|Year : 2018 | Volume
| Issue : 9 | Page : 1114-1120
Impact of abortion laws on women's choice of abortion service providers and facilities in southeastern Nigeria
CC Chigbu1, CO Chigbu2, SE Iwuji1, FC Emenalo3, AK Onyebuchi4
1 Center for Women and Gender Studies, Imo State University, Owerri, Nigeria
2 Department of Obstetrics and Gynecology, College of Medicine, University of Nigeria, Enugu State, Nigeria
3 Department of Education Foundation, Imo State University, Owerri, Nigeria
4 Department of Obstetrics and Gynecology, Federal Teaching Hospital, Abakaliki, Nigeria
|Date of Acceptance||18-Jun-2018|
|Date of Web Publication||29-Aug-2018|
Dr. C O Chigbu
Department of Obstetrics and Gynecology, College of Medicine, University of Nigeria, Nsukka, Enugu State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The liberalization of abortion laws in Nigeria has been an interesting debate for a long time. Both proponents and opponents have defended their positions with similar vigor. However, the opinion of the Nigerian woman on the subject matter has received little attention. It is important to understand the opinion of the Nigerian woman, especially with regard to the potential impact of any abortion law on unsafe abortion. Objective: The objective of this study is to determine the impact of abortion laws on women's choice of abortion service providers and facilities in Southeastern Nigeria. Methods: Women attending the gynecological clinics of two tertiary hospitals in Southeastern Nigeria were interviewed with interviewer-administered questionnaires. Questions were asked on awareness of abortion laws, opinion on liberalization of abortion laws, and the impact of abortion laws on women's choice of abortion service providers in situations of unwanted pregnancies. Results: A total of 1120 women were interviewed. More than half (57.7%) of respondents were aware of the abortion laws of Nigeria. About 59.2% of respondents had previously done abortion for unwanted pregnancies. Some (78.3%) of respondents indicated that abortion laws will not influence their choices of abortion service providers in cases of unwanted pregnancies. Majority (78%) do not support liberalization of abortion laws. Conclusion: The abortion laws in Nigeria do not influence women's choice of abortion service providers and facilities. Factors other than the contents of abortion laws influence women's choices. The findings of this study open a new vista toward the search for the factors that drive unsafe abortion in Nigeria.
Keywords: Abortion laws, Abortion service, Nigeria
|How to cite this article:|
Chigbu C C, Chigbu C O, Iwuji S E, Emenalo F C, Onyebuchi A K. Impact of abortion laws on women's choice of abortion service providers and facilities in southeastern Nigeria. Niger J Clin Pract 2018;21:1114-20
|How to cite this URL:|
Chigbu C C, Chigbu C O, Iwuji S E, Emenalo F C, Onyebuchi A K. Impact of abortion laws on women's choice of abortion service providers and facilities in southeastern Nigeria. Niger J Clin Pract [serial online] 2018 [cited 2019 Aug 24];21:1114-20. Available from: http://www.njcponline.com/text.asp?2018/21/9/1114/240059
| Introduction|| |
Nigeria operates restrictive abortion laws, which prohibit abortion except under exceptional circumstances of preserving the life of the mother. The Nigerian abortion laws are encoded in the portions of the criminal and penal codes related to miscarriage. The criminal code is applicable to Southern Nigeria while the penal code is applicable to Northern Nigeria. Essentially both codes prescribed a penalty of 7–14-year imprisonment for induced nonmedically indicated abortion.
In recent times, there have been agitations for the modification of Nigerian abortion laws to make it more liberal. Human rights and pro-choice groups are the most vocal in this regard. They argue that the restrictive abortion laws of Nigeria are responsible for the unsafe abortions in Nigeria. Unsafe abortions contribute significantly to the high maternal mortality rate in Nigeria. Abortion-related complications fall within the first five major causes of maternal mortality in Nigeria. The restrictive abortion laws of Nigeria are thought to force women with unwanted pregnancies to seek clandestine abortion, most of which take place in unsafe places. By this argument, therefore, it stands to reason that if the abortion laws are liberalized, women will have access to safe abortion from qualified medical personnel and facilities, thereby reducing the risk of complications from unsafe abortions.,
On the other hand, the agitations for liberalized abortion laws in Nigeria have met stiff resistance from pro-life groups. They argue that the high rate of unsafe abortions in Nigeria has nothing to do with the restrictive abortion laws of Nigeria. Furthermore, they argue that liberalization of abortion in Nigeria will increase the number of abortions and by extrapolation and its complications. It is known that a good proportion of private hospitals in Nigeria offer abortion services despite the existing restrictive laws., Pro-life groups quickly point to this as evidence that restrictive abortion laws are not driving abortion services underground and therefore not responsible for the high rate of unsafe abortions in Nigeria.
There is no doubt that unsafe abortion is a major public health problem in Nigeria constituting up to 30% of maternal mortality in some health institutions in Nigeria. It is noteworthy that reliable statistics on abortions in Nigeria (both safe and unsafe) are difficult to come by because of the restrictive abortion laws of Nigeria. Most of the data on unsafe abortion in Nigeria are hospital-based data obtained from patients who present with complications of unsafe abortion. The true pictures of unsafe abortion in Nigeria is bigger and glimmer than the official figures as most of these patients do not make it to formal hospital settings. Furthermore, anecdotal evidence has shown that women presenting to hospitals with complications of unsafe abortion do not give accurate information concerning the abortion due to fear of persecution. For example, most of such patients do not give their real names, their real addresses, and the real names of the places or facilities where the abortion took place. The same anecdotal evidence shows that majority of such patients deny having attempted to abort the pregnancies and claim even again clinical evidence that the abortions were spontaneous. These further weaken the reliability of hospital-based data on abortion and abortion complications in Nigeria.
It is also noteworthy that the primary target of either restrictive abortion laws or liberalized laws is the Nigerian woman. The Nigerian woman will be the primary beneficiary or loser on any type of abortion laws Nigeria operates.
Three critical but yet not-well answered questions arise from the on-going debate on the abortion laws of Nigeria. First, how aware is the Nigerian woman on the existing abortion laws of Nigeria? Some previous studies have tried to answer this question., However, the method used in one of the studies fell short of a critical assessment of the awareness of the women. In the study, the respondents were asked simple “yes or no” questions on whether they are aware of the abortion laws of Nigeria. This method of eliciting awareness has serious limitations of response bias. A “yes” answer may not mean that the respondent knows any of the contents of the abortion laws. It could simply mean that the respondent has heard that there is a law against abortion in Nigeria. The other study evaluated awareness of induced abortion and not awareness of abortion laws. It is important to objectively ascertain the awareness of abortion laws by the Nigerian woman as it forms the basis for any discourse on the subject matter. The second question is: what is the opinion of the Nigerian woman on the liberalization of the abortion laws of Nigeria? A study had previously tried to answer this question, but the study evaluated the opinion of only undergraduate university students. There is still need to evaluate the opinions of the broader group of the female population. Evaluating the opinions of the Nigerian woman on the liberalization question is important as it gives a clear direction toward the need for liberalizing or retaining the existing abortion laws of Nigeria. It is a way of giving a voice to the Nigerian woman on the abortion law debate. The third question is: what impact does the restrictive abortion laws of Nigeria make on women's choice of place and facility for abortion of unwanted pregnancies? No previous study has evaluated this aspect of induced abortion in Nigeria. Evaluating the impact of abortion laws on the choice of abortion facilities and personnel will provide a good insight into the contributions of the restrictive abortion laws to the burden of unsafe abortion in Nigeria. Answers to these questions will provide evidence-based results that could guide policy-makers on the way forward in the quest toward the reduction of abortion-related maternal mortalities and morbidities. This study is an effort toward providing such answers in a scientific and systematic way. Should the answers support a significant contribution of the restrictive abortion laws to the unsafe abortion rates in Nigeria and/or a majority call for liberalization of abortion laws, the findings from the study can be used as an evidence for advocacy toward a more liberalized abortion laws in Nigeria. On the other hand, should the answers to these research questions support otherwise, that would point to a need to beam the searchlight on unsafe abortion causes to different issues other than the abortion laws.
| Methods|| |
The study took place in Enugu and Abakaliki in Enugu and Ebonyi States of Nigeria, respectively. These are two out of five states that make up Southeastern Nigeria. The official total female population in these two states is 2,784,586.
The study population comprised women who attended the gynecological clinics of University of Nigeria Teaching Hospital, Enugu and Federal Teaching Hospital, Abakaliki. The average daily clinic attendance for the two centers is 75. Sample selection was by simple random sampling using computer-generated random numbers. Participants who picked numbers that ended in even numbers were selected and interviewed using a pretested, structured questionnaire.
The questionnaires were interviewer administered and contained only close-ended questions. Response options to the questions were ranked using a four-point rating scale and the responses weighted as follows:
- Strongly agree……………………….........…4 points
- Agree (A)…………………………….………3 points
- Disagree (D).…………………………………2 points
- Strongly disagree……………………………..1 point.
The absence of a neutral score was to avoid the masking of negative responses.
Mean scores of 2.50 benchmark was used. Any question whose average response scores were not up to 2.50 was regarded to have been answered in disagreement with the questions. Questions with mean response scores of 2.50 and above were deemed to have been answered in agreement with the questions (affirmative answers).
The questionnaire was developed from findings of review of existing literature. The questionnaire was critically validated for content by a panel of experts comprising three senior lecturers using the average congruency percentage (AVP). The AVP for the questionnaire was 90%. The test–retest method was carried out to test the reliability of the instrument while the internal consistency of the questionnaire was assessed using the Cronbach's alpha coefficient. A test–retest reliability coefficient of 0.8 and Cronbach's alpha of 0.8 were obtained. These were considered adequate.
Statistical comparisons were done to evaluate the differences in responses according to age, education, and marital status, using t-test at 95% confidence level. P < 0.05 was considered significant.
The study protocol was approved by the Center for Women and Gender Studies, Imo State University, Owerri, Nigeria.
| Results|| |
A total of 1120 women participated in the study. The mean age was 31.5 ± 3.2 (range: 21–62) years. Five hundred and thirty-nine (48.1%) respondents were <40 years of age while 581 (51.9%) respondents were 40 years of age and above. Five hundred and two (44.8%) respondents had university education while 618 (55.2%) did not have university education. Some 487 (43.5%) respondents were employed while 633 (56.5%) were unemployed. Six hundred and sixty-three (59.2%) respondents indicated that they had done abortion in the past for unwanted pregnancies.
The overall mean score of the responses to the questions on awareness of abortion laws was 2.9 [Table 1]. This was taken as an overall positive response, indicating that majority of the participants had sufficient knowledge of the abortion laws of Nigeria. The mean score for women who had a previous abortion was 2.9, while that for women who had no previous abortion was 2.8. There was no difference in the mean scores between the two groups (P = 0.08).
Some 1029 (91.9%) respondents indicated knowledge that abortion was prohibited by law in Nigeria. While 755 (67.4%) respondents knew that women seeking for abortion except for maternal health reasons and under physicians' recommendation are punishable by imprisonment, 646 (57.7%) knew that any doctor who provides abortion except for maternal health reasons is punishable by imprisonment in Nigeria [Table 1].
The questions on the influence of the existing abortion laws of Nigeria on women's choice of facility for abortion recorded a mean score of 1.7 [Table 2]. This was taken as an overall negative response, indicating that majority of the participants do not agree that the existing abortion laws of Nigeria have impact on their choice of abortion service providers and facilities. The mean score for women who had a previous abortion was 1.7, while that for women who had no previous abortion was 1.7. There was no difference in mean scores between the two groups (P = 1.0). The fear of abortion laws will not influence the choice of abortion service providers and facilities for 877 (78.3%) of the respondents. Similarly, 1008 (90.0%) will not consider whether abortion is legal or not in deciding where to go for abortion services in cases of unwanted pregnancies [Table 2].
|Table 2: Influence of existing abortion laws on respondents' choice of abortion service providers and facilities|
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The overall mean score of responses to the questions on women's opinion on the liberalization of the abortion laws of Nigeria was 1.8 [Table 3]. This was taken as an overall negative response, indicating that majority of the participants had a negative opinion toward the liberalization of the abortion laws of Nigeria. The mean score for women who had a previous abortion was 1.7, while that for women who had no previous abortion was 1.8. There was no difference in mean scores between the two groups (P = 0.08).
|Table 3: Respondents' opinion on the liberalization of abortion laws in Nigeria|
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Some 874 (78.0%) respondents did not support that the existing abortion laws of the country should be liberalized. The same proportion of respondents did not support that doctors should be permitted by law to perform abortion on women with unwanted pregnancies [Table 3].
[Table 4] shows the comparative analysis of the responses based on age, education, and employment status of the respondents, respectively. The mean scores of the responses to the three research questions were similar between respondents who were employed and those who were unemployed. Furthermore, respondents who were <40 years of age and those who were 40 years and above had similar mean scores in their responses to all three research questions. Although women with university education had significantly higher mean score to the questions on awareness than women without university education, the later still had a positive mean score [Table 4].
|Table 4: Comparison of mean scores of responses according to age, education, employment, and previous abortion|
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| Discussion|| |
The study looked at the abortion debate from the perspective of the Nigerian woman, her opinion on liberalization of the abortion laws of the country, and the possible implications of the existing abortion laws on the choice of facility and providers of abortion services in cases of unwanted pregnancies. The study presents some interesting and important findings.
The high level of awareness recorded in this study is quite noteworthy. Expectedly, the awareness score was significantly higher among women with university of education. However, majority of women without university education were also aware of the abortion laws in Nigeria. Previous studies have shown poor level of awareness of the abortion laws of Nigeria across board. Awareness of the abortion laws was assessed in this study using six different questions with Likert-like responses. Hence, response bias could not have contributed to the high awareness recorded in the study. It is possible that the “heat” generated by the abortion law reform debates in Nigeria has impacted positively on the awareness level of the Nigerian woman regarding the abortion laws of Nigeria. This debate has been on for decades. This is a positive development that is worthy of documentation. The implication of the improved awareness is the potential for the abortion law reform debate to become more robust and more evidence based.
The results showed that the existing abortion laws will not influence the choice of abortion service providers and facilities for the majority of the women. This finding was consistent across age, education status, and employment status. This is a very important finding. The long-held notion that the abortion laws in Nigeria contribute significantly to unsafe abortion may not be true after all. To the best of our knowledge, this is the first study to evaluate this long-held notion. Unsafe abortion is defined as termination of unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal medical standard or both. If the abortion laws of Nigeria do not influence women's choice of abortion service providers and facilities, it then follows that it will not contribute to unsafe abortion. The implication of this finding is that health policy-makers should begin to seek to understand the factors that drive unsafe abortion in Nigeria. Till date, no such prospective study has been done in Nigeria to understand the factors that drive unsafe abortion. Policy-makers have been working on the premise that the abortion laws were responsible for the high rate of unsafe abortion in Nigeria. Another important implication of this finding is that liberalizing abortion laws in Nigeria might not bring the expected significant decline in unsafe abortion rates. Evidence from high-income countries point to a correlation between liberalizing abortion laws and declining unsafe abortion rates. This might not be true in Nigeria. Evidence show that the abortion laws in Nigeria are not being respected as many clinics openly offer abortion services and so changing the laws may not make any difference., This underscores the influence of environment on people's behaviors and the need to adopt health policies that reflect the sociocultural realities of the people. The huge proportion of the respondents (59.2%) who indicated having done a previous abortion for an unwanted pregnancy gives a clue to the magnitude of induced abortions in Nigeria despite the existing abortion laws. Although a wide range of contraception services are available within the study setting, usage is low. A recent report from the study setting indicated that as more than half of women with unplanned pregnancies blamed denial of their right to contraception by their spouses as the cause of the unwanted pregnancy. It will be interesting to study the factors that drive unsafe abortion in Nigeria. Quite a good number of studies in Nigeria have shown the reasons for seeking abortion in Nigeria, but none has evaluated the factors that determine the choice of abortion service providers and the facilities. Until this is done, Nigerian health authorities cannot be in a position to enact remedial policies to stem down unsafe abortion in Nigeria.
Majority of the women in this study did not support the liberalization of abortion laws in Nigeria. It is noteworthy that this issue was assessed in the study using four different questions representing four different scenarios of liberalization, yet all four scenarios recorded very low support for liberalization. Again, this lack of support was consistent across age, education status, and employment status. This is in agreement with previous reports on the subject matter. The Nigerian woman is morally and religious bound and is very unlikely to support any policies that will be interpreted as an affront to morality or religion, which liberalization of abortion laws appears to represent to majority.,
| Conclusion|| |
The existing abortion laws in Nigeria appear not to impact on women's choice of abortion service providers and facilities in Southeast Nigeria. Majority of the Southeast Nigerian women despite having engaged in illegal abortion do not support the liberalization of abortion laws in Nigeria. Studies to evaluate the factors that influence Nigerian women's choice of abortion service providers are recommended. The findings of the study will make an evidence-based contribution to the abortion law debate in Nigeria.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]