Unsafe abortion as described by World Health Organization (WHO) is considered as a procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the medical standards, or both [1]. Countries with narrow bases for legal abortion are highly vulnerable for large burden of unsafe abortion and related mortality. Globally, 26% of the world’s population lives where abortion is prohibited altogether or permitted only on certain circumstances like to save the woman’s life. Of those peoples, majority of them are found in the developing world [2].

Each year, about 585,000 women die every year worldwide due to pregnancy and childbirth related complications, out of which 99% of them occur in developing countries. The leading causes of maternal death include hemorrhage (25%), infection (15%) and unsafe abortion (13%) [3].

The World Health Organization (WHO) estimates that every year, nearly 5.5 million African women have an unsafe abortion. As many as 36,000 of these women die from the procedure, while millions more experience short or long term illness and disability. The unsafe abortion mortality ratio (the number of unsafe abortion-related deaths per 100 000 live births) varies across regions. About half of all deaths from unsafe abortion are in Asia, with most of the remainder (44%) in Africa. Generally, in Africa maternal mortality is estimated as high as 900/100,000 live births [4]. Many studies identified that the foremost determinants of unsafe abortion in different settings include level of utilizing family planning, emergency contraceptive, and legalization of abortion and the skill of the health professionals [5].

Legal abortion service markedly reduces deaths from abortion complications and the overall maternal mortality [6]. For instance a case from Romania confirmed that, due to legalization of abortion in 1989, maternal mortality ratio was dropped from 170/100,000 live births in 1989 to 60/100,000 live births in 1992, which was mainly attributed to the improved safety of abortion after the legalization [7].

In Ethiopia, one in seven women die from pregnancy-related causes, and of this unsafe abortion contribute for maternal deaths of more than half of the 20,000 that occur annually. Also other studies revealed that Ethiopia has the fifth highest number of maternal deaths in the world: One in 27 women die from complications of pregnancy or childbirth annually [8]. To make unsafe abortions safe, national policies including making induced abortion legal reforms are the prerequisites [1].

However, for much of Ethiopia’s modern history, safe abortion services were unavailable. Currently, motivated by the growing death toll from unsafe abortion and other related causes, the Ethiopian government made abortion to be allowed by law in certain conditions. By considering its significance, in 2005, Ethiopia expanded its abortion law, which had previously allowed the procedure only to save the life of a woman or protect her physical health [5].

It is fact that only setting Legal reforms alone in a given country cannot reduce abortion related deaths especially in Ethiopia. Creating awareness within the community through different campaigns are crucial to modify society’s attitude towards abortion, prevent unsafe and illegal practices, and inform about legal and safe abortion care services. If government did not work on improving knowledge and attitude of peoples they are not likely to benefit from the legal reform and services.

Therefore’ this study was aimed to fill the existing information gap by assessing knowledge and attitudes of men and women towards legalization of induced abortion.

General objective

To assess knowledge and attitudes of men and women aged between 15-49 years towards legalization of induced abortion in Mizan Aman Town, Bench Maji zone, South West Ethiopia.

Specific objectives

• To assess knowledge of men and women aged between 15-49 years towards induced abortion and its legalization in Mizan Aman Town, Bench Maji zone, 2016.

• To assess attitudes of men and women aged between 15-49 years towards legalization of induced abortion in Mizan Aman Town, Bench Maji zone, 2016.

• To assess factors affecting knowledge and attitudes of men and women aged between 15-49 years towards legalization of induced abortion in Mizan Aman Town, Bench Maji zone, 2016.

Study area

Mizan-Teferi is found in bench Maji zone located at the south western part of Ethiopia, about 561 kilometers south west from Addis Ababa and 849 km from Hawassa which is capital city of SNNP region. The zone is bordered in north and north east with Kaffa zone and North West with Sheka zone, in south east with Debub Omo zone, south west with Gambella region and south Sudan.

According to the Ethiopian censes 2007 Bench Maji zone a total population of 760313 (male 450106 and female 310210). Currently the name Mizan Teferi is changed into Mizan Aman which consists of two sub cities Mizan and Aman 6 km apart from each other.

Study design and study period

Community based cross-sectional design was conducted from October 2015 to June 2016 to assess the attitudes of 15-49 year old women and men towards legalization of abortion, in Mizan-Aman town, Bench Maji zone, SNNP region.

Source population

All men and women with age of 15-49 years old that are found in Mizan Aman town was the source population.

Study population

Men and women aged 15-49 years old that are found in Mizan Aman town and who are available during data collection were the study population.

Inclusion criteria

Those who are men and women aged between 15-49 years old, those who are volunteers and who are relatively healthy to provide information were included in this study.

Exclusion criteria

Those who are severely ill could not talk and hear, and who were involuntary and not available at time of study were excluded from this study.

Sample size determinations

The sample size was determined by using single population proportion formula using 95% confidence interval at 5% margin of error and since there was no research done on attitude and knowledge towards legalization of abortion in this locality.

The sample size was calculated by taking value of population proportion (50%) for maximum sample size, using the following formula:

N= (Zα/2)² p (1-p) /d²

n= (1.96)² × 0.5 (1-0.5)/(0.05)²=0.96604/0.0025=384

Then we add non response rate of 10%, so n=422

Where, z=value of 95% from z table (1.96) p=proportion of the population (50%) and d=margin of error (5%)

Sampling technique

Systematic random sampling method was used for this study to select households.

Dependent variables

• Knowledge and attitudes towards legalization of induced abortion

Independent variables

• Socio demographic characteristics of respondents (Age, sex, educational level, marital status, religion, occupation and income status)

• Previous experience related to unsafe abortion

• Knowledge about complication of unsafe abortion

Knowledge: Awareness about current legal status of abortion in Ethiopia context and post abortion complication. Also it includes those who are aware of the possible measures to prevent morbidity and mortality which is caused by abortion.

Attitude: It is the way to which clients are thinking or behaving about legalization of abortion.

Abortion: is termination of pregnancy before viability of fetus (<28) weeks of gestation in Ethiopia OR <20 weeks of gestation in USA and according to WHO).

Unsafe abortion: World Health Organization (WHO) definition, “as a procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the medical standards, or both”.

Data collection tools

Questionnaire that was prepared after reviewing similar literature and modified to our context was used to collect data. Two weeks earlier to the actual data collection period, pretest/pilot study was carried out in other nearby town to check its reliability.

Data was collected by three 4^th year public health students.

Data quality control

Data collectors were trained by instructors in public health department. Daily checking of the completeness of questions was made by supervisors.

Data processing and analysis

Data entry and analysis was done using Epi Data V3.1 and SPSS V20. The data was summarized using descriptive statistics and chi square test for significant association between dependent and explanatory variables.

Finally, the result was displayed using tables, graphs, and figures as well.

Plan for result dissemination

The copy of the research was disseminated to Mizan Aman health bureau, Mizan Tepi university teaching hospital and Mizan Tepi University.

Socio-demographic profile of respondents

A total of 422 individuals were included in this study, of those, male participants constitutes 224 (53.1%) of the total and the remaining 198 (46.9%) were female respondents.

Majority of respondents, 89 (21%), were found in the age range of between 26-30 years of old.

The ethnic groups which have large number in Mizan Aman town were Bench and Amhara with a value of 179 (42.5%) and 128 (30.5%) respectively (Table 1).

Table 1: Socio demographic status of respondents in Mizan Aman town, Bench Maji zone, SWE, 2016.

History of abortion among interviewed reproductive age women in past pregnancies

The result of this study discovered that women’s who had history of terminating pregnancy constitutes 28 (14.1%) of total women’s interviewed.

Most, 21 (75%) and 20 (71.4%), of women who have terminated their pregnancy were identified premarital pregnancy and unintended sex as a major reason for undertaking abortion respectively.

Majority of abortions, 23 (82.1%), were induced by health professional and 18 (64.3%) of abortions were done using oral drug (modern) method.

Eighteen, 18 (64.3%), of abortions made were induced in hospital.

Majority, 20 (71.5%), of women who did induced abortion faced mainly abdominal pain (Table 2).

Table 2: History of abortion and reason for termination among reproductive age women in Mizan Aman town, Bench Maji zone, SWE, 2016 [*Multiple responses were allowed and hence totals could be greater than actual size].

Knowledge and attitudes respondents on induced abortion, and legalization of induced abortion

Attitude of respondents towards legalization of induced abortion

Out of the total respondents, 238 (56.4%) preferred legalization of induced abortion in Ethiopia. Of those who preferred legalization of induced abortion majority, 41.9%, of respondents considered unsafe abortion as a major health problem on the contrary of those who opposed legalization of induced abortion, 54.9%, of them had perceptions that termination of pregnancy was homicide. Out of the total, 234 (55.6%) believed that people would use legal abortion services, if induced abortion were legalized in Ethiopia.

Also 234 (55.6%) of respondents replied that they would encourage a friend other individuals who are in need to go for an abortion if abortion is legalized (Table 3).

Table 3: Attitude of respondents towards legalization of abortion in Ethiopia, in Mizan Aman town, Bench Maji zone, SWE, 2016 [*Multiple responses were allowed and hence totals could be greater than actual size].

Out of those who preferred legalization of abortion, 360 (85.2%) preferred hospitals. Of all, 200 (47.5%) and 127 (30.1%), said both partners, and the pregnant woman should have equal right to make decision to terminate pregnancy, respectively. Majority, 148 (35%), of respondents replied that unmarried women should have allowed to make abortion in legal way other than other groups. Of all respondents, 156 (36.9%) believed that a woman has the right to terminate her pregnancy, if she wants, while 266 (63.1%) of them were against it (Table 4).

Table 4: Respondents preferred places to abortion, who should decide and what type of women should be allowed to terminate pregnancy in Mizan Aman town, Bench Maji zone, SWE, 2016 [*Multiple responses were allowed and hence totals could be greater than actual size].

Out of all respondents, 359 (85%) of them had awareness about the complication of abortion. Health problems related to unsafe abortion, which were mainly mentioned by respondents include, death 321 (76.1%) and HIV/AIDS transmission. Majority, 99%, of respondents suggested at least one solution to solve the problem related with unsafe abortion, while 1% of them responded that they did not know. Out of the total, 288 (68.3%) respondents believed that legalization of induced abortion would reduce problems related to unsafe abortion (Table 5).

Table 5: Knowledge of respondents towards the health effect of unsafe abortion in Mizan Aman town, Bench Maji zone, SWE, 2016 [*Multiple responses were allowed and hence totals could be greater than actual size].

Knowledge of respondents towards the current legal status of induced abortion in Ethiopia

Only 24 (5.7%) of respondents replied that the country law allow induced abortion for specific peoples who are in need.

On the contrary 346 (82%) of them replied as induced abortion was currently illegal in Ethiopia (Figure 1).

Figure 1: Knowledge of respondents towards current legal status of abortion in Ethiopia, Mizan Aman town, Bench Maji zone, SWE, 2016.

Factors affecting attitudes of respondents towards legalization of abortion

According to the finding of this study knowledge of respondents about complication of abortion has an association with an attitude towards legalization of abortion, where X²=6.89, p=0.008 which was P<0.05. Respondents preference to terminate unwanted pregnancy and their belief whether legalization of abortion would reduce associated complication have a significant association with attitudes towards legalization of induced abortion with X²=77.36, and X²=86.37 respectively where both have P<0.005.

The remaining variables such as sex, marital status, religion and educational status of respondents did not showed any significant association with attitudes of respondents towards legalization of induced abortion (Table 6).

Table 6: Factors affecting attitude of respondents towards legalization of abortion, in Mizan Aman town, Bench Maji zone, SWE, 2016 [OR-Odds ratio, *-variables which were found to have significant association with attitude towards legalization of abortion].

Lack of awareness about the current abortion law can influence individual decision making regarding contraceptive use, lead to accessing unsafe abortion and unsafe post abortion care. Recently, the Ministry of Health (MoH) has emphasized that increasing of knowledge and vital safe abortion care information at grass-root level are crucial to provide the required service especially for women in areas of the country where the level of awareness and service is low [5].

The result of this study revealed that only 24 (5.7%) of respondents had knowledge of current legal status of abortion by law while, majority, 346 (82%), of them were replied as induced abortion was illegal in Ethiopia. This study was comparably similar with a result obtained in Jimma town where only 10.8% of respondents replied as the country had legalized abortion with some circumstances [9] and Sri Lanka where only 11% of the respondents knew the situations in which abortion was legal in [10].

Also, despite the liberalized abortion law Ethiopian women are facing major obstacles such as lack of awareness of the liberalized abortion law and access to safe abortion services. Moreover, health professionals also lack awareness about the new law. This may be attributed to poverty, lack of services, religion, culture, and fear of health risks are the possible reasons [11].

Unsafe abortion complications are most common in poor women and younger age women, who are also the ones with limited access to abortion care and family planning services and with higher proportion of unwanted pregnancies [12]. The result of this study estimated that from women’s who had history of terminating pregnancy which constitutes 28 (14.1%) of total women’s interviewed, most, 21 (75%) and 20 (71.4%), of women who have terminated their pregnancy were mentioned premarital pregnancy and unintended sex as a major reason for undertaking abortion respectively.

Majority of abortions, 23 (82.1%), were induced by health professional which was similar with a result obtained in Gambella Hospital where among patients admitted to Gynecological ward during the period from June 1997 to May 1998, 70% of all were reported to be cases of abortion, of which 35.7% were induced [5].

Informants’ attitudes toward the abortion law varied widely depending on a lot of factors. Having negative attitudes towards abortion and lack of skills and information for termination of pregnancy were found to be the two commonest reasons for not providing services as required as possible [13]. Out of the total respondents, 238 (56.4%) preferred legalization of induced abortion in.

Of those who preferred legalization of induced abortion majority, 41.9%, of respondents considered unsafe abortion as a major health problem, on the contrary of those who opposed legalization of induced abortion, 54.9%, of them had perceptions that termination of pregnancy was homicide.

This result was comparatively better than a result obtained in Nigeria, where more than one-third of informants opined that abortion should not be legal under any circumstance, and a significant proportion suggested that the solution to unsafe abortion is not to legalize the procedure but to provide sexuality education. Religious and moral concerns were the most common reasons for opposing liberalization of abortion laws [14].

Public perceptions on induced abortion can influence not only the outcome of the unwanted pregnancy but also health sector policy response. In this study area more than 234 (55.6%) of total respondents, believed that people would use legal abortion services, and they would encourage a friend or other individuals who are in need to go for an abortion which was indicator of positive perception towards induced abortion.

Women right to undertake decision on their fetus can be significant factor that play a critical role to enhance utilization of abortion services [13]. In this study of all, 200 (47.5%) and 127 (30.1%), said both partners, and the pregnant woman should have equal right to make decision to terminate pregnancy, respectively. As well, 156 (36.9%) believed that a woman has the right to terminate her pregnancy, if she wants, while 266 (63.1%) of them were against it.

From this study a significant proportion of participants, 359 (85%), of them had awareness about the complication of abortion. Health problems related to unsafe abortion, which were mainly mentioned by respondents include, death 321 (76.1%) and HIV/AIDS transmission. Majority, 99%, of respondents suggested at least one solution to solve the problem related with unsafe abortion.

Out of the total, 288 (68.3%) respondents believed that legalization of induced abortion would reduce problems related to unsafe abortion. This result was similar with a result obtained in Uganda [15] and Ethiopia [16] where more than 90% knew at least one complication of an induced abortion and 75% of respondents knowing the complications of induced abortions respectively.

This study showed that knowledge of respondents about complication of abortion, (X²= 6.89, p=0.008), respondents preference to terminate unwanted pregnancy (X²=77.36, p<0.005) and their belief whether legalization of abortion would reduce associated complication (X²=86.37, P<0.005) has an association with an attitude towards legalization of abortion. This finding was coherent with other similar study in Argentina [17], Uganda [15], Ethiopia [17] and Jimma [9].

Also this study discovered that there were not have statistically significant association between sex, marital status, religion and educational status of respondents and their attitudes towards legalization of induced abortion. This result was similar with a finding in Jimma where educational status has no association with an attitude towards legalization X²=7.217 which P=0.301 [9].

But it is different from a result obtained from a study conducted in Ethiopia where the educational status has a statistical significant association with an attitude that is X²= 69.84 which P value is P<0.05 [18].

Strengths

Since this study was the first conducted on knowledge and attitudes of men and women towards legalization of induced abortion in the country which was a community based, gives strength to this study.

Limitations

• The study conducted only in urban settings and thus it is difficult to generalize both for urban and rural community.

• The study was cross sectional, thus, under reporting of induced abortion might exist.

• In contrast to other studies attitudes of respondents towards legalization of abortion were good, where more than half of the people in the study area had positive attitudes towards legalization of induced abortion.

• Also more respondents believed that people would use legal abortion services, and they would encourage a friend or other individuals who are in need to go for an abortion which was the main reflection of positive attitude towards legalization of induced abortion.

• Large number of respondents in the studied area prefers induced abortion to be legalized in their locality. Majority of them were aware of any complications related with unsafe abortion and thus most of them consider unsafe abortion as a major health problem.

• The result of this study revealed low number of respondents had knowledge of current legal status of abortion in their country.

• Knowledge of respondents about complication of unsafe abortion, respondent’s preference to terminate unwanted pregnancy and their belief whether legalization of abortion would reduce associated complication has an association with an attitude towards legalization of abortion.

• Most of women who have terminated their pregnancy were mentioned premarital pregnancy and unintended sex as a major reason for undertaking abortion.

• It is very critical to increase awareness of community towards the current legal status of abortion and existing services. Thus concerned bodies such as professionals, CBOs and other influential individuals should be involved to enhance community knowledge and perception towards legal aspects of abortion otherwise since it can affect decision making on abortion legal reforms.

• It is better prepare discussion on the risk of unsafe abortion and current legal status of abortion in Ethiopia with the community particularly with reproductive age groups that are found in Mizan Aman town.

• Unintended pregnancy were identified as a common cause of unsafe abortion in the studied area and thus promotion of information and education on unsafe abortion related problems, the benefits of safe legal abortion services, family planning is very essential.

• The attitude of communities in Mizan town were in good status in contrast to other studies but since communities negative attitude can be a cause for failure of a countries policy it is expected to disseminate information on risks of unsafe abortion and prevention of unwanted pregnancies, and promotion legal abortion.

• The researchers suggested that further studies need to be conducted to assess the magnitude of problems related with unintended pregnancy.

Ethical permission was obtained from Mizan Tepi University, college of health science. Verbal consent was obtained from each study subject included in the study. The participant who was included in the study was given enough information in order to make an informed decision. Each piece of information that was given by every responding subject was strictly kept confidential.

We would like to pass our heartily felt acknowledgement to Mizan Tepi University, College of health science for their cooperation in doing this research. Our sincere appreciation also goes to staff members of public health department for their support and encouragement. Finally we want to appreciate the cooperation of all concerned officials and respondents in Mizan Aman town.