Main findings
Zanzibari women terminate pregnancies using multiple methods, for a range of reasons, at various life stages, and usually without complications requiring PAC. While abortions from medical providers were most often effective, nearly half our participants aborted without medical providers. The broad variation of experiences is noteworthy in light of our non-random sampling method.
Women in Zanzibar terminate pregnancies in a situation of multiple uncertainties. While some legal exceptions exist for abortion in Tanzania, a Center for Reproductive Rights report states that Tanzania’s law and policies about abortion are inconsistent and unclear [
18]. Most women (and people) in Zanzibar believe that all abortion is illegal. And in the Zanzibari context, illegal abortion provision is not regulated with oversight from the health care system, and thus by definition, is unsafe. Nevertheless, women in our study described a range of abortion methods and experiences, most of which terminated the pregnancy without physical sequelae or need for PAC. It is possible that women who had a
daktari terminate their pregnancies were given prophylactic antibiotics, thus reducing the risk of infection and potentially seeking formal PAC at the hospital; two participants mentioned being given pills by the
daktari but they did not know what the pills were. A clear dichotomy between ‘safe’ and ‘unsafe’ may not represent reality in Zanzibar. While we cannot classify illegal abortions as ‘safe’ (because of the lack of regulatory oversight), those our participants experienced were perhaps ‘safer’ unsafe abortions. For example, using misoprostol or MVA for an early termination is illegal, but if used in recommended ways, it may be safe, even if the woman later presents for PAC for perceived incomplete abortion. While we do not know anything of the medical credentials of the
daktari who provided terminations, they had some knowledge of abortion procedures, and some used what sounds like MVA or D&C techniques despite conducting terminations at non-health facility locations. Many of the abortion methods used by our participants have been reported in other studies in Tanzania [
19]. The persistent use of these unregulated methods reflect the lack of easy alternative abortion options and signify the need for abortion policy which will pave the way for safe abortion services.
In this exploratory study, we demonstrate that chain-referral sampling is effective in gathering abortion experiences from a community-based population. In addition to efficiency (identifying people with characteristics of interest), participants came in with trust, having been recruited by someone they knew, and they were aware that participation involved talking about induced abortion, reducing likelihood of misclassification. Abortion is not rare among Zanzibari women, but it goes largely unreported, so chain-referral sampling facilitated successful exploration of an experience otherwise hidden from researchers. Despite the stigma of abortion, women talk with social contacts about abortion, and thus can connect each other via chain-referral sampling.
Most data about abortion in contexts where it is illegal are extrapolated from PAC data [
20]. Our data highlight the extent to which such studies may underestimate how many abortions take place in a community, and potentially misestimate morbidity and mortality of abortions that do occur, although women who receive PAC do not necessarily represent only the least safe abortions, but also include women who had incomplete or worrisome abortions. Participants described keeping their abortions secret; perhaps many abortions would not have been reported in household surveys.
We found, as others have across sub- Saharan Africa, that women use local plants boiled down to concentrated tea to induce abortions [
19]; several species have demonstrated uterine contractile activity [
21]. Drawbacks to herbal methods include the inability of tea-makers to control pharmacoactive agent doses, the possibility of side-effects, and lack of data about efficacy and safety. Our participants often did not know what methods were used by health providers to terminate their pregnancies. Herbal methods may be more welcome for this reason—drinking a concocted tea may be less threatening than undergoing a procedure with unfamiliar methods. In mainland Tanzania and Zanzibar, women turn to traditional birth attendants and pharmaceutical retailers for help with abortions, as they offer greater convenience, privacy, and lower costs than physicians [
22,
23]. Finally, while a distinction does exist between an abortion (illegal) and PAC (legal), women may not see this distinction, especially in contexts where both the providers, and methods of abortion and PAC may be the same.
While many participants noted using drinks made from local plants, multiple participants used strong black tea alone or in conjunction with local plants. We believe that we are the first to report induced abortion via ‘strong black tea:’ participants described boiling down up to 1 kilogram of black tea leaves to make one cup of tea which they drank. Tea with very high caffeine content, such as one cup made from 1 kg of tea leaves, could theoretically cause abortion. A meta-analysis of 43,000 pregnancies found a small but statistically significant [OR 1.36 (95 % confidence interval 1.29–1.45)] increase in spontaneous abortions among women consuming more than 150 mg caffeine daily [
24]; the average regular cup of tea contains approximately 50 mg of caffeine, and 1 kg of tea leaves makes approximately 400 cups, leading to 20,000 mg of caffeine in a cup made from 1 kg of tea leaves. In other work, Klebanoff et al. [
25] assessed serum levels of paraxanthine, a caffeine metabolite, to estimate caffeine doses at matched time points in women who did and did not have spontaneous abortions. Extremely high serum paraxanthine concentration levels were associated with spontaneous abortion [
25]. Perhaps the concentrated black tea used by our participants contains enough caffeine to induce abortions. While only one woman successfully terminated her pregnancy using
only strong black tea, the women who used black tea in combination with other herbs considered the black tea to be an active part of the treatment necessary to terminate their pregnancies. No women talked about the black tea as an inert vehicle for whatever else they boiled along with the black tea leaves. We submit that black tea as an abortion method is important because if a woman believes she terminated a pregnancy having used black tea (solely or in combination with other items), that woman contributes to the dialogue that circulates among Zanzibari women regarding how to terminate a pregnancy with this method.
While we cannot preclude the possibility that some women may have used ineffective methods to attempt induced abortion, and may instead have had spontaneous abortions or delayed menses, we demonstrate that multiple methods of abortion are known and used with the intent of terminating unwanted pregnancies in Zanzibar. Several more dangerous abortion methods described in other studies and from PAC providers we interviewed—including inserting objects into the vagina or uterus—were not mentioned by our participants [
22,
26‐
27] (S. Yoseph, A. Gossa, and E. Tadesse, “A survey of illegal abortion in Addis Ababa, Ethiopia,” unpublished, 1993). It is particularly noteworthy that participants described the presence of both medical/herbal and surgical abortion, and that they found a range of non-traumatic options available.
Limitations
Our study benefited from chain-referral sampling to understand hidden behaviors among women in Zanzibar. Our methodology, however, favored participation from women who lived near, or were willing to travel to, the urban center where the study was based. Our small sample size precluded use of statistical adjustments to produce generalizable samples and using chain-referral does not allow for true characterization of the sample in reference to the larger population. Our sample is not generalizable to Zanzibar as a whole, but is reflective of women living close to an urban center.
Chain-referral sampling may have been more likely to capture women who had recent abortions and/or more complicated abortions, as these may have been remembered more by their acquaintances. Alternatively, women with complicated abortions may have been less likely to want to participate. By its design, our study only captured women who told someone about their abortion; we cannot comment on the experiences of women who were able and/or wanted to keep their terminations more secret. Finally, women with unsuccessful terminations and women who died were not captured with our design. Because we recruited only women who did terminate a pregnancy, our study design excludes women who tried but failed to terminate a pregnancy. This may be a large number, and represents a dual public health problem: continuation of unwanted pregnancy and potential sequelae from ineffective abortion attempts.
Some participants described long past abortions, which may lead to recall bias regarding the details of their termination experience or whether or what sort of contraception they were using at the time they became pregnant. Gestational age at the time of termination was by participant self-report, and there is no way to confirm the validity of the dating. Additionally, many women were uncertain of the specifics regarding the methods of their terminations, as mentioned above.