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Women’s perception about accessibility of safe abortion care services at selected public institutions in Addis Ababa, Ethiopia.

Background Ethiopia ratified its abortion law in 2005, primarily to reduce the incidence of unsafe abortion and the availability of safe abortion services has increased. However, service availability has not led to a significant reduction in unsafe abortion. Objective The aim of this study was to assess women’s perception about accessibility of safe abortion care services at selected public institutions in Addis Ababa, Ethiopia. Method Institution-based cross-sectional study was conducted among 432 women of reproductive age who work in non-health related public institutions. A structured questionnaire was used to collect the data. Data were entered into Epi-data and cleaned and exported to SPSS version 24.0 for data analysis. Data analysis involved descriptive statistics, independent-sample t-test, one-way analysis of variance (ANOVA), and linear regression. Statistical significance was set at 5%. Multi-categorical independent variables were dummy coded before entering into the models. Results In this study, more than half (60.2%) of the participants reported that they had pregnancy at least once. Seventy eight respondents (18.1%) had history of previous miscarriage, among these the greater number (74.4%) has happened due to spontaneous abortion. Among the respondents studied, 283 (65.5%) of them have heard of abortion care and media was the major source of information. Closely half of (46.2%) the females who had miscarriage history were treated at governmental health institutions; followed by private clinics (35.9%) and traditional methods (6.4%). Whereas, 11.5% of them didn’t get any abortion care service. There was significant difference in mean scores of participants faced post abortion complications and treated at traditional healer, and particularly the respondents attended traditional healer makes the strongest unique contribution to explaining the perception score.


Introduction
Background to the Study Abortion is the termination of pregnancy before foetal viability, which is conventionally taken to be less than 28 weeks from the last normal menstrual period (LNMP). If the LNMP is not known, a birth weight of less than 1000gm is considered as abortion [1]. Unsafe abortion is defined by the World Health Organization (WHO) as a procedure for terminating an unintended pregnancy, carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both [2]. Unsafe abortions are frequently performed by providers lacking qualifications and skills to perform induced abortion, and some abortions are self-induced. Unsafe abortion remains a leading cause of maternal mortality and morbidity in Africa, including Ethiopia [3]. The WHO [4] estimates that an annual 22 million unsafe abortions occur globally, almost all of which take place in developing countries, and account for 13% of all maternal deaths [3].
Complications from unsafe abortion result in maternal deaths and abortion-related morbidities worldwide, placing high strain on limited health system resources and leading to severe physical, psychological, and financial consequences for women [5].
One in 27 women die from complications of pregnancy or childbirth [6,7], the number of maternal deaths is fifth highest in the world [8] and the maternal mortality ratio, estimated to be 412 per 100,000 live births, is still enormously high in Ethiopia [9]. In Ethiopia 32% of all maternal death is due to unsafe abortion [1]. In addition, unsafe 4 abortion accounts for nearly 60% of all gynaecologic admissions and almost 30% of all obstetric and gynaecologic admissions in the country [1,10].
Evidence shows that the induced abortions are more likely in countries in which abortion is illegal or restricted compared to those liberated [11].Death and disability from unsafe abortion can be prevented in three ways: by preventing unintended pregnancy, treating the complications of women who seek post abortion care or providing a safe, legal alternative to unsafe abortion [7].
Cognizant of the extent of the problem of unsafe abortion, and with due recognition of the need for an integrated approach to reducing maternal morbidity and mortality, Ethiopia liberalized its abortion law in 2005 and consequently authorized midlevel health care providers to offer abortion services [1]. In most political systems, the enactment of a law alone is however no guarantee of its implementation [12].
This has been true for abortion laws in particular, because internationally legal liberalization has not reliably led to increased access to services, particularly in more traditional settings where abortion is prohibited on religious grounds [13,14].
While legal reform took place in Ethiopia ten years ago, social norms about abortion are just start to change, and the expansion of safe abortion services has advanced steadily [7]. As current studies, both in and outside of Africa, recommend legal reform is not adequate to eradicate unsafe abortion. Researchers and policymakers have emphasized the need to decrease abortion stigma, inform citizens of their rights and address inequities in abortion accessibility [1,15].
Access to and provision of correct information is a key determinant on the pathway to safe abortion. The absence of accurate knowledge and the fear of violating law creates a chilling effect and deter women from seeking health care services [2,16].Women's own knowledge of the law is only one factor in their being able to access appropriate care.

5
Knowledge of accessible safe abortion services, providing women with information on the legal context and methods to allow access to such information assist in decreasing the chances that a woman will seek unsafe abortion services and consequently decreasing her likelihood of suffering from abortion related morbidity or mortality [16]. Therefore, it is imperative to understand on women's perception and knowledge about accessibility of safe abortion care services.
Unsafe abortion is a major contributor to maternal deaths (32%) in Ethiopia [1,17]; young and poor women suffer most from unsafe abortion, but all sub-groups of women are also at risk [17]. Increasing access to safe abortion services is the most effective way of preventing the burden of unsafe abortion, which is achieved by increasing safe choices for pregnancy termination [18].
Although Ethiopia liberalized its abortion law in 2005, service availability has not led to a significant reduction in unsafe abortion [7]. In addition to legal and policy interventions, a number of interventions to increase the availability of safe abortion services have been implemented in Ethiopia [1,19]. For instance, there has been a rapid expansion of health facilities eligible to provide legal abortion services in Ethiopia since 2008. Comprehensive abortion services also increased from 20% of the recommended level in 2008 to 38% in 2014 [19]. Disappointingly, these policy and service delivery interventions have not led to a significant reduction in unsafe abortion [7] or related maternal mortality and morbidity in Ethiopia primarily because of limited access to and utilization of safe abortion services.
The Ethiopian ministry of health has also recognised that the revision of legal policies alone might not in itself ensure the accessibility of the service if other factors were not addressed as well [1]. Available safe abortion services are underutilized due to various individual and community-level factors, such as lack of awareness of the legality of abortion, negative attitude of the providers, limited understanding on the implications of 6 unsafe abortion and lack of information on availability of safe providers and methods [20,21]. Ensuring that all women know that safe abortion is available and legal for many indications will further reduce morbidity from unsafe abortions [7].
While there are few previous studies on safe abortion in Ethiopia and elsewhere in the world [22] there seems to be a gap on women's knowledge of and perceptions on accessing safe abortion services [16]. Therefore, this study aimed to contribute to filling this critical gap and focus on women's perception and knowledge about accessibility of safe abortion care services at selected public institutions in Addis Ababa, Ethiopia.

General Objective
The objective of this study is to assess women's perception about accessibility of safe abortion care services at selected public institutions in Addis Ababa, Ethiopia.

Study design and period
An institutional based quantitative research method was conducted from April 1 to June

30, 2019
Source of population 7 Women of reproductive age residing in Addis Ababa were the source population for this study.

Study population
All reproductive age women who work in non-health related public institutions were study population of this study.

Inclusion and exclusion criteria
Inclusion criteria: Women with the following characteristics were included in this study: In a reproductive age, Working in one of the selected public institution of the Addis Ababa City Administration Willing to participant in the study.

Exclusion criteria:
Being on annual or sick leave during the data collection time and unwillingness to participate in the study was an exclusion criterion.

Sample size determination
The sample size for this study has been calculated using online calculator for women by using 95% confidence limit, 80% power and 0.2 effect size. We have used 10,000 population variance for women's group. Accordingly, the sample size required the women's group was 393. The final sample size was 432 for women after including 10% non-response rate.

Sampling method
Since it was impossible to obtain the list of reproductive age women, one-stage cluster sampling of the institutions was used in order to enroll the required samples in this study.
Accordingly, 30% of the Bureaus or institutions in the Addis Ababa City Government were selected using a simple random sampling method. This resulted in a cluster of 13 nonhealth institutions. Finally, using a proportional allocation to the size approach 432 reproductive age women were selected from the 13 non-health institutions.
00Data Collection procedures and methods Data was collected using structured questionnaire adapted from other studies [25] to 8 assess women's' perception about accessibility of safe abortion care services. The questionnaire consisted of six socio-demographic items for women, 11 reproductive health characteristics items for women, and 10 Likert scale type items to assess women's perception of the accessibility of safe abortion care. The questionnaire was translated from English to Amharic by a bilingual expert and back translated to English by another bilingual expert in order to ensure meaning equivalence between the two language versions. The Amharic version questionnaire was pretested on 5% of the study sample in institutions not selected for the parent study prior to the actual data collection. Four data collectors and 2 supervisors (voluntary health professional) were recruited from outside selected public institutions. The data collectors and supervisors were trained based on the training manual 5 work days by the principal investigator and co-investigators. An additional training on data completeness, cross-checking and correction actions was given to the supervisors.

Operational definitions
Accessibility: Within health care, access is always, defined as access to a service, a provider or an institution, and thus defined as the opportunity or ease with which consumers or communities are able to use appropriate services in proportion to their needs [26]. In our study accessibility is defined as the opportunity for women in reproductive age to reach and obtain appropriate safe abortion care services within easyto-reach distance, at the right health facility, by a skilled provider at an affordable price.
Perceived accessibility of safe abortion care: The Oxford Advanced Learner's Dictionary (2010:1132) defines 'perception' as a particular attitude towards something or view point.
In this study, perception refers to client views on accessibility of safe abortion care services. In this study perceived accessibility of safe abortion care is defined as the woman's and health providers expressed satisfaction and attitude concerning the 9 convenience of care, its coordination and cost, providers courtesy, information obtained, and quality of care.
Perceived accessibility of safe abortion care will be measured by a 10-item Likert scale with 5 response options. The response options involve 'Strongly Disagree = 1, Disagree = 2, Neutral = 3, Agree = 4, and Strongly Agree = 5.' The total score was computed for each respondent and it ranges from 10-50. A higher score indicates more favorable perception.

Data processing and analysis procedures
After data collection, filled questionnaires were coded, checked, cleaned and entered in to Epi data software, then imported to SPSS version 24.0 software for analysis. Incomplete and inconsistent data were excluded from the analysis. Data analysis involved descriptive statistics, including frequency, percentage, mean and standard deviations. Bivariate analysis using correlation coefficients, independent-sample t-test, and one-way analysis of variance (ANOVA) were conducted to assess factors associated with knowledge and perception about accessibility of safe abortion care. Statistical significance was set at 5%.
Multiple linear regression analysis was used to identify variables independently predicting knowledge and perception about accessibility of safe abortion care.
Multi-categorical independent variables were dummy coded before entering into the models. To avoid issues associated with multicollinearity, we have checked to see if (a) the condition index was < 3, (b) that the variance inflation factors (VIF) were < 5, and (c) tolerance was > 0.2.

Data quality control
To maintain data quality, all data collectors were health professionals and all of them were trained on data collection procedures by principal investigator and co-investigators.
Moreover, the data collection instrument and procedures were pretested on 5% of the study sample in the institutions not selected for parent study to see the accuracy of responses, language clarity, appropriateness of data collection tools, estimate the time required and the necessary amendments were considered.

Ethical consideration An ethical approval was obtained from Institutional Review Board (IRB) of the College of Health Sciences at Addis Ababa University. Letter of permission was obtained from Addis
Ababa Health Bureau which also provided us letter of cooperation written to all selected public institutions. Following an explanation of the purpose of the study informed consent was obtained from those who met the inclusion criteria and agreed to participate. Also information regarding their unconditional right to withdraw consent and discontinue participation without any form of prejudices was provided. Confidentiality of information and privacy of participants has been maintained for all the information provided, to preserve the confidentiality the data has been kept in a locked cupboard and not accessible by any other person except the principal and co-investigators.

Socio-demographic characteristics
A total of 432 women participated in this study with 100.0% of response rate. More than half (55.8%) of the respondents were married and majority (81.5%) of them were orthodox Christian. The age of study participants ranged from 18 to 48 years, with an average age of 28.5. The distribution by biosocial characteristics of the respondents is shown in Table   1.   Factors affecting women's perceptions towards abortion care service provision Table 3 shows an independent-samples t-test conducted to compare the perception scores among dichotomous independent variables. There was significant difference in scores for  Moreover, the univariate linear regression model indicated that there is significant differences in the perception score with the participants' level of knowledge. The size of the estimated regression coefficient suggests that for one additional knowledge mark, the respondents' perception also increases by 0.5 score. The models did not show any significant differences in the score with marital status, number of deliveries and religion.
The factors influencing women's perception about accessibility of safe abortion care services In addition, multiple linear regressions were used to assess the effect of a number of factors to predict levels of perception. After the variance explained by all other variables in the model is controlled, the respondents those attended traditional healer makes the strongest unique contribution to explaining the perception score recording a standardized beta value of 0.328. As shown in the table; the knowledge on abortion and women who attended traditional healer is making a significant unique contribution to the prediction of the perception level. The aim of this study was to develop an evidence base to realize concerns related to the perception of accessibility of safe abortion services in Addis Ababa from the perspective of public servant women. The researchers discussed findings about women's sociodemographic characteristics, information exposure, reproductive history, place of abortion care seeking, and perceptions. The findings have implications for the promotion of safe abortion service and reduction of unsafe abortion which is one of the leading cause of maternal morbidity and mortality in Ethiopia.
In this study, one fifth of the participants had history of previous miscarriage and it has happened predominantly due to spontaneous abortion. The study is in contrast to a study done in southern Ethiopia which showed that virtually all of the abortions were induced and the reason may relies in the study population, which was among tertiary education students [27,28]. In addition, another study done in rural southern Ethiopia revealed high level of induced abortion, and the discrepancy was probably due to the study setting where modern family planning is less spread and as a result consequences unwanted pregnancy [29]. Furthermore, it is not in agreement with a study done in Cambodia whish shown that induced abortion was widely used [30] and the reason could be the study population as the study participants were women sex workers which might rise chance of the unwanted pregnancy.
Among the respondents studied, two third of the women have heard of safe abortion care and media was the major source of information. This in an agreement with the study done in South Africa which indicated that radio and television as their main source of information and little has been done to promote safe abortion service through health care providers and other means of communications [31]. In contrast a study conducted in India showed that the respondents had limited exposure to mass media [32]. This could be on account of most of the participants in the Indian research had never attended school.

15
Although access to basic abortion care services in Ethiopia exceeded the recommended level of facilities providing the service [33], the current study showed that about 46.2% of the women stated that they attended governmental health institutions to get abortion care service; while the others went to private clinics (35.9%), traditional procedures (6.4%), and 11.5% of them didn't get any abortion care service. This is in parallel with the studies done in Kenya which showed that abortion services outside public health facilities were mentioned frequently [34,35]. Probably the reasons are the need for confidentiality to escape condemnation, hesitation about the law, and perceived expensive safer abortion services.
WHO reported that abortion performed by qualified persons using correct techniques and in sanitary conditions is safe and seldom presents complications [36]. In present study, when asked about complications after abortion, three fourth of the women reported that they didn't face any complication. This could be as a result of large number of the respondents reported spontaneous abortion which proceeds rare fatality and infrequently acquires complications. However, the study revealed that hemorrhage was the commonly reported type among the women who suffered the post abortion complication.
After the variance explained by all other variables in the model is controlled, the respondents those attended unhygienic procedure makes the strongest unique contribution to explaining the perception score. Moreover, the knowledge on abortion is making a significant unique contribution to the prediction of the perception level. This is in line with the study conducted in Ihar and Jharkhand, India [32]. Dissimilarity, the study conducted in western Kenya indicated that the health care provider, the social, economic and cultural norms influenced perception of women's access to safe abortion services [34].

Conclusions 16
Ethiopian federal ministry of health declared and implemented policies and guidelines about access to women centred services that are provided by trained and competent professionals with up-to-date technologies and that are easy-to-reach, inexpensive, and unbiased over the past decade in order to reduce the magnitude of unsafe abortion complications and deaths. However, this study indicated that significant number of women still unheard about accessibility of the safe abortion care and attending the untrained personnel services and risky procedure of care. There is an urgent need for the government and other stakeholders to provide more awareness on the accessibility and advantage of safe abortion services in the community. from Addis Ababa city municipality, and then informed written consent of individual participants was obtained after being fully informed of the study purpose and procedures.
During the consent process, they were provided with information regarding the purpose of the study, why and how they selected for this study and opportunity given to ask questions if they had. Participants also assured about confidentiality of the information obtained from them during the data collection by not using personal identifiers and analysing the data in aggregates. Confidentiality and anonymity was ensured. No name or other identifying information included in the instrument.

Consent for publication: Not applicable
Availability of data and material: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests:
The authors declare no conflict of interest, financial or otherwise.