Socioeconomic determinants of access to safe abortion and experiences along the care trajectory: A survey of women with a five-year abortion history in Abuja and Lagos, Nigeria

doi:10.21203/rs.3.rs-5283631/v1

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Research Article

Socioeconomic determinants of access to safe abortion and experiences along the care trajectory: A survey of women with a five-year abortion history in Abuja and Lagos, Nigeria

https://doi.org/10.21203/rs.3.rs-5283631/v1

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Background:

Unsafe abortion remains a significant cause of maternal morbidity and mortality in many African countries, including Nigeria. There is limited evidence on abortion safety or experiences of abortion care in Nigeria. This study aims to fill gaps in understanding of how abortion safety has evolved since previous estimates and provide new insight on pregnant people’s experiences along the abortion care trajectory and how sociodemographic factors correlate with these experiences and the overall safety of abortion.

Methods:

Data presented are drawn from a larger study that was conducted in Lagos and Abuja, Nigeria in 2023 using a total market assessment approach. This analysis drew exclusively on data from a quantitative survey of women of reproductive age with a 5-year history of induced abortion(s). Abortion safety was operationalised based on two dimensions in line with a previous analysis of Nigeria PMA survey data: (1) whether the method(s) used included any non-recommended methods and (2) whether the source(s) used were clinical or non-clinical. Analyses include frequencies of abortion safety and experiences along the abortion care trajectory and bivariate and multivariate assessments of sociodemographic and reproductive history correlates.

Results:

Two hundred women completed the survey of which 197 reported their abortion method and were included in this analysis. Almost half (44.7%) of respondents’ reported abortions were categorised as most unsafe involving non-recommended methods and non-clinical source(s). Those living in rural areas and those who were living in severe poverty were significantly more likely to have had the most unsafe abortions. Those living in poverty were also at increased likelihood of being unable to access an abortion from their preferred source and of experiencing any complications.

Conclusion:

These findings confirm that abortion in Nigeria is a public health concern and an issue of social inequity. Efforts to improve equitable access to in-facility services, particularly surgical procedures and post-abortion care is critical to ensure management of complications from unsafe abortion. Simultaneously, increasing awareness of the availability of quality-assured medication abortion drugs for self-management and/or training of lower-level providers on management of medical abortion can help mitigate the toll of unsafe abortion-related morbidity and mortality.

Abortion care

abortion safety

unsafe abortion

abortion experience

post-abortion care

maternal health

health inequities.

Unsafe abortion remains a leading cause of maternal mortality in low- and middle-income countries, contributing to 8–15% of maternal deaths (1). Despite progress in the availability of safe abortion care and a revolution in access to quality medical abortion products over the last two decades, the prevalence of unsafe abortions remains high (2). While there are limited variations in abortion rates by geographic setting, abortion safety is greatly impacted by the legal environment (2). Most unsafe abortions worldwide take place in legally restrictive settings where 40% (approximately 753 million) of women of reproductive age live (3). Although abortions performed in accordance with medical standards have a high safety profile (4), unsafe abortion remains a significant threat to maternal health because access to the required standard of care is limited.

Nigeria has one of the most restrictive laws in the region. Induced abortions are only legally permitted to save the woman’s life and when performed by qualified practitioners (5). The legal framework varies regionally, with the penal code applying in the North, where Abuja is located, while the criminal code applies in the Southern part of Nigeria where Lagos is situated. In Lagos, induced abortion is slightly less restricted, being permitted to preserve the woman’s life and physical health (5). Despite this restrictive environment in Nigeria, induced abortion is a common reproductive health experience, with an estimated 46 abortions per 1000 women aged 15 to 49 years, according to a 2017 confidante method-estimated incidence (6), amounting to 2.4 million abortions annually based on 2023 estimates of the population of women of reproductive age (7). This marks an increase from a 2012 estimate of 33 abortions per 1,000 women aged 15–49, estimated based on an abortion incidence complication method, amounting to 1.25 million abortions annually (8). The only national study of abortion incidence in Nigeria preceding Bankole et al. (2015) estimated a rate of 25 abortions per 1,000 women aged 15–44 in 1996 (9), suggesting that abortion incidence may have increased over the past two decades.

Previous evidence indicates that two-thirds of abortions in Nigeria are most unsafe, involving non-recommended methods (i.e., methods other than surgery or medication abortion drugs) from non-clinical providers (10). Estimates from 2012 indicate that these predominantly unsafe abortions resulted in nearly 500,000 women experiencing serious health consequences, with less than half (212,000) receiving treatment for these complications (8) – these numbers are likely much higher today with rapid population growth in Nigeria. Unsafe abortions continue to contribute to Nigeria’s high maternal mortality ratio, estimated at 1047 maternal deaths per 100,000 live births in 2020 (11). A recent analysis of a population-based and nationally representative survey of women aged 15–49 in Nigeria found that unsafe abortion is an issue of health inequity. Women aged 15–19, those who have never attended school, and women within the poorest wealth bracket are most likely to experience an unsafe abortion (6).

This study draws on data from a larger study that employed a total market approach to assess the context of abortion and post-abortion care in Lagos and Abuja, Nigeria. The primary objective of this study is to determine the safety of reported abortions in our sample and explore in-depth the social determinants of experiencing a less safe abortion, including both sociodemographic and reproductive history characteristics. An improved understanding of factors that may contribute to women accessing a less safe abortion care option in this setting can inform harm reduction efforts that seek to reduce morbidity and mortality due to unsafe abortion.

The secondary aim is to explore how the same social determinants can influence abortion care-seeking trajectories, from taking a pregnancy test to experiencing any complications or having social support throughout one’s abortion care pathway. While it is important to understand the social determinants of access to safe abortion, a more granular exploration of how any inequities in access may play out at different stages of one’s abortion care pathway can help inform targeted harm reduction efforts and help improve access to safer, client-centred services and ultimately reduce morbidity and mortality due to unsafe abortion.

Study design

This paper draws on data from one component of a larger, cross-sectional study in Lagos and Abuja, Nigeria employing a total market approach and combining qualitative and quantitative methods. The primary quantitative data collection included a sample of health-facilities and individual providers (both informal and formal providers) providing either abortions or post-abortion care in the last 3-months, mystery client survey at all health facility sites/providers surveyed, and a quantitative survey of women who had an induced abortion in the five years preceding the survey. The qualitative component included key informant interviews with strategic stakeholders, including policymakers, representatives of client groups, and programme delivery organisations. All data collection was completed in October 2023.

This analysis for this paper draws exclusively on the data from the quantitative survey of women with a history of an induced abortion in the 5-years preceding the survey. The survey employed a convenience sampling approach, targeting a purposive sample of 200 women aged 15–49 in Lagos and Abuja who had experienced at least one induced abortion, with an equal sample of 100 per study location. Eligible women had their most recent induced abortion in the past five years preceding the study. While the study locations were Abuja and Lagos, clients could reside anywhere in Nigeria, provided they received their abortion care in these two locations.

Through this survey approach, we explored several questions related to women’s experiences with abortion and post-abortion care including the pathway to care, cost, incidence of complications, source of care, methods used, quality of care, stigma, and social support.

Survey participants were recruited through (1) referrals by abortion and PAC providers, (2) initial seeds found at known PAC service delivery sites, (3) peer recruiters, and (4) community health volunteer referrals. All respondents provided written consent to participate before the beginning the survey. Interviews were conducted face-to-face by trained interviewers primarily in Hausa, Yoruba or English. Surveys were professionally translated into Hausa and Yoruba from English and piloted with native speakers before data collection. Surveys were programmed on OpenDataKit software for administration using smartphones.

Measures

In the questionnaire, women could report all abortion methods and providers/locations (referred to as source) used if they reported doing multiple things to end the pregnancy. Respondents describe the place, methods used, safety and experience of all reported abortions. The abortion method and location measures in this analysis draw on the woman’s least safe abortion method or source in the case that they reported multiple abortion methods or sources.

In this analysis, we categorised abortion methods into surgery, medication abortion (MA) drugs, other pills, or pills without sufficient information to categorise as MA, and traditional or other methods (like herbal drinks, injections, alcohol, or other traditional remedies). Any respondents with missing values were excluded from the analysis (n=3). We further classified abortion methods as recommended and non-recommended (i.e., other than WHO-approved surgical procedures or MA drugs) that put the woman at potentially high risk of abortion related morbidity or mortality (4). For recommended surgical procedures, we excluded all surgical procedures reported other than WHO-approved methods of electric vacuum aspiration (EVA), manual vacuum aspiration (MVA) and dilation and curettage (D&C) (4). For recommended medical abortion methods, we included Misoprostol-alone as well as the combination regiment of misoprostol and mifepristone (4). If a respondent reported doing multiple things and used a method other than a WHO-approved surgical method or MA drugs at any point in the termination, we categorised the abortion as non-recommended.

We categorised abortion method sources into public facilities and private facilities (including non-governmental organisations and private doctors), pharmacies or chemist shops and traditional or other non-medical sources (including shops, markets, friends or relatives or home). We further classified abortion source as clinical or non-clinical. Clinical sources included all public and private facility types while non-clinical sources included pharmacies, drug shops and traditional or other non-medical sources. Missing values for the abortion method source variable (n = 87) were classified as ‘other’. All respondents with missing values had reported using only a traditional or other non-medical method for their pregnancy termination. In line with the abortion method classification, we categorised an abortion as non-clinical if at any point the respondent reported using a source other than a public or private facility.

Using this data, we operationalised abortion safety based on two dimensions in line with a previous analysis of Nigeria PMA2020 survey data (6): (1) whether the method(s) used included any non-recommended methods and (2) whether the source(s) used were clinical or non-clinical. To generate our primary abortion safety outcome, we combined source and method information to categorise a woman’s abortion into one of the following four safety categories: (1) recommended method(s) involving only clinical source(s); (2) recommended method involving non-clinical source(s); (3) non-recommended method(s) involving clinical source(s) and (4) non-recommended method(s) involving non-clinical source(s). For our binary outcome variable, abortions in group four were deemed the most unsafe with the first three categories grouped together as safer services.

For our secondary outcomes of experiences along the abortion care trajectory, we included the use of a pregnancy test or other medical examination (binary: yes/no), abortion decision making role (binary: sole decision/other person involved in decision), the abortion method used (binary: recommended/non-recommended), source of method used (binary: clinical/non-clinical source), was able to access preferred source (binary: yes/no), experienced any complications (binary: yes/no), had social support in terms of someone who provided advice about abortion care (binary: yes/no).

In this analysis, we also examined several respondent sociodemographic and reproductive history characteristics at the time of her abortion. Sociodemographic characteristics included age (categorical), school attendance, marital status, religious affiliation, employment status (binary), urban, peri-urban or rural residence, and poverty status using the global Multidimensional Poverty Index (MPI) and categorised women both as living in multidimensional poverty and severe multidimensional poverty (12). Reproductive history characteristics of the participants included the number of children, the number of previous abortions, and any contraceptive use.

Data analysis

We first used descriptive statistics to examine the sociodemographic and reproductive history characteristics, safety of abortion, and experiences along the abortion care pathway. To address our primary aim, we explored differences in sociodemographic and reproductive history characteristics between women who accessed the least safe abortions and safer abortions, assessed via bivariate and multivariate logistic regressions. All sociodemographic and reproductive history covariates that were significant in the bivariate logistic regression were included in the multivariate logistic regression, along with study location which was maintained to control for any effect of study location. Individual multivariate regressions were run for multidimensional poverty and severe multidimensional poverty, given the collinearity between these variables.

To address the secondary study aim, bivariate logistic regressions were run with each of the abortion care pathway measures treated as the dependent variable and the suite of sociodemographic and reproductive history covariates as the independent variables. As with the primary outcome analysis, all covariates that were significant in the bivariate logistic regression along with study location were included in the multivariate logistic regression.

Statistical significance was determined to be at p < 0.05. All analyses were conducted using Stata 16.1 (College Station, TX).

Ethical approval

This study protocol was approved by MSI’s independent Ethical Review Committee (application reference number: 003-23). Further, IRB approvals were also sought and received from the Federal Capital Territory Health Research Ethics Committee in Abuja (approval number: FHREC/2023/01/136/25-07-23) and Lagos State University Teaching and Hospital Health Research Ethics Committee in Lagos (approval number: LREC/06/10/2210). Informed consent was sought from all participants immediately before the commencement of the survey.

Sample characteristics

A total of 200 women of reproductive age completed the survey, with 197 (98.5%) providing information on the method of their abortion and were thus included in this analysis. The average age of respondents was 32 years old; most had attended some higher education (60.4%) and the majority were currently married or cohabiting (52.8%) (Table 1). Respondents primarily identified as Christian (73.6%) and lived in urban (43.7%) or peri-urban areas (44.7%). Many respondents were nulliparous (46.7%), yet nearly one in five had 3 or more children (18.8%). Two-thirds of respondents were not living in multi-dimensional poverty, with 32.5% living in poverty and 13.7% living in severe poverty. Over half (61.4%), had been using some form of family planning at the time of their most recent pregnancy that they terminated. However, only 2.5% reported using a long-acting method (IUD, n=1; Implant, n=3). Of note, almost a third (30.6%) reported using emergency contraception. Another third (38%) reported using condoms (22.3%) or traditional methods (15.7%).

Table 1: Demographic and reproductive history sample characteristics

Primary outcome: Abortion safety

About half (51.8%) terminated their pregnancy using recommended methods, with a larger proportion using recommended surgical methods (28.4%) than medical (22.8%). Only 28.4% only received care from clinical sources with the remaining 71.6% accessing non-clinical care. Combining both criteria, almost half the respondents’ (44.7%) abortions fell into the most unsafe category, involving non-recommended methods dispensed by non-clinical or non-medical providers (Table 2). Only about 1 in 5 (22.3%) abortions were categorised as most safe, involving recommended method(s) dispensed in clinical settings, while 26.4% involved recommended methods involving non-clinical source(s) and 6.6% involved non-recommended method(s) involving clinical source(s).

Table 2: Safety characteristics of the abortion care accessed

Examining abortion safety by sociodemographic and reproductive history characteristics, respondents residing in rural areas were significantly more likely to have had the most unsafe abortions (OR 6.91, 95% CI: 2.44-19.57) as were those from peri-urban areas compared to urban areas (OR 2.67, 95% CI: 1.43–5.00). Those living in poverty (OR 2.20, 95% CI: 1.20-4.04) and severe poverty (OR 2.86, 95% CI: 1.21-6.73) were also more likely to have experienced the most unsafe abortions. Previous use of family planning methods was a protective factor. Respondents who reported using family planning at the time of their most recent pregnancy that was terminated had a decreased likelihood of an unsafe abortion (OR 0.50, 95% CI: 0.28–0.89).

Results from a multivariable logistic regression indicated that place of residence was independently associated with abortion safety among respondents, with those living in rural areas having the greatest likelihood (aOR 4.87, 95% CI: 1.64-14.44) of most unsafe abortion (Table 3). Living in poverty had an increased odds of having experienced a most unsafe abortion in the multivariable model (aOR 2.08, 95% CI: 1.08–4.00). In the multivariate model, living in severe poverty was only marginally significant (p < 0.01) associated with having increased odds of having experienced a most unsafe abortion. Family planning use remained significantly associated with lower odds (aOR 0.51, 95% CI: 0.26-0.99) of having experienced a most unsafe abortion (table 3).

Study location was not significantly associated with abortion safety in either the bivariate of multivariate model.

Table 3: Bivariate and multivariate regressions of characteristics associated with experiencing an unsafe abortion.

Secondary outcomes: Experiences along the abortion care pathway

Most respondents (74.6%) had used a pregnancy test or accessed a medical examination to determine their pregnancy. In terms of the respondent’s role in deciding to terminate their pregnancy, almost half (40.1%) reported that it was mainly their decision while half (50.3%) reported that it was a joint decision, 7.6% reported that it was mainly their husband or partner’s decision, and a remaining 2.0% reported that it was someone else’s decision. Almost one out of three (30.9%) were not able to access their preferred source, mainly those who had accessed a non-clinical source but would have preferred a clinical one. Further, one in ten (10.7%) respondents reported experiencing any complications, and two-thirds (67.0%) reported having someone who could provide them advice about abortion care.

Table 4: Frequencies of experiences along the abortion care pathway

Examining experiences along the abortion care pathway by sociodemographic and reproductive history characteristics, respondents who were divorced, separated, or never married were significantly more likely to be the sole decision-maker. Those divorced and separated were also significantly more likely to have experienced any complications (Table 5).

The only significant difference by religion was whether a respondent had experienced any complications, with those of the Islamic faith being significantly more likely to have experienced complications (Table 5).

Residence status was significantly associated with using a pregnancy test/medical examination to confirm pregnancy, using an approved surgical or medical method, accessing their preferred source of abortion, and having social support available for advice on abortion. Those living in peri-urban or rural areas were significantly more likely to have used a pregnancy test, more likely to have accessed their preferred source of their abortion method used, and those in peri-urban areas were more likely to have had social support, as compared to urban areas. Those in peri-urban and rural areas were also less likely to have used an approved surgical or medical method of abortion.

When looking at poverty status, those living in poverty were less likely to use a clinical source or have accessed their preferred source of abortion. They were also more likely to have experienced any complications. Those living in severe poverty were less likely to have used an approved method (did not remain independently significant in the multivariate model) and far more likely to have experienced any complications (aOR 6.96, 895%CI: 1.29-37.62).

In terms of previous abortions, those with more than 1 previous abortion were less likely to have any social support for advice.

Lastly, previous use of family planning was significantly associated with a lower likelihood of using a pregnancy test, an increased likelihood of being the sole decision maker, and a decreased likelihood of having had any social support for advice.

There were no significant associations with any of the abortion care pathway experiences by age, education, and employment status.

Abortion safety

This study describes the frequency of unsafe abortions in Lagos and Abuja, Nigeria and provides new insights into the sociodemographic correlates with women’s experiences along their abortion care trajectory. Almost half of the abortions (44.7%) in our sample were unsafe, with those living in rural areas and those living in poverty at the greatest risk of having unsafe abortions. Previous use of family planning was a protective factor, with those who reported any use of family planning at the time of their most recent pregnancy that was terminated having a decreased likelihood of having an unsafe abortion. These findings are consistent with previous literature suggesting that the most disadvantaged women are those most likely to resort to unsafe means of termination (13; 6; 14; 15; 16) . While, like previous evidence, we found that already vulnerable and disadvantaged women were most like to experience unsafe abortion, specifically those living in rural areas and those living in poverty, other sociodemographic factors that have been found to be associated with unsafe abortion, including being younger, unmarried, and uneducated women were not in our sample. This could be due to various factors, including a limited sample size to have the necessary power to detect the association and a sample that was skewed towards older and more affluent women due to the peer-to-peer recruitment approach.

Our estimate of the proportion of unsafe abortions was also lower than the previous estimate of 63.4% in 2017 (and 73.7% from the same study for the past five years) (6). These 2017 estimates are also lower than the unsafe abortion estimates for Western Africa in 2010–2014 at 84.7% (13). This could be due to various reasons including that our sample may not be representative of the national population of women who access abortions and is likely biased towards a more affluent population. The potential bias in our sample is due to the sampling process whereby providers linked interviewers to women who had received abortion care from them. Such women are likely to have received safer care involving clinic-based providers which may not be representative of the care for the general population. However, this estimate may also be capturing that abortion is becoming safer in Nigeria.

It is probable that safe abortion options are becoming more available in Nigeria, largely due to the increased availability of medication abortion drugs (Mifepristone and Misoprostol) in recent years. Mifepristone was registered for use in 2017 and Misoprostol has been on the country’s Essential Medicines List for incomplete and spontaneous abortion since 2010 (17). A 2018 review of referral hospital medical record data showed an increase in Misoprostol use for induced abortions over a nine-year study period, and this was associated with a reduction in severe morbidity (18). Other studies have indicated that women increasingly have the option to self-manage their abortion by purchasing the drugs through pharmacies, chemist shops, abortion hotlines and accompaniment models (19) (20). This trend toward out-of-facility medical management of abortion appears to have been captured in our study as well, with 26.4% of respondents reporting using recommended methods (medical abortion) from non-clinical sources, compared to just 5.4% in 2017 (6). We also observed a decrease in the use of recommended method(s) involving only clinical source(s) compared to the 2017 data, at 22.3% versus 29.1% (6). This indicates that while the overall safety of abortion may be improving, there has been a shift away from clinical sources of abortion which may mean future gaps in needed access to clinical care for surgical options and management of complications. The apparent shift away from clinical sources captured in this study may also reflect more recent effort to train pharmacist to provide safer medication abortion (21; 22).

Experiences along the abortion care trajectory

Women’s decisions regarding where to seek abortion care, the method(s) and source(s) that they eventually use, the quality of care they receive, and their access to or use of any follow-up care are influenced by a number of factors. Coast et al. developed a comprehensive framework that encompasses the full range of factors that shape women’s abortion care-seeking trajectories, which includes the abortion-specific context, women’s individual context, and the international or sub-national context (23). Previous evidence from the Nigerian context found that non-clinical providers (55.0%) were more often used than clinical providers (45.0%); however, clinical providers were preferred by most women (55.6%) (24). While, we found a lower use of clinical sources (28.4%), we saw a similar trend in preference for clinical providers, with 90.7% of those who accessed a clinical source reporting that they had accessed their preferred source compared to just 59.8% of those who had accessed non-clinical sources. We also found that those who were living in poverty had a significantly decreased likelihood of accessing their preferred source and accessing a clinical source, indicating important wealth inequities in ability to exercise choice in source of abortion and importantly in access to facility-based care. We also found that women living in poverty and severe poverty were significantly more likely to have experienced any complications (MPI poor OR: 2.55, 95% CI:1.02-6.37; MPI severe poor OR: 5.09, 95% ci: 1.87-13.84). When adjusting for other demographic covariates, severe poverty remained significantly associated with experiencing any complications, demonstrating the public health imperative of ensuring improved equitable access to safe – with options for both facility and out-of-facility - sources of care.

Limitations and strengths of the study

Our study has some limitations. First, we relied on women’s self-reporting of their abortion experiences in a social context where such information is highly sensitive and in a legal context where one can be prosecuted for securing abortion. Self-reporting under such circumstances could introduce social desirability bias, leading to underreporting or misreporting experiences. Previous studies have highlighted the challenge of underreporting and misreporting of abortion (25). Apart from the information being sensitive, laypeople may be unable to accurately report medical information. Further to social desirability bias, recall bias, introduced because of the study's retrospective nature, could also limit the reliability of the results; it is realistically challenging for women and girls to recall with exactitude the experiences that may have happened in the past five years.

The second limitation relates to the sample and sampling approach. Our sample of 197 may not be representative of the broader population of women who have had abortions in Abuja and Lagos, let alone Nigeria. We also used a peer-to-peer sampling approach which may create an underrepresentation of certain demographic groups or an overrepresentation of well-connected individuals, affecting the generalizability of the findings. To further compound this limitation, we identified the seed samples from facility-based providers, who are likely to have introduced the research team to women likely to receive care from formal healthcare settings.

Notwithstanding the limitations discussed, this study has significant strengths. Our utilization of a respondent-driven sampling approach ensured the resulting sample included women who received abortions from a wide spectrum of sources and providers, thereby capturing a broad range of abortion services and experiences. This approach allowed us to capture women who received services from formal and informal providers, highlighting service characteristics outside the formal health sector and comparing the varied sources and experiences. Further, the study examined abortion safety based on the WHO guidelines and examined the method(s) used and the outcomes of abortion care (4). This study provides valuable contributions by categorizing abortions into safety categories and assessing the determinants of safe abortion practices to highlight necessary programmatic intervention for improvement in quality of care and improved health outcomes. Finally, the sociodemographic characteristics and reproductive histories of respondents explored in this study provide an understanding of disparities in access to safe abortion care and the resulting health outcomes. This allows us to situate access to abortion as socially determined, especially based on social status and income.

Our study suggests that while the overall safety of abortion could have marginally improved over the last five years, still almost half of abortions in Lagos and Nigeria in our study were the most unsafe, with the use of non-recommended methods outside of a clinical setting. Our findings further indicate that economically disadvantaged women living in rural areas with limited ability to navigate and access safe abortion in this legally restrictive setting are most at risk of having an unsafe abortion, clearly highlighting that abortion in Nigeria is a public health concern and an issue of social inequity. Efforts to expand the legal conditions for abortion in Nigeria are critical. Previous evidence has shown that restrictive abortion laws negatively impact abortion safety without reducing overall abortion incidence rates (13). In the absence of legal expansion, women will continue to seek services from providers who are not regulated and may not have appropriate training but are motivated to provide abortion for financial gain and/or to alleviate suffering associated with unwanted pregnancies or seek sub-quality products to self-manage their abortion. In the meantime, harm reduction efforts to increase awareness of quality MA drugs to self-induce more safely and/or train lower cadre providers on medical management of abortion can help mitigate the toll of abortion-related morbidity and mortality.

Additionally, improved availability of contraceptive services, including counselling to counteract fears of contraceptive-related infertility, is needed to reduce women’s reliance on unsafe abortion alone to control their fertility. We found that previous use of family planning was associated with a decreased likelihood of having an unsafe abortion. This could be due to various factors such as an established, trusted connection to the health care system and specifically a sexual and reproductive health provider and thus improved access to information and knowledge about where to access a safe abortion care service.

Furthermore, expanded availability of quality, facility-based services including surgical abortion and PAC is critically needed to reduce abortion-related morbidity and mortality given the frequent recourse to unsafe abortion. Given the existing inequities in access to these services, it is essential that any future efforts focused on improving access to safe abortion services prioritise mitigating these gaps in access to ensure that already disadvantaged women and populations do not continue to be left behind.

D&C	Dilation and curettage
EVA	Electric Vacuum Aspiration
IRB	Institutional Review Board
MA	Medication abortion
MVA	Manual Vacuum Aspiration
PAC	Post-abortion care
SAC	Safe abortion care
SRH	Sexual and Reproductive Health
SRHR	Sexual and Reproductive Health and Rights
WHO	World Health Organisation

Ethical approval and consent to participate.

This study protocol was approved by MSI’s Ethical Review Board as part of MSI's larger study entitled “A total market assessment for safe abortion and post-abortion care in Abuja & Lagos, Nigeria” with application reference number 003-23. Further IRB approvals were sought and received from the Federal Capital Territory Health Research Ethics Committee in Abuja (approval number: FHREC/2023/01/136/25-07-23) and the Lagos State University Teaching Hospital Health Research Ethics Committee (approval number: LREC/06/10/2210.

Informed consent to participate was obtained from all participants.

Consent for publication

Informed consent was obtained from all participants for data to be shared in publication.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors have no conflicts of interest to declare.

Funding

The development of the study design, protocol and ethical review was supported by a large anonymous donor.

Authors’ contributions

MR led the study design, supported the development of the protocol and data collection tools, led the analysis and interpretation, and drafted the manuscript.

BU and AA contributed to the study design, developed the protocol and data collection tools, supported the tool scripting, testing, and surveyor training, supervised data collection, contributed to the analysis and interpretation, and substantially contributed to the manuscript.

AT, OO and OI contributed to the conception and design of the study, provided oversight to data collection training, contributed to the interpretation of data, and contributed to the manuscript.

All authors read and approved the final manuscript.

Acknowledgements

The authors would like to knowledge and thank the contribution of the team of data collectors and research assistants who made this study possible, as well as all the study respondents who gave their time to participate in this study and share their experience with us.

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Tables 1 to 5 are available in the Supplementary Files section.

No competing interests reported.

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Socioeconomic determinants of access to safe abortion and experiences along the care trajectory: A survey of women with a five-year abortion history in Abuja and Lagos, Nigeria

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Abstract

Background:

Methods:

Results:

Conclusion:

Background

Methods

Study design

Measures

Data analysis

Ethical approval

Results

Sample characteristics

Primary outcome: Abortion safety

Secondary outcomes: Experiences along the abortion care pathway

Discussion

Abortion safety

Experiences along the abortion care trajectory

Limitations and strengths of the study

Conclusion

Abbreviations

Declarations

Ethical approval and consent to participate.

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors’ contributions

Acknowledgements

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1