Family Planning and Protection Association
Baseline Survey on Safe/Unsafe Abortion
In Selected Refugee Camps
In West Bank
Dr. Sumaya Y. Sayej RN MSN Ph D
Al- Quds University
Palestinian Family Planning and Protection Association-PFPPA
Al Akhtal Alsaghier, P.O Box 19999, Jerusalem
Tel : +972 2 6283636 Fax : +972 2 6281675
E-mail : email@example.com Web : www.pfppa.org
Copy right for Palestinian Family Planning & Protection Association-PFPPA
This baseline survey has utilized descriptive exploratory approach to address the sexual and reproductive health issues particularly the safe/unsafe abortion among refugee women in reproductive age (15-49) living in the West Bank camps and to identify the health and social services provided for them.
The study is presented in two complementary parts; the first part and through quantitative data collection procedures, a structured questionnaire was developed to identify the socio-demographic characteristics, and to assess women’s knowledge and attitudes toward their sexual and reproductive health, the social, cultural and religious barriers to accessibility and use of family planning methods, abortion incidence and services, and impact of abortion complication and consequences on the women’s health. The second part and through qualitative in-depth interviews discussion with UNRWA health providers and community centers leaders to identify the health and social services offered to these women in their communities. This survey as well aimed to allow PFPPA to develop a five years strategic preventive and intervention plans to improve SRH, social conditions, gender issues and rights of women in reproductive age (15-49).
The sampling procedures utilized for this study were designed to produce random representative samples of the camps and the households selected in each camp through statistical procedure that allowed for weighting the camps and the households selected. Percentages of participants were relative to weight of each camp from the overall population in all West Bank camps. Eleven camps out of 19 in West Bank and 333 households were randomly selected from those 11 camps.
There were three sources for data collection for this study; primary and secondary sources of literature and previous studies done in this area, the quantitative data through a structured questionnaire to gather information from women in reproductive age (15-49) living in refugee camps, this questionnaire was tested for reliability and validity being newly constructed. And the two types of in-depth interviews that were conducted with UNRWA providers and community centers’ leaders at the targeted camps.
There were 9 data collectors and two supervisors whom followed on and supervised the field work and conducted the in-depth interviews in each camp clinic and women’s centers after a permission granted from UNRWA headquarters. A total number of 333 questionnaires from camps’ households were obtained, and 10 UNRWA health providers and 13 community centers’ leaders were interviewed
The questionnaires were analyzed by SPSS program and the data results were compiled into tables and interpretation of the results were presented in depth and reported into narrative style in the analysis chapter and discussion chapters. The qualitative data analysis has utilized a thematic analysis approach and all data collected including the field notes and the personal comments was assembled as expressed by the respondents under each question.
The interviewed women were all married with a mean age of 32.7 years at the time of the data collection and with an average of 18 years when they were married. Around 31% of the surveyed women were married at very young age 13-17 years and 52.5% were married between 18-22 years, and around 30% of these women are living within extended families. The number of pregnancies for these women has ranged from (0-16) times, around 39% had 3-5 pregnancies and 30% had 6-9 pregnancies. The number of children ranged from (0 – 14); 57% are having 2-5 children, 23% are having 6-9 children, 6% are having 10-14 children with an average income of 1599 NIS/month although 18% of the surveyed women and 84% of their husbands were having a job
Regardless of the identified well acceptable level of education for the women and their husbands, yet the figures obtained indicates early marriage, frequent pregnancies, and large number of children coupled with low financial resources. Such socio-demographic indicators should be noted and made to policy makers and health providers to consider since such factors have a major impact on women and consequently on their families from all aspects of their living conditions including health, life style and child bearing and rearing practices. Not to forget that around one third of these women are living within extended families where culturally family ties are strong and in this situation the women’s decision regarding their SRH issues including family planning use and pregnancy is controlled by either their husbands, in laws or others as been acknowledged by the surveyed women.
The overall picture of the results indicated that the surveyed women are well aware of the importance of FP methods, the restrictive factors on its utilization such as the religious attitudes toward its use and the social pressure imposed on them by husbands and others to hinder their autonomy for its utilization, beside their poor adherence. They are also knowledgeable of the facilitative factors to FP use through its accessibility, availability and the awareness programs they receive from health service providers. Such data requires the attention of health providers to promote contraception utilization and compliance and to involve husbands and significant others to support women for FP use
The women attitudes toward circumstances where most women seek abortion have ranged according to the circumstances given; as for example their attitudes were positive regarding women’s health conditions such as having bleeding or having certain diseases. There were discrepancies in their responses for economic and demographic factors where religiosity and cultural attitudes toward having more children was evident. The majority opposed for women to seek children if she was of lower educational level or having a job. A strong positive attitude was regarded for having many children or perceived she is pregnant with a girl. Such statements identify a positive attitude of the respondents toward gender equality and reflect adverse opinions on the boy’s preference as well as express the value of having many children as known in the Palestinian society
It was evident that the perceptions of surveyed women toward legality of abortion are very well influenced by their religious beliefs and abide by the ethical and cultural views on abortion. A substantial support for the availability and legality of abortion was found on issues related to women physical and mental health. And more than two third supported legality of abortion on issues related to infant’s having physical and mental abnormalities. More than two third endorsed a positive attitude toward abortion legality and availability for specific indications such as the case of rape and incest. On the contrary, more than two third opposed abortion for the women age whether young or old, and more than the half opposed the general availability of abortion.
The participants were asked about their knowledge of the incidence of abortion among relatives or others as well as among themselves; an astonishing figures were found where 54.4% knew of others had an abortion, and around 40% of the study participants have experienced an abortion, of those 21% had it for one time, 8% had it for 2 times, 6% had it for 3 times, 1.2% had it for 4 times. Such figures require further investigations to minimize the incidence of abortion among them. Yet, the surveyed women’s were knowledgeable of the legal and religious laws, importance of following the health professional’s advice, proper timing for abortion and for seeking abortion services from health professionals. Around 10% of the participants new about women who seek abortion from traditional Dayas and 16% have agreed on the women themselves to induce abortion, which means around 26% of abortion practices are unsafe. A striking evidence was found that these women have utilized the voluntary trauma which worth attention to have awareness regarding the consequences of such practices.
The participants possessed a high level of knowledge about post abortion complications and consequences where over 90% agreed that women who experience abortion needed hospitalization, needed blood transfusion, and had vaginal bleeding. The participant’s knowledge of consequences of abortion also indicated a high level of knowledge and awareness where 85% agreed on general weakness and body aches, 68% for weak uterus, 64% for the urinary tract infections and 50% for infertility.
The participant’s responses toward the emotional feeling and psychological attitudes indicated that the majority agreed on the statements “felt it was a feeling of killing of a child”, “felt guilty, remorse and fear”, “regretting the decision to have an abortion” agreed on “felt it was a sin” and more than the half agreed on “felt shame”, also more than the half responded negatively toward the “feeling of freedom”.
The in-depth interviews findings from UNRWA health personnel; indicated the provision of the different FP methods in all service localities with the majority of women utilize IUDs, then oral contraceptive pills and to less extent the male condoms while emergency contraception is not a method that is utilized or provided. UNRWA has neither policy nor services directly provided to women who needed abortion or post abortion care and thus no difficulties encountered regarding this issue. Provision of post abortion care is indirectly provided through antenatal care and FP clinics particularly when there are women at risk and through monitoring of pregnancy outcomes
UNRWA emphasizes health education and awareness programs as one of its most important primary health care activities where consistent health education/awareness programs on SRH issues including the use, benefits and risks of FP methods, breast feeding practices and many other issues supported with distribution of leaflets and brochures on the topics and complemented with home visits by the nurses/midwives to ensure women’s compliance and follow up of the instructions they received.
UNRWA as institution support gender equality through provision of equal opportunities for boys and girls to access basic health services in addition to provision of the integrated non-communicable disease care for both males and females, this equality was surmounted by having employees of both sexes working within its facilities.
Health professionals recommended having further education and awareness programs for the staff to be able to introduce quality awareness on SRH for the women. They also recommended widening their role of education into the community through launching workshops and seminars for women in the camps. Surprisingly, no one suggested the involvement of husbands or in laws which means there is a need to promote the health professional prospective on abortion from social, religious and legal perspectives
The in-depth interviews findings with community center’s leaders; The community centers goals and strategies do not deal with the issue of abortion and their activities are directed mostly toward social and cultural issues and health to less extent. Most of the centers offer awareness programs on women’s health issues geared toward promoting breast feedings, nutrition and to less extent sex education, and FP methods which is not consistent and not in all camps. For emergency contraception, no one heard of this issue, and for abortion and post abortion care they are not interested to deal with as they considered it a medical, religious and cultural issue. Other awareness programs target young women and adolescents with focus on their developmental stage, early and consanguineous marriages. The most significant topic presented all through the centers was the gender awareness that was presented frequently in some centers by other women institutions to increase women understanding of their rights and social roles.
Four out of 11 camps appreciated the collaborative efforts they shared with UNRWA through joint health education programs related to women’s SRH particularly on family planning methods in addition to utilization of the counseling services offered by the clinic for women who need such service.
These community leaders recommended to have a full cooperation with UNRWA and other community centers to have a clear strategy and future vision for dealing with SRH issues including abortion and to coordinate the work through workshops and ongoing organized activities in order to allow women have the necessary information and health awareness even if this access required to go into their own homes
In conclusion and regarding abortion in specific, the surveyed women were knowledgeable of the proper time for termination of pregnancy and having attitudes to seek abortion services provided by health professionals. Yet 26% of respondents indicated unsafe abortion practices; 10% seek abortion from Dayas and 16% of women induce abortion by themselves where 83% of those have utilized the voluntary trauma approach which means that unsafe abortion exist. In addition, they expressed a feeling of low self esteem and emotional status which requires attention from several institutions governmental and non governmental to have further and deeper studies and to launch policies to reduce this phenomenon
Therefore, it is necessary for governmental and non governmental institutions including UNRWA to address safe and unsafe abortion as public health concern to meet women SRH needs and from the women perspectives particularly for those living in a conservative society as the case in Palestine. Discussing the issue of abortion was not really a problem to uncover when the women were approached through the data collection where they expressed interest and willingness to reveal the information they have. This could be explained as a venue to ventilate through since no one formally approached them on these issues. While there have been many positive findings of the surveyed women knowledge and attitudes regarding SRH issues investigated, further changes are needed to be made to achieve social equity and gender balance when it comes to decisions regarding early marriage, family planning use, and frequent pregnancy which ultimately lead to increased abortion incidence.
List of Abbreviations
Table of Contents
List of Figures
List of tables
Introduction and background
Palestinian Family Planning and Protection Association (PFPPA) aims to improve (SRH) conditions and rights of Palestinian Refugee women living in the West Bank camps through the reduction of safe/unsafe abortion incidence among them. The PFPPA is implementing a comprehensive project about abortion and unwanted pregnancies in Palestinian refugee camps, to establish a baseline survey is part of this project which will target women in reproductive age (15-49) years old living in 11 selected camps in the west bank.
Abortion is a sensitive and contentious issue with religious, moral, cultural, and political dimensions. It is also a public health concern in many parts of the world. More than one-quarter of the world’s people live in countries where the procedure is prohibited or permitted only to save the woman’s life. Yet, regardless of legal status, abortions still occur, and nearly half of them are performed by an unskilled practitioner or in less than sanitary conditions, or both (Mesce, Manager, 2006). Population Reference Bureau (PRB, 2006) reported that abortion is one of the neglected problems of health care in developing countries and characterized by inadequacy of skills on the part of the provider and use of hazardous techniques and unsanitary facilities.
The United Nations for Relief and Working Agency and since its establishment in 1950 has been serving the Palestinian refugees and improving their health and social conditions. The family health program at UNRWA aims to improve the general health and quality of life of the refugee population by focusing on preventive care to women and children. Comprehensive mother-and-child health care (MCH) was expanded in 1993 and all health facilities now offer family planning services. A key objective of the maternal health care programs is to ensure that refuge women attend for antenatal care early in pregnancy for regular monitoring and risk identification and management to meet the WHO recommended standard of 4 visits or more during the antenatal period (UNRWA Report, 2006).
According to UNRWA pregnancy risk scoring system, 11.9% of pregnant women were in the high-risk category and 21.7% were at alert category (at moderate risk). This meant that one third of pregnant women under supervision needed special attention and care during pregnancy, including assistance during delivery. The rates varied from one Field to another with the highest high-risk rate of 13.7% in Gaza Strip (UNRWA Report, 2003).
Given the scarce information about abortion in the Palestinian society in general and among women living in the refugee camps in specific, this survey will provide data and other information obtained on knowledge and attitudes of women living in the camps regarding SRH issues including abortion and family planning methods. It will also provide data on health and social services provided to these women through in-depth interviews conducted with UNRWA and community women centers personnel to help shed light of the public health aspects on this issue. The survey results will be the basic block to assist the PFPPA in developing a five years strategic preventive and intervention plans to improve sexual and reproductive health (SRH), social conditions, gender issues and rights of women in reproductive age (15-49) years.
1.1 Significance of the study
Information on incidence of safe or unsafe abortion is crucial for identifying policy and programmatic needs aimed at reducing unintended pregnancy. Data on abortion is rarely collected or analyzed in countries where abortion is illegal as the case in Palestine although more data is available in countries where abortion is legal (PRB, Report 2006). Abortion estimates in occupied Palestinian territories is not available in any census, yet the Allen –Guttmacher latest report (Oct. 2007) on abortion worldwide estimates for countries in Western Asia in which Occupied Palestinian Territories (OPT) is one of them indicated that 15% of pregnancies in this area ends into abortion; 10% are safe and 5% are unsafe.
Data on unsafe abortion for those that are self-induced or provided by unskilled persons are considered a major cause of maternal deaths and disability. Abortion is a relatively safe procedure when performed by health providers using correct techniques under sanitary conditions. But in countries where abortion is illegal or abortion services are not available, women with unwanted pregnancies may seek clandestine abortion services or drugs or other means of inducing abortion. Unsafe abortion whether legal or illegal accounts for 16% of maternal mortality in the developing world (Ashford, 2002), but death is not the only tragic cost. Many more women survive the experience and suffer lifelong from consequences of serious complications: sepsis, hemorrhage, and uterine perforation, cervical trauma, leading to problems of infertility, permanent physical impairment and chronic morbidity. Literature also shows that reproductive and sexual health research must be planned in its social, cultural and behavioral contexts, to gain a better insight into the relationship between abortion and contraceptive behavior. The significance of the enormous and often hidden activity of abortion are not explored widely for the variety of motives and pressures to abort, neither has examined abortion’s links with women’s reproductive health, nor discussed policy options (WHO 2001, P.131).
Most Arab Countries including OPT policy is usually classified as rather constrictive when compared on a worldwide scale, as abortion is permitted in cases where health risk endangers the life of the pregnant woman. Islamic theologists generally view the termination of a pregnancy to save a women’s life as acceptable even beyond the 120 days that is frequently cited in the literature. If an abortion is performed for reasons other than saving the women life; both the woman and the provider are subject to legal persecution (Hunington. and Abdel-Hady 2000) However, among the many unfortunate results of the social religious, and legal restriction on abortion in OPT today is the absence of reliable data on the incidence of abortion, and the little information available about the post abortion complication.
Thus, this study intends to identify the socio-demographical characteristics of Palestinian women living in refugee camps in the West Bank, and to explore the social, cultural and religious barriers to accessibility and use of family planning and abortion services and impact of abortion consequences on the women’s health. Furthermore it will explore the health and social services offered to these women through exploration of the leaders of health and social institutions available in their communities. This survey will allow PFPPA to develop a five years strategic preventive and intervention plans to improve SRH, social conditions, gender issues and rights of women in reproductive age (15-49).
1.2 Goal and Objectives
To establish a baseline measurement of SRH indicators among women in reproductive age (15-49) living in selected refugee camps in the West Bank toward their sexual and reproductive health with specific focus on safe/unsafe abortion and family planning complemented with assessment of the health and social services provided for these women by UNRWA and Community women centers
To achieve this goal the following objectives are set:
This chapter will present the literature review and international and regional studies according to the concepts of the study and in a sequential manner to reflect on studies done within the same domain and correlate with the study findings.
2.1 A sense of the Concept
Abortion is a controversial issue with religious, moral, cultural, and political dimensions. It is also a public health concern in many parts of the world. More than one-quarter of the world’s people live in countries where the procedure is prohibited or permitted only to save the woman’s life such as the case is in Palestine for example. Yet, regardless of legal status, abortions still occur in every country, and nearly half of them are performed by an unskilled practitioner or in less than sanitary conditions, or both.
Types of abortion fall into two prime categories. Spontaneous abortion or miscarriage is the termination of a pregnancy without exogenous causes, an unintended abortion that is due to natural or accidental causes; internationally, a time limit (before the 20th or 28th week, differing across countries) or size of the fetus (less than 35 cm length) may also be used to define a spontaneous abortion and to distinguish it from a still birth.
An induced abortion is the intentional termination of a pregnancy before the fetus have reached extra uterine viability, through use of a range of procedures, including safe methods such as surgical and pharmacological methods, and unsafe methods that range widely in type and effectiveness (Population Reference Bureau, 2006).
Abortion laws generally fall into five categories, from least to most restrictive as:
In addition, many countries allow abortion in cases of rape, incest, and fetal impairment. Countries also may:
In many cases, requirements such as these are intended to raise the quality of care, but they also can serve as barriers to safe abortion.
At the 1994 International Conference on Population and Development (ICPD) in Cairo, Egypt, governments agreed that: “In no case should abortion be promoted as a method of family planning. All Governments and relevant intergovernmental and non-governmental organizations are urged to strengthen their commitment to women’s health, to deal with the health aspect of unsafe abortion as a major public health concern and to reduce the recourse to abortion through expanded and improved family-planning services. Prevention of unintended pregnancies must always be given the highest priority and every attempt should be made to eliminate the need for abortion Women who have unintended pregnancies should have ready access to reliable information and compassionate counselling. Any measures or changes related to abortion within the health system can only be determined at the national or local level according to the national legislative process. In circumstances where abortion is not against the law, such abortion should be safe. In all cases, women should have access to quality services for management of complications arising from abortion. Post-abortion counselling, education and family-planning services should be offered promptly, which will also help to avoid repeat abortions” (WHO, 2004).
A condition under which abortion is legally permitted varies among countries. Abortion laws can be complex and diverse. There may be discrepancies between the exact wording of the law and its application, which means that common practice, can assist or hamper the procurement of legal abortion. There may be additional requirements regarding consent and counselling, etc., and countries often impose a limit on the period during which women can access the procedure.
In some countries access is highly restricted; for example, in Chile, El Salvador, and Malta abortion is not permitted on any grounds. In others, pregnancy termination is available on broad medical and/or social grounds or on demand. Sometimes, however, even where induced abortion is legal, cumbersome rules may present awe-inspiring obstacles to women, attitudes of medical staff may be discouraging, and abortion services may be insufficient to meet the demand or inadequately distributed or of poor quality. In addition, women may be unaware of the availability of abortion services or their right to access within the legal framework (WHO, 2004).
2.2 An overview of incidence of abortion worldwide
Anderson in his Policy and Research Paper (1998, No.10) on Abortion, Women's Health and Fertility indicated; the World Health Organization estimated that worldwide, about 50 million abortions were induced annually in the years circa 1990. Combining this estimate with others, WHO concluded that each year in this period, approximately 3.4% of women in the childbearing ages of 15 to 49 years had an abortion (the abortion rate), and 25% of all pregnancies ended in abortion (the abortion ratio). These estimates imply that at least a substantial minority of the world's women have the experience of undergoing or self-administering a procedure to induce abortion sometime during the span of their childbearing years. Many are at high risk for procedure-related morbidity and mortality, with repercussions too. So many abortions and complications are deeply troubling, emotionally or morally to many people. They impose considerable strains on health budgets, personnel and resources, which, in some areas might seriously compromise the ability to pursue other health objectives
Around a decade later, the World Health Organization (WHO) estimates that worldwide 211 million women become pregnant each year and that about two-thirds of them, or approximately 136 million, deliver live infants. The remaining one-third of pregnancies ends in miscarriage, stillbirth, or induced abortion. Of the estimated 46 million induced abortions each year, nearly 19 million are performed in unsafe conditions and/or by unskilled providers and result in the deaths of an estimated 68,000 girls and women. This represents about 13 percent of all pregnancy-related deaths.
Almost all unsafe abortions take place in developing countries, and this is where 99 percent of abortion-related deaths occur. This is at the time when women in developed and developing regions of the world turn to abortion at similar rates; annually, 34 abortions are performed per 1,000 women in developing countries, compared with 39 per 1,000 women in developed countries (Population Reference Bureau, 2006).
Nevertheless, the incidence of unsafe abortion is affected by legal provisions governing access to safe abortion, as well as the availability and quality of legal abortion services. Restrictive legislation is associated with a high incidence of unsafe abortion. The outcome of complications of unsafe abortion will depend not only on the availability and quality of post-abortion services, but also on women’s willingness to turn to hospitals in the event of complications, and the readiness of medical staff to extend services. It is thus the number of maternal deaths, not abortions, that is the most visible consequence of legal codes (WHO, 2004).
Figure1: Unsafe Abortions by Age Group, Around Year 2000 (%)
* Excludes Eastern Asia (China, North Korea, South Korea, and Mongolia). Note: Figures may not add to 100 due to rounding. Source: Iqbal Shah and Elisabeth Ahman, “Age Patterns of Unsafe Abortion in Developing Country Regions,” Reproductive Health Matters 12, no. 24 (supplement, 2004).
The figure above clearly shows that the ages at which women have unsafe abortions differ markedly across regions. Nearly 60 percent of women in sub-Saharan Africa who have unsafe abortions are younger than 25, and 25 percent are still in their teens. In Asia, 70 percent of unsafe abortions are among women 25 and older; many of them already have children and want to limit family size. In Latin America and the Caribbean, more than half of unsafe abortions occur among women who are in their 20s, suggesting that women in this region use unsafe abortion to space births and limit family size.
Taking Pakistan as an example of a Moslem developing country where induced abortion is permitted only to protect the woman’s life and physical health, an estimated 890,000 induced abortions occur annually. The estimated national abortion rate (both spontaneous and induced) is 29 per 1000 women. An estimated 197,000 women are treated each year for complications resulting from unsafe induced abortion, in public health facilities and private teaching hospitals. The empirical evidence indicates that the large majority of unwanted pregnancies, and especially those ending in induced abortion, occur to relatively older married women who already have several living children (Population council, 2004).
2.3 Reasons for conceiving an unwanted pregnancy
Around 80 million pregnancies each year are unintended and more than one-half result in induced abortion. About one-third (26.5 million) of unintended pregnancies each year result from incorrect use or failure of contraceptives. For that no contraceptive method is 100% effective. According to research based on U.S. women using a single contraceptive method for one year, male condoms used correctly and consistently will fail 2 percent of the time; with more typical use, which is not always correct or consistent, the failure rate of male condoms rises to 15 percent. The failure rate of oral contraceptives is less than 1 percent with perfect use, but the rate rises to 8 percent with less-than-perfect use. Sixty one percent of the world’s women who are married or are in an informal union use some form of contraception (Population Reference Bureau, 2006).
In Pakistan, four separate research studies were conducted in 2002 and 2003: a survey of health professionals, a survey of health facilities, a survey of women who suffered from post-abortion complications, and in-depth qualitative interviews with women (and their husbands) who had experienced an induced abortion. In that massive project four common reasons were given for an induced abortion as follows; roughly one-half state that they had reached their desired family size, and one half indicate that it would be very difficult to afford another child. One-quarter report that their youngest child is still very young and one-quarter is concerned about the stress on their health of another pregnancy. The dominant picture of women who wish to terminate their pregnancy were their anxiousness about the burden of pregnancy on their health, and the burden on household economic situation– of another pregnancy and birth (Population Council, 2004).
Figure 2: Unintended Pregnancies by Region, 1995–2000
Note: Percentage of women answering “no” to a Demographic and Health Survey question asking whether their last birth was wanted; it does not include mistimed births. Source: Global Health Council Promises to Keep (2002).
In his study of women’s reproductive health in El Wihdat Palestinian refugee camp in Jordan and within the framework of his Masters Thesis completion in demographic studies Hishmeh (2000) interviewed a total of 400 randomly selected refugee women. He found out that a total of 37.2% of children born during the year preceding the survey were the outcome of unintended and/or poorly timed pregnancy. More than half of the interviewed women (53.3%) experienced spontaneous abortion at least once with the total average of 1.3 abortions per women throughout the reproductive years of life.
Conducting his multivariate analysis Hishmeh found that there is a relationship between the; woman’s educational level, number of living children, and woman’s age at first marriage on the one hand and frequency of spontaneous abortion on the other. He also reported a higher frequency of spontaneous abortion among women who were married at 20 years of age or less and at more than 35 years of age.
2.4 Reasons for women to seek abortion
The immediate explanation women often give for seeking induced abortion is that the pregnancy was unplanned or unwanted. However, the numerous social, economic and health circumstances that underlie such explanation have not yet been fully explored.
Findings from 32 studies in 27 countries were used to examine the reasons that women give for having an abortion, regional patterns in these reasons and the relationship between the given reasons and women's social and demographic characteristics. The most commonly reported reason women cite for having an abortion is to postpone or stop childbearing. The second most common reason includes disruption of education or employment; lack of support from the husband; desire to provide schooling for existing children; and poverty, unemployment or inability to afford additional children. In addition, relationship problems with the husband or partner and a woman's perception that she is too young are other important categories of reasons. With few exceptions, older women and married women are the most likely to identify limiting childbearing as their main reason for abortion (Bankole, Sing and Haas, 1998).
In the Dabash et al study (2004) in Latin American and Caribbean Countries (LAC); providers suggested several main reasons for which women seek abortion in their countries. These included poverty (50%), sexual violence (49%), lack of preparedness on the part of women to have a child (40%), and lack of sufficient access to contraceptive information and/or services (31%). Some (40%) providers believed that the need for abortion was indicative of irresponsibility on the part of women. Despite broad recognition of the highly restrictive abortion legislation in most of the association countries, the majority (57%) of providers still perceived women who physically or chemically induce an abortion as irresponsible.
A 2003 study in Brazil on attitudes towards abortion compared opinions of teenage women who had aborted, women who had considered abortion but ultimately did not abort, and women who did not abort. Initially, teens who had aborted and who had considered abortion were more tolerant of abortion than those who did not abort; however, their acceptance level decreased over time. Over the one-year follow-up period, the teens that did not consider abortion became more accepting of abortion. On average, across the three groups, 66% thought that an abortion was justified when the woman's life or health was in danger, 63% thought it was justified in the case of rape, and 47% felt that it was justified in the case of congenital anomalies (Bailey et al, 2003).
Later in the same year, Faúndes et al (2003) surveyed a national sample of 4,261 Brazilian obstetricians-gynecologists (OB-GYNs) about abortion, asking participants whether they had helped their patients or relatives to have an abortion, and whether they themselves had had an abortion. The authors found that the respondents were progressively more accepting of legal abortion the closer they were to the person with the unwanted pregnancy: 41% of respondents had helped a patient to obtain an abortion, 49% had helped a relative to obtain an abortion, 78% of female physicians had obtained an abortion when they themselves had an unwanted pregnancy, and 80% of male physicians had helped their partners to obtain abortions. The vast majority of participants believed abortion should be legal if the woman's life is at risk (79%), if the pregnancy resulted from rape (80%), and in cases of fetal malformation (77%). Younger respondents were less supportive of abortion when confronted with unwanted pregnancies of patients or relatives, and twice as many physicians with no religious beliefs had helped patients or relatives to have an abortion compared to physicians to whom religion was very important. Nevertheless, when the physician herself or the male physician's partner had an unwanted pregnancy, almost 70% of those to whom religion was very important had had an abortion.
A case control study was conducted to elucidate how contraceptive attitudes among Danish-born and immigrant women influence the request of induced abortion. The case group comprised 1095 Danish-born women and 233 immigrant women requesting abortion, in comparison with a control group of 1295 pregnant women intending to give birth. The analysis used hospital-based questionnaire interviews. Lack of contraceptive knowledge and experience of contraceptive problems were associated with the choice of abortion. This association was most pronounced among immigrant women, where women lacking knowledge had a 6-fold increased odds ratio (OR) and women having experienced problems a 5-fold increased OR for requesting abortion. Further, in this group of women, a partner's negative attitude towards contraception was associated with an 8-fold increased OR for requesting abortion. Contraceptive failure was prevalent; 21% of the women who did not plan to become pregnant but intended to give birth had experienced contraceptive failure. The same applied, respectively, for 45% of the Danish-born women and 36% of immigrant women, who requested abortion. Women who had experienced contraceptive failure were significantly more likely to request abortion (Rasch et al, 2007).
A study was conducted in one of the villages in India to assess the knowledge, attitude and practices about family planning among women of Manipur (India). Respondents were asked about the conditions under which they would approve/disapprove of abortion. They were addressed with four conditions including; likelihood of infant deformity, economic hardship of parents (unaffordable), rape, and contraceptive method failure. Respondents’ approval of abortion ranged between 82% in the case of parents economic hardship to 66% in contraceptive method failure (Mao, 2007).
2.5 Attitudes towards legality of abortion
To document opinions and decision-making strategies of young adults regarding abortions for young women 89 male and 215 female college students completed a questionnaire on abortion during routine visits to their university health center. Among the salient findings, most respondents took a pro-abortion stance for girls under 18 in cases of rape (92% of students), incest (90%), or danger to the girl's health (90%). A much lower priority was given for abortion in cases of fetal abnormalities (55% of students), economic hardship (51%), or for girls who were married (55%). Abortion was considered acceptable regardless of circumstances by 46% of students and never a good idea by 18%. 90% of students agreed on the outcome of unplanned pregnancies for minors should be decided by the girl herself, 55% for the partner, 29% for the parents, 8% for the state or federal law. Abortions for minors should require parental notification (45%) or consent (33%). Although only one student felt illegal abortions were safe, 19% would seek this kind of abortion and 4% of females would try to cause their own miscarriage if abortions were outlawed in the United States. The study concludes that the vast majority of young adults believed that girls under 18 should retain the right to decide the outcome of their pregnancy and should not be subjected to governmental restrictions. The highest priority for abortion was given to girls who had been victimized or whose health was at risk. Although nearly all respondents are aware of the hazards of criminal abortions, many would resort to such unsafe practices if legal alternatives were no longer available (Gondar et al, 1996).
In a comparative study between USA and Greece using data from 1,494 Greeks and 1,993 Americans, it was found that social abortion attitudes are a separate dimension from physical abortion attitudes. According to the study abortion attitudes are influenced significantly by religiosity and sexual liberalism. Three major differences between Greece and the United States were observed. First, in Greece religiosity has a smaller impact on sexual liberalism, and sexual liberalism has a much weaker impact on both types of abortion attitudes, particularly social abortion attitudes. Second, in Greece religiosity is more strongly related to abortion attitudes than in the United States, particularly to social abortion attitudes. Third, education has a weaker influence on abortion attitudes in Greece than in the United States (Bahr & Marcos, 2003).
One Irish study argues that the individualistic approach to abortion as a health issue for individual women has led to emphasis being placed on the potentially negative psychological effects of the procedure. This in turn- the study maintains-created an impression of abortion as intrinsically risky for women and therefore a very limited account of the relationship between the social context in which women experience abortion and their responses to it has been largely neglected. A rare qualitative study investigates the experience of seven women from Northern Ireland (where abortion is very restricted) who had traveled to England for abortions. The analysis revealed strong links between the women's experience and the very negative public constructions of abortion in Northern Ireland (Boyle & McEvoy, 1998).
Between September 2003 and May 2004 a quantitative assessment of IPPF staff and provider knowledge, attitudes and practices was carried out in 6 Latin America and the Caribbean associations (1,811 staff, including 799 clinical providers in 74 association sites). Eight in ten providers characterized complications of unsafe abortion, including mortality as a “very serious” health problem in their setting. The vast majority (83%) of providers also agreed that greater access to abortion services could reduce maternal mortality. While most providers (67%) agreed that expansion of access to quality abortion services was a key step to reducing the toll of unsafe abortion, only half of providers believed that their association should be directly involved in the provision of safe abortion services to meet that need. A considerable proportion of providers (44%) said that they personally would not feel comfortable working in a site that performed terminations of pregnancy. Providers working in associations under restrictive abortion legislation were more likely report this discomfort than those working in either a setting where abortion was either fairly permissible or highly restricted. One in three providers said they believed abortion to be a sin. Only four in 10 providers surveyed said they would support the decision of a friend or relative to terminate an unwanted pregnancy (Dabash et al, 2004).
In the year 2006, one rare Palestinian study investigated attitudes of 146 never married female students at Bethlehem University toward abortion and "honor killing". The survey instrument comprised of 125 questions and was divided into five sections. In the fourth section five separate hypothetical situations were presented and then a series of attitudinal, opinion, and knowledge assessment questions were posed. Participants were asked to reflect on how they would react to and advise a friend who became pregnant outside of marriage. Of those who responded to the question, 15.1% would advise the friend to get an abortion; 42.5% would advise her to try to get married immediately and if unsuccessful to get an abortion. Approximately 25% of the participants discussed the threat of “honor killings” and explained that the friend would have to have an abortion to both preserve the honor of her family and protect herself.
As for the participants overall knowledge about abortion, sought responses reveal considerable information gaps among the study participants with regards to permissibility and availability of abortion in Palestine which they appear to have confused with their own personal wishes and expectations. According to the study, the majority reported abortion being permissible for married women in a limited number of circumstances including when the pregnancy threatens the woman’s physical health or in cases of fetal impairment, and always permissible if the woman is unmarried as she has engaged in illicit sex and therefore is already engaged in a prohibited act. Further, approximately one fourth reported that abortion was not only permissible but also obligatory for unmarried women, as these women needed to protect themselves from so-called “honor-killings”. Interestingly, however, participants reported limited knowledge of abortion services and about 10% suggested that unmarried women self-induce abortions with a variety of medicinal and physical techniques (Foster et al, 2006).
Abortion is generally more restricted in developing countries than in developed countries. Sixteen percent of developing countries and 67% of developed countries permit abortion upon request. Abortion is permitted in virtually every country at least to save the life of the pregnant woman as the case is in Palestine for example (Population Reference Bureau, 2006).
Until April 1990, abortion was illegal in Belgium; still, in 1982, researchers estimated that 13,400-15,900 abortions were performed each year in public and private hospitals, abortion clinics, and family planning and abortion centers in Brussels and Wallonia. Recent estimates indicate that around 60% of abortions are performed in outpatient facilities, 32% in hospitals, and about 8% in private clinics in Belgium. The providers' personal, psychological, and ethical reactions to abortion were investigated in Belgium before and after abortion were made legal. 143 standardized questionnaires were completed: 86 by women and 57 by men. Nearly half of the respondents were physicians. The questionnaires covered aspects of the provision of medical abortion: 1) providers' objective reactions to the organization of services; 2) providers' subjective reactions to abortion service, including self-image, perception of legal restrictions, and perception of clients’ attitudes, personal values, personal motivations, and feelings about their own role in the practice. Many of those who had decided to work in abortion services initially considered doing so to be a normal part of their job to help women cope with unwanted pregnancies. Nearly two-thirds of the respondents expressed a negative emotional reaction to requests for repeat abortions; one-third was accepting or neutral. 70% of physicians appeared to be emotionally affected by repeat abortions compared to 47% of non-physicians. 95% of all 143 respondents expressed the view that conscientious objection to performing abortion is legitimate (Donnay et al, 1993).
In the same aforementioned IPPF study, the majority of providers (71%) in support of liberalization of abortion legislation were only in favor of nominal liberalization of the law to allow women the right to access abortion services under certain very restricted circumstances. The majority said they believed that women should have legal access to abortion under specific conditions, such as to save a women’s life (92%), in cases of sexual violence such as rape or incest (85%), in cases of fetal malformation (82%), or in case of endangerment to the health of the mother (69%). Half said that it should also be allowed in cases of financial hardship but only 28% believed that it should be legally permitted in case of contraceptive failure. Very few providers (4%) accepted the idea that a woman should be legally allowed to terminate a pregnancy because it could negatively impact her career (Dabash et al, 2004).
A total of 572 randomly selected obstetrician-gynecologists affiliated with the Brazilian Federation of Obstetricians and Gynecologists participated in a survey investigating their knowledge, attitudes and practices (KAP) about abortion law. Except for rape, more physicians believed that abortion should be legal than believed abortion is currently legal. In the case of rape, almost all (93%) correctly identified that abortion is legal and a lesser percentage (85%) thought that it should be legal. A sizeable difference emerged in the case of severe fetal malformations, where 36% of physicians incorrectly believed that it was a legal case for abortion, while 89% thought that abortion should be legal in this case. The study observed a similarly large difference when the woman's health is at risk; 7% incorrectly thought that the law currently allowed for an abortion in this case, whereas 30% of physicians thought that abortion should be legal in this case (Goldman et al, 2005).
2.6 Feelings and attitude of women post –abortion
The weight of evidence suggests that women who freely choose to terminate a pregnancy are unlikely to experience significant mental health risks. However, some studies have documented psychological distress in the form of posttraumatic stress disorder (PTSD) and depression in the aftermath of termination.
Choice of anesthesia has been suggested as a determinant of post–abortion outcome. One study compared the effects of local anesthesia and intravenous sedation, administered for elective surgical termination, on outcomes of pain, cortisol and psychological distress. A total of 155 women were recruited from a private abortion clinic and state hospital (mean age: 25.4 ± 6.1 years) and assessed on various symptom domains, using both clinician-administered interviews and self-report measures just prior to termination, immediately post-procedure, and at 1 month and 3 months post-procedure. Morning salivary cortisol assays were collected prior to anesthesia and termination. The group who received local anesthetic demonstrated higher baseline cortisol levels (mean = 4.7 vs. 0.2), more dissociative symptoms immediately post-termination (mean = 14.7 vs 7.3), and higher levels of pain before (mean = 4.9 vs. 3.0) and during the procedure (mean = 8.0 vs. 4.4). However, in the longer-term (1 and 3 months), there were no significant differences in pain, psychological outcomes (PTSD, depression, self-esteem, state anxiety). More than 65% of the variance in PTSD symptoms at 3 months could be explained by baseline PTSD symptom severity and disability, and post-termination dissociative symptoms. Of interest was the finding that pre-procedural cortisol levels were positively correlated with PTSD symptoms at both 1 and 3 months.
The study concludes that high rates of PTSD characterize women who have undergone surgical abortions (almost one fifth of the sample meet criteria for PTSD), with women who receive local anesthetic experiencing more severe acute reactions. The choice of anesthetic, however, does not appear to impact on longer-term psychiatric outcomes or functional status (Suleiman et al, 2007).
2.7 Physical consequences of induced abortion
Some women rely on unskilled providers for pregnancy termination, even though medical services are available. While menstrual regulation is available in rural health facilities in Bangladesh, one study in 1996 showed that only 58 of 143 women seeking abortion turned first to health facilities, while others saw two or three providers; in the end, four of the women had to be referred to the district hospital with serious complications, and one died. Untrained practitioners included; homeopaths, herbalists, religious healers, village doctors, relatives and traditional birth attendants (Adhikari, 1996).
A study in Ilorin, Nigeria, in 1992–1994, which included 144 women who underwent abortion, half of whom were under 20 years of age, reported typical complications: death, 9%; sepsis, 27%; anaemia (haemorrhage), 13%; sepsis with anaemia, 3%; cervical tear, 5%; pelvic abscess, 3%; uterine perforation with peritonitis, 3%; injury to gut, 4%; chemical vaginitis, 4%; laceration of vaginal wall, 3%; and vesicovaginal fistula, 1%. Only 25% had no complications (Adu, 1996).
Severe complications, such as sepsis, haemorrhage, genital and abdominal trauma, perforated uterus and poisoning due to ingestion of harmful substances, may be fatal if left untreated. Death may also result from secondary complications such as acute renal failure. Unsafe abortion may lead to reproductive tract infections (RTIs), chronic pelvic pain, pelvic inflammatory disease (PID), and at times to infertility; genital trauma and infection may also warrant an immediate hysterectomy. An increased risk of ectopic pregnancy, premature delivery, or spontaneous abortion in subsequent pregnancies is another possible consequence of a poorly performed abortion. Women with a sexually transmitted infection (STI) are at increased risk of an ascending post abortion infection (Agadjanian & Qian, 1997; Agadjanian, 1998).
Studies indicate that about 20–30% of unsafe abortions may lead to RTI, of which between 20% and 40% lead to PID and consequent infertility. It has been estimated that the prevalence of infertility and long-term RTI as a consequence of unsafe abortion corresponds to 2% and 5%, respectively, of women of reproductive age (Ahiadeke, 2001).
Whereas a spontaneous or an uncomplicated abortion may require up to three days of hospitalization, complicated cases may need a hospital stay five times longer. The treatment of abortion complications in hospital consumes a significant share of resources, including hospital beds, blood supply, and medication, and often requires access to operating theatres, anesthesia and medical specialists. Thus, the consequences of unsafe abortion place great demands on the scarce clinical, material and financial resources of hospitals in many developing countries (Akin & Ergör, 1997).
Major social, financial and emotional costs are also incurred by the women who undergo unsafe abortion.
2.8 Post-abortion complications
A Mexican study focuses on lowest income Mexican women who attended for abortion-related complications in a public hospital. The objective was to investigate the women’s experience of having a spontaneous abortion and their related strategies to avoid stigmatization. Four strategies emerge from women’s testimonies: presenting themselves as women who "play by the rules," insisting on ignorance of the pregnancy, stating that they had already accepted their pregnancy, or presenting the abortion as the result of an accident. Women use these strategies to deflect any blame to which they might be subjected to and as a means of dealing with the stigma attached to a behavior that breaches social norms regarding reproduction. Far from being passive receptors of the social imperative, which makes motherhood compulsory; women fluctuate strategically within the margins of a seemingly uniform normative discourse and thereby ensure their moral survival (Erviti, Castro, and Collado, 2004).
In some areas of the developing world, as many as half of the admissions to hospital gynecological wards, are women in need of treatment after unsafe abortions. Women who seek medical treatment after an unsafe abortion may require extended hospital stays, ranging from several days to several weeks. This consumes hospital resources, including personnel time, bed space, medications, and blood supply. Studies show that hospitals in some developing countries spend as much as 50 percent of their budgets to treat complications of unsafe abortion (Population Reference Bureau, 2006).
In 2000 the Senegalese Ministry of Health introduced integrated post-abortion care (PAC) services in lower-level health facilities in rural areas of Senegal where the need is greatest. Data collection took place both prior to the intervention and 14 months later and included client and provider interviews, facility observations, and service statistics. Baseline findings revealed several problems: only one-third of the doctors and midwives who regularly provided PAC services at district health centers were trained; available services were poor in quality with little pain control for clients; and there was no integration with other reproductive health services, including family planning.
The intervention included training for doctors and midwives at district health centers on management of abortion complications, including the use of manual vacuum aspiration (MVA) with local anesthesia. Along with the health center staff, nurses from health posts participated in workshops on PAC counseling, including family planning and other reproductive health counseling, and contraceptive technology updates. Major findings indicated that integrated PAC services were successfully introduced in all six district health centers. There was an overall increase in the number of PAC cases managed by the district health centers after 14 months (460 versus 373, a 23% increase). The majority of clients (57%) receiving PAC services were treated with MVA with local anesthesia instead of digital curettage or manual evacuation typically performed without anesthesia. The proportion of health center PAC clients referred by health posts more than doubled after the intervention (from 13% to 31%).
Integration of family planning counseling and services with PAC resulted in increased access to family planning information and informed method choice. Nearly twice as many PAC clients reported receiving family planning counseling after the intervention than at baseline (70% versus 38%). PAC clients had access to condoms, pills, injectables, and implants at all health centers. Twenty percent of all PAC clients left the facility with a modern contraceptive method versus none at baseline as clients received only referrals.
2.9 Provision of abortion services
In the Belgium study previously mentioned where 143 providers were investigated, the providers believed that various factors affect the quality of abortion services, as reported by 109 providers, including the high number of abortions performed; a high turnover of personnel (22% and 41%, respectively); lack of staff collaboration (20% and 11%); and the legal situation (4% and 8%) (Donnay et al, 993).
Around a decade later, in 2002, the Ministry of Health in Mozambique conducted an assessment of abortion services in the public health sector to inform efforts to make abortion safer. Interviews were held with a total of 461 women receiving treatment for abortion-related complications in 37 public hospitals and four health centers in the ten provinces of Mozambique. One head of both uterine evacuation and contraceptive services at each facility was also interviewed, and 128 providers were interviewed on abortion training and attitudes. Women reported lengthy waiting times from arrival to treatment, far longer than heads of uterine evacuation services reported. Similarly, fewer women reported being offered pain medication than head staff members thought was usual. Less than half the women said they received follow-up care information, and only 27% of women wanting to avoid pregnancy said they had received a contraceptive method. Clinical procedures such as universal precautions to prevent infection were less than adequate, in-service training was less than comprehensive in most cases, and few facilities reviewed major complications or deaths. Use of dilatation and curettage was far more common than medical or aspiration abortion methods (Gallo et al, 2004).
Physicians surveyed in the LAC IPPF-providers study had the most experience using D&C (66%), misoprostol (55%) and MVA (42%). Many physicians reported having received formal training in use of these methods for the treatment of abortion complications. Few of the physicians (8%) surveyed reported that they were already providing any first trimester abortion services to clients. The majority (67%) of those providing termination of pregnancy services said they were mostly doing so in their private facilities. A minority (18%) of those providing services were doing so at the IPPF association.
Despite provider recognition that women may prefer medical methods of abortion (59%), physicians showed strong preference for surgical methods as well as misconceptions about the safety and efficacy of medical methods such as mifepristone and misoprostol, with which they had considerably less experience. Six in 10 physicians said that they would prefer to use surgical methods should they offer termination of pregnancy services and 8 in 10 of physician preferred surgical methods to medical methods for treatment of incomplete abortion.
In the same study still, in regards with building individual and site capacity to address unsafe abortion, providers noted many challenges to expanding surgical abortion services in their facilities, including some perceived resistance from colleagues (18%). More providers were concerned with the limitations imposed by restrictive national or state legislation (66%), insufficient provider training (27.5%), lack of clear institutional guidelines and protocols for abortions services (38%), and the scarcity of necessary equipment and supplies (33%). Despite the fact that 48% of physicians and 39% of other providers reported feeling that the introduction of abortion services would greatly increase the workload of staff and providers, only 10% reported this to be a major challenge to expansion (Dabash et al, 2004).
Composite findings from the Pakistani unsafe abortion research project indicate that government facilities bear the burden of the caseload from abortion complications, averaging one or two per day. In the hospitals and other health facilities, the women receive a variety of treatments, depending on the nature of the complication from which they are suffering. The Health Facilities Survey provided information on the types of procedures and treatments they offer. Antibiotics are offered at virtually all facilities. Dilatation and curettage (D&C) is also usually available (89% of facilities), as is evacuation and curettage (E&C) (86% of facilities). Blood transfusion and surgery other than D&C are also available at a majority of the facilities (83% and 68%, respectively).
Parallel information was gathered in the Post-Abortion Survey, which sampled women who had received care at a facility (either an induced abortion or care for a post-abortion complication). These women were asked what care they actually received for post-abortion complications. Virtually all of them received “medicines” (91%), presumably antibiotics and painkillers. Of more consequence, 68% report that they were hospitalized, and 54% report having undergone a D&C (Population Council, 2004).
One Nigerian study examined the practice of private medical practitioners in Calabar on abortion, post-abortion care and post-abortion family planning. Forty eight private practitioners who were proprietors of private clinics in the city were interviewed using a structured questionnaire. The results showed that 22.9% of the doctors routinely terminate unwanted pregnancies when requested to do so by women, while 83.3% of them treat women who experience complications of unsafe abortion. The major reasons given by some of the doctors for not terminating unwanted pregnancies were religious, moral and ethical considerations rather than respect for the Nigerian abortion law. Only 18.2% of the doctors use standard procedures such as manual vacuum aspiration (MVA) for the management of patients with abortion and abortion complications. A good number of them did not routinely practice integrated post-abortion family planning and STDs management. The study concludes that there is need for a comprehensive programme of retraining of private medical practitioners in Calabar on the principles and practices of safe abortion, post-abortion care and family planning (Etuk, Ebong, and Okonofua, 2003).
2.10 Methods of induced abortion
The composite research findings from the Pakistani huge study uncovered many different procedures that are employed in Pakistan to induce abortion. In the Health Professionals Survey, the respondents were asked to list the techniques that are used. About twenty-five were mentioned (some of low efficacy and/or with serious health risks), falling into three groups: surgical, vaginal (drugs or instruments) and oral. The health professionals were then asked to select the two procedures that, in their opinion, are used most frequently for inducing abortion in Pakistan. The five procedures named most often are D&C and various forms of intra-uterine sticks were most commonly cited as procedures used to induce abortions. Intra-uterine sticks include a variety of intra-uterine objects, such as knitting needles, catheter and bamboo sticks. IUCD while well known as a contraceptive method, in this instance was being used to induce an abortion.
Similar procedures were reported by women interviewed in the Post-Abortion Survey. However, as this sample of women was drawn disproportionately from NGO clinics that rely heavily on the Manual Vacuum Aspiration (MVA) technique, this was the second most common technique that they reported. MVA was included among the twenty five techniques listed by the health professionals, but very few of the health professionals identified MVA as one of the two most common procedures. Medical abortion (pills) is also named more often by the women in the Post-Abortion Survey than by health professionals.
The Health Professionals Survey also asked about the techniques that women themselves use to induce abortion. The techniques mentioned are; drugs such as hormones and analgesics, herbs taken orally or inserted into vagina and other methods including insertion of objects, heavy exercise, heavy massage on abdomen and hot dietary items such as dry dates, eggs or cheese (Population Council, 2004).
In an Egyptian study, researchers used random sampling procedures to select 569 public-sector hospitals in Egypt, and asked designated medical staff to complete a medical abstract form for each post-abortion patient admission during a continuous 30-day period. Data were analyzed to assess the state of post-abortion care in Egypt, and using data from the 1995 Egypt Demographic and Health Survey and other sources, to estimate the rate of induced abortion in Egypt. Among the 22,656 admissions to the obstetrics and gynecology departments during the 30-day study period, approximately one of every five patients (19%) was a woman admitted for treatment of an induced or spontaneous abortion. Projections yielded an estimated induced abortion rate in Egypt of 14.8 per 100 pregnancies. The mean gestational age of the lost pregnancies was 10.8 weeks, and a large majority (86%) was lost at 12 weeks or less. Fourteen percent of the women arrived at the hospital suffering from excessive blood loss, 1% exhibited one or more signs of physical trauma and 5% had one or more signs of infection. Dilatation and curettage under general anesthesia was the principal surgical treatment provided. The study concludes that treatment for complications from unsafe abortion consumes substantial resources within the Egyptian health care system. Post-abortion care could be improved if vacuum aspiration under local anesthesia were used as the primary post-abortion treatment, and if adherence to antiseptic measures were increased (Huntington et al, 1998).
An investigation of choice of and satisfaction with methods of medical and surgical abortion among U.S. clinic patients included 304 women participating in a clinical trial of medical abortion, 186 received a methotrexate-induced abortion and 118 were offered the option of a medical abortion but chose a surgical procedure instead. Study participants completed self-administered questionnaires before the abortion and again at a follow-up visit. Women were more likely to choose medical abortion if they placed greater importance on a method that was non surgical, one that resembled a miscarriage or one that could take place at home (odds ratios, 2.0-3.3). Conversely, women were less likely to choose medical abortion if they valued methods that were quick, that did not involve painful cramping or seeing blood or blood clots and that needed a doctor or nurse to be present (odds ratios, 0.3-0.5). Compared with those who had a surgical abortion, women who had a methotrexate-induced abortion expected more bleeding (mean scores, 3.5 vs. 3.1) and reported more pain (3.4 vs. 2.9), heavier bleeding (3.4 vs. 2.5) and bleeding of longer duration (3.3 vs. 2.6). The overwhelming majority of women in the medical and surgical abortion groups reported that they were either very or somewhat satisfied with their abortion method (81% and 82%, respectively), would recommend it to others (82% and 78%) and would choose the method again (89% and 93%). The study concludes that factors affecting the choice of abortion method appear to be numerous and complex. This means that providers need to be sensitive to differences in women's values and life circumstances when counseling them about an abortion method (Harvey, Beckman, and Satre, 2001).
A later American study describes present methods for induced abortion used in the United States. The most common procedure is first-trimester vacuum curettage. Analgesia is usually provided with a Para cervical block and is not completely effective. Pre treatment with non-steroidal analgesics and conscious sedation augment analgesia but only to a modest extent. Cervical dilation is accomplished with conventional tapered dilators, hygroscopic dilators, or misoprostol. Manual vacuum curettage is as safe and effective as the electric uterine aspirator for procedures through 10 weeks of gestation. Early abortion with mifepristone/misoprostol combinations is replacing some surgical abortions. Twelve percent of abortions are performed in the second trimester, the majority of these by dilation and evacuation (D&E) after laminaria dilation of the cervix. Uterine evacuation is accomplished with heavy ovum forceps augmented by 14–16 mm vacuum cannula systems. Cervical injection of dilute vasopressin reduces blood loss. Operative ultra-sonography is reported to reduce perforation risk of D&E. Dilation and evacuation procedures have evolved to include intact D&E and combination methods for more advanced gestations. Vaginal misoprostol is as effective as dinoprostone for second-trimester labor-induction abortion and appears to be replacing older methods. Mifepristone/misoprostol combinations appear more effective than misoprostol alone. Uterine rupture has been reported in women with uterine scars with misoprostol abortion in the second trimester. Fetal intra-cardiac injection to reduce multiple pregnancies or selectively abort an anomalous twin is accepted therapy (Stubblefield, Carr-Ellis, and Borgatta, 2004).
This descriptive exploratory study has utilized quantitative and qualitative methods for data collection methods in a complementary manner to comprehensively cover the research components. A description of the quantitative and qualitative data and construction of the study tools, sampling frame, data collection procedures, access and ethical consideration, data analysis procedures and study limitation will be presented in this chapter.
3.1 Data sources
Upon drafting this baseline survey Term of Reference (TORs) by PFPPA and through phone calls and one meeting between the society and the research team leader, a detailed TOR was reviewed and finalized, methodology was explained and support was sought. There were three sources for data collection in this study:
3.2 Study approach and design
Construction of the study tools
3.2.1 Construction of the women questionnaire (refer to annex A)
The purpose of this tool was to assess demographic and socioeconomic conditions of the surveyed women followed by questions reflected their knowledge and attitudes regarding their SRH with emphasis on FP methods and abortion issues. The questionnaire was constructed under subcategories and composed of 71 statements or items, there are 42 items arranged in a Likert scale at 4-point response format; these items reflected women’s knowledge on accessibility and use of family planning methods and emergency contraception, attitudes toward abortion issues regarding its legality, reasons for women to seek abortion, and psychological and emotional attitude of women post–abortion. The other 29 items were arranged in a 3-point response format reflected the participants’ stance on abortion/post abortion care and services available, physical complications and consequences of abortion. The women were given a chance to comment or ask questions through the interview to gain insight of their subjectivity of the topics presented during the interview with the data collector.
The tool reliability and validity
Reliability of the tool was obtained on 52 questionnaires as pilot study first, reliability Cronbach's coefficient alpha was established for each subcategory; for items related to family planning methods, abortion issues regarding its legality, reasons for women to seek abortion, and psychological and emotional attitude of women post–abortion the coefficient alpha ranged from =.78-.84.4. The reliability coefficient alpha and to less extent has varied from =.59-.66.5 on abortion/post abortion care and services available, physical complications and consequences of abortion. Cronbach's Alpha assesses the internal consistency of the instrument by correlating each item with all other possible combinations of other items (Nunnally, 1987), Polit and Hungler (2003) added that alpha provides a good indication of internal consistency as long as the items on the scale are all related to one concept. The goal for the study instrument was to achieve reliability coefficients alpha around =.70. This alpha represents a respectable alpha for a newly developed scale, but would be problematic if the scale was well established (Polit and Hungler, 2003).
The content validity was established by giving the questionnaire to three local experts; one in research, and the other two are women’s health specialist who have examined the instrument in both languages Arabic and English, and according to their comments, the study researcher made the changes required where rewording, adding or deleting some items was needed. The tool was developed in English first; then translated into Arabic language to collect the data for the pilot study to ensure its reliability again prior to its distribution on the study participants. The items were adopted or modified from international tools and literature to meet the study concepts and objectives.
3.2.2 In-depth interview discussion with UNRWA health Providers (refer to Annex B)
In-depth interviews were conducted with UNRWA Health clinics personnel; one with the field family health officer at UNRWA headquarters, 3 physicians and 7 nurses in charge of the maternal clinics in the targeted camps. The semi-structured interview format covered the following areas; SRH services offered to women in reproductive age (15-49) which included family planning and emergency contraception, abortion/unwanted pregnancy and post abortion care, counseling and education activities and UNRWA community involvement with local camp institutions/centers on these issues. Level of administrative and decision maker’s involvement to promote women's rights regarding SRH and gender issue. Difficulties and constraints they face and lastly their future recommendation regarding health policies and services to decline abortion/unwanted pregnancy incidence within the scope of their work
3.2.3 In-depth interviews discussion with community centers leaders (refer to Annex C)
In-depth interviews were conducted with 13 community centers’ leaders at the targeted camps. The semi-structured interview format covered the following areas; the centers involvement in offering SRH services and awareness programs for women in reproductive age (15-49) with emphasis on family planning and emergency contraception, abortion and post abortion issues. Questions related to difficulties and constraints when dealing with the issue of abortion at the women and community level, and their cooperation with UNRWA services regarding this issue. In addition, they were asked about their recommendation for future strategies and policies to reduce the incidence of abortion and to promote women’s SRH and gender issues within the scope of these centers work
3.3 The Sampling Frame
The sampling procedure was designed to produce representative samples of camps and the households in each camp. To have a representative sample for the target population under study and in consultation with the statistician, two random selection procedures were done; one for the camps and the other for the households in each randomly selected camp. The probability sampling method was utilized to select the targeted camps, and the household selected in each camp. The probability sampling method has utilized a statistical procedure that allowed for weighting the sample to be selected from each camp. In other words, the number of women interviewed in their households for quantitative data in each camp was proportional to camp size taking into consideration the sample size (300-350) required by the TOR (for details of the sampling procedures, please refer to annex F). 11 camps out of 19 camps in WB and 333 households out of 24205 households in those 11 camps were selected (the married women in each household were selected for the study)
3.4 Data collection procedures
The data collection from the study participants was obtained after one day training workshop held with the data collectors. There were 9 data collectors and two supervisors whom followed on and supervised the field work and conducted the in-depth interviews in each camp clinic and women’s centers. A total number of 333 questionnaires were collected from randomly selected households in 11 randomly selected camps in the West Bank. Please refer to (table 1) for name of camps and the number of participants in each camp. The researcher of the study and the field data collectors has coordinated the activities to have a consensus on obtaining the data from respondents as close as possible. To this end, they explained the purpose of the interviews, encouraged all participants to voice their opinions and explain the available services they offer to promote women SRH and reduce abortion incidence. The questionnaires were initially sent to be discussed with both PFPPA and UNRWA personnel for suggestions prior to its distribution
Table 1: Name of the camps and number of participants in each camp
3.5 Access and Ethical Consideration
Gaining access to the 11 targeted UNRWA clinics was granted by the General Director of Health at UNRWA Headquarter after being approached formally by the PFPPA management team and the investigator describing the purpose of the study. All responses to quantitative and qualitative questionnaires were sought on voluntary basis. Participants were ensured anonymity and confidentially and that results and conclusions made through information received will be used for the research purposes only. The camps have local committees that need to be approached prior to conducting household surveys because UNRWA permission is authorized to access the clinics only. (Please refer to the letter of agreement attached with the questionnaire in annex A)
3.6 Data entry and analysis procedures
The data entry and analysis was of two types;
After the data collection was carried out, the complied data was entered, cleaned, and analyzed by using SPSS program (Statistical package for Social Science). The data results was compiled into tables, and interpretation of those results will be analyzed in depth and reported into narrative style in the analysis chapter. Descriptive statistics was utilized for the demographic data and analytical statistics utilized the T test and level of significance for the items presented under each category of the questionnaire.
The qualitative data analysis was a thematic analysis approach that is guided by the objectives and key questions of the in-depth interviews. Bogdan and Biklen (1998) describe qualitative data analysis as “the process of qualitative data analysis is like a funnel, things are open at the beginning (or top) and more directed and specific at the bottom". All the data collected including the field notes and the personal comments was assembled and carefully read through and thoroughly until the investigator become intimately familiar with them. This process has facilitated the formation of the themes by clustering and coding the statements expressed by the respondents under each question. Also the findings will be compared and contrasted with existing literature and other theoretical perspective of the proposed study
3.7 Study limitation
Accessing camps households was problematic in some camps as the case in Jalazoon and one camp in the south that needed to have a permission from the camps committee to study the questionnaire prior going into the houses and this delayed the data collection in these two camps for one week.
The in-depth interviews with some UNRWA health employees were delayed and their feedback on the questionnaires was not obtained. Additionally, interviewing the health providers at the clinics were added during the data collection phase to have a clear understanding of the services provided for the women’s SRH and abortion issues
Analysis and Findings
This chapter presents analysis and interpretation of the quantitative and qualitative data results. Descriptive statistics were utilized to analyze the socio-demographic variables in frequencies and percentages. Statistical analysis procedures were utilized for questionnaire items which are ranked in ordinal measure of frequency and percents and presented in tables. The in-depth interviews discussion with UNRWA health providers and community leaders are presented in thematic approach and presented sequentially according to the semi structured question.
4.1 Statistical analysis and results
4.1.1 Socio-demographic data
The profile of the participants’ socio-demographic variables was obtained for women’s participants’ age, age at marriage, family type, number of pregnancies, number of children, work and education as well as their husbands’ work and education and average income of households (NIS) per month. It is worth mentioning that the socio-demographic variables were not manipulated or correlated with the dependent variables. They were presented to give an idea about the participants’ socio-demographic characteristics.
The age of the women who participated in this study has ranged from 14 - 49 years, with a mean of 32.7 and mode of 30 years.
The women’s participant age at marriage has ranged from 13 to 36 years, with a mean of 19.4, and mode 18 years (table 2). 30.6% of the surveyed women were married between the ages 13-17 years, a very large proportion and very small age. 52.5% were married between 18-22 years, and 13.5% were married at an age 23-27 and very few 3% were married later at an age between 28-36 years.
Table 2: Women’s participants’ age at marriage
Family type (table 3), the PCBS survey (2002) indicated that the nuclear families comprise 81.4% compared to 18.6% extended families for the general population which differs largely with the given figures of this survey where nuclear families comprises 69.1% compared to 29.4% extended families.
Table 3: Family type
Number of pregnancies (table 4); since the study aims to identify abortion indicators for women camps, the participants were asked about the number of pregnancy to allow for further knowledge of the women’s reproductive conditions. Pregnancy among surveyed women has ranged from 0 to 16 times; 38.7% had 3-5 pregnancies, 29.7% had 6-9 times, 19% had 1-2 times and 11.7% their pregnancy ranged from 10-16 times during their marriage life. There was one lady only who did not get pregnant.
Table 4: Number of pregnancies
Number of children (table 5); the number of children for the surveyed women has ranged from (0 – 14); the majority 57% are having 2-5 children, 23.1% are having 6-9 children, 6.3% are having 10-14 children, 11% has one child and 1.8% have no children.
Table 5: Number of children
The employment and economy categories; 18.3% of the surveyed women and 83.8% of their husbands were having a job vs. 15.3% of husbands were not. These numbers shows improvements in the unemployment rate which was 38.1% for males and 11% for females in 2002 (ICPD, 2004). According to World Bank estimates in 2005, approximately two-thirds of the Palestinian population lives under the poverty line ($2/day), this fact is evidenced by the average income per household surveyed was 1599 NIS/month and a median of 1000 NIS or 1500 NIS, and ranged from 0- 7000 NIS.
The level of the husband’s education (table 6) indicates that 62.5% of the women’s husbands have completed their High school (Tawjihi), which means 12 years of schooling. Tawjihi is considered a turning point in individuals lives whether males or females; in this regard most of those who do not continue education will go to work and start their life careers earlier. 14.1% of husbands are having diploma, 5.4% are having Bachelor's degree and 1.5% are having Masters’ degree.
Table 6: The level of education for the husbands
The level of the surveyed women education (table 7) indicates that 65.5% have completed their High school (Tawjihi), 7.8% are having diploma, 10.5% are having Bachelor's degree and 0.9% are having Masters’ degree, 13.5% completed elementary education and 0.9% being uneducated or illiterate. The educational level for the surveyed women is much better compared to 32.2% of females of the same category in the general population as been indicated in the PCBS (2002) survey.
Table 7: The level of education for the surveyed women
14.1% of the husbands studied diploma vs. 7.8% for the women, for bachelor degree 5.4% for husbands vs. 10.5% women. These results contradict many other Palestinian studies where the males are prioritized by families to University education. Other local studies highlighted the cultural perspectives on raising children and particularly adolescents where males are allowed to be free and go around while girls of the same age are not and thus spend more time studying at home. Regardless, these figures indicate Palestinians precision toward progressive achievement in education despite the continuous challenges they are facing.
4.1.2 Data analysis of the questionnaire
The quantitative data analysis has utilized the SPSS analytical statistics utilized frequencies; percentages, T test and level of significance, and Cronbach’s alpha reliability test for each subcategory of the questionnaire (please refer to annex G for the detailed statistical analysis of the questionnaire). Analysis on statements with 4- point Likert scale were strongly agree, agree, disagree and do not know were given a value label coded from (4 to 1) sequentially and statements with 3- point scale were yes, no, and do not know were given a value label coded from (3 to 1). Tables are presented for the responses for each subcategory; the responses with agree and strongly agree were combined together since it gives almost the same value on the statement presented. Some subjective responses by the participants are added to the discussion of the analysis.
Table (8) reflects women’s participant’s knowledge and attitudes toward the use of family planning methods including emergency contraception.
To analyze this subcategory, 8 statements were identified in table (8). Regarding the use of FP methods, 67.8% of the surveyed women agreed on the statement “husband unwillingness to use contraceptive methods himself” vs. 27% who did not agree. 61.8% agreed on the statement “husband unwillingness to allow his wife to use a contraceptive method” vs. 34% did not agree and felt that they have the choice to use or not to use FP methods as some women commented that there is agreement between couples on the use of FP methods. Regarding the lack of accessibility to FP services 56.6% disagreed to that because they all live in camps and familiar with family planning programs that UNRWA have consistently enhanced contraceptive use among women utilizing its health facilities in the camps beside it provides contraception for free of charge supported with education and awareness. Yet, 61.5% agreed that women may not adhere to contraceptives utilization instructions.
Regarding their knowledge about emergency contraception (EC); 54% agreed that they lack knowledge about EC, 22.2% did not know about this issue, and 23.4% reported that they know about it. This could be explained and as part of the FP clinic nurse job at UNRWA is to advice women who forgot to take one pill through her course of contraception is to take another pill immediately, in case the woman forgot to take two pills or more, then she is advised to substitute by taking a pill for three days morning and evening, these instruction were reported from some nurses interviewed during the survey at UNRWA clinics. Emergency contraceptives (EC) are back-up methods of preventing pregnancy after unprotected sexual intercourse. They do not terminate existing pregnancies, and they do not protect against sexually transmitted diseases (Population Reference Bureau, Unmet Need for Family Planning, 2003).
Regarding the social and religious barriers on the FP use as perceived by the study participants; 58.8% agreed that social pressure imposed mostly by their husbands and mother in law as justified by many when said “our families wants more children” few others said “they want more boys”. Few women mentioned that “we want to have our children while we are at younger age” and some women wanted to have more children to secure themselves by not allowing their husbands to get married to another wife as commented by few interviewed women. While 36.3% of women did not agree and reported no social pressure was imposed on them, and were autonomous to make decisions concerning reproduction and pregnancies.
There was a discrepancy about the participant’s responses regarding religious barriers on the use of FP methods. About half of the women 49.2% did not agree on the statement that says “objects to use FP because of religious barriers” and 42.3% agreed to that. This discrepancy could be either the women do not know much about their religious doctrine or very much religious to refuse any thing that interfere with God’s will as some of them commented. Women living in the camps are aware that contraceptives are used instead of the natural methods such as withdrawal and breast feeding practices and accepted from Islamic religious perspectives as others commented.
Women perception on the consequences and side effects of the contraceptives use; 53.4% agreed Vs 36.3% did not agree to that. For those who agreed have the perception that CP makes women fatter, develop more hair on the face, and may cause cancer. Such statements is worth studying to launch more awareness programs regarding CP use and its effects
Table 8: Family planning statements
Table (9) reflects participant’s knowledge and attitudes of the circumstances for women to seek abortion
To analyze this subcategory, 8 statements were identified in table (9). The participants’ responses for the statement that women may seek abortion if they got pregnant soon after the delivery of newborn were almost similar; 46.8% agreed vs. 49.5% did not agree to that where many women believe “it is a sin if abortion to be sought in this case” and its “God’s will and cannot do any thing about it” as some other women commented.
The majority of respondents 79.6% agreed for women to seek abortion if she gets bleeding or miscarriage, an evidence of healthy attitude regarding this issue as some of them “commented this is very legitimate and women should seek abortion in such case to preserve her health”
54.4% of the respondents opposed the statement on women having many children and do not want more and 56.5% opposed the statement on women with limited income to seek for abortion. Around 42% and 38.4% of respondents agreed to these two statements and consequently explains the different attitudes these women hold regarding the causes and circumstance for which abortion could be sought.
71% of the respondents agreed on women to seek abortion in case they have certain diseases (heart, cancer, diabetes etc…), which means they are aware of the impact of pregnancy on their life status in case there is certain diseases, yet 20.4% did not agree and as commented by some “the women should make sure of her physical condition prior to getting pregnant”. 70.3% opposed the statement on those who perceive or new that they have female fetus while having other daughters. The economical conditions, number of children and sex of the fetus are not perceived to be reasonable factors for women to seek abortion.
The participants’ responses for the statement that women may seek abortion if her educational level is low were almost similar; 46.8% agreed vs. 44.4% did not agree. In similar responses on the statement on working women and pregnancy may add further impact on their lives (efforts, lose job etc...) 43.5% agreed with this statement vs. 48.3% opposed this statement.
Table 9: Circumstances where most women seek abortion
Table (10) reflects participant’s perceptions and attitudes toward legality of abortion
To analyze participant’s perceptions on abortion legality, ten circumstances were identified. The responses are classified for those who agreed with abortion being legal in a given circumstance as having a liberal opinion about that circumstance, and those who disagreed as having a conservative opinion.
A substantial support for the availability and legality of abortion was found among the surveyed women; 96.7% of the participants’ agreed on abortion to be legal when the woman's life is endangered, 96.1% agreed when the woman's physical health is endangered and 82.5% agreed when the woman's mental health is endangered. 74.4% agreed on the statement “when there is evidence that the baby may be physically impaired” and 71.7% agreed “when there is evidence that the baby may be mentally impaired’.
More than two third 66.9% endorsed attitudes toward abortion legality and availability for specific indications such as rape; 14.7% did not know, and 18% opposed. Around 68% agreed to have a legal abortion for incest cases, 15% disagreed and 16.8% did not know about this issue. A similar figures of the respondents opposed legality of abortion for the age of the women; 65.8% disagreed for women under 15 and 67.6% disagreed for women over the age of 40 years. 57.1% opposed the general availability of abortion without conditions vs. 27.9% agreed to that.
Table 10: Women’s perception on legality of abortion
Table (11) reflects participant’s knowledge on incidence and provision of abortion services in their surroundings; to analyze participant’s perceptions on these issue 7 statements were identified; the last three consisted of more detailed statistical analysis and interpretation
The majority of the respondents 76.6% have agreed with the statements that woman should be knowledgeable with the legal and religious laws and regulations prior seeking abortion, and 75% seems to have a healthy attitude toward SRH and abortion issues by agreeing to follow health professional’s advice.
Regarding the participant’s knowledge on abortion incidence among relatives or friends; 54.4% knew someone vs. 41.7% do not know about. When participants were asked if they knew about someone died as a result of abortion 40.9% said yes vs. 57.6% said no and 11.4% did not know or were not sure. Some of the women who knew about the abortion and death incidences of a woman as result of abortion reported that they heard from others about them
Table 11: Participant’s knowledge on incidence and provision of abortion services
Regarding the incidence of abortion among the study participants as indicated in statement 5. Around 40% (No.132/333) of the surveyed women have had experienced abortion; 20.7% had it for one time, 7.8% had it for 2 times, 6% had it for 3 times, 1.2% had it for 4 times. Two of them had it for 6 times and one for 10 times as indicated in table (12). Some of the women who had abortion experience commented that it was spontaneous abortion and without their will which made them feel sad.
Table: 12 Incidence of abortion among study participants
Table (13) reflect statement 6 that assessed the participant knowledge on the time for pregnancy termination; it was found that participants posses a high level of understanding on termination of pregnancy where 85.3% knew that it should be provided at the first trimester, and 88.3% opposed for pregnancy to be terminated at the second trimester. 90% opposed for abortion to be performed at any point of pregnancy.
Table 13: when abortion can be provided?
Table (14) reflects statement 7 that assessed the participant knowledge on the provision of abortion services; 91.6% indicated that abortion is provided by physicians and health professionals, 16.2% indicated that abortion is provided by the woman herself and 9.9% indicated that abortion is provided Dayas.
Table 14: Who provide abortion?
Table (15) indicated participant’s knowledge regarding the methods provided by health professional (Doctors/Nurse/midwives) to induce abortion; 75.7% knew about the use of Dilation and Curettage, 18.6% do not know about it, probably these women did not have the experience of abortion. 42.3% knew about the injection methods used by health professionals while 35.4% did not know. 28.5% new about oral medicine and 17.4% only knew about other methods like intra-vaginal placement such as white tablets or plastic tubing.
Table 15: Methods provided by health professional to induce abortion
Table (16) indicated participant’s knowledge regarding the methods provided by Dayas or others to induce unwanted pregnancy. Majority of the responses fell under the no and do not know category. Only 35.7% agreed that Dayas use natural liquids and food and 11.4% agreed on the statement about insertion of physical objects placed intra vaginally. For others specify category in item 4; many women indicted that they were advised by the Dayas to drink some traditional herbs such as cinnamon, cumin, mariamieh, parsley and some kind of seeds like barn and hilba.
Table 16: Methods provided by Dayas or others to induce unwanted pregnancy
Table (17) reflected the participants’ knowledge about women practices and methods utilized to induce their unwanted pregnancies. 82.6% have utilized the voluntary trauma. 56.5% mentioned the use of home made drinks of herbs and seeds and 14.1% mentioned the insertion of physical objects placed intra vaginally.
Table 17: Methods used by the woman herself to induce unwanted pregnancy
This section will present analysis of questions that are related to participant’s knowledge and attitude on post abortion complications, consequences, and feelings and attitude toward abortion.
Table (18) reflects participant’s knowledge about post-abortion complications; 96.1% knew that women who aborted needed hospitalization and 91% needed blood transfusion. 90% indicated that women experience vaginal bleeding, 77% experience pelvic infection and laceration and 63.1% knew about sepsis and high grade fever
Table 18: Participant’s knowledge of post-abortion complications
Table (19) reflects participant’s knowledge of physical consequences of Post-abortion; the majority of participant’s indicated a high level of knowledge and awareness regarding consequences of abortion; 85% knew on general weakness and body aches, 67.9% knew about weak uterus, 64.3% knew about urinary tract infections and 49.5% agreed on infertility
Table 19: Participant’s knowledge of Post-abortion consequences
Table (20) reflects the participant’s perception on post - abortion emotional feeling and psychological attitudes; most of the responses ranked high; 74.5% felt it was a feeling of killing of a child, and 73% felt guilty, remorse and fear. 70.6% agreed on regretting the decision to have an abortion. 50% of women responded negatively toward the statement “has allowed her to feel free”, while 42.6% agreed vs. 42.3 disagreed regarding the item on best decision at that time.
Table 20: Feelings and attitude of women post - abortion
4.2 In-depth interviews discussion with UNRWA Personnel
The interviews with UNRWA Health personnel were conducted with field family health officer and clinic physicians and nurses at the targeted camps (please refer to annex E for the list of clinic physician and nurses interviewed); the discussion will be presented sequentially as follow:
4.2.1 Services offered to women in reproductive age (15-49) attending maternal health clinics regarding;
Family planning (FP) and emergency contraception services; UNRWA field family health officer described the different FP methods provided for women seeking their use at the FP clinics. He estimated that around 54% of women use intrauterine devices (IUDs), and to a less degree 25% use oral contraceptive pills (OCP) of both types the mini-pills and progesterone pills followed by minimal use of injectables such as Depovera 2%. For the barriers methods; around 20% of husbands uses condoms but there is no use of women barrier. The emergency contraception (EC) use is not advisable in UNRWA clinics and not used as said “we need to have a continuous FP methods and not emergency family planning methods”, and further added for the natural methods he commented on breast feeding as “exclusive breast feeding is not advisable and we can’t be rely on as a contraceptive method”.
The health clinics personnel agreed with on the field officer mentioned regarding the different FP methods utilized by the women living in the camps as the majority of women use IUDs, then oral contraceptive pills (OCP) and male condoms. They added that they emphasize the use of FP methods through intensive health awareness programs and discussion on each method complemented with their home visits to ensure their compliance with its use.
Regarding UNRWA abortion/unwanted pregnancy policy and services; the family health officer reported that UNRWA has neither policy nor services directly provided to women who needed abortion or post abortion services. He further explained that UNRWA is in the process of initiating a pre-conception program that aims to promote FP methods use, identify women’s at risk at future pregnancy, improve pregnancy outcomes, which he believed that indirectly will lead to avoid abortion and unwanted pregnancies. Yet, he reported that UNRWA has a very well integrated registry system, and policies to follow on pregnancy outcomes as reported in 2007 identified 97% of these outcomes whether normal delivery, stillbirth or abortion. He further estimated that 5-6% of the pregnancy outcomes were abortion in 2007 and justified this low rate due to the high level of care and awareness programs that UNRWA launch to its clients in all its facilities. He further reported post abortion care is indirectly provided through antenatal care and FP clinics especially when there are women at risk or contracting sexually transmitted diseases (STIs), TORCH and reproductive tract diseases.
The health clinics personnel also reported there is no direct involvement in abortion care, but in case a woman have bleeding or miscarriage they do some laboratory tests and advise her to seek care from other health providers. They emphasized the quality of care provided for women with high risk pregnancy is by examining her physically; offer her the treatment and counseling followed by home visits and health education regarding their conditions. Also they provide folic acid in case a woman wants to get pregnant again beside psychological counseling and guidance.
Health education and counseling activities on abortion; The family health officer reported that UNRWA emphasizes health education and awareness programs as one of its most important primary health care activities that are stressed through the maternal and child health clinics (MCH). He further added that 85% of women register for antenatal clinic by 12 weeks of pregnancy, this is believed due to women awareness of UNRWA instruction that is delivered by health personnel consistently (UNRWA instruction is to investigate for pregnancy if amenorrhea for two weeks). He added health education activities emphasizes SRH issues through sessions held at the clinics and distribution of leaflets according to topics discussed, FP methods are emphasized through discussing the use, benefits and risks of each method, in addition to pre-conception awareness and counseling as a component of maternal health care. Additionally, maternal and child nutrition awareness particularly for exclusive breast feeding are example of other health education activities, also they provide supplementation such as iron for pregnant women and Vitamin A for breast feeding mothers.
Regarding counseling and psychosocial work is out of the antenatal care scope; it’s another division where women who needs counseling are referred to as for example women with psychosocial problems and particularly those subjected to abuse and domestic violence
The health clinics personnel appraised their role in contributing to women’s health through conducting health education awareness sessions and distribution of leaflets and brochures on many topics related to reproductive, maternal and child health issues. Psychological counseling and guidance is offered on top of the physical examination and follow up on the women general condition
4.2.2 Managers and decision maker’s involvement on women's rights and gender issues
The family health officer reported that UNRWA administrative personnel monitor health indicators through its health information system and accordingly reporting and dissemination of information to all clinics is made and discussed with clinics. UNRWA as institution provides equal opportunities for access of boys and girls to basic health services including growth monitoring, school health, health education and medical care. In addition to patients receiving integrated non-communicable disease care at UNRWA primary health care facilities are men and women. Gender equity is also promoted through UNRWA by hiring both males and females as for example the large number of female nurses working at UNRWA clinics
The health clinics personnel expressed disappointment from the camps society and described it as “we live in male dominant society” while they appraised UNRWA policy to promote women's rights regarding (SRH) and gender issues in addition to their support of the female employees
4.2.3 Difficulties encountered in dealing with the issue of abortion at the women and community levels
The family health officer reported that within the context of maternal health care UNRWA only provides medical treatment and care and if abortion was needed for a woman, they only refer to hospitals, and then its up to the woman and family where to go. UNRWA policy is not to address the abortion issue and not to be involved into the dilemma of medico-legal and religious issues. He added, “in case there is a woman who’s at risk and want to get pregnant, we only offer the advice and if she insists on getting pregnant we ask her to sign against advice consent”. He believed such monitoring and follows up assist the woman not to be pregnant and consequently abortion is avoided. UNRWA emphasis on contraceptives use and its distribution for free of charge also decreases the incidence of abortion
The health clinics personnel do not face any difficulty regarding the issue of abortion since it is not permitted in the UNRWA clinics. Many of the interviewed reported that they knew many women who sought abortion in the private sector.
4.2.4 Factors that may influence women's perception toward abortion
The family health officer and clinic personnel referred to the societal norms that usually interfere with the women’s lives and affects their emotional and social status as said “women may be scared of her husband getting married another wife”, “women tend to have more children to keep her marriage”. Mothers in laws are source of threat since they are the ones who govern the family and direct the family practices; others mentioned the influence of female neighbors, and many times the religious and socioeconomic status of the family are all factors to influence the women’s perception toward pregnancy and abortion.
4.2.5 Cooperation and collaboration with local community women’s centers
The family health officer reported that cooperation with community centers is not available in UNRWA plan because of the deficiency in the employees as well as the educational facilities and aids. As UNRWA responsibility is to follow through the antenatal clinics on the defaulters especially for those women at risk. The health clinics personnel reported the lack of combined programs with the community centers but some of the clinics reported that they connect with the local community centers particularly on health awareness on FP and family health issues.
4.3 In-depth interviews discussion with community centers leaders
The interviews were conducted with community centers leaders at the targeted camps; there were 13 interviews where some of the camps have more than one women community center. The discussion will be presented for all responses in general but for details of each community center representative (please refer to appendix E in Arabic).
4.3.1 Reproductive health services offered by community center to women age (15-49) years
It was obvious that community centers do not offer reproductive health services as said by some of the women interviewed “this is not our job”. Other leader mentioned that they offer awareness programs on FP and its importance to have a healthy mother and baby. For example Fara’ah community center leader reported that they trained a group of young women on F.P issues and through the center these young women conducted session on this topic to other women in the camp. She added “it was a good experience but it was not repeated”. For emergency contraception, no one heard of this issue.
The community centers have neither policy nor strategies for the abortion issue, and do not offer any kind of care or services as some justified “we do not interfere with medical cases”, others said “abortion is a sin and we do not deal with and ”. Ama’ari and Duhiesh camps leaders’ reported that they help women on such issue by referring them to UNRWA counseling clinic and as said “that’s all we can do”.
Some of the centers offer awareness programs on women’s health issues through hosting other institutions and local NGOs. The most frequent topics offered to women camps in reproductive age were issues on promoting breast feedings, sex education and nutrition. Many times there was a distribution of leaflets or presentation of a film related to the topics discussed, few mentioned that some times they hosted a physician to present topics related SRH but not on abortion. Other programs targeted young women and adolescence with focus on their developmental stage, in addition to early and consanguineous marriages. Majority of the centers offer gender awareness programs and on regular basis as the case of Fara’ah, Jenin, Shufaat and Duhiesheh camps through guest speakers coming from institutions that advocate for women’s rights and gender issues.
4.3.2 Cooperation and collaboration with UNRWA health clinics
Some of the centers such as Fara’ah, Askar, Jenin, Ama`ari and Duhiesheh camps appreciated the cooperative efforts made among the two institutions and found no difficulties dealing with each other. These efforts included different activities; health education programs on issues related to women’s SRH and reproductive rights but not direct information provided on abortion, referral of women for counseling at UNRWA counseling department for those who needs such service. Most women who needed counseling were having social problems within their home environment such as violence, divorce or problems with in laws. For example Ama`ari center camp has allocated UNRWA counselor at its premises and all women needed this service were coming to the center. In Jenin center, there is a counseling program and in joint work with UNRWA counseling personnel held monthly meetings among the two institution to have a consensus on the provision of counseling services to meet the women’s needs. Some centers such as Jalazoon and Tulkarem do not have this cooperation, while Ayda clinic is closed.
4.3.3 Difficulties encountered to deal with the issue of abortion at the women and community levels
The centers do not deal with the issue of abortion and do not launch awareness programs on such matter as said by most of the interviewed leaders. There is no difficulties faced dealing and talking with the aborted woman at social level such as listening to her worries and complaints where she cannot express her concerns among her family members as said by few leaders. Some of the center leaders and through their connection within their environment and particularly with the women have discussed their experience regarding the reasons for abortion to occur which they could postulate was mostly a result of early marriage and socioeconomic status where large families and poor income. It is noteworthy these comments was rather a postulation and not built on formal and scientific information.
4.3.4 Factors that influence the women's perception toward abortion
The responses has varied and considered many factors related to women's perception toward abortion such as the educational level and the way these women deal with their pregnancy and childbirth especially for those who are married at early age. Others believed that poverty and families having many children, women over 40 and those who have certain disease such as diabetes and high blood pressure will consider abortion. They further commented that the community centers goals and strategies do not deal with such issue and all they know is through their life experience. They also added that counseling for abortion is not accepted by their husbands or in laws. They also reported that some women attitudes toward abortion are related to their worries regarding the consequences of abortion on their health, lack of community acceptance for the idea of abortion and sometimes abortion is a result of domestic violence as for example; one of the centers employees at Duhiesheh has aborted because she was beaten by her husband, also he did not allow her to be treated for 3 months in which at the end it led to serious consequences such as hormonal disturbances, irregular cycle, and anemia.
This chapter presents discussion of the findings commencing with the socio-demographic data first, followed by discussion of the subcategories on women’s knowledge of and attitudes toward SRH indicators. In the second part a summary of the in-depth interviews conducted with 10 UNRWA health professionals and 13 community centers leaders (please refer to the details in the finding chapter)
5.1 Discussion of the socio-demographic data
A total of 333 married women aged (15-48) were selected randomly through household survey in 11 refugee camps. Percentages of participants were relative to weight of each camp from the overall population in all West Bank camps. The interviewed women were all married with a mean age of 32.7 at the time of the data collection and with an average of 18 years when they got married. Around 31% of the surveyed women were married at very young age 13-17 years and 52.5% were married between 18-22 years. Palestinian literature has always documented that Palestinian women marriage and their childbearing begin at young age. The 2004 national demographic data and health survey (DHS) shows that 7% of women ages 15-19 had already given birth to a child or were pregnant, it also reported the median age at first marriage for females (15-54) years old to stand at 18 years (PCBS, 2004). While in very recent statistics (PCBS, 2007) reported that the median age for female marriage has increased to 19.4 years in 2005, which means the results obtained in this study still as it was in 2004.
Such figures bring into questioning the decision making and negotiation power these women can exercise regarding their reproductive health including marriage, pregnancy and pregnancy outcomes. Coupled with around 30% living within extended families compared with 18.6% for the general population as indicated by the PCBS survey (2002) is another demeaning factor that decreases the women own decisions regarding her SRH. This size of extended families in the camps could be due to limited geographical space and overcrowding that allows families to live closer to each other more than the case in the towns or villages. Another form of extended families in the Palestinian traditions and culture of what is called a "shared dwelling or kin-based living arrangement", in that, new families often live very close to parents and other relatives; either in the same neighborhood, same building or street where dominance of kin may be an organizing element in living patterns of the family dynamics in the Palestinian society (Birziet University Household Survey, 2002). Culturally family ties are strong and this situation is frequently emphasized by sharing many family activities, traditions and concerns including pregnancy which ultimately affects the women autonomy regarding her health and social status.
A further highlight on reproductive health indicators among the surveyed women was the number of pregnancy which ranged from (0 – 16) times; around 39% had 3-5 pregnancies, 30% had 6-9 times, 19% had 1-2 times and 12% their pregnancy ranged from 10-16 times during their marriage life. It is worth noting these women are mostly at the peak of their reproduction as indicated earlier with a median age of 32.7 years, which means still there is a long way for them to have more pregnancies and children.
To complement the information on surveyed women SRH and pregnancy outcomes, they were questioned about the number of children they have. Large families are common and typical characteristics of Palestinians families, this survey results approved these characteristics for number of children that ranged from (0 – 14); 57% are having 2-5 children, 23% are having 6-9 children, 6% are having 10-14 children, 11% has one child and 1.8% has no children. The PCBS children statistics report (2007, No. 10) indicated the total fertility rate (TFR) for women living in Palestine was 4.6 children, a significantly higher than women in neighboring countries that have similar levels of education and access to health services (Women in Gaza have 5.4 births, on average, while women in the West Bank have an average of 5.2 births) and the average of lived children was 4.7 (5.0 in GS and 4.6 in WB), the report indicated there is no specific numbers on the district or camps’ levels. In a recent report by World Health Organization on UNRWA refugee camps regarding high-risk pregnancies indicated that the Gaza Strip and the West Bank have the highest proportion of high-risk pregnancies among all UNRWA refugee areas although the maternal mortality rate apparently decreased between 2002 and 2005, concerns remain about shortcomings in quality of care (WHO, May, 2007). Such findings on the number of pregnancies and number of children could be correlated in further studies to identify the abortion ratio.
Although 18% of the surveyed women and 84% of their husbands were having a job, the average income per household surveyed was 1599 NIS/month. Given these large figures of pregnancies with many children and low financial resources are factors that should be noted and made to policy makers and health providers to consider since these factors have a major impact on women and their families living conditions including health, life style and child rearing practices.
The level of education for the participant’s husbands indicated that 62.5% completed their High school (Tawjihi), 14.1% are having diploma, 5.4% are having Bachelor's degree and 1.5% are having Masters’ degree. Almost the level of education for the surveyed women was slightly better where 65.5% have completed their High school, 7.8% are having diploma, 10.5% are having Bachelor's degree with very minimal rates for elementary education or illiterate. This could be explained due to the commitment of UNRWA in provision of schools in each camp to at least the 9th grade for males and females, in addition to the cultural and social values that Palestinians hold toward education. The PCBS (2004) reported that the proportion of females and males schools enrollment is almost equal in the occupied Palestinian Territories.
5.2 Discussion of the quantitative data
5.2.1 Family planning knowledge and attitudes
The international and regional literature regarding FP and unwanted pregnancies reviewed for this study indicated that the primary cause of abortion is unplanned pregnancy. The (PRB) Policy brief on the Middle East and North Africa Region (MENA, 2003) indicated that 60% of the women practice family planning. The latest Palestinian Demographic and Health Survey (DHS) conducted in 2004 on use and trends of contraceptives indicated that 48% of married women in reproductive age (15-49) use contraception with a variety of methods (PCBS, DHS, 2004). The overall picture of the results indicated that the surveyed women are well aware of the importance of FP methods, the restrictive and hindrances factors as well as the facilitative factors to its use. The results indicated that 57% of the surveyed women agreed on the accessibility and availability of FP methods, and 61.8% agreed on the poor adherence to its use. Such responses require the attention of health providers to promote CP utilization and compliance for its use. Around 68% of the respondents agreed on the husband’s unwillingness to use CP method himself and 62% agreed on husband’s unwillingness to allow his wife to use CP coupled with 59% who agreed for the social pressure imposed on women by husbands and in laws or others to use CP, and to a less extent 42.3% agreed on not to use CP because of religious barriers. Such responses are hindering and restrictive factors that are imposed on women to use FP methods and thus to allow for more unwanted pregnancy and consequently for abortion to occur. Brudi-Fahmi in the MENA report (2003) indicated that surveys throughout the region show there is a large unmet need for family planning as measured by the number of women who report that they would prefer to avoid pregnancy but are not using contraceptives. A recent pregnancy, fear of side effects, and opposition from husbands and relatives are issues commonly cited by women’s unmet need where this is very much congruent with the study participant’s responses.
In such circumstances there is a need for health providers to advocate on this issue through involvement of influential religious leaders to clarify the use of family planning from religious perspective for women, men and significant others (mother or sister in law) in order to reduce the social pressures imposed on women. Around one-third of women perceived the utilization of FP methods positively where no social pressure imposed on them and indicates a step forward for the women to be autonomous in their decision regarding the SRH
5.2.2 Circumstances where most women seek abortion
The literature indicated important categories of reasons where women generally may seek abortion; such categories those that may interfere with the health, economic and demographic status, the educational level and work conditions of the pregnant woman. The study participants’ responses indicated positive attitudes regarding health conditions; around 80% agreed for women to seek abortion if there is bleeding or miscarriages and 71% agreed for women having certain diseases. Such responses indicate that the participants are aware of consequences of pregnancy and its implication on women’s physical health and believed abortion is legitimate in such circumstances. Yet, and within the domain of physical health the participants’ attitudes toward women seeking abortion if they got pregnant soon after the delivery of newborn was different and the agreement/disagreement on such condition was almost similar 47% vs. 50%. Because of the ethical consideration and their own personal views, almost half of the respondents tend to appear unsympathetic to women with unwanted pregnancies in such condition.
For the economic and demographic factors; 54% the respondents opposed seeking abortion for women having many children and do not want more and 57% opposed for women with limited income to seek abortion. For those who opposed commented those children are blessing and gift from God that should not be refused while others said “the child is born and his ration is born with him”. Regardless of their socioeconomic status, such responses explain the value that Palestinian families hold regarding children and the way they believe in their upbringing and raising them. Around 42% and 38% agreed on abortion for these statements as commented “we need to have a quality of life for ourselves and our children” while few rationalized their responses as “abortion should be performed if the husband is married to another wife”. On the contrary 70% opposed the statement on those who perceive or new that they have female fetus while having other daughters, such disagreement was noted when said by some “girls are better than boys”. Such statements identify a positive attitude of the respondents toward gender equality and reflect adverse opinions on the boy’s preference in the Palestinian society. These responses are also consistent with Esposito and Basow study results (1995) that did not find consistent relationship between attitudes about abortion and gender. Some of the participants commented “its God will whether a boy or a girl”, also this comment emphasize the respondents religious beliefs and acceptance to have a girl. Esposito and Basow (1995) referred to many factors that have been associated with attitudes towards abortion; some of these factors include religion and degree of religiosity, knowledge of abortion, age, gender, and educational level and found that those more accepting of abortion tended to be less religious, older, and more knowledgeable and experienced
The responses were almost similar where 46.8% agreed vs. 44.4% did not agree for women with lower educational level to seek abortion. For some of those who did not agree justified their responses as said “the uneducated women are more committed toward children because they are the source of their strength”. In similar responses 44% agreed vs. 48% did not agree that pregnancy for working women may add further impact on their lives. For those agreed believed that pregnancy and newborn care would add further impact on their lives and would interrupt their life and their career as some commented. To have a clear explanation of the last two statements a further study is needed to correlate these responses with the age, educational level and working status of the women.
5.2.3 Legality of abortion
For the participant’s perceptions on abortion legality; the responses are classified for those who agreed with abortion being legal in a given circumstance as having a liberal opinion about that circumstance, and those who disagreed as having a conservative opinion. A substantial support for the availability and legality of abortion was found among the surveyed women; more than 96% of the participants’ agreed for abortion to be legal on 3 consecutive statements related to women’s life in danger, women’s physical and mental health are endangered. The agreement has relatively reduced to 74% on the statement “When there is evidence that the baby may be physically impaired” and 72% “when there is evidence that the baby may be mentally impaired’. For fetus disability some women suggested counseling the religious leaders on abortion, and for those who opposed abortion endorsed attitudes that were very influential when said by many “this is God’s gift and we have to take it”.
More than two third 70% endorsed an attitude for abortion legality and availability for specific indications such as rape as some of the women commented “the perpetrator should be found and obliged to marry the girl”, 14.7% did not know the response for such condition and 18% opposed. This is very much congruent with perception of attitudes and opinions of female University students in Palestine study conducted (2006) who responded to such question; 15% would advice on having an abortion and 42.5% would advice to try to get married immediately and if unsuccessful to get an abortion for such circumstances. Approximately 25% of the participants discussed the threat of “honor killings” and explained that abortion is advised to both preserve the honor of her family and protect the woman subjected to rape. Social stigmatization of such incidence was reflected by some participant’s responses and comments as said “the girl who got pregnant illegally should be killed”, “abortion should be induced to get rid of the fetus”. Around 68% agreed to have a legal abortion for incest cases, 15% disagreed and 16.8% did not know about this issue. Such social and familial problems are always enclosed within the family and rarely were explored to the public or identified as risk factors on the woman’s health.
A similar figures of the respondents opposed legality of abortion for the age of the women; 65.8% disagreed for women under 15 and 67.6% opposed for women over the age of 40 years as said by some “age is not an excuse for women to have an abortion”. 57% opposed the general availability of abortion without conditions. It is evident that the perceptions of surveyed women toward legality of abortion is very well influenced by their religious beliefs and abide by the ethical and cultural views on abortion
5.2.4 Knowledge on incidence and provision of abortion services
Women’s knowledge of the legal and religious laws, importance of following the health professional’s advice, timing of abortion and provision of abortion services are all indicators of women’s awareness regarding their SRH conditions and the influencing factors that may positively or negatively affect their health status. The surveyed women perception regarding these matters indicated positive responses where 76.6% agreed that women should be knowledgeable with the legal and religious laws prior seeking abortion and 75% expressed a healthy attitude toward seeking advice from the health professional’s regarding issues on women’s SRH and abortion.
To have further discussion on these issues, the participants were asked about their knowledge of the incidence of abortion among relatives or others as well as among themselves. An astonishing figures were found; 54.4% knew of others had an abortion, and 40% of the study participants have experienced an abortion, of those 21% had it for one time, 8% had it for 2 times, 6% had it for 3 times, 1.2% had it for 4 times. A study of women’s reproductive health in El Wihdat Palestinian refugee camp in Jordan Hishmeh (2000) interviewed a total of 400 randomly selected refugee women and found out that a total of 37.2% of children born during the year preceding the survey were the outcome of unintended and/or poorly timed pregnancy, and more than half of the interviewed women 53.3% experienced spontaneous abortion. Compared to the surveyed women in this study where 54.4% knew of others had an abortion and 40% of the study participants have experienced abortion indicates a very high rate of abortion in the Palestinian camps whether in Jordan or West Bank. Another worrying factor was that 41% of the participants new or heard about someone who died as a result of abortion. This huge figure not necessarily reflects such large number of deaths, but it could be postulated that most women in the same camp heard about same incidence on death.
Such alarming figures requires further surveys not among the women in the camps only who are considered relatively privileged for the health care they receive from UNRWA but for other strata in the Palestinian community where no one statistical study was found, neither was indicated in any demographic surveys or even mentioned under the subcategory of high risk pregnancy. Yet, 85% of surveyed women were knowledgeable of the proper time for termination of pregnancy to be at first trimester, 88% opposed for pregnancy to be terminated at the second trimester, which indicates that women are well informed about the best time for pregnancy termination. And 90% opposed for abortion to be performed at any point of pregnancy which reflects cultural and religious conservative attitudes toward abortion.
A further positive response was that 92% of the surveyed women knew that abortion is provided by physicians and health professionals, 16% indicated that abortion is induced by the woman herself and 10% indicated that abortion is provided Dayas. Such responses indicate very well aware respondents regarding their reproductive health where very minimal resources other than health professionals are utilized for abortion services. Yet it is worth studying the incidence and reasons of abortion performed by the women themselves.
The methods utilized for provision of abortion through health professionals have varied and indicate a positive attitude for women to seek help from them; 76% of respondents knew about Dilation and curettage, those who knew about this procedure either they had the experience abortion or they knew or heard about it. Injections have ranked the second method for inducing abortion where 42% knew or experienced such method, 29% knew about oral medicine methods and only 17% new about other methods like Intra-vaginal placement such as white tablets or plastic tubing. Such figures on abortion practices require further investigations from abortion providers to either support such responses or not and to have more reliable information abortion services in the health care facilities.
The participant’s knowledge regarding the methods provided by Dayas or others to induce unwanted pregnancy; 36% agreed that Dayas use natural liquids and food and 11.4% knew about the use of physical objects inserted intra vaginally. This reflects very well prepared women who have healthy attitudes and behaviors toward their health by less seeking traditional practices and more professional ones as indicated earlier. Such healthy attitudes could be related to the fact that the majority are at young age and educated, also due to UNRWA role in launching awareness programs through its clinics. In addition the modern life regarding satellites educational programs could have assisted these women to endorse healthy attitudes and practices.
Regarding the participants’ knowledge on methods used by the woman herself to induce their unwanted pregnancies; the majority 83% have utilized the voluntary trauma approach through varied techniques such as asking someone like a son or a daughter to step on their back or the belly, jump from a height, lift heavy objects and few mentioned sports. 57% mentioned the use of home made drinks and mostly used were cinnamon, ginger, kizha parsley, henna or mixed herbs, few women mentioned the use of castor oil and poisonous substances such as chlorine. Seed was also utilized like fenugreek (Hilba) and lupine (turmus). 14.1% mentioned the use insertion of physical objects placed intra vaginally. These figures reveal that women are unaware of the high risk practices of such dangerous techniques particularly the use of voluntary trauma which is very abundant and those few who mentioned drinking chlorine requires to launch awareness programs on the consequences of such approaches to induce abortion.
5.2.5 Post-abortion complications and consequences
The participants possessed a high level of knowledge about post abortion complications where the majority over 90% agreed that women who experience abortion needed hospitalization, needed blood transfusion, and had vaginal bleeding. To less extent 77% agreed on the women to have Pelvic infection and laceration, and 63% to have sepsis and high grade fever. Women’s knowledge on hospitalization and blood transfusion is very much congruent with 96% of respondents who reported previously their knowledge on the provision of abortion by physicians and health professional and Dilation and curettage was mostly preferred procedure
The participant’s knowledge of consequences of abortion also indicated a high level of knowledge and awareness where 85% agreed on general weakness and body aches, 68% for weak uterus, 64% for the urinary tract infections and 49% for infertility. Compared to the findings of two reproductive health studies conducted in Egypt; first a rural Egyptian study by Zuriek (1994) indicated that many women do not realize that they have treatable reproductive tract infections because they were taught to accept the symptoms as part of being a woman, and the second and in more recent pilot study conducted in other rural Egyptian community by Tala’at (2001) found that reproductive health problems were hidden and women rarely, if ever, sought care for such problems. The participants’ knowledge about complication and consequences of abortion in this study could be reflected to the facts that women living in the camps are offered health services and awareness programs provided by UNRWA constantly. Yet further studies in the Palestinian society and rural areas could be of interest to compare for these positive responses of the participants.
Aside from the physical trauma, women may suffer from psychological trauma and social guilt imposed by society. The participant’s responses on their perception on related post - abortion emotional feeling and psychological attitudes were; over 71% agreed on the statements “felt it was like killing the baby”, “felt guilty, remorse and fear”, “regretting the decision to have an abortion” 67% agreed on “felt it was a sin” and 55% agreed on “felt shame”. 43% agreed vs. 42% disagreed regarding the statement “best decision at that time” and 50% responded negatively toward the statement “allowed her to feel free”. Furthermore, some women said “if a woman think of abortion, then she is considered criminal” and others commented “remorse, fear and shame should be the feeling of any women who wants to have an abortion”. Some of the participants agreed on abortion in case the pregnancy was illegal and the pregnant woman and her family want to get rid of shame and mortification that will stigmatize them forever. Other women said abortion may happen without the will of the woman or her family especially for those who felt that they need the child and their pregnancy was precious. In a South African Study (Maforah, Medical Research Council, 2003), the compulsion among women to terminate pregnancy overrode the legal and religious considerations and demonstrated the isolation and loneliness of the women in their situation. They were willing to risk their lives just to rid themselves of the unwanted pregnancy. Most could not talk because of fear of being stigmatized and lack of trust. Some women did not even tell their partners about the pregnancy and the intention to abort because of fear of violent reactions.
5.3 Discussion summary of the in-depth interviews with UNRWA personnel
UNRWA health providers appraised the different FP methods including male barriers provided for refugee women aged (15-49) attending the maternal and FP clinics in all its localities. The majority of women use IUDs, then oral contraceptive pills and to less extent the male condoms, while emergency contraception is not a method that is utilized or provided. Provision of consistent health education/awareness programs regarding FP use, benefits and risks of each method complemented with home visits by the nurses/midwives of the clinics to ensure women’s compliance.
UNRWA has neither policy nor services directly provided to women who needed abortion or post abortion care. Yet UNRWA has a very well integrated registry system, and a policy on following on pregnancy outcomes as their report in 2007 identified 97% of the pregnancies outcomes whether normal delivery, stillbirth or abortion, and according to their estimates of abortion incidence was about 5-6% (UNRWA Family Health Offcer). Provision of post abortion care is indirectly provided through antenatal care and FP clinics especially when there are women at risk or contracting sexually transmitted diseases (STIs), TORCH and reproductive tract diseases.
UNRWA emphasizes health education and awareness programs as one of its most important primary health care activities that are stressed through the maternal and child health clinics (MCH). 85% of women register for antenatal clinic by 12 weeks of pregnancy, this is believed due to women awareness of UNRWA instruction that is delivered by health personnel consistently (UNRWA instruction is to investigate for pregnancy if amenorrhea for two weeks). Regarding counseling and psychosocial work is out of the maternal care scope. The health clinics personnel appraised their role in contributing to women’s health through conducting health education awareness sessions and distribution of leaflets and brochures on many topics related to reproductive, maternal and child health issues.
UNRWA as institution provides equal opportunities for access of boys and girls to basic health services including growth monitoring, school health, and health education in addition to the integrated non-communicable disease care for both males and females. Gender equity is also promoted through hiring both males and females as for example the large number of female nurses working at UNRWA clinics
No difficulties encountered at the women or community level regarding the issue of abortion since it is not permitted in the UNRWA clinics. Many of the interviewed reported that they knew many women who sought abortion in the private sector. Yet if there is a woman at risk and wants to become pregnant they offer the medical advice
Some of the factors mentioned to influence women's perception toward abortion was the traditional and cultural norms that usually interfere with the women’s lives and affects their emotional and social status where they lack autonomy regarding their reproductive health as been governed either by the husbands or in laws coupled with lack of cooperation between UNRWA and community women’s centers regarding the issue of abortion.
Health professionals recommended having further education and awareness programs for the staff to be able to introduce quality awareness on SRH for the women. They also recommended widening their role of education into the community through launching workshops and seminars for women in the camps. Surprisingly, no one suggested the involvement of husbands or in laws which means there is a need to promote the health professional prospective on abortion from social, religious and legal perspectives.
5.4 Discussion summary of the in-depth interviews with community center’s leaders
It was obvious that community centers goals and strategies do not deal with the issue of abortion and their activities are directed toward social and cultural issues and to less extent health issues. They do not offer reproductive health services except awareness programs on FP methods which is not comprehensive and continuous and not in all camps. For emergency contraception, no one heard of this issue. For abortion and post abortion care they have no strategy for such issue and do not offer such service and not interested to deal with as considered a medical and religious issue and this is not their business.
The women’s health issues that most of the centers discuss and offer are awareness programs geared toward promoting breast feedings, nutrition and to less extent sex education. Other programs targeted young women and adolescence with focus on their developmental changes, early and consanguineous marriages. Many times these sessions are complemented by distribution of leaflets or presentation of a film related to the topics discussed, few mentioned that sometimes they hosted a physician to present topics on SRH but not on abortion per say. The most significant topic presented all through the centers was the gender awareness that was launched on regular basis in some centers and through guest speakers from other women institutions to increase women understanding of their rights and social roles. Such information indicates the role of funding agencies to play regarding awareness issues launched to women in their communities that needs further studying and cooperation to have a balanced programs regarding the women SRH including sensitization on the issue of abortion from gender perspective where men and women could be involved to reduce the incidence of abortion and to allow for women to have the decision on her pregnancy and her reproductive health.
Four out of 11 camps appreciated the collaborative efforts they shared with UNRWA to benefit the women living in camps such as health education programs related to women’s SRH and reproductive rights with no direct information provided on abortion, in addition to referring women to counseling department for those who needs such service.
Regarding the factors that may influence the women's perception toward abortion, the community centers leaders considered many factors such as the educational level, the way these women deal with their pregnancy and childbirth especially for those who are married at early age. Others believed that poverty and families having many children, women over 40 and those who have certain disease such as diabetes and high blood pressure will consider abortion. They also reported that some women attitudes toward abortion are related to their worries regarding the consequences of abortion on their health, lack of community acceptance for the idea. It is noteworthy these comments was rather a postulation and not build on formal and scientific information from the community centers leaders.
Conclusions and Recommendations
Regardless of the low socio-economic conditions and the well acceptable level of education for both husbands and wives, the Palestinian families’ attitudes toward early marriage and large number of pregnancies and children did not change as evidenced by the data presented in this survey. Such findings and in the absence of a national data system correlating socio-economic conditions with reproduction patterns requires:
The overall picture of the results indicated that the surveyed women are familiar with the family planning methods except for emergency contraceptives beside their knowledge of its availability and accessibility; yet there was a large percent who believed in poor adherence and the side effects to its use. On top of that the social pressure that was highlighted by opposition from husbands and in laws and religious beliefs is another hindering factor toward utilization of FP methods. Thus in such circumstances there is a need for:
It is evident that the attitude of surveyed women toward legality of abortion is very well influenced by their religious beliefs and cultural norms, as well as expressed conservative attitude toward seeking abortion for economic and employment status, number of children and sex of the baby. Yet, the study revealed a very high incidence of abortion among women living in the Palestinian camps; 54.4% of the surveyed women knew of others had an abortion, 40% of the study participants have experienced abortion. And furthermore 40.9% knew or heard someone who died as a result from abortion.
Therefore it is necessary to break the silence on the issue of abortion whether safe or unsafe and start exploring the issue in terms of incidence, condition under which abortion is performed, morbidity and mortality specific to abortion. Thus it is recommended to:
Although the surveyed women were knowledgeable of the proper time for termination of pregnancy and having attitudes to seek abortion services provided by health professionals. Yet 26% of respondents indicated unsafe abortion practices; 10% seek abortion from Dayas and 16% of women induce abortion by themselves where 83% of those have utilized the voluntary trauma approach which means that unsafe abortion exist. In addition, they expressed a feeling of low self esteem and emotional status which requires attention too.
It is vital that governmental and nongovernmental organizations including UNRWA deal openly with safe/unsafe abortion as a major public health concern.
UNRWA health professional recommendation regarding health policies, services and educational activities to decline the abortion/unwanted pregnancy included:
The women centers leaders recommendation regarding health policies, services, and educational activities to decline the abortion/unwanted pregnancy for the women camps
Addressing women’s SRH health needs from the women perspective particularly in a conservative society as the case in Palestine, was not really a problem when the women were approached through the data collection where they expressed interest and willingness to reveal the information they have. This could be explained as a venue to ventilate through since no one formally approached them on these issues. While there have been many positive findings of the surveyed women knowledge and attitudes regarding SRH issues investigated, further changes are needed to be made to achieve social equity and gender balance when it comes to decisions regarding early marriage, family planning use, and frequent pregnancy which ultimately lead to increased abortion incidence.
Prevention of unintended pregnancies must always be given the highest priority and all attempts should be made to eliminate the need for abortion. Women who wish to terminate their pregnancy should have ready access to reliable information, compassionate counseling and, in parallel, services for the prevention of unintended pregnancy and management of complications as outlined in the Programme of Action of the International Conference on Population and Development (1994)
Thus, investment in women’s reproductive health not only advances human rights and improve the health and well being of the individual woman and their families, but also benefits their society. Although reproductive health issues are sensitive topics, abortion issue is more sensitive to be uncovered among lay people, health professionals, and at institutional and country level where data could not be obtained. Thus it is important that culturally appropriate discussion of public policy and institutional strategies on SRH issues particularly abortion and unwanted pregnancies be initiated. Failure to pay attention to and invest in the improving reproductive health today will only result in a greater health and social costs in the future.
Baseline Survey on Safe/Unsafe Abortion and Family Planning Methods
In Selected Refugee Camps in West Bank
Hello my name is------------------------------------- I am working on research project for the Palestinian Family Planning and Protection Association.
The aim of this interview is to assess the knowledge and attitudes of married women aged 15-49 years living in selected West Bank Refugee camps toward safe/unsafe abortion and family planning methods.
Your participation is entirely voluntary, anonymous, and the information you give is very confidential. You may refuse to answer any question and can decide to withdraw from the interview at any moment you want.
The results obtained in this way will provide the health care providers and policy-makers with a precise knowledge to improve (SRH) conditions and rights of women through the reduction of unsafe abortion incidence and unwanted pregnancy in the Refugee camps in the West Bank.
Dr. Sumaya Sayej RN MSN Ph D
Camp name: ------------------------------------
Camp number: ------------------------------------
Household number: --------------------------
Please answer your position in the following areas
1. Age ---------------
2. Age at marriage ---------------------
3. Family type -------------------
4. Number of pregnancies----------------------
5. Number of children --------------------
6. Does your husband have a job? Yes No
7. Do you have a job? Yes No
8. What is the average income of households (NIS) per month ------------------?
9. What is your educational level --------------------?
10. What is the educational level of your husband ---------------------?
B. The following statements are related to women’s knowledge of and perception toward the use family planning methods, the reasons where most women seek abortion and legality of abortion. For each statement, please mark ◊ for your response on whether you strongly agree, agree, disagree or do not know
D. the following questions reflects the women knowledge and attitude regarding post abortion complications, consequences, feelings and attitude toward abortion
Note: Please write comments, needs or questions raised by the women participant.
In-depth interview with UNRWA Health Clinics Key Personnel in targeted Refugee Camps
Will you please tell me about?
In-depth Interview with Women Centers/Institution’ Leaders working
In targeted refugee camps
Will you please tell me about?
Name of targeted camps and number of households, community centers, and name of data collectors
List of UNRWA clinics health professionals interviewed
Dr. Elias Habash; Family Health Field Officer
Participant’s selection and sampling approach
A random sampling approach for households will be utilized for the proposed study. In order to select a randomly selected and representative sample of all refugee camps households in the West Bank, so we need the following information
The following information was obtained from the UNRWA website:
The process of random selection
To have a representative sample for the target population under study and in consultation with the statistician, it was agreed that there are two random selection procedures to be done; one for the camps and the other for the households in each randomly selected camp
The probability of household selection will be weighted by each camp size. In other words, the number of women to be interviewed in the household for quantitative data in each camp will be proportional to camp size taking into consideration the sample size required by the TOR (300-350).
To have a random size of the camps in each region we need to do the following calculation procedure:
Number of camps in a given region / Total number of camps in the West Bank) * sample size (required by TOR)
This will give us the number of camps to be studied in a given region. To choose the north sample for example; we need to number all camps (knowing which number represent which camp), each one on a small piece of paper, and then we draw up randomly a number of small papers as was decided by the calculated size sample, and so forth for the other regions.
For example; 7 camps in the North/19 camps in West Bank * 12 (sample size is given number by the TOR) = 4.4 number of camps to be studied in the north
To have an even number of the calculated sample size in each camp, if we have a sample size of 11 camps, then we will come up with number 4 for those in the north and also for those in the middle regions (7 camps in each area), and 3 for the south region because there is a total of 5 camps.
So we decided to have our sample size for all randomly selected camps to be 11 camps and not 12 as referred to in the TOR.
To have a random size of the households in each randomly selected camp we need to do the following calculation procedure:
Number of households in a randomly selected camp / Total number of households of all randomly selected camps) * size of sample (300-350)
For example; 2091 HH in Shufat camp/24205 HH in selected 11 camps * 320 (sample size) is = 27 HH to be selected in Shufat camp
Regarding the random selection of households and for feasibility, we can use the map counts for the 11 selected camps. Each camp map will be divided into 4 or more sections from the middle point to be distributed to all directions, (north, south, west and east). Then we can select the households randomly by pointing a pencil in each divided section taking into consideration that the distribution of number of calculated HHS to be equally distributed in these subsection on the map. In this way we can come up with the selected household sample randomly. This process will be followed in all randomly selected camps.
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