Study sites

The Nigerian arm of the study was conducted in nine health facilities (six secondary and three tertiary), in the south-west geo-political zone of Nigeria, where it was estimated that 164,000 induced abortions occurred in 2012 and represents an induced abortion rate of 27 per 1,000 women aged 15–49 years [12]. During the same period in the same geo-political zone, 40% of 59,173 women were treated for abortion complications from induced abortion, rather than miscarriages [12]. The participating health facilities (eight public and one private) were selected based on the availability of a high number of qualified multidisciplinary, full-time medical personnel, a high number of people who utilize the hospitals for sexual and reproductive health issues (especially post-abortion care) and the proximity of the hospitals to the coordinating centre. Five out of the six states within the southwest geopolitical zone of Nigeria were represented in the study.

The qualitative aspect of the study was conducted in seven out of the nine health facilities.

Study participants, recruitment and sampling

Study participants were women who presented with complications of induced abortion in the seven health facilities. The participants were identified by their health provider as having undergone an induced abortion that required admission to the hospital and the method of the abortion and were then enrolled while on admission in these hospitals, after their treatment was complete and they were stable. Purposive sampling technique was used to recruit participants into the study and the trained interviewer obtained written consent and conducted in-depth interviews (IDIs) with the participants. Although a random selection was not employed due to the characteristics of eligible study participants, recruitment of participants continued till saturation of topics were attained. Only two women among those approached to be interviewed refused to participate in the study.

Study instrument

An IDI guide (Table 1) was developed by the study team after extensive literature review and consultation with content experts. The guide was semi-structured, facilitating comparability across IDIs and allowing participants to guide the discussion based on their experiences. Four domains of interest, comprising 14 questions were explored: (1) Introductory question (reasons for coming to the hospital and experience); (2) Choice of abortion methods; (3) Care seeking behavior; and (4) Knowledge of methods.

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Table 1. In-depth interview guide for women who have undergone an induced abortion.

https://doi.org/10.1371/journal.pone.0217616.t001

Data collection and management

Research assistants (RAs) were two female postgraduate social scientists from the University of Ibadan and the Lagos State University and two staff members of the University College Hospital (UCH), Ibadan. All four RAs participated in a five-day qualitative research training workshop from October 8–12, 2012 prior to the commencement of data collection in order to develop their research skills and capacity on qualitative methods of data collection. The training was facilitated by an international consultant engaged by the WHO. The training curriculum focused on interviewing techniques, development of coding scheme, coding of transcripts and use of WEFTQDA software. All RAs signed data confidentiality agreements after the training.

One of the two social scientists conducted the face-to-face interviews while the other was the note taker, who recorded participants’ responses on papers and audiotapes during the interviews. Medical officers at the study sites identified eligible women and thereafter informed the research team to move to the study sites for the interviews. Written informed consent was obtained from all participants by the RAs prior to participation. They were provided with information about the purpose of the study and were given ample time to read the consent form before obtaining their written consent. If required, the consent forms were read to them. Consent forms and IDI guides were available in both English and Yoruba (the local language in south-west Nigeria). All IDIs were conducted by RAs during the period of the women’s admission in the hospitals and in specifically designated rooms at all sites to ensure privacy and confidentiality (only the participant and RAs were present). The IDIs, which were conducted in English or Yoruba, were double audio-recorded and each IDI lasted 30 to 45 minutes.

Data were collected from May 2013 to May 2014, until thematic saturation was reached. The IDIs were conducted in the seven hospitals based on the availability of eligible participants during the period of data collection. The audio recordings were transcribed daily by the RAs, and the transcripts and recorded notes were compared for any missing information and updated appropriately. All the IDIs conducted were transcribed in the language of the interview, and those conducted in Yoruba were translated simultaneously into English after the interview. Identifiers were expunged from the transcripts and the de-identified transcripts (in plain text format) were stored on a password-protected computer system.

Data analysis

The study employed a cross-case content and narrative analysis. The data were analyzed thematically in order to ensure flexibility that assures identification of key themes and sub themes, as well as comparison of similarities and differences in participants’ experiences of induced abortion. Coding schemes were developed independently by two of the authors through a line-by-line coding of a representative sample of the transcripts, selected proportionately through stratification of the number of participants per health facility. Following this process, the similarities and differences in the coding were compared and discussed. A consensus, which included the use of the explanatory thematic framework was thereafter reached and the framework was employed to structure and define the data. Thereafter, the plain text transcripts were imported into qualitative software (WEFTQDA) and categories and subcategories were created in the categories tree using a combined inductive and deductive approach, which used the interview guide and main research questions (deductive) and themes emerging naturally from the data (inductive) to develop the analysis. The transcript texts were coded by marking text passages from the transcripts as related to each of the created categories and all the document sections coded by each category were reviewed side-by-side to allow for comparison of similarities and differences. Narrative texts and illustrative quotes were used to identify patterns in the data and respondent clusters (related themes), and to draw connections between recurrent themes and distinct patterns as they evolved from the richness of the data.

Ethical and institutional approvals

Approval to conduct the study was obtained from the Institutional Ethics and Research Boards covering all the health institutions where the study was conducted (approval reference numbers inserted in parentheses); University of Ibadan/University College Hospital Ethics Review Committee (UI/UCH/11/0258), Lagos State University Teaching Hospital Health Research and Ethics Committee (LREC/10/06/228), Obafemi Awolowo University Teaching Hospitals Complex Ethics Committee (ERC/2012/12/01) and Oyo State Ethical Review Committee (AD13/479/257). Administrative approvals were also obtained from the participating health facilities. This paper is reported in accordance with the consolidated criteria for reporting qualitative research (COREQ) [26]

Reasons for terminating pregnancy

Participants noted four common reasons for terminating their pregnancy. Some of them adduced more than one reason for this decision:

1. Too young/still in school/training/not ready:

Irrespective of their demographic status, participants cited this reason for terminating their pregnancy and some of them further expressed the personal consequences associated with continuing the pregnancy. Specifically, all the student participants were among those who articulated this reason. According to a 20-year-old Artisan and mother of one, she “wasn’t ready then and there was no money”.

A 23-year-old student also stated that when she got pregnant, she felt like she didn’t want a baby yet, so she tried to abort the pregnancy. Another student remarked that: “It is not yet time for me to have a baby…because I am still young and I want to further my education” [21 years old, Student].

The influence of some participants’ significant others was a factor in the decision to have an abortion. For these women, their partners clearly expressed that they were not ready to have children. Whereas one of these women remarked that her partner expressed this non-readiness prior to getting pregnant: “when I had my first pregnancy, I didn’t tell my husband about it, so I went to abort it…I thought he was going to get angry because he already told me that he is not ready for pregnancy” [22 years old, Nurse], another stated that when she told her partner, he “accepted it but he said he didn’t want it because he had no money” [20 years old, Student].

2. Have had the desired number of children:

Some women terminated their pregnancy because either they or their partners did not want more children. Some of these women offered explanation on why they did not want more children: “my husband said he doesn’t want any more children that we should stop it…I had to do something about it, I aborted it” [36 years old, Artisan]. Another participant perceived that she would be stigmatized, in form of verbal abuse, if people became aware of her pregnancy:

R: I have had the children I wanted and I don’t want any more children…what I was just considering was that people would start asking that what else am I looking for [37 years old, Trader].

3. Last baby too young and still breastfeeding:

Becoming pregnant while still nursing a child was a reason adduced by some participants for terminating their pregnancy, with one participant associating this with her inability to cope with the care of the children coupled with the effect this would have on her job:

R: I terminated the pregnancy there because I was still nursing a baby and the child was just about 9 months still breast feeding. So when I saw that, I couldn’t cope with both, I didn’t want the child to be affected so I terminated the pregnancy.

I: When you got pregnant, you were sure you didn’t want it right?

R: Yes…It wasn’t like I really wanted to abort it, I did it because of work, I didn’t want it to affect my job [37 years old, Book keeper].

4. Fear of congenital deformation:

Some participants were on medication when they found out they were pregnant, the fear of bringing forth a deformed child informed their reasons to terminate such pregnancy.

R: …I had preeclampsia [during previous pregnancy] so I knew I wasn’t ready for another child yet. So when noticed I missed my period, I told my husband and he wanted me to keep it, but I told him I have used this and that, I don’t want a deformed baby [34 years old, Trader]

Another 34-year-old mother of two said:

R: I had used a number of drugs for boil [abscess]; also used Gynaecosid [drug indicated for the treatment of secondary amenorrhea which produces a bleed] to prevent pregnancy. When I missed my period, I told my husband that I did not want a deformed baby. I did a pregnancy test, which was positive. I therefore used misoprostol.

Choice of abortion methods

Sixteen (51.6%) and 11 (35.5%) women respectively used misoprostol and D & C to terminate their pregnancy, whereas four women used other methods.

R: So when I had made the mistake and he [her husband] said he doesn’t want any more children, I had to do something about it, I aborted it with D & C, I didn’t use drugs [36 years old, Artisan].

In their attempts to successfully terminate their pregnancy, while some participants used only one method, others employed the use of different methods and/or drugs and were spurred by the “desperate” need to get rid of the pregnancy, previous successful termination or recommendations by significant others. Among these participants, some used more than one method to induce abortion. These women procured their abortion through D & C following a failed attempt using drugs. One participant described this: “it was terminated with D & C but firstly, I used drugs, it didn’t work, so I went for the D & C” [20 years old, Student]. Another described in detail the “mixed drugs” she used prior to having the D & C:

I: Apart from the D & C, what other methods have you tried?

R: I used drugs, those ones they mix together…Buscopan, Flagyl, Chloramphenicol and some others

I: Have you ever used those drugs to induce abortion?

R: Yes, may God forgive me…The first time I used it, the blood came and there was no problem, but this time it seems different [26 years old, Trader].

Some other participants used up to two different drugs to achieve their pregnancy termination, including drugs that are not indicated for abortion like postinor 2: “I took the Postinor last month and I just take [sic] Cytotec [misoprostol] this month” [25 years old, Trader]; gynaecosid:“So when I used the gynaecosid, the thing wasn’t coming down and I had a lot of plans before me, so I had to seek that friend’s advice and she told me to use misoprostol” [28 years old, Nurse]; and Alabukun and Andrew liver salt: “…I know is alabukun and Andrew liver salt and she said I should use it with Regal dry gin, but the rest of the drugs I don’t know their names” [19 years old, Student].

For some of the participants who used various drugs to either prevent pregnancy or induce their abortion, previous “successful” use influenced their perceptions that these drugs are effective. Nevertheless, these perceptions were incorrect and misleading for reasons including the timing of use and the drugs not indicated for the purpose it was used. Hinging on a previous perception of successful use of gynaecosid as an emergency contraceptive following unprotected sexual intercourse, a participant who ended up using misoprostol to terminate her pregnancy remarked that:

R: when my husband and I had intercourse, I sensed that I wasn’t in my safe period so I decided to use a preventive measure by taking a drug. I took gynaecosid so after a while I found that I have missed my period… [34 years old, Trader].

Cost of methods used

The cost of treatment varied and was dependent on the type, number of methods/drugs used, dosage of drugs procured and the source of procurement. Participants who underwent D & C paid between two thousand (about USD 10.00, at the time of the study) and ten thousand Naira (about USD 50.00) while those who used misoprostol paid between eight hundred (about USD 4.00) and eight thousand Naira (about USD 40.00). Other participants who mixed drugs or used drugs like gynaecosid spent between one hundred (about USD 0.50) and two hundred and seventy Naira (about USD 1.35) for treatment. Women often paid for treatment by themselves, while a few of them stated that their husband or boyfriend paid.

Knowledge and use of abortion methods

Care seeking behavior

Visiting hospital for post-abortion care was not part of the expectations of use because they “never even thought there will be consequences”. Majority of the respondents did not envisage that they would have to visit the hospital for evacuation or other post-abortion care after the D & C or after the use of misoprostol as prescribed. One of the participants who obtained the abortion drug from her husband—who is a medical practitioner—however remarked that she knew she might end up in the hospital for evacuation. Below are some responses why visiting hospital was not part of their expectation.

R: I never thought I will come to (the hospital), with hopes that I will be fine, because I sought advice and I was told that that’s her specialization so I never thought so [37 years old, Book keeper].

R: No, even when I was having the bleeding, I went to her and she said it would stop that she will give me some drugs, vitamin K that it would stop the bleeding, she said I should come and buy it in the evening, that she doesn’t have it in her shop, so before evening, I fainted and they rushed me to the hospital [19 years old, Student].

Since women’s experiences with the abortions were not at par with their expectations, they ended up going to the hospital to seek care. The decision to seek care at the hospital was usually after experiencing complications (abdominal pains, fever, dizziness or continuous bleeding), or indications that the abortion was incomplete. This decision making was commonly a last resort after every other effort to manage it had failed.

R: Although, I felt pains that day but I was hoping it was because I just had it, the second day, I use drugs, no changes…the second day after I had it, I saw blood and water, it was this blood and water that continued to come, it didn’t stop, later it became black…so on the third day, when I saw no improvement I had to come back here [37 years old, Trader].

I: So when did you decide to come to the hospital?

R: It was about 3 days at night and I still didn’t get myself, we went to a nurses’ home then injected me but instead of getting better, it became worse so my mum brought me [26 years old, Trader].

R: I didn’t have any intention of visiting the hospital but when I began to bleed, the blood came gradually. About a few weeks later, I began to have severe stomach ache, my parents thought it was malaria so my younger sister went to get a drug for me at the chemist, a white drug sort of, that was what I used and I was relieved. I couldn’t even check the name because of my condition. So when I used it, I felt ok for about 2 weeks but on Saturday the pains began again and I was bleeding that is why my grandma brought me here [23 years old, Chemist].