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Unsafe abortion continues to impact negatively on women’s health in countries with restrictive abortion laws. It remains one of the leading causes of maternal mortality and morbidity. Paradoxically, modern contraceptive prevalence remains low and the unmet need for contraception continues to mirror unwanted pregnancy rates in many countries within sub- Saharan Africa. This qualitative study assessed women’s knowledge; their expectation and experiences of the methods employed for abortion; and their health care-seeking decisions following a complicated abortion. Women who presented with abortion complications were purposively sampled from seven health facilities in south-west Nigeria. In-depth interviews were conducted by social scientists with the aid of a semi-structured interview guide. Coding schemes were developed and content analysis was performed with WEFTQDA software. Thirty-one women were interviewed. Misoprostol was used by 16 women; 15 women used other methods. About one-fifth of respondents were aged ≤20 years; almost one-third were students. Common reasons for terminating a pregnancy were: “too young/still in school/ training”; “has enough number of children”; “last baby too young” and “still breastfeeding”. Women had little knowledge about methods used. Friends, nurses or pharmacists were the commonest sources of information. Awareness about use of misoprostol for abortion among women was high. Women used misoprostol to initiate an abortion and were often disappointed if misoprostol did not complete the abortion process. Given its clandestine manner, women were financially exploited by the abortion providers and only presented to hospitals for post-abortion care as a last resort. Women’s narratives of their abortion experience highlight the difficulties and risks women encounter to safeguard and protect their sexual and reproductive health. To reduce unsafe abortion therefore, urgent and synergized efforts are required to promote prompt access to family planning and post-abortion care services.
The Nigerian arm of the study was conducted in nine health facilities (six secondary and three tertiary), in the south-west geo-political zone of Nigeria, where it was estimated that 164,000 induced abortions occurred in 2012 and represents an induced abortion rate of 27 per 1,000 women aged 15–49 years [12]. During the same period in the same geo-political zone, 40% of 59,173 women were treated for abortion complications from induced abortion, rather than miscarriages [12]. The participating health facilities (eight public and one private) were selected based on the availability of a high number of qualified multidisciplinary, full-time medical personnel, a high number of people who utilize the hospitals for sexual and reproductive health issues (especially post-abortion care) and the proximity of the hospitals to the coordinating centre. Five out of the six states within the southwest geopolitical zone of Nigeria were represented in the study. The qualitative aspect of the study was conducted in seven out of the nine health facilities. Study participants were women who presented with complications of induced abortion in the seven health facilities. The participants were identified by their health provider as having undergone an induced abortion that required admission to the hospital and the method of the abortion and were then enrolled while on admission in these hospitals, after their treatment was complete and they were stable. Purposive sampling technique was used to recruit participants into the study and the trained interviewer obtained written consent and conducted in-depth interviews (IDIs) with the participants. Although a random selection was not employed due to the characteristics of eligible study participants, recruitment of participants continued till saturation of topics were attained. Only two women among those approached to be interviewed refused to participate in the study. An IDI guide (Table 1) was developed by the study team after extensive literature review and consultation with content experts. The guide was semi-structured, facilitating comparability across IDIs and allowing participants to guide the discussion based on their experiences. Four domains of interest, comprising 14 questions were explored: (1) Introductory question (reasons for coming to the hospital and experience); (2) Choice of abortion methods; (3) Care seeking behavior; and (4) Knowledge of methods. Research assistants (RAs) were two female postgraduate social scientists from the University of Ibadan and the Lagos State University and two staff members of the University College Hospital (UCH), Ibadan. All four RAs participated in a five-day qualitative research training workshop from October 8–12, 2012 prior to the commencement of data collection in order to develop their research skills and capacity on qualitative methods of data collection. The training was facilitated by an international consultant engaged by the WHO. The training curriculum focused on interviewing techniques, development of coding scheme, coding of transcripts and use of WEFTQDA software. All RAs signed data confidentiality agreements after the training. One of the two social scientists conducted the face-to-face interviews while the other was the note taker, who recorded participants’ responses on papers and audiotapes during the interviews. Medical officers at the study sites identified eligible women and thereafter informed the research team to move to the study sites for the interviews. Written informed consent was obtained from all participants by the RAs prior to participation. They were provided with information about the purpose of the study and were given ample time to read the consent form before obtaining their written consent. If required, the consent forms were read to them. Consent forms and IDI guides were available in both English and Yoruba (the local language in south-west Nigeria). All IDIs were conducted by RAs during the period of the women’s admission in the hospitals and in specifically designated rooms at all sites to ensure privacy and confidentiality (only the participant and RAs were present). The IDIs, which were conducted in English or Yoruba, were double audio-recorded and each IDI lasted 30 to 45 minutes. Data were collected from May 2013 to May 2014, until thematic saturation was reached. The IDIs were conducted in the seven hospitals based on the availability of eligible participants during the period of data collection. The audio recordings were transcribed daily by the RAs, and the transcripts and recorded notes were compared for any missing information and updated appropriately. All the IDIs conducted were transcribed in the language of the interview, and those conducted in Yoruba were translated simultaneously into English after the interview. Identifiers were expunged from the transcripts and the de-identified transcripts (in plain text format) were stored on a password-protected computer system. The study employed a cross-case content and narrative analysis. The data were analyzed thematically in order to ensure flexibility that assures identification of key themes and sub themes, as well as comparison of similarities and differences in participants’ experiences of induced abortion. Coding schemes were developed independently by two of the authors through a line-by-line coding of a representative sample of the transcripts, selected proportionately through stratification of the number of participants per health facility. Following this process, the similarities and differences in the coding were compared and discussed. A consensus, which included the use of the explanatory thematic framework was thereafter reached and the framework was employed to structure and define the data. Thereafter, the plain text transcripts were imported into qualitative software (WEFTQDA) and categories and subcategories were created in the categories tree using a combined inductive and deductive approach, which used the interview guide and main research questions (deductive) and themes emerging naturally from the data (inductive) to develop the analysis. The transcript texts were coded by marking text passages from the transcripts as related to each of the created categories and all the document sections coded by each category were reviewed side-by-side to allow for comparison of similarities and differences. Narrative texts and illustrative quotes were used to identify patterns in the data and respondent clusters (related themes), and to draw connections between recurrent themes and distinct patterns as they evolved from the richness of the data. Approval to conduct the study was obtained from the Institutional Ethics and Research Boards covering all the health institutions where the study was conducted (approval reference numbers inserted in parentheses); University of Ibadan/University College Hospital Ethics Review Committee (UI/UCH/11/0258), Lagos State University Teaching Hospital Health Research and Ethics Committee (LREC/10/06/228), Obafemi Awolowo University Teaching Hospitals Complex Ethics Committee (ERC/2012/12/01) and Oyo State Ethical Review Committee (AD13/479/257). Administrative approvals were also obtained from the participating health facilities. This paper is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) [26]
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