Key determinants of induced abortion in women seeking postabortion care in hospital facilities in Ouagadougou, Burkina Faso

International Journal of Women's Health, Volume 6, No. 1, Year 2014

Interpretation

Introduction: Despite the universal recognition of unsafe abortion as a major public health problem, very little research has been conducted to document its precipitating factors in Burkina Faso. Our aim was to investigate the key determinants of induced abortion in a sample of women who sought postabortion care. Materials and methods: A cross-sectional household survey was carried out from February to September 2012 in Ouagadougou, Burkina Faso. Data of 37 women who had had an induced abortion and 267 women who had had a spontaneous abortion were prospectively collected on sociodemographic characteristics, pregnancy and birth history, abortion experience, including previous abortion experience, and selected clinical information, including the type of abortion. A two-step regression analysis consisting of a univariate and a multivariate logistic regression was run on Stata version 11.2 in order to identify the key determinants of induced abortion. Results: The findings indicated that 12% of all abortions were certainly induced. Three key factors were significantly and positively associated with the probability of having an induced abortion: whether the woman reported that her pregnancy was unwanted (odds ratio [OR] 10.45, 95% confidence interval [CI] 3.59-30.41); whether the woman reported was living in a household headed by her parents (OR 6.83, 95% CI 2.42-19.24); and if the woman reported was divorced or widowed (OR 3.47, 95% CI 1.08-11.10). On the contrary, being married was protective against induced abortion, with women who reported being married having an 83% (OR 0.17, CI 0.03-0.89) lower chance of having an induced abortion, even when the pregnancy was unwanted. Conclusion: This study has identified three major determinants of induced abortion in Ouagadougou, Burkina Faso. Improved targeted programs on family planning counseling, methods of contraception, and availability of contraceptives should be widely promoted. © 2014 Ilboudo et al. Burkina Faso, a landlocked country located in the heart of West Africa, has a weak health care system.21 The country has a population of 16 million, essentially young and fertile.22 The low purchasing power of the population and of women in particular, limits their access to education, clean water, and health care. Maternal mortality is high, with a rate of 300 per 100,000 births.23 Contraceptive use is low, with large disparities between poor and rich population groups.24 Since 2006, a national subsidy policy for normal deliveries and emergency obstetric care has been active, in order to reduce financial barriers to care and thereby improve access to qualified care.25 In spite of this policy, utilization of health care services in Ouagadougou city is still unsatisfactory, with large inequities between poor and rich women. In order to explore the key determinants of induced abortion, this paper uses data from a cross-sectional study that investigates the costs associated with abortions in Ouagadougou. Because of the difficulty of recruiting abortion cases in the community,26 participants were prospectively recruited from two hospital facilities. These hospital facilities included one referral-level teaching hospital – a top referral hospital in Ouagadougou to which complications from abortion are directed for better care – and one private health clinic, affiliated with the International Planned Parenthood Federation, with long-standing expertise in treating abortions. A total of 307 women with either a spontaneous or induced abortion were sampled for this study. In each facility, an experienced midwife, generally responsible for the manual vacuum-aspiration ward, was in charge of identifying women with induced or spontaneous abortions based on clinical definitions. Additional information on the nature of the abortion was also obtained by interviewing the woman. A case was classified as an induced abortion when the clinical ascertainment was confirmed by the woman herself reporting that she had had an induced abortion. All other abortions were classified as possibly spontaneous. This procedure of classifying the cases may have led to some induced abortions being inaccurately classified as spontaneous.3,27 Because of this, women were labeled as “certainly induced abortion” and “reportedly spontaneous abortion”. Two women did not consent to participate in the study. Another woman was excluded because she did not complete the interview, leaving a sample size of 304. Data collection took place between February and September 2012. After they were identified by the health staff, the women were directed to two female interviewers who were in charge of establishing contact with them for further investigation. All women who met the eligibility criteria were invited to participate in the study. At discharge, subjects who consented to participate in the study were interviewed at the health facility, at the clinic, or at home. The two qualified female interviewers collected data from all the women who had had an induced or a spontaneous abortion, using an interviewer-administered face-to-face questionnaire. Prior to fieldwork, interviewers were given comprehensive training on data collection procedures and extraction of clinical data from medical records. During this training session, anticipated difficulties in filling in the questionnaires were thoroughly discussed in order to minimize errors. Two structured questionnaires were used for data collection. The main questionnaire that was administered to the women contained a range of questions pertaining to sociodemographic characteristics, pregnancy and birth history, abortion experience, asset ownership and place of residence, and expenditures on abortion and postabortion care, including prereferral costs. The abortion-experience section of the women’s questionnaire included questions pertaining to previous abortion experiences and to the type of abortive method used. The women’s questionnaire was complemented with a health worker questionnaire, which was intended to extract selected medical information from hospital records. This questionnaire included information related to the gestational age of the pregnancy and the clinical ascertainment of the type of abortion. The dependent variable was the type of abortion, a dummy variable set to 1 when the pregnancy termination was reported as induced or 0 when alleged to be a spontaneous abortion. The empirical literature on factors associated with abortion showed that educated women,28–32 young women,28–30,33–36 unmarried women,28,30,34,37,38 women who had had previous experiences of abortion,31,34,39 women who had living children,29,33,34 and women who did not want the pregnancy28,39–41 were more likely to have an induced abortion. Therefore, such variables as age, education, marital status, number of children, desire for pregnancy, and previous experience of abortion were considered independent variables. Researchers have also demonstrated that women who were experiencing their first pregnancy in life,30 Christian women (compared to Muslim women),33,36,39 and women who did not use contraceptives40 were also more likely to have an induced abortion. We therefore also considered the number of pregnancies, the use of contraceptives, and the women’s religion as explanatory variables. Finally, we included the status of the household-chief (whether the household is headed by the woman, the husband, or by the woman’s parents) in the analysis of abortion determinants. A descriptive analysis was undertaken in order to understand the distribution of induced and spontaneous abortions relative to each independent variable. Chi-squared tests were used to test for significant differences between the groups of women. To identify the key determinants associated with induced abortion for women seeking postabortion care in hospitals in Ouagadougou, a two-step analysis consisting of one univariate and one multivariate logistic regression was carried out. The univariate logistic regression was run to determine the association between each of the independent variables and the dependent variable. All the variables that were associated with induced abortion in the univariate logistic regression with a level of significance of 0.05 and 95% confidence were subsequently analyzed in a stepwise multivariate logistic regression. The multivariate regression permitted adjustment among variables and the determination of possible confounding factors. To identify the key factors associated with induced abortion, a downward procedure that minimizes the number of variables while maximizing the accuracy of the model was followed.42 All analyses were conducted on Stata version 11.2 (StataCorp, College Station, TX, USA).

AI Digest

Study Justification:

– Unsafe abortion is a major public health problem in Burkina Faso.
– Limited research has been conducted to understand the factors contributing to induced abortion in the country.
– This study aims to investigate the key determinants of induced abortion in women seeking postabortion care in hospital facilities in Ouagadougou, Burkina Faso.

Highlights:

– The study found that 12% of all abortions were induced.
– Three key factors were significantly associated with the probability of having an induced abortion: unwanted pregnancy, living in a household headed by parents, and being divorced or widowed.
– Being married was found to be protective against induced abortion, even in cases of unwanted pregnancy.

Recommendations for Lay Reader and Policy Maker:

– Targeted programs on family planning counseling, methods of contraception, and availability of contraceptives should be widely promoted.
– Improve access to education, clean water, and healthcare for women in Burkina Faso.
– Address the social and economic factors that contribute to unwanted pregnancies and increase the risk of induced abortion.

Key Role Players:

– Government health agencies and policymakers
– Healthcare providers and midwives
– Non-governmental organizations (NGOs) working on reproductive health
– Community leaders and religious leaders
– Women’s rights organizations

Cost Items for Planning Recommendations:

– Development and implementation of family planning programs
– Training and capacity building for healthcare providers
– Distribution of contraceptives and family planning supplies
– Education and awareness campaigns on reproductive health
– Infrastructure improvements for healthcare facilities
– Research and monitoring to evaluate the effectiveness of interventions

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study conducted a cross-sectional household survey and used regression analysis to identify key determinants of induced abortion in women seeking postabortion care in Ouagadougou, Burkina Faso. The study found three significant factors associated with induced abortion: unwanted pregnancy, living in a household headed by parents, and being divorced or widowed. The study provides specific odds ratios and confidence intervals to support these findings. However, the study sample size is relatively small (37 women with induced abortion and 267 women with spontaneous abortion), which may limit the generalizability of the results. To improve the strength of the evidence, future research could consider a larger sample size and include a more diverse population. Additionally, conducting a longitudinal study could provide more robust evidence on the determinants of induced abortion.

Abstract

Burkina Faso, a landlocked country located in the heart of West Africa, has a weak health care system.21 The country has a population of 16 million, essentially young and fertile.22 The low purchasing power of the population and of women in particular, limits their access to education, clean water, and health care. Maternal mortality is high, with a rate of 300 per 100,000 births.23 Contraceptive use is low, with large disparities between poor and rich population groups.24 Since 2006, a national subsidy policy for normal deliveries and emergency obstetric care has been active, in order to reduce financial barriers to care and thereby improve access to qualified care.25 In spite of this policy, utilization of health care services in Ouagadougou city is still unsatisfactory, with large inequities between poor and rich women. In order to explore the key determinants of induced abortion, this paper uses data from a cross-sectional study that investigates the costs associated with abortions in Ouagadougou. Because of the difficulty of recruiting abortion cases in the community,26 participants were prospectively recruited from two hospital facilities. These hospital facilities included one referral-level teaching hospital – a top referral hospital in Ouagadougou to which complications from abortion are directed for better care – and one private health clinic, affiliated with the International Planned Parenthood Federation, with long-standing expertise in treating abortions. A total of 307 women with either a spontaneous or induced abortion were sampled for this study. In each facility, an experienced midwife, generally responsible for the manual vacuum-aspiration ward, was in charge of identifying women with induced or spontaneous abortions based on clinical definitions. Additional information on the nature of the abortion was also obtained by interviewing the woman. A case was classified as an induced abortion when the clinical ascertainment was confirmed by the woman herself reporting that she had had an induced abortion. All other abortions were classified as possibly spontaneous. This procedure of classifying the cases may have led to some induced abortions being inaccurately classified as spontaneous.3,27 Because of this, women were labeled as “certainly induced abortion” and “reportedly spontaneous abortion”. Two women did not consent to participate in the study. Another woman was excluded because she did not complete the interview, leaving a sample size of 304. Data collection took place between February and September 2012. After they were identified by the health staff, the women were directed to two female interviewers who were in charge of establishing contact with them for further investigation. All women who met the eligibility criteria were invited to participate in the study. At discharge, subjects who consented to participate in the study were interviewed at the health facility, at the clinic, or at home. The two qualified female interviewers collected data from all the women who had had an induced or a spontaneous abortion, using an interviewer-administered face-to-face questionnaire. Prior to fieldwork, interviewers were given comprehensive training on data collection procedures and extraction of clinical data from medical records. During this training session, anticipated difficulties in filling in the questionnaires were thoroughly discussed in order to minimize errors. Two structured questionnaires were used for data collection. The main questionnaire that was administered to the women contained a range of questions pertaining to sociodemographic characteristics, pregnancy and birth history, abortion experience, asset ownership and place of residence, and expenditures on abortion and postabortion care, including prereferral costs. The abortion-experience section of the women’s questionnaire included questions pertaining to previous abortion experiences and to the type of abortive method used. The women’s questionnaire was complemented with a health worker questionnaire, which was intended to extract selected medical information from hospital records. This questionnaire included information related to the gestational age of the pregnancy and the clinical ascertainment of the type of abortion. The dependent variable was the type of abortion, a dummy variable set to 1 when the pregnancy termination was reported as induced or 0 when alleged to be a spontaneous abortion. The empirical literature on factors associated with abortion showed that educated women,28–32 young women,28–30,33–36 unmarried women,28,30,34,37,38 women who had had previous experiences of abortion,31,34,39 women who had living children,29,33,34 and women who did not want the pregnancy28,39–41 were more likely to have an induced abortion. Therefore, such variables as age, education, marital status, number of children, desire for pregnancy, and previous experience of abortion were considered independent variables. Researchers have also demonstrated that women who were experiencing their first pregnancy in life,30 Christian women (compared to Muslim women),33,36,39 and women who did not use contraceptives40 were also more likely to have an induced abortion. We therefore also considered the number of pregnancies, the use of contraceptives, and the women’s religion as explanatory variables. Finally, we included the status of the household-chief (whether the household is headed by the woman, the husband, or by the woman’s parents) in the analysis of abortion determinants. A descriptive analysis was undertaken in order to understand the distribution of induced and spontaneous abortions relative to each independent variable. Chi-squared tests were used to test for significant differences between the groups of women. To identify the key determinants associated with induced abortion for women seeking postabortion care in hospitals in Ouagadougou, a two-step analysis consisting of one univariate and one multivariate logistic regression was carried out. The univariate logistic regression was run to determine the association between each of the independent variables and the dependent variable. All the variables that were associated with induced abortion in the univariate logistic regression with a level of significance of 0.05 and 95% confidence were subsequently analyzed in a stepwise multivariate logistic regression. The multivariate regression permitted adjustment among variables and the determination of possible confounding factors. To identify the key factors associated with induced abortion, a downward procedure that minimizes the number of variables while maximizing the accuracy of the model was followed.42 All analyses were conducted on Stata version 11.2 (StataCorp, College Station, TX, USA).

Materials

N/A

Innovations

The research findings suggest several recommendations to improve access to maternal health in Burkina Faso:

1. Implement targeted programs on family planning counseling: Provide comprehensive and accessible family planning counseling services to women in Burkina Faso. This can include education on contraceptive methods, their benefits, and how to use them effectively.

2. Improve availability of contraceptives: Ensure a consistent supply of contraceptives in healthcare facilities across Burkina Faso. This can involve strengthening the distribution system, training healthcare providers on contraceptive methods, and addressing any barriers to access.

3. Promote methods of contraception: Raise awareness about different contraceptive methods and their effectiveness through community outreach programs, media campaigns, and educational initiatives.

4. Address socio-economic factors: Develop interventions that address the socio-economic factors influencing induced abortions, such as poverty and limited access to education and healthcare. This can involve implementing programs that empower women economically, improve access to education, and provide financial support for maternal healthcare services.

By implementing these recommendations, Burkina Faso can work towards reducing the incidence of induced abortions and improving the overall well-being of women and their families.

AI Innovations Description

Based on the research findings, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Implement targeted programs on family planning counseling: Provide comprehensive and accessible family planning counseling services to women in Burkina Faso. This can include education on contraceptive methods, their benefits, and how to use them effectively. By increasing knowledge and access to contraception, women can make informed decisions about their reproductive health and reduce the need for induced abortions.

2. Improve availability of contraceptives: Ensure a consistent supply of contraceptives in healthcare facilities across Burkina Faso. This can involve strengthening the distribution system, training healthcare providers on contraceptive methods, and addressing any barriers to access. By making contraceptives readily available, women will have more options to prevent unintended pregnancies and reduce the demand for induced abortions.

3. Promote methods of contraception: Raise awareness about different contraceptive methods and their effectiveness through community outreach programs, media campaigns, and educational initiatives. This can help dispel myths and misconceptions surrounding contraception and encourage women to consider and use appropriate methods. By promoting a range of contraceptive options, women can choose the method that best suits their needs and preferences.

4. Address socio-economic factors: Develop interventions that address the socio-economic factors influencing induced abortions, such as poverty and limited access to education and healthcare. This can involve implementing programs that empower women economically, improve access to education, and provide financial support for maternal healthcare services. By addressing these underlying factors, women will have better opportunities to plan and manage their pregnancies, reducing the need for induced abortions.

Overall, these recommendations aim to improve access to maternal health by focusing on family planning, contraceptive availability, education, and addressing socio-economic factors. By implementing these innovations, Burkina Faso can work towards reducing the incidence of induced abortions and improving the overall well-being of women and their families.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, the following methodology can be used:

1. Identify the target population: Determine the population in Burkina Faso that would benefit from improved access to maternal health, specifically focusing on women of reproductive age.

2. Collect baseline data: Gather data on the current state of maternal health in Burkina Faso, including indicators such as maternal mortality rate, contraceptive use, and access to family planning counseling and contraceptives.

3. Develop a simulation model: Create a simulation model that incorporates the key determinants of induced abortion identified in the research findings. This model should include variables such as pregnancy intention, marital status, household composition, education level, and access to family planning counseling and contraceptives.

4. Define the interventions: Implement the main recommendations as interventions in the simulation model. This can involve increasing the availability of family planning counseling, improving access to contraceptives, promoting different contraceptive methods, and addressing socio-economic factors.

5. Simulate the impact: Run the simulation model with the interventions in place to determine the potential impact on improving access to maternal health. This can be done by comparing the outcomes of the simulation to the baseline data collected in step 2.

6. Analyze the results: Evaluate the results of the simulation to assess the effectiveness of the interventions in improving access to maternal health. This can involve analyzing changes in maternal mortality rate, contraceptive use, and other relevant indicators.

7. Refine the interventions: Based on the simulation results, refine the interventions if necessary to further enhance their impact on improving access to maternal health. This can involve adjusting the implementation strategies, targeting specific population groups, or addressing any unforeseen challenges.

8. Communicate the findings: Present the findings of the simulation study, including the potential impact of the interventions on improving access to maternal health, to relevant stakeholders such as policymakers, healthcare providers, and community leaders. This can help generate support and resources for implementing the recommended interventions.

By following this methodology, researchers and policymakers can gain insights into the potential impact of the main recommendations on improving access to maternal health in Burkina Faso. This can inform decision-making and guide the implementation of effective interventions to address the identified challenges.

Authors & Co-Authors

Statistics:

Citations: 14

Authors: 3

Identifiers:

DOI: 10.2147/IJWH.S60709

Research Areas:

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

Study Countries:

Burkina Faso, Multi-Countries

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female