Proportion and Determinants of Repeat Induced Abortion Among Women Seeking Abortion Care Services At Debre Markos Town Health Institutions, Amhara Regional State, Ethiopia, 2017

Objective the aim of this study was to assess the proportion and determinants of repeat induced abortion among women seeking abortion care services at Debremarkos town health institutions, Amhara regional state, Ethiopia, 2017.Result from the total 567-sample size, 547 women were participated in the study making a response rate of 96.5%. In this study 191 woman reported that they had at least one previous abortion, making the proportion of repeat induced abortion 34.9%. In multivariable logistic regression analysis; illiteracy (AOR=8.45, 95%CI; 1.85, 36.49), living in an urban area (AOR=5.14, 95%CI; 2.29, 11.53), having multiple sexual partner (AOR=6.16, 95%CI; 3.25, 11.68), consuming alcohol (AOR=2.77, 95%CI; 1.52, 5.05) and having a history of physical violence by a male partner (AOR=2.68, 95%CI; 1.45, 4.94) were signicantly associated with repeat induced abortion at p value less than 0.05.


Introduction
Induced abortion (IA) is a surgical or medical termination of a live fetus that has not reached viability and repeat induced abortion (RIA) is a binary indicator of whether the woman had an induced abortion prior to the current one (1).
Globally, the estimated number of IA that occurred from 2010 to 2014 were 56 million per year. Fifteen percent around 8.3 million of them occurred In Africa and 2.7 million IA per year had occurred in East Africa. In 2014, in Ethiopia, there was an estimated number of 620,300 IA with an annual rate of 28 abortions per 1,000 reproductive age women (2,3,4,5). RIA accounts for a signi cant proportion of all IA in many countries, with reports ranging from 16% to 71% (1,6). RIA account for 30%-33.6% of all IA in Ethiopia (7,8,9).
Woman who have undergone repeated induced or spontaneous abortions are at increased risk of adverse pregnancy outcomes like mid trimester pregnancy loss and preterm birth (10). In Ethiopia, the number of women receiving treatment for complications from an abortion performed outside as well as inside a health institution increased between 2008 and 2014, rising from 52,600 to 103,600 (5).
Several measures have tried to prevent the impact of IA in Ethiopia. The major measure taken was providing post abortion care (PAC) as a response to avert deaths and injuries from abortion complications. Post abortion family planning (PAFP), a key component of PAC, has been provided targeting speci cally to prevent repeat unintended pregnancies and repeat abortions (11). The International Conference on Population and Development (ICPD) Program of Action states that, "In no case should abortion be promoted as a method of family planning (FP)" (12). Nevertheless, facts on unintended pregnancy and abortion in Ethiopia states that younger women who want to space births are using IA (13).
Despite the efforts to improve FP access and PAC and speci cally PAFP, the higher magnitude of repeat abortion in Ethiopia is worrisome. Furthermore, there is no study done on RIA and associated factor in Amhara region. Even if, there are few studies done in Addis Ababa, the capital city of Ethiopia, the available knowledge is insu cient to answer the relation of partner physical violence and substance exposure with RIA. Therefor this study aimed to assess the magnitude and associated factors of RIA in Debre Markos town, Amhara region, Ethiopia.

Study design and period
An institutional based quantitative cross sectional study was conducted from October 1 to November 30, 2017 GC at health facilities of Debremarkos town, Amhara region, Ethiopia.

Source and study population
All reproductive aged women who seek abortion care services at health institutions of Debre Markos town was the study population, and those who seek the service at the selected health institutions of the town during the study period was the study population. Women on therapeutic abortion or those who had an abortion service somewhere else and came to the institution for PAC service were the exclusion criteria for the study.
Sample size and sampling procedure The nal sample size, 567, was calculated using single population proportion formula with the assumption of 95% con dence interval, 5% margin of error, 33.6% magnitude of RIA in Addis Ababa from a previous study (9), 10 % non-response and a design effect of 1.5. Multi stage sampling was the technique used to select the study participants. First, by using strati ed sampling technique, health facilities with safe abortion service was strati ed based on facility ownership as public, NGO and private facilities. There were four public health centers and one public referral hospital, two facilities owned by Non-Governmental Organizations (NGO) and six private clinics in the town. By simple random sampling technique, two public, one NGO and four private health facilities were selected from each strata. After allocating proportional sample for each strata, based on their average monthly abortion service, systematic random sampling technique nally employed to select the study participants from each health institution. The sampling interval K calculated by using the formula K = N/n and every second women was selected from each facility.

Data collection tool and procedures
Data collection was conducted by eight female diploma midwifes using an interviewer-administered questionnaire and supervised by four BSc midwifes. They were given proper training about the instrument and way of getting consent for an interview for three days prior to the data collection. The data collection tool was prepared from literatures and it was rst translated from English to the native language of the region (Amharic), and then re-translated to English language to ensure consistency. Pretest on 28 woman who came for induced abortion service at University of Gondar referral hospital, Gondar town was conducted and relevant modi cations were done before the actual data collection period. The questionnaire contains; Part I -socio-demographic characteristics, Part II -sexual and reproductive health history, Part III-FP use and fertility intentions, Part IV -substance exposure status and Part V -gender based violence.

Statistical analysis
The data were rst coded, entered and cleaned using Epi info statistical software version 7 and then exported into SPSS statistical software version 20 for analysis. Descriptive statistical analysis such as simple frequencies, measures of central tendency and measures of variability were used to describe the characteristics of participants. To see the association between each independent variable with the outcome variable, bivariate logistic regression was used and a variables with a p-value <0.2 were selected for multivariable logistic regression. Independent predictors of RIA was determined by Multivariable logistic regression and crude and adjusted odds ratios (COR & AOR) together with their corresponding 95% con dence intervals were computed to see the strength of association. Finally, level of statistical signi cance was declared at p-value < 0.05.

Results
Socio-demographic characteristics Out of the total 567-sample size, 547 woman were participated in the study making a response rate of 96.5%. The mean age of the participants was 23.98 (+4.27) years and 42.6% of the participants were in the age group of 20-24 years. Half of the participants had an educational level of more than secondary (50.1%) and the majority (82.6%) were urban residents. [ Table 1].

Sexual and Reproductive characteristics
In this study 191 woman reported that they had at least one previous abortion, making the magnitude of RIA 34.9% (95% CI (30.7-38.8)). Most of the participants had their last pregnancy unplanned and unwanted (78.6%). Among woman with RIA, the majority had only one previous abortion (91.6%), over half (60.1%) received a PAFP method before they left the facility and pregnancy was medical terminated in 78.5% of the cases. 31.8% of the participants reported they have given birth previously. 47.2% and 72.5% of the participants reported a history of physical and sexual violence by their male partners, respectively. [ Table 2] Factors associated with RIA Five variables was signi cantly associated with RIA on multivariable logistic regression. Educational status had an association with the outcome variable; Participants with no education (AOR = 8.45, 95%CI; 1.85, 36.49), with primary educational level (AOR = 5.46, 95%CI: 2.06, 14.47) and with secondary educational level (AOR = 12.96, 95%CI; 6.16, 27.29) were 1.85, 5.46 and 12.96 times more likely to have RIA compared to those who were above secondary educational level. Compared to rural residents, Woman who were urban residents, had 5.14 times chance of RIA (AOR = 5.14, 95%CI; 2.29, 11.53).
Woman who had multiple sexual partner were 6.16 times more likely to have RIA compared to their counter parts (AOR = 6.16, 95%CI; 3.25, 11.68). Alcohol consuming woman had 2.77 times more chance to experience RIA compared to non-users (AOR = 2.77, 95%CI; 1.52, 5.05). Woman who had physical violence by a male partner had 2.68 times more chance of engaging in RIA than those who had not (AOR = 2.68, 95%CI; 1.45, 4.94) [ Table 3].

Discussion
The overall magnitude of RIA for this study was 34.9% (95% CI (30.7-38.8)), the result is found to be comparable with two studies conducted at public and Non -governmental health institutions of Addis Ababa city, Ethiopia, 31% and 33.6%(8, 9).
The gure however is slightly higher than a study done in Kenya and Nigeria with magnitude of RIA 16% and 23% respectively (1,14). This might be due to the liberalized abortion law in Ethiopia may encourage women to seek for abortion care in a health institution. On the contrary, this study has smaller magnitude compared to the study done in Tunisia (42.2%) (15). This may be due to the long time history of the liberalization of abortion law in Tunisia. Furthermore, this study has a much lower gure compared to two studies conducted in United States of America (USA) in New York (57%) and San Francisco (59%), (16, 17). This may be due to the relatively better development stage of the country may contribute to better reporting of previous abortions.
Our study has found out that participants who had no education and had an educational level of primary and secondary were more likely to undergo a RIA than those who had an educational level of more than secondary. The nding is in consistent with the study in Ethiopia, Kenya, Tunisia, Georgia, and Russia (1,8,15,18,19). Unplanned pregnancy secondary to poor contraceptive knowledge and use among those with a lower educational level might be the possible reason.
This study has found out urban residents had ve time higher risk of having RIA than rural residents. This nding is consistent with the study done in Kenya(20). This may be due to the low institutional service utilization of woman from rural area, and rather than seeking for safe abortion, they may choose to use unsafe abortion to terminate the pregnancy that reduces the gure.
In this study, woman who had multiple sexual partner were 2.68 times more likely to have a RIA than those who did not. This nding is consistent with the study done in Addis Ababa, Ethiopia and in Britain (8, 21). This could be due to; having multiple sexual partner will make those women to be in an unstable relationship, which leads to irregular use of contraceptive that will cause contraceptive failure and unwanted pregnancy.
This study has identi ed an association between alcohol use and RIA. Those who had used alcohol had a 2.7 times higher risk of having a RIA. This nding is consistent with the research done in San Francisco General Hospital, USA and with the study done in Russia (17, 19). This may be because of the impact of alcohol on logical thinking of women and might lead them to have unprotected sex.
Finally, those who had a history of physical violence by a male partner had a 2.6 times higher risk of having a RIA than those who did not have a history of physical violence. This result is consistent with the studies done in Tunisia (15). This could be due to fear of telling her male partner about the pregnancy and tend to protect themselves by having an induced abortion. Ethical clearance was obtained from the Department of Midwifery under the delegation from Ethical Review Board of the University of Gondar. Written consent was obtained from each study participants after informing the objective of the study. In the consent, statements about potential risk, bene t, and con dentiality were included.

Consent for publication: Not applicable
Data Availability: The authors declare that the data regarding this manuscript can be accessed as per the request of any interested body and can be submitted for publication in Spring Nature as supplementary materials.
Competing Interest: The authors declare that they have no competing interests Funding Statement: The funding source of this research was from the University of Gondar and the University has no role in design, data collection, analysis, decision to publish as well as preparation of the manuscript.
Authors' contributions: DG and ME; involved in the conception and design of the study, participated in data collection, analyzed the data, drafted the manuscript and approve the nal version of the manuscript. EA, TS and AT; approved the proposal with some revisions, participated in data analysis and interpretation, in revising subsequent drafts of the manuscript and approve the last version of the manuscript. All authors read and approved the nal manuscript.