Incidence of Induced Abortion and Post-Abortion Care in Tanzania

13 Pages·2015·0.56 MB·English

RESEARCHARTICLE
Incidence of Induced Abortion and Post-
Abortion Care in Tanzania
SarahC.Keogh1*,GodfatherKimaro2,ProjestineMuganyizi3,JessePhilbin1,
AmosKahwa2,EstherNgadaya2,AkinrinolaBankole1
1 GuttmacherInstitute,NewYork,UnitedStatesofAmerica,2 NationalInstituteforMedicalResearch
(NIMR),Dar-es-Salaam,Tanzania,3 MuhimbiliUniversityofHealthandAlliedSciences(MUHAS),Dar-es-
Salaam,Tanzania
*[email protected]
Abstract
Background
Tanzaniahasoneofthehighestmaternalmortalityratiosintheworld,andunsafeabortion
OPENACCESS isoneofitsleadingcauses.Yetlittleisknownaboutitsincidence.
Citation:KeoghSC,KimaroG,MuganyiziP,Philbin
J,KahwaA,NgadayaE,etal.(2015)Incidenceof Objectives
InducedAbortionandPost-AbortionCarein
Tanzania.PLoSONE10(9):e0133933.doi:10.1371/ ToprovidethefirsteverestimatesoftheincidenceofunsafeabortioninTanzania,atthe
journal.pone.0133933 nationallevelandforeachofthe8geopoliticalzones(7inMainlandplusZanzibar).
Editor:SharonCameron,NHSlothianandUniversity
ofEdinburgh,UNITEDKINGDOM Methods
Received:April27,2015 Anationallyrepresentativesurveyofhealthfacilitieswasconductedtodeterminethenum-
Accepted:June16,2015 berofinducedabortioncomplicationstreatedinfacilities.Asurveyofexpertsonabortion
wasconductedtoestimatethelikelihoodofwomenexperiencingcomplicationsandobtain-
Published:September11,2015
ingtreatment.Thesesurveyswerecomplementedwithpopulationandfertilitydatatoobtain
Copyright:©2015Keoghetal.Thisisanopen
abortionnumbers,ratesandratios,usingtheAbortionIncidenceComplications
accessarticledistributedunderthetermsofthe
CreativeCommonsAttributionLicense,whichpermits Methodology.
unrestricteduse,distribution,andreproductioninany
medium,providedtheoriginalauthorandsourceare
Results
credited.
InTanzania,womenobtainedjustover405,000inducedabortionsin2013,foranational
DataAvailabilityStatement:Allrelevantdataare
availablefromFigshare:http://dx.doi.org/10.6084/m9. rateof36abortionsper1,000womenage15–49andaratioof21abortionsper100live
figshare.1521553. births.Foreachwomantreatedinafacilityforinducedabortioncomplications,6timesas
Funding:ThisstudywasfundedbytheNetherlands manywomenhadanabortionbutdidnotreceivecare.Abortionratesvarywidelybyzone,
MinistryofForeignAffairs(http://www.government.nl/ from10.7inZanzibarto50.7intheLakezone.
ministries/bz),grantnumber24590;theDepartment
forInternationalDevelopmentoftheUKGovernment
Conclusions
(https://www.gov.uk/government/organisations/
department-for-international-development),grant
Theabortionrateissimilartothatofothercountriesintheregion.Variationsbyzoneare
number203177-101;andtheNorwegianAgencyfor
explainedmainlybydifferencesinfertilityandcontraceptiveprevalence.Measuresto
DevelopmentCooperation(http://www.norad.no/en/
front/),grantnumber1300340.Thefundershadno reducetheincidenceofunsafeabortionandassociatedmaternalmortalityinclude
PLOSONE|DOI:10.1371/journal.pone.0133933 September11,2015 1/13
AbortionIncidenceinTanzania
roleinstudydesign,datacollectionandanalysis, expandingaccesstopost-abortioncareandcontraceptiveservicestopreventunintended
decisiontopublish,orpreparationofthemanuscript. pregnancies.
CompetingInterests:Theauthorshavedeclared
thatnocompetinginterestsexist.
Introduction
Withthe2015MillenniumDevelopmentGoals(MDG)deadlineuponus,countriesareevalu-
atingtheirprogressinreachingtheirtargets.Despiteachievinga55%reductionbetween1990
and2015,TanzaniaisfallingshortofitsMDG5targetofcuttingmaternalmortalitybythree
quarters,andcontinuestohaveoneofthehighestmaternalmortalityratiosintheworld,at
410per100,000livebirths[1].Innationalconsultationsonthepost-2015developmentagenda,
reducingmaternalmortalitywasupheldasoneofthetenkeygoals.Yetthiscannotbeachieved
withoutaddressingoneofitsleadingcauses,unsafeabortion.
Globally,unsafeabortionsaccountforbetween8%and18%ofmaternaldeaths[2,3],and
millionsmorewomensuffernonfatalhealthconsequencesofunsafeabortioneveryyear[4].In
EastAfricaalone,anestimated613,000womenwerehospitalizedforcomplicationsfrom
inducedabortionin2005,or10per1,000womenofreproductiveage.Manymorewomensuf-
fercomplicationsbutdonotaccesscare:worldwide,anestimatedonethirdofthe8.5million
womenwithabortioncomplicationsarenottreatedinfacilities[4].Globalandregionalesti-
matesofabortionincidenceindicatethatabortionsarenolesscommon,andmuchmorelikely
tobeunsafe,insettingswithrestrictivelawsthaninsettingswithliberallaws[5].Moreover,in
countrieswhereabortionisillegalorhighlyrestricted,statisticsareoftennotavailable,making
itdifficulttoascertainthemagnitudeofunsafeabortionanditsconsequences.InTanzania,no
nationallyrepresentativestudieshavebeenconductedtodeterminetheincidenceofabortion.
However,accordingtoregionalestimates,in2008therewere2.4millionunsafeabortions,or
36perthousandwomenofreproductiveage,inEastAfrica[6].
ThelittleevidenceavailableforTanzania,mainlyfromsmall-scalehospital-basedstudies,
pointstoinducedabortionbeingwidespread,largelyunsafe,andassociatedwithhighmorbid-
ityandmortality.Accordingtothesestudies,justover60%ofwomenadmittedtohospitalfor
amiscarriagehadinfacthadaninducedabortion[7–9].Unsafeabortionsaccountedfor38%
ofhospitalizationsforobstetriccomplicationsinonestudy[10],androughlyaquarterof
maternaldeathsintwootherhospitalstudies[11,12].
ThelegalstatusofabortionisambiguousinTanzania:thePenalCodeisbroadlyunderstood
toauthorizeabortiontosaveawoman’slife,butremainsunclearonitslegalitytopreservethe
woman’sphysicalormentalhealth[13].AlthoughTanzaniaratifiedthe2007AfricanCharter’s
ProtocolontheRightsofWomeninAfricaallowingabortionincasesofrape,incestorifthe
pregnancyendangersthewoman’slife,mentalorphysicalhealthorthelifeofthefetus[14],
thegovernmenthasnotincorporatedtheseprovisionsintoitsnationallaw.Thereisalsoambi-
guityoverwhetherauthorizationisneededfrommorethanoneproviderbeforeperformingan
abortion[13,15].Thislackofclaritycreatesconfusionamongsthealthcareprovidersand
womenalike,andfearofprosecutiononbothsidespusheswomentoseekclandestineabor-
tionsthatareoftenunsafe.Asfewpeoplearewillingtotalkaboutabortion,verylittleinforma-
tionisavailableonthescopeoftheproblem.Thisperpetuatestheinvisibilityofunsafe
abortion,resultinginthegovernmentgivingitlittlepriorityinpolicydecisions,servicedelivery
orprogramimplementation.
Inrecentyears,theTanzaniangovernmenthasshownstrongcommitmenttoreducing
maternalmortalityandmorbiditythroughinitiativessuchastheNationalRoadMapStrategic
PlantoAccelerateReductionofMaternal,NewbornandChildDeaths[16],andtheapproval
ofMisoprostolfirstforpostpartumhemorrhagein2007andthenfortreatmentofincomplete
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abortionin2011[17].Buildingonacomprehensivepost-abortioncare(PAC)trainingpro-
gramlaunchedin2000,theTanzanianMinistryofHealthandSocialWelfarehassince2007
beenexpandingPACservicestolowerlevelfacilitiesinanefforttoincreasetheiravailability
throughoutthecountry.However,stillmoreneedstobedonetoensureuniversalaccessto
PAC.Manylowerandmid-levelfacilitiesstilllackequipmentsuchasmanualvacuumaspira-
tionkits[18,19],andmanyhospitaldeathsfollowinganabortioncouldbeavoidedwithade-
quatetrainingandstaffing[12].EffortstoexpandaccesstocomprehensivePACrequiremore
evidenceonthescaleofinducedabortioninTanzania,bothatthenationalandsub-national
level,todeterminewhereinvestmentsaremostneededandhowtoallocateresources.
Reducingunsafeabortionalsoimpliestacklingitsrootcause,unintendedpregnancy.The
wantedtotalfertilityrate(TFR),at4.7childrenperwoman,remainssignificantlylowerthan
theactualTFRof5.4,dueinparttolowcontraceptiveuse(25%amongstmarriedwomen)
[20].In2010,26%ofbirthswereunplanned,representingaslightincreasesince2005.Estimat-
ingthemagnitudeofunintendedpregnancy,crucialforinformingreproductivehealthpro-
gramsandcontraceptiveservicedelivery,requiresdataonabortionincidence.
Thispaperpresentsfindingsfromthefirst-evernationallyrepresentativestudymeasuring
theincidenceofabortioninTanzania.Thisstudyrespondstotheexpressneedsofin-country
andinternationaladvocatesworkingtopromotereproductivehealthinTanzania,whohave
highlightedthedearthofevidenceonabortionasamajorbarriertoinformeddebateonthe
issue.Thispaperprovidesnationalandzonalestimatesoftheincidenceofinducedabortion,
abortioncomplicationsandunintendedpregnancy,withaviewtoinformingstrategiesto
reducethecountry’shighmaternalmortality.
MaterialsandMethods
Incountrieswhereabortionislegallyrestrictedandstigmatized,theapproachtoestimating
abortionincidencemustoftenbeindirect.Toovercomelimitationsintheavailabilityofofficial
statistics,theGuttmacherInstitutehasdevelopedtheAbortionIncidenceComplicationsMeth-
odology(AICM)[21]toestimateabortionincidenceinthesesettings.TheAICMhasbeen
appliedinabout25countriesworldwide,includingSenegal[22],Ethiopia[23],BurkinaFaso
[24],Uganda[25],Rwanda[26],Kenya[27],andMalawi[28]insub-SaharanAfrica.Themeth-
odologyinvolvesestimatingthenumberofinducedabortioncomplicationstreatedinfacilities,
andusingexpertopinionstoestimate,foreachcomplicationthatreachesafacility,howmany
inducedabortionsareoccurringwithoutcomplicationsorwithuntreatedcomplications.
Theprimarydataforthisstudycomefromtwosurveysconductedbytheauthors:aHealth
FacilitiesSurvey(HFS)tomeasurethenumberofabortioncomplicationstreatedinhealth
facilities,andaHealthProfessionalsSurvey(HPS)toestimatethelikelihoodofwomen
experiencingabortioncomplicationsandofobtainingtreatmentatahealthfacility.Thestudy
designandprotocolsareadaptedfrompreviousapplicationsofthemethodology,toberelevant
totheTanzaniancontext.DatacollectionwasledbytheTanzanianNationalInstituteforMed-
icalResearch(NIMR)inDar-es-Salaam,withtechnicalsupportfromMuhimbiliUniversityof
HealthandAlliedSciences(MUHAS)andtheGuttmacherInstitute.Thedatafromthetwo
surveyswereusedtogetherwithestimatesofbirths,unintendedbirths,andwomenofrepro-
ductiveage,compiledfromthe2010TanzaniaDemographicandHealthSurvey[20]andthe
2012Tanzaniannationalcensus[29]andprojectedto2013usingTanzania'sintercensalannual
growthrate.Estimateswereobtainedatthenationallevel,aswellasforeachofthe8geopoliti-
calzonesofTanzania(7inmainland,plusthesemi-autonomousZanzibararchipelago).
FieldworkwasconductedfromJulytoSeptember2013.Interviewerswererecentmedical
graduateswithpreviousexperienceadministeringsurveys.FortheHFS,ateamoffour
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interviewerswasassignedtoeachzone,andmembersoftheresearchteamatNIMRactedas
teamleads.TheseteamleadsalsoconductedtheHPSinterviews,astheHPSquestionnaire
requiredmoreskillandexperience,andmanyrespondentswereseniorprofessionals.Allinter-
viewersandteamleadsunderwentaweek-longtraininginDar-es-Salaam.Bothsurveyswere
pilotedin5facilitieswhichwerenotpartofthefinalsample.
HeathFacilitiesSurvey
ThesamplingframeconsistedoftheMinistryofHealth’smostrecentlistofallhealthfacilities
(publicandprivate)consideredlikelytoprovidepost-abortioncare(PAC).Aseparatelistofall
publicandprivatefacilitieswasobtainedfromtheZanzibarMinistryofHealth.Facilitiesthat
didnotprovideprimarycare,thatwerespecializedinnon-reproductiveservices,orthatother-
wiselackedthecapacitytoprovidePAC(asforsomedispensaries),wereexcludedfromthe
samplingframe.Toensurethatthelistwasuptodate,alldistrictmedicalofficersinthecoun-
trywerecontactedtoconfirmthatallhealthfacilitiesintheirdistrictwereincludedinthelist,
andtodeterminewhichfacilitieswereequippedtoprovidePAC.
ThefinalsamplingframeoffacilitieslikelytoprovidePACincluded952facilities,ofwhich
5(0.5%)wereconsultanthospitals,20(2.1%)regionalhospitals,224(23.6%)sub-regionalhos-
pitals(districthospitalsorotherhospitals),526(55.2%)healthcentersand177(18.6%)dispen-
saries(Table1).AlthoughtherewerethousandsofdispensariesinTanzania,only177provided
orwereexpectedtoprovidePACatthetimeweconductedthestudy.Thenomenclaturefor
facilitiesinZanzibarisslightlydifferent,withPrimaryHealthCareCenters(PHCCs)beingthe
equivalentofhealthcenters,andPrimaryHealthCareUnits(PHCUs)beingtheequivalentof
dispensaries.WithinPHCUs,someprovideonlybasicprimarycareservices(PHCU),while
othersareequippedtoprovideawiderrangeofservicesincludingPAC(PHCU+).PHCCsand
PHCU+werecombinedwithhealthcentersanddispensariesrespectivelyinthenationallevel
analyses.
Thesamplingframewasstratifiedbyfacilitylevelwithineachzone,toensurethattheesti-
matesofabortionincidencewererepresentativeatboththenationalandzonallevels.Within
eachzone,weselected100%ofconsultantandregionalhospitals,66%ofnon-regionalhospi-
tals,45%ofhealthcenters,and44%ofdispensariesequippedtoofferPAC,resultinginatotal
of487healthfacilitiesintheinitialsample.Ofthese,481agreedtoparticipateinthesurvey
(Table1).Tominimizerefusals,lettersfromtheMinistryofHealthintroducingandauthoriz-
ingthestudyweresenttoallfacilitiesinadvanceofthefieldwork,andfacilityin-chargeswere
Table1. Characteristicsofsample,byfacilitytype,HealthFacilitiesSurvey,Tanzania2013.
Numberoffacilitieslikelyproviding Number Number NumberprovidingPACbyownership
PAC selected responded
(sampling (response
proportion) rate)
Public Private Faith-based Total
organization
Facilitylevel
Consultanthospital 5 5 (100%) 5 (100%) 3 0 2 5
Regionalhospital 20 20 (100%) 20 (100%) 18 0 2 20
Non-regional 224 149 (66%) 144 (97%) 60 23 59 142
hospital
Healthcenter 526 235 (45%) 234 (100%) 181 9 18 208
Dispensary 177 78 (44%) 78 (100%) 68 2 3 73
Total 952 487 (51%) 481 (99%) 330 34 84 448
doi:10.1371/journal.pone.0133933.t001
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contactedtoinformthemabouttheupcomingsurvey.Ofthefacilitiesthatresponded,448
(93%)actuallyprovidedPACservices.MosthealthfacilitiesinTanzaniaaregovernment-
owned,andthisisreflectedinthesample:only26%ofallfacilities(mostlyhospitals)werepri-
vateorfaith-based(Table1).
Astructuredquestionnairewasadministeredbyaninterviewertothemostqualifiedstaff
memberorthepersoninchargeofprovidingPACineachfacility,typicallythechiefofthe
ObstetricsandGynecologydepartmentinlargerfacilities,andthefacilityheadinhealthcen-
tersordispensaries.Respondentswereaskedwhethertheirfacilitiesprovidetreatmentfor
abortioncomplications(frombothspontaneousandinducedabortion),andifso,toestimate
thenumberofPACpatientstreatedasoutpatientsandinpatients,inanaveragemonthandthe
pastmonth.Specifyingtwotimeframesincreasesthelikelihoodofcapturingvariationfrom
monthtomonth.Thesetwonumbersweresubsequentlyaveragedandmultipliedby12topro-
duceanestimateforthe2013calendaryear.
HealthProfessionalsSurvey
TheHealthProfessionalsSurveyinterviewedapurposivesampleof202expertsknowledgeable
aboutabortionprovisioninTanzania.Thesamplewascreatedthroughconsultationwitha
broadnetworkofcolleaguesengagedinresearch,policy,communityandregional-levelpublic
healthprograms,whichaimedtoidentifytheindividualsmostknowledgeableabouttheprovi-
sionofabortionatthenationallevel,aswellasineachzone.Theexpertscamefromawide
rangeofprofessions.Forty-sixpercentwerehealthprofessionals,includingobstetricians/gyne-
cologists,midwivesandnursesfromthepublicandprivatesector,aswellasasizeablepropor-
tionofnon-formallytrainedhealthworkerssuchascommunityhealthworkers,traditional
birthattendantsandtraditionalhealers(15%oftotalsample).Theremaining54%ofthesam-
plewascomposedofresearchers,reproductivehealthadvocates,non-governmentalorganiza-
tion(NGO)andwomen’sgroups’representatives,lawyers,journalistsworkingonreproductive
healthissues,programmanagersandpolicymakers,communityleaders,andyouthleaders.
Respondentsweredistributedequallybetweenthe8zones.Particulareffortwasmadetoensure
thattherewassufficientrepresentationofexpertswithknowledgeofruralareas.About36%of
respondentshadworkedatleast6monthsinruralareasduringthelast5years.All202pro-
spectiverespondentsagreedtoparticipate.Questionnairessoughtinformationonthepropor-
tionofwomenwhoexperienceacomplicationfromaninducedabortion,andtheproportion
likelytoreceivecareinafacilityshouldtheyexperienceacomplication,separatelyforrural
andurban,poorandnon-poorwomen.
Ethicsstatement
EthicalapprovalwasobtainedfromGuttmacher’sInstitutionalReviewBoard,theTanzanian
MedicalResearchCoordinatingCommittee,andZanzibarMedicalResearchCouncil.All
respondentsinbothsurveysgavewritteninformedconsentbeforebeinginterviewed.
Dataanalysis
FromtheHealthFacilitiesSurvey(HFS),weobtainedestimatesofthenumberofpatients
treatedforabortioncomplicationsnationallyandforeachzone.Toensureestimateswererep-
resentativeatthenationalandzonallevels,weightswereassignedtoeachfacilitybyleveland
zone,basedontheirselectionprobabilityandonnon-responserates.Toavoiddouble-counting
patientstreatedatonefacilitylevelthenreferredtoanotherforadditionaltreatment,wesub-
tracted75%ofpatientstreatedthenreferredateachfacilitylevelfromthenumbertreatedat
thenextlevel,basedonaninformedestimatethatroughly75%ofpatientsreferredforobstetric
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complicationsfollowupinTanzania(urbanandruralsettingscombined)[30].Duetothesim-
ilaritybetweencomplicationsfrominducedandspontaneousabortions,andthepossibilityof
patientsand/orprovidersmisreportinginducedabortionsasspontaneousforfearoflegalsanc-
tions,itisdifficulttoobtainaccurateestimatesofcomplicationssolelyfrominducedabortions
atthefacilitylevel.Thereforethesurveyrecordedthenumberofcomplicationsfromallabor-
tions(bothinducedandspontaneous),fromwhichwethensubtractedthoseduetospontane-
ousabortion,toobtainthenumberofinducedabortioncomplicationstreatedinhealth
facilities,nationallyandbyzone[21].Thenumberofspontaneousabortioncomplications
treatedinfacilitieswascalculatedusingindirectestimationtechniques.Assumingthatonly
secondtrimesterspontaneousabortionsrequirecare,andthattheseequal3.41%oflivebirths
basedonclinicalstudies[31,32],weobtainedthenumberofspontaneousabortionsthatwould
needtreatmentnationallyandbyzone.However,notallspontaneousabortionsrequiringcare
willactuallybetreatedinfacilitiesforanumberofreasons,includinglackofaccessoraprefer-
encetoseektreatmentfromuntrainedproviders.Toestimatetheproportionofspontaneous
abortionsneedingcarethatwereactuallytreatedinhealthfacilitiesineachzone,weassume
thatthisproportionissimilartotheproportionofrecentbirthsthatwereeitherdeliveredin
healthfacilitiesornotdeliveredinhealthfacilitiesbecauseitwasnotcustomaryornecessary.
The2010DHSestimatewasprojectedto2013basedonpercentchangebetweenthelasttwo
DHSrounds)andadjustedittoincludewomenwhowouldhavedeliveredinhealthfacilities
haditbeencustomaryornecessaryusingDHSinformationonwomen’sreasonsfornotdeliv-
eringatfacilities.
Butnotallinducedabortionswillresultintreatedcomplications.Somewillbedonewithout
complications,whileotherswillendincomplicationsthatarenottreatedinhealthfacilitiesfor
variousreasons,includinglackofaccess,fearofprosecution,preferencetoseektreatmentfrom
untrainedprovidersorevendeath.TheHPSprovidedestimatesoftheprobabilityofexperienc-
inginducedabortioncomplicationsbytypeofabortionprovider,andtheprobabilityofseeking
careforcomplications,forfourwealth-residencegroups:urbanpoor,urbannon-poor,rural
poorandruralnon-poor.Multiplyingthesetwosetsofprobabilities,weobtainedthepropor-
tionofallinducedabortionsthatresultedincomplicationsthatweretreated,foreachofthe
fourgroups.Thesewerethencombinedintoasingleweightedproportionbasedonthepopula-
tiondistributionofthefourgroups(fromtheDHS),nationallyandseparatelyforeachzone.
Theinverseofthisproportionisthemultiplierorinflationfactorneededtoaccountfor
inducedabortionswhichwereeitherwithoutcomplicationsorwithcomplicationsthatwere
nottreatedinafacility.Thismultiplierpresentsthenumberofsuchabortionsforevery
inducedabortioncomplicationtreatedinafacility.Thehigherthemultiplier,thehigherthe
proportionofabortionsthatiseitheruncomplicatedorwithuntreatedcomplications[21].We
multipliedthisfactorbythenumberofinducedabortioncomplicationstreatedinhealthfacili-
ties(fromtheHFS),toobtainthetotalnumberofinducedabortionsnationallyandforeach
zonein2013[21].Thenumberofinducedabortionsisexpressedper1,000womenaged15–49
(abortionrate)andper100livebirths(abortionratio).
Wealsocalculatedthenumberandratesoftotalpregnanciesandunintendedpregnancies
nationallyandforeachzone.Thetotalnumberofpregnanciesiscalculatedasthesumofthe
annualnumbersofinducedabortions,birthsandmiscarriages(estimatedas20%oflivebirths
plus10%ofinducedabortions[31,33]).Expressingthisnumberper1,000womenofreproduc-
tiveagegivesthepregnancyrateforeachzoneandnationally.Thetotalnumberofunintended
pregnanciesisthesumofinducedabortions,unplannedbirths(obtainedbymultiplyingthe
proportionofrecentbirthsthatwereunintendedintheDHSbythetotalnumberofbirthsin
2013),andunplannedpregnanciesresultinginmiscarriage(equalto20%ofunplannedbirths
plus10%ofinducedabortions,assumingthatallinducedabortionsresultfromunintended
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pregnancies[33]).Thisestimatecanbeexpressedper1,000womenofreproductiveageto
obtaintheunintendedpregnancyrate.
Results
Abortiontreatmentrates,incidenceratesandratios
Therearejustunder8facilitiesprovidingPACper100,000womeninTanzania(Table2).
AccessibilityofPACvariesacrossthecountry:Zanzibaristhebestservedwithover10facilities
per100,000women,whiletheEasternzonehadthelowestdensity,withunder6facilitiesper
100,000women.ConsultantandregionalhospitalstreatthemajorityofTanzania’spost-abor-
tioncarecases.In2013,onaverage,eachconsultantandregionalhospitaltreatedabout1,140
and710PACcases,respectively,comparedtoaverageannualcaseloadsofabout250ateach
sub-regionalhospital,70ateachhealthcenter,andlessthan30ateachdispensary.Overall,
about66,640womenweretreatedinfacilitiesforcomplicationsfrominducedabortions,ata
rateof5.9per1,000womenage15–49(Table3).Thisratevariedconsiderablybyzone,froma
lowof2.9inducedabortioncasestreatedper1,000womenintheEasternzonetoahighof7.9
per1,000intheSouthernHighlands.
Womenobtainedapproximately405,000inducedabortionsinTanzaniain2013,fora
nationalrateof36abortionsper1,000womenage15–49andaratioof21abortionsper100live
births(Table4).Thenationalmultiplieris6.08,meaningthatforeachwomantreatedinafacil-
ityforinducedabortioncomplications,6timesasmanywomenhadanabortionbutdidnot
receivePAC–eitherbecausetheydidnotexperiencecomplications,orbecausetheircomplica-
tionswentuntreated.Bothabortionincidenceratesandmultipliersvarywidelybyzone.Zanzi-
barhasthelowestmultiplier,3.6,andthelowestabortionrate,10.7(Table4).TheLakezone
hasbyfarthehighestabortionrate,51,whiletheEasternzonehasthehighestmultiplier,8.
The95%confidenceintervalforthenationalnumberofinducedabortioncomplications
treatedinfacilitieswasmultipliedbythenationalmultipliertoobtainlowerandupperbounds
forthenumberofabortionsandnationalabortionrate.Thelowerandupperboundsforthe
nationalabortionratewere25and47(Table4).Becausethenumberoffacilitiesineachzone
Table2. NumberoffacilitiesprovidingPAC,andaveragecaseload,byzoneandnationally,Tanzania2013.
Central Eastern Lake Northern Southern SouthernHighlands Western Zanzibar Total(national)
NumberoffacilitiesprovidingPACa
Total 65 134 199 155 64 104 121 37 877
Per100,000women 8.2 5.8 8.4 9.2 7.2 7.1 8.8 10.5 7.8
AnnualaveragePACcaseloadbyfacilitytype
Level
Consultanthospital N/A 174 1,620 330 N/A 2,640 N/A 930 1,139
Regionalhospital 912 531 1,144 580 442 670 720 N/A 707
Sub-regionalhospital 216 216 410 216 166 173 355 170 247
Healthcenter 42 101 91 60 48 93 68 19 72
Dispensary N/A 38 18 20 N/A N/A 35 20 26
Ownership
Public 174 137 130 126 132 236 99 107 140
Faith-basedorganization 103 230 485 210 120 131 436 12 254
Private N/A 156 84 99 N/A 89 118 N/A 128
aAdjustedtodiscountfacilities"likelyprovidingPAC"thatdonotinfactprovidePAC.Facilitiesintheinitialsamplethatwerefounduponsurveyingtonot
providePACwereproportionallysubtractedfromtheuniverseoffacilitieslikelyprovidingPAC,separatelyforeachzone.
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Table3. Numberofwomentreatedforabortioncomplications,byzoneandnationally,Tanzania,2013.
Women Womentreatedfor Womentreatedfor Womentreatedforinduced Rateoftreatmentforinduced
aged15–49 abortioncomplications miscarriagesinfacilities abortionsinfacilities abortioncomplications
Zone
Central 789,106 6,772 3,024 3,748 4.7
Eastern 2,289,015 16,106 9,398 6,708 2.9
Lake 2,382,254 28,408 10,354 18,054 7.6
Northern 1,683,655 18,009 5,106 12,903 7.7
Southern 876,956 6,343 2,661 3,682 4.2
Southern 1,470,700 16,079 4,444 11,635 7.9
Highlands
Western 1,370,458 13,986 5,116 8,870 6.5
Zanzibar 348,499 2,305 1,264 1,041 3.0
Total 11,210,642 108,008 41,367 66,641 5.9
(national)
doi:10.1371/journal.pone.0133933.t003
wastoolowtoobtainrobustconfidenceintervalsofPACcases,weonlypresentthisinforma-
tionatthenationallevel.
Unintendedpregnancyrate
Thenumberofinducedabortionswasusedtocalculatepregnancyratesforeachzoneand
nationally(Table5).ThepregnancyrateforTanzaniais245per1,000womenofreproductive
age,withwidevariationsbyzonefrom184intheEasternzoneto318intheWesternzone.The
unintendedpregnancyrateissomewhatlowerat92.7per1,000womenofreproductiveage,
rangingfrom61.5inZanzibarto123.8intheLakezone.
Thedataonunintendedpregnancies,births,abortions,andmiscarriageswereusedtoesti-
matethedistributionofpregnanciesbyoutcomeandintentionstatus.Inthecountryasa
whole,15%ofpregnanciesendedinabortions,52%inintendedbirths,18%inunintended
births,and15%inmiscarriages(Fig1).Thesedistributionsvaryacrosszones;forexample,the
percentageoftotalpregnanciesendinginabortionrangesfrom6%inZanzibarto18%in
SouthernHighlands.
Table4. Estimatesofinducedabortion,byzoneandnationally,Tanzania,2013.
Estimatedtotalnumberofinduced Abortionrate(per1,000women Abortionratio(per100live Multiplier
abortions 15–49) births)
Zone
Central 21,923 27.8 13.6 5.85
Eastern 54,655 23.9 18.2 8.15
Lake 120,857 50.7 25.0 6.69
Northern 51,965 30.9 22.2 4.03
Southern 23,465 26.8 19.2 6.37
Southern 68,910 46.9 27.0 5.92
Highlands
Western 59,592 43.5 19.3 6.72
Zanzibar 3,714 10.7 7.1 3.57
Total(national) 405,081 36.1 21.1 6.08
Lowerbound 282,588 25.2 14.7
Upperbound 527,573 47.1 27.5
doi:10.1371/journal.pone.0133933.t004
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Table5. Unintendedbirths,pregnancies,andpregnancyrate,byzoneandnationally,Tanzania2013.
Total Wanted %women %women %sexually %sexually %women Total Total Pregnancy Unintended
Fertility Total 15–49 15–49who activewomen active withunmet preg- unintended rate(per pregnancy
Ratea Fertility sexually havenever usingany women needfor nanciesb preg- 1,000 rate(per
Ratea activein hadsexual contraceptive using contra- nanciesc women) 1,000
last4 intercoursea methoda modern ceptiona women)
weeksa methodsa
Zone
Central 6.5 5.7 58.2 13.0 35.4 33.6 26.7 217,645 81,532 275.8 103.3
Eastern 3.9 3.6 55.3 11.3 51.4 41.6 13.0 421,092 160,257 184.0 70.0
Lake 6.3 5.1 62.9 12.3 18.5 16.8 25.1 712,069 295,033 298.9 123.8
Northern 4.6 3.8 54.7 18.0 54.0 44.4 16.1 338,511 116,342 201.1 69.1
Southern 4.4 4.0 61.1 7.7 51.8 39.5 17.1 172,384 62,400 196.6 71.2
Southern 5.4 4.7 56.3 14.7 48.8 36.5 15.1 381,564 116,303 259.4 79.1
Highlands
Western 7.1 6.3 57.5 13.5 24.4 19.3 18.9 435,603 133,992 317.9 97.8
Zanzibar 5.1 4.8 48.5 33.8 19.7 14.5 20.7 66,771 21,408 191.6 61.4
Total 5.4 4.7 55.3 13.8 35.6 29.7 19.1 2,745,637 1,039,001 244.9 92.7
(national)
aObtainedfromthe2010TanzanianDHS
bSumofestimatednumberofabortions(fromthisstudy)andestimatednumberofbirthsandmiscarriages(fromtheDHS).
cSumofestimatednumberofabortions(fromthisstudy)andestimatednumberofunintendedbirthsandmiscarriages(fromtheDHS).
doi:10.1371/journal.pone.0133933.t005
Discussion
The2013abortionrateforTanzania(36abortionsper1,000womenofreproductiveage)isthe
sameasthe2008rateestimatedbyWHOforEastAfricaasawhole[6],suggestingTanzaniais
representativeoftheregion.Thelatestnational-levelestimatesforneighboringcountriesusing
theAICMindicateTanzania’srateislowerthanKenya’s(48per1,000),similartoUganda’s
(37),andhigherthantheratesforEthiopia(23),Rwanda(25)andMalawi(24)[25–28].
AlthoughestimatesforEthiopia,Rwanda,MalawiandUgandaareforwomenaged15–44
ratherthan15–49,therankingsremainunchangedifestimatesusethesamedenominator.
Thewidevariationsbyzoneintheestimatesofabortionincidence,complicationsandtreat-
mentreflectdifferencesinaccesstohealthservices,aswellasdemographicandculturaldiffer-
ences.ThehighestabortionratesandratiosarefoundintheLakeZoneandSouthern
Highlands,whereratesoftreatmentforinducedabortioncomplicationsarealsohighest.Inthe
Lakezone,thehighabortionrateismostlikelyaconsequenceoflowcontraceptiveuse(lowest
inthecountry)andhighunmetneed,whicharealsoresponsibleforthehighestunintended
pregnancyrateinthecountry.Incontrast,intheSouthernHighlandswherecontraceptiveuse
ishighandunmetneedrelativelylow,thehighabortionrateisexplainedbythefactthat
womenaremorelikelytoresorttoabortiontoendanunintendedpregnancythaninother
zones:59%ofunintendedpregnanciesendedinabortioninSouthernHighlands,comparedto
lessthan45%inotherzones.Consequently,theSouthernHighlandshavethelowestpropor-
tionofunintendedpregnanciesendinginbirth,andthelowestrateofunplannedbirths.
Zanzibar’slowabortionincidencerate,at11perthousand,ismainlyduetoithavingthe
lowestunintendedpregnancyrateinthecountry(61perthousand).However,thishasnot
beenachievedthroughhighcontraceptiveuse,sinceZanzibarhasthelowestmodern-method
contraceptiveprevalence(14.5%)andsecondlowestall-methodprevalenceinTanzania.
Instead,unintendedpregnancyratesmaybelowerduetoreducedsexualactivity:Zanzibarhas
thelowestproportionofwomenage15–49whoweresexuallyactiveinthelast4weeks(49%
vs.58%inMainlandoverall)andthehighestproportionofwomenwhohaveneverhadsexual
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AbortionIncidenceinTanzania
Fig1.Distributionofpregnancyoutcomes,nationallyandbyzone,Tanzania2013.InTanzaniain2013,15%ofallpregnanciesendedinabortions,
52%inintendedbirths,18%inunintendedbirths,and15%inmiscarriages.Thedistributionofpregnancyoutcomesvariedacrosszones:intheLakezone,
41%ofpregnancieswereunintended,and17%endedinabortion.Incontrast,inZanzibaronly32%ofpregnancieswereunintended,and6%endedin
abortion.
doi:10.1371/journal.pone.0133933.g001
intercourse(34%vs.13%).WomeninZanzibaralsotendtoinitiatesexualactivitylater(ata
medianageof19.2years)thantheirMainlandcounterparts(medianageof17.4)[20].Zanzibar
being98%Muslim,extramaritalfertilityandsexoutsideofmarriagearetaboo[34],whichmay
contributetoexplainingthesepatterns.Higherproportionsofwomeninpolygynousrelation-
shipsinZanzibar(29%)comparedtotheMainland(21%)mayalsocontributetolowersexual
activitylevels,althoughevidencetosupportthishypothesisislacking.
TheWesternzone,whichhasthehighestpregnancyrate,alsodisplaysthehighestwanted
TFRinthecountry(6.3),andhasrelativelylowcontraceptiveuse.TheWesternzone'sunin-
tendedpregnancyrate,ontheotherhand,isrelativelylowduetohighdesiredfertility.The
lowestpregnancyrateintheEasternZoneisconsistentwiththeobservedlowestdesiredand
actualfertilityandhighestcontraceptiveuseinthecountry.
Theregionaldifferencesintreatmentratesforcomplications,whilepartlyreflectingdiffer-
encesinabortionincidencerates,alsohighlighttheunequaldistributionofPACproviders
throughoutthecountry,withsomeregionsmuchbetterservedthanothers.Thisunderscores
theimportanceofinvestinginPACatalllevelsofthehealthsystem.WhileZanzibarhassuc-
cessfullyexpandeditsPACprogramtoallPrimaryHealthCareUnits(PHCU+),initiativesto
decentralizePACprovisiontolowerlevelfacilitiesinMainlandhavenotyetbeenrolledoutinall
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