CHAPTER TWO

LITERATURE REVIEW

The study's review of the theoretical and empirical literatures on the use of post-abortion care

can be found in this section. The concept of post-abortion care was first developed and

explained in this chapter. The chapter next conducted a literature review on relevant topics,

including the uptake of PAFP, method choices, sociodemographic factors, and reproductive

factors.

2.1 Post-Abortion Care

All the elements of PAC are crucial to the delivery of maternity care. PAC is an original

method of providing public health services. It is both curative and preventative, curing

incomplete abortions and treating sepsis and hemorrhage symptoms, while preventing repeat

abortions and unwanted pregnancies by offering family planning services to fill unmet needs

for contraception (Huber et al., 2016). Standard PAC encompasses the delivery of emergency

care, which includes the use of intravenous lines for resuscitation, the use of blood and blood

products for transfusion when necessary, and the administration of antibiotics. This should be

accessible at all district hospitals, with well-defined service delivery norms and provider

training to guarantee high-quality care. It also encompasses treatment of sexually transmitted

infections, Human Immunodeficiency Virus (HIV) counselling and testing, family planning

and contraceptive use and community empowerment.

Women who need care for unsafe abortions make up up to half of the admissions to some

hospital gynecological units in the poor countries (Center for Reproductive Rights, 2003).

Prolonged hospitalization lasting several days to many weeks is one of the effects of

undergoing medical therapy for unsafe abortions. According to the research that are currently

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available, treating complications from unsafe abortions can consume up to 50% of the

budgets of some health facilities in impoverished nations (WHO, 2011). Treatment provided

to women who visit a clinic or hospital with complications from an incomplete abortion or

miscarriage, typically bleeding or infection (WHO, 2011). Medical and preventive care are

also offered as PAC services. The lady receives medical care, such as drugs or surgery, to

remove her uterus and preserve her life, while preventative care is counseling the patient to

voluntarily use a contraceptive method to avoid further unexpected pregnancies. The

International health organizations generally recognize post-abortion care to include: “(1)

Emergency treatment for complications of abortion or miscarriage; (2) Counseling to

identify. and respond to women’s emotional and physical health needs and other concerns;

(3) Contraceptive and family planning services to help women prevent an unwanted

pregnancy or unsafe abortion or to practice birth spacing; (4) Management of sexually

transmitted infections; and (5) Reproductive and other health services that are provided on-

site or through referrals to other accessible facilities” (Post-abortion Care Consortium

Community Task Force, 2002).

Every year, it's projected that 75 million women need PAC services after safe or unsafely

instigated abortions and miscarriages (Huber et al., 2016). An estimated 16,000 maternal

fatalities in 2014 were attributable to unsafe abortions, or 9% of all maternal deaths.

According to regional estimates for West Africa in 2008, unsafe abortions contributed to

about 12% of all maternal fatalities (World Health Organization, 2011). According to a study

conducted in Tanzania by Keogh, Kimaro, and Muganyizi (2015), six more women did not

seek or receive care following an abortion for every one who received PAC for

complications. According to another study, 38% of hospitalizations for obstetric

complications were the result of unsafe abortion. Due to the lapses in provision of PAC

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services as indicated above it is of utmost importance that quality PAC services be

incorporated within health systems globally.

2.2 Uptake of PAFP

The oral pill was listed as the most popular technique (42.0%) among the patients of the main

maternity hospital in Gabon in the study by Mayi-Tsonga et al. (2014) on the introduction of

post-abortion contraception. The study also showed that more than 90% of the patients agreed

to use a contemporary method of contraception after having an abortion. In this study, 66.8%

chose the pill, 14.6% chose DMPA, and 9.3% chose a LARC technique. Only 9.1% of the

women chose to forgo using any form of birth control. Clients used post-abortion

contraception at a rate of 74.4% in the study by Abamecha, Shiferaw, and Kassaye (2016) in

the Gambella Health Facilities in South West Ethiopia. Kokeb et al. (2015) reported a 59.2

percent rate of post-abortion contraception use in Ethiopia as part of their study. According to

the Prata, Bell, Holston, Gerdts, and Melkamu (2011) study on the variables influencing post-

abortion contraception choice in Addis Abeba, Ethiopia, post-abortion contraception uptake

was around 44%.

2.3 Sociodemographic factors and PAC

Age, marital status, and education level all affect one's knowledge of and access to

reproductive health services like abortion and post-abortion care.

2.3.1 Age

Nearly 60% of unsafe abortions in Africa involve young girls under the age of 25.

Adolescents around the world frequently experience complications from unsafe abortions

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(WHO, 2011). They also exhibit a history of repeated abortions and are less likely to receive

advice on contraception or a method prescription after discharge. Over 70% of the women in

the study were younger than 25 years old, with the majority falling between the ages of 20

and 24, according to a study by Mutua et al. (2015) that looked into delays in obtaining PAC

in Kenya. According to Adde et al(2018) .'s patient reports on the provision of abortion

services in the Volta Region of Ghana, 80% of the women seeking treatment for

complications related to abortion were in their 20s, while 15% were in their 30- to 39-year-

old years. According to hospital data from underdeveloped nations, 38–68% of women

treated for complications related to abortion are under the age of 20, with adolescents making

up the majority. Young women, particularly those between the ages of 15 and 29, are more

likely to report having had a bad experience with post-abortion care. They complained about

a number of services, including receiving subpar care and support and being treated

disrespectfully by the medical staff.

2.3.2 Education

Access to and utilization of reproductive health treatments, including abortion, are positively

correlated with education (Osur et al., 2015). Greater access to safe abortion and high-quality

post-abortion care is related to education level (Diaz, 2014). Women with less education tend

to have unsafe abortions more frequently, which raises their risk of complications. In

Zimbabwe, 71% of women seeking care at medical facilities after performing unsafe

abortions only had a secondary education or less (Izugbara, et al., 2017). These results concur

with those made in China by Wang, Liu, and Xiong (2020). In their study, secondary

education was the highest level of education for almost 79% of the participants who

experienced difficulties from unsafe termination methods. Women receiving post-abortion

treatment in a teaching hospital in Nigeria had similar results. Only secondary education was

reached by 59% of the women, while university education was only attained by 20% of them.

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2% of people had no formal education, while another 19% had just completed elementary

school (Kalu et al., 2012). But the results in Ethiopia were different. Women who had only

completed secondary school made up 23.3% of the population. 33 percent of respondents had

only completed elementary school, and 16.6 percent had completed tertiary education (Hagos

et al., 2018 cited in Adom-Asomaning, 2020). The ability of a woman to make

knowledgeable decisions regarding her health increases with her level of education.

Additionally, education increases their knowledge of the risks associated with abortion,

increasing their propensity to seek therapy early (Jejeebhoy et al., 2010). Delays in decision-

making when seeking safe abortion services are also correlated with education. Women

without any formal education were found to be 2.4 times more likely to delay their decision

to seek a safe abortion than women with at least a secondary education, according to a study

on decision-making and the factors that influence safe abortion conducted in Ethiopia.

Similar to this, those with only a secondary education were 2.2 times more likely to delay

than those with a higher level of education. This was due to the fact that women without

formal education did not easily have access to knowledge on concerns relating to

reproductive health, which made them less aware of the effects of delayed abortion care

(Adom-Asomaning, 2020).

2.3.3 Religion

Opinions on abortion are influenced by one's religious affiliation, beliefs, and practices.

Many religions continue to have strong opinions on abortion and the problems it raises. Most

religions view abortion as wicked and forbid it almost entirely. There has been evidence that

African religious organizations are vehemently opposed to abortion. As a result, persons who

support abortion, provide abortion services, and have an abortion are ostracized and reviled.

Therefore, when faced with an undesirable pregnancy, women who identify as religious are

more likely to turn to high-risk pregnancy termination techniques (Rominski & Lori, 2014).

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Respondents were surveyed about their opinions on abortion in Ghana and Nigeria.

According to the survey, people who practiced a religion and went to church were against

abortion, and those who had no religious affiliation thought it was sometimes acceptable. In

general, those who identified as Christian or Muslim did not support abortion since it was

doctrinally forbidden (Adom-Asomaning, 2020). Respondents in the Ashanti region (89 out

of 111) shared similar opinions, viewing abortion as a sacrilegious act whether it was safe or

not. Abortion was perceived as a sin against God, and individuals who sought abortions were

branded as murderers (Atakro et al., 2019). Due to this religious opposition to abortion,

women typically choose to have their terminations done privately and in secret, despite the

fact that this is riskier than having them at a medical facility where their confidentiality is

guaranteed (Payne et al., 2013). The decision to offer abortion services and the caliber of the

care provided are both influenced by religion. According to a study of Ghanaian midwives,

their religious beliefs prevented them from offering safe abortion services even though they

were aware of the risky and illegal means that women utilized to get abortions. However,

some of them did not oppose to PAC. They believed that the abortion had already begun, so

they were attempting to protect the women from the difficulties that would follow (Oppong-

Darko et al., 2017). On topics like abortion and religion, midwives in Uganda voiced similar

viewpoints. Midwives who opposed the liberalization of abortion regulations invoked

religious convictions to support their argument that a more liberal law would increase sexual

immorality and result in more fatalities from abortion. Additionally, they explained that

although providing abortion and PAC was required, it was challenging to care after women

who they thought or knew had undergone an induced abortion because it went against their

religious convictions (Cleeve et al., 2019 cited in Adom-Asomaning, 2020).

2.3.4 Marital status

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Young and single women encounter difficulties when seeking PAC. These difficulties are

linked to causes like immorality and rejection of sexual abstinence rules. The biggest

obstacles that single and unmarried women had to face when requesting PAC were shame

and embarrassment. These two causes caused large delays in getting PAC, which raised the

chance of fatal complications and severe complications. They conceal the fact that they are

presenting due to complications from improper abortions for individuals who eventually seek

care, which further delays receiving the proper care (Osur et al., 2015). According to a study

conducted in two Indian states, unmarried women were more likely than married women to

encounter obstacles when obtaining abortion services. When they appeared at medical

institutions, they were also more likely to experience treatment delays (Jejeebhoy et al.,

2010). Married women in China were found to use PAC at a considerably higher rate than

single women. This was in contrast to research by Hagos et al. (2018) that found married

women were less likely to use PAC services in Ethiopia. The variation in PAC service use

may be related to how much a woman's husbands control her access to services. Married

women in patriarchal settings would be less likely to seek services and have less control over

decisions affecting their health. But if women make these choices on their own, they'll be

more likely to get help (Wang et al., 2020).

2.3.5 Wealth index

Poor women and girls bear the brunt of discrepancies in access to safe abortion and post-

abortion care services. Wealthy women typically have access to safe abortion care from

licensed healthcare professionals and medical facilities and are more likely to obtain post-

abortion care of any kind (Izugbara et al., 2017). In their study on the severity and treatment

of post-abortion complications in Kinshasa, Bankole et al. (2018) found that single and

underprivileged women frequently lacked access to information about where to get safe

abortion procedures. They always ended up presenting with issues as a result of using risky

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procedures as a result. Ganle et al. (2016) classified wealth quintiles from highest to lowest in

their research of differences in abortion-related care. In the study, the highest quintile

included about 23% of women who had access to safe abortion care, whereas the lowest

quintile included 5.8% of women. The differences were attributed to elements including

poverty, the high cost of treatment associated with abortions, as well as other social expenses.

Haitian wealth was categorized as low, middle class, and rich in another survey. Women in

the middle class and the wealthy quintile were found to have greater abortion rates. Because

they have better access to knowledge about safe abortion care services and can afford better

treatment, wealthy women are also more likely to adopt safe methods of termination (Meffen,

Burkhardt, & Id, 2018).

2.4 Contraceptive Method

Modern family planning methods are more popular now than ever before because of the

shortcomings and difficulties of traditional family planning methods (Kopp et al., 2017).

Three major categories can be used to categorize modern contraceptive methods: Short-acting

methods include oral contraceptive tablets, condoms, spermicides, and injectable hormones.

Long-acting reversible methods include hormonal implants and intrauterine devices.

Permanent methods include tubal ligation or vasectomy (Sekyere, 2018). The most popular

Short-Acting contraceptive techniques are combined oral contraceptive pills (COCP),

injectable contraceptives (CIC and POI), and progestin-only tablets. POPs are oral

contraceptives that only contain synthetic progestogens (progestins) as their active

ingredients, with no estrogen (Curtis et al., 2016). Short-term treatments that use progestin

and estrogen together as their active ingredients include combined oral contraceptive tablets,

vaginal rings, and skin patches. (2017) Curtis et al. The POPs are referred to as small pills in

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everyday speech. These little pills, which solely contain progestogen in contrast to the more

popular COCPs, which also contain an estrogen and a progestin, are taken continuously.

Three possible processes may be used by progestin-only tablets to prevent conception. The

primary mechanism is by forming a plug of cervical mucus that is largely impermeable to

sperm. A secondary mechanism is by preventing the growth of the endometrium, which has

the additional impact of ciliary inactivation in the fallopian tube. These two consequences

may lessen the possibility of implantation (Raymond, 2011). The third mechanism involves

varyingly suppressing ovulation. Progestin-only tablets' efficacy is not thoroughly

established. When it comes to preventing pregnancy, combined oral contraceptives function

similarly to progestin-only pills. To ensure continuous protection from pregnancy, the user

must wait seven days after stopping a cycle of active agents rather than the usual 21 days.

The user consumes a placebo during those seven days, which is typically a nutritional

supplement.

In Assam's Silchar Medical College and Hospital, only 7% of women used modern

contraceptive methods (MCM), even though 67 percent of them were aware of them

(Barbhuiya, 2016, cited in Sekyere, 2018). The short-term strategy using oral contraceptive

pills was the most popular technique among Assamese women (Barbhuiya, 2016). The pill,

female sterilization, and IUCD were the most popular modern contraceptive methods also

utilized in Manipur, India (Gogoi et al., 2017). The study by Kopp et al. (2017) provided

evidence of a declining tendency in the use of conventional procedures over time and an

upward trend in the use of long-acting and permanent methods (LAPM). Only 18% of people

in the Talensi district in Ghana's Upper East Region had ever utilized modern family

planning methods, even though 89% were aware of them (Apanga and Adam, 2015). The

study in Ghana's Nkwanta district also revealed modest MCM usage. The district's

predominant MCMs were short-term strategies (Eliason et al., 2014). Evidence from the

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review literature suggests that customers favor short-term contemporary methods more than

long-term and permanent ones.

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