Estimating abortion incidence among adolescents and differences in postabortion care by age: a cross-sectional study of postabortion care patients in Uganda

Abstract

Objectives: To provide the first estimate of adolescents' abortion incidence in Uganda and to assess differences in the abortion experiences and morbidities of adolescent and nonadolescent postabortion care (PAC) patients.

Study design: We used the age-specific Abortion Incidence Complications Method, drawing from three surveys conducted in Uganda in 2013: a nationally representative Health Facilities Survey (n=418), a Health Professionals Survey (n=147) and a Prospective Morbidity Survey of PAC patients (n=2169). Multivariable logistic and Cox proportional hazard models were used to compare adolescent and nonadolescent PAC patients on dimensions including pregnancy intention, gestational age, abortion safety, delays to care, severity of complications and receipt of postabortion family planning. We included an interaction term between adolescents and marital status to assess heterogeneity among adolescents.

Results: Adolescent women have the lowest abortion rate among women less than 35 years of age (28.4 abortions per 1000 women 15-19) but the highest rate among recently sexually active women (76.1 abortions per 1000 women 15-19). We do not find that adolescents face greater disadvantages in their abortion care experiences as compared to older women. However, unmarried PAC patients, both adolescent and nonadolescent, have higher odds of experiencing severe complications than nonadolescent married women.

Conclusions: The high abortion rate among sexually active adolescents highlights the critical need to improve adolescent family planning in Uganda. Interventions to prevent unintended pregnancy and to reduce unsafe abortion may be particularly important for unmarried adolescents. Rather than treating adolescents as a homogenous group, we need to understand how marriage and other social factors shape reproductive health outcomes.

Implications: This paper provides the first estimate of the adolescent abortion rate in Uganda. Studies of adolescent abortion and reproductive health must account for sexual activity and marital status. Further, interventions to address unintended pregnancy and unsafe abortion among unmarried women of all ages in Africa should be a priority.

Keywords: Abortion complications; Adolescent; Family planning; Induced abortion; Unintended pregnancy.

Fig. 1.

Abortion rate by age group in Uganda in 2013, including abortion rates for all women, ever-sexually active women and recently sexually active women (reported sex in the past 12 months).

Fig. 2.

Percentage of all pregnancies in Uganda that are unintended by age group and outcome, 2013. Notes: UP = unintended pregnancy.

Fig. 3.

Odds ratios, hazard ratios and 95% confidence intervals of abortion care experiences among adolescent postabortion care patients as compared to nonadolescent postabortion care patients in Uganda, 2013. Notes: Dependent variables for each model were (1) reporting their pregnancy as unintended, (2) being past the first trimester, (3) reporting someone other than a medical professional helped them interfere with their pregnancy, (4) delays in reaching care, (5) having severe abortion complications and (6) receiving a modern postabortion family planning method (see Table 1). All models controlled for urban residence, highest level of education attained and previous pregnancy history. For all models other than unintended pregnancy, whether the pregnancy was reported as unintended was included as a control. Severe abortion complications were defined as women who received a blood transfusion, had surgery, had a septic abortion or died. Relying on someone other than a medical professional to help interfere with the pregnancy was only reported by the 611 women who self-reported that they interfered with their pregnancy and reported on who helped them. The postabortion family planning coefficient is not sensitive to the exclusion of condoms from the list of modern methods. Reference group is nonadolescent women.

Fig. 4.

Odds ratios, hazard ratios and 95% confidence intervals of abortion care experiences among unmarried adolescent, married adolescent and unmarried nonadolescent postabortion care patients compared to married nonadolescent postabortion care patients in Uganda, 2013. Note: Dependent variables for each model were (1) reporting their pregnancy as unintended, (2) being past the first trimester, (3) reporting someone other than a medical professional helped them interfere with their pregnancy, (4) delays in reaching care, (5) having severe abortion complications and (6) receiving a modern postabortion family planning method (see Table 1). All models controlled for urban residence, highest level of education attained and previous pregnancy history. For all models other than unintended pregnancy, whether the pregnancy was reported as unintended was included as a control. Severe abortion complications were defined as women who received a blood transfusion, had surgery, had a septic abortion, or died. Relying on a nonmedical professional to help interfere with the pregnancy was only reported by the 611 women who self-reported that they interfered with their pregnancy and reported on who helped them. Reference group is married nonadolescent women.