Family Medicine & Medical Science Research
Open Access

Assessment of Knowledge, Attitude and Practice Women of Reproductive Age Group towards Abortion Care at Gambella Health Facilities, South West of Ethiopia

Ataguadil Mekonnen1^*, Zemnu Awoke2 and Wondwossen Terefe2 ^*Correspondence: Ataguadil Mekonnen1, Department of Human Nutrition and Dietetics, School of Public Health, College of Health Sciences, Gambella Health Science College, Gambella, Ethiopia, Email:

Author info »

Introduction

Abortion can be defined as termination of pregnancy (spontaneous, therapeutic or induced) before the fetus has become viable outside the uterus or before the fetus is capable to have a life outside of the womb [1]. Spontaneous abortion refers to a natural biological process by which some pregnancies end with no known cause and usually referred as miscarriage and an induced abortion takes place when a pregnancy is terminated by the deliberate removal of the fetus from the uterus by the use of external methods as a result of an unwanted pregnancy [1,2]. Elective abortion is the voluntary termination of pregnancy performed either surgically or medically. A therapeutic abortion takes place when a pregnancy is terminated by the removal of the fetus from the uterus by the use of external methods, however, unlike an induced abortion therapeutic abortion is performed to either to save the life of a pregnant woman or when a woman’s physical or mental health is in jeopardy or savior fetal congenital disorder or to selectively decrease the number of fetuses to reduce health risks linked with multiple pregnancies [3].

Changing maternal mortality will be achievable if unsafe abortion will be replaced by medical abortion since thousands of lives could be saved each year by implementing medication abortion [4]. Medical abortion is the commonly performed safe abortion technology which uses medications in place of traditional surgical interventions for terminating an early unintended pregnancy [5].

Legal abortion like medication abortion can be performed if the life of the woman will be jeopardized by the pregnancy and unsafe abortion will usually occurs where abortion is illegal. Unsafe abortion is defined by WHO as a procedure for terminating an unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standards, or both [1,3,6]. When the pregnancy is resulted from rape or incest, the woman’s or fetus lives are threatened, the fetus has severe abnormalities, the woman has physical or mental disabilities and when a minor is physically or psychologically unprepared to raise a child. According to the new law there is no need of proof for age or whether the pregnancy is resulted from rape or incest [7]. Unwanted pregnancies and unsafe abortion are commonly neglected reproductive health care problems in developing countries and pose major health risks to women in the reproductive age group [8].

Access to medication abortion is commonly restricted, not only by the law, but also by other barriers like Social, religious, cultural impediments, lack awareness, maternal perception towards abortion also contribute to delays in seeking abortion to a time beyond the limit set by the law and thus when faced with an unintended pregnancy, women seek abortion and self-induce it or find providers, irrespective of the law and Unsafe abortions present a critical public health and human rights challenge of the present time [9,10].

Ethiopia is the 5th in maternal mortality according to the WHO 2005 report and unsafe abortion accounts for 32% of the causes of maternal death. It is also one of the top 10 reasons for mothers to seek hospital admission in Ethiopia [1,3].

Unsafe abortion can be prevented and reduced by expanding and improving family planning services and choice. Many married women in developing countries do not have the access to the contraceptive methods of their choice. Besides maternal mortality, unsafe abortion causes other serious complications like hemorrhage, sepsis, uterine perforation, lower genital tract

trauma disseminated intra vascular coagulation, shock, renal and cardiac failure which may result in permanent disability and incapacitating condition like infertility and psychological problem [1,3,6]. Ethiopia has a high maternal mortality ratio, 412 deaths per 100,000 live births for the period 2009-2016 [3,6] and reproductive health experts in the country believe that the proportion due to abortion complications is also excessive which is an estimated 1.9 million (38%) Ethiopian women have unintended of 4.9 million (62%) total pregnancies and 620,300 induced abortions (13%) were performed in 2014 [11-16]. Between 2008 and 2014, the proportion of abortions occurring in facilities raise from 27% to 53%, nonetheless, an estimated 294,100 abortions occurred outside of health facilities in 2014 [15]. The number of women receiving treatment for complications from induced abortion nearly doubled which is 52,600 to 103,600 [6,13]. The finding of this study help to know the knowledge, attitude and practice of reproductive age groups towards abortion care and to determine what methods are more appropriate to educate reproductive age groups about abortion care. Future researchers will also use this finding for further study. Furthermore, policy makers in sexual and reproductive health clinics, religious and community stakeholders will also use the evidence of this finding to improve strategies, and program policies to tackle the root causes. Therefore, The main aim of this study was to assess knowledge, attitude and practice towards to abortion care among reproductive age group women in selected sexual and reproductive health clinics of Gambella, Ethiopia

Materials and Methods

Study setting

The study will be conducted at Gambella hospital which is found in Gambella region. The region has an elevation ranging from 400 to 600 meters above the sea level and largely hot climatic zone. It covers a total area of 23,127 square kilometer. The capital city of the region is Gambella town which is located at 768 km from the capital city of Ethiopia, Addis Ababa to Southwest direction. The study was conducted from August 15 to September 30, 2019 .

Study design

An institutional based Cross-sectional study design was employed at Gambella Health facility. The source populations for this study were all reproductive age women attending in sexual and reproductive health clinics at Gambella Health facility.

Study population

The study populations for this study was those All reproductive age women who were visited sexual and reproductive health clinics at Gambella Health facility during data collection period and fulfilling the eligibility criteria.

Eligibility criteria

All reproductive age women who visit for service in selected SRH clinics during data collection period will be included, and only those who gave their consent to participate during the study period and volunteer to respond and hear will be eligible to the study. Reproductive age women who are seriously ill and/or difficulty to communicate, whose age less than 18 years will be excluded from the sample, and who willingly disclosed this information were will be excluded from the study. Emergency cesarean delivery: A type of cesarean section done after the onset of labor or for immediate threat to the life of the woman or the fetus.

Sampling technique and procedure

Two Public health institutions (Gambella Hospital and Gambella health center) and three Private Clinics will be selected by using simple random sampling because it was a public health institution which was physically accessible, located in town where all representative ethnic groups of the region reside, and its environs seek health care services from this health facility. A systematic random sampling technique will be employed to select the study participants. In order to get sampling interval (K), the total population was divided by the sample size required. K=Nt/ nf=1266/422=~3. Of the first three subjects, one woman will be randomly selected from first day list by lottery method, and then taking every 3rd other Reproductive age women will be selected to participate in the study until the desired sample sizes of 422 Reproductive age women will be obtained. To avoid redundancy the client card number will be used and after data will be collected code was given to the client chart.

Data collection technique and procedures

Data were collected using structured and pretested questionnaire for the quantitative data. For the qualitative, FGD was used as a method, which used guidelines/checklists for data collection. All individuals sayings were tape recorded, using cassettes and manually documented. Data collection was done by four data collectors who were University students. Supervisors were students who were doing their second degree. For the Qualitative part, participants of FGDs were grouped by sex in order to establish homogeneity within the group that affects group interaction. The discussion was moderated by principal investigator with the assistance of tape-recorder and trained note taker, which is responsible for observing and noticing all nonverbal responses of the participants (smiles face impressions, movements, head nodding, and Gestures). Discussions were ended after no more information was elicited. Prior to discussion, informed consent was obtained orally from each participant. A questionnaire was developed after reviewing of different literatures of similar studies. It was prepared first in English language and then translated into Amharic and Agnuac language and then was translated back to English to check its simplicity and consistency. A total of Four (two midwives and two laboratory technical) trained data collectors and two BSc Nurse supervisors with a minimum of one year work experience including the principal investigator was involved in the data collection.

Data quality assurance

Appropriate study design and sampling technique was used and well-structured data collection tools were developed. The questionnaire was translated to local language and back translated to English to check for their consistency. For effective and quality data, one week prior to the actual data collection period the four data collectors (two midwifery and two laboratory technicians) and two supervisors was trained on the objective, relevance of the study, confidentiality of information, respondent’s right, informed consent, techniques of interview and measurement for two days. Moreover, class room practical demonstration of the interview was carried out. Pre-test of questionnaires was done in 10% of the total sample size in a similar population at Gambella woreda health center before the actual data collection. During the pre-testing data collectors, supervisors and investigator were participated in the evaluation of the tool.

Data analysis

The descriptive statistics show the distribution of respondents by the key variables. Continuous variables were checked for normality using scatter plots. Descriptive statistics such as frequencies and percentages for Categorical variables and the mean (± SD) values for continuous variables were computed. Descriptive summaries such as frequency tables, graphs, and percentage and mean values were used to present the study results. A bivariate logistic regression analysis was used to see the crude relationships exist between dependent variable and independent variables. Candidate variables from bivariate analysis were selected and transferred to multivariable binary logistic regression by using pre-set p-value of 0.05), indicating the model fits the data well. Finally, significance was obtained at odds ratio (OR) with 95% CI and p-value< 0.05.

Operational definitions

•interference with provable concepts with the aim of termination of pregnancy

•abortion technique that lack or inadequate skill of provider, hazardous technique and unsanitary conditions.

•what a woman knows about abortion (meaning, place where it is done, drugs used for medication abortion and gestational age medication abortion is used).

•the predisposition to respond in a favorable or unfavorable manner towards abortion, medication abortion and related issues such as advising colleague to have abortion or for oneself in case of unplanned pregnancy, which type of abortion is preferable. Mekonnen A, et al. Fam Med Med Sci Res, Vol.10 Iss.3 No:270 4

•is the overt health behavior, habit or customs of a woman related to abortion or those who have experienced or practiced abortion at least once in past.

•in this study “good knowledge” represents that respondents who answered 70% and above of the statement on knowledge questions, while “poor knowledge” represents those who answered below 70% of the statement on knowledge questions.

•in this study “favorable (positive)” attitude was for those who answer 70% and above of the statement on attitude, whereas “unfavorable (negive)” attitude was for those who answer below 70% of the statement on attitude.

 

Result

Out of 422 sampled women of reproductive age group (15-49 years of age), 412 were interviewed making up a response rate of 97.6%. Two hundred seventy neigh (67.8%) of the study participants were urban dwellers. Slightly more than one third, 162 (39.3%) of the study participants were in the age group (20-24 years), whereas, a small proportion 34 (8.2%) of them were 35 and above years of age. The mean ages of mothers were 26.88 years (SD ± 5.698 years) standard division (SD) with a range of 27 years (15, 44 years). Nearly half, 179 (43.4%) of Primary education (1-8) Secondary education. (9-12) 139 33.7 72 17.5 them were protestant in religion (Table 1).

Reproductive health related characteristics of the study participants

A round 93 (22.6%), of participants had first pregnancy at a time of data collection. Of all respondents, 112 (36.1%) of the study participants had a parity of 1 to 2 (Table 2).

Knowledge of the study participants on induced abortion

Out of the 412 study participants, 295 (71.6%) of them responded that they had ever heard about safe abortion service, the remaining 28.4% were did not. Of those who heard about safe abortion, nearly half 124 (42%) of them heard from health professional and only fifty seven 57 (19.5%) of them heard from mass media (Table 3).

Overall Knowledge score towards induced abortion: Twelve (12) questions were prepared to assess overall knowledge of respondents towards induced abortion. Regarding the overall knowledge, more than half of the Reproductive age women Group two-third, 286 (69.5%) have inadequate knowledge and the remaining 126 (30.5%) of them had adequate knowledge on induced safe abortion.

Discussion

In the current study, more than two-third, 286 (69.5%) of women in reproductive age group have inadequate knowledge towards safe abortion. Of these most believed that safe abortion should be allowed under any circumstance. The World Health Organization (WHO) estimates that every year, nearly 5.5 million African women have an unsafe [3]. To minimize this burden associated with unsafe abortion it is important to legalize abortion which might enhance the provision of quality service. In addition to this improving the knowledge, attitude and practice of women in reproductive age group towards safe abortion is critical. This study was intended to assess the knowledge, attitude, practice of women of reproductive age groups towards induced abortion because knowledge on abortion will improve their practices towards safe abortion practices, which will further reduce the incidences of maternal mortality and morbidity due to complications of unsafe abortion.

Overall knowledge on abortion is good in our study respondents i.e. 126 (30.5%). This is slightly lower than the finding from Debre markose, Nepal, and Urban Slums Of Guwahati City where overall knowledge were 76%, 71.2%, and 83.47, respectively (34-367). Good knowledge on abortion in the respondents might be due to adequate amount of awareness.

provided by their relatives as a source of knowledge on abortion. Out of the different types of abortions 39.1% and 35.7% had knowledge on medical abortion and surgical abortion respectively, but only 20.7% of them knew about spontaneous abortion. One study conducted in Debre Marquos claims that the odds of male students were 2.5 times more likely to have adequate knowledge than females [3]. But this is dissimilar with this current finding; women in reproductive age group were 1.6 more likely to have adequate knowledge related to safe abortion than males. The reason is because females are becoming more accessed to different mass media and getting more information about the problem than males and the number of females going to schools and Universities is improving. In addition females have different information regarding health problems and their awareness is increased through establishing gender clubs at schools and Universities to have open communication regarding females’ problems which are related to major obstacles for their education and other health related problems. According to the finding of this study only 67 (16.3%) of women of reproductive age group knew the legal status of induced abortion in Ethiopia. This study was found to be much lower than a result obtained in Nepal among medical college students where satisfactory proportions (66.5%) of the respondents were aware about legalization of abortion with the country [11]. This might be attributed to the difference in level of education among students in two study areas.

Unsafe abortion was reported as it is a major health problem by 322 (78.1.9%) of the study subjects. This is higher than the finding from Addis Ababa study that is 26% [13]. This might be due to difference in study subjects only first year students were included in this study, whereas Addis Ababa study subjects includes first year and above. It is fact that as the year of study increases the level of knowledge of students also increased [11,12]. This study showed that 48.2% of study participants were aware of at least one type of due to induced abortion. This result was similarly supported with the qualitative finding, unsafe abortion was said to cause for increased morbidity, mortality, psychosocial and economic problems, excessive bleeding, genital traumas including uterus perforation, infections, infertility, and increased risk of transmission of STI and HIV/AIDS. This finding was much lower than a knowledge, attitude, practice study conducted in public health practitioners in Tigray, Ethiopia which were 55.9%, 94% [13,14]. Though students are expected to know about complication of abortion. Dissemination of information about the reproductive health problems specially, about abortion has been weak; this results in limited knowledge about the issue. This could lead to unsafe sexual practices. The most commonly cited complications include, bleeding (40.4%), infection (25.3%) and infertility (10.2%). This finding was lower than the study finding obtained in Kampala, Uganda where most (93.1%) of participants knew at least one complication of an induced abortion [12]. The variation might be occurred due to difference in access to health information in different settings. Majority of the respondents 54.7% opposed legalization of abortion Ethiopia. This finding was lower from the study conducted in Jimma where 67% of study participants opposed its legalization [13]. On the contrary the result was much higher than a study conducted in Argentina among college students where only 4.6% of study participants opposed the legalization of induced abortion [13]. The reason why most respondents opposed might be religion and cultural factors which has its influence on one’s attitude.

Regarding to knowledge of Ethiopia’s abortion law, 20.5% responded that Ethiopia has no abortion law. Furthermore most of the FGD discussants did not know whether Ethiopia has abortion law. Few mentioned Ethiopia has abortion law; this finding was lower than a study conducted in Addis Ababa University which reported 39% [14]. The lower response rate of knowing that Ethiopia has abortion law in this study might have been due to dissemination of information about the new penal code has been weak, and have limited knowledge about the issue. Besides, the study sample in this study were first year students but the study samples in the above two universities were exclusively health students. This is expected in the experienced health science students to have higher knowledge regarding safe abortion compared to first year students from other non-health departments.

As part of law reforms in Ethiopia in 2005 the penal code was revised to broaden the indications under which abortion is permitted. Termination of pregnancy is now legal when the pregnancy results from rape or incest, when continuation of pregnancy dangers the health or life of the women or the fetus, in case of foetal impairment, for women with physical or mental disabilities [12]. Despite the relative liberalization and despite the fact that several institutions in the town provided safe abortion services, the fact that significant proportion of Women in reproductive age group resorted to traditional and unsafe services indicates that access to safe abortion remains to be a problem. Furthermore, out of all study participants, only 67 (16.3%) properly identified all the conditions under which abortion is legally allowed in Ethiopia. This demonstrates that liberalization of abortion by itself is not enough and that, in order to ensure that legislative changes improve reproductive health; women must know the legal options they have in the case of unwanted pregnancy. This is in agreement with findings of study conducted in South Africa, where abortion is legal, yet unmet need for abortion information resulted in significant occurrence of unsafe and illegal abortion [12,15].

Conclusion

This study showed that more than two-third (69.5%) of women in reproductive age group had poor level of knowledge about induced abortion. Also most of the studied participants had showed unfavorable/negative attitude toward induced abortion. Abortion is a serious issue in our society, which can never be considered as an isolated phenomenon. Majority of the women in reproductive age group who participated in inducing abortion gave reason for their intervention of the pregnancy was still they were in private clinic and home. Based on the finding of the study it was recommended at health information should be disseminated to school about the effect of unsafe abortion and importance of sex education preventing unwanted and unplanned pregnancy. Health information and education on modern contraceptive methods should be encouraged and modern contraceptives should be available. It would be better if there are conditions where young people discuss about sexual and reproductive health issues with their parents, friends and others. Finally, it was recommended that further study should be done on knowledge, attitude and practice towards induced abortion in this area.

Acknowledgements

We authors are thankful to Gambella University, Gambella T/E/ Health Sciences College, for giving us this opportunity to conduct the research.

Conflict of Interest

The authors have declared no conflict of interest.

Availability of Data and Material

The data that support our conclusion of the study are obtained from the corresponding author up on reasonable request. Because, the data set is not shared publicly

References

1. World health organization (WHO), Unsafe abortion, Global & regional estimates of the incidence of unsafe abortion and associated mortality in 2012, 5th edition Geneva Switzerland, WHO.
2. Yemaneh Y. Assessment of attitudes towards induced abortion among adults residing in Mizan-Aman town bench-Maji zone, snnprs, south west Ethiopia 2017. J Obstet Gynecol. 2017;5(4):50-57.
3. Federal democratic republic of Ethiopia, ministry of health, family health department: technical and procedural guidelines for safe abortion services in Ethiopia. Addis Ababa. 2006.
4. Baggaley RF, Burgin J, Campbell OM. The potential of medical abortion to reduce maternal mortality in Africa: what benefits for Tanzania and Ethiopia. PLoS One. 2010;5(10):13260-13269.
5. Borkowski L, Strasser J, Allina A, Wood S. Medication abortion: Overview of research and policy in the United States-References by topic area. 2015;260-271.
6. Solomon H, Mesganaw F. Knowledge, attitude and practice assessment towards induced abortion among evangelical women residing in Addis Ababa. 2015;20(2):79- 83.
7. Tesfaye G, Hambisa MT, Semahegn A. Induced abortion and associated factors in health facilities of Guraghe Zone, southern Ethiopia. J Pregnancy. 2014;760-769.
8. Assifi AR, Berger B, Tuncalp O, Khosla R, Ganatra B. Women's awareness and knowledge of abortion laws: A systematic review. PLoS One. 2016;11(3):0152224.
9. Yilma M, Fekrie E, Ahmed A, Hilemicheal G, Lukuman Y. Assessment of quality post abortion case in government Hospital A. Ethiopia Med. 2005;43(3):35.
10. Banteyerga H. Boosting maternal health care seeking behavior in rural low income communities: A case study of west Gojam and south Wollo zones in Amhara, Ethiopia. Am J Public Health. 2014;2(6): 378-386.
11. Moore AM, Gebrehiwot Y, Fetters T, Wado YD, Bankole A, Singh S, et al. The estimated incidence of induced abortion in Ethiopia, 2014: Changes in the provision of services since 2008. Int Perspect Sex Reprod Health. 2016;42(3):111-20.
12. Iyengar K, Allvin KM, Iyengar SD, Danielsson KG, Essen B. Who wants to go repeatedly to the hospital? perceptions and experiences of simplified medical abortion in Rajasthan, India. Glob Qual Nurs Res. 2016;3(2).
13. Vibeke R, Hamed M, Ernest U, Staffan B. The problem of illegally induced abortion: Results from a hospital based study conducted at district level in Dar es Salaam. Trop Med Int Health. 2000;5(7): 495- 502.
14. Paluku JL. Knowledge and attitudes about induced abortions among female youths attending Naguru Teenage Information and Health Centre, Kampala, Uganda. J Epidemiol Community Health. 2013;5(4):178-185.
15. Kebede S. A survey of illegal abortion in Jimma Hospital, South West Ethiopia. Ethiop Med J. 2000;38(1).