraceptive use [ 12 ].

Women’s decision-making preceding an induced abortion is influenced by factors at different levels [ 13 , 14 ]. Individual-level factors include marital status, education level, economic independency and whether the woman was a victim of rape or incest [ 15 ]. Interpersonal factors such as parental and partner support have also been found to influence decision-making [ 15 ], as have societal determinants like religion and social stigma and norms [ 13 ]. Relevant organisational factors include access to sexuality education [ 15 ] and the availability of facilities providing abortion services [ 14 ].

The Kenyan context

The majority of the population in Kenya is Christian (83%), with 48% identifying as Protestant and 24% as Roman Catholic [ 16 ]. Kenyan women are economically dependent on men, and Kenyan cultures are largely patriarchal [ 17 ]. Marriage occurs comparatively early; among women aged 25–49 the median age at first marriage was 20.2 years. About 53% of married women of reproductive age use a modern contraceptive method. Among married women aged 15–49 years, 18% have unmet contraceptive need, which contributes to a high total fertility rate (3.9 births per woman) [ 18 ].

A recent national study estimated that about 464,000 induced abortions occur in Kenya annually, with a national abortion rate of 48 abortions per 1000 women of reproductive age (15–49 years) [ 19 ]. This figure is above the rate for all of sub-Saharan Africa (SSA), which is 31 abortions per 1000 women of reproductive age [ 20 ]. It is estimated that the induced abortion rate in Kenya is highest in the Rift Valley region and the combined Nyanza and Western regions [ 19 ].

Until 2010, abortion was only legally allowed to save the life of a pregnant woman. However, in 2010 a revised constitution was adopted permiting abortion when “ in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law ” [ 21 ]. Thus far, the implementation of the constitution has been slow, and both knowledge and practice may differ throughout the country. A lack of transparency and clarity with regard to the circumstances in which abortion is legal contributes to Kenya’s high maternal mortality ratio (MMR) [ 22 ]. The MMR in Kenya has remained almost constant since 1990. According to the 2014 Kenya Demographic Health Survey, the MMR is 362 maternal deaths per 100,000 live births, and unsafe abortion is a major contributor [ 18 ]. Due to restrictive abortion legislation in Kenya [ 21 ], limited access to quality healthcare and stigma, most abortions occur outside authorised health care facilities and are classified as therefore considered unsafe [ 23 ].

Kenya is an important location to study women’s decision-making preceding induced abortion given its high MMR, changing legal framework, social stigma surrounding unplanned pregnancies and the socioeconomic status of the majority of women in the country.

Nyanza province, in which Kisumu is the principal city, has one of the highest MMRs in Kenya [ 24 ], and the total fertility rate for this province is 4.3 children per woman, the fourth highest in the country [ 18 ].

Aim of the study

The aim of this study was to explore decision-making preceding induced abortion among women with unwanted pregnancies in Kisumu, western Kenya.

Study setting

The study was conducted at the Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) and Kisumu East District Hospital (KDH) in Kisumu, western Kenya. Kisumu Medical and Education Trust (KMET), a non-governmental organisation, supported the collaboration with these two public hospitals in Kisumu. At the time of the study, the two facilities treated approximately 80 women per month for abortion-related complications.

Research team and reflexivity

The authors recognise the significance of reflexivity and transparency regarding researcher subjectivity in qualitative research. The research team consisted of five female researchers. The first author (URL) had prior relevant experience from an MSc in Public Health and as a PhD student in the researched subject. The second author (ML) is a social scientist (MSc student) with an interest in women’s SRH. The third author (EF) is a professor in Reproductive and Perinatal Health Care with broad experience conducting quantitative and qualitative research in Kenya and other low-income countries. The fourth author (MO) is the Executive Director of KMET with vast SRH experience in the region. The final author (MKA) is a professor with a PhD in International Health who has extensive experience conducting research in low-resource settings using both quantitative and qualitative methods.

Conducting and transcribing the interviews was physically and emotionally exhausting. During data collection and interview transcription the researchers (ML and URL) had daily contact and discussed their personal experiences. The deep emotional experience of conducting these interviews allowed them to empathise with participants and was used during analysis.

Study design, sample selection and data collection

In total, 15 individual, in-depth interviews (IDIs) were conducted with nine women aged 19–32 years old. Follow-up interviews were conducted with six of the women. Purposive sampling was used to select women seeking care for abortion-related complications. The following inclusion criteria were used: 1) women over 18 years of age 2) who experienced an induced abortion, 3) received post-abortion care (PAC) at JOOTRH or KDH and 4) were willing to be interviewed.

Midwives at the two public hospitals in Kisumu identified possible interviewees between 1 January 2014 to 31 May 2014 by asking PAC-seeking women if they had tried to induce the abortion. All women who met the inclusion criteria and were asked to participate agreed to be interviewed. The respondents were informed about the study’s aim and were assured of their confidentiality. Seven respondents were recruited from JOOTRH and two from KDH. Six women were interviewed face-to-face 7–10 days after receiving PAC, two were interviewed at the time of a three-month follow-up and one woman was approached while she was still admitted at the ward. In addition, a repeated interview was offered to all respondents approximately 2–5 weeks after the initial interview. Five of the respondents were interviewed face-to-face a second time, while one respondent was interviewed over the phone due to distance. Three respondents declined the request for a repeat interview. The reason for conducting follow-up interviews was to further enhance understanding and enrich the material as trust and affinity were built between researcher and informant.

The women were interviewed between February and April 2014 at JOOTRH and KDH by one of the authors (ML) who has a master’s degree in Gender Studies and conducted previous studies in Cultural Anthropology. She was trained in qualitative methodologies and at the time of the study was a postgraduate student in Global Health. The fact that the interviewer was not a clinician and a non-Kenyan might have encouraged respondents to speak to her more openly about a sensitive subject. During one interview the researcher used an interpreter to translate from Lou to English. The translator was an assistant from KMET. During the other interviews, the researcher was the only person in the room with the respondent. The interviews lasted on average 45 min.

A semi-structured interview schedule, using open-ended questions and suggestions for probing, was developed by the research team. The schedule was pilot tested and modified prior to initial data collection. The questions were framed to study women’s decision-making preceding induced abortion, including the role played by their social networks.

Field notes were written directly after each interview to reflect on initial thoughts and reactions. With the written consent of the respondents, all interviews were tape-recorded and transcribed verbatim, including notations for nonverbal expressions, for analysis by the first and second authors (URL and ML) on an ongoing basis as data collection progressed. The interview with a translator was also transcribed in English. The research team met regularly to review progress and discuss interview techniques. Data collection continued until data saturation was reached [ 25 ]. Table  1 presents the characteristics of the respondents.

Data analysis

The data were analysed by the first and second authors (URL and ML) using inductive content analysis, including open coding, category development and abstraction [ 25 , 26 ].

Inductive content analysis is a qualitative approach used to unconditionally analysing the data [ 27 ]. While analysis had already begun during interview transcription, open coding was conducted during the first reading of the transcripts. Thereafter, the transcripts were read through several times and coded manually. Meaning units were identified and transferred to Excel for classification into subcategories, generic categories and main categories. The process of analysis is presented in Fig.  1 . Meaning units and categories were discussed and compared amongst all members of the research team in order to further improve the analysis and to maximise rigour [ 26 ].

Inductive content analysis process [ 27 ]

Inductive content analysis resulted in three main categories: 1) Reasons for induced abortion , 2) A culture of silence and 3) Choosing abortion despite risks and limited information. The results are presented according to these main categories together with their generic categories and citations from the interviews to clarify the findings. The abstraction process is illustrated in Fig.  2 .

Coding tree describing the abstraction process

Reasons for induced abortion

The first main category, Reasons for induced abortion , is described through four generic categories: 1) Financial inability to raise a child , 2) Social pressure associated with mistimed pregnancy , 3) Perceived lack of options and 4) Disagreement between partners and abortion without the woman’s consent.

Financial inability to raise a child

All women described their pregnancies as mistimed, unplanned or unwanted at the time of conception. A lack of financial stability or support were described by most women as driving factors for the decision to terminate the pregnancy.

“I was financially unstable to sustain those children.” (Respondent 8)

In some cases, the woman was the main provider of the household, and the pregnancy jeopardised the stability of her income. The pregnancy might diminish her employment opportunities, as an employer could decide to let a woman go once it was evident she was pregnant. Therefore, pregnancy termination provided the respondents with the potential for continued employment and secured economic independence.

“When [the pregnancy] is visible, you will be sacked. And when you are [alone] at home, who will support you? I have to work.” (Respondent 6)

Women who were still students and living with their parents indicated that their parents would not financially support their costs of living and studies as well as the costs of raising an additional child.

The married respondents stressed that they had to prioritise resources and take care of the children they already had. All women with children mentioned the importance of providing an education for them. High school fees were frequently cited. The respondents stated they could not afford to educate an additional child. Several women specifically articulated their partner’s unwillingness to financially support a child as the reason for terminating the pregnancy.

Furthermore, financial constraints were perceived as a barrier to safe abortion. Women frequently cited not being able to afford to pay a professional to perform the abortion.

Social pressure associated with mistimed pregnancy

The unmarried respondents were concerned about the risk of negative views from family and community members if they continued the pregnancy at that particular time. Although engaged and employed, some women expected to be criticised and “talked about” by people in the community due to the mistimed pregnancy.

“Because [---] okay, people usually talk; in Kenya people will talk. Where you are staying, there are some people, those people like to gossip, people will definitely talk. [---] They’ll say you are still in your mother’s house [---] They won’t be able to understand…and some will even criticise your relationship.” (Respondent 5)

Others explained that having a child would end a harmonious relationship with their parents. Several young women living with their parents mentioned that they would not be welcome in their parents’ house if they were pregnant.

“[---] she [mother] took me to the training [in hotel management and hospitality], she spend some money there,and then I didn’t tell her [about the pregnancy] because she won’t be happy because maybe she will then think that she had taken me to the training and spent money there, and then I will not be able to go and just sit at home [---] She would kick me out of the house, and maybe she would stop the training [---].” (Respondent 7)

The need for a supportive social network, including a stable partnership, emerged as fundamental to avoid severe conflicts in the decision-making process. Social networks could include actors providing either financial or couched support. Male partners had a significant direct or indirect influence on participants’ decisions to opt for induced abortions. Several women expressed unstable partner relationships as a reason why they had chosen to have an abortion.

“I already have two children, I am everything for these children… I am the mother and the father for these two children, so a third one would be too much problem. I just decided. I have to because that man never convinced me; I was not convinced at all that that man would provide anything.” (Respondent 6)

Single women were afraid to raise a child alone.

“So, I just thought that I have another kid and the father is not contributing with the school fees. Even my mother denied helping me. Yeah, for my kid and me also; so that’s why I decided to do away with the abortion.” (Respondent 7)

The social network was emphasised as central for single mothers. An additional child became an added burden, which could not be placed on family or friends.

Perceived lack of options

Some women expressed guilt and distress about lying to their partners and family about the pregnancy. Additionally, women expressed feelings such as heightened shame and self-blame because abortion was perceived as immoral and improper.

“I felt bad because it was like murdering someone, but [---] I felt part of killing the kid because [---] I felt miserable for like a week [---] two weeks.” (Respondent 2)

However, due to their economic, social or health circumstances, the termination of the pregnancy was considered the only available option.

“I didn’t have any option because I just knew that the situation I was in [HIV positive]; I was not able to [---] take care of this baby [---] according to the situation [HIV positive] now I was in.” (Respondent 7)

While some women said that they decided on an abortion immediately upon realising they were pregnant, several respondents described experiencing a lot of stress and ambivalence in trying to decide what to do.

“I was still deciding what to do; I was still doubting. So many things run into my mind until I come with the decision to do [---] to [---] to [---] end the pregnancy. At that time [---] [I] even think I lost [---] [weight] cause [because of the] stress I have [---] having so many stress [---] losing weight cause of the stress.” (Respondent 3)

Disagreement between partners and abortion without the woman’s consent

Almost all women expressed some kind of disagreement with their partner in relation to the pregnancy. Some women articulated that they terminated the pregnancy without notifying their partner, fearing the possible consequences of anger, violence and divorce. On the other hand, a few women expressed their intention to abort and were discouraged and warned not to proceed by the partner. Participants articulated that their partners believed abortion was wrong and could cause complications and death. All single respondents decided not to reveal the pregnancy to their ex-partners. Although some of the respondents decided to terminate the pregnancy, others expressed that they were forced or even misled to terminate the pregnancy by their partners. When women were misled, their respective partners attempted to convince them to opt for an abortion. Although the women insisted on keeping the pregnancy, clandestine abortion providers supported the partners to induce abortion without the women’s consent.

“He suggested for the abortion to be done, I told him no. [---] So he insisted, and he insisted. When he saw I’m not participating, he used a trick and told me that if you don’t want then I want to advice you on how to be when you are pregnant and what drugs [to] use. [---] He injected me through a vein and told me it’s to improve the appetite… [---] After injecting that drug I became unconscious. When I returned from my unconsciousness I found myself naked and I was bleeding.” (Respondent 1)

This reveals that unsafe abortion in Kenya sometimes happens without the woman’s consent. During the interview Respondent 1 disclosed she had reported her ex-partner to the police. While the women explained their partners’ motives were based on social embarrassment and financial obligations, how the partners themselves would describe the situation and justify their actions is beyond the scope of this research.

A culture of silence

The main category A culture of silence is described through two generic categories: 1) Finding individual support while fearing public disclosure and 2) Secrecy as a strategy to avoid social stigma .

Finding individual support while fearing public disclosure

As seen under the first main category, several respondents described the time after they discovered they were pregnant as very stressful. While all of them feared public disclosure to some extent, they also expressed the need to tell someone about their condition. In many cases this person was a sister or a friend who had also been through an induced abortion. Most respondents were reluctant to tell their partners because they feared disagreement or abandonment. Among the women who informed their partners about the pregnancy, this confession commonly entailed asking for financial support. A majority of the non-married respondents also acknowledge that they were reluctant to tell their parents and preferred that their partner did not know about the pregnancy.

Respondents tended to keep the pregnancy to themselves for several weeks due to their fear of possible reactions. If the secret was shared, it had to be with a trustworthy person, usually a sister, as a tactic to avoid public disclosure. Furthermore, women feared receiving opposing advice, which could indicate that they had already made the decision to terminate the pregnancy and only sought affirmation.

“I was doubting what to do and on the other hand afraid of sharing with anybody. I believed if I share it with so many people some people will give me other advice, some will give me this; that’s why I ended up sharing with my sister that I’m staying with because I trusted her.” (Respondent 4)

Not infrequently, respondents indicated that they had chosen to state that the pregnancy had ended in a miscarriage instead of an induced abortion. Women made strategic choices regarding whom they confided in. While some women had the support of a sister or a female friend, others assessed the risk of telling someone to be so profound that they decided to keep the secret to themselves, which meant they had no one who could support them.

“I did not ask someone for advice because if you ask one they will start talking about it and everybody will know about it, so I was afraid to talk about it to someone [---] and maybe it will go back to my partner, and I didn’t want that to happen. [---].” (Respondent 8)

Fear of negative consequences and death as a result of the abortion led some women to share their intention to terminate the pregnancy. Women expressed the desire to inform at least one person about the abortion; if there were negative consequences, someone would know where to look for the woman if she were not to return home.

Secrecy as a strategy to avoid social stigma

The majority of women expressed fear of rumours, social isolation and judgment if the abortion were revealed. Respondents believed that people in the community would perceive them as “killers”. Additionally, they believed their peers would exclude them and avoid interacting with them. Social stigma and discrimination were expressed as segregation, as well as being perceived as a prostitute, labelled as a murderer, accused of being unfaithful and believed to be a poor candidate for marriage.

“ In campus if you get pregnant and your boyfriend says I cannot take care of the baby, I’m not the father and stuff, they will start saying you are just like the others [---] maybe you have sex for money? Maybe you don’t know the father of the kid? [---] So, they start calling you names like whore, slut [---] Someone says you are just a whore like anyone else, and after that everyone starts to isolate you [---]” (Respondent 2)

Fear of judgment and losing social respect created a culture of silence, where the harmful nature of rumours and negative responses fostered secrecy and silence surrounding abortion and a mistimed pregnancy. Women became afraid to share their decision to terminate the pregnancy with others, including friends, family and healthcare professionals due to a lack of trust and fear that their confidentiality would not be maintained. Induced abortions were secrets kept to avoid negative reactions.

Religious values and beliefs were apparent in all the interviews. Almost all women mentioned that abortion was a sin and not accepted by their church. Therefore, it was critical that other church members were not aware of the decision to terminate the pregnancy. A few respondents elaborated on this during follow-up interviews, clarifying the guilt, anxiety and angst they felt when attending church. They accused themselves of being sinners and struggled to ask for forgiveness from God.

“You see as a married women [---] you see [---] it seems like the woman is not even ready for the marriage [---] so something is wrong with her that cannot be explained, so they [the husbands] don’t like it so easy, they see it as a sin, so there is no way I can tell about the abortion to him as I know the consequences can be bitter for me [---] when you do such thing [abortion] since you are giving away God’s blood, then you are trying to be like the Father. God gave you the child, and now you are removing it so it’s a sin because you are competing with God.” (Respondent 9)

Choosing abortion despite risks and limited information

The main category Choosing abortion despite being aware of the risks is explained through three generic categories: 1) Being aware of the risks related to abortion , 2) Significant others and storytelling as guides for selecting an abortion provider and 3) Unmet need for information concerning safe abortion methods.

Being aware of the risks related to abortion

The respondents generally described abortion as risky. All of them said they were aware of the health risks of having an abortion. Death, infertility, long-time infection, weakness and loss of body weight were commonly mentioned. Death was the most emphasised consequence and was frequently repeated. Women described having an induced abortion as gambling with life and death.

“I was [very] scared [---] because I know how dangerous it is. But I was like, okay – let it be, and if I’m going to die, so be it, that is how, that is my destiny now. [---] I had now decided; it’s either death or survival. I was ready for anything.” (Respondent 5)

All women highlighted abortion as an unsafe procedure in Kenya. The respondents were fully aware of the severity of abortion complications, and their decisions were framed with this knowledge in mind. Women considered the risk of giving birth to a child to be similarly high. Going through a pregnancy was also associated with health risks (including sickness during and after pregnancy), but abortion was framed as the preferred risk. However, some respondents were anxious about the future and did not want to be blamed for their decision to terminate the pregnancy.

Significant others and storytelling as guides in selecting an abortion provider

Evidence-based information regarding induced abortion was limited. Common information sources about induced abortion methods and procedures were informal social networks at high school and friends who had experience of abortion. Only a few respondents had consulted professional healthcare providers. Some women stated they knew about Marie Stopes, a reliable abortion provider; however, due to high transportation fees they opted for medical abortions using Misoprostol, which was provided by chemists.

“When I was in high school we used to have some cases [of abortion] so I had that knowledge from school, so I just decided to do it on my own. [---] I also knew about other methods, but I was afraid to use the others because I had not tried to do it before.” (Respondent 9)

Unmet need for information concerning safe abortion methods

Respondent knowledge about safe abortion methods was low. Almost all women described induced abortions as very risky, even with the possible consequence of death. The general consensus was that no abortion is safe. Women tended to ask the local chemist about abortion drugs (Misoprostol) or quinine instead of reaching out to safe professional abortion providers due to a lack of accurate understanding of abortion legislation and safe abortion methods in Kenya.

“[Abortion is] when you take drugs [---] traditional herbals also terminate the pregnancy. Some people take juice, highly concentrated juice [---] only those once [are the abortion methods I know of].” (Respondent 6)

“I didn’t know anything. I have a friend who went through it before [---], but she passed away two weeks after the abortion [---].” (Respondent 2)

Similar to previous studies, this study reveals that the main reasons for induced abortion are socio-economic stresses and a lack of support from partners [ 28 , 29 , 30 , 31 ]. In cases where women informed their partners about the pregnancy, the principal decision maker was often the male partner who pressed for pregnancy termination indirectly by declining his financial or social responsibilities or directly by demanding the woman terminate the pregnancy. In some cases, the male partner misled the woman, overruling her decision to continue the pregnancy by arranging an unsafe abortion without her consent. A lack of financial security seemed to diminish participants’ perceptions of available options. Furthermore, as mentioned above, gender-based power relations hindered women from actualising their decisions. Previous studies from Uganda and Ghana have disclosed similar findings where women’s decision-making power regarding abortion was restricted by gender norms and power imbalances [ 30 , 31 , 32 ].

Similar to earlier studies, female friends or sisters were commonly referred to as important sources of information and moral support when undergoing an induced abortion. While sisters were believed to be trusted to keep knowledge about the abortion within the family, important knowledge-sharing also took place via female friends who had themselves been through an abortion. Together with sisters, these friends were regarded as trustworthy.

Regardless of relationship status, all respondents expressed concern about publicly disclosing the abortion, fearing negative remarks, the loss of social respect, isolation and divorce. Similar findings have been shown in Ethiopia, Sri Lanka and Kenya [ 33 , 34 , 35 ] and in further conceptualisations of abortion stigma, which entails shaming and discriminating against women and their families [ 36 , 37 ]. Kumar et al. argue that abortion stigma builds on injustices and discrimination in society by depending on and appropriating existing power axes [ 36 ]. This study showed perceived stigma, referring to the perception that pregnancy termination will result in a woman being seen as inferior, to be very present in the participants’ accounts [ 36 ]. Similar to Shellenberg et al.’s arguments, the fear of judgment effectively curtailed participants’ willingness to disclose their abortion intention or experience [ 37 ]. Women handled these risks by making strategic choices regarding whom they confided in. A lack of trust and the fear of rumours confirm that other people’s opinions are highly important to sustaining a positive social life. In many cases, lying, hiding and planning to escape were preferable to telling the truth.

A direct consequence of this secrecy is that it creates a culture of silence around mistimed pregnancies and abortion. Although it may protect women from social shame, hiding one’s pregnancy and abortion makes women reluctant or scared to seek professional reproductive health information and care, which in turn makes them more vulnerable to complications, morbidities and mortality. This aligns with findings from a similar context showing that fear of stigma related to unintended pregnancy among young women, including the shame it brings to the family, as well as negative social sanctions, is a great driving force for unsafe abortion [ 33 , 38 ]. The study also shows that fear of stigma delays care-seeking and consequently increases the risk of morbidity and mortality.

This study reveals that women encounter challenges in obtaining safe abortion information and services, regardless of the legal status of abortion in the country. A previous study from Kenya has similar findings [ 39 ].

Abortion-related social stigma preventing women’s access to comprehensive SRH

Essential elements regarding abortion-related stigma found in this study should be reflected in the planning and implementation of SRH services in Kenya. Women who participated in this study repeatedly noted significant social stigma around induced abortion, which affected their decision-making regarding pregnancy termination. The abortion-related social stigma revealed in this study delayed and prevented the seeking of professional and safe PAC. Similarly, an earlier facility-based study from Kenya confirms the correlation between stigma and abortion-seeking behaviours among women seeking abortion care [ 40 ]. Young unmarried women faced both the stigma of pregnancy outside of marriage and abortion-related stigma. Previous research has shown comparable findings [ 41 ].

A recent systematic literature review critically analysed abortion stigma among healthcare providers in sub-Saharan Africa and Southeast Asia [ 42 ]. The findings demonstrate that healthcare providers have moral, social and gender-based reservations related to induced abortion. Furthermore, the study reveals that nurses and midwives often have pejorative attitudes towards women seeking abortion care and commonly reported an unwillingness to provide abortion care. As a consequence, nurses and midwives overlooked their responsibilities as caregivers and acknowledged that due to negative rapport between abortion provider and client, women seeking abortion care received inadequate care [ 42 ]. Because stigma is transmissible, it also deters healthcare providers who are prepared to provide abortion care from delivering these services. This stigmatisation enforces negative labels for the caregiver and may result in harmful professional consequences [ 43 ].

Abortion stigma is deep-rooted in government and political landscapes, organisations, communities and personal relationships [ 36 ]. The constant denial of a woman’s right to freely decide on the number and spacing of her children directly influences maternal mortality [ 44 ]. Abortion-related stigma is a barrier to safe and accessible abortion care [ 43 , 45 ]. Hence, decreasing social and cultural stigma around abortion among abortion providers would potentially strengthen women’s access to quality reproductive healthcare and improve women’s health by preventing future unintended pregnancies, as well as induced abortions and related complications.

Strengths and limitations

Despite the high prevalence of induced abortions in Kenya [ 19 , 46 ], there is a shortage of qualitative research that analyses women’s reasons for obtaining induced abortions in the country.

Studies on abortion in Kenya have primarily focused on incidence, clinical outcomes and stigma [ 19 , 39 , 47 , 48 ]. The strengths of the present study are, first, that it focusses on women who terminated their pregnancies in the recent past and thus have fresh memories of the abortion experience. Second, the interviewer was nonclinical, from outside the Kenyan healthcare system and ensured participants’ confidentiality. Third, the interviewer established a rapport with the participants, which facilitated insightful responses. Finally, six respondents agreed to a repeated interview, which provided a unique opportunity to ask follow-up questions, probe for additional information and circle back to key questions to generate richer material.

A limitation of this study is that partners and other significant family members were not included as study subjects. Partners might have given different accounts of the decision-making process. The methodological challenges in gaining access to both partners’ and parents’ accounts first and foremost relate to privacy, as partners and parents were not necessarily informed of the pregnancy and/or abortion. Ethical concerns prevented the recruitment of partners via the participants as this would require the women’s consent, which, in turn, could influence the sample. Similarly, ethical concerns prevented the inclusion of women under 18 years of age in the study and by coincidence there were no women over the age of 32 years interviewed. It could be argued that adolescent women and older women would have responded differently about decision-making preceding induced abortion. Even though research among underage women is difficult to conduct, young women are by far the most affected by severe complications due to unsafe abortions [ 47 ]. More research is therefore needed to understand underlying social attitudes towards young women who have undergone induced abortions.

Furthermore, contraceptive failure and change of pregnancy intention during pregnancy were not included in this study, which could be perceived as a limitation.

The impact of HIV status on decision-making in relation to induced abortion has been demonstrated in other studies [ 49 , 50 ]. This sample included two women who reported themselves as HIV positive, which also influenced their decisions to have induced abortions (along with financial reasons). However, analysis of this relationship should be based on a larger sample.

The results from this qualitative study are the reports of PAC-seeking women in Kenya during in-depth interviews.

A lack of financial independence, a lack of social support, deviance from family expectations and gender-based norms influenced abortion decision-making among women with unwanted pregnancies. Strategic choices regarding whom to confide in were employed as protection against abortion stigma. This, however, contributed to a culture of silence around abortion and mistimed pregnancy. Silence and stigma act as driving forces for unsafe abortions and put women in situations where an unsafe abortion can occur without their consent. Unwanted pregnancies can also be stressful for men, and interventions targeting unsafe abortions must take both sexes into consideration and address the problem of forced abortions as a reproductive health issue.

Abbreviations

Human Immunodeficiency Virus

In-depth interview

Jaramogi Oginga Odinga Teaching and Referral Hospital

Kisumu East District Hospital

Kisumu Medical and Education Trust

Maternal mortality ratio

Post-abortion care

Sexual and reproductive health

Sexual and reproductive health and rights

Sub-Saharan Africa

World Health Organization

Ganatra B, Gerdts C, Rossier C, Johnson BR, Jr., Tuncalp O, Assifi A, et al. Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model. Lancet 2017;390(10110):2372–2381.

Article   Google Scholar  

Darroch J, Audam S, Biddlecom A, Kopplin G, Riley T, Singh S, et al. Adding it up: investing in contraception and maternal and newborn health. 2017. https://www.guttmacher.org/fact-sheet/adding-it-up-contraception-mnh-2017 . Accessed 16 June 2018.

Google Scholar  

World Health Organization. Packages of interventions for family planning, safe abortion care, maternal, newborn and child health. Geneva: World Health Organization; 2010.

World Health Organization. Safe abortion: technical and policy guidance for health systems. Geneva: World Health Organization; 2012.

Singh S, Wulf D, Hussain R, Bankole A, Sedgh G. Abortion worldwide: a decade of uneven progress. New York: Guttmacher Institute; 2009.

World Health Organization. World Health Organization information sheet in unsafe abortion incidence and mortality global and regional levels in 2008 and trends during 1990–2008. Geneva: World Health Organization; 2012.

Ganatra B, Tunçalp Ö, Johnston HB, Johnson BR, Gülmezoglu AM, Temmerman M. From concept to measurement: operationalizing WHO’s definition of unsafe abortion. Bull World Health Organ. 2014;92(3):155.

United Nations. Global Sustainable Development Report. New York: Department of Economic and Social Affairs; 2016. p. 2016.

Petruney T, Wilson LC, Stanback J, Cates W Jr. Family planning and the post-2015 development agenda. Bull World Health Organ. 2014;92(8):548–548A.

Tsui AO, McDonald-Mosley R, Burke AE. Family planning and the burden of unintended pregnancies. Epidemiol Rev. 2010;32:152–74.

Sedgh G, Hussain R. Reasons for contraceptive nonuse among women having unmet need for contraception in developing countries. Stud Fam Plann. 2014;45(2):151-69.

Hakansson M, Oguttu M, Gemzell-Danielsson K, Makenzius M. Human rights versus societal norms: a mixed methods study among healthcare providers on social stigma related to adolescent abortion and contraceptive use in Kisumu. Kenya BMJ Glob Health. 2018;3(2):e000608.

Alhassan AY, Abdul-Rahim A, Akaabre PB. Knowledge, awareness and perceptions of females on clandestine abortion in Kintampo north municipality. Eur Sci J. 2016:95–112.

Frederico M, Michielsen K, Arnaldo C, Decat P. Factors influencing abortion decision-making processes among young women. Int J Environ Res Public Health. 2018;15(2).

Gbagbo FY, Amo-Adjei J, Laar A. Decision-making for induced abortion in the Accra metropolis. Ghana Afr J Reprod Health. 2015;19(2):34–42.

PubMed   Google Scholar  

Kenya National Bureau of Statistics (KNBS). The 2009 Kenya population and housing census. Kenya National Bureau of statistics (KNBS). https://www.knbs.or.ke/category/census-2009-summary-of-results/ . Accessed 15 June 2018.

Mutongu ZB, Women’s Participation in Community-Based Organizations’ Development as a Strategy for Poverty Reduction in Kenya. https://www.cbeinternational.org/sites/default/files/Women%27s_Muntongu.pdf . Accessed 18 June 2018.

Kenya National Bureau of Statistics. Kenya Demographic and Health Survey 2014. Rockville, MD, USA: Kenya National Bureau of Statistics. https://dhsprogram.com/pubs/pdf/fr308/fr308.pdf . Accessed 18 June 2018.

Mohamed SF, Izugbara C, Moore AM, Mutua M, Kimani-Murage EW, Ziraba AK, et al. The estimated incidence of induced abortion in Kenya: a cross-sectional study. BMC Pregnancy Childbirth. 2015;15:185.

Sedgh G, Singh S, Shah IH, Ahman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from 1995 to 2008. Lancet. 2012;379(9816):625–32.

Government of Kenya. The Constitution of Kenya. Revised Edition. Nairobi, Kenya: National Council for Law Reporting (NCLR). 2010. http://www.wipo.int/edocs/lexdocs/laws/en/ke/ke019en.pdf . Accessed 18 June 2018.

Hussain. R. In: Brief: unintended pregnancy and abortion in Kenya. New York: Guttmacher Institute. p. 2012.

Ziraba AK, Izugbara C, Levandowski BA, Gebreselassie H, Mutua M, Mohamed SF, et al. Unsafe abortion in Kenya: a cross-sectional study of abortion complication severity and associated factors. BMC Pregnancy Childbirth. 2015;15:34.

National Council for Population and Development (NCPD) and UNFPA Kenya Country Office. Kenya Population Situation Analysis. Nairobi: NCPD and UNFPA; 2013.

Polit DF, Beck CT. Nursing research: generating and assessing evidence for nursing practice. Tenth edition. Philadelphia: Wolters Kluwer Health; 2017.

Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: implications for conducting a qualitative descriptive study. Nurs Health Sci. 2013;15(3):398–405.

Elo S, Kyngas H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–15.

Arambepola C, Rajapaksa LC. Decision making on unsafe abortions in Sri Lanka: a case-control study. Reprod Health. 2014;11:91.

Maina BW, Mutua MM, Sidze EM. Factors associated with repeat induced abortion in Kenya. BMC Public Health. 2015;15:1048.

Schwandt HM, Creanga AA, Adanu RM, Danso KA, Agbenyega T, Hindin MJ. Pathways to unsafe abortion in Ghana: the role of male partners, women and health care providers. Contraception. 2013;88(4):509–17.

Chae S, Desai S, Crowell M, Sedgh G. Reasons why women have induced abortions: a synthesis of findings from 14 countries. Contraception. 2017;96(4):233–41.

Cleeve A, Faxelid E, Nalwadda G, Klingberg-Allvin M. Abortion as agentive action: reproductive agency among young women seeking post-abortion care in Uganda. Cult Health Sex. 2017;19(11):1286–300.

Osur J, Orago A, Mwanzo I, Bukusi E. Social networks and decision making for clandestine unsafe abortions: evidence from Kenya. Afr J Reprod Health. 2015;19(1):34–43.

Kebede MT, Hilden PK, Middelthon AL. The tale of the hearts: deciding on abortion in Ethiopia. Cult Health Sex. 2012;14(4):393–405.

Olsson P, Wijewardena K. Unmarried women's decisions on pregnancy termination: qualitative interviews in Colombo, Sri Lanka. Sex Reprod Healthc. 2010;1(4):135–41.

Marlow HM, Wamugi S, Yegon E, Fetters T, Wanaswa L, Msipa-Ndebele S. Women's perceptions about abortion in their communities: perspectives from western Kenya. Reprod Health Matters. 2014;22(43):149–58.

Kumar A, Hessini L, Mitchell EM. Conceptualising abortion stigma. Cult Health Sex. 2009;11(6):625–39.

Shellenberg KM, Moore AM, Bankole A, Juarez F, Omideyi AK, Palomino N, et al. Social stigma and disclosure about induced abortion: results from an exploratory study. Glob Public Health. 2011;6(Suppl 1):S111–25.

Rossier C. Abortion: an open secret? Abortion and social network involvement in Burkina Faso. Reprod Health Matters. 2007;15(30):230–8.

Yegon EK, Kabanya PM, Echoka E, Osur J. Understanding abortion-related stigma and incidence of unsafe abortion: experiences from community members in Machakos and trans Nzoia counties Kenya. Pan Afr Med J. 2016;24:258.

Yegon E, Mwaniki P, Echoka E, Osur J. Correlates of individual-level stigma and unsafe abortions among women seeking abortion care in trans Nzoia and Machakos counties, Kenya. Annals of Tropical Medicine and Public Health. 2016;9(4):226–34.

Gipson JD, Hirz AE, Avila JL. Perceptions and practices of illegal abortion among urban young adults in the Philippines: a qualitative study. Stud Fam Plan. 2011;42(4):261–72.

Rehnstrom Loi U, Gemzell-Danielsson K, Faxelid E, Klingberg-Allvin M. Health care providers' perceptions of and attitudes towards induced abortions in sub-Saharan Africa and Southeast Asia: a systematic literature review of qualitative and quantitative data. BMC Public Health. 2015;15:139.

Hessini L. A learning agenda for abortion stigma: recommendations from the Bellagio expert group meeting. Women Health. 2014;54(7):617–21.

Dunn JT, Lesyna K, Zaret A. The role of human rights litigation in improving access to reproductive health care and achieving reductions in maternal mortality. BMC Pregnancy Childbirth. 2017;17(Suppl 2):367.

World Health Organization. Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008. In: Sixth edition; 2011.

Ministry of Health Kenya. Incidence and complications of unsafe abortion in Kenya: Key findings of a national study. 2013. https://www.guttmacher.org/sites/default/files/report_pdf/abortion-in-kenya.pdf . Accessed 18 June 2018.

Mutua MM, Maina BW, Achia TO, Izugbara CO. Factors associated with delays in seeking post abortion care among women in Kenya. BMC Pregnancy Childbirth. 2015;15:241.

Orner P, de Bruyn M, Cooper D. "it hurts, but I don't have a choice, I'm not working and I'm sick": decisions and experiences regarding abortion of women living with HIV in Cape Town, South Africa. Cult Health Sex. 2011;13(7):781–95.

Chi BK, Hanh NT, Rasch V, Gammeltoft T. Induced abortion among HIV-positive women in northern Vietnam: exploring reproductive dilemmas. Cult Health Sex. 2010;12(Suppl 1):S41–54.

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Acknowledgements

The authors wish to express their sincere appreciation to the women who took part in this study and to the directors of JOOTRH and KDH for granting permission to collect data. In addition, special recognition goes to the staff of KMET for their assistance during data collection in Kisumu. This article represents the opinions of the named authors and not the necessarily the views of their institutions or organisations.

The Swedish International Development Agency (Sida) funded the study by providing a Minor Field Study grant to ML. The Doctoral School in Health Care Sciences at Karolinska Institutet provided a PhD grant to URL. The funders had no role in the study planning, implementation or analysis, the decision to publish or the preparation of the manuscript.

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The datasets generated and analysed as part of this study are not publicly available in order to maintain the confidentiality of the respondents. However, all transcripts are available from the corresponding author on reasonable request.

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Ulrika Rehnström Loi, Matilda Lindgren & Elisabeth Faxelid

College of Health Sciences, School of Nursing Sciences, University of Nairobi, Nairobi, Kenya

Monica Oguttu

Kisumu Medical Education Trust (KMET), Kisumu, Kenya

Department of Women’s and Children’s Health, Karolinska Institutet, SE-171 77, Stockholm, Sweden

Marie Klingberg-Allvin

School of Education, Health and Social Studies, Dalarna University, Högskolegatan 2, 791 31, Falun, Sweden

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MKA and EF conceived the presented study and developed the study design with contributions from URL. ML conducted all face-to-face interviews with support from URL. URL and ML led the content analysis with input from all authors. All authors discussed the results. URL wrote the first draft of the article. All authors commented on and approved the final manuscript. The research team included MO, a Kenyan and senior professional as co-author as she was involved in the study’s planning, supported data collection and also contributed to the improvement of the manuscript.

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Correspondence to Ulrika Rehnström Loi .

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Ethical approval was granted by the Regional Ethics Appeals Board in Stockholm (Reference number 2013/902–31/1) and the JOOTRH Ethics and Review Committee in Kisumu (Reference number ERC 42/13). Verbal and written consent were sought and received from all respondents. Information about the confidentiality and safe storage of the data was provided both orally and in writing. The participants were informed that they could withdraw their participation at any time without consequence. Confidentiality was protected as the interviews were conducted in a private room where conversations could not be overheard, and only researchers involved in the study had access to the interview material. Participants were given small financial compensation to cover transportation costs and the potential loss of income; the amount was low enough to not jeopardise the voluntary nature of participation. The study area was not included in the presentation of sociodemographic information to protect the anonymity of the respondents. After conducting the first two interviews, the research team perceived that some women may require professional support. Therefore, the author who conducted the interviews (ML) arranged for such care by KMET.

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Rehnström Loi, U., Lindgren, M., Faxelid, E. et al. Decision-making preceding induced abortion: a qualitative study of women’s experiences in Kisumu, Kenya. Reprod Health 15 , 166 (2018). https://doi.org/10.1186/s12978-018-0612-6

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Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009

Affiliation.

• 1 Human Development and Family Studies, 16 D FCS Building, Bowling Green State University, Bowling Green, Ohio 43402, USA. [email protected]
• PMID: 21881096
• DOI: 10.1192/bjp.bp.110.077230

Background: Given the methodological limitations of recently published qualitative reviews of abortion and mental health, a quantitative synthesis was deemed necessary to represent more accurately the published literature and to provide clarity to clinicians.

Aims: To measure the association between abortion and indicators of adverse mental health, with subgroup effects calculated based on comparison groups (no abortion, unintended pregnancy delivered, pregnancy delivered) and particular outcomes. A secondary objective was to calculate population-attributable risk (PAR) statistics for each outcome.

Method: After the application of methodologically based selection criteria and extraction rules to minimise bias, the sample comprised 22 studies, 36 measures of effect and 877 181 participants (163 831 experienced an abortion). Random effects pooled odds ratios were computed using adjusted odds ratios from the original studies and PAR statistics were derived from the pooled odds ratios.

Results: Women who had undergone an abortion experienced an 81% increased risk of mental health problems, and nearly 10% of the incidence of mental health problems was shown to be attributable to abortion. The strongest subgroup estimates of increased risk occurred when abortion was compared with term pregnancy and when the outcomes pertained to substance use and suicidal behaviour.

Conclusions: This review offers the largest quantitative estimate of mental health risks associated with abortion available in the world literature. Calling into question the conclusions from traditional reviews, the results revealed a moderate to highly increased risk of mental health problems after abortion. Consistent with the tenets of evidence-based medicine, this information should inform the delivery of abortion services.

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• Abortion and mental health. Tyrer P. Tyrer P. Br J Psychiatry. 2011 Nov;199(5):433. doi: 10.1192/bjp.199.5.433. Br J Psychiatry. 2011. PMID: 22045951 No abstract available.
• To meta-analyse or not to meta-analyse: abortion, birth and mental health. Kendall T, Bird V, Cantwell R, Taylor C. Kendall T, et al. Br J Psychiatry. 2012 Jan;200(1):12-4. doi: 10.1192/bjp.bp.111.106112. Br J Psychiatry. 2012. PMID: 22215864
• Abortion and mental health: guidelines for proper scientific conduct ignored. Howard LM, Rowe M, Trevillion K, Khalifeh H, Munk-Olsen T. Howard LM, et al. Br J Psychiatry. 2012 Jan;200(1):74; discussion 78-9, author reply 79-80. doi: 10.1192/bjp.200.1.74. Br J Psychiatry. 2012. PMID: 22215867 No abstract available.
• Abortion and mental health: guidelines for proper scientific conduct ignored. Abel KM, Susser ES, Brocklehurst P, Webb RT. Abel KM, et al. Br J Psychiatry. 2012 Jan;200(1):74-5; discussion 78-9, author reply 79-80. doi: 10.1192/bjp.200.1.74a. Br J Psychiatry. 2012. PMID: 22215868 No abstract available.
• Abortion and mental health: guidelines for proper scientific conduct ignored. Littell JH, Coyne JC. Littell JH, et al. Br J Psychiatry. 2012 Jan;200(1):75-6; discussion 78-9, author reply 79-80. doi: 10.1192/bjp.200.1.75. Br J Psychiatry. 2012. PMID: 22215869 No abstract available.
• Abortion and mental health: guidelines for proper scientific conduct ignored. Polis CB, Charles VE, Blum RW, Gates WH Sr. Polis CB, et al. Br J Psychiatry. 2012 Jan;200(1):76-7; discussion 78-9, author reply 79-80. doi: 10.1192/bjp.200.1.76. Br J Psychiatry. 2012. PMID: 22215870 No abstract available.
• Abortion and mental health: guidelines for proper scientific conduct ignored. Goldacre B, Lee W. Goldacre B, et al. Br J Psychiatry. 2012 Jan;200(1):77; discussion 78-9, author reply 79-80. doi: 10.1192/bjp.200.1.77. Br J Psychiatry. 2012. PMID: 22215871 No abstract available.
• Abortion and mental health: guidelines for proper scientific conduct ignored. Robinson GE, Stotland NL, Nadelson CC. Robinson GE, et al. Br J Psychiatry. 2012 Jan;200(1):78; discussion 78-9, author reply 79-80. doi: 10.1192/bjp.200.1.78. Br J Psychiatry. 2012. PMID: 22215872 No abstract available.
• Abortion and mental health: guidelines for proper scientific conduct ignored. Lagro-Janssen T, van Weel C, Wong SL. Lagro-Janssen T, et al. Br J Psychiatry. 2012 Jan;200(1):78; discussion 78-9, author reply 79-80. doi: 10.1192/bjp.200.1.78a. Br J Psychiatry. 2012. PMID: 22215873 No abstract available.
• Abortion and mental health: guidelines for proper scientific conduct ignored. Puccetti R, Del Poggetto MC, Di Pietro ML. Puccetti R, et al. Br J Psychiatry. 2012 Jan;200(1):78; discussion 78-9, author reply 79-80. doi: 10.1192/bjp.200.1.78b. Br J Psychiatry. 2012. PMID: 22215874 No abstract available.
• Abortion, mental health and charges of guilt by association. Reardon D. Reardon D. Br J Psychiatry. 2012 Mar;200(3):255-6. doi: 10.1192/bjp.200.3.255a. Br J Psychiatry. 2012. PMID: 22383770 No abstract available.

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• Published: 11 November 2015

The effect of abortion on having and achieving aspirational one-year plans

• Ushma D. Upadhyay 1 ,
• M. Antonia Biggs 1 &
• Diana Greene Foster 1  

BMC Women's Health volume  15 , Article number:  102 ( 2015 ) Cite this article

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Women commonly report seeking abortion in order to achieve personal life goals. Few studies have investigated whether an abortion enables women to achieve such goals.

Data are from the Turnaway Study, a prospective cohort study of women recruited from 30 abortion facilities across the US. The sample included women in one of four groups: Women who presented for abortion just over the facility’s gestational limit, were denied an abortion and went on to parent the child (Parenting Turnaways, n = 146) or did not parent (Non-Parenting Turnaways, n = 64), those who presented just under the facility’s gestational limit and received an abortion (Near-Limits, n = 413) and those who presented in the first trimester and received an abortion (First Trimesters, n = 254). Participants were interviewed by telephone one week, six months and one year after they sought an abortion. We used mixed effects logistic regression to assess the relationship between receiving versus being denied abortion and having an aspirational one year goal and achieving it.

The 757 participants in this analysis reported a total of 1,304 one-year plans. The most common one-year plans were related to education (21.3 %), employment (18.9 %), other (16.3 %), and change in residence (10.4 %). Most goals (80 %) were aspirational, defined as a positive plan for the next year. First Trimesters and Near-Limits were over 6 times as likely as Parenting Turnaways to report aspirational one-year plans [Adjusted Odds Ratio (AOR) = 6.37 and 6.56 respectively, p < 0.001 for both]. Among all plans in which achievement was measurable ( n = 1,024, 87 %), Near-Limits (45.6 %, AOR = 1.91, p = 0.003) and Non-Parenting Turnaways (47.9 %, AOR = 2.09, p = 0.026) were more likely to have both an aspirational plan and to have achieved it than Parenting Turnaways (30.4 %).

Conclusions

These findings suggest that ensuring women can have a wanted abortion enables them to maintain a positive future outlook and achieve their aspirational life plans.

Peer Review reports

Women report having abortions for a variety of reasons related to achieving personal life goals. A recent national study based on data from the Turnaway study (which is also the data source for the current study), found that among the primary reasons for wanting an abortion were: feeling not financially prepared (40 %), not the right time (36 %), and having a baby now would interfere with future opportunities (20 %) [ 1 ]. Another national study conducted in 2004 among 1209 abortion patients found that the primary reasons for abortion are to mitigate the effects of unintended pregnancy on life course plans [ 2 ]. Specifically, among the top reasons women reported having an abortion were: a baby would dramatically change their lives, that they could not afford a baby now, that they did not want to be a single mother or had problems with their relationship, and that they were not ready for a child or another child. Many of these reasons suggest that women felt that carrying the unintended pregnancy to term would interfere with their plans and that abortion would help them achieve their personal goals.

Kirkman and colleagues reviewed the literature on reasons women have abortions. Of the 19 papers they reviewed that met the inclusion criteria, they found that almost all papers included reasons that are classifiable as wrong timing, “which encompassed a sense of not being ready for motherhood and the desire not to disrupt education, work, or life plans”[ 3 ].

Several legal scholars and philosophers have used a gender equality framework to support abortion and reproductive rights [ 4 , 5 ]. The gender equality framework contends that the right to abortion is necessary to ensure equality between men and women. Alison Jaggar argues, “The social assignments of caretaking and often financial responsibility for their children to mothers means that the birth of a child, especially an unwanted child, often severely disrupts women’s life plans” [ 6 ].

Popular support for abortion is often based on a desire for women to have access to life opportunities [ 7 ]. A recent poll conducted in two states in the US found that the public considers motherhood or being a primary caregiver as one of the top “things [that] might prevent women from having the same opportunities in life or in work as men.”

Despite the prevalent attitudes that abortion enables women to pursue life’s opportunities, only a couple of studies have investigated whether an abortion enables one to achieve specific milestones, and such studies usually focus on educational achievements. For example, a 2-year longitudinal U.S. study found that black teenagers from Baltimore who had an abortion were more likely to continue their education than those who carried to term or those who had never been pregnant [ 8 ]. Similarly, a 25-year longitudinal study in New Zealand examined the extent to which abortion mitigated educational, economic, and social disadvantages associated with pregnancy among women less than age 21 [ 9 ]. The study found that compared to young women who had unintended pregnancies and carried to term and young women who did not have unintended pregnancies, young women who obtained abortions were more likely to achieve educational milestones. However, there were no differences found in achievement of economic or relationship milestones. The study also found that family, social, and educational characteristics were more likely to explain subsequent life outcomes than whether the woman had an abortion.

Both of these studies had a narrow focus—they looked at adolescent women and used predetermined goals such as high school graduation. They did not include women across the lifespan nor did they consider the woman’s own stated life goals. The one U.S. study was done in a single city (Baltimore), and published over two decades ago when access to abortion services and economic conditions were different. Therefore, findings from that study may not be generalizable to the current U.S. context as a whole.

Probably the greatest weakness of these studies, is that they did not include appropriate comparison groups. Women choosing to have an abortion after an unintended pregnancy may be systematically different than those who never had an unintended pregnancy or those who chose to carry to term. Such unobserved factors may confound any effects found between choosing abortion and achieving life milestones. This study overcomes these methodological weaknesses by comparing two groups of women seeking abortion; women obtaining a wanted abortion compared to women denied a wanted abortion.

Data from University of California, San Francisco’s Turnaway Study were used to examine the impact of having an abortion on women’s own reported one-year plans. Women who obtained a wanted abortion were compared to women who wanted an abortion but were turned away from getting the procedure because they presented for care after the provider’s gestational limit. First, all one-year plans were categorized and it was determined whether each plan expressed a positive goal for the coming year (aspirational). It was assessed whether women who were able to have a wanted abortion were more likely to report an aspirational one-year plan than women denied an abortion. Second, it was assessed whether women who were able to have a wanted abortion were more likely to achieve these aspirational one-year plans one year later.

The Turnaway Study is a 5-year longitudinal study of women seeking abortion. The study was designed to assess a variety of outcomes of receiving an abortion compared with carrying an unwanted pregnancy to term. The study received approval from the University of California, San Francisco, Committee on Human Research. All participants provided informed consent.

From 2008 to 2010, the Turnaway Study recruited women from 30 abortion facilities across the United States. Study sites were identified using the National Abortion Federation membership directory and by referral. Sites were selected based on their gestational age limits to perform an abortion procedure, where each facility had the latest gestational limit of any facility within 150 miles. Gestational age limits ranged from 10 weeks to the end of the second trimester. Facilities performed over 2,000 abortions a year on average [ 10 ]. They were located in 21 states distributed relatively evenly across the country.

Women were recruited on a 1:2:1 ratio: women who presented up to 3 weeks over the facility’s gestational age limit and were turned away (“Turnaways”), women who presented up to 2 weeks under the limit and received abortions (“Near-Limits”), and women who presented in the first trimester and received abortions (“First Trimesters”). Since the majority (92 %) of abortions in the U.S. occur in the first trimester of pregnancy [ 11 ], comparisons between the Turnaways and the First Trimesters served to assess whether the experiences of women seeking later abortions differ from the typical experience of women having abortions in the U.S.

It was anticipated that relatively few women would meet the Turnaway eligibility requirements; therefore, to ensure a large enough overall sample for analysis without being restricted by the low number of women eligible for the Turnaway group, twice as many Near‐Limit participants were enrolled as Turnaways or First‐Trimester participants. For this analysis, the Turnaway group was divided into Parenting Turnaways and Non-Parenting Turnaways (which included Turnaways who subsequently had an abortion elsewhere, reported that they had miscarried, or placed the child for adoption).

Women were eligible for participation if they sought an abortion within the gestational limits for each of the study groups, spoke English or Spanish, and were aged 15 years or older. Further details on recruitment and methods can be found elsewhere [ 12 , 13 ]. After the baseline survey, participants were contacted for a follow-up phone interview every six months for five years. Turnaway Study data for this analysis come from interviews done at baseline (one week), six months, and one year after they were recruited at their abortion-seeking visit.

To reduce losses to follow up, researchers collected detailed contact information and participants’ preferred methods of communication and confidentiality protection preferences; they also called women after two months to confirm that the woman’s primary and secondary contact information was still valid. When participants could not be reached, researchers called each day for up to 5 days. If she still could not be reached, researchers sent up to 3 follow-up letters by mail or email (according to her stated contact preferences) and continued to call at the same frequency for a maximum of 10 sequential days. To compensate respondents for their time, each received a $50 gift card to a large retail store upon completion of each interview.

During the baseline Turnaway Study interview, participants were asked about sociodemographic characteristics, their reproductive histories, and a final, open-ended question “How do you think your life will be different a year from now?” which was used to capture respondents’ one-year plans. Respondents were permitted to provide as long a response as desired. The 6-month and one-year follow-up interviews included questions about whether they were going to school, whether they were working full or part time, what they did for work, their personal and household income, their household composition, their relationships, their children, their life satisfaction, and their emotions regarding the abortion. These items were used to assess whether women achieved their one-year plans.

Many women reported multiple one-year plans. Each individual plan in a dataset that was blinded to study group was considered (although some women’s plans were suggestive of her study group). Each plan was categorized by topic: Education, Employment, Financial, Child-related, Emotional, Living Situation/Residence, Relationship Status, and Other. The Other category included vague plans, plans for personal growth, car ownership, health and other plans that did not fit into one of the other eight topics.

Then, the outlook of the plan was determined—whether it was positive, negative or neutral. This determination was based on the tone of the statement and the qualifiers used. If determination was unclear, the plan was categorized as neutral. Two researchers reviewed each plan. Identification of a plan as positive or negative required both researchers agreeing. Positive plans are referred to as “aspirational.”

Finally, survey items in the six-month and one-year interviews that would indicate achievement of the plan were identified. Some specific plans required all co-authors to discuss and agree upon the meaning of the plan and whether our interview items were sufficient to measure achievement. The exact timing for residential moves could not be determined so when a plan involved a residential move, she was considered to have achieved the goal if there was evidence that she moved by the second year of the study.

Data analysis

First, sample was described, comparing the socio-demographic characteristics of each group to the Turnaway-Parenting group. For all analyses, mixed-effects regression models that included random effects for facility were used, and p -values that adjust for the clustering of participants within each site are presented. The Turnaway-Parenting group was the reference category for all comparisons.

One-year plans were described by topic and by outlook (negative/neutral/positive). Mixed-effects multinomial logistic regression was used to assess differences in proportions among the study groups.

Finally, two mixed-effects logistic regression models were conducted: The first modeled the likelihood of having an aspirational one-year goal and the second modeled the likelihood of having an aspirational goal and achieving it. Both models assessed the effects of study group and adjusted for baseline covariates: age, race, education, employment, poverty status, union status, parity, and history of anxiety/depression. The unit of analysis was one-year plans and because some women reported multiple plans, mixed-effects models were used to account for clustering by woman and within each site. Statistical significance was set at p < 0.05 for all comparisons and adjusted odds ratios (AORs), and 95 % confidence intervals are reported. All statistical analyses were performed using STATA 13 (Stata Corp, 2012).

Overall, 37.5 % of eligible women consented to complete semi-annual telephone interviews for five years, with no differential participation by study group. A total of 956 women completed a baseline interview 8 days after seeking an abortion. One facility was excluded ( n = 76) from all analyses because 95 % of women initially denied an abortion obtained one elsewhere, and thus the site did not contribute an adequate sample of Turnaways. Three women in the Near-Limit abortion group and First-Trimester group were excluded because they reported that they chose not to have an abortion after agreeing to participate in the study, leaving a final sample of 877 participants at baseline. This analysis was limited to those who completed a one-year follow up interview—146 Parenting Turnaways, 254 First-Trimesters, 413 Near-Limits, and 64 Non-Parenting Turnaways (see Fig.  1 ). Of the 877 participants who completed the first interview, 86 % also completed the one year follow-up interview with no differences between those with follow-up data and those who were lost to follow up in the kinds of plans reported at baseline. The final sample of participants in this analysis was 757.

Sample by study group

Participant characteristics

The only significant differences in socio-demographic characteristics between the Near-Limit Abortion group and the Parenting Turnaway group (among those with one year follow up data) were age and parity (see Table 1 ). Parenting Turnaways were younger and less likely to have previous children than Near-Limits. They did not differ significantly by race, education, marital status, school/employment status, history of child sexual abuse, or history of anxiety or depression.

Topics of one-year plans

Because each respondent could give multiple one-year plans, the 757 respondents reported a total of 1,304 plans. Among all participants, plans were distributed among the following themes: Educational (21.3 %), Employment (18.9 %), Other (16.3 %), Changes in Living Situation/Residence (10.4 %), Child-related (10.3 %), Financial (7.8 %), Relationship (5.3 %), Emotional (5.1 %), and Don’t know (4.5 %).

At baseline, approximately one week after receiving or being denied an abortion, women in the Parenting Turnaway group were most likely to mention one-year plans related to children—significantly more than Near-Limits, First Trimesters (both p < 0.001), and Non-Parenting Turnaways ( p = 0.001).

Parenting Turnaways were significantly less likely to mention one-year plans related to employment than Near-Limits ( p = 0.045). They were also significantly less likely to mention one-year plans related to relationships than Near-Limits ( p < 0.045) and First Trimesters ( p < 0.002) (see Fig.  2 ).

Proportion of one-year plans by topic/theme category, by study group, n = 1,304 plans. % of one year plans is significantly different than Parenting Turnaways at * p < 0.05, ** p < 0.01, or *** p < 0.001

Outlook of one-year plans

The majority of one-year plans were aspirational (80.2 %), followed by neutral/matter of fact one-year plans (17. 6 %) and negative one-year plans (2.2 %). The following are examples of typical aspirational one-year plans in each category (each quoted clause represents a different participant):

Child-related: “Give a good life to my kids,” “My daughter will be done with the first year of high school.” Education: “I hope that I will be back in school,” “Finished my education.” Emotional: “I just want to be happy,” “Less stressful.” Employment: “have a better job,” “Hopefully I’ll be opening my own business.” Financial: “more financially stable,” “more money,” “I am hoping to be able to support me and my daughter on my own.” Residence: “won’t live with my parents anymore,” “I’ll probably be in a different country, hopefully Australia,” “have my own place for me and my son.” Relationships: “I’ll be married,” “I hope to be divorced,” “better relationship,” “As long as I stay away from the person I was with, I’ll be 100 % better.” Other: “I’m hoping to take better care of myself,” “Have my own car,” “Good, I mean, I don’t know.”

Neutral/matter of fact responses most often included having a child, but also included statements about life being the same, or life being different without further comment suggesting how the respondent felt about it. The following are examples of typical neutral one-year plans in each category:

Child-related: “I guess I will have three children instead of two,” “Kids will be older.” Emotional: “This experience has changed me. I can’t quite articulate it yet but I imagine it will still be impacting me a year from now” Residence: “In process of moving.” “living situation will be the same.” Relationships: “I don’t plan on having a family or getting married.” “I don’t think I want to have any relationships. Or think about anything like that” Other: “I don’t know,” “I don’t think it will be any different.”

Among all groups, there were 30 negative one-year expectations and one-third of these focused on the change in quality of life and the woman’s emotions with a new child. The following are examples of typical negative one-year plans in each category:

Child-related: “More stressful and hectic with having two kids” and “I’ll be running back and forth to day care having to pay someone to watch my child.” Education: “I don’t think I’ll be going to school,” “I am going to have to work twice as hard to get through school and stuff.” Emotional: “I’ll still be thinking about the abortion,” “It will be very different. I don’t think I will be happy. It will be very difficult for me. I don’t know what I will do.” Employment: “I believe that I will be working two jobs, working really hard to support two kids.” Financial: “I think that I will have four children instead of three and I will probably have less money,” “My living situation is all I can afford.” Residence: “I won’t be living with my family and I’ll have a kid. I think it will be a little bit more challenging.” Other:” I’m living day by day, so I don’t know.” “I think that it will be the same. I don’t see a future.”

One-year plans were significantly more likely to be aspirational among First Trimester (84.3 %), Near-Limit (85.6 %), and Turnaway-Not Parenting (80.9 %) groups compared to the Turnaway-Parenting group (56.3 %, p < 0.001 for all comparisons) (see Fig.  3 ). In a model adjusting for potential covariates, First Trimesters and Near-Limits were over 6 times as likely as Parenting Turnaways to report aspirational one-year plans (Adjusted Odds Ratio (AOR) = 6.37 and 6.56 respectively, p < 0.001 for both). Non-Parenting Turnaways were four times as likely to report aspirational one-year plans (AOR = 4.00, p < 0.001). The only other significant predictor of having an aspirational plan was marital status with married women less likely to have positive one-year plans than unmarried women (70.9 % vs 81.1 %, AOR = 0.56, p = 0.04) (see Table  3 ).

Proportion of one-year plans by whether they were negative, neutral/matter of fact or positive, by study group, n = 1,304. ***% of one year plans is significantly different than Parenting Turnaways at p < 0.001

Achievement of one-year plans

Among the 1,046 total aspirational plans across study groups, it was possible to assess whether 87.1 % were achieved by one year using a range of items included in the interview guide. The most common measures used to assess achievement of plans included whether the participant obtained a specific degree or graduated, whether she had a higher income, whether she was in school, whether she was working, whether she moved out of her parents’ house and/or living out on her own, whether she moved, and whether she felt satisfied with her life (used to evaluate happiness).

Achievement of 12.9 % ( n = 133) of life plans could not be measured because they were either too vague or appropriate data to verify if the goal was achieved was unavailable. For example, vague unmeasurable goals included: “I hope and think I’m going to be more on track—more stable. Getting everything straightened up” and “Hopefully be in a better more stable place.” Wanting greater stability in the future was a common unmeasurable theme. Goals that were unmeasurable also included those for which no information was collected such as goals about car ownership, being in a good relationship with a new partner, and participants’ hopes for family members’ achievements.

Among the 899 aspirational plans that were measurable, 47.3 % were achieved. There was no difference by study group in the achievement of aspirational plans among women who reported them—Parenting Turnaways: 46.2 %, First Trimesters: 44.7 %, Near-Limits: 48.3 %, the Non-Parenting Turnaways: 52.3 % (not shown in tables). Among the measurable aspirational plans, women were most likely to achieve child-related plans (88.9 %), which most often entailed having a new baby. Women were also highly likely to achieve their financial (72.9 %) and other plans (72.5) within one year. They were least likely to achieve their educational (30.9 %) and relationship status (18.0 %) plans (Table  2 ). There were no significant differences in achievement within each plan type by study group.

However, among all measurable plans ( n = 1,024), Near-Limits (45.6 %, AOR = 1.91, p = 0.003) and Non-Parenting Turnaways (47.9 %, AOR = 2.09, p = 0.026) were significantly more likely to have both an aspirational plan and to have achieved it than Parenting Turnaways (30.4 %) (see Table  3 ).

This study found that women who were denied an abortion were less likely to have aspirational one-year plans than those who obtained an abortion. Those who were denied an abortion were more likely to have neutral or negative expectations for their future. Whether or not a person has aspirational plans is indicative of her hope for the future. Without such plans or hopes, she misses out on opportunities to achieve milestones in life.

These findings suggest that shortly after being denied an abortion, many Turnaways may have scaled back their one year plans knowing that they were going to have to carry an unwanted pregnancy to term. Turnaways likely changed their one year plans in two ways after learning of being denied an abortion: First, they often incorporated their forthcoming child into their aspirational one-year plans; these child-related goals were often achieved simply by carrying the pregnancy to term. Turnaways were significantly less likely to have vocational goals compared to women who obtained an abortion, likely because employment-related goals felt unattainable while parenting a newborn. Second, women who were denied a wanted abortion were adjusting to the idea of carrying an unwanted pregnancy to term and likely changed from having more aspirational one-year plans to more neutral or negative expectations for the future.

The greater focus on relationship goals among women in the Near-Limit group may reflect their desires for new and better relationships; women who have an abortion may feel free to leave poor relationships compared to women who are going to have a child with the man involved in the pregnancy. Indeed, as reported in other papers from these data, one-third of participants reported their partner as a reason to have an abortion, including poor relationships and undesirable characteristics for fatherhood [ 14 ] and women denied an abortion were slower to end a relationship with the man involved in the pregnancy compared to Near-Limits who received their wanted abortion [ 15 ].

In addition to the straightforward goals of gaining employment or education, many women mentioned personal psychosocial goals they wanted to achieve. A strength of this study is that many points of data on a wide variety of psychosocial and emotional outcomes were available, including life satisfaction, anxiety, and depression allowing us to assess achievement in goals related to mood and happiness which were relatively common. One construct that was not measureable was stability, a common theme among women’s visions for the future. Future studies should aim to measure life stability as well as other emotional outcomes to understand how they are affected by pregnancy decisions.

A strength of the study was the use of appropriate comparison groups to understand the effects of abortion. All of the women in our sample had unintended pregnancies and all sought abortion. Comparing those who were denied an abortion to those who received a wanted abortion allows us to control for any unobserved characteristics that would be associated with abortion-seeking for example, the life circumstances that brought women to their abortion decision. In addition, confounders thought to affect our outcome measures were controlled for.

While most women in all groups had positive one-year plans, fewer than half of the goals were achieved within one year. In other words, many women overestimated what they could achieve in one year.

This study has several limitations. First, the Turnaway study is limited to fewer than one thousand women and many women who were invited to participate declined. This study’s participation rate is in line with other longitudinal studies [ 16 , 17 ] yet the women who declined to participate may be different from those who agreed. This analysis enjoyed a relatively high one-year follow-up rate (86 %) with no differentials in the kinds of plans reported by those who completed the one-year interview and those who did not. Additionally, due to sample size limitations, the analysis was unable to determine achievement by specific theme of the goal. Another limitation is that the analysis was unable to evaluate whether all goals were met and for some goals, measurement may have been imprecise, for example, the timing of residential moves. Finally, because many Turnaways likely changed their goals after learning they were denied an abortion, it could not be determined how abortion (or being denied an abortion) affected the women’s original goals, before some learned they were going to have to carry to term. Future studies should attempt to assess personal goals before unintended pregnancy to further understand the effect of abortion on life course outcomes.

This study demonstrates that women who receive a wanted abortion are better able to aspire for the future than women who are denied a wanted abortion and must carry an unwanted pregnancy to term. Support for a woman to have access to abortion is often based on a belief that when faced with an unintended pregnancy, women who have an abortion have better life course trajectories than women who carry their unintended pregnancies to term. There is a belief that access to abortion is important for equal opportunities for women and for their financial stability [ 7 ]. These findings provide evidence to support this premise.

Women seek abortion for a range of reasons tied to their individual life circumstances and stage of life and oftentimes for the profound effects they perceive that having a baby would have on their life plans. Our analysis is unique because it allowed women to express their life plan in their own words. This study shows that abortion enables women to aspire for a better life in the future and achieve these goals.

Biggs MA, Gould H, Foster DG. Understanding why women seek abortions in the US. BMC Womens Health. 2013;13(1):29.

Article   PubMed   PubMed Central   Google Scholar  

Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Reasons U.S. women have abortions: quantitative and qualitative perspectives. Perspect Sex Reprod Health. 2005;37(3):110–8.

Article   PubMed   Google Scholar  

Kirkman M, Rowe H, Hardiman A, Mallett S, Rosenthal D. Reasons women give for abortion: a review of the literature. Arch Womens Ment Health. 2009;12(6):365–78.

Mackinnon CA. Reflections on sex equality under law. Yale Law J. 1991;100(5):1281–328.

Article   Google Scholar  

Siegel RB. Sex equality arguments for reproductive rights: their critical basis and evolving constitutional expression. Emory LJ. 2006;56:815.

Google Scholar  

Jaggar AM. Abortion rights and gender justice: an essay on political philosophy. In: Tooley M, Devine PE, Wolf-Devine C, editors. Abortion: three perspectives. edn. New York and Oxford: Oxford University Press; 2009. p. 144.

PerryUndem Research/Communication, National Institute for Reproductive Health. Abortion in women’s lives: exploring links to equal opportunity and financial stability. Washington, DC: 2014. p. 1–14.  http://www.nwlc.org/sites/default/files/nirh_abortion_womens_lives.pdf

Zabin LS, Hirsch MB, Emerson MR. When urban adolescents choose abortion: effects on education, psychological status and subsequent pregnancy. Fam Plann Perspect. 1989;21(6):248–55.

Article   CAS   PubMed   Google Scholar  

Fergusson DM, Boden JM, Horwood LJ. Abortion among young women and subsequent life outcomes. Perspect Sex Reprod Health. 2007;39(1):6–12.

Gould H, Perrucci A, Barar R, Sinkford D, Foster DG. Patient education and emotional support practices in abortion care facilities in the United States. Womens Health Issues. 2012;22(4):359–64.

Pazol K, Creanga AA, Burley KD, Hayes B, Jamieson DJ, Centers for Disease C, Prevention. Abortion surveillance - United States, 2010. Morb Mortal Wkly Rep Surveill Summ. 2013;62(8):1–44.

Dobkin L, Gould H, Barar R, Ferrari M, Weiss E, DG F. Implementing a prospective study of women seeking abortion in the United States: understanding and overcoming barriers to recruitment. Women’s Health Issues. 2013;24(1):e115-23. 

Upadhyay UD, Weitz TA, Jones RK, Barar RE, Foster DG. Denial of abortion because of provider gestational age limits in the United States. Am J Public Health. 2014;104(9):1687-94.

Chibber KS, Biggs MA, Roberts SC, Foster DG. The role of intimate partners in women’s reasons for seeking abortion. Womens Health Issues. 2014;24(1):e131–8.

Mauldon J, Foster DG, Roberts SC. Effect of abortion vs. carrying to term on a woman’s relationship with the man involved in the pregnancy. Perspect Sex Reprod Health. 2015;47(1):11-8.

Rothman KJ, Greenland S. Modern Epidemiology. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.

Ejiogu N, Norbeck JH, Mason MA, Cromwell BC, Zonderman AB, Evans MK. Recruitment and retention strategies for minority or poor clinical research participants: lessons from the Healthy Aging in Neighborhoods of Diversity across the Life Span study. Gerontologist. 2011;51 Suppl 1:S33–45.

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Acknowledgements

The authors thank Alejandra Vargas-Johnson for her great efforts coding the one-year plans. They also thank Rana Barar, Heather Gould and Sandy Stonesifer for study coordination and management; Mattie Boehler-Tatman, Janine Carpenter, Undine Darney, Ivette Gomez, Selena Phipps, Brenly Rowland, Claire Schreiber and Danielle Sinkford for conducting interviews; Michaela Ferrari, Debbie Nguyen and Elisette Weiss for project support; Jay Fraser and John Neuhaus for statistical and database assistance and all the participating providers for their assistance with recruitment. This study was supported by research and institutional grants from the Wallace Alexander Gerbode Foundation, the David and Lucile Packard Foundation, The William and Flora Hewlett Foundation and an anonymous foundation.

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Authors’ contributions

UDU conceptualized the analyses for this paper, reviewed the literature, conducted the coding and statistical analyses, interpreted the results, and drafted the paper. MAB contributed to coding the data, interpreting the results, and revising the manuscript for important intellectual content. DGF conceptualized and led the overall Turnaway study design, led the data collection, and contributed to coding the data, interpreting the results, and revising the manuscript for important intellectual content. All authors read and approved the final manuscript and are accountable for all aspects of the work.

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UDU is a Public Health Social Scientist whose work encompasses two overarching themes: the effects of women’s empowerment and gender equity on reproductive health and improving access to reproductive health care for vulnerable populations.

MAB is a Social Psychologist whose research is dedicated to better understanding the barriers faced by economically disadvantaged populations in accessing reproductive health services so that policy can be designed to improve their social and health outcomes.

DGF is a demographer who uses quantitative models and analyses to evaluate the effectiveness of family planning policies and the effect of unintended pregnancy on women’s lives.

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Upadhyay, U.D., Biggs, M.A. & Foster, D.G. The effect of abortion on having and achieving aspirational one-year plans. BMC Women's Health 15 , 102 (2015). https://doi.org/10.1186/s12905-015-0259-1

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Received : 22 May 2015

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DOI : https://doi.org/10.1186/s12905-015-0259-1

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Women’s Perceived Barriers to Accessing Post-Abortion Care Services in Selected Districts in KwaZulu Natal Province, South Africa: A Qualitative Study

M. netshinombelo.

1 Department of Advanced Nursing, University of Venda, South Africa. Private Bag X5050, Thohoyandou, 0950, South Africa

M. S. Maputle

D. u. ramathuba, associated data.

Some raw data used to support the findings are included in the article can be made available from the corresponding author upon request. This manuscript was derived from the doctoral thesis.

Background:

Despite different interventions to curb unwanted pregnancies, repositioning Family Planning and post-abortion care services as critical priorities in health programme in Kwa-Zulu Natal, women are still admitted with induced abortion complications.

The aim was to explore challenges experienced by women who are accessing post-abortion care services at selected public hospitals.

A qualitative explorative, descriptive, and contextual approach was used. The population comprised all women who presented with incomplete abortion and had accessed PAC services in the selected hospitals. Purposive convenience sampling was used to select the 23 participants. Data were collected through in-depth interviews with all participants on discharge and analysed through open-coding method. Trustworthiness was ensured, by considering the criteria of credibility, dependability, applicability, and transferability. Ethical considerations were secured by requesting consent and permission to conduct the study. All interviews were voluntarily conducted following the ethically approved informed consent, anonymity and confidentiality were maintained.

Three themes emerged reflecting challenges from women’s perspectives on accessing post abortion care. These themes were: transportation barriers, stigma, and mistreatment (lack of analgesics, early discharge).

Conclusion:

Conclusion showed the description of perceived barriers and experiences related to accessing, seeking and care received during the process of PAC. Inaccessibility to PAC was due to poor road, poor mode, lack of transport and long distance from the community to the hospital, long waiting queues, stigma, and discrimination. The PAC services should be accessible with the increased number of facilities and adequately trained staff with functional equipment and guidelines. Value clarification workshops for health professionals are essential.

Introduction

The WHO defines abortion as the termination of a pregnancy, whether spontaneous or induced, before 22 weeks of gestation [ 1 ]. Unsafe abortion is defined as any procedure to terminate a pregnancy by persons lacking the proper skills and/or is performed in an unclean, non-medical setting [ 1 ]. Complications of spontaneous or induced abortion are the fourth leading direct cause of maternal mortality globally [ 2 ]. Post Abortion Care (PAC) needs to be introduced effectively to address these complications. PAC is a package of services offered to women after an incomplete abortion due to spontaneous or induced abortion [ 3 ]. PAC focuses on five primary elements, namely: treatment and management of incomplete abortion and complications, counseling, contraceptive and family planning services, reproductive and other health services, and community and service provider partnerships to prevent complications of unwanted pregnancies and unsafe abortion [ 4 ]. The procedures and technologies used includes manual/electrical vacuum aspiration (M/EVA), medication abortion (MA) drugs (Misoprostol and Mifepristone), digital (use of bare fingers) evacuation, forceps, and dilatation and curettage [ 5 ]. PAC is a package of interventions that has been shown to reduce abortion-related morbidity and mortality when available and of good quality [ 6 ]. Women in South Africa are affected mainly by unwanted pregnancies, which lead to illegal abortion [ 7 ]. A research study by Koster revealed that 12% of abortions reported were undoubtedly illegally induced [ 8 ]. The study further revealed three factors possibly associated with women having induced abortions. The majority of women report that their pregnancy was unwanted, 30.4% reported that they were not married or had extramarital sex and became pregnant.

Women experience barriers when needing to access the PAC services [ 9 ]. Lack of access to abortion services leaves women and young girls no other choice than unsafe abortion, thus placing a tremendous burden on the South African health system and making unsafe abortion one of the major contributors to maternal mortality in South Africa including KwaZulu Natal [ 10 ]. Most rural areas and many primary health centres do not offer any emergency stabilization or intervention for women with abortion complications before referral to the next level of care. Decentralization of PAC services are essential, bringing immediate life-saving care and preventing unnecessary deterioration of the woman’s condition when referral and transport are required. Women from rural areas travel long distances to access PAC services compared to women from urban areas. The long-distance estimated from the rural to urban area is 300 km in case of emergency when a woman needs tertiary service. One of the main challenges for women who access PAC services in KZN is the long distances they have to travel to access proper care in the hospital; poor roads and transportation further complicate this in their areas. This was corroborated by Perera et al. that delays in care-seeking due to various reasons, including lack of transport and concerns about costs [ 6 ]. Literature shows that increased distance to health facilities and poor local transportation impedes accessibility to the primary and secondary health care services as well as that the delayed health care provision can worsen people’s health [ 11 , 12 ]. Post-abortion care services should be available and provided to all women who have suffered from complications of abortion. Women and health care workers play a significant role in providing post-abortion care services, however, their religious and cultural beliefs play an essential role in the provision of safe abortion and post-abortion care [ 13 ].

South Africa legalized abortion in 1996 through the Choice in Termination of Pregnancy Act [ 14 ]. Despite the legalization of abortion, the negative attitudes and judgemental behaviours surrounding abortion are enormous and call for urgent actions. Women reported stigma, from health care workers as what keeps them away from the facility and drives them to seek abortion services from traditional birth attendants and bogus doctors who offer unsafe abortions that lead to abortion-related complications and increasing morbidity and mortality [ 9 ]. A study by Gebreselassie found that women tend to be reluctant to seek post abortion care due to fear of ill treatment from the health care workers, especially if they have undergone an illegal abortion [ 15 ]. Shellenberg et al. and Adee et al. reported that two out of three women experienced stigma following abortion, hence most women prefer to keep their abortion secret [ 9 , 16 ].

Women’s access to abortion is determined by legal restrictions that vary across the country and the geographic availability of abortion clinics. In South Africa, new restrictions against the procedure were introduced in Choice on Termination of Pregnancy (CTOP Act), 1996 [ 14 ]. According to CTOPA, a woman can procure an abortion under the following conditions: (1) Within the first 12 weeks of gestation, a woman may terminate her pregnancy on demand. (2) Between 13 and 20 weeks gestation, a woman may terminate her pregnancy if her medical practitioner, after having consulted with the patient, determines that her pregnancy will threaten her mental or physical health; the fetus may be subjected to acute physical or mental disability; pregnancy arose out of rape or incest; or her pregnancy will detrimentally affect her socioeconomic standing. (3) After 20 weeks gestation, a woman may only terminate her pregnancy if her medical practitioner, after consulting with another medical practitioner or registered midwife, determines that the patient’s life is in jeopardy; there is acute malformation of the fetus; or the fetus could be significantly injured during delivery. Most of these restrictions severely curtail women’s access to the procedure by limiting women’s ability to obtain the procedure and physicians’ or clinics’ ability to offer it [ 17 ]. Additional restrictions that do not allow medical practitioners, without accreditation, are in place to discourage providers from opening the clinics and that makes it more difficult for women to access the procedure. Following the accessing of the procedure may accompanied by psychological trauma. Despite different interventions to curb unwanted pregnancies and repositioning of Family Planning (FP) as a critical priority in health programme in KwaZulu Natal (KZN), women are still admitted with induced abortion complications, presumably resulting from unsafe procedures outside these district hospitals [ 18 ]. KwaZulu Natal Districts Health Information System: 2018/19 statistics (April 2018 to March 2019) indicated that 4 869 women experienced incomplete abortions and 183 septic abortions, while the rural areas experienced 2 541 incomplete abortions and 103 septic abortions respectively. Furthermore, women who experience complications also faced challenges in accessing post-abortion care.

The results of unsafe abortion complications depended on the accessibility and quality of PAC services and implementation of guidelines and the capability of women to seek care [ 19 ]. This study aimed to explore challenges experienced by women who were accessing PAC services at selected districts of KZN.

A qualitative approach and explorative, descriptive, and contextual designs were used. The study was conducted in 2019 at 23 hospitals in five selected districts in KwaZulu-Natal: eThekwini, uMgungundlovu, Harry Gwala, uMzinyathi and King Cetswayo (as a subsection of the Ph.D. study) [ 20 ]. The five districts were selected because of incomplete and septic abortions statistics.

Population and sampling

The population comprised all women who presented with incomplete abortion and had accessed PAC services in the selected public hospitals. Twenty-three women, one from each hospital, agreed to participate and were purposely sampled. Women were recruited for interviews by the researcher on discharge. Convenience sampling was employed, and women were recruited irrespective of age and those who refused to participate were excluded from the study. All hospitals in the province that were providing PAC were included in the study and a total of 23 hospitals were purposively sampled.

Ethical considerations

Ethical standards were ensured by obtaining the ethical clearance (Ref: SHS/17/PDC/15/1808), from the University of Ethics Committee, permission to conduct the study from the KZN Provincial Department of Health, the hospital Chief Executive Officer, unit managers, and the participants. Ethical principles of informed consent, privacy, anonymity, confidentiality, and rights to self-determination were adhered to. Participants signed informed consent before participating. The data collection was done in a separate room to guarantee anonymity, privacy, and confidentiality maintained by reporting the coded findings.

Data collection

Data were collected through unstructured face-to-face interviews to gain a detailed narrative of participants on the perceived challenges experienced when accessing post-abortion care services. The researcher requested that the unit manager allocate a quiet room to ensure comfort and privacy during the interview. Central opening questions initiated the interview: “ Kindly share with me the barriers you experienced and the support you received when accessing post-abortion care service .” The interviews were conducted by researchers in the participants’ local language (isiZulu), and each lasted between 30–45 minutes. Permission to use the voice recorder was obtained from participants.

Data analysis

The narrative data from the in-depth individual interviews were analyzed qualitatively using Tesch’s open coding method as postulated by Creswell [ 21 ]. The recorded interviews were translated into English by a language expert. They transcribed word by word, and the nonverbal cues (for example, silence/sigh, frowns, and lean back) were included in the transcripts. All transcripts were read to give meaning, and a list of similar topics clustered. Data were grouped according to categories and sub-categories and field notes were also coded and categorized. A literature control was done to control the results of the study.

Trustworthiness

As outlined in Polit and Beck [ 22 ], the criteria for ensuring trustworthiness were adhered to. Credibility was ensured through prolonged engagement during data collection. The researcher met with the participant to establish rapport and to make an appointment. During the interviews, the researcher spent time with the participants listening to and observing them as they were interviewed. The participants were interviewed to the point at which there was data saturation. A member check was also conducted to validate the truth and confirm the findings. The voice recorder was used to ensure credibility. Transferability was ensured by thick descriptions of the research methodology. The recorded interviews were transcribed verbatim, and the nonverbal cues (for example, silence/sigh, frowns, and lean back) were included in brackets of the transcripts to ensure authenticity. Researchers undertook a qualitative approach to mitigate potential bias and the researcher adhered to the principle of bracketing which is a method used to mitigate the potential deleterious effects of unacknowledged preconceptions related to the research and thereby to increase the rigor of the project.

Presentation of findings

Table 1 present the demographic profile of participants. In this study, there was 52% of single women followed by 35% of married women. The results concur with studies that were done in Nigeria and DR Congo, that single women and women with higher incomes presented more for PAC compared to married, older, and poorer women [ 23 , 24 ]. However, the study by Erko et al. revealed that married women were 6.7 times more likely to utilize post-abortion family planning than unmarried women [ 25 ]. It was thought that married women may be likely to be having sex more regularly than unmarried women, which may explain their high post-abortion family planning utilization [ 26 ]. With parity, the results revealed that 39% of women were nullipara. Contrary to the study that was conducted in Zimbabwe, PAC patients were of higher parity women, while nulliparity was common among women seeking treatment for complications of unsafe abortion [ 27 ]. More women (48%) were not on any contraceptive methods with only 39% were using injectatbles.

Demographic profile of participants (n = 23).

Themes emerged from raw data

Three themes emerged reflecting challenges from’women’s perspectives on accessing post-abortion care. These themes were: (1) transportation barriers (2) experiences of stigma when seeking PAC, and (3) mistreatment (lack of analgesics, early discharge. Postabortion contraceptive counselling was provided, however, some participants felt it was hurried. The findings were discussed and supported by the literature. Narratives from participants were coded in numbering format and district.

Theme 1: Transportation barriers

The findings indicate that women always present at the health facilities late. One of the main challenges faced by women who accessed PAC services was the long-distance travelled to access proper care in the hospital. This was further complicated by poor roads and mode of transport in rural areas. This was supported by several respondents, as shown in the following:

Participant 5 from district A:   Getting to the hospital took a toll on me, and it was awful. It was raining that day; of all the days, it’s raining. I had to take two buses just to get to that appointment. It was the longest day that I can remember having for a long time . Participant 1 from district D:   I stay very far from the clinic. I started bleeding while at home early in the morning. My mother-in-law called an ambulance. The ambulance took 3 hours to arrive, and I felt like I was almost dead because I had lost too much blood . Participant 4 from district D:   I had to travel and change three taxis to come to this hospital, and when I was here, I was given another date to come back again . Participant 2 from district E:   I took some herbs and started bleeding after a day, and I thought the bleeding would stop. The bleeding went on for four days. I went to the clinic and was told to go to the hospital. I had to travel 259 km to come to this hospital, and when I was there, I was given another date to come back, but I couldn’t return .

Another challenge cited was the transport from the primary health care facility to the referral hospital. There were no ambulances as cited by:

Participant 3 from district E:   I was transferred from the local clinic to this hospital and it was so difficult to get here, I had to wait for three hours for an ambulance to come and collect me .

The long distance and attitudes of health workers may have played a role in delay and inaccessibility to PAC in KZN.

Theme 2: Experiences of stigma when seeking PAC

Although abortion is legalized in many developed countries, including South Africa, during data collection, women expressed various ways in which they were being stigmatized for seeking the service in the health institutions. Women reported being labelled as killers, sinners, and mothers of devils. They are told they are a bad influence on the young girls in the community. The following the quotations were cited by participants:

Participant 5 from district A:   I was told that I would never have kids in my life because of the abortion, and when I die, the baby will be waiting for me in heaven crying . Participant 5 from district B:   They see me as a bad girl, and they say that I always sleep around with married men. The other nurse told me I must not associate myself with other young girls because I would teach them how to do an abortion. I felt that I was neglected at the hospital, and I felt like dirt .

Health care providers’ negative attitudes and behaviours towards a woman who was admitted for post-abortion treatment was very concerning. The quote as cited by one participant was:

Participant 4 from district E:   I was admitted with the women who delivered their live babies and the attitude of the health care worker towards me was appalling. The nurse was shouting at me, saying that other women have babies and I have aborted mine. Her words are still haunting me even today . Participant 1 from district C:   The health care worker threatened to call the police to come and arrest me. “It is a sin. I can’t help you because backstreet abortion is against the law .” Participant 3 from district B:   When I arrived at the hospital, I was in pain, and I told the clerk at the reception that I was here for post-abortion care, and he told me that I must go to the next window to get the file because he doesn’t deal with abortion women who are killers .

The findings pointed out that women delayed seeking PAC service even though they were aware of its availability due to fear of stigma and discrimination from the health care workers and the community.

Theme 3: Mistreatment (lack of analgesics, early discharge)

Women complained that they received no medication for managing the pain during the uterine evacuation and they identified the lack of analgesics as inhuman. The following quotes were cited:

Participant 4 from district E:   When I was asked to come in for the procedure, the nurse did not explain anything to me or tell me what she would do. She only asked my age and if I had had an abortion before. No medication was given to me; instead, she put an instrument inside my private part and started cleaning me up. I was screaming, and she kept saying scream like the time when you were sleeping with your boyfriend . Participant 1 from district E:   I felt horrible pain when the doctor started cleaning my womb. When I told him that I am in pain, he told me you deserve it . Participant 3 from district C:   I was bleeding profusely and was told that the doctor is still busy with “emergencies,” the doctor came to assist in evacuating left me with the nurse to clean me up. Immediately after the procedure, I was asked to get out of bed, and it was not easy for me to walk out, the pain was too much. I was told to go home and come back after two weeks . Participant 1 from District C:   They gave me three pills, and then immediately after I swallowed, I started having cramping and heavy bleeding and everything. I was told to go back home because I had cramping and bleeding and was just very uncomfortable. And they said that abortion would take place at home. They did not say anything about me coming back to the hospital for post-abortion care .

Women were discharged early after evacuation, as hospital beds were insufficient to keep them in the hospital. The quotes below confirm this:

Participant 3 from District C:   Because of the shortage of beds, I was discharged on the same day after receiving PAC service . Participant 2 from District E:   I was surprised when I was discharged from the hospital without any antibiotics or pain killers. When I tried to ask the nurse, she told me that everything was done for me, I can go home .

Participants voiced their grievances about how they were treated by health care providers when presenting for PAC. Contrary to the earlier quote, one participant received health information from health care providers. The following quotation confirmed this:

Participant 4 from district E:   The nurse sat down with me and talked about the dangers of not taking antibiotics and the importance of finishing them to protect myself from the infection .

However, women who reported spontaneous abortion (miscarriage) were given preference, making women with induced abortion delay seeking PAC services.

Discussion of findings

Despite evidence that shows that post-abortion care reduces maternal morbidity, mortality, and facilitates the use of contraceptives, the findings revealed barriers experienced when accessing PAC, resulting in a delay in seeking care [ 28 ]. In South Africa, induced abortion is permitted on medical or on broader socio-economic grounds, however, women still resort to abortion performed by unskilled providers or in unsafe conditions because of barriers that impede access to safe abortion [ 29 ]. Such barriers include distance, lack of information, economic constraints, and lack of confidentiality. Participants who resided very far from the health facilities cited lack of transport as a barrier to access PAC services. Consistent with the findings of this study, poor transportation was identified as a barrier to post-abortion care in Uganda as the geography and geographical barriers had various impacts on access to post-abortion services [ 30 ]. Peters et al. and Vlassoff et al. corroborated that increased distance to health facilities and poor local transportation impedes accessibility to primary and secondary health care services [ 12 , 31 ]. Even though the PAC services are free, local transportation results in indirect costs [ 32 , 33 ]. Participants mentioned that hospitals were not having the adequate number of ambulances to fetch women in rural areas, which delays care and leads to PAC complications. The findings were supported by Zaaijman, that the South African Human Rights Commission highlighted the poor health service delivery in rural areas, like insufficient ambulance services [ 34 ]. It also stressed that poor road conditions in remote areas further lead to inaccessibility even if an ambulance were available. The lack of adequate and reliable transport was a significant impediment to rural healthcare delivery, delayed health care provision, and worsened people’s health [ 12 ]. Women had rights to access safe and legal abortion, however, CTOPA, 1996 states the conscientious objection of providers who do not wish to perform abortions is supported by the constitutional rights of all South Africans to freedom of thought, belief and opinion [ 14 ]. The Act further indicates that providers who refuse to perform an abortion must give patients accurate abortion related information of the relevant provider. When the legal abortion services are not assessible or available, women seek help outside the established legal health system, and that brought serious implications on women’s reproductive health and well-being [ 35 ]. Jones and Jerman found that of those who provided abortion services, 96% do so at eight weeks of gestation [ 36 ]. Accessing a legal abortion provider is a challenge to many women, which may explain why abortion rates have declined. More women have greater access to physicians and the posters on the street poles advertising abortion services than they do to clinics, yet few doctors perform the procedure due to lack of training, disinterest, and controversy surrounding the topic.

The study’s findings were consistent with Gebreselassie and Faundes et al. who found that women tend to be reluctant to seek post-abortion care due to fear of ill-treatment from the health care workers, especially if they have undergone an illegal abortion [ 16 , 37 ]. Tagoe-Darko also confirmed that women might hesitate for fear of experiencing disrespect or abuse from providers [ 38 ]. The women were cited to have experienced emotional, physical, and psychological trauma. Most health care workers demonstrated negative perceptions toward PAC services, stating their religious beliefs or conscientious objections [ 39 ]. The attitudes of health care workers were cited as the barrier to accessing the PAC services. Most staff members were not willing to provide care and to share information pertaining to abortion services and this lack of information lead inaccessibility to PAC services, delay and to complications. Stigma and discrimination were experienced by participants. Quinn and Chaudior found that women delay seeking post-abortion care if stigmatized because they were protecting themselves from being the victims of discrimination [ 40 ]. This was confirmed by Perera et al. and Yegon et al. that stigma and poverty, nonetheless, also played a vital role in influencing the decision-making process [ 6 , 41 ]. Demtsu et al. reported an association between the provision of PAC services, religious, cultural beliefs, morals, and values in terms of care of women seeking PAC services [ 42 ].

According to the CTOP Act no 92 of 1996 every woman, regardless of age, race, or background who considers post-abortion care service needs a non-directive professional pre-and post-counseling [ 14 ]. Again, according to WHO recommendations, all women should be routinely offered pain medication for example, NSAIDs like diclofenac 25mg thirty minutes before the procedure and ibuprofen 200mg three times a day post-abortion care [ 1 ]. However, findings revealed that undergoing an evacuation procedure was a harrowing experience. They were not given any analgesics before the procedure or any pre and post counseling. The discharge was immediately after the evacuation procedure, but participants cited self-care and coping deficits if bleeding and pain doesn’t subside when at home. But this was practised due to a shortage of beds at the facility. Health care workers are expected to ensure that the women are given PAC counselling and family planning before discharge and provide assessment and ongoing referral for more specialist treatment if required. It was also confirmed by Savelieva et al. that family planning counselling contribute to success in pregnancy prevention [ 43 ].

Findings revealed that women who accessed PAC identified a lack of facilities that offered PAC service in rural areas. The long distance, poor road and poor mode of transport were barrier to accessing the services. Findings suggest that while some barriers are not unique to PAC, others may be specific to PAC, especially abortion stigma. Women delayed seeking PAC service even though they were aware of its availability due to fear of stigma and discrimination from the health care workers and the community. The attitudes of health workers may have played a role in delay and inaccessibility to PAC services. Other women complained that they received no medication for managing the pain during the uterine evacuation, and they identified the lack of analgesics to be inhuman. These contributed to inaccessibility to PAC services in the selected health facilities.

Recommendations

The PAC services should be accessible with the increased number of facilities and adequately trained health care workers with functional equipment and guidelines. Values clarification activities should also address stigma and bias among health workers to ensure respectful care. In addition, health workers should address the abortion stigma among women. Postabortion family planning counseling should be encouraged to provide universal access to postabortion family planning before the woman leaves the facility [ 44 ]. Facilitate the establishment of community empowerment activities through community awareness and mobilization [ 39 ]. It is essential to disseminate the findings to the Department of Health, Maternal and Child Health Directorate for them to prioritize addressing the barriers to ensure that women have access to this critical life-saving care.

Data accessibility statement

Acknowledgements.

Researchers would like to acknowledge all women accessing PAC services and who agreed to participate in this study, KwaZulu-Natal Provincial Department of Health, and the hospital Chief Executive Officers who granted permission to conduct the study.

Funding Statement

The University of Venda Research and Publication Committee for financial support.

Abbreviations

PAC – post-abortion care

CTOPA – Choice for Termination of Pregnancy Act

Funding information

Competing interests.

The authors have no competing interests to declare.

Author contributions

M.N collected data and drafted this manuscript. D.U.R who was the co-promoter and who conducted the literature review, M.S.M was a promoter and participated in the correcting and finalising the article.