PREVALENCE OF INDUCED ABORTION AND ASSOCIATED FACTORS AMONG WOMEN OF REPRODUCTIVE AGE IN HARARI REGION, ETHIOPIA

Background: Abortion is a very common experience in every culture and society. Out of the 210 million pregnancies that occur each year globally, an estimated 46 million (22%) end up in induced abortion, in relation to that, 19 million women experience unsafe abortions annually. Objective: The aim of the study is to determine the prevalence and associated factors of induced abortion among women of reproductive age group in public health facilities from March 25– April 25, 2019, in Harari Region. Methods: A cross sectional study design was conducted. The sample size was 620 abortion cases. Structured questionnaire was used for data collection. Data were entered to Epi-Data version 3.5.3 and analyzed using SPSS version 20. Descriptive statistics, binary and multivariate logistic regression and odds ratio with 95% confidence intervals was used to identify the independent factors of induced abortion cases status. P-value <0.05 was considered as statistically significant association. Result: The mean age of the respondents was 29.5 years, with a standard deviation of 6.5. In this study the magnitude of induced abortion was 42.7%. Age >30, single marital status, occupational status students and commercial sex worker were statistically significant associated with induced abortion (p<0.05). Conclusion: The study revealed a high level of induced abortion. Unwanted pregnancy is high among abortion patients in the study area. Hence, strict counseling about family planning method reminder, and partner involvement in family planning service should be recommended.


BACKGROUND
Abortion is a termination of pregnancy by the expulsion of a fetus or embryo from the uterus before viability. it can be spontaneous or induced (Cherie & Asmerom, 2017;Leveno et al., 2007). World Health Organization (2012) defines induced abortion as a purposeful termination of pregnancy prior to twenty weeks for developed countries and twenty-eight weeks for developing countries.
An estimated annual number of unsafe abortions in Sub-Saharan Africa for women of reproductive age are 5.5 million, the overall annual abortion rate is 34/ 1,000 women (Åhman & Shah, 2011;Tesfaye, Hambisa, & Semahegn, 2014;The Guttmacher Institute, 2017). It is estimated that there are 3.27million pregnancies in Ethiopia every year, of which approximately 500,000 ends by abortion (Ministry of Health of Ethiopia, 2010). Abortion rate is highest in urban areas of Ethiopia, which 92/1,000 in Addis Ababa and 78/ 1,000 in smaller regions of Ethiopia like Harari & Dire Dawa (The Guttmacher Institute, 2017).
In 2005, Ethiopia expanded its abortion law, which had previously allowed the procedure only to save the life. Currently, abortion is legal in Ethiopia under certain preconditions. Despite the implementation of the new law, almost 6 in 10 abortions in Ethiopia are unsafe (IPAS & Guttmacher Institute, 2010). After legalization of abortion in Ethiopia, trends of abortion ratio decreased but case fatality rate of abortion increased from 1.1% in 2003 to 3.6% (Ministry of Health of Ethiopia, 2010). Legalization of abortion law and fulfilling of unmet need of contraceptive cannot reduce abortion and MMR as needed as possible, rather flow of abortion and related deaths are common (Singh et al., 2010). The aim of this study was to assess the prevalence of induced abortion and associated factors among women of 15-49 years age in Harari region, Ethiopia.

Study Area and Period
The cross-sectional study was conducted from March 25 to April 25, 2019 in health facilities of Harari region, Harari People National Regional State. It is located in Eastern part of Ethiopia, 525 km from Addis Ababa. All public health facilities (two hospitals and eight health centers) and FGA clinic were included in the study.

Sampling Procedure
The sample size was calculated based on the following assumptions: proportion of patients who seek post-abortion care ( = 14.4%) (Worku & Fantahun, 2006). Taken to get the maximum sample size, = 1.96 at 95% confidence interval, =the level of precision (0.05) and non-response rate=10% and design effect of 2; then the total sample size was calculated to be 620. A sampling with proportional to size was used to allocate samples to the health facilities. Convenient sampling technique i.e. all abortion cases who visited gynecological department of public health facilities during the study period were included until the required sample size was obtained.

Data Collection Tools
A semi-structured questionnaire was used for data collection. It was adapted from tools used to assess induced abortion prevalence in different literatures to satisfy the objectives this study. The questionnaire had sub-topics of sociodemographic, reproductive history and family planning related history. The data were collected by trained midwives.

Data Analysis
After data collection, the questionnaire was checked for completeness and coded. The data were entered into Epi-info version 3.5.3 and exported, cleaned and analyzed by using SPSS version-20. Descriptive analyses were performed and bivariate analyses were used to find out the association of independent variables. Variables with a p<0.05 in the bivariate analysis were entered into multiple logistic regression and variables with p<0.05 in the multivariate analysis were considered to have statistically significant associations.

Ethical Consideration
Ethical clearance was obtained from ethical clearance Committee of Harar Health Science College (Reference number: HHSC-79/2019). Consent was obtained from the administrative bodies of the health facilities and from the participants.

Socio-Demographic Characteristics of the Study Participants
A total of 620 patients were identified and 611 women participated in the study making the response rate 98%. Majority, 231 (37.7%), of the respondents were aged between 30 and 49 years. The mean age of the respondents was 29.5 years with a standard deviation of 6.5. More than half, 444 (72.7%), of the participants were married, 134 (21.9%) were illiterate who did not read and write, and 270 (44.2%) were housewives ( Table 1).   Table 2).

Reasons for Unwanted Pregnancy, Place and Methods of Interference
Those who reported their last pregnancy as reason for unwanted stated that 117 (32.23%) partner pressure and 114 (31.40%) forget to take contraceptives regularly as main reasons for the unwanted pregnancy. The majority of the respondents replied that methods used to induce the abortion were MVA. For most of them the induction was performed by 545 health workers (89.2%) ( Table 3). Family Planning Method on Discharge 573 (93.8%) got post-abortion family planning method, and the most common reason for not getting family planning method was, 33 (86.8%) refusal and, 2 (5.3%) not counseled family planning,1(2.6%) referred to other facility,1(2.6%) health reason and1(2.6%). Contraceptives were not available at that time.

Factors Associated with Induced Abortion
In bivariate logistic regression analysis, age of participants, marital status, occupational status, educational status, place of residence, number of pregnancy and previous abortion were statistically associated with induced abortion. Variables that showed statistically significant associations with induced abortion in the bi-variate analysis were entered into a multivariate logistic regression model to see the independent effect of each potential determinant while controlling for possible confounders. After controlling the effect of other predictor variables, the multivariate logistic regression analysis showed statistically significant association between, marital status and occupational status and induced abortion with p<0.05.
The study findings showed that those single marital status patients were about five times more likely to induce abortion than those widowed (AOR = 5.5, 95% CI = 1. 22,25.5, p=0.027). Students were about three times more likely to induce pregnancy than those house maid (AOR = 2.95; 95% CI = 1.02, 8.51) and Commercial sex worker were about fourteen times more likely to have induced abortion than that of house maid (AOR =14,95%, CI = 1. 42-148.8, p=0.024)

DISCUSSION
In this study, the magnitude of induced abortion was 42.7%. It is very high compared to study done in health facilities of Guraghe zone, Southern Ethiopia which was 12.3 % (Tesfaye et al., 2014), Wolayita Sodo 6.5 % (Gelaye, Taye, & Mekonen, 2014), Nigeria 10% (Awusi & Okeleke, 2010), and Guraghe Zone, Ethiopia12.3% (Tesfaye et al., 2014). This might be due to relaxed restrictions on abortion provision for safe abortion in Ethiopia that include medical abortion. This relaxation of laws and advertising on safe abortion increases in awareness level and seeking care behavior of the community on safe abortion that are capable of creating awareness better than the previous strategy in Ethiopia.
In this study the finding showed that those single marital status mothers were about five times more likely to undertake induce abortion than those of widowed. This finding is in agreement with the study conducted in Jimma Ethiopia (Bonnen, Tuijje, & Rasch, 2014), Tigray, Northern Ethiopia (Abera, Berhanu, Kahsay, Gebru, & Aregay, 2012), and Burkina Faso (Ilboudo, Somda, & Sundby, 2014). The possible explanation could be due to some single girls become pregnant from their spouse before marriage without knowing so that due to fear of the family and the community so that they have high chance to had induced abortion.
Our study showed that commercial sex worker were fourteen times more likely to have unwanted pregnancy and induced abortion compared to house maid. Similarly other health facility based research conducted in northern, Ethiopia reveals that commercial sex workers had significantly higher chance to induce abortion (Abera et al., 2012). This study showed that students were about three times more likely to had induce abortion than those of house maids similarly a study done in Jimma, Ethiopia (Bonnen et al., 2014). Schwandt et al. (2011) showed that students were associated with induced abortion. This might be due to the fact that children in school will live with their family under strict parental supervision which prevents them from unwanted pregnancy which ends up with induced abortion.

Strength and Limitation of the Study
The study covered all public health institutions providing abortion related health care serves in Harari region, and since the study was facility based and only it incorporates public facility but not private facilities, so the findings may not be generalizable for general population.

CONCLUSIONS
Generally, the study revealed a high level of induced abortion. Unwanted pregnancy is high among abortion patients in the study area. Marital status and occupational status of the mothers were factors significantly associated with induced abortion. It is therefore suggested to promote and increase access of family planning method (condom) use among high school/ university students and commercial sex workers.

Declaration of Conflicting Interest
The authors would like to declare that they have no conflict of interests in this study.