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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.
- Tolley.
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Friends, Family Influence Abortion
Decisions |
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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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