11 Background InformationZambia is a landlocked country covering a total of 752

1.1. Background InformationZambia is a landlocked country covering a total of 752 614 square meters and a total estimated population of 10.3 million people in 2002 with an annual growth rate of 2.9% in the year 2000. Although there are differentials in rural and urban percentages in male and female population, the differences are not very significant. Copperbelt province has the highest population followed by Lusaka, Northern; Southern and Eastern provinces. Sparsely populated, the population density stands at 10.4 people per kilometer. The rural- urban disparity continues with 60 % of the population residing in the rural areas. Reducing maternal mortality is one of the Millennium Development Goals (MDGs). Zambia has a high mortality ratio, estimated in the Zambia Demographic and Health Survey [ZDHS] of 2001-2002 at 729 per 100,000 live births (CSO et al 2003). This is an increase from the 1996 ZDHS figure of 649 per 100,000 live births (CSO et al 1997), though the 2007 ZDHS estimated it to be 591 (CSO 2009) – though no trend towards a decrease can be surmised due to wide confidence intervals. The Zambian millennium target is 162/100,000 (which is one quarter of the ZDHS1996 figure). The five major causes of maternal mortality include hemorrhage, hypertensive disorders, obstructed labour, sepsis and complications of unsafe abortion (Nsemukila & Phiri, 1998). Most of these are preventable causes of maternal mortality.Tackling unsafe abortion alone could bring Zambia close to achieving its millennium target. Worldwide, it is estimated that unsafe abortions contribute 13% to the maternal mortality rate and in East and Southern Africa 15 to 30% (Kinoti, 1995). In Zambia 30% of maternal mortality is caused by unsafe abortions (UNICEF, 1994). At the University Teaching Hospital (UTH), for the year 2005, 29.5% of the maternal deaths were abortion-related (UTH Obstetrics and Gynaecology Department mortality records). The magnitude of unsafe abortions in Zambia has not been clearly established. The high number of clients receiving post abortion care (PAC) suggests a high incidence of abortions (unsafe and illegal). At UTH 50% of admissions to the emergency gynaecological ward are due to incomplete abortions (UTH records). Most of these cases are referrals from the local clinics which are part of the Lusaka District Health Management Team (DHMT) and many are suspected to have been induced. Abortion in Zambia is legal under the provisions of the Termination of Pregnancy Act of 1972, yet the number of unsafe and illegal abortions remains persistently high. The Zambian abortion law allows abortion even for social economic circumstances and could be among the most liberal laws in Africa. The demand, as shown by the figures of clients receiving PAC, is high but access is low. Manual vacuum Aspiration (MVA) was introduced in 1988 to improve abortion care in Zambia. After this introduction the ratio of patients receiving PAC to those having elective (legal) pregnancy terminations reduced from 25 to 1 in 1988 to 5 to 1 in 1990 (Bradley et al 1991). Most patients treated for complications of unsafe abortions are young women and most of them in their early teens (Kaseba et al 1998). This group generally has no access to family planning services though they seem to be very knowledgeable about where to access an abortion but avoid health facilities for fear of mistreatment (Webb 2000). Most of them also assume that abortion is illegal in Zambia (Webb 2000). The abortion law in Zambia requires three doctors to approve an elective abortion and one of these should be a specialist in the related field. This restricts access to lawful and hence safe abortion. This is because very few places in Zambia will have the luxury of three doctors let alone a specialist. Clinical officers and nurses are not allowed by law to perform an elective abortion but the same group has been successfully trained to provide PAC which involves performing a manual vacuum aspiration (MVA). It is not known how many of these can perform a safe elective abortion. It is known that some of the unsafe abortions are conducted by health workers including doctors (Castle et al 1990). Castle and colleagues (1990) also observed that doctors at UTH were reluctant to give appointments for elective legal abortions to seekers despite the permissive law. Monetary gain on the part of health workers appears to be another barrier to access of abortion services. UTH records show that when there was monetary benefit to the doctor, in 1996 and 1997, elective abortion recorded were 1570 and 1661 respectively. But when fees were abolished in 1999 and 2000, the numbers dropped to 212 and 138 respectively. This indicates that health workers are able to offer the service but their attitude hinders them. In South Africa where the abortion law was changed such that it allows abortion on demand up to 12 weeks’ gestation, accessibility to the service is still low and the attitudes of the providers was shown to be the contributing factor (Dickson et al 2003).1.2. Statement of the problemThe cases of incomplete abortion and other complications of unsafe abortions referred to NTH from the local clinics continue to be high despite a law that legalizes abortions under stipulated conditions. Health workers in these referring clinics could be contributing to this problem due lack of knowledge of the abortion law or their attitudes. In 2017 NTH recorded unsafe abortions (4%) of unsafe abortions of the total cumulative percentage of the annual cases. These causes occurred as a result of early pregnancy (75% of maternal deaths occur among teenage mothers), short spacing between pregnancies, home deliveries, illegal abortions and long distances to clinics. It is from this noted discrepancy that the researcher is prompted to conduct a study to determine the perception of unsafe abortion among women aged between 18 and 45 years at Twapia market of Ndola district.1.3. Justification Incomplete abortion is a major cause of morbidity and mortality among women that experience an abortion. Women with incomplete abortion present with varying clinical conditions. A typical clinical presentation of incomplete abortion is that of vaginal bleeding, lower abdominal cramps, and dilated cervix with partial expulsion of products of conception. However, some present with severe bleeding others with infected retained products of conception, or with injury to reproductive health organs and some just in poor general health and need immediate resuscitation and surgical evacuation of the uterus. Others come with retained products of conception but in good general condition. Thus the findings of this study will help government through the Ministry of Health and other stakeholders to work on the identified issues in order to help them plan for better services to improve human health.1.4. Literature Review1.4.1. Overview of Abortion World Wide Abortions occur in all countries but ninety-five per cent (95%) of unsafe abortions occur in developing countries (World Health Organization 1998). Research has shown that about seventy thousand (70,000) women die from unsafe abortions per year worldwide (WHO, 1997). This means that close to 200 women die every day worldwide from unsafe abortions. Globally, unsafe abortion contributes to about thirteen percent (13%) of maternal deaths (WHO, 1998). In addition to these numbers tens of thousands of women suffer long-term health consequences including infertility. Major complications of abortion such as excessive hemorrhage and infection result from incomplete abortion. Therefore, finding affordable, effective and acceptable treatment of incomplete abortion can significantly help reduce morbidity and mortality from incomplete abortion. The use of sharp curettage is discouraged by the World Health Organization (WHO), as it is considerably more painful for women than vacuum aspiration, and less safe (rates of major complications are two to three times higher than those of vacuum aspiration), (Grimes et al, 1979; Grimes et al, 1977). 1.4.2. Alternatives for Treatment of Incomplete Abortion While both MVA and sharp curette are effective, they require specialized equipment and skills. Furthermore, they subject the woman to the dangers attendant on a surgical procedure such as trauma, perforations, infections, bleeding due to instrumentation, and reactions to anesthesia, among others. For these reasons, determining an effective nonsurgical approach to treatment is a priority.1.4.3. Misoprostol for Treatment of Incomplete Abortion Misoprostol, a prostaglandin E1 analogue, is a medical alternative to manual vacuum aspiration and other uterine evacuation methods such as dilatation and curettage (D&C) for treatment of incomplete abortion. It is an orally active prostaglandin analogue that is widely available, inexpensive, easy to administer, and stable at room temperature. Initially registered for the prevention of gastric ulcers during long-term use of non-steroidal anti -inflammatory drugs, misoprostol is now registered and used in many countries for numerous obstetric and gynecologic indications including induction of labor, preparation of the cervix for surgical procedures, prevention or treatment of postpartum hemorrhage, and pregnancy termination (Winikoff B. 2006). The World Health Organization expert committee on the selection and use of essential medicines has now recommended misoprostol for treatment of incomplete abortion and put the drug on the essential drugs list (WHO Technical Report Series, May 2009). The committee identified 22 relevant studies that directly compare the use of misoprostol with surgery for the treatment of incomplete first trimester abortion. Based on these data, there is no statistically significant difference between surgery and oral misoprostol in terms of uterine clearance up to 14 days after administration. Comparison of adverse effects showed that while misoprostol administration was associated with predictable adverse effects (such as bleeding and pyrexia) due to the pharmacological actions of the medicine, these effects generally did not require further interventions (such as blood transfusion) and were reported as acceptable by the women. The adverse effect profile of misoprostol needs to be compared with the potential risks of surgery in unsafe settings i.e settings with no staff trained in surgical uterine evacuation methods or settings that does not meet minimal medical standards (WHO Technical working group report 1992). With respect to use of misoprostol for the treatment of incomplete abortion, the Committee decided that the evidence showed that misoprostol is as effective as surgery and in some settings may be safer as well as cheaper and therefore recommended inclusion of the 200 micrograms tablet on the complementary list with a note indicating the appropriate use: ―for management of incomplete abortion and miscarriage”. (WHO Technical Report Series, May 2009). Management of incomplete abortion with misoprostol offers other advantages over surgical procedures and includes: Bagratee et al 2004; Weeks A et al, 2005) have indicated that the uterotonic and cervical ripening properties of misoprostol make it a safe and highly effective method of evacuating the uterus in cases of incomplete abortion. Misoprostol’s stability at room temperature and low cost makes it an ideal treatment in low-resource settings. While some studies of misoprostol for incomplete abortion have employed the vaginal route of administration, (Demetroulis et al, 2001; Sahin et al, 2001, Ngai et al, 2001; Pang et al 2001), the majority of such studies that had high success rates have employed the oral route. 1.4.4. Overview of Abortion in AfricaIn a survey of Zimbabwe’s heath workers’ attitudes on abortion found that most health workers supported provision of safe abortion and liberal abortion laws. His findings showed that religion had little bearing on the attitudes but the knowledge of the complications of unsafe abortion. Health care provider attitudes appear to vary from nation to nation and from institution to institution. Where the attitudes are negative women avoid the health institutions and seek services elsewhere and some end up getting unsafe services (Kasule J. 1999).In Nigeria where the abortion law is very restrictive Henshaw et al (1998) found that a large number of unsafe and safe abortions are conducted by medical personnel.In Kenya, Baker and Khasiani (1992) studied case histories of induced abortions and found that one of the major causes of unsafe abortions was the cost of getting the service from a trained provider. Similar findings were reported by Paxman et al (1993) in Egypt where only rich women got access to relatively safe abortions.1.4.5. Overview of Abortion in Zambia Unsafe abortion is one factor contributing to the high maternal mortality ratio in Zambia. As reported in the 2007 Zambia Demographic and Health Survey, the maternal mortality ratio in Zambia is estimated at 591 per hundred thousand live births (ZDHS 2009). A hospital based study in 1983 by M’hango et al found that abortion contributes to about 15% of maternal mortality. Mati et al found that it contributed 30% (Situations Analysis UNICEF 1994). Therefore, addressing unsafe abortion can significantly reduce maternal mortality in Zambia. While abortion complications are a common medical emergency in developing countries such as Zambia, care given to women with such conditions is often delayed due to critical shortage of health care workers and medical supplies. Realizing this problem, in 2002 Zambia embarked on a program to expand Post Abortion Care (PAC) services around the country. The PAC program anticipates the need for emergency treatment of post abortion complications; plans ahead to meet that need and provides family planning to prevent repeated abortions. The program has been successfully implemented and is being expanded to reach all districts of Zambia. It was aimed at using midlevel providers as a means of increasing access to PAC through training of nurses and midwives. This was brought about by the Nurses and Midwives act of 1997 which allows them a wide scope of practice, thereby ensuring that services are provided as close to the communities as possible (Kaseba et al, 1998). It was envisaged that the PAC services would provide such a service contributing to the reductions in the maternal mortality and morbidity (Kaseba et al, 1998). 1.4.6. Incomplete Abortion Incomplete abortion is a major cause of morbidity and mortality among women that experience an abortion. Women with incomplete abortion present with varying clinical conditions. A typical clinical presentation of incomplete abortion is that of vaginal bleeding, lower abdominal cramps, and dilated cervix with partial expulsion of products of conception. However, some present with severe bleeding others with infected retained products of conception, or with injury to reproductive health organs and some just in poor general health and need immediate resuscitation and surgical evacuation of the uterus. Others come with retained products of conception but in good general condition. Record inspections at the University Teaching Hospital, where this study was done, revealed that on average 430 Manual Vacuum Aspiration (MVA) procedures are performed per month for incomplete abortion. About 80% of these are for pregnancies 12 weeks or less as estimated by the last menstrual period. It was also found that abortion related conditions accounted for about 30 to 50% of admissions to the gynecologic emergency ward at the UTH. Women often wait for hours before the vacuum aspiration is done due to the huge workload resulting from inadequate material resource, limited space and in some cases due to antiquated practices. The treatment for incomplete abortion at the UTH is currently using manual vacuum aspiration (MVA) though before the 1990s management was by dilatation and curettage (D&C) under general anaesthesia.1.5. ObjectivesI. General objectiveTo determine the perception of unsafe abortion among women aged between 18 and 45 yrs.II. Specific objectivesa. To examine factors that may influence unsafe abortion.b. To assess women’s attitude towards unsafe abortion.c. To evaluate the possible effects of unsafe abortion.d. To find out the sources of information concerning unsafe abortion.1.6. Research Questionsa. What are the factors that may influence women to practice unsafe abortions?b. How is women’s attitude towards unsafe abortion?c. What could be the possible complications of unsafe abortion?d. What may be the source of information concerning unsafe abortion?1.7. MeasurementsFactor-A circumstance, fact or influence that contributes to a result. (1) Good if respondents score above 60% and above (2) Moderate if respondents score between 40% and 60% (3) Bad if respondents score below 40%.Information- Facts provided or learned about something or someone. What is conveyed or represented by an arrangement. (1) Good if respondents score above 60% and above (2) Moderate if respondents score between 40% and 60% (3) Not reliable if respondents score below 40%.Effect- A change, which is a result or consequence of an action or other cause. (1) Positive if respondents score above 60% and above (2) average if respondents score between 40% and 60% (3) Negative if respondents score below 40%.Attitude- A tendency to respond to respond positively or negatively towards a certain idea, object, person or situation. (1) Good if respondents score above 60% and above (2) Moderate if respondents score between 40% and 60% (3) Bad if respondents score below

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