Trends in and predictors of pregnancy termination among 15–24 year-old women in Nigeria: a multi-level analysis of demographic and health surveys 2003–2018

Pregnancy termination or induced abortion, defined as a pregnancy that is terminated by choice through intervention, is a major public health issue in Africa [1]. Abortion services in Africa are restricted with only 4 out of 54 countries having relatively liberal abortion laws [1]. Between 2010 and 2014, of the 6.86 million abortions carried out each year in Africa, 75.6% (95% confidence interval (CI) 66.4 to 81.4%) of these were classified as unsafe (using untrained practitioners and/or non-recommended methods) [2]. Unsafe abortion has serious adverse health consequences such as infections and fatality [2]. Young women aged 15–24 years account for 57% of abortions in Sub-Saharan Africa (SSA) [3], with unsafe abortion being the leading cause of maternal mortality in this age group [4‐7].

In Nigeria, the situation is further exacerbated by socio-cultural and religious beliefs whereby termination of pregnancy is viewed as murder and carries harsh penalties for providers [8, 9]. These factors contribute to women seeking clandestine abortion services with private providers who are mostly untrained, carry out procedures in unsafe environments using dangerous invasive methods [10, 11]. Notwithstanding, the punitive abortion laws in Nigeria, in 2012 the incidence of induced abortion was estimated as 33 per 1000 women [12]. More recently a pooled analysis of the Nigerian Demographic and Health Survey data (NDHS) for 2003–2013 reported the percent of married women who had ever terminated a pregnancy as 3.8% (95% CI 3.3 to 4.2%) amongst 15–19-year olds, and 11.7% (95% CI 11.0 to 12.5%) for 20–24-year olds [13].

While much research has been published reporting on young people’s knowledge, attitudes, practices and prevalence of pregnancy termination in SSA especially in Nigeria [3, 9, 12, 14], fewer studies have investigated factors influencing termination. The prevalence of pregnancy termination is higher in women of older age [8, 15, 16]; young age of sexual debut [17]; employed women [13], unintended pregnancy [8, 16], forced or transactional sex [18], physical or sexual intimate partner violence [19, 20], higher number of living children [18, 21], and higher wealth index [13, 22]. Being married [8, 13, 22, 23], having a secondary education [15, 22, 24], modern contraceptive use [23] and residing in rural areas have been associated with lower prevalence of induced abortion [13, 15].

Socio-cultural factors such as religion, mass media, and ethnicity have also been found to influence termination of pregnancy among adolescents and young people [8]. At the community and societal levels, place of residence, region of residence, community (mean education, attitudes justifying wife-beating, median age of first marriage, contraceptive use) and facility-level factors (policy, limited availability of health facilities providing abortion services and lack of patient-centredness of health services) have been noted to significantly predict termination of pregnancy [20, 23, 25].

Although the evidence above sheds light on some factors that are associated with pregnancy termination in women overall, they fall short of ascertaining the determinants specifically for 15–24 year-old women in Nigeria. The studies that involved young people were of adolescents in school [16, 17] and sample sizes were small and not representative of the general population, limiting inferences that can be drawn from the findings. Moreover, the studies largely focused on individual-level socio-economic and demographic factors with limited attention on the contextual community and state-level factors that influence pregnancy termination. Ignoring these factors especially in Nigeria with wide variation in socio-economic/cultural and regional characteristics hampers development of interventions to mitigate early pregnancy among 15–24 year-old women [26]. Furthermore, empirical studies outside of SSA have shown that contextual level factors such as cultural norms, inadequate quality or lack of sexual health education in schools, and lack of youth-friendly services may influence pregnancy termination among young people [27, 28].

One of the targets of the UN Sustainable Development Goals (SDG) is to reduce the global maternal mortality ratio to fewer than 70 per 100,000 live births by 2030. Reaching this target in Nigeria would require a maternal mortality ratio reduction of 7.5% per year [29]. The mortality burden among 15–24 year-old women due to unsafe abortion, along with the limitations in the previous studies, underscores the importance of understanding what factors influence pregnancy termination amongst this age group in Nigeria. Such knowledge would be of value to inform the development of tailored interventions and programmes to reduce the burden of maternal morbidity and mortality [30] particularly in Northern Nigeria- the region with the highest maternal and under-five mortality in the country [31]. Our aim was to examine the trends in prevalence of pregnancy termination, and the individual and contextual-level factors that influence pregnancy termination among 15–24 year-old women in Nigeria.

To our knowledge, this is the first comprehensive analysis of the NDHS from 2003 through 2018 that focuses specifically on the influence of both individual and contextual-level factors on pregnancy termination among women aged 15 to 24 years, a demographic group that is often overlooked in terms of research and public health interventions. Our key findings reveal a declining trend in pregnancy termination between 2003 and 2013, with a reversal in trend in 2018. Additionally, whilst the overall trend in pregnancy termination between 2003 and 2018 showed a decline, amongst some groups of young women there were disparities in the trends particularly for measures of socioeconomic status: young women with no education/primary education, and those from the poorest/poorer households showed no decline in pregnancy termination as opposed to those who were educated or were from wealthier households. The observed trend in pregnancy termination mirrored the trends in contraceptive use, and age at sexual debut, which were found to be significant factors associated with pregnancy termination in the multivariable model. The declining trend in pregnancy termination persisted especially from 2003 to 2013 after individual and contextual factors were controlled for. One potential explanation for these observed declining trends in termination could be due to the impact of the nationwide introduction of the school-based Family Life and HIV Education (FLHE) curriculum in 2003, which was designed amongst other things to provide young people with sexual health literacy skills. Recent evidence shows that in states where the FLHE was effectively implemented, an improvement in sexual health knowledge of youth was found [38]. However, overall, implementation of this programme has dwindled in recent years due to limited continued financial and technical support from government agencies [38]. Moreover, in some regions the FLHE has been fraught with setbacks as individual states can modify the content of the curriculum coupled with the minimal acceptance of sexuality education particularly in regions with highly conservative religious and cultural values [39, 40]. The sub-optimal implementation may be a factor contributing to the increase in early sexual initiation and pregnancy termination we observed in the data from 2013 to 2018 [32]. The declining trend between 2003 and 2013 we found, albeit with lower percentages, is similar to another study using DHS data for Nigeria but limited to married women of a wider age range (15–49 years) [13].

Surprisingly, we found a significant decline in contraceptive use from 2003 to 2018 for 15–24 year-old women. This important finding has not been evident in previous studies that aggregated data for a wider age range of women (15–49 years) in Nigeria [32], perhaps due to an ecological fallacy [13, 14, 16, 17]. This calls into question whether the current National Reproductive Health Policy and Strategy to achieve Quality Reproductive Health and Sexual Health for All Nigerians including the provision of free family planning services in public facilities [41] has benefited all women of reproductive age in Nigeria. Our findings indicate that 15–24 year-old women are still being left behind on reproductive health matters despite increasing global attention to prioritising their health.

Another interesting finding was the influence of contextual level factors on pregnancy termination. Although the majority of the variation was at the individual level, significant variation in pregnancy termination was found between women aged 15–24 years across communities and states. While some community and state-level variables were not significantly associated with pregnancy termination, contraceptive prevalence at community level, which we derived from the individual-level variable ‘contraceptive use’ and then used as a proxy for reproductive health service accessibility within a community, was strongly positively associated with pregnancy termination. This suggests that communities with higher levels of reproductive health services, indicated by higher prevalence of contraceptive use, are linked to higher prevalence of pregnancy termination. This may indicate that despite availability of reproductive health services and contraceptives, factors such as pressure to have children and stigma surrounding non-marital sexual activity may hinder accessing them [42]. Interventions to discourage early marriage and dispel misconceptions and stigmatising attitudes towards contraceptive use such as scientifically accurate Comprehensive Sexuality Education (CSE) could help overcome these barriers and should be encouraged [18, 42]. However, these results contradict the findings of a previous study in Nigeria which found that residing in a community with contraceptive use at levels above the median for the community was associated with a lower likelihood of terminating pregnancy [20]. The disparity in the findings could again be attributable to the fact that the previous study [20] focused on a wider age range of women (15–49 years). The integration of a wider age range of women in the study may have influenced the results as evidence has shown that older women have more contraceptive utilisation rate compared to younger women [12, 43].

Furthermore, at the individual level, we found that pregnancy termination was higher among women aged 20–24 than those aged 15–19 after controlling for confounding factors. This is not surprising as the NDHS report in 2018 revealed that the median age at first sexual intercourse is 17.2 years for women of reproductive age in Nigeria [32]; meaning that older women are more likely to be sexually active or exposed than their younger counterparts, which predisposes them to unwanted pregnancy, leading to abortions in many cases [44, 45]. The higher risk of pregnancy termination among older women persisted, even after the age of sexual debut was controlled for. It is possible that younger women are less likely to report or seek abortion services due to cultural, socio-economic and institutional barriers [42, 44]. Several other studies have reported similar findings [13, 15, 33].

Marital status was found to be a strong predictor of pregnancy termination. Currently married women aged 15–24 years, those living with a partner or previously married and not living with a partner were more likely to terminate pregnancy than never-married women. This could be linked to social desirability bias as never-married 15–24 year old women may be reluctant to report pregnancy termination due to social stigma surrounding non-marital sexual activity or use of contraceptive [46]. However, this is inconsistent with the findings of previous school-based studies in Nigeria [16, 18] and facility-based studies among older women in Ethiopia [23], Burkina Faso [47] and Ghana [22], which found that unmarried youth are more likely to terminate a pregnancy than their married counterparts. The conflicting findings could be due to the difference how pregnancy termination was defined. In this study it was defined as any pregnancy that resulted in a miscarriage, abortion or stillbirth, which may not accurately reflect the main outcome of interest (induced abortion) [48]. While the school-based and facility-based studies measured only abortion. Although evidence from the DHS methodological report shows that only 2–5% of women who reported their pregnancy ending in miscarriage during a face-to-face interview changed their responses to induced abortion in a self-administered questionnaire [49].

Also, the results of this study revealed that 15–24 year-old women from both Igbo and Yoruba ethnic groups (predominantly in the South) have a lower tendency for pregnancy termination than those from Hausa ethnic group (predominantly in the North). The states with the highest risk of pregnancy termination are predominantly in the North rather than the South. This could conceivably be attributable to the disparity in the level of education, rates of early marriage, and cultural norms/beliefs across different ethnic groups in Nigeria [50]. For example, the average age at marriage for most girls in Northern Nigeria is 15 years compared with a median age of 24 years in the Southern regions of the country, Girls in the Southern regions are more likely to access formal education, while in the Northern regions, girls are less likely to access formal education and, consequently, experience sexual initiation at earlier ages [51‐53]. It is also worth stressing that maternal mortality and under-five mortality rates in Nigeria vary considerably with some Northern states reporting nearly 50% more deaths for both indicators than the national average [31, 54]. Furthermore, the North-South disparity in education supports our findings that young women educated to primary level and above are less likely to terminate a pregnancy than their uneducated counterparts. Young women who are educated are more likely to have access to information and available services and possibly, delay childbearing and marry later than those with no education. These findings are consistent with the findings of other studies [8, 15, 22, 24]. Also, in Ethiopia, evidence has shown that women with higher education were less likely to have induced abortion [55]. Lack of education and early sexual initiation/exposure, without doubt, expose young women to unintended pregnancy; leading to pregnancy termination [16].

This study provides insight into the trends and individual/contextual level predictors of pregnancy termination among women aged 15–24 years in Nigeria. Although most predictors of pregnancy termination occurred at the individual level, community and state level factors also predisposed women aged 15–24 years to terminate pregnancy. While there was a general decline in pregnancy termination among women aged 15–24 years in Nigeria, those with lower socioeconomic status may not have benefited from the current policy and programmes to the same extent as women of higher status. Consideration of whether a shift in policy direction and service provision is required, and these findings also highlights the need for further research to understand why the available services are not benefitting all women of reproductive age. The study suggests the need to shift from the current one size fits all service provision to targeted and tailored services to meet the SRH health needs of young women. Integrating an innovative community-based health programme such as the Health Extension Program (HEP) into the existing services to expand access to SRH services may be a viable option. The findings show the need for multifaceted programs to address the influence of socio-cultural norms and contextual factors that influence pregnancy termination among young women in Nigeria. Policy interventions such as scientifically accurate Comprehensive Sexuality Education to delay early sexual debut and build agency to use contraception among young women especially those with no education, from the Hausa ethnic group and who reside in rural communities should be encouraged. This could reduce poor maternal health outcomes especially in Northern Nigeria with highly conservative religious and cultural values. Together these could make a positive impact on the SDG target to reduce maternal mortality.