Even though voluntary abortion has been legalised in more than 100 countries, mostly in the developed world, it remains a controversial procedure in medical practice. The United Nations has agreed that abortion should never be promoted as a family planning method, and should be utilised only when contraception has failed.¹ Given the many safer family planning methods, abortion, with its associated risks of sterility and mortality, is unsuitable as a family planning method.

Abstract

Background: This study determined the profile of women seeking termination of pregnancy (TOP) in the Free State and whether TOP was used as a family planning method.

Methods: Seven hundred and fifty women (15-47 years old) seeking TOP at the Reproductive Health Unit of the National Hospital in Bloemfontein were included in this cross-sectional study. The women who gave verbal consent completed a questionnaire during counselling.

Results: The median age of the participants was 24 years and 77.3% were single. Most participants (73.3%) were not using any family planning method at the time of the study. One-fifth (19.1%) had previously had at least one TOP, while for 80.9% of the participants it was their first visit. Some participants (16.6%) considered TOP a family planning method, 39.7% were unsure and 43.7% indicated that TOP is not a family planning method. Thirty-nine women failed to answer this question. When asked the reason for TOP, 3.5% chose the option “contraceptive method”.

Conclusions: The relatively high percentage of participants who consider TOP a contraceptive method or are unsure, associated with the fact that most were young, single, not using contraception and had applied for induced abortion just because the conception represented an unwanted pregnancy, implies that some of our population is not aware that termination of pregnancy is not a family planning method. (SA Fam Pract 2005;47(5): 52-55)

Introduction

Even though voluntary abortion has been legalised in more than 100 countries, mostly in the developed world, it remains a controversial procedure in medical practice. The United Nations has agreed that abortion should never be promoted as a family planning method, and should be utilised only when contraception has failed.¹ Given the many safer family planning methods, abortion, with its associated risks of sterility and mortality, is unsuitable as a family planning method.

Globally, millions of women and men do not have access to reliable family planning methods. Women continue to die and suffer pain, ill health and permanent disability as a result of pregnancy and childbirth complications. Each year, twenty million unsafe abortions are performed, resulting in 70 000 deaths.² Pregnancy and childbirth are major killers of young women aged 15 to 19 years.² Women are also least able to protect themselves from violence and rape, STD and HIV/AIDS, unsafe abortion and sexual exploitation.²

In November 1996, the Choice of Termination of Pregnancy Act was introduced in South Africa.³ The Act was approved to protect many women for whom a pregnancy could represent a life-threatening condition or a severe risk of physical or mental abnormality to the foetus. Its purpose is also to assist the victims of rape or incest, and those who could be affected significantly, both socially and economically, by the pregnancy. Termination of pregnancy (TOP) is available on request during the first trimester.

To render a better and more accessible service, the government of the Free State Province has increased the number of clinics performing TOP in the region from one to five. A considerable number of nurses go for training every year, which improves the quality of the service offered. Nurses perform TOP up to 12 weeks.

The aim of this study was to determine the profile of women seeking TOP in the Free State and to find out whether TOP was being used as a family planning method. The use of TOP as a family planning method could indicate the failure of promotional health services. No similar study has been reported in South Africa.

Methods

A total of 750 women between the ages of 14 and 47 were included in this prospective cross-sectional study. Women who visited the Reproductive Health Unit at the National Hospital, Bloemfontein (one of the five TOP sites in the Free State) for the purpose of TOP from April to November 2002 were eligible for inclusion. A nurse opened a file for each woman arriving at the Reproductive Health Unit before the doctor’s examination during which the gestational age was determined. The nurse obtained the woman’s verbal consent to participate in the research. For those who gave consent, a questionnaire was included in the file, which was completed during the counselling. The participant completed the questionnaire herself in complete privacy in the counselling room. A nurse was always available to inform the patient of the procedure, contraception, STD and HIV/AIDS. She was also able to address any further questions, including those arising from the questionnaire. The nurses counted the number of women who refused to be included in the research. Only 11 chose not to participate.

The nursing staff and several doctors from the Department of Family Medicine gave their input during the development of the questionnaire. A pilot study was conducted on 12 women who visited the clinic prior to the study. Thereafter, the questionnaire was amended accordingly. The Ethics Committee of the Faculty of Health Sciences, University of the Free State approved the protocol. Verbal consent was obtained from the participants, who were informed that refusal to participate in the study or to complete the questionnaire would not influence the treatment they would receive at the Unit. This information was also provided on the front page of the questionnaire.

Some respondents did not complete all the questions, and sample sizes are therefore indicated in the tables. The results were summarised using frequencies and percentages. Chi-squared tests were performed to determine the statistical significance of associations between the variables.

Results

The response rate was 750 out of 761 (98.6%). The participants ’ demographic data are given in Table I; most were 22 to 30 years old (43.7%) and single (77.3%). The median age was 24 years. The participants’ ethnic distribution was as follows: black (89.9%), coloured (7.0%), white (2.2%), and other (Chinese, 1.0%). The highest level of education completed was Grade 10 or above for 64% of the participants.

Contraception and family planning

Many participants (84.3%) had previously received information on family planning. The most common place for obtaining information was the family planning clinic (49.3%), followed by the school (36.2%) and the home (23.6%).

The participants’ contraceptive use and family planning information is given in Table II. Many participants (73.5%) had previously used a family planning method, the most common being the injection (54.6%) and pills (29.6%). A similar number of participants (73.3%) were not using any family planning method at the time of the study, while 26.7% were using some form of contraception. Condoms were being used most often (48.2%), followed by pills (21.1%) and the injection (20.6%).

Nearly two-thirds of the participants (62%) had visited a family planning clinic before, while 38% had not. For 47 participants (10.7%), the staff of the family planning clinic did not address their expectations, mainly because the family planning method was not explained to them. The median age at which the participants (n=671) had their first sexual experience was 18 years. The most common frequency of sexual relations was once a month (31.4%), followed by once a week (27.3%), less often than once a month (24.5%), and more than once a week (16.9%). Most participants (89.2%) indicated that they had had only one sexual partner during a year. More than two-thirds of the participants (68.6%) had discussed family planning with their partner.

Termination of pregnancy

The participants’ TOP information is given in Table III. One-fifth (19.1%) of the participants had previously had at least one TOP, while it was the first visit for 80.9% of the participants. Of those who had a previous TOP, 74.6% were not using any form of contraception. Regarding the relationship between first abortion and age group, 89.2% of participants in the group 14-21 years were there for their first abortion, 76.0% of the group 22-30 years and 77.1% of the group 31-47 years (chi-squared test p<0.0001). Some participants (16.6%) considered TOP as a family planning method, while 39.7% participants answered “I don’t know”, less than half (43.7%) indicated that TOP is not a family planning method and 39 participants failed to answer this question. The percentage being unsure was the highest in the age group 14-21 years (47.3% compared to 37.3% and 32.6% in the other age groups respectively; chi-squared test p=0.0248). In the age group 14-21 years, only 32.7% had visited a family planning clinic before, compared with 71.9% and 86.7% in the other two age groups respectively (chi-squared test p<0.0001).

Unexpected pregnancy was the most common reason for TOP (64%), followed by economic reasons (32.1%) and being a student (31.5%). Twentysix participants (3.5%) were using TOP as a contraceptive method, and 14 participants (1.9%) went to the clinic after being raped. This was a closed question, with options being provided from which the respondent could choose more than one. The major differences between the three age groups were that 57.0% of the youngest age group indicated their reason as studying (compared with 24.6% and 4.9% in the other age groups, chi-squared test p<0.0001) and 49.6% of the oldest age group indicated economic reasons, compared with 20.7% and 32.4% of the other two age groups (chi-squared test p<0.0001). In all three age groups (14-21 years, 22-30 years and 31-47 year), unexpected pregnancy was the main reason (66.8%, 61.1% and 65.2% respectively, chi-squared test p=0.3421).

More than half the participants (55.3%) indicated that nobody had influenced their decision to undergo TOP. The partner represented the strongest influence (23.2%), followed by the parents (11.5%).

Discussion

Most participants in the study (73.5%) had previously used family planning methods. Adewole et al. reported that 30.4% of abortion seekers in Nigeria indicated ever having used any form of contraceptive method, with oral contraceptives being used most commonly.⁴ In Denmark, Wielandt et al. found that 95% of the young women in their study who had experienced sexual intercourse had used contraception during their most recent sexual relationship. The number of births and induced abortions among teenagers has decreased in Denmark, and teenage parenthood is now rare.5 This study also demonstrates a better efficacy of promotional activities regarding contraception.

In our study, the participants’ median age of first sexual intercourse was 18 years. In the United States, 9% of females aged 15-19 years become pregnant, 5% give birth each year, 3% have induced abortion and 1% have miscarriages or stillbirths. These American rates are much higher than those in other developed countries.⁶ According to the US Centre for Disease Control and Prevention, 65% of teenagers engage in sexual intercourse before they graduate from high school, 18% of 9th grade students initiate intercourse before age 13, and approximately 4 million teenagers in the US contract a sexually transmitted disease each year.⁷ In a multi-staged stratified cluster sample of 2 430 South African youth aged 15 to 24 years, it was found that the median age of first sexual intercourse was 16.5 years for both genders.⁸

Many participants had discussed family planning with their partners. Larsson et al. reported a higher percentage (97%) doing so in Sweden.⁹ Contrary to our results and those from Sweden, it was found that only 24% of the participants in a Vietnamese study had discussed family planning with their partners.¹⁰ One-fifth of the participants had received a previous TOP. A Swedish study reported that 53% of participants had received one or more legal abortions,⁹ while Rotondi et al. found that 24% of Italian women reported a previous induced abortion.¹¹

The reviewed literature confirmed an extensive variety of reasons for TOP. In the Swedish study, the main reasons were financial concerns, worries about the relationship and bad timing of the pregnancy.⁹ In Cuba, interruption of education was the predominant reason among teenagers, with other reasons including being a single mother and poor socioeconomic conditions.¹² In a study done in Bangladesh, the reasons given were that the women did not want any more children or wished to space births.¹³ Counselling on family planning is done routinely when TOP is performed at the Reproductive Health Unit in Bloemfontein. In Nigeria, post-abortion counselling increased the percentage of women using contraception from 27.8% at the time of the abortion to 49.1% at the time of the follow-up interview.¹⁴ In Britain, a qualitative study on peri-abortion contraceptive counselling seemed to have little impact, partly because the discussion of contraception is often done at the post-abortion follow-up visit, which was not attended by all the respondents.¹⁵

It is interesting to note that, although the Reproductive Health unit provides a full range of family planning services, it is mainly used for TOP. We recommend that counselling on family planning and the education of target groups such as school children be given greater priority. As stated in a study from Sri Lanka, each encounter by a health worker with a woman of reproductive age should be considered an opportunity for family planning counselling.¹⁶

The limitations of our study are related to the sensitive nature of the investigation. Although anonymity was ensured, some respondents did not answer all the questions, or chose the option “I don’t know”/“unsure”. It is difficult to surmise what this answer would mean to a question such as the one asking whether TOP is used as a family planning method. Due to the sensitive nature of the topic, we also decided not to ask further questions relating to previous TOPs – information that could have given better insight into the patients’ views on TOP as a family planning method.

An area of concern not covered by our study relates to women who receive TOP after 12 weeks. They have to administer medication at home and often do not return to the Reproductive Health Unit for the follow-up. A study dealing with this topic could show that the period during which TOP is allowed in South Africa needs to be revised.

Conclusion

The relatively high percentage of participants who consider TOP to be a contraceptive method or are unsure, associated with the fact that most were young, single, not using contraception, and had opted for induced abortion just because the conception represented an unwanted pregnancy implies that some of our population is not aware that termination of pregnancy is not a family planning method. It also discloses a lack of appropriate information about family planning in general.

Acknowledgements

The authors would like to thank the staff of the Reproductive Health Unit, Dr WJ Steinberg, the statistician, Mr FC van Rooyen and the medical writer, Mrs L van der Westhuizen, as well as two anonymous reviewers of the draft manuscript.

Conflicts of interest
None declared

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