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Induced Second Trimester Abortion and Associated Factors at Debre Markos Referral Hospital: Cross-Sectional Study

Background: Although most induced abortions in Ethiopia are performed in the first trimester, many women will still require second trimester abortions. While access to abortion in Ethiopia is limited, few data are being available concerning the demand for and associated outcomes of second trimester abortions. This knowledge is important for planning the health service response to abortion. Objective: The main objective of this study was to determine the proportion and associated factors of second trimester abortion among women presenting for abortion care services at Debre Markos Referral Hospital, Debre Markos, Northwest Ethiopia. Methods: An institution-based cross-sectional study was conducted at Debre Markos Referral Hospital on a sample of 262 calculated using the single population proportion formula. Women who sought abortion services were interviewed consecutively from 12 February 2017 to 14 March 2017. Data were collected in a face-to-face exit interview and document review and analyzed using SPSS version 24.0 software. Bivariate and multivariable analyses were undertaken to identify factors. Result: Of the women who presented for abortion care services in Debre Markos Referral Hospital, 73 (29.6%) had induced second trimester abortion. Unmarried women (adjusted odds ratio = 4.93, 95% confidence interval = 1.41–17.16) and women employed at private business (adjusted odds ratio = 6.17, 95% confidence interval = 1.16–32.76) were associated with induced second trimester abortion. Conclusion: This study revealed that almost one-third of women who presented for abortion care services at Debre Markos Referral Hospital had induced second trimester abortions. Raising awareness of the health consequence of second trimester abortion at community levels and counseling to avoid further occurrences are helpful to minimize the problem. Furthermore, early management of induced second trimester abortion is very crucial to prevent further complications.


Background
Globally, around 56 million induced abortions occur every year with an annual rate of 35 abortions per 1000 women of childbearing age occurring in low and lower middle income countries (LMICs). 1 Abortion-related maternal deaths worldwide range from 8% to 18%, [2][3][4] and death due to legally induced abortion in the United States is 0.7 out of 100,000 procedures. 5 Moreover, abortion imposes a high financial burden on the limited healthcare resources of LMIC with an annual cost of US$562 million for postabortion care. 2 Induced second trimester abortion is associated with high maternal complications and varies across different regions of the world, such as India, South Africa, 6 Kenya, 7 Nigeria, 8 and Ethiopia. 9 According to literature published in South Africa, Ethiopia, and India, poor utilization of modern contraceptive methods, restrictive abortion laws and policies, gender discrimination, a lack of safe abortion services, and abortion-related stigma were the main factors associated with second trimester termination of pregnancies. [10][11][12][13][14][15] Induced abortion or the deliberate termination of pregnancy is one of the most controversial issues in legal discourse. In 2005, the Ethiopian Government amended the country's Penal Code to expand instances in which a woman could legally obtain an abortion. Prior to this time, abortion was only allowed in cases, done to save the pregnant woman from grave and permanent danger to life or health, which is impossible to avert in any other way. This determination had to be made by two physicians, qualified as specialists in the alleged defect of health from which the pregnant woman was suffering, compounding the risk to pregnant women in a country that had just one physician for every 50,000 Ethiopians in 2000. 16 At the time, Ethiopia amended its Penal Code, the country's maternal mortality rate (MMR) was 743 per 100,000 live births, among the highest in the world, though decreasing slightly due to the introduction and uptake of modern contraceptives and expanding healthcare infrastructure especially in urban areas. 17 Following revision, standards and guidelines that first took effect in Ethiopia in 2006 now allow abortion to be performed legally in cases involving rape or incest, if the woman has a physical or mental disability, to preserve her life or health or if she is a minor who is physically or mentally unprepared for childbirth. 18 In 2008, Ethiopia had an abortion rate of 24 per 1000 women of reproductive age, which is lower than that for the Eastern Africa region (34 per 1000). 19,20 Nonetheless, changing generations of behaviors resulting in unsafe abortions and ending centuries of stigma and silence may take time. [21][22][23] Although the scaling up of legal abortion services throughout the healthcare system has progressed relatively rapidly since legal reform, 23,24 women continue to use unsafe methods to induce abortions outside of health facilities. In addition, the provision of skilled abortion care has been hampered by a shortage of trained healthcare providers and variable health service availability across the largely rural population of more than 95 million people. 25,26 Even though second trimester abortion accounts only for a small percentage of all induced abortions, it is associated with two-thirds of the major abortion-related complications and half of the abortion-related mortality. 27 Second trimester abortion is associated with higher rates of complications than first trimester terminations such as uterine perforation, uterine rupture, infection, and hemorrhage. 18 The Ethiopian Ministry of Health has estimated that abortion, including second trimester abortion-related deaths accounted for more than 30% of all maternal deaths in the country. 28 Among mothers who needed post-abortion complication care, over one-third presented due the second trimester period in Ethiopia. 29 The prevalence of induced second trimester abortion in Northern Ethiopia was reported at 31.3% in 2006. 9 Providing universal access to sexual and reproductive health and reducing the global MMR to less than 70 per 100,000 live births by 2030 is a key to the attainment of the Sustainable Development Goals. The provision of safe abortion care is a critical part of meeting these goals. Despite the country's enormous improvements in contraceptive use over the past two decades, one in four married women in Ethiopia has an unmet need for contraception. 30 As a result, more than one in three pregnancies in Ethiopia are unintended. According to a national study on abortion conducted in 2008, 42% of unintended pregnancies ended in abortion-contributing to an abortion ratio of 13 abortions per 100 live births. 19 Similarly, the magnitude of unsafe abortion is attributable to poverty, social inequity, and denial of women's human rights. Countries with restricted abortion or where abortions are clandestine and unsafe, its consequences to women's health are harmful, particularly for young, poor, and low-education women. Therefore, assessing the nature of induced second trimester abortion is important for designing interventions to avert the problem and to protect mothers from abortion-related morbidity and mortality. Thus, this study was conducted to assess the proportion of induced second trimester abortion and associated factors at Debre Markos Referral Hospital.

Study design and setting
An institution-based cross-sectional study of women seeking abortion care was conducted from 12 February 2017 to 14 March 2017, at Debre Markos Referral Hospital. This hospital is located 300 and 265 km from Addis Ababa and Bahar Dar, the capitals of Ethiopia and the Amhara Regional State, respectively. The hospital is situated in Debre Markos town and provides comprehensive maternal and child-related services to an estimated catchment population of 3.5 million. During data collection, there were approximately 998 patients receiving abortion services in Debre Markos Referral Hospital in the previous 6 months. At the time of the study, there were 192 nurses, 25 midwives, 28 general practitioners, three emergency surgeons, 10 specialists, three gynecologists, and obstetricians. The hospital has 20 outpatient clinics including one for gynecology and one for obstetrics and one gynecology and obstetrics ward. 31 In Ethiopia, mothers delivered at health facility were 34%, 32 and 620,300 induced abortions were performed, 33 whereas in Debre Markos Referral Hospital, 1 month prior to study conducted, the number of deliveries was 1300 and induced abortion cases were 270.

Sample size and sampling technique
The sample size was calculated using the formula for a single population proportion by taking the proportion of induced second trimester abortion as 19.2%, 34 a confidence level of 95%, and degree of precision of 5%, in addition, a 10% of non-response rate, yielded a total sample size of 262. However, the total population was too small during the study period. As a result, all of them were included in the study (census method). Female patients who presented for abortion care services were interviewed from 12 February 2017 to 14 March 2017.

Data collection and data quality assurance
Data were collected by interview using structured questionnaire and document review by three trained diploma graduate midwives. Data collection took 30 days, and the principal investigator followed the process daily. To ensure data quality, the questionnaire was pretested on 5% of the populations at Finote Selam Hospital, 1 week before the study commenced. In response to this, several modifications were made to the questionnaire and the interview protocol. Facilitators were trained and given information about the importance of the study. Data were reviewed and checked for completeness before data entry.

Data analysis
Data were entered into EpiData version 3.1 and exported to SPSS version 24.0. Frequencies, percentages, and means were used to describe demographic and associated health characteristics. The outcome variable was illustrated by demographics and health-related characteristics using cross tabulations. P-values (P < 0.2), crude odds ratio (COR), and 95% confidence intervals (CIs) were employed to present the results of the bivariate analysis. All predictor variables which had associations in the bivariate analysis with a P-value less than 0.2 were entered in the multivariable logistic regression model to assess associated variables.
Multivariable analyses using the logistic regression models were performed to evaluate the predictors of induced second trimester abortions and to control the potential confounders. The variables that showed higher values of P were removed one by one until only variables with statistical significance remained in the final model. The association of outcome variables with independent variables was described using adjusted odds ratios (AORs) with 95% CIs. Statistical significance was defined at a probability level of 0.05. The Hosmer-Lemeshow goodness-of-fit statistic was used to check if the necessary assumptions for the multivariable logistic regressions were fulfilled, and the model had a P-value = 0.105 (>0.05) which proved the model was good.

Ethical considerations
Ethical approval was obtained from the Debre Markos University Ethical Clearance Committee with reference number of HSC/R/C/Ser/Co/141/11/10. Permission to gather data was provided by the manager of Debre Markos Referral Hospital. All women receiving induced second trimester abortion were informed about the study in order to obtain their verbal consent. Verbal consent was also obtained from each client and introduced the objective of the study that it contributes to set interventions and strategies to improve services. Any client who was not willing to participate in the study had the right to refuse at any time of interviewing. Data were collected after full informed consent is obtained and confidentiality of the information was maintained by excluding names as identification in the questionnaire and keeping their privacy during the interview by interviewing them alone.

Results
Of the 262 women recruited, 247 completed the interviewbased questionnaire with a response rate of 94.3%. A detailed analysis was undertaken of the data from the 73 (29.6%) of mothers who had induced second trimester abortion as diagnosed by the obstetrician.

Proportion of induced second trimester abortion
The proportion of induced second trimester abortion among women who presented for the service at Debre Markos Referral Hospital was 29.6% (n = 73). The cases were classified as an early second trimester (between gestational ages of 13 and 20 weeks) which comprised 63 (25.9%) and late second trimester (between 21 and 28 weeks) consisting of 10 (17.4%).

Reproductive characteristics
Over half, 139 (56.3%), of all respondents seeking abortion care had regular menstrual cycles while 108 (43.7%) had irregular ones prior to abortions. Two hundred and three (82.2%) respondents had been pregnant one to three times before their recent abortion. More than half of the cases, 142 (57.5%), were nullipara. Of the 152 (61.5%) respondents have no living children. Twenty-eight (11.3%) of the women had abortions earlier. One hundred and sixty-eight participants (68.0%) reported that they had not planned their pregnancies (Table 2).

Medical factors
Sixty-four (25.9%) of the respondents were scanned with ultrasound and 7(2.8%) of the respondents surveyed had had their pregnancies terminated as a result of fetal-related problems. The pregnancies of two women (0.8%) were terminated as a result of chronic illnesses of the mothers themselves.

Bivariate and multivariate analyses
Data analysis was conducted on 247 who presented for abortion care services. Age, marital status, occupation, monthly income, nature of menses, parity, number of live children, and planned pregnancy were found to be associated in the bivariate analysis at P-value less than 0.2. The variables were entered into the multivariable logistic regression model. Finally, the model retained only factors which had significant associations at P-value < 0.05 level. Factors such as occupation and marital status were associated, whereas age,  monthly income, nature of menses, parity, number of live children, and planned pregnancy status were not associated with induced second trimester abortion in the multivariate analyses. Unmarried mothers were five times more likely to have induced second trimester abortion compared to married ones (AOR = 4.928, 95% CI = 1.414-17.166). Women employed at private organization were six times more likely to undergo induced second trimester abortions than students (AOR = 6.172, 95% CI = 1.163-32.761) ( Table 3).

Discussion
This study describes risk factors for second trimester abortion in a setting where safe abortion service has been recently made available by law. Unmarried women and women employed at private businesses were strong predictors for induced second trimester abortions. Hence, unmarried women account for a disproportionate share of late abortions in our study, a notably, due to fear of the stigma attached to non-marital sexual activity, are having particular difficulties in avoiding unintended pregnancies. This fear may inhibit them from obtaining contraceptive services and from using methods correctly and consistently. Single women are susceptible to induced abortion because of the stigmatizing and economic conditions that makes single motherhood highly disadvantaged. Similarly, women employed at private businesses were also shared high number of late abortions in our study. This is due to financial insecurity if they gave birth. Moreover, the private profit oriented organizations never tolerate for delivery leave, since it has negative impact on their profit. This finding is in line with earlier studies in South Africa which reported proportions of 25%-30% 7 and in India 35 but less than those in Kenya (34%). 7,36 However, we found a greater proportion of induced second trimester abortion than reported in hospitals in the Amhara region of Ethiopia were induced second trimester abortions were recorded at 19.2%. 9 There are several reasons why induced second trimester abortions are higher in our study. Many women may seek care at the Debre Markos Referral Hospital because it is only zonal hospital in East Gojjam zone serving more than 3.5 million people. Private health institutions and other district public hospitals in the area are not equipped to provide abortion care in advanced pregnancy in the catchment area. Moreover, contraceptive utilization is very low among poorly educated and illiterate mothers. As a result, many young women may not have been exposed to sexual and reproductive health education particularly in the rural part of catchment area. Finally, there are many reasons why women may have delayed seeking an early abortion that are linked to changes in personal circumstances often leading to indecision. Delays in detecting a pregnancy may also affect late care seeking and health service-related barriers that hindered access to abortion services. Even though abortion is legal in Ethiopia, it is still stigmatized and not a subject discussed openly in the communities. As a result, some women are reluctant to visit healthcare providers or clinics within their communities for fear of being recognized and ostracized, consequently impacting on their right to choose early an abortion service.
The global proportion reported was 10%-15%, 37 while studies carried out in the United Stated, Nigeria, 38 England and Wales, 35 and New Delhi 39 found 12%, 10%, 8.6%, and 2%, respectively, which is lower compared to this finding. The possible explanation might be the socio-demographic differences among study areas.
In our study, being single was associated with induced second trimester abortion, and women in this category were five times more likely to have an induced second trimester abortion than married respondents (AOR = 4.93, 95% CI = 1. 41-17.12). This finding is similar to studies in Israel, 40 Jimma, and Southwest Ethiopia 41 and could be due to fear of discrimination and stigma that follows premarital sexual activity, as well as difficulties associated with accessing abortion for unintended pregnancies.
In this study, second term abortion was associated with a woman's employment in a private business. Being employed may have affected the ability of these women to attend a health service to gain a termination. They may not have had time due to long working hours or held on making a decision in the hope that their partner indicated a desire for marriage.
Even though educational status, age, and monthly income were not associated with second trimester abortion in the multivariate analysis, there were high frequencies at cross tab results. However, less than half (45%) of the women with secondary school education and above had had induced second trimester abortions. This finding is consistent with those studies at universities and colleges in the northwestern parts of Ethiopia. 42 Women with high educational status are likely to have greater awareness about the legal status of abortion and are more likely to have induced abortions.
Young girls in the age group of 20-24 years were less likely to have second trimester abortions compared to the age group of 15-19 years just like study reports in Israel, 40 the Netherlands, 43 and Jimma. 41 The proportion of induced second trimester abortions among women with less than ETB 500 was higher compared to others, and this is similar to that of a study in the Amhara region because of fear of family, community, and economic problems. 34,44,45 In this study, mothers who delivered once were 95.3% less likely to undergo induced second trimester abortion than nulliparous mothers. The result is similar to that of a study conducted in Jimma in the southwest of Ethiopia. 41 But it contradicts the findings in United States that reported that 59% of the abortions were by patients who had at least one previous birth. 46 A study by Mulat et al. found that 46% of all women requesting abortions were neither married nor cohabiting. Such women may not be adequately prepared to prevent unintended pregnancies due to low knowledge of the consequences of unprotected sex or a lack of access to contraceptives. In the Amhara regional state of Ethiopia logistics, rural residence, inability to recognize pregnancy early, and the irregular nature of menses were found to be associated with the second trimester abortion. 34 The strength of this study is that it investigated the little known area of second trimester abortion. However, the study is likely to have some limitations. First, social desirability bias might have interfered with the provision of correct answers although conditions were facilitated in the method to control or minimize it. In addition, recall bias might have also have affected the responses to questions about past events. Finally, the consecutive sampling technique of the study is likely to have a limiting effect on the generalizability of the results.

Conclusion
This study revealed that one-third of the women who presented for abortion care services at Debre Markos Referral Hospital had induced second trimester abortions. Unmarried women and women employed at private businesses were associated with induced second trimester abortions. Creating community awareness on safe second trimester abortion services for indicated cases, increasing accessibility of contraceptive methods, counseling reproductive age group mothers especially unmarried, employed at private businesses are helpful to reduce late abortions. Furthermore, early management of induced second trimester abortion is very crucial to prevent further complications.