See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/265344787 Factors associated with induced abortion at selected hospitals in the Volta Region, Ghana Article  in  International Journal of Women's Health · August 2014 DOI: 10.2147/IJWH.S62018 · Source: PubMed CITATIONS READS 13 101 2 authors: Ellen EYI Klutsey Augustine Ankomah University of Health and Allied Sciences University of Ghana 6 PUBLICATIONS   20 CITATIONS    52 PUBLICATIONS   486 CITATIONS    SEE PROFILE SEE PROFILE Some of the authors of this publication are also working on these related projects: safe conception training View project All content following this page was uploaded by Augustine Ankomah on 25 October 2014. The user has requested enhancement of the downloaded file. International Journal of Women’s Health Dovepress open access to scientific and medical research Open access Full Text article O r I g I n a l r e s e a r c H Factors associated with induced abortion at selected hospitals in the Volta region, ghana ellen eyi Klutsey1 Background: Induced abortion rates remained persistently high in the Volta Region of Ghana augustine ankomah2 in the 5 years from 2006 to 2011. Some hospitals, both rural and urban, report induced abortion- 1school of nursing and Midwifery, related complications as one of the top ten conditions in hospital admissions. This study explored University of Health and allied demographic and other factors associated with induced abortion, and also assessed awareness sciences, Ho, Volta region, of abortion-related complications among women of reproductive age in the Volta Region. 2Department of Population, Family and reproductive Health school of Methods: A quantitative, hospital-based, unmatched case-control study was performed. The Public Health, University of ghana, Volta Region was stratified into two health administration zones, ie, north and south. For each legon, accra, ghana zone, hospitals were stratified into government and private hospitals. Employing simple random sampling, one private and three government hospitals were selected from each zone. This study is therefore based on eight hospitals, ie, six government hospitals and two private hospitals. Results: Marital status, employment status, number of total pregnancies, and knowledge about contraception were found to be associated with induced abortion. Multiple logistic regression showed a 4% reduction in the odds of induced abortion in married women compared with women who were single (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.07–0.22). Unemployed women of reproductive age were found to be 0.35 times less likely to seek induced abortion compared with their employed counterparts (OR 0.35, CI 0.19–0.65). It was also observed that women with their second pregnancies were 3.8 times more likely to seek induced abortion and women with more than two pregnancies were 6.6 times more likely to do so (OR 3.81, CI 1.94–7.49 and OR 6.58, CI 2.58–16.79, respectively). Women with no knowledge of contracep- tive methods were 4.6 times likely to seek induced abortion (OR 4.64, CI 1.39–15.4). Compared with women who had not had induced abortion, women with a high number of pregnancies and no contraceptive knowledge were more likely to have induced abortion. Conclusion: It was found that lack of knowledge about contraceptives and being single or employed were associated with increased likelihood of induced abortion. It was also found that women with a higher number of pregnancies have a greater odds of induced abortion. No association was found between induced abortion and maternal age, education, contraceptive use, or religion. Keywords: induced abortion, case control, maternal mortality, hospital-based, Volta Region, Ghana Introduction Although abortion is practiced in most countries, with a worldwide rate of 29 per correspondence: augustine ankomah 1,000 women, there are substantial regional and subregional variations in its incidence Department of Population, Family and reproductive Health school of Public and prevalence. 1 The bulk of unsafe induced abortions occurs in the developing world. Health, south legon road, legon According to the World Health Organization,2 more than one third of the approximately campus, University of ghana, legon, accra, ghana 205 million pregnancies that occur worldwide annually are unintended. Of the estimated email aankomah@ug.edu.gh 182 million pregnancies that occur yearly in developing countries, more than one third submit your manuscript | www.dovepress.com International Journal of Women’s Health 2014:6 809–816 809 Dovepress © 2014 Klutsey and Ankomah. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) http://dx.doi.org/10.2147/IJWH.S62018 License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Klutsey and ankomah Dovepress are unintended, with 19% ending in induced abortion, 8% less educated rural counterparts.6 A study involving women safely and 11% unsafely.2 Worldwide, an estimated 5 mil- admitted to hospital for post- abortion care found that only lion women of reproductive age are hospitalized annually 17% had ever used contraception.19 Another study found that for treatment of abortion-related complications, and Africa women in formal employment are more likely to seek abor- accounts for 1.7 million of this figure. Deaths from induced tion.5 In contrast, Oye-Adeniran et al12 found that the single abortion are known to contribute to approximately 14% highest group represented among abortion seekers comprised of all maternal deaths in Africa.1,2 It is also noted that almost students while the others were predominantly traders. all a bortion-related deaths occur in developing countries, and The Volta Region, where the present study was done, Africa records the highest estimated mortality, ie, 650 deaths contributed 18% of the national burden of induced abortions, per 100,000 unsafe abortions.2 being the third highest among the ten regions of Ghana.20 Abortion is a key proximate cause of maternal mortality The number of recorded induced abortions increased from in Ghana.3,4 Fifteen percent of all women in the reproductive 676 in 2010 to 1,060 in 2011 in the Volta Region.20 Although age group (15–49 years) were found to have sought induced induced abortion is a key health issue, very little is known abortion,5 with induced abortion accounting for 11% of the about it in this region of Ghana, which is culturally different maternal mortality rate of 350 deaths per 100,000 live births. from other regions in the country. It is expected that data on The complications associated with illegal abortion have factors associated with induced abortions will be important serious public health implications for Ghana because they for advocacy and policies in the region for prevention of increase maternal mortality and morbidity and divert limited unwanted pregnancies and the betterment of maternal health. health resources.5 Thus, the findings of this study will help to outline specific Abortion rates in Ghana vary from site to site. A study in priorities aimed at eliciting local evidence-based solutions southern Ghana estimated 17 abortions per 1,000 women,6 geared towards prevention of unwanted pregnancies, and Mote et al7 reported a rate of 21.3% from Hohoe in the Volta subsequently, induced abortion. The main objectives of Region, while another study reported 22.6% in the Brong this study were to identify factors associated with induced Ahafo Region.8 abortion in the Volta Region and to assess awareness of the In terms of quinary age distribution, analysis of data from potential complications associated with the procedure in the several countries around the world9,10 identified the age group Volta Region. of 20–24 years as the cohort with the highest proportion of abortions. However, studies in sub-Saharan Africa show that Materials and methods a fairly large number of women who terminate pregnancies This was a quantitative, unmatched, hospital-based case- are teenagers.11–14 This corresponds with the finding that ado- control study carried out in the Volta Region of Ghana from lescents comprise a substantial proportion of abortion seekers May to July 2012. Data were collected using an interviewer- in many countries, and 59% of all abortions in Africa are administered close-ended questionnaire. The study popula- estimated to occur in women aged younger than 25 years.11,12 tion comprised two groups of women (cases and controls) of In a hospital-based study in Nigeria,12 60% of the sample reproductive age who were seeking care at selected hospitals (n=1,876) was aged 14–24 years, with adolescents (15–19 in the Volta Region, Ghana. years) accounting for 23%. In Ghana, studies have confirmed youth as comprising the bulk of abortion patients.5,6,15,16 In sampling contrast, a study in Hohoe municipality7 found that women The sample size was 380, comprising 76 cases and aged 45–49 years were over five times more likely to undergo 304 c ontrols. Given that the study outcome, ie, abortion, an abortion than those aged 15–24 years. is rare, it was both necessary and cost-effective to increase Abortion has also been found to be associated with marital the numbers of controls. Since 80% of maximum efficiency status. Some studies report that never-marrieds are more likely can be obtained with four controls per case, it is generally to seek abortion.12,16–18 Others have found the highest propor- unnecessary to seek a higher ratio. In general, the number of tion of abortion seekers among single ever-marrieds (divorced, controls should be less than four, because there is no further separated, and widowed) compared with marrieds.5 Generally, gain of power above four controls per case.21 The region was women in urban areas are more likely to have an abortion than stratified into two health administration zones, ie, north and rural women.7 Studies in Ghana have reported that educated south. For each zone, hospitals were stratified into govern- urban women are more likely to seek an abortion than their ment and private hospitals. Using simple random sampling, 810 submit your manuscript | www.dovepress.com International Journal of Women’s Health 2014:6 Dovepress Dovepress Induced abortion at selected hospitals in Volta region, ghana one private and three government hospitals were selected ethical considerations from each zone. Therefore, the study included eight hospitals Approval for the study was obtained from the ethics review (six government and two private). committee of the Ghana Health Service. Further approval was also granted from the Volta Regional Health Directorate cases as well as the gatekeepers at the various hospitals selected Cases were women of reproductive age seeking health care for the study and larger communities where necessary. at the selected hospitals for induced abortion or its complica- Confidentiality was maintained and informed consent was tions or receiving antenatal care but who had had induced obtained from all participants before the questionnaires were abortion in the previous 5 years. We excluded women who administered. were receiving treatment for complications of induced a bortion but were too ill to talk or were younger than 15 years Results of age. Based on medical records, women of reproductive sociodemographic characteristics of age who had had induced abortion, had been hospitalized, respondents or reported abortion-related complications on review in the The sociodemographic characteristics of the respondents are selected h ospitals were recruited as cases if they consented presented in Table 1. The mean age of respondents overall was to participate in the study. Cases were selected from the 23.6±4.8 years, the mean age of the cases was 22.6±5.1 years, medical records of pregnant women to identify those who and the mean age of the controls was 23.8±4.8 years. The had a history of induced abortions. Also included as cases majority of respondents in both subpopulations had at least were women who, during the study period, reported at the primary level education. Among the cases, only 7.9% did facilities with abortion-related problems. not have any formal education compared with 16% of the controls controls. More than half of each subpopulation (cases 56.2%, controls 59.2%) had at least primary education and at most a The controls were selected from antenatal and postnatal clinics (up to 6 weeks after delivery), and comprised Table 1 sociodemographic characteristics of cases and controls pregnant or lactating women seeking prenatal or postnatal of induced abortion in the Volta region care at the respective hospitals but who had never had Characteristic Frequency (%) an induced abortion. We excluded pregnant women who Cases (n=76) Controls (n=304) reported a history of induced abortion, pregnant women age, years who were too ill to talk, and those who were younger than , 20 23 (30.3) 54 (17.8) 15 years of age. 20–29 46 (60.5) 214 (70.3) 30+ 7 (9.2) 36 (11.9) Data collection Marital status s ingle* 58 (76.3) 97 (31.1) Modified structured questionnaires were administered Married 18 (23.7) 207 (68.1) during face-to-face interviews after a pretest. Two regis- ethnicity tered general nurses with prior field research experience e we 59 (77.6) 226 (74.3) Others 17 (22.4) 78 (26.7) were recruited from each selected hospital and trained as religion interviewers. c hristian 68 (89.5) 240 (78.9) non-christian 8 (10.5) 64 (21.1) Data processing and analysis educational level no formal education 6 (7.9) 47 (15.5) Double entry was performed during data processing for Primary education 8 (10.5) 59 (19.4) consistency. Using Stata MP version 11.0 software ( StataCorp Jss/middle school education 37 (48.7) 112 (36.8) LP, College Station, TX, USA), Pearson’s chi-squared test secondary and above 25 (32.9) 86 (28.3) Occupation was used to investigate the association between induced Unemployed 46 (60.5) 96 (31.6) abortion and each of the independent variables, and thus the employed 30 (39.5) 208 (68.4) bivariate analysis. Logistic regression was used to investigate residence the effect of each of these variables on the odds of induced U rban 65 (85.5) 236 (77.6) rural 11 (14.5) 68 (22.4) abortion. Variables that emerged with a P-value of 0.05 or Note: *singles include never married and divorced women. less were included in the logistic regression model. Abbreviation: Jss, junior high school. International Journal of Women’s Health 2014:6 submit your manuscript | www.dovepress.com 811 Dovepress Klutsey and ankomah Dovepress middle school/junior high school education. Over one third twenties and tapered off in the teens and women in their of cases (39.5%) were employed, while more than two-thirds thirties. However, there was no statistically significant dif- (68.4%) of the controls were employed. Both cases and ference in age with regard to induced abortion. In terms of controls were predominantly of the Ewe ethnic group (cases marital status, the two groups were significantly different. 77.6%, controls 74.3%) and were Christian (cases 89.5%, As shown in Table 2, more than three quarters (76.3%) controls 78.9%). of the cases were single compared with only 31% of the More than two thirds (71.1%) of the cases were aged controls (P,0.0001). There was a significantly higher pro- 15–24 years, and 30.3% were in their late teens. Likewise, portion of Christians among the cases (89.5%) compared more than half (59.3%) of the control subjects were 24 years with controls (78.9%). Cases were also more likely to be or younger. Induced abortion peaked among women in their Christian (P=0.040). Table 2 Potential risk factors in cases and controls for seeking induced abortion in the Volta region Characteristic Frequency (%) Pearson chi-square Cases (n=76) Controls (n=304) P-value age, years , 20 23 (30.3) 54 (17.8) 0.057 20–29 46 (60.5) 214 (70.3) 30+ 7 (9.2) 36 (11.9) Marital status s ingle 58 (76.3) 97 (31.1) ,0.0001 Married 18 (23.7) 207 (68.1) ethnicity ewe 59 (77.6) 226 (74.3) 0.449 Other 17 (22.4) 78 (26.7) religion christian 68 (89.5) 240 (78.9) 0.040 Other 8 (10.5) 64 (21.1) employment status e mployed 30 (39.5) 208 (68.4) ,0.0001 Unemployed 46 (60.5) 96 (31.6) educational level no formal education 6 (7.9) 47 (15.5) 0.050 Primary 8 (10.5) 59 (19.4) Jss/middle school 37 (48.7) 112 (36.8) senior secondary or above 25 (32.9) 86 (28.3) area of residence U rban 65 (85.5) 236 (77.6) 0.130 rural 11 (14.5) 68 (22.4) number of pregnancies O ne 30 (39.5) 154 (50.7) ,0.0001 Two 33 (43.4) 100 (32.9) Three 13 (17.1) 50 (16.4) number of children living n one 65 (85.5) 260 (85.5) 1.000 One 7 (9.2) 28 (9.2) Two or more 4 (5.3) 16 (5.3) contraceptive knowledge Knows at least one FP method 67 (88.2) 290 (95.4) 0.006 Knows no FP method 9 (11.8) 14 (4.6) contraceptive use FP prior to current pregnancy 42 (55.3) 164 (53.9) 0.840 non FP prior to pregnancy 34 (44.7) 140 (46.1) awareness of complications a ware of at least one complication 67 (88.2) 279 (91.8) 0.977 Unaware of complications 9 (11.8) 25 (8.2) Abbreviations: Jss, junior high school; FP, family planning. 812 submit your manuscript | www.dovepress.com International Journal of Women’s Health 2014:6 Dovepress Dovepress Induced abortion at selected hospitals in Volta region, ghana Both cases and controls were predominantly Ewes of pregnancies, there was a 4% reduction in the odds of (cases 77.6%, controls 74.3%) and from the urban community induced abortion among married women compared with (cases 85.5%, controls 77.6%). Table 2 shows that ethnicity women who were single (odds ratio [OR] 0.11, confidence and area of residence were not significant factors influenc- interval [CI] 0.07–0.22; P,0.0001). Similarly, after adjust- ing the likelihood of seeking induced abortion (P=0.449 and ing for the combined effects of marital status and number P=0.130, respectively). Employment status was a statistically of total pregnancies, those who were unemployed were significant factor in relation to induced abortion (P,0.0001). 0.35 times less likely to have induced abortion compared At the bivariate level, those who were employed were more with those who were employed (OR 0.35, CI 0.19–0.65; likely to have had induced abortion. P,0.001). In terms of education, only 7.9% of the cases did not have Adjusting for the combined effects of employment any formal education, but the rest had at least primary level status and marital status, there was evidence that women education. Sixteen percent of the controls also had no formal with their second pregnancies were 3.8 times more likely education. Thus, 92.1% of cases and 84.5% of controls had at to seek induced abortion, while women with more than least primary level education. Among both the case and control two pregnancies were 6.6 times more likely to do so. The groups, most subjects had junior high school or middle school increase in the odds of induced abortion with regard to education as their highest level of formal education (cases increase in number of total pregnancies, suggests a dose- 48.7%, controls 36.8%). Table 2 shows a significant association response relationship; thus, the higher the number of between education and induced abortion, with more educated total pregnancies, the higher the odds of induced abortion women having a higher likelihood of induced abortion. (P,0.0001, Table 3). When marital status and employment The number of pregnancies is significant in relation status as well as religion were accounted for jointly, women to induced abortion (P,0.0001) but not parity (P=1.00) who had no knowledge of contraceptive methods were 4.6 (Table 2). times at risk of induced abortion. Although there was an Most of the respondents (88.2% of cases and 95.4% association between induced abortion and each of age, of controls) knew of at least one method of contracep- religion, and educational level in bivariate analysis (Table tion; however, fewer cases (55.5%) and controls (53.9%) 2), no statistically significant associations were found at were using a contraceptive method prior to their recent the multivariate level (Table 3). The lack of association p regnancy. Although there was strong evidence of an between religion and abortion supports the findings of association between contraceptive knowledge and induced Schwandt et al16. abortion (P=0.006), there was no evidence of an association between contraceptive use and induced abortion (P=0.840, Discussion Table 2). This case-control study was carried out in selected hospitals With regard to abortion complications, 88.2% of cases in the Volta Region to determine factors associated with knew of at least one complication of induced abortion induced abortion. Marital status, employment status, number compared with 91.8% of controls. The most common post- of total pregnancies, and contraceptive knowledge were found abortion complication reported by the women was death to have a strong association with induced abortion. Although (82%), followed by infertility (58%), whereas the least known there was an association between induced abortion and each complication reported by the women was foul smelling dis- of age, religion, and educational level in bivariate analysis, charge (2.6%, data not shown). Statistically, there was no these associations were not statistically significant at the association between induced abortion and awareness of the multivariate level. complications of induced abortion. The study showed strong evidence of a reduction in the odds of induced abortion among married women com- logistic regression pared with women who had never married or were divorced. Multiple logistic regression was used to assess the pos- More than three quarters of the women who sought induced sible association between the independent variables and abortion were unmarried. This is similar to findings from abortion while controlling for other factors. Marital status, other studies in Ghana16,17 reporting that abortion seekers employment status, and total number of pregnancies were were likely to be unmarried (never marrieds, divorced, or found to be associated with induced abortion. After adjust- separated). However, our findings are in contrast with those ing for the effects of employment status and total number of another study in Ghana which found that women who International Journal of Women’s Health 2014:6 submit your manuscript | www.dovepress.com 813 Dovepress Klutsey and ankomah Dovepress Table 3 crude and adjusted odds ratios of risk factors for seeking induced abortion among women of reproductive age (15–45 years) in the Volta region Potential risk factors Crude OR Adjusted OR P-value (95% CI) (95% CI) Marital status s ingle (ref) Married 0.11 (0.07–0.22) 0.15 (0.08–0.26) ,0.0001 number of pregnancies First pregnancy (ref) second pregnancy 1.69 (0.97–2.95) 3.81 (1.94–7.49) ,0.0001 Third of more pregnancies 1.33 (0.65–2.76) 6.58 (2.58–16.79) Occupation e mployed (ref) Unemployed 0.30 (0.18–0.51) 0.35 (0.19–0.65) ,0.01 contraceptive knowledge Knows at least one FP method (ref) Knows no FP method 0.58 (0.29–1.17) 4.64 (1.39–15.4) 0.01 religion christian (ref) non-christian 0.44 (0.20–0.97) 0.75 (0.3–1.62) 0.59 educational level no formal education (ref) Primary education 1.06 (0.34–3.27) 1.09 (0.33–3.58) 0.59 Jss/middle school education 2.59 (1.02–6.54) 1.86 (0.67–5.15) secondary and above 2.28 (0.87–5.94) 2.19 (0.75–6.35) age, years 15–19 (ref) 20–24 0.58 (0.31–1.08) 1.21 (0.22–6.59) 0.83 25–29 0.40 (0.19–0.83) 1.18 (0.25–5.48) $30 0.46 (0.18–1.17) 1.16 (0.27–5.28) residence Urban (ref) rural 0.59 (0.29–1.18) 0.52 (0.24–1.14) 0.10 Abbreviations: CI, confidence interval; FP, family planning; JSS, junior high school; OR, odds ratio; ref, reference. sought induced abortion were more likely to be married.6 with more than two previous pregnancies were 6.6 times The findings of this study reflect the tradition in the Volta at risk. This observation supports the view that in adopt- Region of society frowning on premarital sex as well as ing the ideals of small family size in developing countries, childbearing outside wedlock. The stigma associated with the number of unintended pregnancies will increase, and pregnancy outside wedlock could explain the higher rate of in turn increase the likelihood of women seeking induced induced abortion among single women. abortion.23 Employment status is another factor strongly associated Women who had no knowledge of contraceptive meth- with induced abortion. Women who were unemployed were ods were at greater risk (OR 4.7) of inducing abortion less likely to seek induced abortion than those who were compared with those who knew of at least one method of employed. This finding confirms other studies in Ghana7 contraception. This finding is consistent with other stud- and Nigeria,12 and supports the observation that employed ies showing that rates of termination of pregnancy tend to women are more likely to seek induced abortion than their decline with increased knowledge about contraception.2,18 counterparts who are not working.9 Calves22 also noted that This may stem from the fact that women with no knowledge women in Cameroon who sought induced abortion were more of contraception are unable to protect themselves against likely than others to be employed. unintended pregnancies and so seek abortion to avoid hav- Increasing parity was also observed to be strongly asso- ing unwanted children. ciated with induced abortion. Compared with women with Our finding that women who seek induced abortion are a single pregnancy, women with a second pregnancy were more likely to report no religious affiliation confirms the report 3.8 times more likely to seek induced abortion, and women of Schwandt et al.16 However, unlike other studies,2,6,16 we did 814 submit your manuscript | www.dovepress.com International Journal of Women’s Health 2014:6 Dovepress Dovepress Induced abortion at selected hospitals in Volta region, ghana not find any association between induced abortion and age, religion in this study. There is a need for regular integrated education, or contraceptive use. The absence of an associa- community-based outreach programs aimed at creating com- tion between formal education and induced abortion may munity awareness of effective contraception and avoidance be due to the use of induced abortion as a means of ending of unintended pregnancy. There is also a need for qualitative unintended pregnancies by both educated and noneducated research to understand better the key risk factors for induced women. Regarding contraceptive use, it could be that women abortion to help plan specific interventions aimed at eliminat- who had induced abortion started using contraceptives after ing abortion-related health risks. the abortion, hence the absence of an association between induced abortion and contraceptive use. A recent study in Disclosure Ghana appears to support this by noting that a number of The authors report no conflicts of interest in this work. respondents who had their first abortion earlier had since gained knowledge of contraceptives and were using them.24 References It must be noted that this study did not obtain information 1. Allan Guttmacher Institute. Facts on Abortion in Africa. Available on the timing of contraception. from: http://www.guttmacher.org/pubs/IB_AWW-Africa.pdf. Accessed June 18, 2014. 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Exploring contraceptive knowledge and use among women 2011;15:47–55. experiencing induced abortion in the Greater Accra Region, Ghana. 2 0. Ghana Health Service, Volta Regional Health Management Team. Afr J Reprod Health. 2011;15:37–46. 2008 Annual Report. Ho, Ghana, 2009. Available from: http:// www.ghanahealthservice.org/documents/2011%20ANNUAL%20 REPORT%20FINAL.pdf. Accessed June 23, 2014. International Journal of Women’s Health Dovepress Publish your work in this journal The International Journal of Women’s Health is an international, peer- a very quick and fair peer-review system, which is all easy to use. reviewed open-access journal publishing original research, reports, Visit http://www.dovepress.com/testimonials.php to read real quotes editorials, reviews and commentaries on all aspects of women’s from published authors. healthcare including gynecology, obstetrics, and breast cancer. 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