December 2014 Unintended Pregnancy and Induced Abortion In Burkina Faso: Causes and Consequences Akinrinola Bankole, Rubina Hussain, Gilda Sedgh, Clémentine Rossier, Idrissa Kaboré a nd Georges Guiella English translation of Grossesse non désirée et avortement provoqué au Burkina Faso: causes et conséquences, 2013 This report was written by Akinrinola Bankole, Rubina Hussain and Gilda Sedgh of the Guttmacher Institute; and by Clémentine Rossier, Idrissa Kaboré and Georges Guiella of the Institut Supérieur des Sciences de la Population (ISSP Université de Ouagadougou). Peter Doskoch edited the report, and Kathleen Randall supervised its layout and production; both are at the Guttmacher Institute. The authors thank Patricia Donovan, Jessica Malter, Susheela Singh and Gustavo Suarez, all of the Guttmacher Institute, for providing assistance at various stages of the report’s preparation. They also appreciate the valuable input of the following external reviewers: Zakari Congo, GIZ; Jean Christophe. Fotso, African Population and Health Research Center; Patrick Ilboudo, University of Oslo; Jean-Francois Kobiané, ISSP; Thomas Le Grand and Afiwa N’Bouke, University of Montreal; Boureihiman Ouédraogo, L'Association Burkinabè pour le Bien-Être Familial; Ramatou Ouédraogo, Institue de Recherche pour le Developpmént; Hantamalala Rafalimanana, United Nations Department of Economic and Social Affairs; and Danielle Yugbare, Institut de Recherche en Sciences de la Santé. The report draws on data from three surveys conducted in 2009: the Health Facilities Survey (HFS), the Community-Based Survey (CBS) and the Health Professionals Survey (HPS). Idrissa Kaboré, Clémentine Rossier Rossier, Gilda Sedgh and Akinrinola Bankole were the co- investigators for these surveys and were responsible for their overall design and implementation; they were also responsible for data analysis, for which they received valuable support from Rubina Hussain and Suzette Audam. Romaric Aristide Bado, Sylvie D. Marie-Jeanne Goumbre and Abella Kaboré provided support in training interviewers and Blandine Thiéba/Bonané provided advisory support. Idrissa Kaboré, Salamata Ouédraogo and Sié Néha supervised fieldwork for the HFS; Arsène Sanou, Soumaila Coulibaly, Zakaria Gansané, Nazaire Franck Garanet, Tiéba Millogo, Solange Kontogom and Dénis Kontogom served as HFS interviewers. Fieldwork for the CBS was supervised by Pascaline P. Yaméogo/Ouédraogo, Flora Kalmogo, Fatima Sawadogo, Habibou Meda, Maria G Kantiono, Armelle P. Coulidiaty, Fatimata Sanogo, Assata Belem/Diabaté; the survey was fielded by Safiatou Sonde, Safiatou Boly, Rosine G. Coulidiaty, Mamounata Ouédraogo, Marie-Jeanne Sawadogo, Nadège Compaoré, Annabelle A. 2 Coulidiaty, Mamounata Ouédraogo, Marie-Jeanne Sawadogo, Nadège Compaoré, Annabelle A. Palenfo, Vinebare Somé, Solange G. Zeba, Anastasie Bado/Bationo, Bernadette B. Lompo, Sandrine Gnoulla, Roseline M. Millogo, Denise Hien, Ramatou Gouba and Henriette B. Djessana. Finally, interviews for the HPS were conducted by Idrissa Kaboré, Salamata Ouédraogo, Sié Néha, Natacha Mariam Yaméogo/Compaoré, Jocelyne Edoxie Kyélem and Jean Nana. The authors would like to thank the medical and nonmedical experts who participated in the HPS for sharing with us their invaluable knowledge and insights about induced abortion in Burkina Faso. This report was supported by a grant from the Dutch Ministry of Foreign Affairs. In addition, the Guttmacher Institute gratefully acknowledges the general support it receives from individuals and foundations—including major grants from The William and Flora Hewlett Foundation, The David and Lucile Packard Foundation and the Ford Foundation—which undergirds all of its work. 3 Suggested citation: Bankole et al., Unintended Pregnancy and Induced Abortion in Burkina Faso: Causes and Consequences, New York: Guttmacher Institute, 2013. Guttmacher Institute 125 Maiden Lane New York, NY 10038 USA Telephone: 212-248-1111; Fax: 212-248-1951 E-mail: [email protected] 1301 Connecticut Avenue NW, Suite 700 Washington, DC 20036 USA www.guttmacher.org ©2013 Guttmacher Institute, a not‐for‐profit corporation advancing sexual and reproductive health worldwide through research, policy analysis and public education. All rights, including translation into other languages, reserved under the Universal Copyright Convention, the Berne Convention for the Protection of Literary and Artistic Works and the Inter‐ and Pan American Copyright Conventions (Mexico City and Buenos Aires). Rights to translate information contained in this report may be waived. English translation of Grossesse non désirée et avortement provoqué au Burkina Faso: causes et conséquences, ISBN: 978-1-934387-16-0. 4 Executive Summary 6 Chapter 1: Introduction 10 Box: Data Sources 15 Chapter 2: Prevalence and Patterns of Induced Abortion 18 Box: Methodology for estimating abortion incidence 23 Chapter 3: The Practice of Induced Abortion 27 Chapter 4: The Consequences of Unsafe Abortion 32 Chapter 5: Unintended Pregnancy: The Underlying Cause of Unsafe Abortion 37 Chapter 6: Conclusions and Recommendations 44 Box: More Research Is Needed to Fill the Gaps in our Knowledge 50 Appendix Table 1 52 Appendix Table 2 53 Chapter Tables and Figures 56 References 71 5 Executive Summary Induced abortion is permitted in Burkina Faso only to save the life and protect the health of a pregnant woman, or in cases of rape, incest, and severe fetal impairment. As a result, the vast majority of women who end unintended pregnancies do so in secrecy, out of fear of prosecution and to avoid the social stigma that surrounds this practice. Most clandestine abortions are carried out in unsafe conditions that jeopardize women’s health and sometimes their lives. This report presents estimates of the number and rate of induced abortions that occurred in Burkina Faso in 2008 and 2012; reports levels of unintended pregnancy (the major reason that women seek abortions in the first place); and describes some of the adverse consequences of unsafe abortion for women, their families and society. The incidence of abortion • Using findings from three national surveys, we can now estimate the level of induced abortion in Burkina Faso. In 2008, the rate was 25 pregnancy terminations for every 1,000 women aged 15–49. The rate was 23 per 1,000 in rural areas and 28 per 1,000 in Ouagadougou, but it was highest—42 per 1,000—in urban areas other than Ouagadougou. • The large differences between the country’s urban and rural areas in levels of unintended pregnancy and induced abortion are the result of cultural, ethnic, religious and demographic factors that influence sexual and reproductive behavior and attitudes in the two regions. The importance that couples and social groups place on having large families in an especially important factor. The average desired family size, for example, is 5.9 children in rural areas, compared with 2.8 in Ouagadougou. • One-third of all pregnancies each year in Burkina Faso are unintended, and one-third of unintended pregnancies are ended by abortion. • Women who have induced abortions are not typical of all women of childbearing age. They tend to be younger and better educated than other women, and are more likely than other women to live in urban areas, to be unmarried and to not have any children. 6 The conditions and consequences of unsafe abortion • Between one-half and two-thirds of all women who have abortions go to traditional providers with no special skills or training, or end their own pregnancies, often using dangerous methods. Only about one in seven abortions are carried out by doctors (3%) or trained health assistants (12%); these safe procedures are most frequently obtained by better-off women who live in urban areas. While one-fourth of abortions obtained by these women are performed by a doctor and another one-fourth by a trained health assistant, doctor-assisted pregnancy terminations are almost non-existent among poor rural women, and only one in 11 of their abortions are performed by a trained health assistant. • Four in 10 women who have unsafe abortions are estimated to experience complications that can threaten their health and even their life. While this proportion is lower for better-off urban women (one in four), nearly half of poor rural women who have abortions experience health- related complications. • Almost six in 10 women who go to traditional practitioners and half of those who induce their own abortions are estimated to experience complications, compared with about one in five women who go to midwives, trained male birth attendants or other medical workers, and with only one in 10 women who use a doctor’s services. • Some women who experience complications do not get the postabortion care they need. Nationally, almost four in 10 women with abortion-related complications receive no care; this proportion is highest for poor women living in rural areas and lowest for better-off women living in urban areas, reflecting that postabortion care services are more accessible in urban than in rural areas (as long as women can afford to pay for them). • Half of women receiving postabortion care for complications from unsafe abortions are treated in primary health care facilities. Another one-quarter receive care from a centre médical avec antenne chirurgicale or from an even more basic centre médical. 7 Unintended pregnancy   • Average family size in Burkina Faso is high, although it has declined from 6.9 children per woman in 1993 to 6.0 in 2010. However, average family size in 2010 was smaller in Ouagadougou (3.4 children) than in other urban areas (4.4) or in rural areas (6.7). • The conditions that would allow most women to avoid unintended pregnancies do not currently exist in Burkina Faso. Contraceptive use is very low: In 2010, only 16% of married women of childbearing age were using a contraceptive method. The overall level of contraceptive use has doubled since 1993, when it was 8%, and the use of modern methods tripled during that period. Nevertheless, the low level of contraceptive use in is the main reason for Burkina Faso’s high rate of unintended pregnancy. •Unmet need for contraception is high in Burkina Faso and has been for the past 10 decade. In 1998-1999, 26% of married women aged 15–49 did not want a child soon or ever but were not using any contraceptive method. In 2010, this proportion was virtually unchanged (24%). • Among single but sexually active women in this age group, unmet need is even higher—it was 35% in 1998-1999 and 38% in 2010. Policy implications of the findings • Contraceptive use must increase if more women in Burkina Faso are to be able to avoid becoming pregnant when they do not wish to. A reduction in the level of unintended pregnancy is the major solution to bringing down the country’s current level of unsafe abortion. • Possible strategies to facilitate the wider adoption of modern contraceptive methods in Burkina Faso include the expansion and promotion of family planning programs through the country’s primary health services, and the provision of family planning methods as an essential part of postabortion care. 8 • Policymakers in Burkina Faso should consider lowering the obstacle of high cost that appears to prevent many poor women from obtaining family planning services. In public health clinics, women are charged—albeit at a subsidized price—for contraceptive supplies. • In light of the finding that women who have abortions are disproportionately likely to be young and unmarried, special attention should be given to providing nonjudgmental and accessible family planning services to these groups. • Seven in 10 women of childbearing age in Burkina Faso have had no schooling. It is unlikely that contraceptive use levels will rise substantially in the absence of a concerted national effort to improve educational levels among women. • To reduce levels of severe morbidity and death associated with abortion-related complications, access to high quality postabortion care services needs to be improved. Efforts should be made to subsidize the cost of postabortion care for all complications, irrespective of types of treatment received. Postabortion services should include contraceptive counseling and supplies to help women prevent future unwanted pregnancies.   • Because abortion is legal in Burkina Faso under certain circumstances, efforts should be made to ensure that eligible women have access to safe legal abortions within the limits of the law. All medical students, and all medical practitioners (including midlevel staff) working in hospitals, should be trained to meet this need through the correct use of manual vacuum aspiration—a technique with a very low risk of complications when properly used. 9 Chapter 1. Introduction Burkina Faso, a predominantly rural country whose population of about 17 million inhabitants is growing at a rate of 3.1% a year,1,2 is located in the Sahelian region of Sub-Saharan Africa. In 2006, it had one of the world’s lowest per capita incomes.A The social fabric of the country is grounded in community, ethnic group, lineage and the extended family. In this context, women’s role in childbearing, which ensures continuation of the family and social group, is a particularly important aspect of life.3 However, the centrality of family and a woman’s fecundity coexists with the fact that almost eight in 10 women of childbearing age want to postpone their next birth or stop childbearing altogether (Appendix Table 1), and that one in three pregnancies is unintended (i.e., the woman did not want to be pregnant at all or would have preferred to be pregnant at a different time). On average, women in Burkina Faso are having 6.0 children, but they say they want only 5.2 (Appendix Table 2), indicating that many women are having more children than they desire. The major reason for the high level of unintended pregnancy in Burkina Faso is that the vast majority of women do not use contraceptives—only 15% of married women of childbearing age (15–49) use a modern method.4 Moreover, 24% of married women aged 15–49, and 40% of sexually active unmarried women aged 15–24, do not currently want to get pregnant but are not using any method. For some of these women, particularly those who are unmarried,5,6 induced abortion may play an important (but dangerous) role in their efforts to avoid an unwanted birth. In fact, three in 10 unintended pregnancies in Burkina Faso end in abortion.7 Most of these abortions are performed in secret by traditional or unskilled providers using unsafe methods, because the procedure is legally permitted only on narrow grounds—to save a woman’s life, to protect her physical health, or in cases of rape, incest or severe fetal impairment8—and because the legal requirements for abortion are so cumbersome that few, if any, women are able to meet them.9 Clandestine abortions carried out in unsanitary conditions or by unskilled providers often                                                                                                                 AIn 2011, Burkina Faso was ranked 181st out of 187 countries in Human Development Index scores (source: United Nations Development Program, Human Development Report, New York: Palgrave Macmillan, 2011, Table 1). 10