abortion and young people in nigeria: realities and ...€¦ · 85.0 (176) 15.0 (31) average number...

Abortion and Young People in

Nigeria: Realities and Research

Needs

1st National Conference on Adolescent Health

Society in Nigeria

April 11th - 13th, 2019

Previous Research on Induced

Abortion in Nigeria

• 41.3 million women of

reproductive age1

• 64% of women of

reproductive age live in rural

areas2

• More than half of girls do not

attend secondary school3

Nigeria Context

Sources: 1. United Nations, Department of Economic and Social Affairs, Population Division (2017) World Population Prospects. 2. 2017 Multiple Indicator Cluster Survey 2016-17 3. Nigeria DHS 2013

Nigeria Context, cont’d.

• On average, the # of children

Nigeria women have remained

unchanged in the last 16 years:

TFR = 5.7 in 20031, 5.5 in 20162

• Modern contraceptive use is very

low among women (15%)3 and has

increased slightly since 20031

• About 1 in 5 women of have an

unmet need for family planning and

3 in 10 births is mistimed or

unwanted3

Sources: 1. Nigeria DHS 2003 2. United Nations, Department of Economic and Social Affairs, Population Division (2017) World Population Prospects. 3. PMA 2017

NIGERIA CONTEXT, cont.

• MMR has reduced recently but

still ranks among the highest in

the world

• 576 deaths/100,000 live

births (2013)

• Unsafe abortion complications

are a major contributor to

maternal morbidity and

mortality

Nigeria Context, cont’d.

Source: DHS 2013

Despite legal restrictions, abortion is

common in Nigeria

• Induced abortion is legally restricted in Nigeria except when performed

to save a woman’s life

• Yet pregnancy terminations are quite common, and previous studies

have shown that many are unsafe (e.g., performed clandestinely or by

unskilled providers)

• 2012 estimates suggest that 1.25 million induced abortions occurred

Nigeria1, whilst 2017 estimates suggests that an about 1.8 to 2.7 million

abortions occurred annually2

Sources: 1. Bankole A et al., The incidence of abortion in Nigeria, International Perspectives on Sexual and Reproductive Health, 2015, 41(4):170–181. 2. PMA2020 Abortion Survey Results: Nigeria, April – May 2018

Abortion rates vary widely by region

Number of abortions per 1,000 women 15-49, 2012

26.5 27.1 30.6 31.0

40.5 44.3

32.8

-

10.0

20.0

30.0

40.0

50.0

South West

North Central

North West

South East

North East

South South

Nigeria

Source: Bankole A et al., The incidence of abortion in Nigeria, International Perspectives on Sexual and Reproductive Health, 2015, 41(4):170–181.

Characteristics of women and their

pathways leading to abortion:

• Prior research shows that women substantially underreport their

experience with abortion because it is a stigmatized behavior

• 66% of abortions were unsafe, and 11% of women got medical

treatment for abortion-related complications

• Women living in rural areas, women with no education, and

women who are poor were most likely to have unsafe abortions

• Most lower level public facilities and private facilities did not

provide safe abortion services or postabortion care

Source: PMA2020 Abortion Survey Results: Nigeria, April – May 2018

Characteristics of women and their

pathways leading to abortion

36.5

6.5

23.1

10.3

23.7

0

10

20

30

40

50

60

70

80

90

100

Abortion method

Perc

en

tage

% of abortions done using each method

Surgery Misoprostol / Mifepristone Other pills / pill type unknown Injection Traditional / other methods

Source: PMA2020 Abortion Survey Results: Nigeria, April – May 2018

Women’s experiences with Misoprostol

use in Lagos, Nigeria

© Guttmacher Institute 2019 11 20/03/19

What is misoprostol?

• Misoprostol is a drug approved and registered in

Nigeria for the treatment of gastric ulcers, postpartum

hemorrhage and incomplete and spontaneous

abortion (miscarriage)

• Prescription is legally required

• In contexts with restrictive laws, women often use

misoprostol, typically obtained from pharmacies,

patent medicine vendors and street sellers, to induce

abortions


What were the study objectives?

To describe women’s access to and experience

using misoprostol acquired from drug sellers

To assess drug sellers’ knowledge, attitudes and

practices regarding the provision of misoprostol


Where was the study done?

Study Components

Drug Sellers Component

Mystery Client Component

Women’s survey Component


Study Population

Drug sellers/providers of medical abortion

Women aged 18-49 who utilize medical

abortion obtained from drug sellers to terminate

a pregnancy

Sampling of drug stores

Drug sellers

mapping

We listed all drugs

stores (pharmacies

and patent medicine

vendors) in 6 local

government areas

in Lagos (universe)

and sent (Mystery

clients\ MCs to

them

(N=905)

Drug sellers

survey

Drug stores that

agreed to recruit

women were invited

to participate in a

cross sectional KAP

survey. We included

those where a

respondent

consented

(N=207)

Screener and

invitation to

participate in

women’s study

We conducted a

short survey with

all drug sellers

identified. We then

invited all those

who reported

selling misoprostol

to recruit women

into the study

(N=324)

Mystery Client Profile

Mystery client profile • 18-24 year old woman

• Unmarried

• Childless

• In a state university or

polytechnic

• Approximately 4 weeks

pregnant

Mystery client script Request something for late

menses

Medication spending

limit

800 Nigerian Naira

(USD 2.50)

Prospective women’s study recruitment-

Nigeria

231 (71% of all invited) Agreed

Eligible* women had 3 phone

interviews over 1 month

1-2 days after purchase

5-7 days after first interview

3 weeks after second interview

Six

mo

nth

s

148 (67% of those who agreed)

were successful

324 drug sellers reporting selling

misoprostol during mapping were

invited to recruit women

*Inclusion criteria

Women aged 18-49 who purchased

misoprostol to terminate a pregnancy

Collected

Gave women

Recruitment and retention of women

501 women recruited by drug sellers into the study

1st interview (1-2 days after purchase)

485 women agreed to interview

Number verified as eligible after 1st interview*

446 women

Number completing 2nd interview

(5-7 days after purchase)

423 women

Number completing 3rd interview

(3 weeks to 1 month after purchase)

394 women


Results


Drug Seller Study Results


Characteristics of Drug Store and Respondent

(n=207)

% (n)

Location

Urban

Periurban

85.0 (176)

15.0 (31)

Average number of employees 3.2 (range 1 to 11)

Average number of employees that can prescribe drugs 2.2 (range 1 to 7)

Average age of respondent 34.7 years (Range 19 to 66

years)

Sex of respondent

Male

Female

60.4 (125)

39.6 (82)

Highest level of education of respondent

Some junior secondary school

Some senior secondary school

Completed secondary school

Higher education

1.5 (3)

5.3 (11)

33.8 (70)

59.4 (123)

Modal length of employment of respondent Over a year to five years (46%)

Proportion of staff in store with health-related qualifications

46.4 (96)


Medical Abortion Knowledge

(n=207)

% (n)

Proportion mentioning the following options as questions to ask

before prescribing MA

Gestational age

Last Menstrual Period (LMP)

Pregnancy test taken

Current use of IUD

Prescription

Woman’s age

Number of children

Marital status

Religion

Seller doesn’t need to ask anything

Refused to answer

47.3 (98)

57.0 (118)

56.0 (116)

5.3 (11)

28.0 (58)

14.0 (29)

4.4 (9)

13.0 (27)

0.5 (1)

5.3 (11)

4.8 (10)

Correctly answered the question how to calculate gestational age 67.6 (140)

Up to how many weeks can you give women MA

Don’t know

Refused to answer

<=9 weeks

10-12 weeks

>12 weeks

22.7 (47)

6.8 (14)

44.4 (92)

19.8 (41)

6.3 (13)


Medical Abortion Prescription Practices

% (n)

Is information provided on how to use medications provided for

pregnancy termination*

No I don’t provide information at all

Yes I provide information to all clients

Yes I provide information to some clients

Missing

25.9 (36)

51.8 (72)

21.6 (30)

0.7 (1)

Source of information provided (yes to options below)

Clinical knowledge

Store practices

Information from pharmaceutical formulary

Internet

Drug inserts

Training charts at the pharmacy

Other

69.9 (72)

8.7 (9)

5.8 (6)

15.5 (16)

35.9 (37)

10.7 (11)

17.5 (18)

Those who inform clients about potential complications 79.6 (82)

Those who tell clients how to confirm she is no longer pregnant 76.6 (79)

Those who have (or know colleagues that have) refused women

medicines to terminate pregnancies 76.9 (107)


Mystery Client Study Results


Drug seller characteristics and medications

offered to MCs

(n=898)

% (n)

Drug Seller Characteristics

Male

Female

45.1 (405)

54.9 (493)

Percentage of MCs offered a medication 39.9 (358)

Abortifacient

Misoprostol containing medication

Mifepristone alone

Methotrexate

64.0 (229)

62.6 (224)

- (4)

- (1)

Non-abortifacient 12.6 (45)

Other 40.8 (146)

Percentage of MCs only offered information about medications 6.8 (61)

Percentage of MCs only referred elsewhere 53.3 (479)

Range of abortifacient regimen costs (USD) 0.28 - 41.67


Prospective Women’s Study Results


Demographic characteristics of women that

completed all three interviews (1)

Demographic characteristics N=394 % (n)

Median age 28 years (range 18-48)

Parity 1.6

Highest level of education

No schooling or incomplete primary

Primary/Junior secondary school

Senior secondary school

Some higher education

Completed higher education

Postgraduate studies

0.8 (3)

7.4 (29)

54.1 (213)

21.3 (84)

15.7 (62)

0.8 (3)

Employment

Work outside the home

Work in a family business or subsistence farming

Housewife

Student

Unemployed

51.5 (203)

24.1 (95)

3.8 (15)

13.2 (52)

7.4 (29)


Demographic characteristics of women that

completed all three interviews (2)

Demographic characteristics N=394

% (n)

Relationship status

Currently married

Living with a man (not married)

Separated/divorced

Widowed

Never married or in union

46.2 (182)

3.8 (15)

4.3 (17)

0.8 (3)

44.9 (177)

Previous attempt to end a

pregnancy

Yes

No

15.5 (61)

84.5 (333)

Who purchased the medicine

Medicines bought by the woman

Medicines bought by someone else

95.2 (375)

4.8 (19)


Percentage of women whose eligibility for

MA was assessed by drug sellers

All women

(n=394)

% (n)

MCs offered a medicine

in Nigeria (n=358)

% (n)

If she had taken a

pregnancy test 79.4 (313) 47.8 (171)

When was her last

menstrual period 74.1 (292) 48.3 (173)

If she had a prescription 31.5 (124) 9.2 (33)


Information on complications and side effects

comparing Mystery Clients and women

Women in prospective

study who were told

(N=394)

% (n)

MC’s offered medicine

who were told (N=358)

% (n)

Bleeding 66.5 (262) 42.7 (153)

Cramping/abdominal pain 35.3 (139) 26.5 (95)

Fever or chills 4.1 (16) 5.6 (20)

Percentage told to seek

medical care if they

experienced symptoms

suggesting a complication

24.6 (97) 8.1 (29)


Information on side effects and complications

given to women

N=394 Women who

were told

% (n)

Women who

reported

experiencing these

side effects

% (n)

Women who

experienced

potentially severe

side effects

suggestive of

complications

% (n)

Bleeding 66.5 (262) 84.5 (333) 19.5 (77)

Cramping/abdominal

pain 35.3 (139) 70.6 (278) - (8)

Fever or chills 4.1 (16) 8.4 (33) - (5)

Foul smelling or

colored vaginal

discharge

-- - (2) - (2)


How women evaluated termination of the

pregnancy

95% (376/394) of women reported complete termination of their

pregnancies at the third interview.

How the woman assessed complete termination % (n)

Took a blood pregnancy test 16.0 (60)

Took a urine pregnancy test at home 33.2 (125)

Took a urine pregnancy test at a facility 5.1 (19)

Had an ultrasound/sonogram 4.0 (15)

Felt she no longer had pregnancy symptoms 24.7 (93)

Her period returned 53.7 (202)

She expelled products of conception 13.3 (50)

She got “cleaned” at a facility 1.9 (7)

Other 0.8 (3)


Summary of key Drug Seller findings

Self reported quality of care and information around

provision of the misoprostol was poor.

Overall the actual practices of drug sellers

observed from the women’s and mystery client’s

perspectives were worse than drug seller’s self-

reported practice in the survey.


Summary of key Mystery Client findings

MCs found medications to terminate pregnancies

relatively easy to access from drug sellers in

Nigeria despite its restrictive laws.

Misoprostol was most common medication drug

sellers offered MCs in Nigeria.

Quality of care and information around provision of

the misoprostol was poor.


Summary of key Women’s findings

95% of women reported complete pregnancy

terminations after a month.

Although using self report (with well documented

limitations), about 77 (20%) women reported potentially

serious bleeding and 15 (4%) women reported signs

associated with serious infection.

– Only 7 (9%) of those reporting such symptoms sought

care for bleeding whilst 4 (27%) women sought care for

the infection.


In summary….

Although the law is restrictive and the society appears conservative

induced abortions commonly happen in Nigeria; a substantial number

of women still obtain their abortions unsafely and likely suffer health

complications as a result

However in larger cities where misoprostol is available, women may

be able to access medical abortion which is much safer than

procedures like D&C’s or visiting traditional healers

However the quality of care provided by drug sellers when women

purchase misoprostol is less than optimal

Findings have implications for adolescent health in Nigeria: to inform

policy & programme actions as well as stimulate new efforts in the

research domain & especially among new generation of researchers


Discussion!

abortion and young people in nigeria: realities and ...€¦ · 85.0 (176) 15.0 (31) average number...

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