The incidence of induced abortion in Nigeria: Levels and trends

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1 The incidence of induced abortion in Nigeria: Levels and trends Akinrinola Bankole, Guttmacher Institute Isaac F. Adewole, University of Ibadan Rubina Hussain, Guttmacher Institute Olutosin Awolude, University of Ibadan Background Each year in Nigeria, hundreds of thousands of women have unintended pregnancies, many of which end in abortion. According to a community based study, 28% of Nigerian women had an unwanted pregnancy; and half of those women (14%) reported that they attempted to have an abortion and 10% actually succeeded in terminating the pregnancy. i Low levels of contraception use undoubtedly contribute to the high prevalence of unintended pregnancies only 15% of married women use any method of contraception and 8% use a modern method. ii Furthermore, one in five married women does not want a child soon and is not using any method of contraception. A landmark 1996 study estimated that there were 610,000 induced abortions in Nigeria, translating to a rate of 25 abortions for every 1,000 women. iii Because abortion is illegal except to save a woman s life, most procedures are clandestine, and many are carried out either under unsafe circumstances or by untrained providers. Unsafe abortions may lead to serious complications that endanger women s health and life and impose heavy socioeconomic burdens on women, their families and Nigeria s already limited healthcare infrastructure. According to a 2007 study it costs the Nigerian health system an estimated $19 million to treat complications resulting from unsafe abortion. iv The study found that one in four women who had an abortion experienced serious complications, directly leading to the thousands of hospitalizations due to abortion complications in Nigeria annually. i Furthermore, abortion complications contribute to Nigeria s high maternal mortality ratio (MMR) of 610 deaths per 100,000 births one of the highest levels in the world. v

2 Since the 1996 study, there has been no new abortion incidence estimates for Nigeria. As the country continues to urbanize and the healthcare system becomes more privatized, the context in which abortion occurs as well as the prevalence of it may have changed. Abortion, however, remains largely illegal and culturally taboo, and information on the procedure in Nigeria is difficult to obtain. Directly estimating abortion incidence solely through women s own reports is likely to result in an underestimate of the magnitude. In this study we use the same indirect estimation techniques used in the 1996 study to update the number and rate of induced abortion as well as hospitalization due to complications from unsafe abortion in Nigeria and to examine the trends in abortion incidence, nationally and regionally. Methodology Data for the proposed paper come from two surveys: a nationally representative survey of health facilities (HFS) which provides the number of women treated in Nigerian public and private health facilities for abortion complications, and a survey of a purposive sample of health professionals (HPS) knowledgeable on the issues of abortion in the country which is used to estimate the likelihood of women experiencing abortion complications. These surveys were modeled after previous surveys developed by the Guttmacher Institute, including the ones used in the first abortion incidence in Nigeria in Some modifications were made to capture more information and take into account the changing context within the country. Health Facility Survey (HFS) A recent listing of government owned and private sector facilities was the basis for the HFS sample. A nationally representative sample of health facilities that are likely to provide post abortion medical care was drawn from this universe. The sample included facilities in 18 selected states within each of the six geopolitical zones. The states and the

3 facilities were selected in a way that will allow us to develop weights that will be applied to the data collected from the sample to make it nationally representative. The facilities surveyed included the following types: Federal medical centres (FMCs), teaching hospitals, general hospitals, specialist hospitals, other private hospitals, private clinics, comprehensive health centres (CMCs), and maternity centres. At each selected facility, a senior staff member who was knowledgeable about the facility's provision of postabortion care was asked to participate in the survey-- generally the chief of the Obstetrics and Gynecology department of hospitals or the director of the facility in the case of public health centers or clinics. The senior staff member could be an obstetrician/gynecologist in the case of hospitals, but in the case of smaller facilities, the key informant was often a medical doctor, medical officer, nurse, midwife, or a community health officer (CHO) or community health extenstion worker (CHEW) in a position of authority. This survey collected information from the provider respondent about the number of women that the facility treated for complications from both spontaneous and induced abortions in the past month, in an average month. It also collected information about the capacity of the facility as well as the perception of the provider of the burden of post abortion case load to the health facility. Health Professionals Survey (HPS) The HPS interviewed a purposive sample of knowledgeable professionals who are well informed about abortion provision in Nigeria. These interviews sought information on the conditions under which women obtain abortions (methods, providers, costs), differentiating between rural and urban women and between poor and non poor women for certain key questions. This survey obtains information that permits estimation of the proportion of women who are likely to receive care in a facility should they have an abortion and experience abortion complications, a parameter which is essential for estimating the total number of abortions nationally and regionally. The issue of women who experience abortion complications but who do not obtain medical care is highly relevant for Nigeria, given that approximately two-thirds of the population resides in

4 rural areas and has inadequate access to medical and hospital care. ii Fieldwork Fieldwork took place from July 2011 until July The interviewers were all health professionals and they conducted interviews in facilities located in the geopolitical zone in which they worked or resided. Data were entered at the University of Ibadan using a double entry process followed by the correction of inconsistencies using the questionnaires as the basis. Cleaning of the data took place at the Guttmacher Institute in collaboration with the University of Ibadan. Analysis Using the data from the two surveys described above as well as information from other sources including national and regional estimates of women of reproductive age and the annual number of births we calculated the total number of induced abortions and abortion rates (the number of abortions per 1,000 women of reproductive age per year) for Nigeria as a whole as well as for its six geopolitical zones. In addition, we are able to estimate the number of women treated in facilities for abortion complications, and the rate per 1,000 women of reproductive age. To obtain these estimates we applied the indirect estimation procedure called the Abortion Incidence Complications Method (AICM) developed by Guttmacher Institute. vi This methodology has been used to estimate the incidence of induced abortion in several countries with restrictive abortion laws, such as Nigeria. Preliminary results A total of 1039 health facilities were surveyed in 18 states, yielding a total response rate of 94%. Of the facilities surveyed, 46% were public or government owned, 50% were private facilities and the remainder were either mission, faith-based or NGO facilities. Teaching hospitals and FMCs, and most general hospitals and CMCs were public facilities, while a larger proportion of specialist hospitals and clinics were privately

5 owned. Maternity centers surveyed were both publicly and privately owned facilities. The health facilities were distributed across all six geopolitical zones, however, a lower proportion of the total interviewed were in the North West and South South zones where there was difficulty in reaching all the facilities. Nearly 75% of facilities surveyed offered postabortion care (n=758) and 14% of those facilities had a separate postabortion ward. About two-thirds of facilities that treated postabortion patients had functional manual vacuum aspiration (MVA) equipment and 75% had someone on staff trained to perform an MVA. Postabortion patients were most commonly seen as both outpatient and inpatients (82%), but about 10% of facilities treated PAC cases as outpatient only. The respondents in the Health Professional Survey consisted of approximately 50% medical providers (obstetricians/gynecologists and general practitioners, midwives and nurses) and 50% other professionals including researchers, lecturers, advocates, policymakers, program managers and policy makers. Three out of four respondents worked in the public sector. Particular effort was be made to ensure that there was sufficient representation of experts with some work experience and knowledge of rural areas. About 12% of respondents currently worked in rural areas, and 43% had worked in rural areas for at least six months in the past five years. References i Bankole A et al., Unwanted Pregnancy and Induced Abortion in Nigeria: Causes and Consequences, New York: Guttmacher Institute, 2006; Bankole A, Sedgh G, Oye-Adeniran B, Adewole I, Hussain R and Singh S, Abortion-seeking behaviour among Nigerian women, Journal of Biosocial Science, 40(2): ii National Population Commission (NPC) [Nigeria] and ICF Macro Nigeria Demographic and Health Survey Abuja, Nigeria: National Population Commission and ICF Macro. iii Henshaw SK, et al., The incidence of induced abortion in Nigeria, IFPP, 24(4), iv Bankole A et al., Estimating the cost of post-abortion care in Nigeria: a case study, in: Lule E, Singh S and Chowdhury SA, ed., Fertility Regulation Behaviors and Their Costs: Contraception and Unintended Pregnancies in Africa and Eastern Europe & Central Asia, Washington, DC: World Bank, 2007

6 v WHO, UNFPA, UNICEF and World Bank, Trends in Maternal Mortality: , Geneva: WHO, vi Singh S, Garcia SG, Guillaume A, Okonofua F, and Prata N, The health, social, and economic consequences of unsafe abortion: papers presented at an IUSSP seminar, Mexico, 2010, International Journal of Gynecology & Obstetrics, 2012, 118(2 Suppl.):S63-S64. Table 1a. Number of each type of facility surveyed by location (geopolitical zone) Geopolitical zone North North North South South Total Type of facility Central East West South East South West (N) % Teaching Hospital/ Federal Medical Centre (FMC) General Hospital Other Hospital Clinic Comprehensive Health Centre (CMC) Maternity Centre Other Total N % Table 1b. Number of each type of facility surveyed by ownership Ownership of facility Total Mission/ Type of facility Public Private NGO N Teaching Hospital/ Federal Medical Centre (FMC) General Hospital Other Hospital Clinic Comprehensive Health Centre (CMC) Maternity Centre Others Total N * % *21 facilities were missing information on ownership

7 Table 2. Characteristics of health professional respondents Characteristic N % Primary profession General physician Obstetrician/Gynaecologist Other medical professional Program manager/health administrator Lecturer/Teacher Policy maker/politician Activist/Lawyer Researcher Media Other Sector of work Private sector Public sector Mission/Faith based Location of work Urban Sub-urban Rural--currently Rural--ever in past 5 years Total

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