MEKELLE UNIVERSITY COLLEGE OF HEALTH SCIENCES DEPARTMENT OF

MEKELLE UNIVERSITY COLLEGE OF HEALTH SCIENCES DEPARTMENT OF MIDWIFERY INDUCED SECOND TRIMESTER ABORTION AND ASSOCIATED FACTORS IN AMHARA REGION REFERRAL HOSPITALS, NORTH WEST ETHIOPIA Investigators : 1. Amlaku Mulat (MSc, PI) 2. Hinsermu Bayu (MSc, COI) 3. Habtamu Melle(MPH, COI) 4. Amare Alemu (MSc, COI) February , 2017 Harari , Ethiopia 1

Presentation Outline FIntroduction FJustification FObjective FMethods FResults and discussion FConclusion FRecommendations FAcknowledgment 2

Introduction ÜGlobally over 42 million abortions performed annually, 10 -15% take place in the 2 nd Tm period and more than half of considered unsafe [10]. ÜIn sub-Saharan Africa from overall unsafe abortion complications, 2/3 of them are attributable to the second trimester period [11]. ÜSecond trimester abortion usually carries a higher risk of morbidity and mortality as compared to first trimester abortion specially in developing countries where access to safe second trimester abortion service is limited [10]. 3

Introduction ÜOffering safe second Tm abortion service is crucial and appropriate strategy for preventing and managing unsafe abortions, there by reduces suffering and deaths from abortion complications ÜHowever, in Ethiopia access to second trimester abortions is limited. Only 9– 10% of all facilities have a provider who can perform this service [12] 4

Justification/Rationale äWhy do we focus on second trimester abortion? • Firstly, it happens lately • Responsible for 2/3 of major complications & disproportionately contribute to maternal deaths • Most importantly young women are vulnerable • Too few clinicians are willing to provide 2 nd Tm abortion • Too few studies regarding second trimester abortion • More over, improvement in women health is unlikely to be achieved without addressing unsafe abortion and associated morbidities and mortalities. 5

Objective General Objective ØTo assess the prevalence and associated factors of induced second trimester abortion in Amhara region referral hospitals, North West Ethiopia, 2013/14 Specific Objectives 1. To determine the prevalence of induced second trimester abortion 2. To identify associated factors of induced second trimester abortion 6

Methods üStudy design • Institution based cross-sectional study üStudy period • From July 5, 2013, to January 5, 2014 (for 6 months) üStudy area • Conducted in Amhara region referral hospitals • Population 17. 2 million • 5 referral hospitals namely Felege Hiwot, Dese, Debre Markos, Debre Birhan and Gondar university hospital üSource population • women who came for abortion service in Amhara region referral hospitals 7

Methods… üStudy population • All women who came for abortion service in Amhara region referral hospitals during the study period üInclusion criteria • Both spontaneous and induced abortion cases üExclusion criteria • GTD (partial mole) üSample size; usingle population proportion formula, A 95 % CI, p=50%, w=5 % & 10% NRR, final sample size=422 üSystematic sampling technique was used to select study participants 8

Methods… 9

Methods… ü Variables of the study # Dependent variable • Induced second trimester abortion 10 #Independent variables • Socio demographic factors • Reproductive characteristics • Logistical factors • Medical factors

Methods… üData collection procedures • Structured interview administer questionnaire was used to collect the data • Developed in English and translated into Amharic then back to English by different person. • Data were collected by 5 Bsc midwifes and 2 supervisors üData quality assurance • Pretested tool • Data collectors & supervisors were trained • Supervisory activities • Used soft wares for entry and analysis 11

Methods… üData processing and analysis • Checked visually for completeness • Data entry using Epi-info version 3. 5. 1 • Data analysis using SPSS version 20 • Bivariate logistic regression was carried out to look for the crude association b/n independent variables and outcome variables • Finally Multiple logistic regression was applied and level of significance declared with 95 CI, Pvalue<0. 05 by adjusting OR to control confounders. 12

Operational definition ⦊ Induced second trimester abortion- an intentional termination of pregnancy between 13 and 28 weeks of gestation starting from the last missed period (Reproductive updates) ⦊ Logistical problems- refers women who face lack of money, transportation problem, have no idea where abortion service given and referral delay 13

Ethical consideration • Ethical clearance was obtained from Ethical Review Board (ERB) of University of Gondar • letter of cooperation was also obtained from Amhara regional health bureau • Informed consent obtained from the participants • Information was kept confidential (through removing identifiers and locking) and their privacy was maintained during the interview by interviewing them 14 alone.

Results & discussion î 416/422 women were completed the interview. RR 98. 6%. î 80(19. 2%) had induced 2 nd Tm abortion [76(18. 2%) b/n 13 -20 wks and 4(1%) 20 -28 wks] 15

Results &discussion…. . îPrevalence of induced 2 nd trimester abortion was 19. 2%. • in line with south Africa 20% [26] • but greater than study done in Nigeria 10% [8] , & England Wales 8. 6% [6] # The difference might be due to; • Many women presenting to the government hospitals • Private Clinics are not equipped to provide abortion care >12 wks except in rare occasions like private hospitals staffed by specialists (obstetrician/gynecologist) • Moreover, different delaying factors may affect the women not to seek early abortion care in the first trimester period (logistics related problems ) • Fetal malformations 16

Result & discussion… ⦊ More than one-third of all women with abortion complications passed first trimester period and seeking care during second trimester was more common among women who lived in the countryside as compared to urban residence in Ethiopia [12]. ü Likewise this study also revealed that being from rural residence is 1. 86 times more likely to have abortion during second trimester period as compared to urban women (AOR = 1. 86 [95% CI = 1. 11– 3. 14]). • Possibly women from the rural residence may not have information about where the appropriate service is given and usually they are far from the institution. 17

Results &discussion… üWomen who have faced problems related to logistics were 2. 37 times more likely to had abortion in the latter half of second trimester period than their counter parts (AOR=2. 37, 95%CI : 1. 02, 5. 53). # This might be due to; • women took time while just finding money • have no information where the abortion service is given. • inappropriate referral or problem related to transportation 18

Results &discussion…. . üWomen who did not recognize their pregnancy early were two times more likely missed the opportunity to have abortion in the first trimester period than their counter parts (AOR=2. 05, 95% CI: 1. 21, 3. 48). • Consistent with study done in New Delhi # The possible explanation might be; • Irregular nature of women’s menses results unsure of the missing period, thereby unable to identify early symptoms of pregnancy • Time is needed for arrangements to have pregnancy test. 19

Results &discussion… üThose women who had irregular menstrual cycle were 2. 32 times more likely present for termination of pregnancy in the second trimester period compared to regular menstrual cycle (AOR=2. 32, 95% CI : 1. 46, 3. 70). • When the woman’s menstrual cycle becomes irregular it resulted uncertainty about the missing period and make the women more confused to pick up early symptoms of the pregnancy. 20

Conclusion îThe prevalence of induced second trimester abortion is found to be high despite the availability of safe first trimester abortion services. îTherefore, • being from rural, • women who had faced problems related to logistics, • Having irregular nature of menses, & • Unable to recognize their pregnancy early were the most common delaying factors that hinders the women from getting early abortion services 21

Recommendation îSafe second trimester abortion service should further be expanded and strengthen îCounseling for mothers to recognize their pregnancy early and help them to make decisions either to continue or discontinue the pregnancy as early as possible. îProvide logistical supports for mothers who want have an abortion service îRefer advanced GA as early as possible to the nearby eligible hospitals and make sure the women obtain the right information where to get the right services îFurther study is needed on delaying factors using qualitative method such as emotional factors (ambivalent situation) 22

Thank you!. . . ������� ! FUniversity of Gondar for Funding FStudy participants, data supervisors FEPHA conference organizers 23 collectors &