For an adolescent girl, an unplanned pregnancy can have severe consequences: abandonment by her partner, expulsion from school, loss of a job, dishonor for her family if she is unmarried, disease or death.
Because they are afraid, ashamed or desperate, many young women are willing to risk their lives to end an unplanned pregnancy. They seek an illegal abortion, often from an untrained person under unsafe conditions, or they try dangerous ways to induce an abortion themselves by drinking gasoline or detergent, taking drug overdoses, douching with bleaches, or inserting objects into their vaginas.
"When an adolescent girl wants to interrupt a pregnancy, she always goes where she should not, in the most isolated places where she knows no one will see her. She goes to places where there are no gynecologists," says one West African health worker.1
Worldwide, clandestine abortion is an all-too-common occurrence among adolescents. The World Health Organization (WHO) estimates that between 1 million and 4.4 million abortions are performed each year among young women (ages 10 to 24 years), and that most of these are unsafe because they are performed illegally under hazardous conditions by unskilled providers.2
"Adolescents are more likely than adults to deny they are pregnant, not recognize the signs of pregnancy, delay decision-making and seek abortion later in the pregnancy, which puts them at greater risk," said Ashley Montague, a program associate for the U.S.-based Ipas, a reproductive health organization that concentrates on preventing unsafe abortions.
Although not all clandestine abortions are unsafe, they are associated with high rates of illness and death. Unsafe abortion can result in hemorrhage, infection and cuts or chemical burns to the genitals or reproductive organs. Treatment can require hospitalization, blood transfusions, antibiotics and other drugs.
Long-term consequences include chronic pain, ectopic pregnancy and infertility due to infections in the upper genital tract. Infertility can carry serious socioeconomic consequences for women, including abandonment by partners and ostracism by the community. Women who are infertile may not be able to marry, and without marriage, they have little hope of being financially secure or respected by their peers. In addition, many young women who become pregnant are expelled from school or fired from their jobs, further limiting their opportunities to earn income.
To help reduce the numbers of deaths and illnesses caused by abortion, health experts recommend several strategies: make family planning information and services more widely available to adolescents; offer emergency contraception to adolescents who have unprotected sex or who are worried about contraceptive failure; and improve postabortion care, including contraceptive services for women hospitalized due to abortion complications.
Contraceptives for young people
Some of the reasons for unsafe abortion can be traced to a lack of contraceptives and other reproductive health services for young people.
Family planning programs are most often designed for married women, not for young, single women or men. Young people may not know how or where to obtain family planning services; those who do may be discouraged by health workers' judgmental attitudes.
In Dakar, Senegal, 12 young people posing as clients in an FHI study visited family planning clinics and were told "you are too young for that" and "focus more on your studies because these methods are bad for your health."3 In Ghana, family planning workers said marriage was a mandatory requirement for family planning.4
Young adults typically know less about family planning than older people, and when they do use contraception, they tend to use less effective methods, use them incorrectly or abandon contraception altogether.
Lack of access to contraceptive services is one reason for increasing rates of abortion among young women in Vietnam, where abortion is legal and widely available. In Hanoi, 90 percent of 259 women who had undergone abortion were ages 15 to 24 years, one study found. Although 78 percent of the young women knew about family planning, only 26 percent had used a method -- predominantly condoms or withdrawal -- and they used those methods inconsistently or incorrectly.
When asked why they had not used contraception, some of the Vietnamese women explained that they are expected to be virgins when they marry -- seeking family planning would disclose that they are sexually active. Also, not using contraception was perceived as a sign of fidelity and confidence that a relationship would lead to marriage. Some young women explained that they did not know that condoms protect against pregnancy as well as sexually transmitted diseases, while others thought that oral contraceptives cause permanent infertility. Ninety-three percent said they could have avoided pregnancy if they had been better informed about sexuality and contraception.5
Better family life education in schools could help young people delay sexual activity or use contraception correctly when they do become sexually active. "To prevent abortion, you also have to consider the right to education, to information, and to family planning and reproductive health services in general," says Luisa Cabal, an attorney for the Center for Reproductive Law and Policy in the United States. "Access to information and education should be linked with access to services." In addition to quality family planning services, she says, young adults need related services, such as HIV testing and counseling for sexual violence.
"We need to develop adolescent-friendly clinics and policies, with convenient hours and locations, affordable services," says Montague of Ipas. "We need providers who are nonjudgmental and who have received special training in working with adolescents. We must ensure confidentiality and ask adolescents what would help them use contraception effectively.
"Health programs should provide a range of methods, including female condoms and emergency contraception. Providers should explore whether a young woman needs a method that does not require her partner's cooperation or whether she needs a method she can easily conceal from family members. Providers must be sure to address myths and concerns about contraception. And they should expect to provide more outreach -- in schools and in nonclinic settings -- and more follow-up for younger clients."
Improving adolescents' knowledge of and access to emergency contraception could help reduce unplanned pregnancies and abortion, says Montague. While emergency contraception should not be used as a regular contraceptive method, young people may not know it is available, how to obtain it or how to use it correctly.
In Nigeria, a survey was conducted among 156 young women who had previously undergone a clandestine abortion. Most of them had heard of emergency contraception, but fewer than one-third knew about emergency contraceptive pills. 6 A study at a New York center for young adults found only 30 percent knew about emergency contraception.7
Some health experts recommend that emergency contraceptive pills be provided in advance to young people who are sexually active. Pills should be given with written instructions on how and when to take them. Pills can also be given to couples who use condoms, in case a condom breaks or fails.
Postabortion care
For young people who have undergone an abortion, postabortion care, including family planning counseling, is critical in preventing repeat abortions. Young women need to know that fertility can return quickly after an abortion and to understand which contraceptive methods are available to them.
If no complications arise after a woman has had a first trimester abortion, she can use any contraceptive method except periodic abstinence, which is not recommended until her regular menstrual cycle returns. If she has had a second trimester abortion, the fitting of diaphragms or cervical caps should be delayed four to six weeks until uterine size has returned to normal. Intrauterine device (IUD) insertion also should be postponed until four to six weeks after abortion unless the provider is trained in immediate postabortion insertion. Women with infection should not use IUDs or undergo sterilization until the infection is gone (usually about three months). Women with severe injury to the genital tract should not use IUDs, spermicides, diaphragms, cervical caps or sterilization until the injury has healed. Those with severe bleeding and related anemia should not use IUDs or sterilization until the condition has been resolved. Women should not resume sexual intercourse until postabortion bleeding stops -- usually five to seven days -- and until any complications or problems are resolved.8
In many countries, efforts have focused on improving postabortion services. In Kenya, the Population Council, Ipas and the Ministry of Health evaluated different ways of delivering postabortion services. One system offered services at gynecology wards through gynecology staff members. Another offered services at the ward, but given by family planning and maternal health providers. And a third system offered services at family planning clinics.
The evaluation found that the first system, in which gynecology staff provided family planning services on the gynecology ward, was the most effective, the most acceptable to clients and the easiest to administer. Offering contraceptive services on the gynecology ward also gave the hospital staff a chance to counsel male partners when they visited the women.
Before the study, hospitals offered contraceptives to women treated for postabortion complications, but family planning services were located away from the wards, and there were no formal links between the wards and the family planning clinics. Postabortion family planning counseling helped increase women's use of contraception, researchers found. More than two-thirds of postabortion clients decided to use family planning, and more than 70 percent of those received a method before they left the hospital. Before the study, only 22 percent said they would use family planning, and 3 percent received a method before they left the hospital.9
In Bolivia, the Population Council worked with the Ministry of Health in a pilot study to improve postabortion care. Before the study, hospital staff had questioned postabortion patients to identify cases of illegal abortion and had charged higher fees to patients with symptoms of induced abortion. Abortion patients were offered emergency care then quickly discharged with no counseling.
During the study, staff established a special treatment and counseling area for postabortion patients, stressed interpersonal communications, and established a referral system for women needing other reproductive health services, including contraception. Hospital staff members' technical knowledge improved, as did their counseling skills.
Acceptance of contraception increased substantially. In 1995, postabortion contraceptive use was less than 15 percent in La Paz, Santa Cruz and Sucre. By 1997, acceptance had risen to more than 60 percent in Sucre and more than 80 percent in La Paz and Santa Cruz. One consequence of the changes was that the hospital began to treat more adolescent patients with postabortion family planning services as word spread.10
Another strategy to improve postabortion care is to make communities aware of services. In Zimbabwe, the POLICY Project educates young people about the dangers of clandestine abortion. The Amakhosi Theatre Group produced a play about an adolescent couple who succumb to peer pressure and have sex. The young man leaves when he finds out his girlfriend is pregnant, and the young woman seeks an abortion from a commerical sex worker. Complications occur and the young woman's parents take her to the hospital. She survives but cannot have children. The play ends with the mother warning the audience about the dangers of unsafe abortion, the need for immediate medical attention if problems arise and the importance of family planning counseling.
More than 2,500 people have seen the drama, which is used to generate discussions among community members, including city officials, health-care workers, village chiefs, traditional healers and clergy. Based on these discussions, researchers have recommended that adolescents receive more information about family planning and unsafe abortion.11
Because unwanted pregnancy can be the result of unwanted sex, provider training on partner violence, rape and assault is useful. In Mexico City, Ipas conducted workshops at three hospitals to make health providers aware of victims' needs, and Ipas launched a media campaign to encourage rape victims to report their assaults. Both activities are part of a larger effort to increase access to abortion among women who have been victims of violence.
Another suggestion for improving postabortion care is decentralizing services, so that postabortion care is offered at health centers, in addition to hospitals. Ipas also recommends health workers be trained in manual vacuum aspiration, which uses suction to remove contents remaining in the uterus after an abortion, while the traditional method of dilation and curettage involves scraping the uterine wall. Aspiration can avoid the need for a hospital stay.
While maintaining good services is important, simple economic pressures play a role in a young woman's decision to keep a pregnancy or have an abortion -- and even whether she can afford a safe abortion.
In Guinea and Côte d'Ivoire, young people told FHI researchers that a pregnant girl would consider whether she could afford visits to the hospital for checkups, medicine and better food, in addition to the long-term costs of raising a child and the father's willingness to assume financial responsibility. If she decided to have an abortion, costs often determine the method used. "Where they do not have enough money, I think that she will rely on indigenous means," one young man explained, referring to dangerous substances to induce an abortion or using falls and blows to the lower abdomen.12
-- Barbara Barnett
References
Tolley E, Dev A, Hyjazi Y, et al. Context of Abortion Among Adolescents in Guinea and Côte d'Ivoire Final Report. Research Triangle Park, NC: Family Health International, 1998.
Young People and Sexually Transmitted Diseases: WHO Fact Sheet No. 186. Geneva: World Health Organization, 1997.
Naré C, Katz K, Tolley E. Measuring Access to Family Planning Education and Services for Young Adults in Dakar, Senegal. Research Triangle Park, NC: Family Health International, 1996.
Tuun-Baah KA, Stanback J. Provider Rationales for Restrictive Family Planning Service Practices in Ghana. Final Report. Research Triangle Park, NC: Family Health International, 1995.
Bélanger D, Hong KT. Young single women using abortion in Hanoi, Vietnam. Asia-Pac Popul J 1998;13(2):3-26.
Arowojolu AO, Adekunle AO. Knowledge and practice of emergency contraception among Nigerian youth. Int J Gynecol Obstet 1999;66(1):31-32.
Cohall AT, Dickerson D, Vaughan R, et al. Inner-city adolescents' awareness of emergency contraception. J Am Med Womens Assoc 1998;53(5 Suppl 2):258-61.
Post-abortion Family Planning, A Practical Guide for Programme Managers. Geneva: World Health Organization, 1997; Winkler J, Oliveras E, McIntosh N, eds. Postabortion Care: A Reference Manual for Improving Quality of Care. Np: Postabortion Care Consortium, 1995.
Solo J, Billings DL, Aloo-Obunga C, et al. Creating linkages between incomplete abortion treatment and family planning services in Kenya. Stud Fam Plann 1999;30(1):17-27.
Creating new postabortion services: intervention design and implementation. Advances and Challenges in Postabortion Care Operations Research. Summary Report of a Global Meeting. Online. Population Council. Available: http://www.popcouncil.org. May 31, 2000; Díaz J, Loayza M, de Yépez YT, et al. Improving the quality of services and contraceptive acceptance in the postabortion period in three public-sector hospitals in Bolivia. In Huntington D, Piet-Pelon NJ, eds. Postabortion Care: Lessons from Operations Research. New York: Population Council, 1999.
Pierce E, Settergren S. Unsafe abortion and postabortion care in Zimbabwe: community perspectives. Policy Matters 2000;1:1-4.
For many young women, research shows that encouragement to seek an abortion comes from friends, parents and sexual partners.
An FHI study in Brazil among 563 young women seeking prenatal or postabortion care found half of the teenagers in both groups said someone close to them had recommended that they end their pregnancies. For teenagers seeking prenatal care, the suggestions came from friends (48 percent), mothers (20 percent), other relatives (23 percent) and their sexual partners (9 percent). For the young women with induced abortions, suggestions came from friends (29 percent), mothers (27 percent), partners (24 percent) and other relatives (20 percent).1
Studies in Africa have shown that social and family networks are an important source of information about abortion, particularly for young unmarried women. In an FHI study in Guinea, a young woman explained, "I went to see my girlfriend, who showed me one of her friends. Her mother is a midwife. She said OK. She gave me the price." Once an adolescent girl is pregnant, parents' attitudes can affect young women's attitudes about pregnancy and abortion. In Guinea and Côte d'Ivoire, study participants said a young woman might have an abortion to save her family from embarrassment. Some suggested a girl would not have an abortion if her parents approved of the pregnancy.2
In Senegal, young women who become pregnant may be shunned by their parents and forced to leave home. Instead of supporting the girl, one male adolescent told researchers that parents "banish her or chase her from the house." Or if she stays "they ignore her as if she were not part of the family."3
The views of male partners often influence women's decisions about whether to keep or terminate a pregnancy. In Tanzania, of 150 adolescents who underwent abortion, 46 percent said they told their male partners before anyone else, and 27 percent told male partners after telling a friend or relative. Two-thirds of the men who knew about their partners' pregnancies advised them to abort. While only 31 percent of men helped women find someone to perform the abortion, nearly 50 percent were prepared to pay for the procedure.4
Partners influenced women's decisions to seek abortion as well as their initial decisions to use family planning. One 20-year-old woman in Kenya who sought an abortion said she did not want children until after she was married but did not use family planning. She was afraid oral contraceptives would cause permanent infertility, and her partner did not want to use condoms. Whenever she suggested condoms, he gave her a piece of candy and asked her to eat it with the wrapping on, telling her that is how it felt for him to use condoms.5
-- Barbara Barnett
References
Barnett B, Stein J. Women's Voices, Women's Lives: The Impact of Family Planning. A Synthesis of Research Findings from the Women's Studies Project. Research Triangle Park, NC: Family Health International, 1998.
Tolley E, Dev A, Hyjazi Y, et al. Context of Abortion Among Adolescents in Guinea and Côte d'Ivoire. Final Report. Research Triangle Park, NC: Family Health International, 1998.
Nguer R, Niang CI, Katz K, et al. Identifying Ways to Improve Family Life Education Programs. Senegal. Research Triangle Park, NC: Family Health International, 1999.
Mpangile GS, Leshabari MT, Kaaya SF, et al. The role of male partners in teenage-induced abortion in Dar es Salaam. Afr J Fertil Sex Repro Health 1996;1(1):29-37.
Solo J, Billings DL, Aloo-Obunga C, et al. Creating linkages between incomplete abortion treatment and family planning services in Kenya. Stud Fam Plann 1999;30(1):17-27.
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