Private Medical Providers' Knowledge and Practices Concerning Medical Abortion in

Nigeria
Author(s): Friday E. Okonofua, Afolabi Hammed, Tajudeen Abass, Abdulkarim Garba
Mairiga, Abubakar Bako Mohammed, Adeniyi Adewale and Danjuma Garba
Source: Studies in Family Planning, Vol. 42, No. 1 (MARCH 2011), pp. 41-50
Published by: Population Council
Stable URL: http://www.jstor.org/stable/41310707
Accessed: 28-04-2016 04:21 UTC

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 Private Medical Providers' Knowledge
and Practices Concerning Medical Abortion
in Nigeria
Friday E. Okonofua, Afolabi Hammed, Tajudeen Abass, Abdulkarim Garba Mairiga,
Abubakar Bako Mohammed, Adeniyi Adewale, and Danjuma Garba

To investigate the knowledge and practices regarding medical abortion and postabortion care in northern
Nigeria among private physicians- the principal providers of such services in the area- 122 doctors
operating separate clinics in five states- Bauchi, Borno , Kaduna, Niger, and Taraba-were interviewed
by means of a structured questionnaire. The results showed that 22 percent of the doctors reported that
they terminate unwanted pregnancies , whereas nearly all reported that they manage complications
of unsafe abortion. Manual vacuum aspiration and dilatation and curettage performed singly or in
combination were the most common methods of abortion and postabortion care reported by the doctors.
Only one doctor reported exclusive use of medical abortion in the first trimester, and three reported its
exclusive use in the second trimester. Only 35 percent of the doctors listed misoprostol as a drug that
they knew could be used for abortion and postabortion care, and only 12 percent listed mifepristone. By
contrast, 49 percent listed inappropriate or dangerous drugs for use in abortion provision in the first
and second trimesters of pregnancy. We conclude that private practitioners in northern Nigeria have
limited knowledge of medical abortion and postabortion care, and that a capacity-building program on
the subject should be instituted for them. (Studies in Family Planning 2011; 42[1]: 41-50)

Induced abortion is legally restricted in Nigeria; it is per-
mitted only to save the life of the woman and, in the
southern states of the country, also for physical and men-
tal health reasons (Ogiamien 2000). Despite the restric-
tive abortion law, several reports (Okonofua et al. 1999;
Nwogu-Ikojo and Ezegwui 2007; Bankole et al. 2008) in-
dicate that induced abortion is widespread in the country
and that it is associated with high rates of maternal mor-

Friday E. Okonofua is Director and Afolabi Hammed is
Program Officer, Women's Health and Action Research
Center, KM 11 Benin-Lagos Expressway, Igue-Iheya,
Benin City, Edo State, Nigeria. E-mail: feokonofua®
yahoo.co.uk. Tajudeen Abass is Researcher, Department
of Obstetrics and Gynecology, Ahmadu Bello University
Teaching Hospital, Zaria, and Coordinator, Association of
Private Obstetrical Providers, Kaduna State; Abdulkarim
Garba Mairiga is Consultant Obstetrician and Associate
Professor, Department of Obstetrics and Gynecology,
University ofMaiduguri Teaching Hospital, and Coordinator,
Association of Private Obstetrical Providers, Borno State;
Abubakar Bako Mohammed is Consultant Obstetrician
and Gynecologist, Specialist Hospital, Bauchi State, and
Coordinator, Association of Private Obstetrical Providers,
Bauchi State; Adeniyi Adewale is Consultant Obstetrician and
Gynecologist, Department of Obstetrics and Gynecology, State
Hospital, Mina, Niger State and Coordinator, Association of
Private Obstetrical Providers, Niger State; Danjuma Garba is
Medical Director, Gateway Hospital, Jalingo, and Coordinator,
Association of Private Obstetrical Providers, Taraba State.
bidity and mortality. Data from the Federal Ministry of
Health suggest that complications of induced abortion ac-
count for an estimated 20 percent of maternal deaths in Ni-
geria. The most recent estimate of the incidence of induced
abortion, obtained by interviewing practitioners across the
country, indicate that about 760,000 abortion procedures
are carried out in Nigeria each year, the majority of which
are unsafe (Bankole et al. 2008). This figure amounts to an
abortion rate of 25 per 1,000 women of reproductive age,
one of the highest rates of induced abortion in the devel-
oping world. Nearly 70 percent of women attending pre-
natal clinics in urban Nigeria report that they have previ-
ously undergone an induced abortion (Okonofua et al.
2010). Because of the illegal status of the procedure, public
health facilities often do not provide safe abortion services
and only a few offer evidence-based postabortion care.
Several reports indicate that up to 80 percent of induced
abortions and postabortion care in Nigeria is provided by
private physicians (Okonofua and Ilumoka 1992; Okono-
fua et al. 1999; Bankole et al. 2008). Private providers of
abortion and postabortion care are doctors with individ-

Volume42 Number 1 March 2011 41

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ual or group practices or doctors who work in public ser-
vice but who also provide part-time private services.
A study of women in two states of Nigeria (Okonofua
et al. 1999) revealed that more than 30 percent of the wom-
en who indicated that their abortions were performed by
private medical providers mentioned that they had expe-
rienced significant complications following the abortion
procedure. Similarly, audits of complications and deaths
associated with unsafe abortion in various parts of the
country indicate that most abortion procedures that re-
sulted in severe complications and hospitalizations were
carried out by private medical providers (Nwogu-Ikojo
and Ezegwui 2007). Our previous study of private medi-
cal practitioners, which drew upon 2001 data and did not
include questions on medical abortion, revealed that al-
though up to 40 percent reported that they operate a pol-
icy of terminating unwanted pregnancies in their clinics,
many did not employ current evidence-based procedures
for doing so (Okonofua et al. 2005). For example, many
reported that they use the dilatation and curettage (D&C)
procedure for first-trimester abortions rather than the less
traumatic manual vacuum aspiration (MVA) method.
Also, many private physicians have limited experience
with the dilatation and evacuation (D&E) method and
are, therefore, more likely to use D&C, MVA, or vacuum
aspiration for a second-trimester abortion, which carry
increased risk of complications for women. Moreover,
several doctors we surveyed were still using inappropri-
ate methods to care for women who suffer complications
of abortion, and less than 10 percent of practitioners had
well-defined approaches for follow-up care and counsel-
ing of women who had undergone the procedure. Thus,
we determined that a persistent need exists for building
the capacity of private medical practitioners to provide
high-quality abortion and postabortion services within
the limit of the prevailing abortion law as a strategy to re-
duce maternal morbidity and mortality in Nigeria.
The use of drugs such as mifepristone and misopro-
stol for managing unwanted pregnancies and abortion
complications (a practice called medical abortion or
medication abortion) is now widespread throughout the
world (McKinley et al. 1993; Harwood and Mishell 2002).
The World Health Organization has included these two
drugs in its Essential Drugs List and recommended them
as key for managing unwanted pregnancy and improv-
ing abortion safety. Several reports have shown that these
drugs are highly efficacious in terminating unwanted
pregnancies in the first and second trimesters (Fiala et al.
2005; Say et al. 2005), and in managing several complica-
tions of abortion such as missed abortion (delayed mis-
carriage) (Stockheim et al. 2006; Chen and Creinin 2007),
incomplete abortion (Gao and Wang 1999), and retained
42 Studies in Family Planning
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products of conception (Nielsen et al. 1999). Although
misoprostol has been available in Nigeria since the mid-
1990s, not until 2006 was it approved by the government
for the treatment and prevention of postpartum hemor-
rhage (Jadesimi and Okonofua 2006); it was included in
the national Essential Drugs List for the same purpose in
November 2010 (FMOH 2010). By contrast, mifepristone
is currently not registered for use in Nigeria, although it
is available in some large pharmacies in cities across the
country. The use of medical abortion methods will likely
increase the safety and improve the outcomes of abortion
and postabortion care in Nigeria. Currently, however, the
use of these methods are often employed without the ben-
efit of national guidelines, requiring that practitioners rely
on their intuition or their personal knowledge of the litera-
ture to determine dosages and routes of administration.
The tendency for practitioners to use inappropri-
ate surgical procedures rather than prescribed surgical
methods for first- and second-trimester abortion and
postabortion care increases the likelihood of complica-
tions. Therefore, a medical abortion method that reduces
the need for surgical intervention may be what is needed
to decrease the rate of abortion-related complications.
Evidence from Brazil and other South American coun-
tries where abortion is similarly restricted by law (Clark
et al. 2002; Mundigo 2006; da Silva Ramos et al. 2010) in-
dicates that the introduction of misoprostol for abortion
and postabortion care resulted in a significant decline in
abortion-related maternal mortality. We believe, there-
fore, that improving private practitioners' knowledge
and practice of medical abortion in Nigeria could be an
effective strategy for increasing abortion safety and im-
proving postabortion care in the country.
Current empirical information is lacking concerning
what practitioners in many developing countries know
or do not know about abortifacients and concerning their
practices relating to medical abortion. The aim of this
study, therefore, is to determine the knowledge, attitudes,
and practices of private physicians in five states in north-
ern Nigeria concerning medical abortion. The results may
prove useful for designing appropriate interventions to
improve private providers' use of medications for abor-
tion and postabortion care in Nigeria.
Methods
This study was conducted by the Women's Health and
Action Research Centre (WHARC), a nongovernmental,
nonprofit organization in Benin City, Nigeria. It was con-
ducted under the auspices of the Association of Private Ob-
stetrical Providers (APOP), a registered nongovernmental
organization with offices in 11 states of Nigeria that was
formed by WHARC to build the capacity to provide high-
quality private reproductive health services in Nigeria.
The study was conducted in 2009 in 5 of the 19 north-
ern Nigerian states - Bauchi, Borno, Kaduna, Niger, and
Taraba - and was coordinated by the APOP chapters in
these 5 states. The states had participated in similar com-
munity-based research projects on abortion care carried
out by WHARC in the region and were selected on the
basis that they represented the three geopolitical zones
in northern Nigeria (the north-central, northeast, and
northwest zones). Permission to conduct the study was
obtained from the Executive Members of APOP in the five
states. They were informed that the study would gather
information necessary for improving the management of
unwanted pregnancies and abortion complications in the
states. Ethical approval to conduct the study was obtained
from the Ethics Review Committee of WHARC, made up
of individuals who are not staff members of the Centre.
A list of private medical clinics in the capital cities of
the participating states (and their contact information)
was first obtained from the states' ministries of health.
This list consisted of 162 facilities enrolled as private clin-
ics in the five states, which represented about 80 percent
of the total number of clinics in the states; only a few clin-
ics were operating in rural areas. The registration pro-
files of the 162 clinics indicated that 36 did not provide
maternal health care or reproductive health services to
women. The proprietors of the 126 clinics that provided
such care to women were approached to participate in the
study. (Proprietors were selected because in most clinics
the proprietor is the only doctor, and in the few clinics
employing more than one doctor, the proprietor would
be the most knowledgeable about the clinic's policies and
practices relating to medical abortion.) They were assured
of the confidentiality of information obtained and were
told that their names and those of their clinics would not
appear on any documents generated by the research. Of
the 126 clinics, 122 agreed to participate in the study, and
individual physicians at these clinics were interviewed.
Before the study questionnaires were administered, a
short training and debriefing meeting of APOP coordina-
tors in the five states was held at WHARC. The purpose
of the training was to explain the objectives and methods
of the study and, in particular, to increase the capacity of
the project teams of APOP coordinators and research as-
sistants to administer the questionnaires and to conduct
the study correctly. During the workshop, the question-
naire was finalized, and a uniform method for meeting
with the physicians and administering the questionnaires
to them was worked out. The meeting also included sec-
tions on pretesting the questionnaire as well as a demon-
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stration of its use. Pretesting was carried out with a small
group of private doctors in Benin City who did not par-
ticipate in the study.
The pretested structured questionnaire, consisting
of both closed-ended and open-ended questions, was or-
ganized in four sections. Section 1 solicited information
regarding the sociodemographic characteristics of the
respondents - age, sex, marital status, and level of medi-
cal training. Section 2 asked questions about the charac-
teristics of the women seeking abortion and postabortion
care, how the respondent deals with such pregnancies,
whether the respondent terminates a pregnancy at a cli-
ent's request, the procedures followed, and why the re-
spondent terminates or does not terminate unwanted
pregnancies. The third section of the questionnaire so-
licited information on the practitioners' knowledge and
practices of medical abortion. We first asked whether they
know of drugs that can be used successfully for terminat-
ing unwanted pregnancies and for treating postabortion
complications. If they said they do, we asked them to list
such drugs. We asked whether they have prescribed and
used such drugs for their patients. We asked those who
said they have done so to list the drugs and dosages they
used. We followed this question with a series of questions
about the drugs and drug combinations they use for preg-
nancy termination and postabortion care during the first
and second trimesters and the complications they have
experienced using such drugs.
In the final section of the questionnaire, we asked
about postabortion family planning. Specifically, we
asked the practitioners whether they offer family plan-
ning to their clients after abortion, and if so, which meth-
ods and procedures clients have adopted. We also asked
them about the types of family planning commodities
that are available in their clinics and the type of training
they have received for providing postabortion care and
postabortion family planning services.
The questionnaires were self-administered. They
were handed out to consenting private doctors who were
asked to complete them and return them to the study co-
ordinator. A research assistant visited the clinics one week
later to retrieve the completed questionnaires. The coordi-
nators returned the completed questionnaires to the col-
lating center in WHARC for data entry and analysis.
Data analysis consisted of descriptive statistics to de-
termine the physicians' patterns of responses. The analy-
sis was performed individually for the participating states
and subsequently combined to determine the overall pat-
tern of responses for all the states. Categorical variables
were analyzed by use of nonparametric statistics, and dif-
ferences between proportions were compared with chi-
square tests, with Yates correction where appropriate.
Volume 42 Number 1 March 2011 43
Results
One hundred and twenty-two private physicians who
were proprietors of 122 private clinics were interviewed,
representing 99 percent of the clinics offering reproduc-
tive health care in the five states. This total consisted of 14
doctors in Bauchi, 35 in Borno, 36 in Kaduna, 26 in Niger,
and 11 in Taraba. The sociodemographic characteristics
of the doctors are presented in Table 1. Their ages ranged
between 25 and 64, with a median age of 41 years. Ninety-
five percent were males, and 79 percent were married. A
little more than two-fifths of the doctors were Muslim;
the rest were Catholics, Protestants, and Pentecostals.
The numbers of years since their graduation from medi-
cal school ranged between 1 and 38, with a median of 13
years. Forty-five respondents (37 percent) were special-
ists in various fields; the remainder were general practi-
tioners. The specialty practiced by the majority (32, which
is 71percent) of specialists in the sample was obstetrics/
gynecology. Other specialties were internal medicine (7),
dermatology (2), surgery (1), family medicine (1), anes-
thesiology (1), and ophthalmology (1).

Management of Unwanted Pregnancies

Table 1 Percentage distribution of private physicians
surveyed, by selected sociodemographic characteristics,
As shown in Table 2, of the 122 private doctors, 111 (91
Nigeria, 2009
percent) reported that women with unwanted pregnan-
Characteristic Percent (n)
cies consult their clinics. Of the 111 doctors who see these
Age
20-29 10.7 (13) women in their clinics, only 24 (22 percent) indicated that
30-39 29.5 (36) they terminate a pregnancy when a woman requests the
40-49 35.2 (43)
procedure. This proportion comprised 20 percent of all the
50-59 19.7 (24)
60-69 2.5 (3) physicians interviewed. Doctors in Bauchi, Borno, and Ka-
No response 2.5 (3) duna were most likely to answer "yes" to this pregnancy-
Total 100.0 (122) termination question, whereas doctors in Niger and Taraba
Sex
were most likely to say that they do not terminate unwant-
Male 95.1 (116)
Female 4.9 (6)
ed pregnancies. The differences between the answers
Total 100.0 (122) they provided were not statistically significant, however
Marital status (p > 0.05, chi-square test for trends). Among those who
Single 21.3 (26) terminate unwanted pregnancies, 20 (83 percent) report-
Married 78.7 (96)
Total 100.0 (122)
ed that they carry out the procedures themselves; the re-
Religion maining 4 (17 percent) replied that other doctors in their
None 0.8 (1) clinics carry out the procedures. By contrast, 112 of the
Catholic 18.9 (23)
122 doctors (92 percent) reported that they treat women
Protestant 20.5 (25)
Islam 43.4 (53)
who experience complications of abortion (postabortion
Pentecostal 15.6 (19) care) in their clinics.
No response 0.8 (19) Among the 87 doctors who reported that they do not
Total 100.0 (122)
terminate unwanted pregnancies, 64 (37 percent) said
Number of years since graduation from medical school
1-4 19.7 (24)
they counsel the women to continue with their pregnan-
5-9 20.5 (25) cies, 15 (17 percent) counsel the women on the necessity of
10-14 15.6 (19) being morally upright by not engaging in premarital sex,
15-19 12.3 (15)
and 32 (37 percent) refer the women to other doctors.
20+ 32.0 (39)
Total 100.0 (122) To identify the reasons why the doctors do not termi-
Specialist nate unwanted pregnancies, we asked them to grade a list
Yes 36.9 (45) six possible reasons as "extremely important," "slightly
No 63.1 (77)
important," "least important," and "not important." The
Total 100.0 (122)
reasons listed are "against my religion," "against my pro-
Area of specialization
Internal medicine 15.6 (7) fessional ethics," "fear of police harassment," "in obedi-
Surgery 2.2 (1) ence to the Nigerian law on abortion," "past experience
Obstetrics/gynecology 71.1 (32)
of abortion complications," and "against my conscience."
Anesthesiology 2.2 (1)
Family medicine 2.2 (1) The results of the analysis are presented in Table 3. Reli-
Dermatology 4.4 (2) gion appears to have the most profound effect; 83 percent
Ophthalmology 2.2 (1) of those who do not perform abortion identified religion
Total
as being an extremely important reason. Sixty percent

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Table 2 Percentage distribution of private physicians Table 3 Percentage distribution of private physicians
surveyed, by methods they currently use for resolving patients' surveyed, by their reasons for not terminating unwanted
unwanted pregnancies, Nigeria, 2009 pregnancies, Nigeria, 2009
Variable Percent (n) Reason Percent (n)
Do women with unwanted pregnancies consult your Against my religion
clinic/hospital? Extremely important 83.3 (70)
Yes 91.0 (111) Slightly important 7.1 (6)
No 9.0 (11) Least important 2.4 (2)
Total 100.0 (122) Not important 7.1 (6)
If yes, does your clinic terminate the pregnancy if Total 100.0 (84)
the woman desires a termination?
Against my professional ethics
Yes 21.6 (24) Extremely important 60.0 (51)
No 78.4 (87) Slightly important 14.1 (12)
Total 100.0 (111) Least important 4.7 (4)
If yes, who performs the procedure? Not important 21.2 (18)
Clinic proprietor 83.3 (20) Total 100.0 (85)
Other doctor in the clinic 1 6.7 (4) Fear of police harassment
Total 100.0 (24) Extremely important 15.7 (13)
If no, how do you resolve the problem for the woman? Slightly important 4.8 (4)
Counsel her to continue with the pregnancy 42.5 (37) Least important 14.5 (12)
Preach moral codes but do not counsel 2.3 (2) Not important 65.1 (54)
Refer her to other doctor 20.7 (1 8) Total 100.0 (83)
Counsel her to continue with the pregnancy and refer
In obedience to Nigerian law on abortion
her to other doctor but do not preach moral code 1 6. 1 (14)
Extremely important 31 .0 (26)
Counsel her and preach moral code 1 4.9 (1 3)
Slightly important 28.6 (24)
All of the above 2.3 (2)
Least important 1 1 .9 (1 0)
No response 1.1 (1)
Not important 28.6 (24)
Total 100.0 (87)
Total 100.0 (84)
Method used for pregnancy termination at < 1 2 weeks
Past experience of abortion complications
Dilatation and curettage 8.3 (2)
Extremely important 1 3.4 (11)
Manual vacuum aspiration 62.5 (15)
Slightly important 6.1 (5)
Medical abortion 4.2 (1)
Least important 12.2 (10)
Dilatation and curettage + manual vacuum aspiration 20.8 (5)
Not important 68.3 (56)
Manual vacuum aspiration + medical abortion 4.2 (1 )
Total 100.0 (82)
Total 100.0 (24)
Against my conscience
Method used for pregnancy termination at > 1 2 weeks
Extremely important 42.9 (36)
Dilatation and curettage 8.3 (2)
Slightly important 20.2 (17)
Manual vacuum aspiration 12.5 (3)
Least important 10.7 (9)
Oxytocin 4.2 (1)
Not important 26.2 (22)
Artificial rupture of membranes + oxytocin stimulation 29.2 (7)
Medical abortion 12.5 (3) Total

Don 't terminate later than 1 0 weeks 8.3 (2)

Artificial rupture of membranes + medical abortion 4.2 (1 )
Dilation and evacuation 4.2 (1)
Artificial rupture of membranes + oxytocin simulation + Among the 24 doctors who said that they terminate
medical abortion 4.2 (1) unwanted pregnancies, the methods they use are pre-
Refer/counsel her to continue pregnancy 4.2 (1 )
No response 8.3 (2)
sented in Table 2. Manual vacuum aspiration (MVA) is
Total 100.0 (24) the most commonly used method employed in the first
Do you treat women with abortion complications in trimester: 63 percent of the respondents reported using
your clinic?
it exclusively and another 25 percent reported using it
Yes 91.8 (112)
No 8.2 (10)
in combination with another method. Dilatation and cu-

Total rettage (D&C) alone (8 percent) or in combination with

said that pregnancy termination being against their pro-
fessional ethics is an extremely important reason, and 43
percent said performing abortion being "against their
conscience" is so. The proportion of physicians citing the
other reasons as being primary are 31 percent for being
"in obedience to the Nigerian abortion law," 16 percent
for "fear of police harassment," and 13 percent for "past
experiences of abortion complications."
MVA alone (21 percent) was the next most popular meth-
od in the first trimester. Only one doctor in Kaduna State
reported using medical abortifacients for terminating
unwanted pregnancies in the first trimester.
In the second trimester, artificial rupture of mem-
branes and oxytocin stimulation is the method of termi-
nation most commonly reported by 7 (29 percent) of the
respondents. Other methods reported include MVA (13
percent), D&C (8 percent), and combinations of MVA
and D&C. Two doctors (8 percent) reported that they do

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not currently terminate pregnancies beyond ten weeks.
Thirteen percent reported that they use medical abortion
methods alone, and another 8 percent use them in com-
bination with other methods.
Knowledge and Practices of Medical
Postabortion Care
The physicians were asked whether they know of any
drugs that can be used to terminate unwanted pregnan-
cies and manage complications of unsafe abortion (not
shown). Of the 122 respondents, 74 (61 percent) answered
"yes" to the question. When asked to list the drugs,
misoprostol and mifepristone - the two drugs recom-
mended by the WHO as effective for terminating preg-
nancies in the first and second trimesters - were known
only by a minority: 46 (38 percent) listed misoprostol, and
only 16 (13 percent) listed mifepristone. Further analysis
reveals that those who listed these two drugs are more
likely than those who do not to be specialists. Of the 46
doctors listing misoprostol, 36 are specialists (32 obstetri-
cians/ gynecologists and four internists); the 16 who listed
mifepristone are all obstetricians/ gynecologists. By con-
trast, 49 percent of the doctors (especially nonspecialists)
were more likely to list drugs that are not recommended
by the WHO for terminating pregnancies. Eleven (8 per-
cent) listed ergometrine, 20 (15 percent) oxytocin, 3 (2
percent) prostaglandins, 5 (4 percent) methotrexate, and
2 (2 percent) syntocinon, all of which are drugs that may
be useful in managing abortion complications but are less
useful in initiating and completing a pregnancy termina-
tion. The remainder of the respondents listed drugs of
unproved efficacy such as quinine, ventolin, ergotamine,
menstrogen, gynaecosid, and potash iodine.
When asked whether they had ever used these drugs
for terminating unwanted pregnancies, only 20 (16 per-
cent) of the doctors answered "yes" to the question,
while 10 (8.2 percent) listed misoprostol as a drug they
had used previously (not shown). Thus, misoprostol was
mentioned by 50 percent of all doctors who said they had
previously used medications to terminate unwanted
pregnancies. The others mentioned syntocinon, ergome-
trine, and oxytocin, which are not effective in terminat-
ing pregnancies in the first trimester but may sometimes
be useful in the second trimester, especially if combined
with artificial rupture of the membranes. When asked to
mention the dosage of misoprostol used in the first tri-
mester, three doctors reported 400 micrograms, another
three reported 600 micrograms, and three doctors who
said they had used misoprostol previously were unable
to report the dosage of the drug. Only one doctor report-
ed having used misoprostol in the second trimester, but
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he reported a dosage of 200 micrograms. Notably, none
of the doctors had used a combination of misoprostol and
mifepristone, which is recommended by the WHO for in-
duced abortion in the first trimester.
We asked the 20 doctors who had used the drugs pre-
viously whether their patients had experienced any side
effects or complications. All reported that they routinely
follow up with their patients after administration of the
drugs. Nine doctors reported that they had witnessed
complications with some patients. The side effects and
complications they listed included vomiting, bleeding,
retained products of conception, abdominal cramps, diz-
ziness, and collapse.
We asked respondents whether they have ever used
any medications for the management of abortion com-
plications. The patterns of responses to this question are
presented in Table 4. Twenty-eight (23 percent) reported
that they have done so, whereas 71 (58 percent) said that
they have not. The complications of abortion for which
they reported using these drugs include severe bleed-
ing, incomplete abortion, inevitable abortion, retained
placenta, and missed abortion; six listed no specific com-
plications. The drugs the doctors reported having used
include misoprostol, oxytocin, ergometrine, pitocin injec-
tion, and syntocinon.
Additionally, we asked them whether they have ever
encountered patients who presented in their clinics with
abortion complications or side effects following self-use
of abortion drugs, and the kinds of drugs these patients
have used. Sixty-four (52 percent) of the respondents said
they have seen such patients. The complications and side
effects the patients presented with (not shown) include
abdominal pain, dizziness, vaginal bleeding, sepsis, uter-
ine perforation, anemia, incomplete abortion, retained
products of conception, hypertension, and hypoglycemia.
The drugs the patients had self-administered vary consid-
erably and include quinine, flagyl, traditional medicines
and concoctions, gynaecosid, antibiotics, menstrogen,
nostragen, buscopan, ciprocin, prostaglandins, ergome-
trine, chloroquine, unnamed injections, oxytocin, native
alcohol, laundry dye, bleach and lime, carbard, indocid,
ergotamine, and prostinor. Only ten doctors (8 percent)
reported that they have seen patients with complications
following self-use of misoprostol.
Postabortion Family Planning
As shown in Table 5, when asked whether they offer fam-
ily planning to their clients after induced abortion and
treatment of abortion complications, 104 (85 percent) of
the doctors reported that they do. Of these, the large ma-
jority (91, which is 93 percent) reported that they offer
Table 4 Percentage distribution of private physicians Table 5 Percentage distribution of private physicians
surveyed, by their pattern of use of medicines for the surveyed, by their provision of family planning counseling and
management of abortion complications, Nigeria, 2009 services to postabortion patients, Nigeria, 2009
Use of medicines
Services Percent (n)
Do you use abortifacient drugs for management of Offered family planning after abortion care
abortion complications? Yes 85.2 (104)
Yes 23.0 (28) No 14.8 (18)
No 58.2 (71) Total 100.0 (122)
Dontknow 18.9 (23)
If yes, how do you carry it out?
Total 100.0 (122)
Offer family planning counseling 5.8 (6)
Complications encountered Offer family planning services 1 .9 (2)
Bleeding 32.1 (9) Offer both family planning counseling and services 87.5 (91 )
Incomplete abortion 25.0 (7) Refer woman to another family planning clinic 1.0 (1)
Inevitable abortion 10.7 (3) Offer family planning counseling and refer to another
Retained placenta 7.1 (2) clinic 1.0 (1)
Missed abortion 3.6 (1) Offer family planning services and refer to another clinic 1 .0 (1 )
No response 21 .4 (6) Offer family planning counseling and services and
Total 100.0 (28) refer to another clinic 1 .9 (2)
Total 100.0 (104)
Drugs used for abortion complications
Misoprostol 46.4 (13) What family planning commodities do you have in
your clinic?8
Oxytocin 17.9 (5)
Pills 23.4 (95)
Ergometrine 7.1 (2)
Condoms 18.7 (76)
Pitocin injection 3.6 (1)
IUD 20.7 (84)
Syntocinon 3.6 (1)
Foaming tablet 2.7 (11)
No response 21 .4 (6)
Diaphragm 2.5 (10)
Total 100.0 (28)
Injectables 21 .9 (89)
Ever encountered patients who reported to your clinic Postinor 9.1 (37)
with abortion complication as a result of self-medication
Implants 1 .0 (4)
with abortifacient drugs?
Total 100.0 (406)
Yes 52.5 (64)
No 32.8 (40) Do you have printed information materials for patient
seeking family planning or abortion care?
Don't know 14.8 (18)
Yes 40.2 (49)
Total 100.0 (122)
No 59.8 (73)
If yes, list the medicines used Total 100.0 (122)
Quinine 14.6 (12)
Do you think you would benefit from training to improve
Chloroquine 3.7 (3) physicians' knowledge of medication for postabortion
Flagyl 3.7 (3) care and family planning counseling and service delivery?
Misoprostol 12.2 (10) Yes 88.5 (108)
Traditional concoction 12.2 (10) No 11.5 (14)
Gynaecosid 9.8 (8)
Total
Antibiotics 4.9 (4)
aMultiple responses were given to this question.
Mestrogen 12.2 (10)
Others® 26.8 (22)
Total 100.0 (82)

aOther drugs mentioned by < 2 private doctors were: nostragen, buscopan, cipro-
cin, prostaglandins, ergometrine, unnamed injections, oxytocin, native alcohol,
laundry dye, bleach and lime, carbard, indocid, ergotamine, and prostinor.
both family planning counseling and services after in-
duced abortion to prevent a repeat abortion. All but one
of the remaining 13 offer either family planning counsel-
ing or services, and a few also refer women to another
clinic. All respondents offering family planning services
said they provide various family planning methods, in-
cluding oral contraceptives, condoms, the IUD, foaming
tablets, the diaphragm, injectables, and postinor; four
doctors said they have Norplant® implants available in
their clinics. Additionally, 49 doctors (40 percent of all
respondents) said they have behavioral change commu-
nication (BCC) materials about family planning in their
clinics that they give to their patients after counseling.
Finally, 108 (89 percent) of the doctors reported that they
thought they would benefit from additional training to
improve their knowledge and practice of medication for
postabortion care and to improve their postabortion fam-
ily planning counseling and service delivery.
Discussion
The specific objective of this study was to determine the
knowledge and practices of private physicians in north-
ern Nigeria with regard to the use of medications for
managing abortion and abortion complications. The re-
sults indicate that the majority of the respondents have
been consulted in their clinics by women with unwanted
pregnancies and postabortion complications. Less than 20
percent of the doctors terminate unwanted pregnancies; a

Volume 42 Number 1 March 2011 47

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much higher proportion treat women with complications
of induced abortion. These findings are consistent with
previous reports that investigate providers' practices of
induced abortion in Nigeria (Okonofua et al. 2005; Ag-
holor et al. 2010).
International best practices relating to the use of medi-
cal procedures for terminating unwanted pregnancies and
treating abortion complications have been well described.
The surgical methods recommended by the WHO include
MVA with cervical block or conscious sedation in the first
trimester as standard practice. In the second trimester,
most practitioners in the United States use dilatation and
evacuation, whereas in the United Kingdom the combi-
nation of mifepristone and misoprostol is used to termi-
nate unwanted pregnancies (Gao and Wang 1999). In the
case of medical abortion to terminate pregnancies of less
than nine weeks' gestation, the recommendation is that
mifepristone (at varying dosages in different countries -
ranging from 200 mg to 600 mg) is to be taken immedi-
ately, while misoprostol should be taken 48 hours later
(WHO Task Force 2000; von Hertzen et al. 2003). In coun-
tries where mifepristone is not readily available, a WHO
expert panel has recommended the use of misoprostol
alone for pregnancy termination in the first trimester in
doses of 800 mg vaginally, repeated up to three times at 6-,
12-, or 24-hour intervals (Faundes et al. 2007). Misoprostol
alone is not recommended for use in the second trimester,
however, because it may prolong the procedure unneces-
sarily. Similarly, different regimens have also been recom-
mended for the treatment of missed abortion, incomplete
abortion, and other early-pregnancy complications for
which randomized controlled trials have demonstrated
comparative effectiveness (Gynuity Consensus Statement
2004; Ngoc et al. 2004; Zhang et al. 2005).
The results of this study indicate that among physi-
cians in private practice who terminate unwanted preg-
nancies and manage complications of unsafe abortion in
the first trimester, the majority use surgical methods -
manual vacuum aspiration alone or dilatation and curet-
tage either alone or in combination with MVA. In the sec-
ond trimester, artificial rupture of membranes followed
by oxytocin stimulation was the most commonly report-
ed method of termination, followed by MVA, D&C, and
combinations of MVA and D&C. Thus, many of the doc-
tors surveyed clearly do not use accepted international
protocols and guidelines for the surgical management of
abortion and its complications. By comparison, only one
doctor reported exclusive use of abortion medications
in the first trimester, while three reported exclusive use
of medications in the second trimester. Thus, the use of
medical abortion apparently is uncommon among this
cohort of private medical providers, whereas those re-
48 Studies in Family Planning
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porting the use of misoprostol alone do not follow the
currently recommended doses and protocols.
The results of the study also show that poor knowl-
edge of drugs and procedures for medical abortion is the
major reason that the doctors do not use this method cor-
rectly for the management of induced abortion and its
complications. Although the World Health Organization
has approved the use of mifepristone and misoprostol
combined for termination of unwanted pregnancies
(WHO Task Force 2000; von Hertzen et al. 2003), this
study showed that 38 percent of respondents spontane-
ously mentioned misoprostol as an abortion drug that
they are aware of, and only 13 percent listed mifepristone.
By contrast, about half of the doctors mentioned relative-
ly ineffective and, in some cases, highly dangerous drugs
being used in the first and second trimester. Misoprostol
was approved by the Nigerian Federal Ministry of Health
for the prevention and treatment of primary postpartum
hemorrhage in 2006 (Jadesimi and Okonofua 2006; Enak-
pene et al. 2007), which probably accounts for its being
relatively well known among the practitioners surveyed.
Misoprostol is now available in many pharmacies in Ni-
geria and can be purchased over the counter. No recom-
mendations currently exist for its use for the management
of abortion and its complications, however, which prob-
ably explains why the appropriate dosage for this indica-
tion is little known among the survey respondents. That
ten doctors reported previously treating women who
presented with severe bleeding after self-administering
misoprostol to induce abortion suggests that the general
population may be becoming aware of the abortifacient
effects of the drug.
The doctors' lack of knowledge of mifepristone is
probably due to its generally poor availability and high
cost (up to US$70 per dose) in Nigeria. Moreover, be-
cause abortion is illegal in Nigeria, information about
the relevant drugs and procedures are not included in
the training curricula of undergraduate and postgradu-
ate medical students (Etuk et al. 2003), and opportunities
are limited for in-service training in pregnancy termina-
tion and postabortion care. Doctors' general knowledge
of abortion procedures, particularly of MA, may likewise
be limited because of the procedure's illegality.
The results of this study indicate that private physi-
cians are likely to use inappropriate surgical procedures
(D&C in the first and second trimesters and artificial
rupture of membranes followed by oxytocin stimula-
tion in the second trimester) for terminating unwanted
pregnancies. These procedures are likely to increase the
risks of complications. Because the opportunity is limited
for medical doctors to study and acquire proper surgi-
cal skills for terminating unwanted pregnancies during
their medical training, complications such as incomplete
abortion, uterine perforation, and postabortion sepsis are
more likely to occur in procedures carried out by such
practitioners than if they had received such training.
Thus, physicians' continued use of surgical methods will
likely incur more risks for women and result in increased
maternal morbidity and mortality in Nigeria. Clearly, the
need exists to build the knowledge and skills of doctors in
private practice in this part of Nigeria concerning medical
abortion and the appropriate procedures for using drugs
for managing complications of abortion and postabortion
care. Their training would reduce the need for surgical
procedures and complement the existing surgical abor-
tion methods in the country.
Available evidence points to a high rate of repeat
abortion among Nigerian women who have experienced
induced and unsafe abortion (Okonofua 1997; Mitsu-
naga et al. 2005; Okonofua et al. 2010). Every episode of
abortion increases the risks of morbidity and mortality
for women. Therefore, practitioners must be able to pro-
vide family planning counseling and services as part of
comprehensive abortion and postabortion care in order
to reduce the incidence of repeated unwanted pregnan-
cies and abortion. This study found that 85 percent of the
physicians surveyed offer family planning counseling
and services to women after provision of abortion and
treatment for abortion complications. Although the re-
spondents reported recommending various contracep-
tive methods to patients in their clinics, we were unable
to confirm availability of these methods at the time of the
interview, nor did we determine the postabortion family
planning procedures and practices that were adopted in
the clinics. Clearly, postabortion family planning provi-
sion and services should be a focus of any retraining pro-
gram designed to improve the quality of postabortion
services provided by practitioners in Nigeria.
A major limitation of this study is that we were not
able to conduct face-to-face interviews with the doctors or
to examine the abortion and postabortion-care procedures
they adopt in their clinics. A face-to-face approach would
have compromised providers' anonymity, which was part
of the ethical assurance for the project and would likely
have limited the cooperation we received from the doc-
tors. Moreover, because abortion is legally restricted in Ni-
geria, some portion of the sample may have felt compelled
to underreport their abortion-service provision. Thus, the
proportion of doctors who perform abortions may be con-
siderably higher than that found in this study. Our use of
the state chapters of the Association of Private Obstetrical
Providers in coordinating the study increased the partici-
pation of its members and also reduced considerably the
risks associated with participating in the study.
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The results of this study indicate that private prac-
titioners in northern Nigeria have limited knowledge
of medical abortion and, therefore, have limited experi-
ence in the use of drugs that are indicated for abortion
and postabortion care. The correct use of medications for
abortion and postabortion care would likely reduce the
complications associated with induced abortions per-
formed by private practitioners and would reduce sig-
nificantly abortion-related maternal morbidity and mor-
tality in Nigeria. We recommend the capacity building of
private medical practitioners as an approach to improve
the quality of postabortion care and to reduce maternal
morbidity and mortality in northern Nigeria.
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Acknowledgments
We are grateful to the chapters of the Association of Private
Obstetrical Providers in the Nigerian states of Bauchi, Borno,
Kaduna, Niger, and Taraba for their assistance and coopera-
tion in conducting the study. The study was funded as part of
a grant offered to the Women's Health and Action Research
Centre by the Lucile and David Packard Foundation to improve
the quality of private provision of reproductive health services
in northern Nigeria. We are grateful to Mairo Mandara, the
country representative of the Packard Foundation in Nigeria,
for her assistance in implementing the study.