Is Abortion Incidence Rising In Nigeria?

Abstract

Unsafe abortion remains a major public health problem in Nigeria.  Although the national law is largely restrictive of abortion, the practice continues with dire consequences for women’s reproductive health.  Abortion is probably the fourth leading cause of maternal mortality in Nigeria and accounts for significant proportions of maternal morbidity and long term reproductive ill-health. Over the past 20 years, huge efforts have been made by several local and international organizations to reduce the incidence of unsafe abortion and its complications in Nigeria. Ipas has led these efforts through its campaign on skills building for service providers as well as the education of at-risk women to adopt safe sex practices, including the use of contraceptives. However, recent reports suggest that these efforts may not be leading to the optimal goal of reducing the overall incidence of unsafe abortion in the country. 

Two studies of the incidence of abortion in Nigeria were reported in the late 1990s.  The first, based on interviews with health providers in 672 health facilities across the country, reported an abortion incidence of 610,000 abortions (nearly 25 abortions per 1000 women of reproductive age) ¹. The second paper published a year later² was based on a household survey of women of reproductive age in four out of the six geopolitical zones of the country. Participants in the study were interviewed with the indirect interviewing technique rather than by direct technique. The results showed an abortion incidence of nearly one million abortion cases among the women studied. In 2006, another study based on interviews with health professionals reported an abortion incidence of 760,000 cases in the preceding year³, indicating an increase over the 1998 study that used a similar study design.    Evidence of a rising pattern in abortion incidence in the country became manifest in a recent facility-based study that again interviewed health professionals. The study published in December 2015⁴ conducted interviews with 194 health professionals in 772 health facilities, and reported an abortion incidence of 1.25 million abortions in 2012 (33 abortions per 1000 women of reproductive age).

Thus, if interviews with health professionals alone are taken into account, it would suggest that there is a rising incidence of abortion in Nigeria. However, interviews with health professionals working in health facilities is not sufficient as these can only document abortion cases seen in hospitals.  They rarely provide insights into abortions that take place outside the hospital.  Due to the restrictive abortion law in the country, induced abortions only come to the knowledge of health professionals when they are associated with complications. Many abortions that end up safely without complications (and they are many) are often not known to health professionals. This suggests that there are inherent flaws in basing abortion incidence on interviews with health professionals. Only the self-reporting of abortion by a representative sample of women is likely to truly and accurately estimate the incidence of abortion in an unbiased manner. However, getting accurate information from women in contexts were abortion is legally restrictive can be extremely daunting, but there are ways to overcome the difficulties.

Our study of a sample of women attending antenatal clinic in a teaching hospital in Nigeria where we requested information on their previous use of abortion indicated that up to 70% of the women have had induced abortions⁵. This was based on the hypothesis that women seeking health care services would be more willing to give accurate information on their previous use of abortion. Although women interviewed in the context of antenatal care in hospitals is still not representative of all women, the results of this study suggest that the recent report of abortion incidence in Nigeria based on reports by health providers⁴ may have been mired by substantial under-reporting. If women in the same locality were to be interviewed confidentially and accurately, the true incidence of abortion would be more evident.

Thus, the first challenge that needs to be overcome is to determine the true incidence of abortion in Nigeria.  Self-induced abortions by women using abortion pills have become widespread throughout the world.  Mifepristone and misoprostol, the two main abortion pills are widely available in Nigeria and have been reported to be highly effective in Nigerian women⁶. However, the extent to which women use abortion pills to self-induce abortions has not yet been investigated in Nigeria. We believe this would be sizeable in view of the increasing number of women who present in hospitals having taken pills to induce abortion. Therefore, only by interviewing a representative sample of women using confidential and accurate interviewing techniques will the correct estimate of abortion incidence be known.  Any study of abortion incidence must aim to attain both internal validity and external validity so that the results would be reproducible over time and therefore allow accurate measurement of trends in abortion incidence.

Despite the difficulty in measuring abortion incidence, we believe that the recent report which suggests a rising incidence in induced abortion in Nigeria calls for sober reflection. Despite years of huge investments by international donor agencies in promoting family planning, Nigeria still has one of the lowest contraceptive prevalence rates (less than 10%) and highest unmet need for contraception (>20%) in Africa. It is now evident that resistance to contraception in the country is based on cultural and religious preachments that favour high fertility and the erroneous perceptions by women that contraception is associated with serious long term side effects. Efforts to increase contraceptive prevalence rate and reduce abortion incidence must therefore address these issues, and would have to be driven internally from within the country, if rapid results are to be attained. The predominance of donor-driven family planning promotional efforts not attended by country ownership has tended to lead to non-sustainable interventional results.  Fortunately, one of the lead authors of the recent paper which showed increased incidence of abortion is currently Nigeria’s Minister of Health. We believe this creates a unique opportunity for the country to do things differently and to develop an agenda for change to lead the implementation of evidence-based interventions for promoting family planning and reducing abortion incidence in the country. This period also corresponds with the timing of the implementation of the Sustainable Development Goals, especially Goal 3 which provides for the attainment of optimal health for all persons. So, the moment to reverse the consequences associated with abortion in Nigeria has come and must be handled with every sense of urgency and responsibility.