Elsevier

Contraception

Volume 72, Issue 5, November 2005, Pages 377-382
Contraception

Original research article
Scaling up postabortion contraceptive service — results from a study conducted among women having unwanted pregnancies in urban and rural Tanzania

https://doi.org/10.1016/j.contraception.2005.04.015Get rights and content

Abstract

Introduction

It is well recognized that unwanted pregnancies and unsafe abortion are significant public health problems in sub-Saharan Africa. At the International Conference on Population and Development held in Cairo in 1994, postabortion care was prioritized as a means to reduce maternal morbidity and mortality associated with unsafe abortion. However, only a few postabortion care programs have been implemented and most of them have been confined to urban settings. The present study describes the magnitude of the problem of unwanted pregnancies among women with incomplete abortion in urban and rural Tanzania and evaluates the outcome of a postabortion care intervention.

Methods

Data were collected among 781 women admitted with incomplete abortion in Dar es Salaam region (urban Tanzania) and 575 women in Kagera region (rural Tanzania).

Results

Sixty-seven percent of the women in urban Tanzania and 42% in rural Tanzania stated that their pregnancy was unwanted. Contraceptive acceptance among women with unwanted pregnancies was high; 93% in urban Tanzania and 71% in rural Tanzania left with a contraceptive method.

Conclusion

The high proportion of women with unwanted pregnancies in urban and rural Tanzania underlines the need of scaling up postabortion contraceptive service.

Introduction

Since ancient times, women from all over the world have experienced unwanted pregnancies and have undergone abortions to terminate these pregnancies. Despite women's obvious need for safe abortion care, access to abortion is often difficult due to legal restriction. As a result, many women experiencing unwanted pregnancies resort to unsafe abortions, which may account for a third of all maternal deaths in African countries [1].

The risk of unwanted pregnancy is far less among women who use effective contraception and there is strong evidence that abortions will decline with better availability and proper use of contraceptives [2]. Like women in the rest of the world, African women are increasingly trying to prevent or delay future pregnancies. The average family size in Africa has, during the past decades, declined from seven to eight children to four to six children [3]. It may be anticipated that a desire for smaller families may initially lead to an increase in the use of both contraception and abortion to regulate fertility. In such a situation, for the abortion rate to subsequently drop, contraceptives must be widely and consistently available for sustained use [2]. However, this is not the situation for many African women, and furthermore, due to the legal situation of abortion, most African women who experience an unwanted pregnancy will have to resort to an illegal, unsafe abortion if they want to have the pregnancy terminated [4].

In Tanzania, pregnancy interruption is illegal with few exceptions; consequently, unsafe abortion is a prevailing phenomenon. The exact magnitude of the problem of unsafe abortion in Tanzania is unknown, but the prevalence of women hospitalized with complications from incomplete abortion indicates that such terminations are common [5]. Furthermore, 60% of all women admitted to the hospital with incomplete abortion in Dar es Salaam have in fact had an unsafe abortion [6]. This figure comprises only women with admitted unsafe abortion and it may be assumed that the true proportion of women having unsafe abortion in Dar es Salaam is even higher. The fact that so many Tanzanian women risk their lives to terminate an unwanted pregnancy is a powerful reminder that they need access to a wide range of family planning methods to help them to safely control their fertility.

At the International Conference on Population and Development (ICPD) held in Cairo in 1994, it was stated that postabortion care should be prioritized in order to reduce the maternal morbidity and mortality associated with abortion. Contraceptive service is an important component of postabortion care as it helps women avoid future unplanned pregnancies, thereby reducing the likelihood of future abortions. In spite the compelling logic of preventing future unplanned pregnancies by providing postabortion contraceptive counseling, only a few postabortion care programs have been implemented and most of them are confined to urban settings and most often only implemented at the regional level. Hence, throughout sub-Saharan Africa there seems to be a need of scaling up postabortion care programs.

A recent follow-up study conducted among women having unsafe abortion in Dar es Salaam found that 90% of the women accepted the contraceptive service offered and 86% were still using contraception after 1–6 months [7]. Based on these results, it was decided to extend the postabortion care intervention to include district hospitals in urban and rural Tanzania and evaluate the outcome of the intervention.

Section snippets

Study setting

The study was conducted at the district level in Dar es Salaam region and Kagera region, Tanzania. Dar es Salaam comprises three districts, Ilala, Kinondoni and Temeke, each district is served by one district hospital. Data were collected at all three district hospitals during the period of August to October 2003. Kagera region comprises six districts: Karagwe, Ngara, Biharamulo, Muleba, Bukoba Rural and Bukoba Urban. These six districts are served by 10 hospitals. Seven of these hospitals are

Results

Among women admitted with incomplete abortion in urban Tanzania, 76% stated that their pregnancy was unplanned and 67% that the pregnancy was unwanted. In rural Tanzania the corresponding figures were 46% and 42%, respectively.

The demographic characteristics of women with wanted and unwanted pregnancies are summarized in Table 2. In both settings, a strong positive association was found between being single, divorced or widowed and experiencing an unwanted pregnancy. In urban Tanzania, more

Discussion

The problem of unwanted pregnancy among women admitted with incomplete abortion was pronounced in both settings. In urban Tanzania, 67% of the women interviewed stated that their pregnancies were unwanted. In rural Tanzania the corresponding figure was 42%. Urban women with unwanted pregnancies were more likely to leave the hospital with a contraceptive method than rural women were.

Conclusion

A significant finding of the study is that unwanted pregnancy among women having incomplete abortions is a great problem in urban as well as rural Tanzania. In addition, the study documents a high contraceptive acceptance rate among women having unwanted pregnancies. These results should encourage policy-makers to work for a broader implementation of postabortion contraceptive service throughout Tanzania. Furthermore, to assure women in the most remote areas of Tanzania access to high-quality

Acknowledgment

The study was supported by the Health Sector Programme Support within Danida (Danish International Development Agency).

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    1

    The author designed the study, performed the analyses and led the writing.

    2

    The authors assisted in designing the study and supervised the implementation of the study.

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