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Biomedica Vol. 21 (Jan. - Jun. 2005)
(A) E: Biomedica ABORTION PREVALENCE AND
ABORTION PREVALENCE AND
SOCIO-DEMOGRAPHIC DIFFERENTIALS
AYESHA HUMAYUN*, NAHEED H. SHEIKH** AND MAIMOONA ASHRAF***
*Department of Community Health Science, FMH College of Medicine and Dentistry, Lahore
**Department of Community Medicine, A.I.M.C., Lahore
***Department of Obst. and Gynae. L. G. H., Lahore
This study was performed to estimate the prevalence of abortions and to evaluate its
association with the socio-demographic factors in an urban slum. The data was collected
based on recall obstetric history from186 females through systematic random sampling
from 01.04.2001 to 30.06.2001. It was found that the abortion rate was 419.35 / 1000
women of reproductive age group. Abortion ratio was 109.39 / 1000 live births. There was
strong association of induced abortion with non-Muslim family, working of female and
illiteracy of husband. On the other hand gravidity 5 or above (increasing gravidity) was
statistically associated with total abortions. It was concluded that there is an unmet need for
controlling unwanted pregnancies and promoting birth spacing among Pakistani women.
Some important social and demographic factors determine the abortion behavior in
Pakistan.
Key words: Abortion Prevalence, Induced abortion and socio-demographic factors.
INTRODUCTION
Abortion is the expulsion of product of conception
before 20
th
week of gestation or if the weight is
500 grams or less
1
.
Abortions are categorized as spontaneous and
induced. Induced are illegally induced or therape-
utically induced. The WHO classification scheme
is based on the following criteria:
Certainly induced abortion: when a woman her-
self provides this information, or when such infor-
mation is provided by a health worker or a relative
(in the case of the dying woman), or when there is
evidence of trauma or a foreign body in the genital
tract. Probably induced abortion: when a woman
has signs of abortion accompanied by sepsis or
peritonitis, and she states that the pregnancy was
unplanned (she was either using contraception
during the cycle of conception or she was not using
contraception because of reasons other than
desired pregnancy). Possibly induced abortion: if
only one of the "probably" induced conditions
listed above is present. Spontaneous abortion: If
none of the conditions listed above is present or if
a woman states that the pregnancy was planned
and desired.
These criteria may be considered too strict in
some settings, and might in fact underestimate the
number of induced abortions. More detailed
clinical evaluation taking into account fever and
the extent of the pelvic infection can be used to
shift many of the "probable" and "possible" into
the "certainly" induced category; however, abso-
lute accuracy is not necessary here
2
.
Abortion is one of the direct causes of maternal
deaths e.g hemorrhages, 21.0%, hypertensive dise-
ases, 18.6%, sepsis, 13.3%, abortions, 11.0% and
others, 36.1%
3
.
In developing countries, 5 out of 10 leading
causes of Disability Adjusted Life Years (DALY’s)
are related to reproductive health, including the
consequences of unsafe abortion and chlamydia.
Almost all of this loss to healthy life is avoidable.
Unsafe abortion is a procedure of terminating an
unwanted pregnancy either by persons lacking the
necessary skills or in an environment lacking the
minimal medical standards or both
4
. Morbidity
and mortality due to unsafe abortion continue to
pose a serious global threat to womens’ health and
lives. It is estimated that worldwide, every year,
almost 20 million unsafe abortions take place and
80,000 women die from complications following
unsafe abortion
5
.
Unsafe abortion is entirely preventable. Yet, it
remains a significant cause of maternal morbidity
and mortality in much of the developing world.
Estimates based on figures for the year 2000
indicate that 19 million unsafe abortions take place
each year, that is, approximately one in ten
pregnancies end in an unsafe abortion, giving a
ABORTION PREVALENCE AND SOCIO-DEMOGRAPHIC DIFFERENTIALS
13
Biomedica Vol. 21 (Jan. - Jun. 2005)
ratio of one unsafe abortion to about seven live
births. Almost all unsafe abortions take place in
developing countries. Worldwide an estimated
68,000 women die as a consequence of unsafe
abortion. The risk of death in developing countries
is estimated at 1 in 270 unsafe abortion pro-
cedures.
6
As a signatory to International Conference of
Population and Development (ICPD) in 1994,
Pakistan accepts the deceleration of reproduction
and sexual health as a right for both men and
women
7
.
In a study conducted in Bangladesh, the
incidence of abortion was higher among women
who had six or more births or who became
pregnant fewer than 12 months after the previous
pregnancy
8
. From a study conducted in Canada, as
a part of Canadian perinatal surveillance system,
we found that twenty percent of abortions, in 1995,
were obtained by females less than 20 years of age;
52% by women 20-29; 26% by women 30-39 and
all others by women 40 years and older. Over half
(54%) of women who obtained an abortion had a
previous delivery; a third of these women had a
previous abortion
9
.
A study in Nepal was conducted in women
admitted to hospitals with abortion-related
complications. Thirty-six percent of the women
were between 25 and 29 years of age, and 43% had
two living children. Forty percent had more than a
high school education, 91% were from Kathmandu
of these 48% practiced contraception. The primary
motivation for seeking abortion in 34% women
was due to the desire for no more children.
Women residing in urban areas who never had an
induced abortion tended to be younger, of lower
parity and more educated than those in rural
areas
10
.
"National study on unwanted pregnancy and
post-abortion complications in Pakistan" in 2004,
its aim was to achieve a better understanding of
the magnitude of and underlying reasons for
unwanted pregnancies and induced abortions in
Pakistan. The study estimated the national abor-
tion rate at 29 per 1,000 women of reproductive
age, implying that a sizeable proportion of
Pakistani women have abortions. Older married
women with several children account for the large
majority of unwanted pregnancies. About 890,000
unsafe induced abortions occur annually. In
addition, about 200,000 women suffer from post
abortion complications in Pakistan each year
11
.
The community under study was socioeconomic-
cally mixed type of peri-urban population. People
living in such areas constitute 60% of all urban
population in Pakistan and the number is on rise.
People living in peri-urban areas are legal settlers
but they are living in un-sanitary housing and
environmental conditions
12
.
This study was conducted in a socio-
economically mixed type of community within the
limits of Lahore. This community comprises of
brick, mud, mix and tent houses. It is almost 1 km
from Jinnah Hospital Lahore (a tertiary care
teaching hospital). The community is deprived of
many basic needs. Total population is 5554 and
930 families were residing in that community.
There is one dispensary being operated by Jinnah
Hospital and a Family Planning Center under the
Prime Minister Program of Pakistan.
METHODS
It was a descriptive cross-sectional epidemiolo-
gical study, aimed to evaluate the prevalence of
different categories of abortion in a defined
selected slum area and to find out its association
with socio-demographic factors. Study was con-
ducted in the urban slum Shah-Di-Khoi adjacent
to Allama Iqbal Medical College and Jinnah
hospital Lahore, Pakistan. Out of 930 women
residing in the defined study area, representative
sample of 186 was drawn through systematic
random sampling. Every 5
th
woman was inter-
viewed and structured questionnaire was filled,
based on recall obstetric history. Data was col-
lected through house-to-house survey regarding
social factors, demographics and abortions. The
results were entered and compiled in SPSS
(Statistical Package of Social Sciences version 10).
Systematic random sampling was carried out and a
representative sample of married females of
reproductive age group (15 – 45) was drawn.
Inclusion criteria: All the married ever-gravid
females of reproductive age group (15- 45 years)
were included in the study. Exclusion criteria: All
unmarried, abortion due to rape and infestile non-
gravid married females were excluded from the
study. (3 females were found infertile, therefore,
next were interviewed).
Universe of the study:
A total of 930 married ever-gravid females of
reproductive age group (15-45 years) residing in
that area were the universe of the study.
Sample size:
Sample size of 186 was calculated by a software
package, Epi-Info version 6.1. All the 930 married
females of reproductive age group were numbered
and then systematic random sampling was done.
Every 5th married ever-gravid woman was
approached and samples of 186 females were
drawn.
14
AYESHA HUMAYUN, NAHEED H. SHEIKH AND MAIMOONA ASHRAF
Biomedica Vol. 21 (Jan. - Jun. 2005)
We carried out a Pilot study, and necessary
alterations done in the questionnaire. The survey
was carried out in the selected community from
01.04.2001 to 30.06.2001. Closed-ended struc-
tured questionnaires were filled during house-to-
house survey. The related information regarding
abortions, based on recall obstetric history was
collected and entered in the questionnaire.
Abortions conducted during the survey period
were also included (up to 30.06.2001). A total of
186 females were interviewed. About 30-40
minutes were required to fill one questionnaire, as
abortion is a sensitive issue to explore.
Operational definitions:
Abortion is a termination of pregnancy before the
foetus becomes viable i.e. capable of living inde-
pendently; this has been fixed administratively at
28 weeks of gestation.
Abortion rate is number of abortions per 1000
ever-pregnant women of reproductive age [15-45}.
Abortion ratio is number of abortions per 1000
live births.
Unsafe abortion is that which was conducted by
untrained or inadequately trained person without
having kit with her.
Socio-demographic factors: In this study these
factors were:
Age: three groups were made, 15-25 years, 26-35
years and 36-45 years.
Religion: Muslims and non-Muslims.
Education: Illiterate one who cannot read or write
in local language, Literate who can read and write
in local language, Under Matric and Matric and
post Matric.
Income: Cut off point for income per capita per
month was taken Rupees 1200. [Less than $1 a
day]
Working of females: Non-working and working
females were taken as two groups.
Gravidity: Cut off point was Gravida 5.
RESULTS
Impact of socio-economic factors on abortion rates
and ratios (both spontaneous and induced) were
calculated in the selected urban slum area of
Lahore. Statistical analysis was performed to find
out any significant association between socio-
demographic differentials and abortion. In this
per-urban slum of 5554 inhabitants, 930 married
ever gravid reproductive age group (15-49) females
were residing. A total of 186 females were
interviewed and it was observed that they had a
total of 801 pregnancies (4.3 pregnancies per
women) and 25 respondents were pregnant at the
time of visit (pregnancy rate 13.4%). Out of these
pregnancies 723 were delivered (713 were live and
10 were stillbirths) and 78 pregnancies terminated
as abortion among 55 females (1.4 abortions per
women of reproductive age group).
In 78 abortions, 60 (76.9%) were spontaneous
and 18 (23%) were induced unsafe abortions,
which, they ever had during their reproductive
span. The abortion rate was 419.35 / 1000 women
of reproductive age group. Abortion ratio was
109.39 / 1000 live births. Induced abortion ratio
was 25.24 / 1000 live births and induced abortion
rate was recorded as 96.77 /1000 women of
reproductive age group.
A total of 62 (33.33%) women out of 186
belonging to the age group 15-25 years, 19 (30%)
respondents experienced 29(37%) abortions ,out
of which 25 (86%) spontaneous and 4 (14%)
induced. There were 77 (41.39%) women from the
age group 26-35 years out of which 22 (29%)
respondents experienced 31 (38.46%) abortions in
which 21 (67.7%) were spontaneous and 10
(32.2%) were induced. There were 47 (25.2%)
females in the age group of 36-45years. Fourteen
females (29.7%) had 18 (23%) abortions, out of
which 14 spontaneous (77.7%) and 4(22.2%) were
induced
The association of age groups with abortions
was non significant. In case of total abortions,
[Chi-square=2.79, d.f = 2, P = 0.05], while in
induced abortions [Chi - square = 0.05, d.f = 2,
P = 0.05].
There were 90 (48.3%) respondents Gravid-5
and above and they experienced 54 (69.2%)
abortions, 15 (27.7%) were induced illegally and 34
(61.76%) were spontaneous. There were 96
(51.6%) respondents who were Gravid-4 and
below, and they experienced 24 (30%) abortions, 3
(12.5%) were induced and 21 (88.4%) were
spontaneous. The association of increasing gra-
vidity on total abortions (spontaneous & induced)
was very significant [Chi-square=5.61, d.f= 1,
P=0.05]. The impact of gravidity on induced
abortion was not statistically significant. [Chi-
square=2.12, d.f=1, P=0.05].
Among 186 females, 117 (62.9%) were illi-
terate, and experienced maximum number of
abortions i.e. 45 (57.6%). Out of 186 females 93
(50%) women had illiterate husbands, and they
underwent 41 (52.5%) abortions. The results of
total abortions and literacy of couple were not
significant. But in case of induced abortions and
literacy of husband, chi-square was 7.35, the result
ABORTION PREVALENCE AND SOCIO-DEMOGRAPHIC DIFFERENTIALS
15
Biomedica Vol. 21 (Jan. - Jun. 2005)
was significant whereas it is not significant in case
of females.
Association of family income with abortion
was analysed. Family income of 163 (87.6%)
respondents was less than Rs. 1200 per capita per
month. Chi-square test was not significant in case
of total abortions as well as induced abortions.
In this community majority of respondents
[139 (74.7%)] were non-working and they
experienced 51(65.3%) abortions and 6 (11.7%)
were induced. 47 (25.2%) females were working
and they experienced 27 (34.6%) abortions and 12
(44%) were induced. Chi-square was not
significant in case of working females and
abortion, but [chi-square=10.5 with P=0.05] was
significant in case of induced abortions and
working females.
Table 1: Abortions among respondents according to their gravidity.
Number of
respondents
experienced abortions
Number of
abortions
Spontaneous
abortions
Induced
abortions
Gravid–1 2 (3.6) 2 (2.56) 2 (3.3) 0
Gravid–2 5 (9) 6 (7.69) 6 (10) 0
Gravid–3 8 (14.5) 9 (11.5) 7(11.6) 2(11.1)
Gravid–4 6 (10.6) 7 (8.9) 6 (10) 1 (5.5)
Gravid–5 14 (25.4) 19 (24.3) 17 (28.3) 2(11.1)
Gravid–6 or above 20 (36.36) 35 (44.8) 22 (36.6) 13 (72.2)
Total 55 (100) 78 (100) 60 18 (100)
(figures in parentheses are percentages)
Table 2: Abortion and their relation with respondent’s occupations.
Number of
respondents
experienced abortion
Number of
abortions
Spontaneous
abortions
Induced
abortions
House wife 37 (67.2) 51 (65.3) 45 (75) 6 (33.3)
Housemaid 9(16.36) 12 (15.36) 6 (10) 6 (33.3)
Self-employed 7 (12.7) 12 (15.36) 8 (13.3) 4 (22.2)
Office worker 2 (3.6) 3 (3.8) 1 (1.6) 2 (11.1)
Total 55 (100) 78 60 18
(figures in parentheses are percentages)
Table-3: Impact of regilion on induced abortions.
Religion
Experienced
induced
abortion
Not
experienced
induced
abortion
Total
Muslims 10 54 64
Christians/
others
8 6 14
Total 18 60 78
chi-square = 11.01 with 1 degree of freedom and 0.05
probability
Figure 1: Percentage distribution of educational
status of respondents
’
husbands
.
ILLITERATE
50%
LITERATE
8%
UNDER
MATRIC
22%
MATRIC
15%
POST
MATRIC
5%
16
AYESHA HUMAYUN, NAHEED H. SHEIKH AND MAIMOONA ASHRAF
Biomedica Vol. 21 (Jan. - Jun. 2005)
A total of 144 (77.2%) respondents were
Muslims and they experienced a total of 64 (82%)
abortions, of these 10 (15.6%) were induced. Forty
two (22.5%) Christians respondents experienced a
total of 14 (17.9%) abortions, of these 8 (57.1%)
were induced. Chi-square was non-significant in
case of religion and total abortions. On the other
hand induced abortions were had significant
association in case of Christians [Chi-square
=11.01 with P=0.05]. The spontaneous abortion
rates are noted to be high as compared to the
induced abortions, in Muslim respondents.
DISCUSSION
This is a cross-sectional or prevalence study which
helps us to assess the burden of abortions in our
community. The association of socio- demographic
factors with Induced abortions is statistically
significant in case of Non-Muslim families,
working female and illiteracy of husband. Incre-
asing gravidity is statistically associated with total
abortions. On the other hand income and edu-
cation of couple (except illiterate husband facing
significantly high induced abortions) have no
impact on abortion rates and ratios’. Similar
findings regarding these variables were found in a
study carried out in Ukraine to asses the
differences in social and demographic characteri-
stics between women undergoing an induced
abortion and antenatal care attendants in the
Ukraine. This was a hospital-based unmatched
case control study. A higher risk for an induced
abortion was found among women with a history
of previous induced abortion(s). Neither income
nor educational level was identified as a risk factor
for pregnancy termination”
13
.
To address the huge burden of abortions in
our society we have to improve access to contra-
ceptive methods (prevent unwanted pregnancy)
and provide quality post-abortion care (that in-
cludes comprehensive counselling, access to con-
traception and family planning to prevent future
unwanted pregnancies or to practice birth spacing,
and access to reproductive and other health
services).
As a conclusion a significant number of
women practice contraception, induced abortion is
also used, primarily to control family size and for
birth spacing. Increased promotion and use of
contraceptive methods are needed to decrease the
number of abortions, especially those that are
high-risk and unsafe. Where contraception is
inaccessible or of poor quality, many women will
seek to terminate unintended pregnancies, despite
restrictive laws and lack of adequate abortion
services. Prevention of unplanned pregnancies
must therefore be the highest priority, followed by
improving the quality of abortion services and of
post-abortion care.
Every pregnancy interrupted by abortion
requires that the procedure be carried out by the
appropriate technique under safe, sterile con-
ditions, by trained, competent professionals in
order to protect the health and future fertility of
the patient. Abortions will be chosen whether they
are legal or illegal. When abortion was illegal in
this country, it was brought about by dangerous,
self-induced methods often by untrained,
practitioners under clandestine, un-sterilized
conditions with no follow-up care. Many women
suffered reproductive tract damage, infection,
bleeding, permanent sterility, or death
14
.
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