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Unsafe abortion, its determinants and associated factors: the case of malawi. a systematic literature review..

Alexander Mkulichi Follow

Date of Award

Fall 1-6-2017

Degree Type

Degree name.

Master of Public Health (MPH)

Public Health

First Advisor

Dr. Ike S. Okosun

Second Advisor

Dr. Kim R. Ramsey-White

INTRODUCTION: Unsafe abortion is a public health problem globally, but disproportionately affects the developing world. Interventions aimed at addressing the determinants and risk factors of unsafe abortion have proven to be effective in the reduction of unsafe abortion-related maternal mortality. Identification of determinants of unsafe abortion is important in intervention planning and implementation.

AIM: To determine whether religion, marital status and mother’s level of education are related to unsafe abortion practices in Malawi, and find which categories are associated with reduction rates in seeking unsafe abortion.

METHODS: Relevant online publications were identified from selected databases, then critically appraised. Study methodologies as well as reported data were examined with focus on post-abortion care (PAC) mother’s marital status, education and religion.

RESULTS: Majority of studies were cross-sectional and hospital-based. The largest proportion of PAC mothers were married, educated and Christians. Educated mothers, single or unmarried mothers are more likely to seek unsafe abortion.

DISCUSSION: Health facility and community level stigma deters unmarried women from accessing contraception and PAC services. Increased number of unsafe abortion among educated mothers (most of whom were current students) than their counterparts could be explained by the desire to remain in school. These findings could also be attributed to improved health-seeking behavior among this group in comparison with the uneducated who may not have sought care. The role of religion in influencing the likelihood of seeking unsafe abortion has not been studied in Malawi.

CONCLUSION: Complications of unsafe abortion includes heavy bleeding, infection, reproductive tract injury, and death. Abortion-related deaths account for about 23.5% of all maternal deaths in Malawi. The single or unmarried, and educated (attained at least primary education) Malawian women are more likely to have unwanted pregnancy and subsequent unsafe abortion than their counterparts.

https://doi.org/10.57709/9448993

Recommended Citation

Mkulichi, Alexander, "Unsafe Abortion, Its Determinants and Associated Factors: The Case of Malawi. A Systematic Literature Review.." Thesis, Georgia State University, 2017. doi: https://doi.org/10.57709/9448993

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Peer-reviewed

Research Article

Induced abortion among female students in higher education institutions in Ethiopia: A systematic review and meta-analysis

Roles Conceptualization, Formal analysis, Methodology, Software, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Roles Data curation, Methodology, Validation

Roles Formal analysis, Methodology, Writing – review & editing

Roles Methodology, Validation, Writing – review & editing

Roles Software, Validation

Affiliation Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Roles Methodology, Writing – review & editing

Affiliation Department of Midwifery, School of Nursing and Midwifery, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Roles Formal analysis, Writing – original draft

Affiliation Department of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Roles Conceptualization, Formal analysis, Validation, Writing – review & editing

Affiliation Department of Health Promotion, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Roles Conceptualization, Data curation, Validation, Writing – review & editing

Affiliation Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia

Bereket Kefale,
Yitayish Damtie,
Mastewal Arefaynie,
Melaku Yalew,
Bezawit Adane,
Tenagnework Dilnesa,
Segenet Zewdie,
Yitbarek Wasihun,
Metadel Adane

Published: January 20, 2023
https://doi.org/10.1371/journal.pone.0280084
Reader Comments

Female students in institutions of higher education are at higher risk of abortion and its consequences. There is no nationally representative data on induced abortion among students in higher education institutions in Ethiopia. Hence, this study aimed to estimate the pooled prevalence of induced abortion among female students in institutions of higher education in Ethiopia.

This study used a systematic review and meta-analysis of studies conducted from January 1, 2010, to June 30, 2022, in Ethiopia. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. PubMed, Cochrane Library, Hinari, Google Scholar, CINAHL, and Global Health electronic databases were searched. The analysis was performed using STATA 14 software. Heterogeneity and publication bias were assessed using I 2 statistics and Egger’s test, respectively. Duval and Tweedie’s ‘trim and fill’ method was also performed to adjust the pooled estimate. Forest plots were used to present the pooled prevalence with a 95% confidence interval (CI) of meta-analysis using the random effect model.

This systematic review and meta-analysis included a total of 10 studies and 4656 study participants. The pooled prevalence of induced abortion among female students in institutions of higher education in Ethiopia was 5.06% (95%CI: 2.16, 7.96). The rate of induced abortion was 51 per 1000 women.

Conclusions

The pooled prevalence of induced abortion among female students in institutions of higher education in Ethiopia was high. Thus, concerned bodies should design and implement an effective strategy to realize friendly and non-judgmental family planning and comprehensive abortion care service to curb the problem.

Citation: Kefale B, Damtie Y, Arefaynie M, Yalew M, Adane B, Dilnesa T, et al. (2023) Induced abortion among female students in higher education institutions in Ethiopia: A systematic review and meta-analysis. PLoS ONE 18(1): e0280084. https://doi.org/10.1371/journal.pone.0280084

Editor: Aklilu Habte Hailegebireal, WCU: Wachemo University, ETHIOPIA

Received: March 19, 2022; Accepted: December 12, 2022; Published: January 20, 2023

Copyright: © 2023 Kefale et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Abbreviations: AOR, Adjusted Odds Ratio; CI, Confidence Interval; EDHS, Ethiopian Demographic and Health Survey; JBI, Joanna Briggs Institute; SDG, Sustainable Development Goal; UNFPA, United Nations Population Fund; UNICEF, United Nations Children’s Fund

Introduction

Induced abortion is one of the leading causes of maternal morbidity and mortality [ 1 ]. Globally, three out of ten pregnancies, and six out of ten unintended pregnancies, ended in an induced abortion [ 2 ]. About 45% of all abortions are unsafe, of which 97% occur in developing countries [ 3 ]. An estimated 33 abortions occur each year per 1,000 women aged 15–49 in Sub-Saharan Africa, of which more than three-fourths are unsafe [ 4 ]. In Ethiopia, about 28 abortions per 1,000 women aged 15–49 took place in 2014 [ 5 ]. A multilevel analysis based on the 2016 Ethiopian Demographic Health Survey (EDHS) also showed that the magnitude of abortion among youths was 2.5% [ 6 ]. The magnitude of induced abortion among higher education institution female students in Ethiopia ranged from 2.8% to 18.8% [ 7 , 8 ].

Unsafe abortion is a serious reproductive health problem that adversely affects women’s physical, mental, and social well-being throughout their lifetime [ 9 – 15 ]. Unsafe abortion accounts for 4.7 to 13.2% of maternal deaths that occur globally [ 1 ]. The physical health complications caused by unsafe abortion consist of; haemorrhage, infection, incomplete abortions, uterine perforation, and damage to the genital tract [ 9 , 11 – 14 ].

As indicated by various studies, induced abortion is affected by a wide range of factors such as age [ 16 ], residence [ 8 , 17 ], accommodation [ 7 , 18 ], year of study [ 19 , 20 ], substance use [ 17 , 19 , 21 , 22 ], history of contraceptive use [ 22 , 23 ], knowledge on abortion law [ 7 ], age first sex [ 23 ], and the number of sexual partners [ 22 ] are factors affecting induced abortion.

Advancing women’s access to safe and legal abortion is a priority for women’s reproductive health and rights, per the Sustainable Development Goals (SDGs) focused on health and gender equality [ 24 ]. For this reason, reducing induced abortion particularly unsafe abortion has caught the attention of numerous global and national organizations. The government of Ethiopia had revised the abortion law to reduce unsafe abortion and its complications [ 25 ]. Improving equitable access to quality reproductive services is also one of the key strategic objectives of the National Reproductive Health Strategy of Ethiopia (2016–2020) [ 26 ]. Moreover, a communication strategy on HIV/AIDS and sexual reproductive health was developed to reduce sexual and reproductive health problems of students of higher education institutions [ 27 ]. However, induced abortion has continued to be a major reproductive health problem in higher education institutions in Ethiopia. Knowing the magnitude of induced among students is critical for designing and realizing effective interventions to curb the problem. The studies done on induced abortion among female students in higher education institutions in Ethiopia found varied and inconclusive findings. The prevalence of induced abortion among female students in institutions of higher education in Ethiopia varied from 2.8% in Arba Minch town [ 7 ] to 18.8% in Mizan Tepi University [ 8 ]. Thus, this review aimed to estimate the pooled prevalence of induced abortion among female students in higher education institutions in Ethiopia.

Study design and search strategy

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guideline was rigorously followed throughout this review [ 28 ] ( S1 Table ). A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) was also used [ 29 ] ( S2 Table ). A systematic review and meta-analysis of published and unpublished studies were performed to assess the pooled prevalence of induced abortion among higher education institutions in Ethiopia. Electronic databases such as PubMed, Cochrane Library, Hinari, Google Scholar, CINAHL, and Global Health were used. The following key terms were used to search studies: "prevalence", "magnitude", "proportion", "incidence", "induced abortion", "abortion", "safe abortion", "unsafe abortion", "miscarriage", "legal abortion", “illegal abortion”, and “criminal abortion”, "factors", "determinants", "predictors", "factors associated", "associated factors", "risk factors", "University", "College", "Higher education institutions", "campus", "students", "undergraduate students", "female", "Ethiopia" by a combination of Boolean operators “AND” or “OR” as applicable and the search was made by two authors independently (BK and BA).

Inclusion and exclusion criteria

This review includes all accessible studies done from January 1, 2010, to June 30, 2022. All published and unpublished studies conducted on the prevalence of induced abortion in higher education institutions in Ethiopia were incorporated in the review. All observational studies with English language publications that measured the prevalence of induced abortion among female students were considered in this review. But, studies with poor methodological quality were omitted from the review.

Study selection, quality appraisal, and data extraction

All articles explored from selected databases were exported to Endnote X8 and duplicate files were dropped. Two investigators (YD and MA) screened the leftover articles and abstracts for inclusion in the full-text appraisal. The difference between reviewers was managed through discussion, and disagreement was handled by the third party (MY). The Joanna Briggs Institute (JBI) critical appraisal checklist for the prevalence study was used to evaluate the quality of articles that fulfilled the inclusion criteria [ 30 ]. Two reviewers independently assessed articles prior to inclusion in the review. Articles with quality scores of fifty and above were considered in the final review.

Microsoft Excel 2010 sheet was used for data extraction. The information on the author’s name, year of publication, year of study, study design, study area, response rate, sample size, study quality score, and prevalence were contained in the data extraction tool.

Statistical methods and analysis

The analysis was carried out using STATA 14 software. Forest plots were used to present the prevalence of induced abortion among female students in higher education institutions in Ethiopia. The heterogeneity was assessed by using the I 2 statistics, and it was declared using a p-value of less than 0.05 [ 31 ]. Subgroup analyses were performed by different study characteristics such as study year (before 2015 or 2015 and above), sample size (large or small), response rate (high or low), and study quality score (low or high score). The Egger regression asymmetry test was also used to check publication bias and confirmed with a p-value of less than 0.05 [ 32 ]. Moreover, Duval and Tweedie’s ‘trim and fill’ method was done to estimate the number of missing studies from the meta-analysis [ 33 ].

Study selection

This review included published and unpublished studies on induced abortion among female students at higher education institutions in Ethiopia. A total of 1210 records were identified through electronic database searching. Ninety-two duplicated records were removed, and the rest 1105 articles were excluded using their titles and abstracts. Thirteen full-text articles were evaluated for eligibility. From these, 3 full-text articles were omitted, and a total of ten articles were considered in the review ( Fig 1 ).

PPT PowerPoint slide
PNG larger image
TIFF original image

https://doi.org/10.1371/journal.pone.0280084.g001

Characteristics of included studies

All studies included in this systematic review and meta-analysis were cross-sectional [ 7 , 8 , 16 , 18 – 23 , 34 ]. The sample size of the studies ranged from 213, a study done at Addis Ababa University [ 18 ] to 813, another study done in Arba Minch town [ 7 ]. Overall, this systematic review and meta-analysis included a total of 4656 study participants. The studies were carried out from 2011 to 2021 in different parts of Ethiopia ( Table 1 ).

https://doi.org/10.1371/journal.pone.0280084.t001

Prevalence of induced abortion

The overall pooled prevalence of induced abortion among female students in higher education institutions in Ethiopia was 8.64% (95%CI: 5.94, 11.33). However, due to the presence of publication bias trim and fill method of analysis was done to correct for funnel plot asymmetry and adjust the final pooled estimate. Therefore, the final adjusted pooled prevalence of induced abortion was 5.06% (95%CI: 2.16, 7.96). The highest prevalence of induced abortion was 18.8% in a study done at Mizan Tepi University [ 8 ], and the lowest prevalence of induced abortion was reported in Arba Minch Town (2.8%) [ 7 ]. A significant heterogeneity was detected among included studies in the meta-analysis, I 2 = 92.8%, p < 0.001 ( Fig 2 ). The funnel plot also revealed an asymmetrical appearance ( Fig 3 ). Furthermore, Egger’s regression asymmetry test indicated significant publication bias, p-value = 0.012. Thus, Duval and Tweedie’s ‘trim and fill’ method was performed to estimate the number of missing studies from the meta-analysis as a source of publication bias ( Fig 4 ).

https://doi.org/10.1371/journal.pone.0280084.g002

https://doi.org/10.1371/journal.pone.0280084.g003

https://doi.org/10.1371/journal.pone.0280084.g004

Sub-group analysis

Subgroup analyses were done by different study level characteristics for instance study year, sample size, response rate, and study quality score to detect the source of heterogeneity. But, heterogeneity still exists. Therefore, the heterogeneity may be explained by other factors not considered in this review. The prevalence of induced abortion among studies conducted before 2015 was 5.93% (95%CI: 2.28, 9.58). The prevalence of induced abortion among studies with large and small sample size was 6.70% (95%CI: 3.91, 9.49) and 11.04% (95%CI: 5.15, 16.93), respectively ( Table 2 ).

https://doi.org/10.1371/journal.pone.0280084.t002

Induced abortion is a major public health issue and remains women’s reproductive health and human right concern globally. This systematic review and meta-analysis were conducted to estimate the prevalence of induced abortion among female students at higher education institutions in Ethiopia. The pooled prevalence of induced abortion among higher education institution female students in Ethiopia is 5.06% (95%CI: 2.16, 7.96) or 51 per 1000 female students.

This finding is in line with a systematic review and meta-analysis on induced abortion globally (58.1 per 1000 women) [ 35 ]. This finding is also comparable with the overall rate of abortion in Ethiopia (28 per 1000 women) [ 5 ], Sub-Saharan Africa (33 per 1000 women) [ 2 ], and globally (39 per 1000 women) [ 2 ]. This review considers only induced abortion and the majorities of female students were youths and not married. Female students in higher education institutions are expected to have fewer pregnancy and abortion rates as compared to women of reproductive age as a whole. However, this review finds a high rate of induced abortion which is similar to the national, regional, and global overall abortion rate. This might be due to almost all pregnancies of female students are unintended and end with induced abortion. Moreover, higher education institution students may have better access to abortion care services than other women of reproductive age. Additionally, lack of direct parental control, the need to enjoy their newly discovered freedom, sexual experimentation, lack of comprehensive knowledge on sexual and reproductive health problems, and high rate of sexual violence [ 36 – 38 ] may contribute to the high rate of induced abortion.

This finding is also in line with the magnitude of abortion among youths in Ethiopia (25 per 1000 women) [ 6 ]. However, this review does not include spontaneous abortion. Thus, this review finds a higher induced abortion rate. This could be due to more than one-third of youths included in 2016 EDHS were married and had fewer unintended pregnancies compared to female students in higher education institutions. Furthermore, nearly three-fourths of youths included in the 2016 EDHS were rural residents with various cultural and religious restrictions and poor access to abortion care services.

The level of induced abortion among female students in higher education institutions showed a modest increment. The level of induced abortion among studies conducted in the years 2015 to 2019 [ 8 , 16 , 20 – 23 , 34 ] was higher than the studies conducted before 2015 [ 7 , 18 , 19 ]. This high rate of induced abortion among female students in higher education institutions implies that there was a high rate of unintended pregnancy. This calls for efforts to meet the need for sexual and reproductive health services including sexuality education, family planning, and abortion care services.

Lacks of access to quality abortion care threaten women’s physical and mental well-being and a range of human rights of women and girls. Thus, providing universal access to safe, affordable, timely, and respectful abortion care is an essential and cost-effective strategy for reducing maternal mortality and achieving targets 3.1, 3.7, and 5.6 [ 24 ]. Female students in higher education institutions, in particular, require universal access to youth-friendly and nonjudgmental sexual and reproductive health services.

The PRISMA guideline was rigorously followed at all steps of the systematic review and meta-analysis. However, most of the articles included in the review had a small sample size, which may affect the pooled estimate, decreases statistical power, and permits large standard errors. Besides, there were limited studies that presented factors associated with induced abortion. The factors assessed in those studies also differ across studies. Due to this, this review was unable to identify predictors of induced abortion among female students in higher education institutions.

The rate of induced abortion among female students in higher education institutions in Ethiopia is high. The government and other concerned bodies should make an effort to reduce unintended pregnancy through the provision of youth-friendly and non-judgmental sexual and reproductive health services. Family planning and comprehensive abortion care services should be programming priorities for organizations working on the sexual and reproductive health of university students. Large-scale studies are needed to identify the determinants of induced abortion. Researchers should also investigate the magnitude of unsafe abortion among female students in higher education institutions.

Supporting information

S1 table. prisma-p 2009 checklist..

https://doi.org/10.1371/journal.pone.0280084.s001

S2 Table. AMSTAR 2: A critical appraisal tool for systematic reviews.

https://doi.org/10.1371/journal.pone.0280084.s002

S1 File. The search electronic strategy.

https://doi.org/10.1371/journal.pone.0280084.s003

Acknowledgments

The authors would like to thank Wollo University for providing an office and free internet service.

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4. Bankole A, Remez L, Owolabi O, Philbin J, Williams P. From Unsafe to Safe Abortion in Sub-Saharan Africa: Slow but Steady Progress, New York: Guttmacher Institute; 2020. http://dx.doi.org/10.1363/2020.32446
12. Stillman M, Frost JJ, Singh S, Moore AM, Kalyanwala S. Abortion in India: A Literature Review, New York: Guttmacher Institute; 2014.
24. United Nations General Assembly. Resolution adopted by the general assembly on 25 September 2015: transforming our world: the 2030 agenda for sustainable development. New York: United Nations; 2015.
25. The Criminal Code of the Federal Democratic Republic of Ethiopia—Proclamation No. 414. 2004. http://www.wipo.int/edocs/lexdocs/ laws/en/et/et011en.pdf.
26. Federal Democratic Republic of Ethiopia Ministry of Health. National Reproductive Health Strategy: 2016–2020. http://corhaethiopia.org/wp-content/uploads/2016/08/RH-strategy-2016.pdf
27. Federal Democratic Republic of Ethiopia Ministry of Education. Communication Strategy on HIV/AIDS and Sexual Reproductive Health (SRH) for Higher Education Institution; 2013.
30. The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2014 edition. The Joanna Briggs Institute; 2014. https://nursing.lsuhsc.edu/JBI/docs/ReviewersManuals/Economic.pdf

Research article
Open access
Published: 26 March 2014

Magnitude and risk factors of abortion among regular female students in Wolaita Sodo University, Ethiopia

Amha Admasie Gelaye 1 ,
Kalemelekot Nigussie Taye 1 &
Tesfa Mekonen 2

BMC Women's Health volume 14 , Article number: 50 ( 2014 ) Cite this article

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Induced abortion is one of the greatest human rights dilemmas of our time. Yet, abortion is a very common experience in every culture and society. According to the World Health Organization, Ethiopia had the fifth largest number of maternal deaths in 2005 and unsafe abortion was estimated to account for 32% of all maternal deaths in Ethiopia. Youth are disproportionately affected by the consequences of unsafe abortion. The objective of this study was, therefore, to determine the magnitude and identify factors associated with abortion among female Wolaita Sodo University students.

A descriptive, cross-sectional study was conducted in Wolaita Sodo University between May and June 2011. Data were collected from 493 randomly selected female students using structured and pre-tested questionnaires.

The rate of abortion among students was found to be 65 per 1000 women, making it three fold the national rate of abortion for Ethiopia (23/1000 women aged 15–44). Virtually all of the abortions (96.9%) were induced and only half (16) were reported to be safe. Students with history of alcohol use, who are first-year and those enrolled in faculties with no post-Grade 10 Natural Science background had higher risk of abortion than their counterparts. About 23.7% reported sexual experience. Less than half of the respondents (44%) ever heard of emergency contraception and only 35.9% of those who are sexually experienced ever used condom.

Conclusions

High rate of abortion was detected among female Wolaita Sodo University students and half of the abortions took place/initiated under unsafe circumstances. Knowledge of students on legal and safe abortion services was found to be considerably poor. It is imperative that improved sexual health education, with focus on safe and legal abortion services is rendered and wider availability of Youth Friendly family planning services are realized in Universities and other places where young men and women congregate.

Peer Review reports

Every day, approximately 1000 women die from preventable causes related to pregnancy and childbirth and 99% of all maternal deaths occur in developing countries [ 1 ]. Evidence also suggests that adolescents face a higher risk of complications and death as a result of pregnancy than older women [ 1 , 2 ].

According to the World Health Organization, Ethiopia had the fifth largest number of maternal deaths in 2005 [ 3 ]. The maternal mortality rate (MMR) in Ethiopia was estimated at 673 deaths per 100 000 live births in the year 2005, and unsafe abortion and its complications were estimated to account for 32% of all maternal deaths [ 4 – 6 ].

Abortion is a very common experience in every culture and society [ 7 , 8 ]. Out of the 210 million pregnancies that occur each year globally, an estimated 46 million (22 per cent) end up in induced abortion, in relation to that, 19 million women experience unsafe abortions annually [ 7 – 10 ]. In the Eastern African region, 2.3 million abortions (virtually all unsafe, < 0.05 safe) occurred in 2003, making the abortion rate in the region 39 per 1000 women in reproductive age [ 7 ]. Similarly, some localized and national studies conducted in Ethiopia, document that the prevalence of induced abortion and its negative consequences are increasing from time to time in the country [ 11 – 14 ].

Review of risk factors of abortion shows that several variables have been implicated as risk factors of abortion in studies conducted across different countries. In U.S. poor women were reported to experience abortion more often than their counter parts [ 10 ]. Elsewhere, a study conducted in Hungary, concluded that reliable contraceptive methods were used significantly less frequently by the aborters than by the control group and the likelihood of abortion was significantly lower among those informed by a health-care provider [ 15 ]. A study conducted locally in Northern Ethiopia stated that, place of residence, marital status, contraceptive use, number of pregnancies and level of education attained by the women were found to be significantly and independently associated with induced abortion; while, fear of family criticism was mentioned as reason for resorting to abortion by Jimma University students [ 14 ]. Two other studies documented sexual violence or rape to be primary cause for seeking abortion 20-25% of the cases [ 16 ].

Recent changes in abortion law in Ethiopia are believed to pave the way for access to safe abortion services and subsequently reduce the burden of unsafe abortion and its complications and maternal death [ 5 ]. Notwithstanding the new law, however, almost six in 10 abortions in Ethiopia are unsafe [ 12 ].

Segmented evidence on the problem of abortion, its risk factors, the preference of care seeking behaviour and knowledge of legal status of abortion is imperative to guiding informed reproductive health interventions to youth in the university as well as similar facilities and possibly to shaping national and international policy and strategy to address maternal mortality and morbidity. Data on the problem of abortion among University students is particularly scanty [ 13 ]. It was therefore, necessary and timely to attempt to contribute to this end; this research tried to do just that.

Study design

The study employed a cross sectional study design to assess the magnitude of abortion among 514 female students in Wolaita Sodo University in 2010/11 academic year. Post-hoc control group was utilized to explore factors associated with abortion.

Description of the study area

Wolaita Sodo University is a government University located in Wolaita Sodo town, Southern Ethiopia. The total students enrolled in on a regular basis, during the study period, was 8592. Out of these, 1302 were female students.

Study population and sample

Participants were selected out of all female students enrolled in regular program in Wolaita Sodo University during the 2010/11 academic period. A stratified cluster sampling technique was employed to proportionally recruit students from all schools and faculties of the University.

The required sample size for the study was determined by using the single population proportion formula: n = Z 2 pq/d 2 . A 20% rate of abortion was taken from a community based study in north Ethiopia to estimate the sample size, with a margin of error 5%, 95% confidence level and non-response rate of 5%. design effect of 2 was used to account for the cluster sampling involved. The final sample size was determined to be 514.

Data collection and analysis

Self administered questionnaires were used for data collection. Data collected were entered into and cleared using Epi-INFO software version 3.5.1 and then transported to SPSS version 16 for further statistical analysis. Bi-variate regression analysis was used to look for association between predictors and dependent variables [Age, Academic year, Economic Status, Faculty, Religion, Home residence, Condom Use and Emergency Contraceptive use] and dependent variables [Sexual practice and Abortion] Multivariate logistic regression analysis was done to control for confounding and identify the most important determinant variables. Odds ratio and the respective 95% confidence intervals were used to assess the statistical significance of association among the variables.

Data quality assurance

A pre-test of the data collection tool was carried out in Arba-Minch University in a similar setting and adjustments were made accordingly. Questionnaires were prepared in English (Instructional media of the University) as well as in Amharic. Students were explained the purpose of the study and were assured of confidentiality and the need for providing honest answers. In addition to specific instructions on the questionnaire, participants were given clear oral guidelines on filling out the questionnaire.

Ethical issues

The study was approved by the Research and Publication committee of the Wolaita Sodo University. Written consent was obtained from Research and Publication committee of the University. Verbal informed consent was obtained from the study participants. Necessary precaution was made to ensure confidentiality. Students were thoroughly explained on their rights and the purpose of the research.

Abortion and associated factors

At the beginning of the study 530 female students were identified out of which 514 consented and 493 provided questionnaire responses yielding a response rate of 93%. A total of 32 abortions were reported in the court, making the rate of abortion among Wolaita Sodo University 65 per 1000 women (n = 32/493. Out of these 9.4% were recurrent abortions.

The age of the study participants ranged from 17 to 29 with mean ± SD of 20.0 ± 1.3 years. First year students constituted the major proportion (58.4%) followed by second year students (22.7%). About half (50.9%) of the respondents were Orthodox Christians fallowed by Protestants and Muslims which made up 29% (143) and 14.8% (73) respectively. Virtually all of the students were single 484 (98%). The reported monthly earnings (pocket money) of the students ranged from 0 to 1500ETB with mean ± SD 279 ± 208ETB (mean roughly 20 USD). Most 145 (29.4%) of the respondents were enrolled under the faculty of social sciences and humanities, followed by students in Natural and Computational Sciences faculty and Agriculture faculty, which accounted 19.1% and 16.8% respectively. Table 1 presents detailed socio demographic characteristics of the students.

The percentage of pregnancy experienced in the last twelve months was 7.7% (34) and in 29 (85.3%) of the cases, pregnancy was unwanted. In 37.3% education was considered the primary reason for not wanting pregnancy; in 4 (12.5%) pregnancy was unwanted because it occurred due to low risk perception of pregnancy; in 3 (9.4%) due to contraceptive failure, in 3 (9.4%) others due to rape, in 2 (6.3%) due to inappropriate use of contraceptive and in 1 because it was an incest pregnancy.

Virtually all abortions (96.9%) were induced abortions out of which 34% were self-induced. Only half (16) were reported to be safe, that is, they were performed by a trained health professional in standard health institution. Most(11) of those who had initiated the induction of abortion by themselves reported used excessive drugs (like Ampicillin) and some (8) used traditional remedies like “Embway” - a traditional herbal medicine (a variety of nightshade, Official name: Solanum marginatum L. f) [ 17 ] and the remaining (7) reported use of some kind of physical means to initiate abortion by themselves.

The rate of abortion varied in students from different schools and faculties of the University from as low as 0% among students in the Faculty of Health to as high as 11.7 among the Faculty of Social Sciences students (Figure 1 ). In a similar manner, students in faculties with no post-Grade 10 Science background were about three times more likely to have experienced abortion than students with post-Grade-10 natural science background [adjusted odds ratio 2.91(1.31-6.46) (Figure 1 ).

Number of abortions with respective number of students in each faculty/school, Wolaita Sodo University, June 2011 (n=492).

The study also identified that use of alcohol and class year of students had independent and statistically significant association with likelihood of experience of abortion. Students who reported use of alcohol had about four times more risk of experiencing abortion than students who never used alcohol [adjusted odds ratio 3.95(1.63-11.11)]. Additionally, the odds of having had abortion were again four times as high among fist year students as compared to second year and higher class year students [adjusted odds ratio 3.98(1.50-10.53). On the other hand, reported ever use of condom and emergency contraception did not appear to be protective against abortion [odds ratio 0.47(0.18-1.25) and 0.92(0.38-2.28)] respectively. Table 2 depicts the multivariate regression analysis results for factors associated with abortion.

Several conditions were implicated by study participants as underlying causes for opting to undergo abortion. Some are illustrated in the Figure 2 .

Reported causes for resorting towards abortion among Wolaita Sodo University Students, June 2011 (n=32), more than one factor may be reported.

Study participants reported several places where abortion was performed/initiated. In this regard, the leading spot where most abortions were performed/initiated was traditional abortionist’s home, where 9(28%) of the abortions were induced. Government health institutions follow, accounting 25% followed by private health institutions and NGO clinics, which jointly served for another 25% of the reported abortions. The remaining (22%) abortions were reportedly initiated either at own home or at a relative’s home.

Three fourths of those who undergone abortion reported to have experienced at least one complication following abortion. The most frequently experienced complication being excessive bleeding, which occurred in 21.9% of the cases. Tears (vaginal, uterine, cervical, etc.) were reported in 18.8%, severe pain in 15.6%, infection in 12.5% and retained product of conceptus (incomplete abortion) were reported in 6.3% of the cases.

Respondents also identified several different individuals or institutions as source of information for abortion services. Female peers served as main source of information in 28.1% of the cases while health professionals and partners in 25% each, and male peer in 18.8% of the cases. On the other hand, family and school served as source of information for abortion services in only 6.3% and 3% of the cases respectively.

Sexual experience, condom use and emergency contraception

Close to a quarter of respondents (23.7%) were sexually active. Age at first sex ranged from as early as 12 years to 23 years with mean ± SD 18.75 ± 1.5 years. Most (81.8%) of those who are sexually experienced did so between the ages 18 and 20 and only 39 (33.3%) of them reported use of condom at first sex.

Sexual experience appeared to be inversely related with class year, with the highest proportion being 27.3 percent among first year students as compared to 20.5% and 16.3% among second and third year and above students respectively. Accordingly 1st year students were found to be 2.5 times more likely to have had sex than third year or above students (95% CI 1.2 – 5.4). Similarly, students who are 20 or younger had significantly higher sexual exposure than those who are older than 20. [OR = 1.8, (95% CI 1.1 – 2.9)]. Alcohol use was also found to have statistically significant association with sexual exposure, with those students who ever had alcohol having 5.5 times more likelihood of having sex than their counterparts (95% CI = 1.9 - 16).

Meanwhile, only 35.9% of those who are sexually experienced have ever used condom and 47.9% the same group admitted that they had had at least one unprotected sex (sex without condom) over the last twelve months. Condom use appeared to be higher for students with urban residence 75.5% followed by students from semi-urban areas (34.2%). Students who came from rural areas had the least condom usage (20%).

Less than half of the respondents (44%) ever heard of emergency contraception. Knowledge on emergency contraception increased with increase in class year, accordingly, it was 38.8%, 50% and 53.3% for first year, second year and third and above students respectively. Only 47 (40.2%) of the sexually experienced respondents ever used emergency contraception, with only 45% reporting use of EC within the first 24 hours of unprotected sex and 31.2% reported use.

Knowledge on legal issues of abortion

When it comes to knowledge on Ethiopian abortion law there was sort of bewilderment among participants. Of those who have given responses regarding legal condition of abortion in Ethiopia, 172 (38.8%) replied that Ethiopian law allows abortion while 157 (35.5%) replied it did not and the remaining 114 (25.7%) answered that they didn’t know whether or not abortion is legally allowed in Ethiopia.

From the 172 (38.8%) respondents who claimed abortion is legally allowed, 65 (37.8%) identified serious mental and physical problems as ground for legal abortion; 77 (44.8%) identified pregnancy resulting from rape; 62 (36.3%) identified incest pregnancy; 45 (26.2%) identified minor pregnancies and 72 (41.7%) foetal abnormalities. Significant proportion (25 and 18%) claimed that abortion is allowed for all unwanted pregnancies and for all economic reasons respectively. However, out of all study participants, only 24(4.9%) properly identified all the conditions provided, under which abortion is legally allowed in Ethiopia. On the other hand, 34 (6.9%) identified at least three proper conditions; 39 (7.9%) at least two and 101 (22.8%) identified one proper condition as a basis for legal abortion.

Participants were asked to state conditions/grounds under which they thought abortion should be legalized. Accordingly 62 (12.6%) responded abortion should be available on demand while 255 (51.7%) rejected the idea of providing abortion services on demand. Asked to provide their description of the Ethiopian abortion law, more than half of the respondents (50.7%) did not provide descriptions or simply replied “don’t know”, while smaller proportions, 17.6% and 16% provided opposing views; describing it ‘restrictive’ and ‘legalized’ respectively. Another 10% described it to be appropriate. Similarly, respondents were asked their opinion as to whether more legalization of abortion law was better for maternal health. More people (26%) agreed that more legalization was better for maternal health than opposed (20%). Table 3 depicts the complete list of conditions with their respective percentages.

Students were asked if they were to use abortion services for unwanted pregnancies, provided that abortion services are legalized. Only 18.9% of the students responded that they would resort to abortion for unwanted pregnancy. Most of them (57.4%) replied they wouldn’t opt to abortion even if it were to be legalized. Several factors were raised as primary reasons for declining abortion; the most important one being the belief that ‘abortion was against God’s will’ cited by 214 (43.4%) respondents. The other important reasons provided was a moral issue, that is, considering abortion as murder, as reported by 174 (35.3%) study participants.

Barriers to safe abortion service utilization

Out of the total of 32 individuals who reported to have undergone abortion, appointments were perceived to be barriers/difficulties for service use in 6 (18.8%), non cooperative staff in 4 (12.5%), payment before service in 3 (9.4%), buying drugs and other supplies before service in 3 (9.4%), and absence of service provider was reported in 3 (9.4%). Participants reported to have incurred varying service costs ranging from ETB 40 to 1500 with median cost ETB 250 with IQR ETB 570.

This study revealed very worrisome figures of unsafe abortion and unsafe sexual practices among female Wolaita Sodo University students. The rate of abortion among WSU students was found to be 65 per 1000 women and virtually all of the abortions (96.9%) were induced and only half or 16 were reported to be safe. Study participants reported using a range of traditional and physical methods for inducing abortion. This rate of abortion amounts threefold the national rate of abortion for Ethiopia (23/1000 women aged 15–44); more than threefold the rate of abortion among first year medical students in Mexico City (2%) and significantly higher than the rate of abortion in Jima university which was accounted (4%) [ 13 ].

The findings of this study strongly imply that despite the recent policy changes to liberalize abortion in an effort to reduce unsafe abortion and subsequent maternal mortality, unsafe abortion remains to be a major problem affecting significant number of youth women.

The higher rate of abortion among female Wolaita Sodo University students may partly be explained by type of the study subjects. According to studies, youth carry significantly high proportion of the burden of abortion in their communities [ 18 , 19 ]. Regardless of the type of the study population, however, the rate of abortion among Wolaita Sodo University students can be considered very high.

Virtually all of the abortion in this study was induced accounting 96% of abortions. This figure is much higher than the rate of induced abortion reported by community based studies conducted in North west Ethiopia, Harar, and Eritrea, where only 4.8%, 14.4% and 11% of the abortion were reported to be induced. [ 11 , 20 , 21 ].

The high rate of abortion among Wolaita Sodo University students where sexual exposure appeared relatively low, is particularly troubling and may indicate that most sexual intercourses are unprotected and unsafe and hence raise serious concerns with risk of HIV/AIDS and other STDs.

With regard to risk factors, results of logistic regression analysis of the current study revealed that, alcohol use had statistically significant association with experience of abortion. Students who ever had alcohol were found to be up to four times more likely to have experienced abortion than students who never had alcohol. This is consistent with current evidence on the relationship between alcohol and risky sexual behaviour. Several studies concluded that alcohol was strongly associated with decreased protective behaviours among younger individuals [ 22 , 23 ]. Similarly, students from faculties and departments with high school level and beyond science education [Faculty of Health, Natural Sciences, Agriculture and Engineering] had a significantly lower risk of abortion as compared to students faculties with no post grade 10 level science course, [Faculty of Social Sciences, Faculty of Business and Economics and School of Law] (Figure 1 ). This might be related to a possible preventive role offered by a relatively better knowledge of sexuality and reproductive health gained as part of their natural sciences and health science courses. The multivariate logistic regression also revealed that first year students had a significantly higher risk of experiencing abortion than second year or above students. This is in agreement with results of logistic regression on sexual experience, where, in a similar fashion, the same group of students were found to be more likely to be sexually experienced. This further strengthens other findings that significant number of students are engaged in unprotected sex and hence prone to unintended pregnancy, abortion and STIs.

On the other hand, religious affiliation, age of students and monthly pocket money did not show significant association with the likelihood of having abortion. Similarly, ever use of emergency contraception and condom, did not appear to be protective against abortion in this study. Inconsistent use of condom as well as emergency contraception could explain this paradox. As presented earlier, significant number of students admitted practicing unprotected sex at least in one occasion over the last 12 months. In agreement with this, only 18% of respondents who reported knowing about emergency contraception knew the correct time frame in which emergency contraceptives must be used to be effective. Further research on knowledge and practice of students on emergency contraception in particular and contraceptive methods in general may prove helpful to explore possible barriers to contraceptive use and may unveil areas of action to enhance the reproductive health of students.

Several issues were mentioned by study participants as most important reasons for resorting to abortion. These reasons appear to underscore their understanding of the responsibilities of parenthood and family life. Three-fourths of women cited concern for or responsibility to other individuals; three-fourths said they couldn't afford a child; three-fourths said that having a baby would interfere with work, school or the ability to care for dependents; and half said they did not want to be a single parent or were having problems with their husband or partner [ 23 ].

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 foetus, in case of foetal impairment, for women with physical or mental disabilities [ 4 , 11 ]. Despite the relative liberalization and despite the fact that several institutions in the town provided safe abortion services, the fact that significant proportion of students resorted to traditional and unsafe services indicates that access to safe abortion remains to be a problem. Furthermore, out of all study participants, only 24(4.9%) 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 [ 19 , 24 ].

Study participants raised several issues as barriers to accessing safe abortion services. In this regard, participants mentioned appointments, non cooperative staff and cost. Some study participants spent as much as 1500 ETB (almost 100 US dollars). Such a cost might serve as a huge barrier to this particular segment of the population with relatively limited financial means and deter them from accessing safe abortion services.

In concussion, the rate of abortion among Wolaita Sodo University Students was higher as compared to most local and other rates elsewhere. It amounted three times as high as the rate for the general population in Ethiopia. Even higher rates of abortion might be detected by use of more robust methods. Moreover, alarmingly higher proportions of abortions (50%) were performed or initiated under unsafe circumstances and three fourths of those who had abortion suffered one or more complications. Students who ever used alcohol, who were in their first year and those without natural science backgrounds had significantly higher risk of abortion as compared to their counter parts. Knowledge of students on legal issues of abortion was very low; very few students properly stated all the conditions for legal abortion in Ethiopia. Risky sexual behaviours were widespread and knowledge and practice of students on healthy reproductive health behaviour, including emergency contraception and condom use were found to be very low.

Recommendations

It is imperative that improved sexual health education is rendered and wider availability of Youth Friendly family planning services are realized in Universities and other places where young men and women congregate. Institutions providing safe abortion services, should devise strategies to reach out for youth who are in need of their services and prevent youth from resorting to unsafe abortionists and hence the grave complications of unsafe abortion. Wolaita Sodo University clinic should devise a way to make contraceptives, especially emergency contraceptives available for those in need, overcoming privacy barriers. Information, Education and Communications (IEC) programs on youth reproductive health should be properly tailored to address topics on unwanted pregnancy and safe abortion, especially to fill the knowledge gap of students with regard to legal issues surrounding abortion (Ethiopian abortion law) and safe abortion services. Expanding access to emergency contraception and condom distribution with focus on drinking establishment which students often use, might be equally important. Finally, alongside other efforts, lobbying for further liberalization of abortion services may serve to overcome perceived unnecessary barriers to access to safe abortion services by youth students.

Strength and limitations of the study

The study was the first of its kind in the study population, accordingly provided important evidence on pressing reproductive health issues among university students. Data were collected at the end of academic calendar; hence the possibility of obtaining full year information about students was enhanced. The study involved a reasonably large sample size, leading to a fairly representative figure.

Limitations

Owing to the sensitive nature of the subject investigated and the fact that the research mainly depended on data from respondents, there could have been a room for social desirability bias with possible underestimation of the true prevalence of abortion among the students. The small number abortion cases accrued might undermine the power of statistical tests.

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Acknowledgment

Our heartfelt gratitude goes to Wolaita Sodo University Research and publication office, UNICEF and UNFPA for their initiative and commitment in supporting and funding the research project. We are also grateful for Wolaita Sodo University community, for their interest and comments to make this piece of work better. Most of all we extend our deepest gratitude to the study participants for their time and commitment.

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Amha Admasie Gelaye & Kalemelekot Nigussie Taye

School of Nursing and Midwifery, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia

Tesfa Mekonen

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Correspondence to Amha Admasie Gelaye .

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Authors’ contribution

AAG conceived the study. AAG and KNT equally participated in the design, data collection, statistical analysis and writing-up of the manuscript. TMY participated in study design, participated in data collection, and write-up. All authors read and approved the final manuscript.

Amha Admasie Gelaye, Kalemelekot Nigussie Taye contributed equally to this work.

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Gelaye, A.A., Taye, K.N. & Mekonen, T. Magnitude and risk factors of abortion among regular female students in Wolaita Sodo University, Ethiopia. BMC Women's Health 14 , 50 (2014). https://doi.org/10.1186/1472-6874-14-50

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DOI : https://doi.org/10.1186/1472-6874-14-50

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Induced abortion
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1. " A Discussion of the Aspects of the Right to Health Under National and International Law in Venezuela ." Mary Ann Torres LL.M., University of Toronto, 2000. -----------------------------------------------------------------------------------------------

Obstetric Violence in Argentina: a Study on the Legal Effects of Medical Guidelines and Statutory Obligations for Improving the Quality of Maternal Health by Carlos Alejandro Herrera Vacaflor Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2015

Obstetric Violence is a pervasive phenomenon that affects women’s maternal health worldwide. It has been recognized by the WHO that abusive and disrespectful treatment in facility-based childbirth is a contributing factor in maternal and infant mortality, and the global community has adopted steps in attempting to identify and eliminate all forms of obstetric violence. Within Latin America, Argentina has taken proactive measures legislating the proscription of obstetric violence. This thesis seeks to examine the development of the concept of Obstetric Violence in Argentina, its organic evolution from internal medical regulations and guidelines to national legislation. The thesis will also track evidence about the degrees of success that Obstetric Violence definition, assessment and regulation have had in preventing violations of women’s rights—both on a practical level and in the legal redress of these rights through tort claims.

In Between Categories of Law- a Gender Variant Analysis of Anti-Discrimination Law and Litigation by Ido Katri Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2015

This thesis offers a gender variant perspective on Anti-Discrimination legislation and litigation. Using queer theory, feminist legal theory and critical race theory, this thesis analyzes current debates within the trans movement regarding the use of rights based litigation and the fight for inclusion. I argue that gender variant people’s exclusion from resources and opportunities is inextricably linked, legally and affectively, to gender performance. I will show how performative aspects of the law can be brought forward by applying an “intrasectional” analysis of the protected classes relating to gender variant people within anti-discrimination law and litigation (ADL), and set the stage for the claim that ADL more broadly is intertwined with performativity. Reading the notion of performativity into legal analysis, this thesis suggests the possibility of strategic use of the existing legal rights as an instrument for change.

Sexuality Education in Paraguay: Using Human Rights and International Policies to define adolescents’ right to sexuality education by María José Rivas Vera Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2015 This dissertation explores the issue of sexuality education through the lens of international human right obligations and policy commitments, with a focus on the Paraguayan context. It identifies relevant international human rights instruments and international policy commitments related to sexuality education, and explores their legal and political value. Making use of human rights analytical frameworks, it elaborates on Paraguay’s concrete obligations with regards to sexuality education. It argues that standards reveal a clear link between sexuality education and adolescents’ enjoyment of the enjoyment of their fundamental rights. Taking a substantive equality framework, it argues that the lack of sexuality education policies have a disproportionate effect on certain groups. And concludes by offering concrete standards for the implementation of sexuality education policies. Back to To

Promotion of the availability and accessibility of misoprostol under the CEDAW: Postpartum haemorrhage among the rural women of the Kyrgyz Republic

By Gulnaz Naamatova Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2011

Maternal mortality in Kyrgyzstan is a discrimination of women not only based on sex, but also on rural/urban setting. Rural women are most likely to die of haemorrhage than urban women in Kyrgyzstan. Postpartum haemorrhage constitutes 45 per cent of all maternal deaths in Kyrgyzstan. This work concentrates on the obligations of Kyrgyzstan under articles 12 and 14.b of the Convention on Elimination of all Forms of Discrimination against Women (CEDAW). The work analyses the nature and scope of state obligations under respective articles. Kyrgyzstan has obligations to respect, protect and fulfill rural women’s human rights to address discriminations against rural women, provide appropriate health services and ensure availability and accessibility of misoprostol to rural women. Misoprostol is more suitable to the conditions of rural area than traditionally used oxytocin. Therefore, the availability and accessibility of rural women to misoprostol will prevent avoidable maternal deaths in haemorrhage. Back to Top

The Legacy of Cuerrier: Issues Unresolved, Questions Unanswered

By Ninoslav Mladenovic Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2010

A large body of jurisprudence has developed in Canada criminalizing the conduct of HIV positive persons who transmit or expose others to the HIV infection in an equivocal attempt to be seen to be doing something about individuals who are perceived to be driving the HIV epidemic. Convictions have been obtained for charges ranging from aggravated assault to, most recently, murder. The Cuerrier judgement, a landmark decision of the Supreme Court of Canada, left a number of issues unresolved. Given the ambiguities in the decision, this Thesis will address the unfortunate consequences resulting from the Cuerrier’s decision. In particular, I will argue that while criminalization of non-disclosure may seem logical to many, at the same time it carries a significant public health consequences. The conclusion I will attempt to reach is that criminalization is an inadequate strategy to prevent further HIV infection, its increased use in practice is misguided, and counterproductive to public health goals, thus alternatives to the routine criminalization of HIV transmission that may enhance the goals of public health should be considered. Back to T

Law as a Social Determinant of Unsafe Abortion in Argentina

By Maria Mercedes Cavallo Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2009

This thesis seeks to adapt Scott Burris, Ichiro Kawachi and Austin Sarat’s theory of law as a social determinant of ill-health to the context of unsafe abortion in Argentina. Using Burris et al.’s model of law as a pathway along which social determinants contribute to ill-health, and as a shaper of those determinants as well, this thesis postulates that the law and its application contribute to abortion-related morbidity and mortality among those women who qualify for a legal and safe abortion according to the justifications stipulated in the Criminal Code. This thesis proposes a circular model in order to show how the application of the law, through courts’ rulings, contributes to unsafe abortion. On the one hand, Argentine law acts as a pathway along which inequity in socioeconomic status exposes certain women to pathogenic practices, such as self-induced abortions. On the other hand, the law acts as a shaper of socioeconomic status as it perpetuates gender stereotypes, constructing a normative world where sex-role stereotypes are naturalized, and having an impact in women’s lack of access to legal and safe abortions. Back to To

Doe v. Canada: Lesbian Women, Assisted Conception, and a Relational Approach to Rights

By Sandra Dughman Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2009

This thesis examines Doe v. Canada, a case brought before the Ontario Court of Appeals with the purpose to declare that the definition of “assisted conception” set forth by the respective regulations discriminated against lesbian women. The regulatory framework of assisted conception is embedded with heteronormativity, heterosexism and an over-medicalization of reproduction. The traditional liberal conception of rights, embedded in the Court’s decision, did not allowed lesbian women to have access to assisted conception free from barriers that other women, seeking insemination with semen donated by their spouse or sexual partner, do not have to endure. However, If we shift our perspective of rights from a liberal view to a relational approach, we will be able consider such decisions from a perspective that takes into account not only the physical health implications of the use of this technology, but also all other social, psychological and contextual relevant factors. Back to Top

Women's Reproductive Health Rights, the Rule of Law and Public Health Considerations in Repealing the Criminal Laws on Abortion in the Republic Suriname

By Milton Andy Castelen Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2009

Within the Surinamese jurisdiction the Constitution grants women the right to health and imposes a legal duty on the state to facilitate the realization of this right. Also treaty law, in particular, the ICESCR article 12 and the CEDAW article 12 grant women the right to the highest attainable standard of health and the right to non-discriminatory access to healthcare. But due to the criminal law applicable to abortion women lack non-discriminatory access to reproductive healthcare and therefore do not enjoy the highest attainable standard of pregnancy related health. Despite its decision not to enforce the abortion prohibiting criminal laws, Suriname remains in a state of failure to comply with its legal duties as imposed by the Constitution and treaty law. This, due to the state’s reluctance to repeal the criminal laws on abortion and its failure to enact effective health regulations to facilitate women in need of an abortion. Back to Top

Secular Rights and Monopolies of Morality: Reframing the Legal Discourse of Abortion in the Philippines

By Carolina S. Ruiz Austria Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2008

This thesis introduces and develops the idea of "secular spaces." It proposes a role for the courts in protecting such spaces, and supporting core values behind secularism, rather than engaging in mechanical line-drawing exercises between state and church, the secular and the religious. This idea of secular space is not premised on a complete disentanglement of secular and religious realms but rather builds on the idea of a social space benefiting from state protection as well as from non-intervention. It is a contested and an overlapping space but one which can allow the courts a more meaningful vantage point from which to exercise their role in promoting the values behind secularism and secular state practices. Because the issue of abortion in the Philippines spans both spheres, public/private and secular/religious, the courts need to consider a broader approach in their judgments, one that remains attentive to the Constitutional framework of both religious freedom and women's human rights. The challenge here is to view the issue of abortion and the resulting rights contest not solely or primarily as a competition for legitimacy in which all debates, even the ethical, can and ought to be settled with finality before the courts of law. Back to Top

The Fallacy of Equality: 'Anti-Citizens', Sexual Justice and the Law in India

By Oishik Sircar Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2008

The determinants of citizenship seemingly have little or no relevance to the sexuality of the citizen. However when it comes to the matter of exercising citizenship rights, sexuality acquires great significance where the normative subject of citizenship is the heterosexual citizen. Ideas of citizenship are predicated on hegemonic heterosexuality. Based on this understanding this paper attempts to map how the lives of the sexually marginalized in India, who I refer to as the sexual ‘anti-citizen’, are regulated and disciplined through the dual operation of criminal law and heteronormativity. Drawing from the influential works of French philosopher Michel Foucault and American anthropologist Gayle Rubin the paper argues how the anti-sodomy law in India Sec. 377 of the Indian Penal Code that criminalizes ‘unnatural offences’ operates through a ‘panoptic’ model that results in creating ‘sexual hierarchies’, acutely disenfranchising sexual ‘anti-citizens’ from guarantees to basic rights and freedoms. The paper looks at how the Foucaultian idea of ‘panopticism’ operates to locate the anti-citizen in certain kinds of deviant spaces, and how law works to make criminal these spaces, as well as the bodies that inhabit them. With this I connect how this differential treatment by the law towards ‘citizens-of-a-different-kind’ receives sanction through the ways in which the Constitutional principles of equality and non-discrimination are interpreted by courts. The process is effected through the means of ‘making same’ a criteria on the basis of which constitutional equality is guaranteed. The paper looks at the creation of ‘sexual hierarchies’ (developed by Rubin) through the operation of ‘panopticism’, which make offenders out of certain citizens, not just because of what they can do, but also merely because of what they are and then map how the law criminalizes such ‘status offenders’ and understand the legal strategies employed by the anti-citizen to counter the violence of the law. Back to Top

A Critical Analysis of Statutory Rape Law and its Effects on Adolescents: The Chilean case

By Claudia Ahumada Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2007

This thesis sets forth the interests and conflicts involved in the current Chilean law on statutory rape. Through a thorough investigation of the conceptualization, implementation, and current life of this legislation, the possible effects of the Chilean case on adolescents' rights is investigated and evaluated. Examining the development of this law and its related policy, and if their consequences conflict with the Chilean Constitution or international and regional human rights conventions allows us to evaluate the merits, utility, and potential problems of such legislation. A detailed investigation of the social, legal, and health data available, as well as the concrete liability implications reveals that the policy which implements the Chilean statutory rape provision is in violation with domestic and international human rights law. In conclusion, recommendations are presented to deal with the effects of the implementation, as well as to modify the legislation to uphold adolescents' human rights. Back to Top

Protecting the Human Rights of Women by Re-conceiving the Repugnancy Doctrine in Nigeria: The Case of Muojekwu v. Ejikeme

By Onyema Oluebube Afulukwe Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2007

This paper focuses on the impact of the judicial interpretation of the Repugnancy Doctrine on the human rights of Nigerian women. It examines the origin of the Doctrine and how it has been used by courts to determine when a customary law is enforceable. The paper argues that incorrect interpretations of the Doctrine have caused the courts to uphold customary laws that require the exclusion of women from property inheritance rights. The social, economic and health harms of these exclusions are identified and the argument is made that these harms result in the violation of the human rights of Nigerian women and other vulnerable groups such as children. The paper recognizes the importance of culture in the lives of Nigerians. Accordingly, the argument is made that the Doctrine must be re-conceived in a manner that allows the courts to engage with customary laws respectfully while upholding human rights norms. Back to

Therapeutic Abortion: The Brazilian Case of Anencephaly

By Carmen Hein de Campos Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2007

This thesis analyzes the interpretation of Brazil's criminal law provision regarding "risk to life" as it is applied in cases of anencephaly. Relying on the constitutional and international women's rights framework, I argue that the criminal law provision regarding risk to life should be interpreted in accordance with the fundamental rights set forth in the Brazilian Constitution. The constitutional interpretation of the criminal provision on risk to life allows physicians to perform abortion in case of anencephaly without judicial authorization. Particularly, this understanding extends the meaning of risk to life in a integrative approach that gives effect to women's fundamental rights and international human's rights law. I believe that this perspective is strategic to overcome the unfair situation resulting from the understanding that women need to seek judicial authorization to have abortion in cases of anencephaly. Back to Top

Criminal Prohibition of Sex Selection: A Solution or a Problem? : A critical analysis of the criminal law model as the means to address sex selection in India

By Upasana Sharma Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2006

In India, the use of reproductive technologies for the purpose of male preference sex selection is a manifestation of strong patriarchal norms that perpetuate son preference. Under the confluence of ‘son preference’ and ‘population control policies’, sex selection has come to be viewed as the most appropriate method of family balancing. In the context of widespread social acceptance for sex selection, this paper argues that the Preconception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection) Act, 1994 criminalizing sex selection, does not provide an effective remedy to root out sex selection. Criminal prohibition just amounts to suppressing the symptom without addressing the underlying problem. So long as the underlying problem remains, the symptom will persist. The paper explores the ineffectiveness of the criminal law based legislative approach to curb sex selection on the basis of social anthropological and criminal law theory that explains patterns of non-compliance with laws that are considered antagonistic to prevailing social norms. Back to Top

Ensuring Reasonable Access to Abortion Services in Nepal

By Purna Shrestha Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2006

In 2002, abortion has been legalized under certain circumstances in Nepal. However, Nepalese women are still deprived of the legal and safe abortion services. By developing a framework on reasonable access to abortion services, this study basically explores on what is expected out of any state machineries to guarantee women’s right to abortion. It will further examine the Nepalese government’s obligation under national laws and international human rights instruments to ensure reasonable access to abortion services, and argues that by being unable to do so Nepal violates women’s human rights. Finally, the study put forward recommendations to the Nepalese government for ensuring reasonable access to abortion services to Nepalese women. Back to Top

Pichon and Sajous v. France: Implications for Slovakia

By Adriana Lamackova Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2006

This thesis explores the issue of conscientious objection invoked by pharmacists and its impact on women’s access to reproductive and sexual health care services. The right to conscientious objection has been recognized by several international and European experts as being derived from a right to freedom of religion, thought and belief. It is not, however, an absolute right. When its exercise is in conflict with other human rights and fundamental freedoms, a fair balance must be struck between a right to conscientious objection and other affected human rights and fundamental freedoms. Particularly in the reproductive health care context, states that allow for conscientious refusals must accommodate conscientious objection in such a way that its exercise does not compromise women’s access to these procedures. This analysis of Pichon and Sajous v. France suggests a balanced approach that could be applied in conscientious objection cases involving reproductive health care. Back to Top

An Analysis of the Philippine Legal and Policy Frameworks for the Protection of Women Migrant Workers, particularly the Domestic Workers and Entertainers, from Vulnerability to HIV/AIDS.

By Amparita D. Santa Maria Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2005

Overseas employment predisposes migrant workers to discrimination and exploitation. The women are especially vulnerable to abuses, especially the entertainers and domestic workers. Currently, there is a slow but steady increase of HIV/AIDS infection among migrant workers. In its country report to the Committee on the Elimination of Discrimination Against Women, the Philippines has stated that HIV/AIDS prevalence in women was highest with the 19-29 age groups; and that most of them are in prostitution, although there are also cases found in overseas domestic workers. This thesis examines the HIV/AIDS education implemented by the government as its solution to protecting departing migrant workers from vulnerability to the disease. Analyzing the legal and policy frameworks and its implementing program, the thesis concludes with recommendations on how best to ensure that the information acquired by the women migrant workers translates into behavior that would effectively reduce the risk of their vulnerability to HIV/AIDS. Back to Top

An Approach from the Women’s Fundamental Rights Perspective to the Statutory Defence for Abortion based on Health Risks in Mexico: A legal strategy to overcome the unfairness in its interpretation, operation, and application.

By Adriana Ortega Ortiz Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2005

In this thesis, I analyse the statutory defence regime for abortion in Mexico in general and the statutory defence of health risks in particular. Relying on the constitutional and human rights frameworks, I argue that the legislative incorporation of every statutory defence is a consequence of the Mexican State’s obligation to protect and respect women’s fundamental rights. I analyze the statutory defence of health risks in a way that offers guidance to physicians performing risk assessments in a manner that respects and gives effect to the rights of women that are involved in this defence, particularly the constitutional right to health protection and the human right to health. I understand this approach as a strategy to overcome the unfairness resulting from the varying interpretation and operation of the exceptions to the criminal prohibition of abortion.

Invoking Conscientious Objection in Reproductive Health Care: Evolving Issues in Latin America

By Lidia Casas Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2005

The ability to decide whether, when and how many children to have is central to women's lives. This investigation explores conscientious objection in reproductive health care in Latin America and how this issue could become an obstacle to women's right to health -and even jeopardize their safety and lives. Back to Top

Emergency Contraception Jurisprudence in Latin America: Catholic Doctrine and Women’s Rights

By Fiorella Melzi Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2005

In this thesis, the author analyses legal challenges brought before courts in Chile and Argentina in which the challengers allege that emergency contraception is abortifacient and therefore a violation of the constitutional right to life of the unborn. Demonstrating that these courts have focused on a determination of when life begins, as opposed to when life should be legally protected, the author argues that they have based their rulings on Catholic doctrine rather than on scientific evidence. She contrasts these approaches with those taken in similar cases by courts in the United Kingdom, Spain and in international human rights decisions. The author argues that by enforcing religious norms, these courts are jeopardizing the principle of secularity that is fundamental to democracy. Most importantly, the author demonstrates that these courts have violated women’s constitutional rights by ignoring women’s rights, concerns and needs, thereby frustrating women’s attempts to achieve equality. The author concludes with guidance for judges regarding appropriate reasoning in these cases.

Discrimination and Adolescent Girls’ Reproductive and Sexual Health Rights in Nigeria: A Critical Review

By Folake Morenike Olaleye Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2005

This thesis presents an analysis on the role of the courts and how the courts in Nigeria can improve adolescent girls’ access to reproductive and sexual health services. It argues that the present poor state of adolescent girl’s reproductive and sexual health stems from discrimination in access to reproductive and sexual health services. It further argues that courts in Nigeria through national and international legal instruments on adolescent rights can give domestic effect to those laws and international legal norms, guaranteeing adolescent girls' access to reproductive and sexual health services. Finally, it examines how courts in other jurisdictions have achieved this through case law decisions and interpretation and argues that courts in Nigeria can also explore those avenues to improve adolescent girls' reproductive and sexual health in Nigeria.

Global Security, Human Rights, Public Health and Military Policies on HIV/AIDS: Nigeria as a Case Study

By Sylvanus Babafemi Odunsi Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2005

This thesis presents a view on how the military forces should control HIV/AIDS infection. While the focus is Nigeria, the views canvassed apply to the military globally because of similarity in the nature of military forces and HIV/AIDS being a universal phenomenon. With unsafe heterosexual behaviors being the major cause of HIV/AIDS in the military, change in the behaviors of soldiers is an effective means of control. Because the military as a body largely relies on coercion and sanctions to control its personnel, "tough military measures" may seem the natural means to attain the proper behavior. I argue, however, that safeguarding the human rights of soldiers is a better way of achieving that goal. I further contend that any military policy on HIV/AIDS that fails to protect the human rights of military personnel will not be effective in controlling HIV/AIDS.

A Human Rights Approach to Maternal Mortality in Brazil

By Maria Beatriz Galli Bevilacqua Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2002

This thesis aims to assess the situation of maternal mortality in Brazil using a human rights approach. The Brazilian Constitution establishes motherhood as a social right. In addition, the Brazilian state is part of human rights treaties that can be applied to address maternal mortality. However, maternal mortality rates have remained practically stable in Brazil for the last fifteen years. This is a result of the state’s systematic omission to prevent and remedy avoidable maternal mortality in the 98% of the cases that are preventable. Moreover, the paper argues that the state should take appropriate measures to ensure women’s equal access to health care and protect the human right of women to be free from avoidable maternal death. It recommends that the state should enforce relevant legislation and policies, enact new legislation to foster accountability to prevent and remedy avoidable cases of maternal death, and promote visibility and social awareness of the problem.

Human Rights to Safe Motherhood Under the Scope of Patients’ Rights: Maternal Health Services in Hungary

By Eszter Kismodi Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2002

The thesis argues that enforcement of patients’ rights provisions is a more effective mechanism to protect human rights concerning maternal health than direct application of international human rights law in Hungary. The patients’ rights law can be used to clarify the obligations of the state to protect and respect maternity rights of women. The study includes analyses of the international human rights documents specific to women’s health, the Constitution of Hungary, and the Hungarian Health Care Act with special attention to its Patients’ Rights Chapter.

Promoting Safe Motherhood for Roma Women in Bulgaria: A Task for Sisyphus.

By Nadejda Naydenova Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2002

The thesis endeavours to place safe motherhood in a human rights framework and to consider the questions that such a framework raises about governmental accountability and action for the reproductive health of minority women, with special attention to the position of Roma women in Bulgaria. It specifically argues that the right to equality is the basis of ensuring safe motherhood for Roma women and that the government must act to eliminate the intersection of race and gender discrimination in the reproductive health sector. The current Bulgarian approach to equality is a formal one which fails to protect the most vulnerable groups in the society, including Roma women, who do not fit the dominant model. In this respect, the thesis proposes introduction of a comprehensive reproductive health policy in Bulgaria, which has to be built upon the substantive equality concept that takes into account the “right” to safe motherhood of Roma women.

Socio-Legal and Human Rights Dimensions of Child Marriage in India.

By Dr. Jaya Sagade, S.J.D. Doctoral Thesis Graduate Department of the Faculty of Law, University of Toronto, 2002

The thesis explores socio-legal and human rights dimensions of the age-old problem of child marriage in India. Using social science data, the thesis documents the problem’s extent in India and critically analyses how the patriarchal social structure supports the practice of marrying off young girls in the name of culture and tradition by suppressing women’s life experiences. Child marriage adversely affects health, particularly the reproductive health of young girls; it denies them the right to education and development, keeping them in a state of servility for life. The law enacted in 1929 to regulate the age of marriage remains largely unimplemented, partly because of its many substantive and procedural lacunae, as well as contradictions between it and religion-based marriage laws, guardianship laws, and the rape law. Moreover, the judiciary has not interpreted these laws dynamically, with the result that millions of girls are married off when they are young. The thesis argues that the young girls are discriminated against by the law, culture and society versus their counterparts on the basis of sex, gender and age when they are married off before they attain the legal age. The thesis argues that child marriage is a form of slavery. It analyzes how the practice of child marriage violates human rights that the Indian State is obligated to remedy. It suggests several strategies at national and international levels that would help prevent child marriages in future and in turn would provide opportunities for those girls to live in dignity. The human rights approach adopted in this thesis attempts to offer a pragmatic and holistic solution to the severe social problems associated with child marriage in India.

Legal Restrictions of Abortion in Nigeria: A Manmade Disaster to Women’s Health

By Victor Opara Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2002

Although highly restricted under Nigerian laws, abortions take place in Nigeria in large numbers, mainly under unsafe conditions. The thesis first outlines the abortion laws in the Nigerian criminal jurisprudence, gives the social science data of maternal mortality and morbidity, and defines some basic concepts that form a recurrent theme in the thesis. It then discusses the relationship of law, morality, religion, liberty and freedom vis-à-vis abortion. Next, it construes abortion as a human rights issue, arguing that the denial of access to abortion services to women, especially rape victims, is discriminatory and as such contrary to international human rights conventions ratified by Nigeria. Also included is a comparative analysis of the statutory and case laws of other jurisdictions, and closing recommendations geared toward liberalization of the abortion laws in Nigeria.

Pregnant Women and Testing for HIV-Infection: Can the Practice of Coercive Testing Be Supported By Public Health Concerns When Weighed Against the Privacy Interests of Those Tested? Experience of Canada, Russian Federation and the United States.

By Anna Alexandrova Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2001

Determining the right balance between public health interests and personal liberties is an extremely complicated call for any government in the world. Despite the twenty years recognition of HIV/AIDS, this balance is not yet found. The issue strongly emerges, especially with regard to women, for two main but conflicting reasons: states’ interest in public health and human life, and rights of women. The conflict becomes more distinct with the availability of new treatment that is said to normalize HIV and turn it into “just another disease.” This thesis re-affirms the necessity of unique treatment of the disease, and takes on an approach known as “HIV/AIDS exceptionalism”. It looks into arguments for and against coercive testing of pregnant women for HIV, weighing each of them against possible public health outcomes and burdens on women’s rights. The thesis concludes that the policies of mandatory testing of women are undesirable as they would further discriminate against women and deter them from seeking treatment.

Tripping Over Patents: AIDS, Access To Treatment and the Manufacturing of Scarcity.

By Jonathan Berger Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2001

With an estimated 4.7 million—or approximately one-in-nine—people living with HIV/AIDS, South Africa is in crisis. Understanding that the country’s ability to turn the tide against the epidemic in large part hinges on whether the majority of people with HIV/AIDS will have access to treatment, this thesis explores the extent of regulatory flexibility permissible under the World Trade Organization’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS). It argues that despite the international harmonization of intellectual property law, countries like South Africa are permitted by TRIPS to take certain regulatory steps to ensure the accessibility of essential treatments. When properly interpreted in accordance with recognized principles of international law and in the light of the Constitution of the Republic of South Africa, 1996, TRIPS does not prevent—but rather contemplates and permits—the taking of certain legal steps to ensure meaningful reductions in drug prices.

The Responsibility of States Under International Human Rights Law to Address the Trafficking In Nepalese Girls Into Prostitution.

By Kumar Regmi Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2001

Trafficking of girls into prostitution is a global problem, and has been destroying the lives of thousands of innocent victims, resulting in physical and mental violence and various kinds of diseases. Trafficking violates the human rights of the victims, many of which rights are non-derogable under any circumstances. Nepalese girls trafficked into prostitution are a group of victims who have been sent into brothels in India, in large number every year, because of the grim socio-legal discrimination that prevails at home. The apathy, neglect and discrimination concerning this problem practiced by the states (Nepal and India), including among the judiciary, have further increased suffering of the victims. This thesis argues that, as parties to the various international human rights conventions, it is the responsibility of Nepal and India to fulfill their commitments by making their national laws effective to prevent trafficking and protect the human rights of victims without any discrimination.

Unsafe Abortion: Violation of Women’s Right to Reproductive and Sexual Health: A Study with Reference to Nepal.

By Sonali Regmi Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2001

Women have been taking resort to abortion throughout the ages. However, even today, stringent abortion laws and/or hurdles in access to safe and affordable abortion services that violate their reproductive and sexual rights have led many women to employ unsafe abortion practices, resulting in high maternal mortality rates and life-long complications. This thesis looks into the problem of unsafe abortion in Nepal that has resulted from Nepal’s stringent anti-abortion law, which has affected the health and lives of women and violated their rights. The thesis argues that the government of Nepal is under an obligation to end the continuing violation of women’s reproductive and sexual rights, change its present stringent law relating to abortion to accord with its obligations under national and international law, and provide access to safe and affordable abortion services to all women without discrimination.

Tragedies of Unsafe Abortion in International Law: The Case of Eritrea.

By Kibrom Isaak Teklehaimanot Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2001

The high rate of maternal mortality due to unsafe abortion in developing countries calls for great concern in national and international arenas. This thesis discusses how the right of privacy and the right to life are interpreted under international law. Taking Eritrea as a case study, the thesis analyses the philosophical and practical interpretation of these rights in relation to some social aspects of Eritrean life. Given the communal life of Eritrean society and the practice of international human rights bodies, the right to life is more pertinent than the right of privacy in tackling the tragedies of unsafe abortion. Despite its historical background of narrow analysis, the right to life has recently become broadly interpreted to protect women who are vulnerable to fatal unsafe abortion practices. States have a duty under international law to reduce economic, social, legal, and other factors that force women to resort to unsafe abortion. Accordingly, the central objective of the thesis is to show the indispensability of utilizing the right to life to avoid the consequences of unsafe abortion in developing countries.

A Critique of Anti-Sterilisation Law in Poland.

By Malgorzata Rutkiewicz Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2000

Sterilisation is one of the safest, most effective and most widely used methods of family planning in the world. However, it is illegal and inaccessible in Poland. This thesis argues that there are certain harms imposed by the anti-sterilisation policy in Poland, and that they amount to a violation of human rights. It argues that limiting access to a comprehensive range of contraceptive options is harmful for reproductive and sexual well-being. Certain concerns associated with contraceptive sterilisation (e.g. fear of abuse or post-sterilisation regret) would be addressed more appropriately by less restrictive measures that respect rights of individuals and better respond to their needs. I argue that an array of contraceptive options that is as comprehensive as medical technology and modern health policy will allow is a necessary component of equality for women. As such, sterilisation policy should be part of a comprehensive reproductive health policy, which should be built upon principles of equality and public health rather than on moralities, myths and popular misconceptions about people’s capacity to control fertility.

A Discussion of the Aspects of the Right to Health Under National and International Law in Venezuela.

By Mary Ann Torres Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2000

This thesis analyses the importance of human rights in the context of the AIDS pandemic, specifically addressing medical treatment for HIV/AIDS as fundamental to the exercise of the right to health and the right to life. The two are so interconnected that a meaningful analysis of one must include the other. The thesis analyses the Venezuelan Supreme Court decision in the 1999 Bermudez, et al. v. Ministry of Health. The thesis argued that, in that case, since the State did not provide treatment for those with HIV/AIDS, it was violating individuals’ right to health and their right to life. Although the right to health is enshrined in the Venezuelan Constitution and in international treaties, the enabling social, economic and legal conditions necessary for the exercise of this right are often missing. In conclusion, even though international human rights law has become an effective set of rules on which to base national and international public health strategies towards AIDS, the right to health remains unprotected, especially in the developing world. Back to Top

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Sex Reprod Health Matters
v.28(1); 2020

Language: English | French | Spanish

Abortion knowledge, attitudes and experiences among adolescent girls: a review of the literature

Cecilia espinoza.

a Ipas Senior Advocacy Advisor, Ipas, Chapel Hill, North Carolina, USA

Ghazaleh Samandari

b Independent consultant, Ipas, Chapel Hill, North Carolina, USA

Kathryn Andersen

c Chief Scientific and Technical Officer, Ipas, Chapel Hill, North Carolina, USA

Adolescent girls comprise a considerable proportion of annual abortion deaths, worldwide, with 15% of all unsafe abortions taking place among girls under 20 years of age. Despite recent global attention to the health and welfare of adolescent girls, little is known about their abortion experience, particularly of those under the age of 15 years. This review examines existing peer-reviewed and grey literature on abortion-related experiences of adolescent girls, paying particular attention to girls ages 10–14. In December 2019, the authors conducted a comprehensive search of five major online resource databases, using a two-part keyword search strategy for articles from 2003 to 2019. Of the original 3,100+ articles, 1,228 were individually screened and 35 retained for inclusion in the analysis. Findings show that while adolescent girls may have knowledge of abortion in general, they lack specific knowledge of sources of care and delay care-seeking due to the fear of stigma, lack of resources and provider bias. Adolescent girls do not experience higher rates of physical complications compared to older cohorts, but they are at risk of psychosocial harm. For girls ages 10–14, abortion experience may be compounded by pregnancy due to sexual abuse or transactional sex, and they face even more barriers to care than older adolescents in terms of provider bias and lack of agency. Adolescents have unique needs and experiences around abortion, which should be accounted for in programming and advocacy. Adolescent girls need information about safe abortion at an early age and a responsive and stigma-free health system.

Résumé

Dans le monde, les adolescentes représentent une proportion considérable des décès annuels dus à l’avortement, avec 15% de tous les avortements à risque étant pratiqués sur des filles âgées de moins de 20 ans. En dépit de l’attention mondiale récemment accordée à la santé et au bien-être des adolescentes, on sait peu de choses de leur expérience de l’avortement, en particulier pour celles qui ont moins de 15 ans. Cette analyse examine les publications à comité de lecture et la littérature grise sur l’expérience des adolescentes en rapport avec l’avortement, en s’intéressant particulièrement aux filles âgées de 10 à 14 ans. En décembre 2019, les auteurs ont réalisé une recherche exhaustive de cinq bases de données majeures de ressources en ligne, à l’aide d’une stratégie de recherche par mot clé en deux parties pour les articles de 2003 à 2019. Sur les plus de 3100 articles, 1228 ont été sélectionnés individuellement et 35 retenus pour être inclus dans l’analyse. Les conclusions montrent que si les adolescentes peuvent avoir des connaissances générales sur l’avortement, elles manquent de renseignements précis sur les sources de soins et retardent la demande de soins par crainte de la stigmatisation, manque de ressources et préjugés des prestataires. Les adolescentes ne connaissent pas de taux plus élevés de complications physiques que des cohortes plus âgées, mais elles risquent des dommages psychosociaux. Chez les filles âgées de 10 à 14 ans, l’expérience de l’avortement peut être aggravée par le fait que la grossesse était due à un abus sexuel ou à des relations sexuelles transactionnelles, et elles rencontrent des obstacles encore plus nombreux pour obtenir des soins que les adolescentes plus âgées, du point de vue des préjugés des prestataires et du manque de pouvoir. Les adolescents ont des besoins et des expériences uniques autour de l’avortement, dont il faudrait tenir compte dans la programmation et le plaidoyer. Les adolescentes ont besoin d’informations sur l’avortement sûr à un âge précoce ainsi que d’un système de santé réactif et qui ne les stigmatise pas.

Un considerable porcentaje de muertes anuales atribuibles al aborto ocurre entre adolescentes a nivel mundial, ya que el 15% de todos los abortos inseguros ocurren entre niñas menores de 20 años. A pesar de la atención mundial reciente a la salud y el bienestar de las adolescentes, no se sabe mucho sobre su experiencia de aborto, en particular entre aquéllas menores de 15 años. Esta revisión examina la literatura existente revisada por pares y la literatura gris sobre las experiencias de las adolescentes con relación al aborto, y presta particular atención a niñas entre 10 y 14 años. En diciembre de 2019, los autores realizaron una búsqueda integral en cinco principales bases de datos de recursos en línea, utilizando una estrategia de búsqueda con palabras clave de dos partes de artículos publicados entre los años 2003 y 2019. De los 3,100+ artículos originales, 1,228 fueron examinados individualmente y 35 fueron retenidos para su inclusión en el análisis. Los hallazgos muestran que, aunque las adolescentes tengan conocimientos generales del aborto, carecen de conocimientos específicos sobre las fuentes de servicios y retrasan la búsqueda de atención por temor al estigma, falta de recursos y prejuicios del personal de salud. Las adolescentes no presentan mayores tasas de complicaciones físicas comparadas con grupos de mujeres de edad más avanzada, pero corren riesgo de sufrir daños psicosociales. La experiencia de aborto de niñas entre 10 y 14 años podría verse agravada en casos de embarazo producido por abuso sexual o sexo transaccional; además, estas niñas enfrentan aun más barreras para obtener servicios que las adolescentes mayores, por los prejuicios del personal de salud y la falta de agencia. Las adolescentes tienen necesidades y experiencias únicas con relación al aborto, las cuales deben tomarse en consideración en los programas y en las actividades de promoción y defensa. Las adolescentes necesitan información sobre el aborto seguro a temprana edad y un sistema de salud receptivo y libre de estigma.

Each year, an estimated 3.2 million unsafe abortions (defined as a pregnancy termination performed either by a person lacking the necessary skills or in an environment lacking adequate medical standards) take place among adolescent girls ages 15–19. This number accounts for almost 15% of the total global incidence of unsafe abortion (22 million), and abortion-related mortality among young girls and women accounts for nearly one-third of abortion-related deaths worldwide. 1 Despite recently increased commitments to adolescent reproductive health, our understanding of their abortion experiences is limited. Furthermore, the focus of policy and programmatic attention remains primarily on adolescents ages 15–19, leaving a substantial gap in our understanding of the sexual and reproductive experiences of adolescents ages 10–14. 2–4 Girls in this category comprise a large and growing segment of the population, particularly in highly impoverished regions of the world (estimated at 545 million in 2015). 5 A parallel increase in the age of marriage in many contexts has extended the period of premarital fertility, which further exposes young adolescents to the risk of unintended pregnancy resulting in unsafe abortion. 6–8 Moreover, the majority of unsafe abortion incidence is concentrated in low- and middle-income countries (LMIC) where the 10–14-year-old population is proportionally largest, and where many countries have restrictive abortion laws. 9 , 10

The potential for sexual and reproductive harm among adolescents is a present and growing threat, yet our understanding of abortion in this group is insufficient to properly address their needs through programmatic and policy interventions. The purpose of this literature review is to explore abortion-related knowledge, attitudes and experiences of adolescent girls, paying particular attention to those ages 10–14.

This literature review focused on the abortion knowledge, experiences and attitudes of younger (10–14 years) and older (15–19 years) adolescents from LMIC (as defined by the World Bank). 11

Data sources

We conducted a systematic search of five online resource databases: PubMed, Global Health, Embase, POPLINE and Google Scholar, between June 2018 and December 2019. In addition, we searched websites of organisations that do sexual and reproductive health work with adolescents to locate any additional grey literature. These organisations included Ipas, International Planned Parenthood Federation, Guttmacher Institute, Marie Stopes International and EngenderHealth. We also conducted a general search of the Google search engine to locate any additional grey literature sources.

Search strategy

The search covered the time frame between 2003 and 2019 and was run simultaneously by GS and CE. Databases were searched using a two-part keyword search strategy. The first set of search terms focused on limiting the age group of target populations to only adolescents and included “Adolesc”* OR “young” OR “youth”* OR “girl”* OR “very young girl”* OR “very young adolesc”* OR “adolescent health services”* OR “child” OR “pregnancy in adolescence”. The second set of search terms related to abortion experience and included “Abortion” OR “termination of pregnancy” OR “pregnancy termination” OR “menstrual regulation” OR “postabortion” OR “abortion, induced”OR “abortion applicants”. These terms were used in combination with “tiab” and “MeSH” settings to maximise the identification of keywords in indexed articles in the databases.

Selection criteria

The search included all English, Spanish and French language † peer-reviewed publications of either quantitative or qualitative nature related to the abortion knowledge, attitudes or experience of adolescents ages 10–19. The search was restricted to articles that included findings from adolescents 19 years or younger years of age, meaning articles that included women from older age groups were included so long as data were segregated by age groups and findings for adolescents under 20 years of age could be differentiated from that of older women. The primary focus of this review is on adolescents from low- to middle-income countries.

Articles were excluded if they did not include findings from primary data collection or original secondary analysis of a primary data source, if they did not include data on the abortion experience, knowledge or attitudes of adolescents under the age of 20 years or did not come from an LMIC, with one exception: given that data on younger adolescents are sparse, if a study included segregated data on 10–14-year-olds, it was included in the review regardless of the LMIC status of the sample.

Screening and selection

We conducted screening and selection using the PRISMA guidelines ( Figure 1 ). 12 The search yielded over 3,100 articles, many of which included either duplicate articles of studies pertaining to clinical findings not suitable for the topic of this review (such as unrelated obstetric outcomes). The screening process was multi-stage, whereby first we removed all duplicates and clearly irrelevant articles (for example articles that pertained to highly technical obstetric procedures). We then performed an initial screening based on the abstracts retrieved in the first stage of the search. In this first pass, the reviewer erred on the side of inclusion, so as not to accidentally omit articles that may have provided relevant data in full-text form. After the initial abstract review, we conducted a third screening of full-text articles; only studies for which the full text was available either in English, French or Spanish were retained (as these were the working languages of the authors). Each article was then reviewed for quality by GS and CE using the critical appraisal skills programme checklist for both quantitative and qualitative studies. 13

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PRISMA screening process

Data abstraction and analysis

The articles were abstracted in terms of their publication details (authors, date, title, etc.), geographic scope, purpose, study design, population, methods and main findings. The articles were coded by hand into thematic areas that emerged from initial reading and organisation of the articles. The themes evolved over the course of coding, and the final list of themes included abortion knowledge and attitudes, comparative abortion rates for adolescents versus older women, reasons for abortion, the timing of abortion and postabortion care, sources and methods of abortion, experiences with formal health providers, the experience of complications of abortion, and psychosocial outcomes of abortion. Articles could be assigned more than one code and thus may appear under more than one thematic area.

A total of 35 articles were included in this review ( Table 1 ); five were qualitative, one used mixed methods, and the rest ( n = 29) were quantitative. Twenty-three of the articles were from Sub-Saharan Africa (e.g. Cote d’Ivoire = 1, the Democratic Republic of Congo = 1, Ethiopia = 4, Ghana = 1, Kenya = 2, Malawi = 3, Nigeria = 5, South Africa = 1, Uganda = 1 and Zambia = 1), 6 from Asia (e.g. Bangladesh = 1, India = 1 Japan = 1, Nepal = 1 Thailand = 2) and 6 from the Americas (Brazil = 3, Guadeloupe = 1, Mexico = 2). Sample sizes for the study ranged considerably depending on the method (quantitative versus qualitative) and the focus and design of the study; the largest study involved a national health records review (115,490 live birth records reviewed quantitatively in Thailand) while the smallest was an exploratory qualitative study of 16 girls in Malawi. The results of the study are presented in terms of two broad categories: knowledge/attitudes towards abortion and abortion experience. The category of abortion experience is further divided into abortion rates (comparing <19 girls with other age groups), reasons for abortion, timing and methods used for abortion, complications of abortion, experiences with providers, and psycho-social outcomes. Within these categories, there may be a combination of results pertaining to 15–19 and 10–14-year-old adolescents.

Abortion knowledge and attitudes

Five studies in this review examined the knowledge and attitudes of adolescents around the termination of pregnancy. Although adolescents are cognisant of abortion as a service, their knowledge of legality, methods of termination and access points for abortion are low. Among a sample of 10–19-year-old secondary school girls in Lagos, Nigeria, 83% had knowledge of abortion as a topic and 10–14-year-olds were more likely to know legal indications and methods of abortion than those ages 15–19. 14 In Ethiopia, 63% of adolescents were aware that abortion is safe in some cases, but few could name the indications for legal abortion. 15 An internet survey of students from two technical schools in Brazil showed that the knowledge of abortion methods among 12–14-year-olds was lower than that among 15–16-year-olds (29% vs 40%, respectively). 16 Among 16–20-year-old girls in the Democratic Republic of Congo (DRC), 46% knew of a place to obtain an abortion, 71% knew of someone who had had an illegal abortion, and most were able to name at least one health consequence of illegal abortion (death, infertility, infection and bleeding were the most commonly cited). 17

Attitudes towards abortion among young adolescents are fairly conservative. In Brazil, legal termination of pregnancy was supported by only 56% of male and female adolescent (12–21-years-old) respondents in a school-based study. 16 In Nigeria, younger adolescents (10–14-years-old) were less accepting of abortion than older adolescents (15–19-years-old). 14 In a study of 13–19-year-old males and females in Kenya, most participants disagreed with the use of abortion in the case of unwanted pregnancy and girls were significantly more likely to disagree with abortion than boys (91% vs 87%, respectively; p = 0.007) 18 In the Democratic Republic of Congo, where at the time of the study abortion was only legal to save a woman’s life, 76% of student respondents (16–20 years) were opposed to illegal abortion. 17

Comparative abortion rates/ratios among adolescents vs older groups

Nine studies in this review examined the rates or ratios of abortion among young/very young adolescents compared to older groups of women. In Bangladesh, one study showed a higher abortion ratio among adolescents <18 than 18–19-year-olds (44 vs 23 per 1,000 births, respectively; p < 0.001) and unmarried adolescents were 35 times as likely as married adolescents to abort (20 vs 733 abortions per 1,000 births; p < 0.001). 19 In Thailand, the probability of abortion was significantly higher among 10–14-year-olds than among 20–24-year-olds (OR = 1.18, p < 0.001), while in 15–19-year-olds the probability of abortion is reduced (OR = 0.65, p < 0.001). 20 In another study in the same setting, Thai girls ages 10–14 had nearly double the ratio of unsafe abortion compared to 15–19-year-olds (1,089 vs 602 unsafe abortions per 100,000 live births, respectively). 21 In Brazil, 20% of sexually active 12–14-year-old girls and 27% of 15–19-year-olds reported having had a prior abortion. 22 When adjusting for levels of sexual activity in Ethiopia, 15–19-year-old girls had higher rates of legal abortion than any other age group (64%). 23 In Nepal, however, women ages 20–34 were significantly more likely to report an induced abortion compared to those under 20 years (OR: 5.54; 95% CI: 2.87–10.72). 24

In Malawi, girls ages 10–19 comprised 20–28% of all abortions, second only to the 20–24 age group. 25 , 26 Among all 10–19-year-olds, unmarried adolescents were 11 times as likely to terminate a pregnancy as married girls ( p < 0.05) and among all unmarried women, adolescents (10–19 years) had higher rates of abortion (34%) than women aged 20–24 (12%) or women 25+ (20%; p < 0.05). 26 In a study in India, the majority of those seeking abortions were under 20 years of age (56%), 38% of whom were girls under the age of 16. 27 In Mexico, among 10–14-year-old girls the percentage of all live births ending in abortion rose from 13.6% in 2000 to 16.3% in 2010 while percentages for 15–19-year-old girls remained between 10% and 11% (descriptive abortion rates rose across all other age groups in that same period; however, no significance tests were presented). 28

Reasons for abortion

Nine studies solicited reasons why adolescents sought to terminate a pregnancy which included: the desire to continue education or to protect future aspirations; to avoid the stigma of teenage pregnancy; poverty; health; rape; incest or transactional sex.

In Zambia, girls <19 who had induced abortion did so to continue schooling and protect future aspirations. 29 These findings were echoed in Bangladesh, Brazil, South Africa and Guadeloupe. 19 , 22 , 30 , 31 A study of post-abortion care patients aged less than 19 in Malawi found that 87% were sexually assaulted by someone familiar to them, while another 3% had exchanged sex for money or clothes. 18 In South Africa and Zambia adolescents seeking abortion did so due to experiences of sexual violence (i.e. rape or incest); the South African cohort also reported fears of physical trauma due to childbirth as a reason for abortion. 30 , 31 Baba et al., in Japan, also showed that girls 10–14 were more likely to experience pregnancy due to rape or incest than older adolescents. 32 In Nigeria, adolescents who had undergone abortion were significantly more likely to have experienced transactional or forced sex. 33

Another salient reason for abortion among adolescents was fear of reprisal for getting pregnant outside of marriage or being too young to become a mother, often perpetuated by parents or members of the community. A study of unmarried pregnant adolescents in Uganda found that many girls who sought abortion felt they had to do it to “save face” for their parents; and in some contexts, such as in Mexico, girls reported that parents forced them to seek abortions. 28 , 34 Dahlback et al., in Zambia, and Ramakeula et al., in South Africa, confirmed that girls consider pregnancy shameful and stigmatising for themselves and their families, often leading them to undergo an unsafe abortion. 29 , 30 Poverty and fear for the girls’ maternal health were also important factors in abortion-seeking in a number of contexts including Nigeria and Bangladesh. 19 , 33

Timing of abortion and post-abortion care

Once the decision has been made to terminate a pregnancy, adolescents are more likely to delay the timing of abortion and post-abortion care. The studies with data on the timing of abortion showed that the majority of girls seek abortion in the second trimester and that they are more likely to delay abortion when compared to women in older cohorts.

In a study of girls less than 19 years old in India, 72% sought an abortion in the second trimester. 27 Similarly, in Guadeloupe, 55% of adolescents less than 18 years old reported seeking an abortion after nine weeks of amenorrhoea. 31 Three studies, in Japan, Ethiopia and Nigeria, showed that when compared to older groups of women, girls younger than 19 were more likely to delay abortion until the second trimester. In Nigeria, 45% of girls ages 10–18 sought a second-trimester abortion compared with 30% of women in older groups. 35 In Ethiopia, girls younger than 19 had more than double the odds of aborting in the second trimester, when compared to women aged 25 or older (OR = 2.64% CI: 1.23–5.68). 36 In a study of post-abortion care for patients ages 12–19 in Kenya, adolescents were more likely than older women to have undergone a second-trimester abortion. 37

Sources and methods of abortion

In the 10 studies that examined sources and methods of care among adolescents, the use of herbal or chemical concoctions or foreign objects inserted in the vagina was common, as was the use of traditional healers.

Ahmed et al., in Bangladesh, showed that 57% of abortion attempts among adolescents were performed by traditional healers (defined as persons in the community who provide treatment for abortion but have no formal training). 19 In Zambia, Dahlbeck et al. found that the majority of unsafe abortions (not defined by authors) among adolescents (76%) took place at home, with 47% performed by traditional healers. 29 In Cote d’Ivoire adolescents primarily self-prescribe medication (not medical abortion, but rather other over-the-counter medications) (70%) as the first attempt at termination, followed, in case of failure, by traditional healers (56.4%), then healthcare practitioners only at the third attempt (85.7%). 38 In Ethiopia, half of the adolescents reported attempting abortion at home while the other half terminated at a health centre. 39

Four studies in Brazil, Cote d’Ivoire, Ghana, and Zambia reported the unsafe methods used by adolescents for abortion: ingestion of herbs and roots or over-the-counter drugs like Chloroquine, Panadol and Cafernol; foreign objects such as Nescafe, ground glass, or herbs, sticks or leaves inserted into the vagina; and blunt force trauma to the stomach. These methods may have been in the context of a self-induced abortion or one presided over by a traditional healer. 16 , 29 , 38 , 40

In Nigeria, lack of access to adequate medical personnel, facilities and equipment were predictors of illegal abortion among girls ages 14–21. 41 High cost of safe abortion service fees and distrust in the health care providers were also cited as barriers to accessing safe abortion in Ghana. 42

Experiences with formal health care providers

Three studies showed that adolescents experience bias from health care providers and fear their reprisal, which may make them less likely to seek abortion at a formal health care facility. In Ghana, adolescents under the age of 20 (44%) were the least likely to obtain care from trained abortion providers when compared to women ages 20–29 (57%) or women 30 and older (65%). 40 When controlling for demographic and economic factors and the knowledge of abortion legality, adolescent girls still had a 77% lower odds of a safe abortion compared to women 30 and older. 5 In another study in Ghana, girls perceived providers as being hostile and did not trust providers or facilities to maintain their privacy or confidentiality. 40 In Malawi, girls undergoing abortion identified fear of abuse by health providers as one of the main sources of psychological distress during the abortion process. 43 In Mexico, adolescent girls who sought abortion care on their own (as opposed to with an accompanying adult) were refused abortion counselling and care. 44

Complications of unsafe abortion

Eleven studies in this review addressed the rate and types of complications among adolescent girls undergoing induced abortion, showing that while young adolescents comprise a disproportionate number of unsafe abortions, their risk of complications during abortion as compared to older women is inconclusive.

In Nigeria, adolescents ages 16–20 accounted for 29% of all unsafe abortions (the highest for any age group). 45 Two studies in Kenya and Malawi showed that adolescents were between 2 and 3.5 times more likely to experience mechanical injuries due to abortion than women in older groups (significant findings in each case). 26 , 46 In Cote d’Ivoire, complications among adolescents (11–19 years) were significantly associated with either self-induced abortions or abortions performed by traditional healers. 38 In Nigeria and South Africa, abortion was a leading cause of death among adolescents under the age of 19. 35 , 41 In Mexico, younger adolescents had a considerably lower rate of hospitalisation due to abortion when compared to older adolescents (0.3 vs 7.6 per 1,000 girls, respectively). 28

A South African study of comparative rates of death, or complications due to abortion, found that despite the high rates of abortion among adolescents, adolescents are not at an increased risk of death as compared to women in older groups. 47 An analysis of secondary data in Ethiopia also showed no increased risk of complications for 15–19-year-olds compared to older women. 23 However, Aung et. Al, in Thailand, found that when compared to older age groups, adolescents ages 10–19 had the highest burden of non-fatal morbidity due to complications from unsafe abortion. 21

Psycho-social outcomes of abortion

Five studies in this review touched on the psychosocial outcomes (i.e., depression, anxiety, low self-esteem, etc.) of the abortion process on adolescent girls. In Uganda, Zambia and South Africa, young girls who experienced abortion (specifically unmarried girls) describe facing rejection or denial of paternity by partners during pregnancy, being afraid of bringing shame to their families and fearing stigma from being pregnant out of wedlock. In some cases, particularly among younger adolescents, the pregnancy itself may be a result of rape or incest, which further complicates psychosocial outcomes for girls. 29 , 30 , 34 In Malawi, girls ages 14–19 reported a great deal of psychological distress prior to abortion due to fear of parents discovering the pregnancy, being forced to leave school, judgement for an out-of-wedlock pregnancy, and abuse from providers, all of which contributed to delay in care-seeking. After the abortion, girls reported feelings of guilt stemming from their religious beliefs and grief around the loss of the child (which they may have kept under better circumstances). 43 In Guadeloupe, 43.3% of girls reported psychological problems linked to abortion, mainly due to distress over the deterioration of their relationship with their parents. 31

This review highlights a number of important areas of abortion care that are specific to adolescents, and some differences between adolescents ages 10–14 and other age cohorts. Results show that girls aged 10–14 differ from older cohorts in that they are less accepting of abortion, they have a higher ratio of abortion (both safe and unsafe), and they are more likely to experience pregnancy leading to abortion as a result of rape or incest than older adolescents. Distinctions in younger versus older adolescent knowledge of abortion legality are not clear, as the two studies in Nigeria and Brazil gave conflicting results in the level of knowledge between the two cohorts.

Adolescents give a number of reasons for seeking an abortion, primary among them being their desire to continue their studies or to protect their future prospects from the burdens of early motherhood. This is particularly true among younger adolescents, many of whom are not married and are still attending school full time. Other common reasons include the shame and stigma of teen pregnancy/motherhood, poverty and pressure from their families. In the case of younger adolescents, the pregnancy is likely due to rape, incest or transactional sex, which further motivates a pregnancy termination. These reflect many of the same reasons that women around the world give for seeking an abortion; the main difference being that older women emphasise limiting childbearing as the main motivation for abortion. 48

When compared to older cohorts of women, adolescents consistently tend to delay an abortion into the second trimester, due to fear and shame around the pregnancy, limited knowledge of and access to safe abortion services, delayed recognition of pregnancy status, and fear of health providers. When adolescents do eventually attempt an abortion, the majority try to self-induce with ingested herbal/chemical concoctions or insertion of objects into the vagina, or by seeing traditional healers. Adolescents’ knowledge, resources and mobility to access health care are more limited compared to cohorts of older women; these reasons have been shown to limit general healthcare-seeking behaviour among adolescents, in particular around sexual and reproductive health needs (i.e. contraceptives, antenatal care, etc.), and exacerbate delays in seeking abortion care. 49–51

Adolescents cite strong provider bias and lack of privacy and confidentiality by formal health care workers as the main reasons why they do not seek care from formal health providers. 52 Studies of providers have shown that they can be judgmental, openly hostile or even deny care to adolescent girls seeking abortions. 53 , 54 Furthermore, providers, even those trained in youth-friendly services, may not be protecting girls’ privacy and confidentiality to the extent necessary. These barriers echo those commonly cited in the context of general adolescent sexual and reproductive health care and point to a pattern of bias against girls seeking any type of sexual health care. 55

Although adolescent girls comprise a disproportionate number of women seeking unsafe abortions, they do not necessarily suffer higher rates of complications or maternal mortality than older women. In some of the studies reviewed here, there was evidence of significantly higher rates of mechanical injury (i.e. cut or perforation) among adolescents than among older cohorts, but there were no significant differences in maternal mortality between these groups. However, complications stemming from unsafe abortion are one of the leading causes of death among adolescent girls in LMIC, which may be due to the fact that adolescents tend to delay abortion care until the second trimester. 1

There are several limitations to this review, which should be noted when using the results. First, out of the 208 prospective articles, we were only able to locate 131 full-text versions for review due to resource constraints. This may present bias in the findings due to the omission of 77 potential articles. Furthermore, this review examines findings from a variety of LMIC; however, adolescents in each context have unique personal, social or environmental characteristics that determine their abortion experience. While this review provides a global overview of abortion among adolescents, it is not generalisable to all settings.

There are several ways to improve the delivery of care and knowledge to adolescents, particularly 10–14-year-olds. This group is typically still enrolled in school, which provides a promising entry point for education on and access to safe abortion knowledge and services. Although the subject of abortion may be taboo in some contexts, comprehensive sexual education has been shown to have positive outcomes on youth sexual behaviour, including delaying sex and using contraceptives in some countries, both of which could reduce the risk of unsafe abortion. 56 As adolescents are subject to parental control, interventions aimed at very young adolescents must recognise the role of the parents in abortion decision-making and work to reduce barriers to communication within the child–parent dyad. 57

Pregnancy among 10–14-year-olds is likely due to rape, incest or coerced transactional sex. Implementers and providers must recognise the added trauma of sexual violence that a girl may face and ensure that they are not only receiving adequate and appropriate abortion care but that the underlying sexual violence is also addressed. Trauma-informed care and counselling must also adjust for the fact that for girls, the perpetrator may be her accompanying adult or immediate caregiver. 58 Furthermore, even though adolescents are not at greater risk of psychosocial maladjustment following abortion, the event may still be emotionally significant and require sensitive care. 59 Providers of abortion care may require more intensive training and patient-centred feedback is needed as part of the follow-up performance improvement loop to overcome biases against adolescent patients.

Conclusions

This review highlights several aspects of abortion programming and policy planning for adolescent girls. Many adolescents lack basic knowledge of puberty or sexual and reproductive health, which increases their chances of missing signs of pregnancy and delaying abortion until the second trimester. 5 Sexuality education that is comprehensive and that provides information on puberty and pregnancy, is essential.

Only a handful of the almost 800 studies screened for this paper either focused on or segmented data by adolescents ages 10–14. Researchers should include 10–14-year-olds as a focus of sexual health and abortion studies, examining the types of information and support needed by this group and the most effective ways in which to deliver services, given their unique constellation of issues.

Adolescent girls experience abortion differently than older women and have specific needs for and obstacles to seeking abortion care. By emphasising the unique experiences of these sub-groups of abortion patients, this review may enable programmers and practitioners to build more inclusive, thoughtful and responsive abortion care for the most vulnerable populations around the world.

† The authors are fluent in these three languages and included them in the search to maximise inclusion of articles from low- and middle-income countries.

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Worldwide, an Estimated 25 Million Unsafe Abortions Occur Each Year
Recommendations to reduce the impact of unsafe abortion
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Number of unsafe abortions worldwide each year
Unsafe abortion: an analytic approach of knowledge and attitudes of
Unsafe Abortion

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INTRODUCTION: Unsafe abortion is a public health problem globally, but disproportionately affects the developing world. Interventions aimed at addressing the determinants and risk factors of unsafe abortion have proven to be effective in the reduction of unsafe abortion-related maternal mortality. Identification of determinants of
Reducing the harms of unsafe abortion: a systematic review of the
Introduction. Globally, access to safe abortion is limited. As a result, an estimated 25 million unsafe abortion occur each year, and at least 22 800 women die from resulting complications, almost all in low- and middle-income countries. 1 This is often due to restrictive laws which prohibit abortion; but even in contexts where abortion is legal, other barriers, such as cost, distance and ...
PDF The impact of criminalisation on abortion- related outcomes: a
unsafe abortion or preventing abortion.1 6 7 Meanwhile, public health scholars generally associate decriminalisa-tion with reduced stigma, improved quality of care and ... studies, reports, PhD theses and economic or legal anal-yses that undertook original data collection or analysis. Following a preliminary assessment of the literature,19
Access to Abortion: The Intersection of 'Who You Are' and 'Where You Live'
Abstract. Access to reproductive health services, including abortion services, is essential to the health of women and families. While existing literature has documented the influence of demographic factors ('who you are') on access to abortion in the United States, exploration of the influence of place of residence ('where you live ...
‪Margarate N. Munakampe‬
Contraception and abortion knowledge, attitudes and practices among adolescents from low and middle-income countries: a systematic review. MN Munakampe, JM Zulu, C Michelo ... Magnitude and determinants of unsafe abortion among Zambian women presenting for abortion care services: A multilevel analysis.
Global Consequences of Unsafe Abortion
Incidence of mortality. An estimated 70,000 women died as a result of unsafe abortions in 2005, worldwide, according to the most recent published estimate [4]. More than half of deaths resulting from unsafe abor-tions occur in Sub-Saharan Africa (~38,000) and approximately a third in South Central Asia (~24,000).
PDF Chapter 3. Aim, objectives and design of PhD thesis
conceptualization of unsafe abortion and to improve its measurement taking into account technological changes in medical provision in low - and middle -income countries where the burden is greatest; and second, to generate new substantive knowledge on the burden of unsafe abortion in Zambia. The specific objectives of this PhD are: 1.
"Unsafe Abortion, Its Determinants and Associated Factors: The Case of
INTRODUCTION: Unsafe abortion is a public health problem globally, but disproportionately affects the developing world. Interventions aimed at addressing the determinants and risk factors of unsafe abortion have proven to be effective in the reduction of unsafe abortion-related maternal mortality. Identification of determinants of unsafe abortion is important in intervention planning and ...
PDF Chapter 1. Introduction
13. Chapter 1. Introduction. Unsafe abortion is most easily preventable cause of maternal mortality the a and leading cause of disability amongst women of reproductive age (1) . Recently published studies estimate that unsafe abortions may account for between 8% (2) and 15% (3) of maternal deaths. An abortion performed under safe and sterile ...
PDF Unsafe Abortion and Unsupervised Births Understanding the ...
maternal health outcomes. This thesis comprises of three studies, divided into two themes: (1) unsafe abortion; and (2) community perceptions and experiences of pregnancy and childbirth. METHODS Theme One: Unsafe abortion Through a mixed methods approach, a six month prospective study was undertaken at the Eastern Highlands Provincial Hospital.
Determinants and effects of abortion accessibility in the United States
For these two exposure scenarios, compared to the current abortion provision scenario, increases in the proportion of women within a 30-, 60-, and 90-minute drive time of an abortion-providing facility ranged from 1.25 percentage points, or an additional 781,556 US women aged 15-44 years with accessibility, to 5.66 percentage points, or an ...
State Abortion Policies and Maternal Death in the United States, 2015
Objectives. To examine associations between state-level variation in abortion-restricting policies in 2015 and total maternal mortality (TMM), maternal mortality (MM), and late maternal mortality (LMM) from 2015 to 2018 in the United States. Methods. We derived an abortion policy composite index for each state based on 8 state-level abortion-restricting policies. We fit ecological state-level ...
Women's Perceived Barriers to Accessing Post-Abortion Care Services in
Introduction. The WHO defines abortion as the termination of a pregnancy, whether spontaneous or induced, before 22 weeks of gestation [].Unsafe abortion is defined as any procedure to terminate a pregnancy by persons lacking the proper skills and/or is performed in an unclean, non-medical setting [].Complications of spontaneous or induced abortion are the fourth leading direct cause of ...
A research on abortion: ethics, legislation and socio-medical outcomes
An unplanned pregnancy, socio-economic context or various medical problems [], lead many times to the decision of interrupting pregnancy, regardless the legislative restrictions.In the study "Unsafe abortion: global and regional estimates of the incidence of unsafe abortion and associated mortality in 2008" issued in 2011 by the WHO, it was determined that within the states with ...
Unsafe abortion: the preventable pandemic
Ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative. As with other more visible global-health issues, this scourge threatens women throughout the developing world. Every year, about 19-20 million abortions are done by individuals without the requisite skills, or in environments below minimum medical standards, or both. Nearly all unsafe ...
Post abortion care in Uganda : improving access and quality of care
Unsafe abortions in Uganda continue to cause significant harm to women's health and lives and pose a heavy burden on the health system. ... The aim of this thesis is to identify means to improve access and quality of post abortion care in low-resource settings through task sharing and by exploring the perspectives of young women and ...
PDF safe abortion care and post-abortion contraception
poor, adolescent or unmarried women - at risk of unsafe abortion. Although in many contexts abortion-related care provision is limited to specialist doctors, many of the evidence-based interventions for safe abortion and post-abortion care, particularly those in early pregnancy, can be provided on an outpatient basis at the primary care level.
Induced abortion among female students in higher education ...
Introduction. Induced abortion is one of the leading causes of maternal morbidity and mortality [].Globally, three out of ten pregnancies, and six out of ten unintended pregnancies, ended in an induced abortion [].About 45% of all abortions are unsafe, of which 97% occur in developing countries [].An estimated 33 abortions occur each year per 1,000 women aged 15-49 in Sub-Saharan Africa, of ...
Knowledge, attitude and factors associated with induced abortion among
Around 73 million induced abortions take place worldwide each year. Six out of 10 (61%) of all unintended pregnancies, and 3 out of 10 (29%) of all pregnancies, end in induced abortion. In Africa, nearly half of all abortions occur under the least safe circumstances. In Ethiopia 35% of women obtaining induced abortions service. Therefore, thisstudy aims to assess knowledge, attitude, and ...
Magnitude and risk factors of abortion among regular female students in
Background Induced abortion is one of the greatest human rights dilemmas of our time. Yet, abortion is a very common experience in every culture and society. According to the World Health Organization, Ethiopia had the fifth largest number of maternal deaths in 2005 and unsafe abortion was estimated to account for 32% of all maternal deaths in Ethiopia. Youth are disproportionately affected by ...
Thesis Abstracts
Thesis submitted for the degree of Master of Laws, Graduate Department of the Faculty of Law, University of Toronto, 2009. This thesis seeks to adapt Scott Burris, Ichiro Kawachi and Austin Sarat's theory of law as a social determinant of ill-health to the context of unsafe abortion in Argentina.
Abortion knowledge, attitudes and experiences among adolescent girls: a
Abortion was the leading cause of death for 10-19-year-olds (37%) due to unsafe abortion, eclampsia and sepsis. Risk factors for adolescent maternal mortality found in our study were illiteracy, non-utilisation of antenatal services and Hausa/Fulani ethnic group. Ushie, B. A., et al: 2018
PDF Rajiv Gandhi University of Health Sciences
abortion. Complication of unsafe abortion causes 50,000 to 100,000 deaths in the world each year. 10 Men can accompany their partners to meet family planning counselors or health workers. They can help their partners in using modern methods correctly - such as reminding them to take their pills regularly and daily. They can use a male method

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Magnitude and risk factors of abortion among regular female students in Wolaita Sodo University, Ethiopia

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Study population and sample

Data collection and analysis

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Abortion and associated factors

Sexual experience, condom use and emergency contraception

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Barriers to safe abortion service utilization

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University of Toronto Faculty of Law

Abortion knowledge, attitudes and experiences among adolescent girls: a review of the literature

Ghazaleh Samandari

Kathryn Andersen

Résumé

Data sources

Search strategy

Selection criteria

Screening and selection

Data abstraction and analysis

Abortion knowledge and attitudes

Comparative abortion rates/ratios among adolescents vs older groups

Reasons for abortion

Timing of abortion and post-abortion care

Sources and methods of abortion

Experiences with formal health care providers

Complications of unsafe abortion