Magnitude and determinants of the late request for safe abortion care among women seeking abortion care at a tertiary referral hospital in ethiopia: A cross-sectional study

International Journal of Women's Health, Volume 12, Year 2020

Interpretation

Background: Second-trimester abortions disproportionately contribute to the increased medical cost, maternal morbidity, and mortality compared to the first trimester. Therefore, the aim of the current study was to determine the magnitude and determinants of late presentation for safe abortion care at a tertiary hospital in Ethiopia. Methods: We conducted a cross-sectional study among pregnant women who requested safe abortion care from January 2019 to April 2020. Participants were selected using systematic sampling and data were collected using the interviewer-administered questionnaire. P-value adjusted odds ratios (AOR) with their 95% confidence interval (CI) were used to determine the association between variables. Results: The prevalence of second-trimester abortion was 53.4%. Young age, ≤ 19 years (AOR= 6.37, 95% CI=1.84–22.06), decision ambivalence (AOR=5.64, 95% CI=1.71–18.61), delay to suspect pregnancy (AOR= 8.56, 95% CI=2.11–34.57), delay to diagnose pregnancy (AOR=3.83, 95% CI=1.51–9.75), lack of awareness on pregnancy signs and symptoms (AOR=4.22, 95% CI=1.59–11.23), delay to get the service (AOR =4.43, 95% CI=1.43–13.67), and lack of information where to get the abortion service (AOR=3.90, 95% CI=1.53–9.96) were significantly associated with presentation in second trimester. Conclusion: More than half of women who request safe abortion at Saint Paul’s Hospital Millennium Medical College do so in the second trimester. Young age, delay in diagnosis of pregnancy, delayed decision, and lack of information where to get service were contributing factors. Therefore, comprehensive adolescent sexuality education, increasing access to contraception, and safe abortion service including self-care interventions are very imperative to avert late gestation abortion and its consequences. We conducted a prospective hospital-based cross-sectional study at Michu clinic, SPHMMC in Addis Ababa, the capital city of Ethiopia. SPHMMC is one of the teaching and tertiary referral hospitals directly under the federal ministry of health. According to the statistics office report, the hospital gives service to 200,000 people annually. It gives service under different clinical disciplines which include Obstetrics and Gynecology. Michu clinic is under the Department of Obstetrics and Gynecology department which provides abortion and family planning-related services. Around 1500 women receive abortion care in the hospital annually. The data were collected from January 2019 to April 2020. The study population were all pregnant women requesting a safe abortion service during the study period at Michu Clinic. We included all pregnant women who requested a safe abortion service and gave written informed consent. We excluded those women who seek abortion service for indications of fetal demise, fetal anomaly, and life-threatening maternal medical disorders. Besides, those who presented after the gestational age of viability (≥28 weeks) and those who are seriously ill and unable to communicate during the data collection period were excluded. The sample size was calculated using the single population proportion formula taking a P value of 0.192 from the study done in the Amhara region which shows the prevalence of second-trimester abortion as 19.2%.10 Using the power of 80%, adding a marginal error of 5%, and a contingency rate, the estimated sample size was 246. We used systematic sampling to recruit eligible study participants. Considering 420 data collection days in the study period to recruit 246 participants we recruited every 2nd client prospectively. In cases when the 2nd patient is not eligible the patient immediately before or after the patient will be enrolled. The data were collected at the time of client presentation to Michu clinic by interviewer-administered structured questionnaires. The questionnaire was prepared in English, translated to Amharic which is a local language, and then translated back to English to check for consistency. Pretesting of the questionnaire was conducted on ten women and appropriate modification was applied. Data collectors were trained at Michu Clinic for 02 consecutive days by the principal investigator in pre-tested checklists. The operational manual for the study was prepared to assure a uniform standard for carrying out the study with good quality control. All data were collected and stored anonymously. All filled questionnaires were checked daily for completeness, accuracy, and consistency by the principal investigator. Supervision was carried out by the principal investigator throughout the data collection. Timing for seeking abortion care was the dependent variable and categorized as second trimester (≥13 weeks of gestation and < 28 weeks) and early (< 13 weeks of gestation). The independent variables were socio-demographic characteristics (age, marital status, educational status, place of residency, monthly income, religion), reproductive characteristics (gravidity, parity, abortion history, menstrual nature, gestational age, whether the pregnancy was a result of sexual assault or not), logistic factors (financial, transportation and information problems, service availability around vicinity), interpersonal and intrapersonal factors (partner or family conflict, social or religious stigma, decision ambivalence), level of awareness on reproductive health (pregnancy window period, pregnancy signs and symptoms, contraception use, alternative options for unplanned and unwanted pregnancies, abortion care centers, early and safe pregnancy duration for induced abortion, abortion complications) After data were collected, each questionnaire was given code and checked visually for completeness. The data were entered Epi-info version 3.5.1 and transported to SPSS version 20 software packages for analysis. Further, data cleaning was performed to check for outliers, missed values, and any inconsistencies before the data analysis. For any missed values and inconsistency, the principal investigator cross-checked the patient medical record using the codes and made necessary corrections. Data were analyzed using SPSS 20.0 version. Socio-demographic and reproductive characteristics of the participants and their level of awareness on reproductive health were described using descriptive statistics. Bivariable and Multivariable logistic regression was used to identify independent factors associated with the late request for safe abortion. Bivariate analysis was carried out first to observe the crude association between independent and outcome variables. The variables with P value < 0.2 in bivariate analysis, were considered as candidate variables for the multivariable model. Finally, statistically significant variables that fit the final regression model were identified using the odds ratio with a 95% confidence interval and P value < 0.05. The current study was conducted following the Declaration of Helsinki. Ethical clearance was obtained from the Institutional Review Board (IRB) of SPHMMC including informed written consent for participants under the age of 18 years. Permission to conduct the study was taken from the hospital administration. Informed consent was obtained from each study participants after the objectives of the study were explained. To ensure the confidentiality of participants, we did not collect or store any identifying information about participants. All the datasets used and/or analyzed during the current study are included in the manuscript.

AI Digest

Study Justification:

The study aimed to determine the magnitude and determinants of late presentation for safe abortion care at a tertiary hospital in Ethiopia. This is important because second-trimester abortions contribute to increased medical costs, maternal morbidity, and mortality compared to first-trimester abortions. Understanding the factors associated with late presentation can help inform interventions to reduce the number of late gestation abortions and their consequences.

Highlights:

– The prevalence of second-trimester abortion at the hospital was found to be 53.4%.
– Factors significantly associated with late presentation included young age, decision ambivalence, delay in suspecting and diagnosing pregnancy, lack of awareness on pregnancy signs and symptoms, delay in accessing the service, and lack of information on where to get the abortion service.
– Comprehensive adolescent sexuality education, increasing access to contraception, and safe abortion services, including self-care interventions, are recommended to prevent late gestation abortion and its consequences.

Recommendations:

Based on the study findings, the following recommendations are suggested:

1. Implement comprehensive adolescent sexuality education programs to increase awareness and knowledge about reproductive health, including pregnancy signs and symptoms, contraception use, and available options for unplanned and unwanted pregnancies.
2. Improve access to contraception to reduce unintended pregnancies and the need for abortion services.
3. Strengthen the availability and accessibility of safe abortion services, including self-care interventions, to ensure that women can access timely and appropriate care.
4. Develop and implement information campaigns to raise awareness about where to access abortion services, reducing delays in seeking care.

Key Role Players:

1. Ministry of Health: Responsible for developing and implementing policies and programs related to reproductive health, including adolescent sexuality education and access to contraception.
2. Healthcare Providers: Responsible for delivering safe abortion services and providing accurate information to women seeking care.
3. Educators: Responsible for implementing comprehensive sexuality education programs in schools and other educational settings.
4. Community Organizations: Responsible for conducting awareness campaigns and providing information on reproductive health services.

Cost Items for Planning Recommendations:

1. Training and Capacity Building: Budget for training healthcare providers on safe abortion procedures and counseling techniques.
2. Education Programs: Budget for developing and implementing comprehensive sexuality education programs in schools and other educational settings.
3. Contraception Access: Budget for increasing the availability and affordability of contraception methods.
4. Service Expansion: Budget for expanding and improving the infrastructure and resources of healthcare facilities to provide safe abortion services.
5. Information Campaigns: Budget for developing and disseminating information materials on where to access abortion services and the importance of timely care-seeking.
Please note that the provided cost items are general suggestions and the actual budget items may vary depending on the specific context and resources available.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional study conducted at a tertiary referral hospital in Ethiopia. The study used systematic sampling and collected data using an interviewer-administered questionnaire. The prevalence of second-trimester abortion was found to be 53.4%, and several factors were identified as significantly associated with late presentation for safe abortion care. The study provides specific odds ratios and confidence intervals to support the associations found. However, the study is limited to a single hospital and may not be generalizable to other settings. To improve the strength of the evidence, future research could include a larger sample size and a more diverse population, as well as consider conducting a multi-center study to increase external validity.

Abstract

We conducted a prospective hospital-based cross-sectional study at Michu clinic, SPHMMC in Addis Ababa, the capital city of Ethiopia. SPHMMC is one of the teaching and tertiary referral hospitals directly under the federal ministry of health. According to the statistics office report, the hospital gives service to 200,000 people annually. It gives service under different clinical disciplines which include Obstetrics and Gynecology. Michu clinic is under the Department of Obstetrics and Gynecology department which provides abortion and family planning-related services. Around 1500 women receive abortion care in the hospital annually. The data were collected from January 2019 to April 2020. The study population were all pregnant women requesting a safe abortion service during the study period at Michu Clinic. We included all pregnant women who requested a safe abortion service and gave written informed consent. We excluded those women who seek abortion service for indications of fetal demise, fetal anomaly, and life-threatening maternal medical disorders. Besides, those who presented after the gestational age of viability (≥28 weeks) and those who are seriously ill and unable to communicate during the data collection period were excluded. The sample size was calculated using the single population proportion formula taking a P value of 0.192 from the study done in the Amhara region which shows the prevalence of second-trimester abortion as 19.2%.10 Using the power of 80%, adding a marginal error of 5%, and a contingency rate, the estimated sample size was 246. We used systematic sampling to recruit eligible study participants. Considering 420 data collection days in the study period to recruit 246 participants we recruited every 2nd client prospectively. In cases when the 2nd patient is not eligible the patient immediately before or after the patient will be enrolled. The data were collected at the time of client presentation to Michu clinic by interviewer-administered structured questionnaires. The questionnaire was prepared in English, translated to Amharic which is a local language, and then translated back to English to check for consistency. Pretesting of the questionnaire was conducted on ten women and appropriate modification was applied. Data collectors were trained at Michu Clinic for 02 consecutive days by the principal investigator in pre-tested checklists. The operational manual for the study was prepared to assure a uniform standard for carrying out the study with good quality control. All data were collected and stored anonymously. All filled questionnaires were checked daily for completeness, accuracy, and consistency by the principal investigator. Supervision was carried out by the principal investigator throughout the data collection. Timing for seeking abortion care was the dependent variable and categorized as second trimester (≥13 weeks of gestation and < 28 weeks) and early (< 13 weeks of gestation). The independent variables were socio-demographic characteristics (age, marital status, educational status, place of residency, monthly income, religion), reproductive characteristics (gravidity, parity, abortion history, menstrual nature, gestational age, whether the pregnancy was a result of sexual assault or not), logistic factors (financial, transportation and information problems, service availability around vicinity), interpersonal and intrapersonal factors (partner or family conflict, social or religious stigma, decision ambivalence), level of awareness on reproductive health (pregnancy window period, pregnancy signs and symptoms, contraception use, alternative options for unplanned and unwanted pregnancies, abortion care centers, early and safe pregnancy duration for induced abortion, abortion complications) After data were collected, each questionnaire was given code and checked visually for completeness. The data were entered Epi-info version 3.5.1 and transported to SPSS version 20 software packages for analysis. Further, data cleaning was performed to check for outliers, missed values, and any inconsistencies before the data analysis. For any missed values and inconsistency, the principal investigator cross-checked the patient medical record using the codes and made necessary corrections. Data were analyzed using SPSS 20.0 version. Socio-demographic and reproductive characteristics of the participants and their level of awareness on reproductive health were described using descriptive statistics. Bivariable and Multivariable logistic regression was used to identify independent factors associated with the late request for safe abortion. Bivariate analysis was carried out first to observe the crude association between independent and outcome variables. The variables with P value < 0.2 in bivariate analysis, were considered as candidate variables for the multivariable model. Finally, statistically significant variables that fit the final regression model were identified using the odds ratio with a 95% confidence interval and P value < 0.05. The current study was conducted following the Declaration of Helsinki. Ethical clearance was obtained from the Institutional Review Board (IRB) of SPHMMC including informed written consent for participants under the age of 18 years. Permission to conduct the study was taken from the hospital administration. Informed consent was obtained from each study participants after the objectives of the study were explained. To ensure the confidentiality of participants, we did not collect or store any identifying information about participants. All the datasets used and/or analyzed during the current study are included in the manuscript.

Materials

N/A

Innovations

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide information on reproductive health, pregnancy signs and symptoms, contraception options, and safe abortion services. These apps can also offer reminders for prenatal care appointments and provide access to telemedicine consultations.

2. Community Health Workers: Train and deploy community health workers to provide education and counseling on reproductive health, including the importance of early pregnancy detection and seeking timely abortion care. These workers can also help connect women to local healthcare facilities and resources.

3. Telemedicine Services: Establish telemedicine services that allow pregnant women to consult with healthcare providers remotely. This can help overcome barriers such as transportation issues and lack of nearby healthcare facilities, particularly in rural areas.

4. Comprehensive Sexuality Education: Implement comprehensive sexuality education programs in schools and communities to increase awareness and knowledge about reproductive health, including pregnancy prevention and safe abortion options. This can help address the lack of awareness mentioned in the study.

5. Task-Shifting and Training: Train and empower healthcare providers, including midwives and nurses, to provide safe abortion services. This can help increase the availability of trained providers and reduce the burden on doctors, improving access to timely and safe abortion care.

6. Strengthening Referral Systems: Improve the coordination and communication between primary healthcare centers and tertiary referral hospitals to ensure timely and efficient referrals for safe abortion care. This can help reduce delays in accessing services and prevent second-trimester abortions.

7. Addressing Stigma and Sociocultural Barriers: Implement awareness campaigns and community engagement activities to address stigma surrounding abortion and promote a supportive environment for women seeking abortion care. This can help reduce decision ambivalence and encourage women to seek care earlier in their pregnancies.

These innovations can contribute to improving access to maternal health services, specifically safe abortion care, by addressing various barriers identified in the study. It is important to tailor these innovations to the local context and ensure their implementation is supported by appropriate policies and regulations.

AI Innovations Description

The study conducted at Michu Clinic, SPHMMC in Addis Ababa, Ethiopia aimed to determine the magnitude and determinants of late presentation for safe abortion care. The study found that more than half of the women who requested safe abortion care at the clinic did so in the second trimester. Several factors were identified as significantly associated with late presentation, including young age, delay in diagnosing pregnancy, delayed decision-making, and lack of information on where to access abortion services.

Based on the findings of the study, the following recommendations can be made to improve access to maternal health:

1. Comprehensive Adolescent Sexuality Education: Implementing comprehensive sexuality education programs that provide accurate information on reproductive health, including pregnancy signs and symptoms, contraception use, and options for unplanned and unwanted pregnancies. This education should target young individuals to increase their awareness and understanding of reproductive health.

2. Increasing Access to Contraception: Strengthening efforts to increase access to contraception methods and services. This can include improving availability and affordability of contraceptives, expanding distribution channels, and providing education on contraceptive options and their proper use.

3. Safe Abortion Services: Ensuring the availability of safe abortion services, including early abortion care and self-care interventions. This can be achieved by training healthcare providers on safe abortion procedures, improving the availability of abortion care centers, and reducing barriers to accessing these services.

4. Information and Awareness: Enhancing information dissemination about where to access abortion services. This can be done through community outreach programs, public awareness campaigns, and partnerships with local organizations to ensure that accurate and up-to-date information is readily available to individuals seeking abortion care.

By implementing these recommendations, it is possible to improve access to maternal health and reduce the prevalence of second-trimester abortions, thereby reducing medical costs, maternal morbidity, and mortality associated with late gestation abortions.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Comprehensive Adolescent Sexuality Education: Implementing comprehensive sexuality education programs that provide accurate information on reproductive health, including contraception and safe abortion options, can help young individuals make informed decisions and prevent unintended pregnancies.

2. Increasing Access to Contraception: Ensuring that a wide range of contraceptive methods are readily available and affordable can help individuals prevent unwanted pregnancies and reduce the need for unsafe abortions.

3. Safe Abortion Services and Self-Care Interventions: Expanding access to safe abortion services, including medication abortion, and promoting self-care interventions can help women safely terminate pregnancies in the early stages, reducing the need for second-trimester abortions.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population group (e.g., pregnant women seeking abortion care) that will be the focus of the simulation.

2. Collect baseline data: Gather relevant data on the current state of access to maternal health services, including the prevalence of second-trimester abortions and the factors contributing to late presentation for safe abortion care.

3. Develop a simulation model: Create a mathematical or computational model that represents the dynamics of access to maternal health services. This model should incorporate variables such as age, decision ambivalence, awareness of pregnancy signs and symptoms, availability of services, and other factors identified in the study.

4. Input data and parameters: Input the collected baseline data and parameters into the simulation model. This includes information on the prevalence of second-trimester abortions, the impact of the recommended interventions, and any other relevant data.

5. Run simulations: Run the simulation model multiple times, adjusting the parameters to reflect different scenarios and potential outcomes. This can help estimate the potential impact of the recommended interventions on improving access to maternal health services.

6. Analyze results: Analyze the simulation results to determine the potential impact of the recommended interventions. This may include evaluating changes in the prevalence of second-trimester abortions, the number of women accessing safe abortion services in the early stages, and other relevant indicators.

7. Interpret and communicate findings: Interpret the simulation results and communicate the findings to stakeholders, policymakers, and healthcare providers. This can help inform decision-making and guide the implementation of interventions to improve access to maternal health services.

It’s important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data. The steps outlined above provide a general framework for conducting such simulations.

Author

Dima Health

Statistics:

Citations: 3

Identifiers:

DOI: 10.2147/IJWH.S285282

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Violence and Injury

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female