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Adolescent and Youth Reproductive Health Module: 3. Unwanted Pregnancy and Abortion

Study Session 3  Unwanted Pregnancy and Abortion

Introduction

In this study session, you will learn about factors leading to unwanted pregnancy, the psychosocial impact of unwanted pregnancy and the magnitude (i.e. extent) of the problem. You will also learn that an unwanted pregnancy is often terminated by abortion (sometimes spontaneous but often unsafely induced) and that this may lead to complications. You will learn how you can support a young person with an unwanted pregnancy. You will learn how to provide her with post-abortion care if she needs it.

Learning Outcomes for Study Session 3

When you have studied this session, you should be able to:

3.1  Define and use correctly all of the key words printed in bold. (SAQs 3.1 and 3.2)

3.2  Discuss the various factors leading to unwanted pregnancies and some possible consequences. (SAQ 3.1)

3.3  Discuss the possible reasons why a young person might have an unsafe abortion and explain some of the consequences of unsafe abortion. (SAQs 3.1 and 3.2)

3.4  Describe your role as a Health Extension Practitioner in the support of young people who find they have an unwanted pregnancy or who have had an abortion following an unwanted pregnancy. (SAQs 3.1 and 3.2)

3.5  Describe your role as a Health Extension Practitioner in the prevention of unsafe abortion. (SAQ 3.2)

3.1  Unwanted pregnancy

A boy and girl who are worried after they have learned that she became pregnant following unprotected sexual intercourse
Figure 3.1  A boy and girl who are worried after they have learned that she became pregnant following unprotected sexual intercourse.

Unintended or unplanned pregnancies are pregnancies that are reported to have been either unwanted pregnancies (i.e. the woman has no desire to have a child) or mistimed pregnancies (i.e. they occurred earlier than desired – perhaps the couple wished to have a family after they had completed their formal education or maybe they already had a child but wanted more time before having another baby). Pregnancies ending in induced abortion are generally assumed to have been unintended. Both married and unmarried adolescents experience unwanted pregnancies and births (Figure 3.1).

  • Who do you think is more likely to use antenatal care: adolescents with wanted or unwanted pregnancy?

  • Women with unwanted pregnancies are less likely than those with intended pregnancies to seek antenatal care during the first trimester (i.e. the first three months of the pregnancy).

  • Why do you think these young women do not seek antenatal care?

  • It might be that they do not realise they are pregnant because they have had irregular or scant menses (monthly bleeding/menstrual period). Or it might be that they are in denial – trying to ignore the signs and hoping they will have a miscarriage (spontaneous abortion).

  • What are the disadvantages of not seeking antenatal care?

  • Adolescents who have not obtained antenatal care from healthcare professionals may not have the opportunity to get sufficient information regarding the risk of terminating a pregnancy under unsafe circumstances. Hence they are less likely to get safe abortion care even when they are eligible to get the service.

3.1.1  The extent of unwanted pregnancy

Adolescent pregnancy occurs in all societies, although the extent and consequences vary from place to place. According to WHO estimates, in the year 2007 slightly more than 10% of all births worldwide were to girls in late adolescence (15–19 years old), with over 90% of these births occurring in developing countries such as Ethiopia. Many sexually active unmarried young women experience a pregnancy which is both unplanned and unwanted. A study in Ethiopia in the year 2000 showed that more than half of all births to women under the age of 15 (i.e. those in early adolescence), and more than one in three births to women aged 15–24 were unintended.

The same study indicates that 37% of young women aged 15–24 have begun childbearing – 34% of mothers having at least one child. In general, the older the adolescent, the more likely they are to be pregnant; for example, teenage pregnancy and childbearing increases from 1% among women aged 15 to 40% among women aged 19. Teenage pregnancy is higher among rural women (3%) than urban women (2%) and is highest in the Oromiya Region (4%) and lowest in Addis Ababa (1%) (Youth Reproductive Health in Ethiopia, 2002).

3.1.2  Factors related to unwanted pregnancy

Factors that can lead to unwanted pregnancy include: neglecting to use condoms with each act of intercourse; unplanned sex without the availability of contraceptives; incorrect use of the chosen method of contraception (e.g. condom breakage and slippage); not using contraceptives because of a lack of information on their availability and how to use them; not using an available contraceptive method because of some misconception (e.g. concerning its safety).

Some pregnancies result from rape (forced sexual intercourse) and incest (sexual activity between two people who are considered, for moral or genetic reasons, too closely related to have such a relationship, for example a brother and sister or a girl and her father). You will learn more about rape in Study Session 6.

Many adolescent girls do not discuss family planning with their partners due to fear of being abandoned because the man does not wish to bother with a condom, saying it takes away the pleasure. Or maybe she cannot discuss family planning because the man wishes her to have their baby and does not think of the consequences for a young mother.

As you have learned in Study Session 2 about Life skills, it is important that whenever you talk about the subject of unwanted pregnancy you help adolescents build their self-esteem and teach them how to use negotiation skills, but also to be assertive if necessary. You should also explain the appropriate use of contraceptives based on what you will study in Study Session 8 on contraception options for adolescents and young people. This is especially important with adolescents so that they begin practising safer and protected sex from an early age.

3.1.3  The consequences of unwanted pregnancy

There are many negative consequences of unwanted pregnancies: some are common to all unwanted pregnancies, others depend on the precise domestic situation of the young woman or the couple.

  • What domestic situations might the young woman be in?

  • She might be married to an older man or to a young man. She may be unmarried but in a stable relationship and her partner may be willing to marry her or, she may be unmarried with no one willing to take responsibility for her or the baby.

  • What particular problems will an unmarried mother and her child face?

  • In most communities both the mother and child face the stigma of illegitimacy. As a result, unmarried mothers resort to low-paid jobs such as domestic work or risky jobs such as prostitution to support their children.

An early marriage due to an unplanned pregnancy is frequently an unhappy, unstable one because partners blame each other for the situation they are in. This often leads to divorce and the single mother will have to deal with the stigma of divorce as well as all the practical problems of bringing up the child without the emotional or financial help provided by a husband.

Even if a young couple stay together, they are often ill prepared to raise a child, which may lead to childrearing problems like neglect or even child abuse.

Other problems for young couples relate to their formal education and career opportunities. An unwanted pregnancy often means the end of formal education for girls. Boys who become fathers lose opportunities for education and future economic advancement as they leave school to support their new families.

In Study Session 11 of this Module you will learn about the medical risks associated with becoming pregnant at a young age. Pregnancy during adolescence is associated with an increased risk of medical conditions such as anaemia or hypertension (high blood pressure), unsafe abortion, premature birth, obstructed and prolonged labour, stillbirth and maternal mortality.

Being aware of all these consequences will help you to decide how to provide both psychological and medical support for adolescents who have already become pregnant. It is important to realise that adolescents with unwanted pregnancy are already in significant psychological distress and they should receive appropriate counselling and support during pregnancy and after child birth. (Information on counselling young people is in Study Session 9.)

Some of the common conditions among adolescent pregnant women such as anaemia and hypertension are harmful to the growing fetus, which makes the need for proper follow-up even more essential. Hence, whenever you encounter an adolescent who is pregnant, you need to look for such medical risks (anaemia, hypertension, malnutrition), explain to them that these could harm their own health and that of their baby and refer them to the next higher health facility.

3.2  Abortion

  • Give the correct definition of abortion. (Remember you studied this in Study Session 20 of the Antenatal Care, Part 2 Module.)

  • Abortion is the termination or ending of a pregnancy before fetal viability, which is conventionally taken to be less than 28 weeks from the last normal menstrual period. It can happen on its own (spontaneous abortion or miscarriage), or it can be caused deliberately (induced). Abortion may be induced by medical procedure legally, or it may be an unsafe non-medical intervention, which is illegal.

The conditions under which abortion is legal in Ethiopia are indicated in Section 3.2.2

In many countries, 30–60% of pregnancies among adolescents end in abortion. Studies show that almost 6 in 10 abortions in Ethiopia are unsafe. Women seeking induced abortion in 2008 in Ethiopia had a mean age of 23, the majority (54%) being single. Seeking care after a second-trimester abortion was more common among women who lived in rural areas than among their urban counterparts. According to another study, by the Ethiopian Society of Obstetricians and Gynecologists (ESOG) in the year 2000, three-quarters of patients had spontaneous abortions and one-quarter of them had an induced abortion. However, this figure may not be accurate as women who have an induced abortion do not always tell the truth because of fear and uncertainty of the reaction of other people. 

Adolescents and young people are more likely to have an unsafe abortion, which is the termination or ending of a pregnancy by an unskilled, non-medical provider (Figure 3.2). It may be that a safe service is not accessible, affordable, or permitted by law. This might cause adolescents to try to self-induce an abortion or have the procedure carried out by an unskilled provider. Because of economic problems and/or other reasons, adolescent and young women are also more likely to postpone abortion until after the first trimester, which makes the procedure more risky.

A young woman having an abortion by an unskilled person
Figure 3.2  A young woman having an abortion by an unskilled person. Unsafe abortion can result in life-threatening complications including bleeding and infections.

A study in Addis Ababa in 2001 showed that 28% of abortions were self-induced, while 35% were performed by health assistants and only 9% by medical doctors. Materials used to induce an abortion included plastic catheters (14% of surveyed women), plastic tubes (32%), ampicillin (32%), metallic rods (22%), and roots or herbs (5%). As these figures are from one study, variation is to be expected from region to region and between urban and rural areas.

3.2.1  Possible reasons for unsafe abortion

There can be various reasons why an adolescent with an unwanted pregnancy will resort to an unsafe abortion. Some of these reasons are shown in Box 3.1.

Box 3.1  Reasons why an adolescent or young woman might seek an abortion

Education: fear of dropping out of school or interrupting her studies.

Economic factors: fear of not having the financial ability to support herself and her child.

Social condemnation: fear of what her parents or other people might think or say; a wish to avoid bringing shame and condemnation or blame on herself and her family.

Not having a stable relationship: this is more common in adolescents than in adults.

Circumstances of sexual intercourse: an abortion may also be sought where the pregnancy is a consequence of coerced sex, including rape and incest.

3.2.2  Abortion law in Ethiopia

As you read in Study Session 20 of the Antenatal Care, Part 2 Module, abortion is now legal in Ethiopia in cases of rape, incest or fetal impairment. In addition, a woman can legally terminate a pregnancy if her life or her child’s life is in danger, or if continuing the pregnancy or giving birth endangers her life. A woman may also terminate a pregnancy if she is unable to bring up the child, owing to her status as a minor (aged under 18 years) or to a physical or mental infirmity or illness.

Hence, if you encounter a pregnant adolescent fulfilling at least one of the above conditions, you need to refer her to the nearest health facility where an abortion service is available, to minimise the risk of unsafe abortion.

3.2.3  Complications from unsafe abortion

A young woman who has an abortion may face several negative consequences, including haemorrhage, infection, injury to her reproductive organs, intestinal perforation (if metallic or sharp materials are used), and toxic reactions to substances or drugs used to induce abortion. These complications may result in infertility or even death. A study in north Ethiopia in the year 2001 showed that adolescents who had had an abortion had the following post-abortion complications: anaemia 45%, shock 16%, genital tract infection 21%, injury 9%, incomplete evacuation 2%, peritonitis 6%, and renal failure 0.7%.

Peritonitis is inflammation of the peritoneum, which is the membrane that lines the walls of the abdominal cavity.

Whether there are medical complications or not, adolescent and young women may face negative psychological and social consequences after abortion. They may feel remorse, regret or guilt, or they may encounter negative reactions from peers, family, health care providers and society.

As a health worker, you need to inform and counsel any pregnant adolescent about the possible consequences (medical and psychological) of unsafe abortion. If a young woman with any of the above medical complications visits your health post, you need to immediately refer her to a higher health facility (often a hospital) where she can get sufficient care.

3.3  Post-abortion care

  • What are the components of post-abortion care? (Remember you studied this in Study Session 20 of the Antenatal Care, Part 2 Module.)

  • Post-abortion care has three important components:

    1. Emergency treatment of abortion and potentially life-threatening complications
    2. Post-abortion family planning services including counselling
    3. Making links between the post-abortion emergency services and the reproductive healthcare system.

3.3.1  Emergency treatment

Any adolescent or young woman who has an abortion should be provided with emergency treatment as specified in the national guidelines for care after abortion. Your role is to follow the guidelines you studied in Study Session 20 of the Antenatal Care, Part 2 Module. In general the management depends on the type of abortion and the seriousness of complications. If necessary you should refer the mother to the next higher health facility according to the guidelines.

3.3.2  Post-abortion services

You should also keep in mind that you need to provide counselling on contraceptive options and provide young women who have just had an abortion with the method of their choice. Box 3.2 shows you the important things that you can do at health post level (see also Figure 3.3).

Box 3.2  Services you can provide for a young woman who has just had an abortion
  • Provide reproductive health education, including family planning for adolescents
  • Provide contraceptives
  • Explain to her how to recognise the signs and symptoms of pregnancy
  • Inform her of the legal provisions for safe abortion
  • Educate her on the risks of unsafe abortion
  • Explain to her how to recognise the signs and symptoms of abortion (e.g. vaginal bleeding).
A Health Extension Practitioner explaining about the risks of abortion and importance of family planning
Figure 3.3  A Health Extension Practitioner explaining about the risks of abortion and importance of family planning. (Source: WHO, Adolescent Job Aid, 2010)

3.3.3  Linkage to other reproductive health services

It is important to identify the range of reproductive health (RH) services needed by each adolescent and young woman and to be able to offer her as wide a range of RH services as possible. You may need to explain to her that you will be referring her to post-abortion services at another facility where they can diagnose and treat genital tract infections, screen for cervical cancer and investigate physical damage. If you can counsel her about what to expect and why these procedures are necessary she will be more reassured and likely to keep her appointments.

Overall your role as a Health Extension Practitioner is to educate adolescents and young people about the negative consequences of unwanted pregnancy and unsafe abortion so that they can prevent its occurrence. And if adolescents get pregnant through rape or incest, or if they meet the other conditions specified (in Section 3.3.2), they need to know that they can get safe abortion services in health facilities.

Summary of Study Session 3

In Study Session 3, you have learned that:

  1. Adolescent pregnancy is a common occurrence in many societies including in Ethiopia.
  2. A significant proportion of adolescent pregnancies (between 10 and 40%) are unintended. For instance, a study in Ethiopia showed that more than half of all births to girls below the age of 15 are unintended/unplanned.
  3. There are many factors that may lead to unwanted pregnancy, including unplanned sex without the availability of contraceptives, incorrect use of the chosen contraceptive method and not using contraceptives due to lack of information or unavailability.
  4. Abortion is the termination or ending of a pregnancy before fetal viability, which is conventionally taken to be less than 28 weeks from the last normal menstrual period. It can happen on its own (spontaneous abortion or miscarriage), or it can be caused deliberately (induced).
  5. Studies in Ethiopia indicate that the majority (three-quarters) of abortions are spontaneous abortions; the remainder are induced. Other studies in Ethiopia suggest that the proportion of induced abortions may be much higher than this.
  6. Providers of legal abortions include health assistants and medical doctors but abortion may also be self-induced or illegally induced by other persons.
  7. In Ethiopia materials commonly used for the unsafe induction of an abortion include; plastic catheters, plastic tubes, Ampicillin, metallic rods and roots or herbs.
  8. The reasons why adolescents seek abortions include fear of dropping out of education, financial difficulties, fear about what people might think or say, lack of a stable relationship and where the baby was conceived as a consequence of a non-consensual sexual act such as rape or incest.
  9. Abortion is legal in Ethiopia only under certain conditions, which include cases of rape, incest or fetal impairment; if the mother’s life or her child’s life is in danger, if she is unable to bring up the child owing to her status as a minor (less than 18 years old) or to a physical or mental infirmity or illness.
  10. Post-abortion care involves 3 important aspects of care, which include emergency treatment of abortion and potentially life-threatening complications, post-abortion family planning counselling and services, and linking between post-abortion emergency services and other reproductive healthcare services.

Self-Assessment Questions (SAQs) for Study Session 3

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

First read Case Study 3.1 and then answer the questions that follow it.

Case Study 3.1  Azeb’s story

Azeb is a 17-year-old girl living with her family. Azeb hopes to complete her education and pursue a college education in one of the universities. One day, she found out that her menstrual period had not started as expected and she went to the nearby health facility. After taking a urine sample the Health Extension Practitioner told her that she was three months pregnant. Azeb was shocked by the news as she was not prepared for it. However, Azeb admitted that she never used contraceptives when having sexual activity with her boyfriend.

SAQ 3.1 (tests Learning Outcomes 3.1, 3.2, 3.3 and 3.4)

  • a.How do you describe Azeb’s pregnancy?
  • b.How do you react to her situation?
Answer
  • a.Since Azeb was unhappy and upset when she learned that she was pregnant, we can conclude that the pregnancy was unplanned and unwanted.
  • b.From the story, it is evident that Azeb needs appropriate information and counselling on issues related to her unwanted pregnancy. Specifically, she needs to know that she should attend for antenatal care. The medical risks, such as anaemia and hypertension, should be explained and she should be told the warning signs of complications in pregnancy and what to do if she experiences any of these. You will be aware that she may face social stigma and that there is a danger of her dropping out of school so you should provide reassuring and supportive counselling. It is unlikely that she qualifies for a legal abortion so you should warn her of the dangers of unsafe abortion while being careful to emphasise the possible positive outcomes of having a baby.

First read Case Study 3.1 (continued) and then answer the questions that follow it.

Case Study 3.1(continued) for SAQ 3.2

Azeb came to your Clinic complaining of having had severe vaginal bleeding. When she was asked what went wrong she admitted that she had attempted to end the pregnancy by inserting a sharp instrument as she was ill-prepared to have a child. When her boyfriend, who is also a student in high school, realised that she was pregnant, he stated that he had never had an affair with her.

SAQ 3.2 (tests Learning Outcomes 3.1, 3.3, 3.4 and 3.5)

  • a.What kind of abortion did Azeb have? What are the risks associated with the procedure she had?
  • b.In your opinion, what were the factors that predisposed her to have an abortion in the first place, and what advice would you give her to avoid repeating the same mistake?
Answer
  • a.Since Azeb tried to terminate her pregnancy, this is an example of unsafe induced abortion. Non-medically induced abortion is likely to result in many complications including bleeding (which she experienced), infections and even death.
  • b.Azeb is still in school, strongly hoping to complete her education and have a decent career. In addition, she is not getting any support from her partner (her boyfriend actually denied having a relationship with her). Assuming that the self-inflicted wound has resulted in terminating her pregnancy Azeb needs to get emotional support and be counselled about family planning services to avoid having the same problem again. She also needs to be checked to see whether she is anaemic, and you should refer her for a post–abortion check to ensure she does not have physical damage or genital tract infections.