January, ; Vol2; Issue1

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1 January, ; Vol2; Issue Acceptance of Medical Abortion Method and Associated Factors Among Women Attending Public and n-governmental Organization Clinics in Dire Dawa City Administrative Council Bisrat Gebreegziabehare and Yemane Berhane University of gondar and addiscontinental institute of public health Corresponding Author: Bisrat Gebreegziabehare ABSTRACT Unsafe abortion is estimated to account 3% of maternal mortality globally and % in Ethiopia also was reported to be among the major causes of maternal mortality. Medical abortion method is said to be safe, effective, and acceptable for termination of early pregnancy to women in several countries. This study was aimed to assess women s acceptance of Medical abortion method and associated factors in public and NGO clinic in Dire Dawa city. Method: A facility based cross sectional study. The study population was 422 women aged 5 to 49 years who were attending the health facilities to get MCH services. Simple random sampling procedure was applied to select the health facilities and data was collected by nurses using a structured interviewer questionnaire that was developed according to the study variables. Data was analyzed using Epi info and SPSS 7.0 statistical software. Result: 82.2% of Medical abortion user and 60.9% of non user are willing to accept Medical Abortion methods as a safe abortion method. Ever used contraceptive (OR= % CI (.9, 8.69) and previous experience of induced abortion (OR=3.8 95% CI (.33, 7.57) were highly associated with the acceptance of medical abortion method. Conclusion: There is high positive attitude towards medical abortion method. The positive outcome and high willingness levels to accept the method among the participants, illustrate the importance of an ongoing and improved accessibility of medical abortion for women in Dire Dawa. It is important to improve public awareness to expand opportunities for new users. Keywords: Medical abortion, Acceptance, Public, Clinic. INTRODUCTION Medical abortion was introduced in France in 989 and, for more than twenty years, safe, effective, and acceptable regimens of mifepristone followed by misoprostol. In early pregnancy, medical abortion produces a complete abortion in 96% of women (). In 2005, an estimated 26 million women worldwide used this drug combination to terminate their pregnancies (2). Medical abortion uses medications in place of traditional surgical interventions to induce abortion (3). It is comparable to spontaneous abortion since it is a safe procedure, with less risk of mortality rates for mifepristonemisoprostol combination regimens (4). Medicine. 208;2().

2 Vol;2();207 Statement of the problem It is estimated that nearly 70,000 women die annually from complications of unsafe abortion around the world. Over 69,000 of these deaths occur in developing countries while 23,000 occur in sub- Saharan African countries alone (5). In Ethiopia about 32% of all maternal deaths are the result of complications related to unsafe abortion. Abortion is the second leading cause of death for women, after tuberculosis (6). EDHS of 20 reported that 42% pregnancies among women in reproductive age were unintended. As a result, significant proportion of married women turned to induced abortion to avoid unintended pregnancy (7). A nationwide estimation in 2008, reported the annual abortion rate was 23 per,000 women aged 5 44, and the abortion ratio was 3 abortions per 00 live births. The abortion rate is higher in urban area of the country: in Addis Ababa (49 per,000 women) and 84 per,000 in the smaller urban regions of Dire Dawa and Harari. Overall, about 42% of pregnancies were unintended, and the unintended pregnancy rate was 0 per,000 women (8). Furthermore, study conducted by Goodman et al on implementation of Comprehensive Abortion Care in Ethiopia stated that abortion is resulted from the deep rooted poverty, gender inequalities and lack of commitment of responsible actors to ensuring women rights to safe abortion (9). However, scientific studies show that medical abortion methods in early pregnancy are safe and effective with less risk of death associated and virtually identical to that with spontaneous miscarriage (0).Therefore, increasing access to MA services is the most effective way of preventing the burden of unsafe abortion (). Moreover, medication abortion has the potential to expand not only abortion method choice, but also women s access to safe abortion services (2). Therefore, this study will try to answer the following Research question What does the acceptance of Medical Abortion looks like among MCH users? In the case of medical abortion client s acceptability is a key to the success of the method (3). If a procedure is acceptable, woman would choose it again when they needed to terminate another pregnancy and would recommend it to their friends (4). The service of medical abortion method is recent in public health facilities of Dire Dawa and given in all urban health facilities without fee for the clients who fulfill the revised abortion law and the status of the services especially its acceptance not known. Therefore, this study will assess acceptance and associated factors of the methods and the result will contribute to the improvement of maternal health in the communities as well as nationally by reducing high abortion related mortality. 2. METHODS Study Design Health facility based cross sectional study was employed. The study was conducted from March 3, 202 to September Study population The study population was MCH clients who come for FP, CAC, ANC & Child Care services on selected health facilities during study period. Sample size The sample size was calculated using the formula below. N = [Z ( α ) 2 P (Q)] 2 d2 0% non-response rate was considered (3.846 * 0.25)/ = = 422 Sampling Procedure A total of five public health facilities and one NGO clinic providing MA services was selected and based on the total population around the health facility proportional distribution of study subjects were allocated. Then all consecutives MCH clients who were visited the selected health facilities during the study period were included until the sample size obtained. Data collection procedure A structured interviewer questionnaire was used for data collection by nurse s data collectors who are working on MCH clinics. The questionnaire was originally prepared in English first, then translated in to Amharic, Afan Oromo and Somalie language and back translated in to English in order to maintain its consistency. Data was collected at health facilities on the working days from April 30 to May 8, 202.Moreover, the questionnaire was pre-tested on 0% of the sample size in the health facilities which was not included in the study area and revised accordingly before the main study. Privacy was Medicine. 208;2().

3 Vol;2();207 maintained and confidentiality of information was assured. variate to see their association with the dependent variable. Data analysis The data were coded, entered, cleaned and analyzed using Epi info version 3.7 and SPSS version 7 respectively. A binary logistic regression models were fitted to identify factors affecting acceptance of MA. Logistic regression model were adjusted for sociodemographic variables, knowledge and those representing experience of abortion, and reasoning to choose method. The logistic regression was performed in two steps to determine factors affecting acceptance of MA. First, using bi variate analysis each explanatory variable was separately regressed against the dependent variable subsequently, those explanatory variables whose p values greater than 0.05 were excluded. In the second step, the remaining independent variables were regressed using multi 3. RESULTS Socio-demographic Characteristics A total of 40 women were interviewed during the study period of 422 targeted samples questionnaires distributed, a response rate of 95%. The age range of the women were from 5-40 yrs (mean=23.7). Three hundred eighty two (95.3%) of women s were urban residence, more than half of 247(6.6%) are currently married and half of them 202(50.4%) were Orthodox in religion. Majority 45(36.2%) were house wife in their occupation. Regarding Ethnicity 65(4.%) were Amhara. One hundred ninety three (48.%) were secondary education (9-2). With 25(62.6%) have no income. (Table.) Table : Socio Demographic Characteristics of women Variables Frequency Percentage (%) Age Mean Age group >=30 Marital Status Currently Married Never Married Separated Widowed Current Religion Orthodox Muslim Protestant Catholic Occupation Employed private Gov t Employee House Wife Merchant Student Others* Ethnicity Amhara Oromo Somalie Tigrae Guragae Others Education formal Education Primary Education % 42.9% 28.9% 9.7% (6.6%) (35.9%) (.7%) (0.7%) (50.4%) (4.9%) (5.5%) (2.2%) (.7%) (.2%) (36.2%) (8.7%) (27.7%) (4.5%) (4.%) (35.4%) ((3.5%) (9.7%) (7.2%) (2.9%) (20.7%) (25.9%) Medicine. 208;2().

4 Vol;2();207 Secondary Education Above Secondary Monthly Income Income < Total Others* sex worker, contract worker (48.%) (5.2%) (62.6%) (5.0%) (5.2%) (7.2%) (00%) Marital status of the women (Married and Never married) was significantly different between women who are willing to accept and none willing to accept the method at (p=0.00). Muslim Religion were less likely to be willing to accept the method as compared to other religion (OR % CI (0.33, 0.79). Women with secondary education and above have higher willingness to accept the method than no formal educated women (OR=3.3 95% CI (.9, 5.70) and (OR=3. 95% CI (.04, 9.3) respectively. (Table.2) Variables Placer of Residence Rural Urban Marital Status Currently Married Never Married Religion Orthodox Muslim Protestant Others* Occupation Employed private Gov t Employee House Wife Merchant Student Others* Education formal Education Primary Education Secondary Education Above Secondary *P=<0.05, **P<0.005, fefisher s exact test Table 2: Results of separately regressing socio demographic Acceptance of MA COR (95% CI) (#, %) (#, %) 2(63.2%) 7(36.8%) 26(68.3%) 2(3.7%) 52(6.8%) 94(38.2%) 20(77.4%) 35(22.6%) 48(73.3%) 54(26.7%) 98(58.3%) 70(58.3%) 8(8.8%) 4(8.2%) 8(88.9%) (.%) 34(72.3%) 3(27.3%) 27(60.0%) 8(40%) 87(60.0%) 59(40%) 24(68.6%) (3.4%) 9(82%) 20(8%) 0(55.6%) 8(44.4%) 42(50.6%) 4(49.4%) 66(63.5%) 38(36.5%) 49(77.2%) 44(22.8%) 6(23.8%) 5(76.2%) 0.79(0.3,2.06) 0.5(0.33,0.79) **.64(0.53,5.06) 2.9(0.35,23.8) 0.63(0.27,.5) 0.63(0.3,.29) 0.92(0.36,2.39).93(0.87,4.25) 0.53(0.7,.62).69(0.94,3.05) 3.3(.9,5.70) ** 3.(.04,9.3) * fep-value 0.00 Women with one time pregnancy experiences were (OR= % CI (.2, 5.49) more likely to accept medical abortion method than no pregnancy previously. There was a reduced willingness of acceptance among women who had two time and above live birth (OR= % CI (0.2, 0.8) and (OR= % CI (0.9, 0.69) respectively as compared to those who had no live birth. Women who planned their last pregnancy were less willing to accept the method as compared to those who had not planned (OR= % CI (0.2, 0.5). Women used contraceptive method were.64 times (CI=.04, 2.58) more likely to accept the method compared to their counter parts. Women who heard about medical abortion method were 5.34 times (CI= 3.4, 9.95). Although source of information had significant association with acceptance of the method, women who heard from health provider and ETV were 2.73 and 2.76 times (CI= (.39, 5.36) (CI=.23, 6.34) more likely to accept the method. (Table.3) Medicine. 208;2().

5 Vol;2();207 Table 3: Separately regressing acceptance of MA ( versus ) by Reproductive History and Source of Information Variables Frequency Acceptance of MA (#, %) (#, %) COR (95% CI) Age stpregnancy(n=378) <=8 yrs 9-24 yrs > =25yrs of pregnancy ne One Two Three & Above of Live birth ne One Two Three & Above Last pregnancy planned Ever used Contraceptive Types of Contraceptive Natural Method Injectable Pills rplants IUCD Condom Heard of MA Never Heard Ever Heard Source of Information(n=324) Friends Health Provider Family/Husband ETV *P=<0.05, **P< (37.8%) 202(53.4%) 33(8.7%) 23(5.7%) 73(43.%) 07(26.7%) 98(24.4%) 9(47.6%) 3(28.2%) 47(.7%) 50(2.5%) 209(56.3%) 62(43.7%) 2(27.9%) 289(72.%) 3(4.5%) 44(49.8%) 65(22.5%) 40(3.8%) 4(4.8%) 3(4.5%) 77(9.2%) 324(88.8%) 62(50.0%) 86(26.5%) 22(6.5%) 54(3.5%) 94(65.7%) 49(34.3%) 46(72.3%) 56(27.7%) 20(60.6%) 3(39.4%) 2(52.2%) (47.8%) 26(72.8%) 47(27.2%) 70(65.4%) 37(34.6%) 64(65.3%) 34(34.7%) 43(74.9%) 48(28.%) 77(68.%) 36(3.9%) 26(55.3%) 2(44.7%) 26(52.0%) 24(49.0%) 66(79.4%) 43(20.6%) 90(55.6%) 72(44.4%) 67(59.8%) 45(40.2%) 205(70.9%) 84(29.%) 9(69.2%) 4(30.8%) 97(67.4%) 47(92.6%) 52(80.0%) 3(20.0%) 29(72.5%) (27.5%) 9(64.3%) 5(35.7%) 9(69.2%) 4(30.8%) 28(36.4%) 49(63.6%) 244(75.3%) 80(24.7%) 09(67.3%) 53(32.7%) 73(84.9%) 3(5.%) 6(72.7%) 6(27.3%) 46(85.2%) 8(4.8%).36(0.85,2.5) 0.80(0.36,.74) 2.45(.02,5.94) *.73(0.69,4.3).75(0.68,4.32) 0.7(0.43,.2) 0.42(0.2,0.8) ** 0.36(0.9,0.69) ** 0.32(0.2,0.5) **.64(.04,2.58) * 0.92(0.27,3.3).78(0.47,6.69).7(0.29,4.59) 0.80(0.6,3.99).0(0.8,5.29) 5.34(3.4,9.95) ** 2.73(.39,5.36) **.29(0.48,3.50) 2.76(.23,6.34) * Women s Abortion experiences and attitudes Women with experience of induced abortion were 3.04 times more likely to accept the method as compared to the women with no experience (CI=.93, 4.77). Although more than two times abortion experienced women had higher acceptance than those none and one time abortion experienced (OR= % CI (.62, 8.3). Outcome of previous medical abortion (complete and incomplete abortion) was statistically different between acceptance and none acceptance of the method at p= (0.039). Reason to choose the method found to be statistically significant with avoiding anesthesia and over controlled. (Table.4) Table 4: Separately regressing Abortion experiences and attitudes of women Variables Frequency Acceptance of MA COR (95% CI) (#, %) (#, %) Induced abortion Previously 28(54.4%) 83(45.6%) 25(57.3%) 93(42.7%) 47(80.3%) 36(9.7%) 3.04(.93,4.77)** P-value Medicine. 208;2().

6 Vol;2();207 of previous Abortion ne One time Two and Above Outcome of MA(n=35) Complete abortion Incomplete abortion Individual perception of the method Safety Effectiveness Easiness/Naturalness Privacy Less Time Less Invasiveness 28(54.4%) 36(33.9%) 47(.7%) 30(96.3%) 5(3.0%) 69(24.4%) 80(28.3%) 2(7.4%) 45(5.9%) 7(6.0%) 5(8.0%) 25(57.3%) 93(42.7%) 08(79.4%) 28(20.6%) 39(83.0%) 8(7.0%) 09(83.8%) 2(6.2%) 2(50.0%) 3(50.0%) 53(76.8%) 6(23.2%) 70(87.5%) 0(2.5%) 20(95.2%) (4.8) 38(84.4%) 7(5.6%) 3(76.5%) 4(23.5%) 42(82.4%) 9(7.6%) 2.87(.75,4.70)** 3.62(.62,8.3)** 2.(0.88,5.02) 6.03(0.75,48.5).6(0.6,4.37) 0.98(0.28,3.43).40(0.56,3.50) Reason to choose MA Fear of surgery Less injury to body Convenient for work Avoiding anesthesia Over controlled *P=<0.05, **P<0.005, fefisher s exact test 23(37.8%) 69(2.2%) 49(5.%) 23(7.%) 6(8.8%) 0(89.4%) 3(0.6%) 63(9.3%) 6(8.7%) 39(79.6%) 0(20.4%) 5(65.2%) 8(34.8%) 33(54.%) 28(45.9%).24(0.45,3.43) 0.46(0.8,.3) 0.22(0.079,0.62)** 0.4(0.65,0.299)** Stepwise logistic regression Ever used contraceptive and previous experience of induced abortion are found to be important predictors for the acceptance of medical abortion method. Women who had ever used contraceptive method had higher odds to accept medical abortion method than those who did not used (AOR= % CI (.9, 8.9). Women who had experience of previously induced abortion had 3.8 times likely to accept the methods than those no previous abortion experience (AOR=3.8 95% CI (.33, 7.57). (Table.5) Table 5: Multivariable analysis Adjusted for significant variables (p 0.05) in bivariate analysis Variables Crude OR (95% CI) Adjusted OR (95% CI) Ever used contraceptive Induced abortion previously *P=<0.05, **P< (.04,2.58) 3.04(.93,4.77) 3.22(.9,8.69) * 3.8(.33,7.57) ** 4. DISCUSSION Out of the total respondents 40 majorities 68.% are willing to accept the method in case need arise if offered regardless of alternative. This finding were similar when compared with the study conducted in France were women's initial choices favored the medical method was 64% (2). According to this study 35 (73.8%) had used Medical Abortion previously and 30 (96.3%) of them had complete abortion which is this is consistent when compared with the study conducted in Ethiopia the proportion of women who succeed in having complete abortion were 94.8% (5). More than half of (68.6%) participants who were willing to accept the method were young women aged yrs which is similar with the study in Africa and Ethiopia. Of all respondents 95.3% were urban resident, among this married women accounts 6.6%, undergo Medical Abortion method were 54.0% which show that it is not only unmarried women but also married women are using safe abortion method. Students also share the major portion 30.3% of method user. This could be as a result of risky living environment that could expose them for unwanted pregnancy. Seventy three percent of women were have formal education in which 67.8% were willing to accept the method this is low when compared to a study conducted in rth West Ethiopia which is 85.2 % (5). Medicine. 208;2().

7 Vol;2();207 The proportion of respondents who had ever used contraceptive methods was 72%. Contraceptive utilizations increased with age; 48.6%, 69.2% and 87.% of women in this study with age group 5-9, and respectively use methods of family planning. This could be due to capacity of getting information about family planning method will increase with age. The most popular methods of contraceptive were injectable used by 55.9 % of currently married women. This is higher when compared with EDHS 20 which is 2% of currently married women use injectable method (6). Women with previous experience of induced abortion was 80.3% their willingness to accept the MA method. This is very different when compared to study conducted in northwest Ethiopia in which 4.7% of women with previous history abortion are willing to accept the method. The reason could be due to study time gap and methodology differences with this study (4). Women tended to use the method if they had previous successful experiences and cited as positive features privacy (5.9%), easiness (7.4%), less invasiveness (8.0%) and feeling more in control. Study conducted by Agrawal et al showed that most commonly cited positive attributes were easy and faster (37.5%); private and more confidential (35.22%); natural like menses (23.86%); less invasiveness (8.8%) (7). Young, never married and nulliparous women prefer the medical method and reasoned for choice of medical method were fear of surgery 68 (50.3%), less injury to body 30 (22.2%), convenient for work 30 (22.2%), avoiding anesthesia 7(5.3%). This is slightly different when compared to a study conducted by Ellertson C. reasoned (43.4%) to avoid surgery or anesthesia, less traumatic (30%) and safer or convenient (40%) (4). 5. CONCLUSION This study showed that there is high acceptance of the method among women of Dire Dawa city. Sixty eight percent of participant were accepting the method in which (82.2%) were MA user and 62 (60.9%) non user are highly willing to accept Medical Abortion methods as a safe abortion method. Seventy two percent of participants ever used any of the family planning methods previously. Reason for choosing medical abortion method were many women fear of surgery, effectiveness, easiness, safety, less invasiveness and sense of over control this leads to a high willingness for a medical abortion method. Most of safe abortion service users and non users have awareness on medical abortion method and their predominated sources of information were friends and health providers. And also above 95 % of method user had complete abortion experience. Multivariate analysis revealed that contraceptive use and previous induced abortion shows significant association with acceptance of the method at (p<=0.05). 6. RECOMMENDATION Improving the availability of medical abortion method and make the service delivery even more convenient and responsive to women's needs should be emphasized. Further research should be conducted on women who reasoned not accept the method. Health providers, policymakers and advocates should continue their efforts to make medical abortion available to all women in Dire Dawa so that new clients can benefit from the program. LIST OF ACRONYMS AOR ANC CAC CI COR EDHS ETB ETV FP MA NGOs PAC OR SAC SPSS TOP WHO Adjusted odds ratio Antenatal Care Comprehensive abortion care Confidence interval Crude odds ratio Ethiopian Demographic and Health Survey Ethiopian Birr Ethiopia Television Family Planning Medical Abortion n-governmental Organizations Post-abortion care Odds ratio Safe abortion care Stastical Package for Social Sciences Termination of Pregnancy World Health Organization Medicine. 208;2().

8 Vol;2();207 REFERENCES. Medical abortion consortium, http// (200) 2. Berer M. Medical abortion: a fact sheet. Reprod Health Matters2005; 3: Crenin MD Medical abortion regimens: historical context and overview. Am J Obstetric Gynecology (2000)83: S3 4. Willmott FJ, Scherf C, Ford SM, Lim K Rupture of uterus in the first trimester during medical termination of pregnancy for exomphalos using mifepristone/misoprostol. (2008) 5: Okonofua, F.E. Breaking the silence on prevention of unsafe abortion in Africa. African Journal of Reproductive Health, (2004) 8, Ethiopian Ministry of Health, Technical and Procedural Guidelines for Safe Abortion Services in Ethiopia, Addis Ababa, Ethiopia: Ministry of Health, (2006) 7. ORC Macro. Reported on 2005 Ethiopian demographic and health survey Addis Ababa, Ethiopia and Calverton, Maryland, USA(2006) 8. Singh S et.al: The Estimated Incidence of Induced Abortion in Ethiopia, Addis Ababa Ethiopia, Goodman et.el. Bridging the Gaps: Implementation of Comprehensive Abortion Care in Ethiopia,(2008) 0. Grimes, David. Risks of mifepristone abortion in context. Contraception, (3): 6. Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE, et al. Unsafe abortion: the preventable pandemic. Lancet 2006: Berer M: Medical abortion: issues of choice and acceptability. Reproductive Health Matters 2005, 3(26): Loeber OE: Motivation and satisfaction with early medical vs. surgical abortion in the Netherlands. Reproductive Health Matters 200, 8(35): Ellertson C: Safety, efficacy, and acceptability of medical abortion in China, Cuba, and India: a comparative trial of mifepristone misoprostol versus surgical abortion. American Journal of Obstetrics and Gynecology 997, 76(2): (2) 5. Newhall EP, Winikoff B. Abortion with mifepristone and misoprostol: regimens, efficacy, acceptability and future directions. Am J Obstetric Gynecology 2000;83 : EDHS: Ethiopian Demographic Health Survey. Ethiopia, (20). 7. Agrawal A et al.feasibility and acceptability of medical abortion at BPKIHS. Health renaissance, September-December 200; Vol 8 (.3);42-46 Medicine. 208;2().