Incidence of induced abortion and post-Abortion care in Tanzania

Background Tanzania has one of the highest maternal mortality ratios in the world, and unsafe abortion is one of its leading causes. Yet little is known about its incidence. Objectives To provide the first ever estimates of the incidence of unsafe abortion in Tanzania, at the national level and for each of the 8 geopolitical zones (7 in Mainland plus Zanzibar). Methods A nationally representative survey of health facilities was conducted to determine the number of induced abortion complications treated in facilities. A survey of experts on abortion was conducted to estimate the likelihood of women experiencing complications and obtaining treatment. These surveys were complemented with population and fertility data to obtain abortion numbers, rates and ratios, using the Abortion Incidence Complications Methodology. Results In Tanzania, women obtained just over 405,000 induced abortions in 2013, for a national rate of 36 abortions per 1,000 women age 15-49 and a ratio of 21 abortions per 100 live births. For each woman treated in a facility for induced abortion complications, 6 times as many women had an abortion but did not receive care. Abortion rates vary widely by zone, from 10.7 in Zanzibar to 50.7 in the Lake zone. Conclusions The abortion rate is similar to that of other countries in the region. Variations by zone are explained mainly by differences in fertility and contraceptive prevalence. Measures to reduce the incidence of unsafe abortion and associated maternal mortality include expanding access to post-Abortion care and contraceptive services to prevent unintended pregnancies.

In countries where abortion is legally restricted and stigmatized, the approach to estimating abortion incidence must often be indirect. To overcome limitations in the availability of official statistics, the Guttmacher Institute has developed the Abortion Incidence Complications Methodology (AICM) [21] to estimate abortion incidence in these settings. The AICM has been applied in about 25 countries worldwide, including Senegal [22], Ethiopia [23], Burkina Faso [24], Uganda [25], Rwanda [26], Kenya [27], and Malawi [28] in sub-Saharan Africa. The methodology involves estimating the number of induced abortion complications treated in facilities, and using expert opinions to estimate, for each complication that reaches a facility, how many induced abortions are occurring without complications or with untreated complications. The primary data for this study come from two surveys conducted by the authors: a Health Facilities Survey (HFS) to measure the number of abortion complications treated in health facilities, and a Health Professionals Survey (HPS) to estimate the likelihood of women experiencing abortion complications and of obtaining treatment at a health facility. The study design and protocols are adapted from previous applications of the methodology, to be relevant to the Tanzanian context. Data collection was led by the Tanzanian National Institute for Medical Research (NIMR) in Dar-es-Salaam, with technical support from Muhimbili University of Health and Allied Sciences (MUHAS) and the Guttmacher Institute. The data from the two surveys were used together with estimates of births, unintended births, and women of reproductive age, compiled from the 2010 Tanzania Demographic and Health Survey [20] and the 2012 Tanzanian national census [29] and projected to 2013 using Tanzania’s intercensal annual growth rate. Estimates were obtained at the national level, as well as for each of the 8 geopolitical zones of Tanzania (7 in mainland, plus the semi-autonomous Zanzibar archipelago). Fieldwork was conducted from July to September 2013. Interviewers were recent medical graduates with previous experience administering surveys. For the HFS, a team of four interviewers was assigned to each zone, and members of the research team at NIMR acted as team leads. These team leads also conducted the HPS interviews, as the HPS questionnaire required more skill and experience, and many respondents were senior professionals. All interviewers and team leads underwent a week-long training in Dar-es-Salaam. Both surveys were piloted in 5 facilities which were not part of the final sample. The sampling frame consisted of the Ministry of Health’s most recent list of all health facilities (public and private) considered likely to provide post-abortion care (PAC). A separate list of all public and private facilities was obtained from the Zanzibar Ministry of Health. Facilities that did not provide primary care, that were specialized in non-reproductive services, or that otherwise lacked the capacity to provide PAC (as for some dispensaries), were excluded from the sampling frame. To ensure that the list was up to date, all district medical officers in the country were contacted to confirm that all health facilities in their district were included in the list, and to determine which facilities were equipped to provide PAC. The final sampling frame of facilities likely to provide PAC included 952 facilities, of which 5 (0.5%) were consultant hospitals, 20 (2.1%) regional hospitals, 224 (23.6%) sub-regional hospitals (district hospitals or other hospitals), 526 (55.2%) health centers and 177 (18.6%) dispensaries (Table 1). Although there were thousands of dispensaries in Tanzania, only 177 provided or were expected to provide PAC at the time we conducted the study. The nomenclature for facilities in Zanzibar is slightly different, with Primary Health Care Centers (PHCCs) being the equivalent of health centers, and Primary Health Care Units (PHCUs) being the equivalent of dispensaries. Within PHCUs, some provide only basic primary care services (PHCU), while others are equipped to provide a wider range of services including PAC (PHCU+). PHCCs and PHCU+ were combined with health centers and dispensaries respectively in the national level analyses. The sampling frame was stratified by facility level within each zone, to ensure that the estimates of abortion incidence were representative at both the national and zonal levels. Within each zone, we selected 100% of consultant and regional hospitals, 66% of non-regional hospitals, 45% of health centers, and 44% of dispensaries equipped to offer PAC, resulting in a total of 487 health facilities in the initial sample. Of these, 481 agreed to participate in the survey (Table 1). To minimize refusals, letters from the Ministry of Health introducing and authorizing the study were sent to all facilities in advance of the fieldwork, and facility in-charges were contacted to inform them about the upcoming survey. Of the facilities that responded, 448 (93%) actually provided PAC services. Most health facilities in Tanzania are government-owned, and this is reflected in the sample: only 26% of all facilities (mostly hospitals) were private or faith-based (Table 1). A structured questionnaire was administered by an interviewer to the most qualified staff member or the person in charge of providing PAC in each facility, typically the chief of the Obstetrics and Gynecology department in larger facilities, and the facility head in health centrs or dispensaries. Respondents were asked whether their facilities provide treatment for abortion complications (from both spontaneous and induced abortion), and if so, to estimate the number of PAC patients treated as outpatients and inpatients, in an average month and the past month. Specifying two time frames increases the likelihood of capturing variation from month to month. These two numbers were subsequently averaged and multiplied by 12 to produce an estimate for the 2013 calendar year. The Health Professionals Survey interviewed a purposive sample of 202 experts knowledgeable about abortion provision in Tanzania. The sample was created through consultation with a broad network of colleagues engaged in research, policy, community and regional-level public health programs, which aimed to identify the individuals most knowledgeable about the provision of abortion at the national level, as well as in each zone. The experts came from a wide range of professions. Forty-six percent were health professionals, including obstetricians/gynecologists, midwives and nurses from the public and private sector, as well as a sizeable proportion of non-formally trained health workers such as community health workers, traditional birth attendants and traditional healers (15% of total sample). The remaining 54% of the sample was composed of researchers, reproductive health advocates, non-governmental organization (NGO) and women’s groups’ representatives, lawyers, journalists working on reproductive health issues, program managers and policy makers, community leaders, and youth leaders. Respondents were distributed equally between the 8 zones. Particular effort was made to ensure that there was sufficient representation of experts with knowledge of rural areas. About 36% of respondents had worked at least 6 months in rural areas during the last 5 years. All 202 prospective respondents agreed to participate. Questionnaires sought information on the proportion of women who experience a complication from an induced abortion, and the proportion likely to receive care in a facility should they experience a complication, separately for rural and urban, poor and non-poor women. Ethical approval was obtained from Guttmacher’s Institutional Review Board, the Tanzanian Medical Research Coordinating Committee, and Zanzibar Medical Research Council. All respondents in both surveys gave written informed consent before being interviewed. From the Health Facilities Survey (HFS), we obtained estimates of the number of patients treated for abortion complications nationally and for each zone. To ensure estimates were representative at the national and zonal levels, weights were assigned to each facility by level and zone, based on their selection probability and on non-response rates. To avoid double-counting patients treated at one facility level then referred to another for additional treatment, we subtracted 75% of patients treated then referred at each facility level from the number treated at the next level, based on an informed estimate that roughly 75% of patients referred for obstetric complications follow up in Tanzania (urban and rural settings combined) [30]. Due to the similarity between complications from induced and spontaneous abortions, and the possibility of patients and/or providers misreporting induced abortions as spontaneous for fear of legal sanctions, it is difficult to obtain accurate estimates of complications solely from induced abortions at the facility level. Therefore the survey recorded the number of complications from all abortions (both induced and spontaneous), from which we then subtracted those due to spontaneous abortion, to obtain the number of induced abortion complications treated in health facilities, nationally and by zone [21]. The number of spontaneous abortion complications treated in facilities was calculated using indirect estimation techniques. Assuming that only second trimester spontaneous abortions require care, and that these equal 3.41% of live births based on clinical studies [31,32], we obtained the number of spontaneous abortions that would need treatment nationally and by zone. However, not all spontaneous abortions requiring care will actually be treated in facilities for a number of reasons, including lack of access or a preference to seek treatment from untrained providers. To estimate the proportion of spontaneous abortions needing care that were actually treated in health facilities in each zone, we assume that this proportion is similar to the proportion of recent births that were either delivered in health facilities or not delivered in health facilities because it was not customary or necessary. The 2010 DHS estimate was projected to 2013 based on percent change between the last two DHS rounds) and adjusted it to include women who would have delivered in health facilities had it been customary or necessary using DHS information on women’s reasons for not delivering at facilities. But not all induced abortions will result in treated complications. Some will be done without complications, while others will end in complications that are not treated in health facilities for various reasons, including lack of access, fear of prosecution, preference to seek treatment from untrained providers or even death. The HPS provided estimates of the probability of experiencing induced abortion complications by type of abortion provider, and the probability of seeking care for complications, for four wealth-residence groups: urban poor, urban non-poor, rural poor and rural non-poor. Multiplying these two sets of probabilities, we obtained the proportion of all induced abortions that resulted in complications that were treated, for each of the four groups. These were then combined into a single weighted proportion based on the population distribution of the four groups (from the DHS), nationally and separately for each zone. The inverse of this proportion is the multiplier or inflation factor needed to account for induced abortions which were either without complications or with complications that were not treated in a facility. This multiplier presents the number of such abortions for every induced abortion complication treated in a facility. The higher the multiplier, the higher the proportion of abortions that is either uncomplicated or with untreated complications [21]. We multiplied this factor by the number of induced abortion complications treated in health facilities (from the HFS), to obtain the total number of induced abortions nationally and for each zone in 2013 [21]. The number of induced abortions is expressed per 1,000 women aged 15–49 (abortion rate) and per 100 live births (abortion ratio). We also calculated the number and rates of total pregnancies and unintended pregnancies nationally and for each zone. The total number of pregnancies is calculated as the sum of the annual numbers of induced abortions, births and miscarriages (estimated as 20% of live births plus 10% of induced abortions [31,33]). Expressing this number per 1,000 women of reproductive age gives the pregnancy rate for each zone and nationally. The total number of unintended pregnancies is the sum of induced abortions, unplanned births (obtained by multiplying the proportion of recent births that were unintended in the DHS by the total number of births in 2013), and unplanned pregnancies resulting in miscarriage (equal to 20% of unplanned births plus 10% of induced abortions, assuming that all induced abortions result from unintended pregnancies [33]). This estimate can be expressed per 1,000 women of reproductive age to obtain the unintended pregnancy rate.

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