Determinants of induced abortion among women of reproductive age: evidence from the 2013 and 2019 Sierra Leone Demographic and Health Survey

  • BMC Women's Health, Volume 23, No. 1, Year 2023

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Study Justification:
– The study aims to investigate the determinants of induced abortion among women of reproductive age in Sierra Leone.
– Induced abortion is a crucial issue in maternal health, especially in settings with restrictive abortion laws.
– There is a lack of literature on this topic in Sierra Leone, highlighting the need for research to inform health programs and reproductive health policies.
– The study findings can contribute to improving the country’s maternal mortality indices.
Study Highlights:
– The study analyzed data from the 2013 and 2019 Sierra Leone Demographic and Health Surveys, which are nationally representative surveys.
– The weighted samples included 16,658 women in 2013 and 15,574 women in 2019.
– Descriptive statistics and logistic regression were used to identify correlates of induced abortion.
– The results showed that a minority (9%) of the participants had induced abortion in both surveys.
– Induced abortion was significantly associated with age, marital status, employment status, education, parity, and exposure to mass media.
– For example, women aged 45–49 years, married women, and working women had a higher likelihood of induced abortion.
– Women with primary education and those who watched television once a week were also more likely to terminate a pregnancy.
– Women with six or more children were less likely to terminate a pregnancy compared to those with no child.
Recommendations for Lay Reader and Policy Maker:
– Policies and programs should focus on increasing access to modern contraceptives among women of lower socio-economic status to reduce unwanted pregnancies.
– Education and awareness campaigns should target women with lower education levels and promote the use of contraceptives.
– Efforts should be made to address the specific needs of married women and working women in terms of reproductive health services.
– Mass media can play a role in disseminating information about reproductive health and contraception, particularly through television.
Key Role Players:
– Ministry of Health: Responsible for implementing and overseeing reproductive health programs and policies.
– Non-governmental organizations (NGOs): Involved in providing reproductive health services, education, and awareness campaigns.
– Health professionals: Including doctors, nurses, and midwives who provide reproductive health services and counseling.
– Community leaders: Engaged in promoting reproductive health awareness and facilitating access to services.
– Media organizations: Collaborating in disseminating information and messages related to reproductive health.
Cost Items for Planning Recommendations:
– Contraceptives: Budget for procuring and distributing modern contraceptives to increase access.
– Education and awareness campaigns: Funding for designing and implementing campaigns targeting women with lower education levels.
– Training programs: Budget for training healthcare professionals on reproductive health counseling and services.
– Infrastructure and equipment: Investment in healthcare facilities to ensure adequate provision of reproductive health services.
– Monitoring and evaluation: Allocation of resources for monitoring the impact of interventions and evaluating program effectiveness.
Please note that the cost items provided are general categories and not actual cost estimates.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it is based on secondary data from nationally representative surveys. The study findings provide statistical associations between various factors and induced abortion. However, the abstract does not mention the specific methodology used for data analysis, such as the specific statistical tests employed or the sample size calculation. To improve the evidence, the abstract could include more details about the methodology, such as the sampling technique, data collection process, and statistical analysis methods used. Additionally, providing information on the limitations of the study and potential sources of bias would further strengthen the evidence.

Background: Worldwide, pregnancy termination due to unintended pregnancy is crucial in maternal health, particularly in settings where abortion laws are restrictive. Presently, there is a paucity of literature on determinants of induced abortion among women of reproductive age in Sierra Leone. The study findings could be used to improve the country’s maternal mortality indices and inform health programs and reproductive health policies geared toward tackling induced abortion. Methods: We analyzed secondary data from the 2013 and 2019 Sierra Leone Demographic and Health Surveys. The surveys were nationally representative, with weighted samples comprising 16,658 (2013) and 15,574 (2019) women of reproductive age. Descriptive statistics, including frequencies and percentages, were computed, while Chi-square and Binomial Logistics Regression were employed to identify correlates of induced abortion. Results: The results showed that a minority (9%) of the participants had induced abortion in both surveys. Abortion was significantly associated with age, marital status, employment status, education, parity, and frequency of listening to the radio and watching television (p < 0.05). For instance, women aged 45–49 years (AOR = 7.91; 95% CI: 5.76–10.87), married women (AOR = 2.52; 95% CI: 1.95–3.26), and working women (AOR = 1.65; 95% CI: 1.45–1.87) had a higher likelihood of induced abortion compared to their counterparts. Moreover, women with primary education (AOR = 1.27; 95% CI:1.11–1.46) and those who watch television once a week (AOR = 1.29; 95% CI: 1.11–1.49) were more likely to terminate a pregnancy. Women with six or more children (AOR = 0.40; 95% CI: 0.31–0.52) were less likely to terminate a pregnancy compared to those with no child. Conclusion: The study revealed that a minority of the women had induced abortions. The prevalence of induced abortion did not change over time. Induced abortion was influenced by age, marital status, employment status, education, parity, and exposure to mass media. Therefore, policies and programs to reduce unwanted pregnancies should focus on increasing access to modern contraceptives among women of lower socio-economic status.

Sierra Leone is located on the west coast of Africa and covers an area of 72,000 square kilometers [18]. It shares a border with Guinea on the north and northeast, Liberia on the east and southeast, and the west by the Atlantic Ocean [18]. According to the 2015 Population and Housing Census, the country has a total population of 7,092,113 with just over half being female (50.8%) [24]. This study analyzed the women's data from the two most recent 2013 and 2019 Sierra Leone Demographic and Health Surveys (SLDHS) [18, 22]. The DHS is a household-based, nationally representative survey. It uses a two-stage sample design. For instance, in the 2013 DHS, the first stage involved selecting 435 enumeration areas from 27 strata with probability proportional to size, using the 2004 Population and Housing Census report [23], while the second comprised the selection of 30 households from each cluster. A total number of 13,006 households within the enumeration areas were selected. We obtained 16,658 women as the weighted sample size of women aged 15–49 years. Similarly, in the 2019 DHS, the first stage comprised the selection of 578 enumeration areas from 31 strata, proportional to size employing the 2015 Population and Housing Census report [24], while the second stage involved the selection of 24 households from each cluster, resulting in a total sample size of approximately 13,872. A total of 15,574 women aged 15–49 years were obtained as a weighted sample. The target population was women of reproductive age who had ever terminated a pregnancy and passed the night before the survey in the selected households. The anonymized data was cleaned, missing values were dropped and adjusted for the complex nature of the survey. Permission to use the DHS data was sought from Measure DHS. The anonymized datasets were only downloaded on approval of the request to undertake this analysis. The data analysed in this study were saved on a password-protected personal computer. The data was declared survey data using sampling weight, weight, and strata or employing the 'svy' STATA command. Detailed information about the 2013 and 2019 DHS is included elsewhere [18, 22]. The dependent variable in this study was ever terminated a pregnancy (induced abortion), coded as yes = 1 and no = 0. The independent variables mentioned in the literature include those characteristics of the women who attest to having terminated a pregnancy. These include women's age (15–19 = 1; 20–24 = 2; 25–29 = 3; 30–34 = 4; 35–39 = 5; 40–44 = 6; 45–49 = 7), educational status (no education = 1; primary = 2; secondary = 3; higher = 4), employment status (not working = 1; working = 2), wealth index (poorest = 1; second = 2; middle = 3; fourth = 4; richest = 5), religion (Christianity = 1; Muslim = 2; others religion = 3), place of residence (urban = 1; rural = 2), marital status (never in union = 1; married/in union = 2; single (formerly married/in union) = 3), and parity (none = 1; 1–2 children = 2; 3–5 children = 3; 6 or more children = 4). Other independent variables were current contraceptive use (no method = 1; modern method = 2; traditional method = 3), knowledge about ovulation, correct (halfway between two menstrual periods) = 1; incorrect = 2; don’t know = 3), frequency of reading newspaper, listening to radio and watching television (not at all = 1; less than once a week = 2; at least once a week = 3). All analyses were carried out using STATA/SE version 16 (Stata Corp, College Station., Texas, USA). Descriptive statistics of the background characteristic of respondents were computed and summarized (Table ​(Table1).1). At the bivariate level, the Chi-squared test was used to determine the association between variables under study and the outcome of interest. Similarly, at the multivariable level, binary logistics regression was used to determine the predictors of induced abortion among women of reproductive age. In all, three models were computed. Model 1 looked at predictors of induced abortion in 2013, while model 2 focused on predictors of induced abortion in 2019. The third model (model 3) focused on predictors of induced abortion in 2013 and 2019 (combined) while adjusting for the survey year. The significance for the analysis was set at p < 0.05, while the strength of association was examined using odds ratios and their 95% confidence interval. Participant characteristics

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Based on the provided information, here are some potential recommendations for innovations to improve access to maternal health in Sierra Leone:

1. Increase access to modern contraceptives: Implement programs that focus on increasing access to and awareness of modern contraceptives, particularly among women of lower socio-economic status. This can help reduce the number of unintended pregnancies and subsequently decrease the need for induced abortions.

2. Improve reproductive health education: Develop comprehensive reproductive health education programs that provide accurate information about contraception, family planning, and safe abortion services. This can help empower women to make informed decisions about their reproductive health and reduce the need for unsafe abortions.

3. Strengthen healthcare infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas, to ensure that women have access to quality maternal healthcare services. This includes increasing the number of skilled healthcare providers, improving the availability of essential medical supplies and equipment, and enhancing the capacity of healthcare facilities to provide comprehensive maternal health services.

4. Enhance community engagement: Engage communities and traditional leaders in promoting maternal health and addressing the stigma surrounding abortion. This can be done through community outreach programs, awareness campaigns, and the involvement of community health workers to provide education and support to women and their families.

5. Utilize technology for telemedicine: Explore the use of telemedicine and mobile health technologies to provide remote access to maternal healthcare services, including counseling, consultations, and follow-up care. This can be particularly beneficial in reaching women in remote or underserved areas where access to healthcare facilities is limited.

6. Strengthen policy and legal frameworks: Advocate for the revision of restrictive abortion laws and policies to ensure that women have access to safe and legal abortion services when needed. This includes addressing barriers such as stigma, discrimination, and lack of awareness among healthcare providers.

It is important to note that these recommendations are based on the information provided and may need to be further tailored and contextualized to the specific needs and challenges of Sierra Leone.
AI Innovations Description
Based on the study findings, here is a recommendation that can be developed into an innovation to improve access to maternal health in Sierra Leone:

1. Increase access to modern contraceptives: The study found that women with primary education and those who watch television once a week were more likely to terminate a pregnancy. This suggests that increasing access to modern contraceptives, such as birth control pills or intrauterine devices, can help prevent unintended pregnancies and reduce the need for induced abortions.

Innovation: Develop and implement a comprehensive reproductive health program that focuses on increasing access to modern contraceptives in Sierra Leone. This can include initiatives such as providing free or subsidized contraceptives, improving distribution channels, and conducting awareness campaigns to educate women about the importance of contraception.

By implementing this recommendation, Sierra Leone can reduce the number of unintended pregnancies and subsequently decrease the demand for induced abortions. This will contribute to improving maternal health outcomes and reducing maternal mortality rates in the country.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health in Sierra Leone:

1. Strengthening reproductive health education: Implement comprehensive and accurate reproductive health education programs that provide information on contraception, family planning, and safe abortion services. This can help reduce unintended pregnancies and the need for induced abortions.

2. Increasing access to modern contraceptives: Improve availability and affordability of modern contraceptives, including contraceptives methods such as oral contraceptives, intrauterine devices (IUDs), and implants. This can help women prevent unintended pregnancies and reduce the need for induced abortions.

3. Enhancing healthcare infrastructure: Invest in improving healthcare infrastructure, particularly in rural areas, by increasing the number of well-equipped health facilities and trained healthcare professionals. This can ensure that women have access to quality maternal healthcare services, including antenatal care, skilled birth attendance, and postnatal care.

4. Strengthening referral systems: Develop and strengthen referral systems to ensure that women with complications during pregnancy and childbirth can access emergency obstetric care in a timely manner. This can help reduce maternal mortality and morbidity associated with unsafe abortions.

5. Promoting community engagement: Engage communities in raising awareness about maternal health issues, including the importance of antenatal care, skilled birth attendance, and postnatal care. This can help reduce stigma around reproductive health and encourage women to seek appropriate healthcare services.

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

1. Baseline data collection: Collect data on the current status of maternal health indicators, including maternal mortality rates, contraceptive prevalence rates, and access to healthcare services.

2. Define indicators: Identify specific indicators that will be used to measure the impact of the recommendations, such as the percentage increase in contraceptive use or the reduction in maternal mortality rates.

3. Develop a simulation model: Create a simulation model that incorporates the baseline data and the potential impact of the recommendations. This model should consider factors such as population demographics, healthcare infrastructure, and socio-economic conditions.

4. Input data and assumptions: Input the baseline data into the simulation model and make assumptions about the potential impact of each recommendation. These assumptions could be based on existing evidence or expert opinions.

5. Run simulations: Run multiple simulations using different scenarios and assumptions to assess the potential impact of the recommendations on improving access to maternal health. This could involve adjusting variables such as contraceptive prevalence rates, healthcare infrastructure, and community engagement levels.

6. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on maternal health indicators. This could include comparing the baseline data with the simulated outcomes to assess the effectiveness of each recommendation.

7. Refine and validate the model: Refine the simulation model based on the analysis of the results and validate it using additional data or expert input. This will help ensure the accuracy and reliability of the simulation.

8. Communicate findings: Present the findings of the simulation in a clear and concise manner, highlighting the potential impact of the recommendations on improving access to maternal health. This information can be used to inform policy decisions and guide the implementation of interventions to improve maternal health in Sierra Leone.


Identifiers:
DOI: 10.1186/s12905-023-02175-9
Research Areas:
Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Guinea, Liberia, Multi-Countries, Sierra Leone
Study Design:
Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Female
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