literature review on abortion in nigeria pdf

Inequities in the incidence and safety of abortion in Nigeria

Affiliations.

• 1 Population Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.
• 2 Centre for Research, Evaluation Resources and Development, Ile-Ife, Nigeria.
• 3 Department of Community Medicine, University of Ibadan, Ibadan, Oyo, Nigeria.
• PMID: 32133166
• PMCID: PMC7042592
• DOI: 10.1136/bmjgh-2019-001814

Background: We know little about the frequency, correlates and conditions under which women induce abortions in Nigeria. This study seeks to estimate the 1-year induced abortion incidence and proportion of abortions that are unsafe overall and by women's background characteristics using direct and indirect methodologies.

Methods: Data for this study come from a population-based, nationally representative survey of reproductive age women (15-49) in Nigeria. Interviewers asked women to report on the abortion experiences of their closest female confidante and themselves. We adjusted for potential biases in the confidante data. Analyses include estimation of 1-year induced abortion incidence and unsafe abortion, as well as bivariate and multivariate assessment of their correlates.

Results: A total of 11 106 women of reproductive age completed the female survey; they reported on 5772 confidantes. The 1-year abortion incidence for respondents was 29.0 (95% CI 23.3 to 34.8) per 1000 women aged 15-49 while the confidante incidence was 45.8 (95% CI 41.0-50.6). The respondent and confidante abortion incidences revealed similar correlates, with women in their 20s, women with secondary or higher education and women in urban areas being the most likely to have had an abortion in the prior year. The majority of respondent and confidante abortions were the most unsafe (63.4% and 68.6%, respectively). Women aged 15-19, women who had never attended school and the poorest women were significantly more likely to have had the most unsafe abortions.

Conclusion: Results indicate that abortion in Nigeria is a public health concern and an issue of social inequity. Efforts to expand the legal conditions for abortion in Nigeria are critical. Simultaneously, efforts to increase awareness of the availability of medication abortion drugs to more safely self-induce can help mitigate the toll of unsafe abortion-related morbidity and mortality.

Keywords: abortion; measurement; survey.

© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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Title: Causes And Impact of Unsafe Abortion in Nigeria

Authors: Abbas, Yau Garba

PAGE: vi, 46

Language: En

Subject: Maternal Health – Lessons Learned

Keywords: Unsafe abortion, Nigeria, Unplanned Pregnancy

Abstract: Background: Nigeria is one of the countries with the highest maternal mortality in the world and a significant proportion of it has been attributed to unsafe abortion. There are several factors that expose women to the risk of unsafe abortion like; unplanned pregnancy and for various reasons the pregnancy becomes unwanted. Unsafe abortion can have several health consequences from short term of bleeding, sepsis or perforation of the uterus to the long term of chronic pelvic pains or secondary infertility. Methodology: Literature review of articles, data and reports on unsafe abortion using search engines like PubMed, Google and Google Scholar. Results: Several factors are responsible for unplanned pregnancy like; lack of sexual education in schools, early sexual debut, sexual violence, and unmet need for contraception. Financial constraints, being single, not ready for motherhood, rape and the like have been identified as some of the reasons that force women to seek abortion. Legal restrictions, poverty, failures of the health system are some of the main factors that make abortion unsafe in Nigeria. Conclusion and recommendation: Women continue to procure dangerous abortions being unaware of the health, social and legal consequences. And it continues to threaten the lives of so many young women in the country. Most of these young women are single and in schools. The effort should be made to expand the legal indications for abortion. Meanwhile healthcare workers need to be trained to deliver qualitative abortion and post abortion care. The community, nurses and midwives need resources to sensitize and promote uptake of contraception as one of the measures to reduce unwanted pregnancies.

Organization: KIT - Royal Tropical Institute , VU - Vrije Universiteit Amsterdam

Institute: KIT (Royal Tropical Institue)

Department: Development Policy & Practice

Country: Nigeria

Region: West Africa

Training: Master of Public Health / International Course in Health Development (ICHD)

Category: Research

Right: © 2014 Abbas

Document type: Thesis/dissertation

File: AnnX9ogxFq_2016102609545587.pdf

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• Volume 5, Issue 1
• Inequities in the incidence and safety of abortion in Nigeria
• Article Text
• Article info
• Citation Tools
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• Article metrics

• Suzanne O Bell 1 ,
• Elizabeth Omoluabi 2 ,
• Funmilola OlaOlorun 3 ,
• Mridula Shankar 1 ,
• http://orcid.org/0000-0002-8637-6249 Caroline Moreau 1
• 1 Population Family and Reproductive Health , Johns Hopkins University Bloomberg School of Public Health , Baltimore , Maryland , USA
• 2 Centre for Research, Evaluation Resources and Development , Ile-Ife , Nigeria
• 3 Department of Community Medicine , University of Ibadan , Ibadan , Oyo , Nigeria
• Correspondence to Professor Suzanne O Bell; suzanneobell{at}gmail.com

Background We know little about the frequency, correlates and conditions under which women induce abortions in Nigeria. This study seeks to estimate the 1-year induced abortion incidence and proportion of abortions that are unsafe overall and by women’s background characteristics using direct and indirect methodologies.

Methods Data for this study come from a population-based, nationally representative survey of reproductive age women (15–49) in Nigeria. Interviewers asked women to report on the abortion experiences of their closest female confidante and themselves. We adjusted for potential biases in the confidante data. Analyses include estimation of 1-year induced abortion incidence and unsafe abortion, as well as bivariate and multivariate assessment of their correlates.

Results A total of 11 106 women of reproductive age completed the female survey; they reported on 5772 confidantes. The 1-year abortion incidence for respondents was 29.0 (95% CI 23.3 to 34.8) per 1000 women aged 15–49 while the confidante incidence was 45.8 (95% CI 41.0-50.6). The respondent and confidante abortion incidences revealed similar correlates, with women in their 20s, women with secondary or higher education and women in urban areas being the most likely to have had an abortion in the prior year. The majority of respondent and confidante abortions were the most unsafe (63.4% and 68.6%, respectively). Women aged 15–19, women who had never attended school and the poorest women were significantly more likely to have had the most unsafe abortions.

Conclusion Results indicate that abortion in Nigeria is a public health concern and an issue of social inequity. Efforts to expand the legal conditions for abortion in Nigeria are critical. Simultaneously, efforts to increase awareness of the availability of medication abortion drugs to more safely self-induce can help mitigate the toll of unsafe abortion-related morbidity and mortality.

• measurement

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Key questions

What is already known.

The most recent research on induced abortion in Nigeria suggested there were 33 abortions per 1000 women aged 15–49 in 2012; however, these data lack information regarding the social determinants of abortion or unsafe abortion as the estimates rely largely on a facility-level measure of complications and do not include women’s characteristics.

What are the new findings?

Results indicate there were 45.8 abortions per 1000 women of reproductive age in 2018, approximately two-thirds of which were unsafe.

Young, educated and urban women were more likely to have had a recent abortion while young, uneducated, rural and poor women were more likely to have had an unsafe abortion.

What do the new findings imply?

These findings illustrate that abortion is very common in Nigeria and that unsafe abortion is an issue of health inequity, with the most disadvantaged women most likely to experience an unsafe abortion.

In Nigeria, abortion is only legal to save a woman’s life. Recent estimates extrapolated from facility-based abortion complications indicate there were approximately 33 abortions per 1000 women aged 15–49 in 2012. 1 This is equivalent to 1.25 million abortions annually, representing more than half (56%) of all unintended pregnancies to Nigerian women. These predominantly unsafe abortions resulted in nearly 500 000 women experiencing serious health consequences, less than half (212 000) of whom received treatment for these complications. 1 The only previous national study of abortion incidence in Nigeria estimated a rate of 25 abortions per 1000 women aged 15–44 in 1996, suggesting that women’s use of abortion as a means of fertility control has increased in intervening years. 2

Recent regional estimates of abortion safety indicate that nearly 85% of abortions in West Africa are considered unsafe. 3 These unsafe abortions are a result of women seeking clandestine procedures or self-managing their termination with non-recommended methods outside the formal healthcare system; this is particularly true in the context of legal restrictions. 4 They present a measurement challenge, but more importantly, they put women at risk of abortion-related morbidity and mortality. In Nigeria, there are between 496 (95% uncertainty interval (UI) 336 to 666) and 814 (95% UI 596 to 1180) maternal deaths per 100 000 live births, 5–7 approximately 10% of which are due to unsafe abortion. 8 Using the latest estimates of the general fertility rate, 7 we estimate there are as many as 6000 abortion-related deaths annually, the majority of which are preventable. For each death, there are hundreds of women who experience severe and potentially life-threatening complications. 9 Among gynaecological admissions at a Nigerian teaching hospital in recent years, 7.4% were related to treatment of unsafe abortion, 17% of which ultimately resulted in maternal death. 9 Findings from gynaecological admissions at nine referral hospitals in Nigeria suggest that, although surgical abortion is still the primary method of abortion, the share of postabortion care (PAC) patients who report first using misoprostol is increasing. 10 PAC patients who used misoprostol experienced fewer and less severe complications than PAC patients presenting after a clandestine surgical abortion. 10 While these population level estimates and facility data are essential to track abortion trends and the public health implications of abortion, we know little about the specifics of its occurrence and characteristics of women who seek abortion, particularly those not seeking facility-based care.

Existing evidence indicate that the negative sequelae associated with unsafe abortion is experienced disproportionately by vulnerable women. 4 11–13 A recent study in Nigeria found that young women aged 16–25 were the most likely to present for treatment of postabortion complications at a teaching hospital. 9 Prior studies found that women experiencing abortion-related morbidities were younger, more likely to be unmarried and poorer than women experiencing maternal morbidities for other causes. 11 14 However, these studies and much of the research in low-resource, legally restrictive settings have relied on facility-based, retrospective data, which are limited in the availability of information on women’s characteristics and the generalisability of findings. In addition to the obvious burden of unsafe abortion morbidity and mortality on these women and their families, its treatment is associated with a significant cost to the public healthcare system. 11 14–16

The first objective of this study is to estimate the 1-year incidence of induced abortion in Nigeria overall and by women’s characteristics using direct report and the confidante methodology. 17 18 The second objective is to determine the safety of reported abortions and its social determinants. The study complements facility-based studies of abortion in Nigeria, using a population-based approach to explore women’s recent experiences of abortion within and outside of healthcare facilities.

Data for this study come from a population-based survey of reproductive age women (15–49) in Nigeria conducted by Performance Monitoring and Accountability 2020 (PMA2020). 19 PMA2020 conducts frequent, low-cost and rapid turnaround national or regional surveys in several countries across Africa and Asia using smartphone technology. 19 20 The Centre for Research, Evaluation Resources and Development is the implementing partner for PMA2020 in Nigeria while the Bill & Melinda Gates Institute at the Johns Hopkins Bloomberg School of Public Health oversees the PMA2020 abortion measurement project and provides technical support.

PMA2020 surveys in Nigeria follow a three-stage cluster sampling design. First, seven states were selected using probability proportional to size (PPS) sampling: one state from five of the six geopolitical zones and two states from the North West zone, where 25% of Nigeria’s total population resides. Within each state, geographic clusters defined as enumeration areas (EA) that contain approximately 200 households were selected using PPS sampling and subsequently 35–40 households were randomly selected per EA. Female resident interviewers invited all eligible female respondents ages 15 to 49 from the selected households to consent and participate in the face-to-face interview. This sampling strategy produced nationally representative samples of households and women of reproductive age in Nigeria. Data are also representative at the state level. For this study, we used data from PMA2020 Nigeria Round 5 collected between April and May 2018. The final sample included 11 106 women. The Johns Hopkins Bloomberg School of Public Health and the National Health Research Ethics Committee of Nigeria provided ethical approval for this study. Women provided verbal consent prior to participation.

Patient and public involvement

No patients were involved in the development of the research questions and outcome measures.

The resident interviewers collected information about women’s socioeconomic characteristics, their reproductive history, and their knowledge of and experience using contraception. In addition to these PMA2020 core questions, women also responded to an abortion module exploring the frequency, correlates and nature of abortion experiences in Nigeria.

The abortion module began with questions on the number of close female confidantes the respondent had, followed by questions on the age and highest level of education ever attended by the respondent’s closest confidante. A confidant was defined as a woman aged 15–49, residing in Nigeria, and someone with whom the respondent reciprocally shares personal information. The interviewer then inquired about the closest confidante’s experiences with abortion, specifically asking about pregnancy removal when pregnant or worried she was pregnant and separately about period regulation at a time when she was worried she was pregnant. This indirect approach, relying on respondent's reports of their closest friend’s experience with abortion, builds off prior social network-based measurement of abortion. 17 21–24 Subsequent questions related to the respondent’s own experiences with these phenomena. Other questions investigated pathways to confidantes’ and respondents’ abortions, including whether the women made multiple attempts to end the pregnancy or bring back a period, which method(s) she used, and the source(s) of these methods. If a woman reported doing multiple things to induce an abortion, subsequent questions asked about the first method and source followed by the last method and source. We categorised abortion methods intro surgery, medication abortion (MA) drugs, other pills or pills without sufficient information to categorise as MA, and traditional or other methods (like herbal drinks, injections, alcohol, or other traditional remedies). We categorised sources into public facility types, private facility types (including non-governmental organisations and private doctors), pharmacies or chemist shops and traditional or other non-medical sources (including shops, markets, friends or relatives or home).

Using these data, we operationalised abortion safety based on two dimensions: (1) whether the method(s) used included any non-recommended methods (ie, other than surgery or MA drugs) that put the woman at potentially high risk of abortion related morbidity or mortality and (2) whether the source(s) used were clinical (public or private facilities) or non-clinical (any other source). If a woman reported doing multiple things, we categorised her abortion as non-recommended if she used a method other than surgery or MA drugs at any point in the termination; we similarly categorised an abortion as non-clinical if at any point she used a source other than a public or private facility. We combined source and method information to categorise a woman’s abortion into one of the following four safety categories: (1) recommended method(s) involving only clinical source(s); (2) recommended method involving non-clinical source(s); (3) non-recommended method(s) involving clinical source(s) and (4) non-recommended method(s) involving non-clinical source(s). Abortions in group four we deemed the most unsafe. We have described our safety measurement approach in more detail elsewhere. 25

For the analyses, we first examined the respondent characteristics and the limited demographic characteristics of the confidantes, which only included age and education. We calculated 1-year incidences of induced abortion by averaging the pregnancy removal incidence and the combined pregnancy removal/period regulation incidence separately for the respondent and confidante data. For both the respondents and confidantes, we took the average of the two point estimates as we believe the pregnancy removal data fails to capture some abortions while the period regulation data likely includes experiences that we would not consider to be abortions. In addition, we excluded any abortions where the woman used only emergency contraception and did not seek subsequent care assuming that the woman was not in fact pregnant (respondents n=14, confidantes n=12). For the confidante estimates, we included pregnancy removal and period regulations that the respondent reported with certainty (‘Yes, I am certain’) or with less certainty (‘Yes, I think so’) but for which she could provide details on the method(s) used. We made this adjustment to account for incomplete transmission of information on confidante abortions. 18 For ‘missing’ confidantes (ie, those respondents who reported zero confidantes), we used a Poisson model to predict the likelihood of these ‘missing’ confidantes having had an abortion in the prior year. This involved regressing the respondent’s socioeconomic characteristics on the available confidante abortion incidence data. This analytical approach adjusts for selection bias in the confidante sample. 26 We then predicted the likelihood of the ‘missing’ confidantes having had a recent abortion using results of the Poisson regression. We combined the predicted likelihood for the ‘missing’ confidantes with the reported confidante incidence data to calculate the 1-year confidante abortion incidence estimates (separately for pregnancy removal and pregnancy removal/period regulation combined). To ensure these confidante data had characteristics that reflected the population of reproductive aged women in Nigeria, we constructed post-stratification weights using the weighted respondent data distributions as the reference. We used these adjusted data to calculate separate 1-year abortion incidences overall and by age, education, residence and state for respondents and by age and education for confidantes. We then conducted separate respondent and confidante bivariate and multivariable logistic regression analyses to determine which characteristics were independently associated with having reported a recent likely-abortion (pregnancy and period regulation combined) since we could not investigate these relationships for the average pregnancy removal and pregnancy removal/period regulation at the individual level. Additionally, the confidante data do not include the Poisson predicted estimates for the ‘missing’ confidantes since the outcome variable produced was no longer dichotomous, prohibiting logistic regression analyses that assume Bernoulli distribution.

With regard to safety, we first separately estimated the overall respondent and confidante distribution of abortion across the four safety categories among all reported likely-abortions (pregnancy removals and period regulations combined). We separately estimated the proportion of women who experienced the most unsafe abortions by background characteristics. Additionally, we conducted bivariate and multivariable logistic regressions to examine what characteristics were independently associated with increased odds of experiencing a most unsafe abortion. Unlike the confidante incidence estimate, we did not impute abortion safety for ‘missing’ confidantes in any of the associated analyses. Last, we calculated the 1-year incidence rate of most unsafe abortions and the corresponding annual number of most unsafe abortions in Nigeria.

We conducted all analyses in Stata V.15.1 27 and present results from weighted analyses that used the Taylor linearization approach to account for the complex sampling design and clustering.

Sample characteristics

A total of 11 106 women of reproductive age completed the female survey ( table 1 ). The 10 671 respondents who answered the question on number of close female confidantes reported 0.8 confidantes on average and provided demographic and abortion experience details for their 5883 closest confidantes. Respondents were on average 29.1 years old, most had attended at least some secondary school (46.9%) and the majority were currently married or cohabiting (63.7%). Respondents primarily identified as Christian (not including Catholic) (44.0%) or Muslim (39.2%), and Igbo (22.5%) or Hausa (21.0%) ethnicity. Many respondents were nulliparous (35.1%), yet nearly one in five had five or more children (18.1%). Unadjusted confidante data indicate they were similar in age (average 28.4), but slightly more educated; 26.3% had higher education compared with 20.3% of respondents. Additionally, respondents in rural areas were more likely to report a confidante. After adjusting confidante data to account for respondents who did not report a confidante and applying the post-stratification weights, the distribution of confidante characteristics were no longer statistically significantly different from that of the respondents.

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Characteristics of Nigerian female respondents aged 15–49 and their closest female confidantes aged 15–49 who had a prior abortion*

Incidence estimates

Overall, the 1-year induced likely-abortion incidence (pregnancy removal and period regulation combined) for respondents was 39.4 (SE 3.98) per 1000 women aged 15–49 while the adjusted confidante incidence was 56.5 (SE 2.91); removing the period regulations, the overall pregnancy removal incidence for respondents and confidantes were 18.7 (SE 1.92) and 35.1 (SE 2.04), respectively. To produce the final abortion incidence estimate, we averaged the pregnancy removal and combined pregnancy removal/period regulation rates separately for respondents and confidantes, which resulted in an estimated 29.0 (95% CI 23.3 to 34.8) and 45.8 (95% CI 41.0 to 50.6) abortions per 1000 women of reproductive age, respectively. All subsequent results are for the average pregnancy removal and period regulation incidences, which we refer to simply as abortion and present separately for respondents and confidantes.

The respondent and confidante abortion incidences revealed similar patterns by characteristics ( figure 1 ). Women aged 20–24 among respondents and confidantes had the highest 1-year abortion incidence at 47.9 and 77.6 abortions per 1000 women of reproductive age, respectively, followed by women aged 25–29 (40.8 and 58.0). Women in their 40s had the lowest incidence for respondents and confidantes (13.5 and 25.5 among 40–44 year olds and 8.9 and 23.0 among 45–49 years olds, respectively). With respect to education, respondents and confidantes with secondary (34.8 and 57.1) or higher education (36.7 and 52.0) had the highest incidences of abortion and women who had never received formal education had the lowest (9.8 and 18.1). Respondents in rural areas reported significantly lower rates of abortion at 18.2 per 1000 women of reproductive age compared with 37.4 in urban areas. Women in Rivers state had the highest abortion rate among respondents (57.4) while women in Kano reported the lowest (5.4). The poorest respondents were least likely to have had a recent abortion (14.9). Examining the reporting ratio between the adjusted confidante data and the respondent data, we see that the youngest and oldest respondents were similarly more than two times as likely to underreport an abortion when asked directly about their own abortion experience, while respondents with no education were the most likely to underreport. Using the likely-abortion data, bivariate respondent results confirm patterns identified from examining incidences and were statistically significant ( table 2 ); confidante bivariate results similarly indicated that being aged 20–24 and having secondary or higher education were significantly associated with increased odds of recent likely-abortion. Young age and urban residence remained significantly positively associated with abortion incidence in the multivariable respondent model while some states remained negatively associated. Confidante age and education both remained significant factors in the multivariable confidante model ( table 2 ).

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One-year incidence of abortion (average of pregnancy removal and combined pregnancy removal/period regulation rates) per 1,000 women of reproductive age among female respondents and their closest female confidantes in Nigeria by background characteristics.

Bivariate and multivariate regressions of characteristics associated with experiencing an abortion in the year prior to the survey among Nigerian respondents and confidantes age 15–49*

Safety estimates

A minority of respondents terminated their pregnancy using recommended methods (34.5%) and only 31.2% received care from clinical sources; the corresponding figures based on confidante experiences were 29.5% and 23.9%, respectively. Combining both criteria, most respondent (63.4%) and confidante (68.6%) likely-abortions fell into the most unsafe category, involving non-recommended methods dispensed by non-clinical or no providers ( table 3 ). Few respondent and confidante likely-abortions were categorised as involving recommended method(s) dispensed in non-clinical settings (5.4% vs 7.5%) or non-recommended method(s) dispensed by clinical source(s) (2.1% vs 1.9%), while only 29.1% and 22.0% of respondent and confidante likely-abortions were performed using recommended methods in a clinical setting. Compared with the overall safety distribution among all likely-abortions, those reported in the last 5 years were more likely to involve non-recommended methods from a non-clinical source for respondents (73.6%) and confidantes (72.2%) (estimates not shown). Using the national confidante abortion incidence of 45.8, these safety estimates suggest an unsafe abortion rate of approximately 33 per 1000 women of reproductive age.

Safety of most recent reported likely-abortion among female respondents aged 15–49 and their closest female confidantes aged 15–49 in Nigeria

Examining likely-abortion safety by background characteristics, respondent and confidante results revealed similar patterns ( figure 2 ). Women aged 15–19 were the most likely to have had the most unsafe abortions (87.8% and 84.7%), as were women who had never attended school (79.1% and 86.4%). Respondents residing in rural areas were significantly more likely to have had the most unsafe likely-abortions (70.8%). By state, respondents from Anambra, Kaduna, Nasarawa and Taraba had the highest levels of the most unsafe likely-abortions. Based on respondent data, the poorest women (81.0%) were the most likely to have experienced the most unsafe likely-abortions. Results from a multivariable logistic regression indicated that age was independently associated with likely-abortion safety among respondents and confidantes, with older age associated with lower likelihood of most unsafe likely-abortion ( table 4 ). Greater confidante education remained significantly associated with lower odds of a most unsafe likely-abortion while it was no longer significant among respondents, for whom we were able to adjust for wealth. For respondents, some states and wealth quintiles significantly associated with lower odds of having experienced a most unsafe likely-abortion in the multivariable model, with increasing wealth associated with decreasing odds ( table 4 ).

Percentage of most recent abortions among female respondents and their closest female confidantes in Nigeria that were the most unsafe by background characteristics.

Multivariate regression of characteristics associated with experiencing a most unsafe abortion among Nigerian respondents and confidantes aged 15–49*

Results from this study provide new insights regarding the frequency, correlates and conditions under which women have abortions in Nigeria. Respondent and confidante incidences both indicate that abortion in this setting is common and more likely to be reported among young, educated women while respondent results also suggest greater incidence among urban women. Given the concerns with underreporting of self-reported abortion, 28–30 the respondent 1-year incidence of pregnancy removal (18.7) is likely an underestimate, while the corresponding confidante estimate of 35.2 may also be an underestimate if it fails to capture experiences that women do not consider to be abortions and instead report as period regulations. Compared with the Bankole et al ’s Abortion Incidence Complications Methodology (AICM) study estimate of 33 abortions per 1000 women aged 15–49 in 2012, our self-reported pregnancy removal estimate is lower while our confidante estimate is similar. 1 Experiences captured via the pregnancy removal questions may be most analogous to the abortion experiences captured in an AICM study while reported period regulations may include some non-abortions. However, we believe the true 1-year abortion incidence in Nigeria is between the confidante pregnancy removal rate and the confidante combined pregnancy removal/period regulation rate. Our final point estimate averages the high and low values of the confidante range, resulting in a national 1-year incidence of 45.8 abortions per 1000 women of reproductive age.

Even if some of the period regulations captured in our data were not abortions, to the extent that they identify women taking potentially harmful actions post-coitally to bring back their menses at a time when they were worried they were pregnant, we are concerned about them from a public health perspective. Given the greater visibility of unsafe abortions that result in complications, we believe the confidante safety estimates are biased upward. As such, we think the respondent safety estimates are closer to the truth. Respondent findings indicate that 63.4% of likely-abortions in Nigeria are most unsafe while 73.7% of those that occurred in the prior 5 years were most unsafe; this is lower than the recent unsafe abortion estimates for Western Africa in 2010–2014 (84.7%). 3 This may be because we exclude all clinical sources from the most unsafe category; however, we know many abortions in facilities are performed under unsafe conditions.

Our safety-related findings indicate that the majority of likely-abortions were the most unsafe, with younger, poorer and less educated women at greatest risk of having unsafe abortions. Multivariable results suggest that wealth may be the determining factor in whether a woman undergoes a most unsafe abortion. These results are consistent with previous literature suggesting that the most disadvantaged women are those most likely to resort to unsafe means of termination. 4 11 14 Evidence from this study confirms that abortion in Nigeria is a public health concern and an issue of social inequity.

This study has limitations. Most importantly, we were unable to validate the abortion estimates against an external, objective measure. Thus, while we view the confidante estimates as more accurate than the respondents’, we do not know by how much. Stigma and legal restrictions surrounding abortion in Nigeria (and evidence of incomplete transmission of respondent abortions to their confidantes, which we present elsewhere 18 ) suggest that all confidantes who had an abortion had not told their corresponding respondents. However, our inclusion of the confidante abortions that respondents reported with less certainty acts to counteract this possibility. Had we excluded all less certain respondent reported confidante abortions, the rate would be similar to the respondent rate. Beyond the issue of transmission, the surrogate sample of confidantes may bias estimates of abortion if their sociodemographic characteristics are different from the index population and such differences are correlated with the likelihood of abortion. 26 In our study, 47.0% of women reported no female confidante. We adjusted for this potential bias by using the Poisson prediction approach, which decreased the confidante incidence estimate by 6.1%, but biases may remain. Further work is needed to determine the optimal friend definition that minimises confidante sample selection bias while maximising confidante abortion experience transmission to respondents. Additionally, differential under-reporting could bias our bivariate and multivariate findings. Nonetheless, the patterns of abortion incidence and safety were similar for respondents and confidantes, which lends credibility to the conclusions regarding which groups of women are most likely to have an abortion or most unsafe abortion.

With regard to abortion safety measurement, the potential for differential underreporting by method and source is the primary limitation of the data that would lead to bias. Since the overall distribution and sociodemographic correlates of the most unsafe likely-abortions were similar among respondents and confidantes, we believe this potential bias is unlikely to be significant or to qualitatively affect our conclusions. Another limitation is the potential for misclassification. Women sometimes could not provide sufficient information for interviewers to classify the specific pill used, nor could they distinguish the specific conditions under which the surgery was performed. However, this limitation would have led to misclassifications in both directions (eg, pills recorded as ‘other pills’ that were actually MA drugs, or surgery in a facility that was actually performed by an untrained provider), limiting the extent of systematic error in the overall estimates.

The study has a number of strengths. The data are from a large, nationally representative survey. Investigators took extensive efforts during the questionnaire development and pilot testing to appropriately capture the nuance in how women discuss and refer to abortion experiences locally; this led to the different sets of questions about pregnancy removal and period regulation. The methodological approach enabled estimation of abortion incidence and safety overall and by women’s background characteristics, providing details on the characteristics of women most likely to have had an abortion or an unsafe abortion. Additionally, the use of both respondent and confidante data provided contemporaneous estimates of these abortion-related measures. Having data on both populations confirmed the usefulness of this social-network based indirect methodology in reducing the social desirability pressure and producing more accurate estimates while providing two sources of support regarding the patterns of abortion incidence and safety by women’s characteristics.

The confidante data from this study provide a national 1-year induced abortion incidence of 45.8 per 1000 women of reproductive age, suggesting that abortion is significantly more common than previously estimated. Findings indicate that vulnerable, economically disadvantaged women with limited ability to navigate and access safe abortion in this legally restrictive setting are most at risk of having an unsafe abortion. Efforts to expand the legal conditions for abortion in Nigeria are critical as restrictive abortion laws negatively impact abortion safety without reducing overall abortion incidence rates. 31 In the absence of legal expansion, women will continue to seek services from providers who are not regulated and may not have appropriate training but are motivated to provide abortion for financial gain 32 and/or to alleviate suffering associated with unwanted pregnancie s . In the meantime, some local organisations are currently implementing harm reduction efforts to increase awareness of MA drugs to more safely self-induce, which can help mitigate the toll of abortion-related morbidity and mortality. Additionally, improved availability of contraceptive services, including counselling to counteract fears of contraceptive-related infertility, 33 is needed to reduce women’s reliance on unsafe abortion alone to control their fertility. More broadly, reproductive health policies and programmes must work to ensure equitable access to contraceptive and safe abortion services for legal indications. Furthermore, availability of quality PAC is critically needed to reduce abortion-related morbidity and mortality given the frequent recourse to unsafe abortion. Inadequate action on any of these fronts will result in continued preventable deaths from unsafe abortion.

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Handling editor Sanni Yaya

Correction notice This article has been corrected since it was published. The article type has been updated.

Contributors SB, CM and MS conceived the study and led development of the study instrument. EO and FO led in-country data collection and provided input on the study instrument. SB and MS led the data analysis with input from FO, EO and CM. All authors were involved in the manuscript writing and provided final approval of the manuscript.

Funding This study was funded by an Anonymous Donor (Grant number: 127941).

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement Data are available in a public, open access repository.

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Impact of abortion law reforms on women’s health services and outcomes: a systematic review protocol

Foluso ishola.

Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Purvis Hall 1020 Pine Avenue West, Montreal, Quebec H3A 1A2 Canada

U. Vivian Ukah

Arijit nandi, associated data.

A country’s abortion law is a key component in determining the enabling environment for safe abortion. While restrictive abortion laws still prevail in most low- and middle-income countries (LMICs), many countries have reformed their abortion laws, with the majority of them moving away from an absolute ban. However, the implications of these reforms on women’s access to and use of health services, as well as their health outcomes, is uncertain. First, there are methodological challenges to the evaluation of abortion laws, since these changes are not exogenous. Second, extant evaluations may be limited in terms of their generalizability, given variation in reforms across the abortion legality spectrum and differences in levels of implementation and enforcement cross-nationally. This systematic review aims to address this gap. Our aim is to systematically collect, evaluate, and synthesize empirical research evidence concerning the impact of abortion law reforms on women’s health services and outcomes in LMICs.

We will conduct a systematic review of the peer-reviewed literature on changes in abortion laws and women’s health services and outcomes in LMICs. We will search Medline, Embase, CINAHL, and Web of Science databases, as well as grey literature and reference lists of included studies for further relevant literature. As our goal is to draw inference on the impact of abortion law reforms, we will include quasi-experimental studies examining the impact of change in abortion laws on at least one of our outcomes of interest. We will assess the methodological quality of studies using the quasi-experimental study designs series checklist. Due to anticipated heterogeneity in policy changes, outcomes, and study designs, we will synthesize results through a narrative description.

This review will systematically appraise and synthesize the research evidence on the impact of abortion law reforms on women’s health services and outcomes in LMICs. We will examine the effect of legislative reforms and investigate the conditions that might contribute to heterogeneous effects, including whether specific groups of women are differentially affected by abortion law reforms. We will discuss gaps and future directions for research. Findings from this review could provide evidence on emerging strategies to influence policy reforms, implement abortion services and scale up accessibility.

Systematic review registration

PROSPERO CRD42019126927

Supplementary Information

The online version contains supplementary material available at 10.1186/s13643-021-01739-w.

An estimated 25·1 million unsafe abortions occur each year, with 97% of these in developing countries [ 1 – 3 ]. Despite its frequency, unsafe abortion remains a major global public health challenge [ 4 , 5 ]. According to the World health Organization (WHO), nearly 8% of maternal deaths were attributed to unsafe abortion, with the majority of these occurring in developing countries [ 5 , 6 ]. Approximately 7 million women are admitted to hospitals every year due to complications from unsafe abortion such as hemorrhage, infections, septic shock, uterine and intestinal perforation, and peritonitis [ 7 – 9 ]. These often result in long-term effects such as infertility and chronic reproductive tract infections. The annual cost of treating major complications from unsafe abortion is estimated at US$ 232 million each year in developing countries [ 10 , 11 ]. The negative consequences on children’s health, well-being, and development have also been documented. Unsafe abortion increases risk of poor birth outcomes, neonatal and infant mortality [ 12 , 13 ]. Additionally, women who lack access to safe and legal abortion are often forced to continue with unwanted pregnancies, and may not seek prenatal care [ 14 ], which might increase risks of child morbidity and mortality.

Access to safe abortion services is often limited due to a wide range of barriers. Collectively, these barriers contribute to the staggering number of deaths and disabilities seen annually as a result of unsafe abortion, which are disproportionately felt in developing countries [ 15 – 17 ]. A recent systematic review on the barriers to abortion access in low- and middle-income countries (LMICs) implicated the following factors: restrictive abortion laws, lack of knowledge about abortion law or locations that provide abortion, high cost of services, judgmental provider attitudes, scarcity of facilities and medical equipment, poor training and shortage of staff, stigma on social and religious grounds, and lack of decision making power [ 17 ].

An important factor regulating access to abortion is abortion law [ 17 – 19 ]. Although abortion is a medical procedure, its legal status in many countries has been incorporated in penal codes which specify grounds in which abortion is permitted. These include prohibition in all circumstances, to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, and on request with no requirement for justification [ 18 – 20 ].

Although abortion laws in different countries are usually compared based on the grounds under which legal abortions are allowed, these comparisons rarely take into account components of the legal framework that may have strongly restrictive implications, such as regulation of facilities that are authorized to provide abortions, mandatory waiting periods, reporting requirements in cases of rape, limited choice in terms of the method of abortion, and requirements for third-party authorizations [ 19 , 21 , 22 ]. For example, the Zambian Termination of Pregnancy Act permits abortion on socio-economic grounds. It is considered liberal, as it permits legal abortions for more indications than most countries in Sub-Saharan Africa; however, abortions must only be provided in registered hospitals, and three medical doctors—one of whom must be a specialist—must provide signatures to allow the procedure to take place [ 22 ]. Given the critical shortage of doctors in Zambia [ 23 ], this is in fact a major restriction that is only captured by a thorough analysis of the conditions under which abortion services are provided.

Additionally, abortion laws may exist outside the penal codes in some countries, where they are supplemented by health legislation and regulations such as public health statutes, reproductive health acts, court decisions, medical ethic codes, practice guidelines, and general health acts [ 18 , 19 , 24 ]. The diversity of regulatory documents may lead to conflicting directives about the grounds under which abortion is lawful [ 19 ]. For example, in Kenya and Uganda, standards and guidelines on the reduction of morbidity and mortality due to unsafe abortion supported by the constitution was contradictory to the penal code, leaving room for an ambiguous interpretation of the legal environment [ 25 ].

Regulations restricting the range of abortion methods from which women can choose, including medication abortion in particular, may also affect abortion access [ 26 , 27 ]. A literature review contextualizing medication abortion in seven African countries reported that incidence of medication abortion is low despite being a safe, effective, and low-cost abortion method, likely due to legal restrictions on access to the medications [ 27 ].

Over the past two decades, many LMICs have reformed their abortion laws [ 3 , 28 ]. Most have expanded the grounds on which abortion may be performed legally, while very few have restricted access. Countries like Uruguay, South Africa, and Portugal have amended their laws to allow abortion on request in the first trimester of pregnancy [ 29 , 30 ]. Conversely, in Nicaragua, a law to ban all abortion without any exception was introduced in 2006 [ 31 ].

Progressive reforms are expected to lead to improvements in women’s access to safe abortion and health outcomes, including reductions in the death and disabilities that accompany unsafe abortion, and reductions in stigma over the longer term [ 17 , 29 , 32 ]. However, abortion law reforms may yield different outcomes even in countries that experience similar reforms, as the legislative processes that are associated with changing abortion laws take place in highly distinct political, economic, religious, and social contexts [ 28 , 33 ]. This variation may contribute to abortion law reforms having different effects with respect to the health services and outcomes that they are hypothesized to influence [ 17 , 29 ].

Extant empirical literature has examined changes in abortion-related morbidity and mortality, contraceptive usage, fertility, and other health-related outcomes following reforms to abortion laws [ 34 – 37 ]. For example, a study in Mexico reported that a policy that decriminalized and subsidized early-term elective abortion led to substantial reductions in maternal morbidity and that this was particularly strong among vulnerable populations such as young and socioeconomically disadvantaged women [ 38 ].

To the best of our knowledge, however, the growing literature on the impact of abortion law reforms on women’s health services and outcomes has not been systematically reviewed. A study by Benson et al. evaluated evidence on the impact of abortion policy reforms on maternal death in three countries, Romania, South Africa, and Bangladesh, where reforms were immediately followed by strategies to implement abortion services, scale up accessibility, and establish complementary reproductive and maternal health services [ 39 ]. The three countries highlighted in this paper provided unique insights into implementation and practical application following law reforms, in spite of limited resources. However, the review focused only on a selection of countries that have enacted similar reforms and it is unclear if its conclusions are more widely generalizable.

Accordingly, the primary objective of this review is to summarize studies that have estimated the causal effect of a change in abortion law on women’s health services and outcomes. Additionally, we aim to examine heterogeneity in the impacts of abortion reforms, including variation across specific population sub-groups and contexts (e.g., due to variations in the intensity of enforcement and service delivery). Through this review, we aim to offer a higher-level view of the impact of abortion law reforms in LMICs, beyond what can be gained from any individual study, and to thereby highlight patterns in the evidence across studies, gaps in current research, and to identify promising programs and strategies that could be adapted and applied more broadly to increase access to safe abortion services.

The review protocol has been reported using Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines [ 40 ] (Additional file 1 ). It was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database CRD42019126927.

Eligibility criteria

Types of studies.

This review will consider quasi-experimental studies which aim to estimate the causal effect of a change in a specific law or reform and an outcome, but in which participants (in this case jurisdictions, whether countries, states/provinces, or smaller units) are not randomly assigned to treatment conditions [ 41 ]. Eligible designs include the following:

• Pretest-posttest designs where the outcome is compared before and after the reform, as well as nonequivalent groups designs, such as pretest-posttest design that includes a comparison group, also known as a controlled before and after (CBA) designs.
• Interrupted time series (ITS) designs where the trend of an outcome after an abortion law reform is compared to a counterfactual (i.e., trends in the outcome in the post-intervention period had the jurisdiction not enacted the reform) based on the pre-intervention trends and/or a control group [ 42 , 43 ].
• Differences-in-differences (DD) designs, which compare the before vs. after change in an outcome in jurisdictions that experienced an abortion law reform to the corresponding change in the places that did not experience such a change, under the assumption of parallel trends [ 44 , 45 ].
• Synthetic controls (SC) approaches, which use a weighted combination of control units that did not experience the intervention, selected to match the treated unit in its pre-intervention outcome trend, to proxy the counterfactual scenario [ 46 , 47 ].
• Regression discontinuity (RD) designs, which in the case of eligibility for abortion services being determined by the value of a continuous random variable, such as age or income, would compare the distributions of post-intervention outcomes for those just above and below the threshold [ 48 ].

There is heterogeneity in the terminology and definitions used to describe quasi-experimental designs, but we will do our best to categorize studies into the above groups based on their designs, identification strategies, and assumptions.

Our focus is on quasi-experimental research because we are interested in studies evaluating the effect of population-level interventions (i.e., abortion law reform) with a design that permits inference regarding the causal effect of abortion legislation, which is not possible from other types of observational designs such as cross-sectional studies, cohort studies or case-control studies that lack an identification strategy for addressing sources of unmeasured confounding (e.g., secular trends in outcomes). We are not excluding randomized studies such as randomized controlled trials, cluster randomized trials, or stepped-wedge cluster-randomized trials; however, we do not expect to identify any relevant randomized studies given that abortion policy is unlikely to be randomly assigned. Since our objective is to provide a summary of empirical studies reporting primary research, reviews/meta-analyses, qualitative studies, editorials, letters, book reviews, correspondence, and case reports/studies will also be excluded.

Our population of interest includes women of reproductive age (15–49 years) residing in LMICs, as the policy exposure of interest applies primarily to women who have a demand for sexual and reproductive health services including abortion.

Intervention

The intervention in this study refers to a change in abortion law or policy, either from a restrictive policy to a non-restrictive or less restrictive one, or vice versa. This can, for example, include a change from abortion prohibition in all circumstances to abortion permissible in other circumstances, such as to save the woman’s life, to preserve the woman’s health, in cases of rape, incest, fetal impairment, for economic or social reasons, or on request with no requirement for justification. It can also include the abolition of existing abortion policies or the introduction of new policies including those occurring outside the penal code, which also have legal standing, such as:

• National constitutions;
• Supreme court decisions, as well as higher court decisions;
• Customary or religious law, such as interpretations of Muslim law;
• Medical ethical codes; and
• Regulatory standards and guidelines governing the provision of abortion.

We will also consider national and sub-national reforms, although we anticipate that most reforms will operate at the national level.

The comparison group represents the counterfactual scenario, specifically the level and/or trend of a particular post-intervention outcome in the treated jurisdiction that experienced an abortion law reform had it, counter to the fact, not experienced this specific intervention. Comparison groups will vary depending on the type of quasi-experimental design. These may include outcome trends after abortion reform in the same country, as in the case of an interrupted time series design without a control group, or corresponding trends in countries that did not experience a change in abortion law, as in the case of the difference-in-differences design.

Outcome measures

Primary outcomes.

• Access to abortion services: There is no consensus on how to measure access but we will use the following indicators, based on the relevant literature [ 49 ]: [ 1 ] the availability of trained staff to provide care, [ 2 ] facilities are geographically accessible such as distance to providers, [ 3 ] essential equipment, supplies and medications, [ 4 ] services provided regardless of woman’s ability to pay, [ 5 ] all aspects of abortion care are explained to women, [ 6 ] whether staff offer respectful care, [ 7 ] if staff work to ensure privacy, [ 8 ] if high-quality, supportive counseling is provided, [ 9 ] if services are offered in a timely manner, and [ 10 ] if women have the opportunity to express concerns, ask questions, and receive answers.
• Use of abortion services refers to induced pregnancy termination, including medication abortion and number of women treated for abortion-related complications.

Secondary outcomes

• Current use of any method of contraception refers to women of reproductive age currently using any method contraceptive method.
• Future use of contraception refers to women of reproductive age who are not currently using contraception but intend to do so in the future.
• Demand for family planning refers to women of reproductive age who are currently using, or whose sexual partner is currently using, at least one contraceptive method.
• Unmet need for family planning refers to women of reproductive age who want to stop or delay childbearing but are not using any method of contraception.
• Fertility rate refers to the average number of children born to women of childbearing age.
• Neonatal morbidity and mortality refer to disability or death of newborn babies within the first 28 days of life.
• Maternal morbidity and mortality refer to disability or death due to complications from pregnancy or childbirth.

There will be no language, date, or year restrictions on studies included in this systematic review.

Studies have to be conducted in a low- and middle-income country. We will use the country classification specified in the World Bank Data Catalogue to identify LMICs (Additional file 2 ).

Search methods

We will perform searches for eligible peer-reviewed studies in the following electronic databases.

• Ovid MEDLINE(R) (from 1946 to present)
• Embase Classic+Embase on OvidSP (from 1947 to present)
• CINAHL (1973 to present); and
• Web of Science (1900 to present)

The reference list of included studies will be hand searched for additional potentially relevant citations. Additionally, a grey literature search for reports or working papers will be done with the help of Google and Social Science Research Network (SSRN).

Search strategy

A search strategy, based on the eligibility criteria and combining subject indexing terms (i.e., MeSH) and free-text search terms in the title and abstract fields, will be developed for each electronic database. The search strategy will combine terms related to the interventions of interest (i.e., abortion law/policy), etiology (i.e., impact/effect), and context (i.e., LMICs) and will be developed with the help of a subject matter librarian. We opted not to specify outcomes in the search strategy in order to maximize the sensitivity of our search. See Additional file 3 for a draft of our search strategy.

Data collection and analysis

Data management.

Search results from all databases will be imported into Endnote reference manager software (Version X9, Clarivate Analytics) where duplicate records will be identified and excluded using a systematic, rigorous, and reproducible method that utilizes a sequential combination of fields including author, year, title, journal, and pages. Rayyan systematic review software will be used to manage records throughout the review [ 50 ].

Selection process

Two review authors will screen titles and abstracts and apply the eligibility criteria to select studies for full-text review. Reference lists of any relevant articles identified will be screened to ensure no primary research studies are missed. Studies in a language different from English will be translated by collaborators who are fluent in the particular language. If no such expertise is identified, we will use Google Translate [ 51 ]. Full text versions of potentially relevant articles will be retrieved and assessed for inclusion based on study eligibility criteria. Discrepancies will be resolved by consensus or will involve a third reviewer as an arbitrator. The selection of studies, as well as reasons for exclusions of potentially eligible studies, will be described using a PRISMA flow chart.

Data extraction

Data extraction will be independently undertaken by two authors. At the conclusion of data extraction, these two authors will meet with the third author to resolve any discrepancies. A piloted standardized extraction form will be used to extract the following information: authors, date of publication, country of study, aim of study, policy reform year, type of policy reform, data source (surveys, medical records), years compared (before and after the reform), comparators (over time or between groups), participant characteristics (age, socioeconomic status), primary and secondary outcomes, evaluation design, methods used for statistical analysis (regression), estimates reported (means, rates, proportion), information to assess risk of bias (sensitivity analyses), sources of funding, and any potential conflicts of interest.

Risk of bias and quality assessment

Two independent reviewers with content and methodological expertise in methods for policy evaluation will assess the methodological quality of included studies using the quasi-experimental study designs series risk of bias checklist [ 52 ]. This checklist provides a list of criteria for grading the quality of quasi-experimental studies that relate directly to the intrinsic strength of the studies in inferring causality. These include [ 1 ] relevant comparison, [ 2 ] number of times outcome assessments were available, [ 3 ] intervention effect estimated by changes over time for the same or different groups, [ 4 ] control of confounding, [ 5 ] how groups of individuals or clusters were formed (time or location differences), and [ 6 ] assessment of outcome variables. Each of the following domains will be assigned a “yes,” “no,” or “possibly” bias classification. Any discrepancies will be resolved by consensus or a third reviewer with expertise in review methodology if required.

Confidence in cumulative evidence

The strength of the body of evidence will be assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system [ 53 ].

Data synthesis

We anticipate that risk of bias and heterogeneity in the studies included may preclude the use of meta-analyses to describe pooled effects. This may necessitate the presentation of our main findings through a narrative description. We will synthesize the findings from the included articles according to the following key headings:

• Information on the differential aspects of the abortion policy reforms.
• Information on the types of study design used to assess the impact of policy reforms.
• Information on main effects of abortion law reforms on primary and secondary outcomes of interest.
• Information on heterogeneity in the results that might be due to differences in study designs, individual-level characteristics, and contextual factors.

Potential meta-analysis

If outcomes are reported consistently across studies, we will construct forest plots and synthesize effect estimates using meta-analysis. Statistical heterogeneity will be assessed using the I 2 test where I 2 values over 50% indicate moderate to high heterogeneity [ 54 ]. If studies are sufficiently homogenous, we will use fixed effects. However, if there is evidence of heterogeneity, a random effects model will be adopted. Summary measures, including risk ratios or differences or prevalence ratios or differences will be calculated, along with 95% confidence intervals (CI).

Analysis of subgroups

If there are sufficient numbers of included studies, we will perform sub-group analyses according to type of policy reform, geographical location and type of participant characteristics such as age groups, socioeconomic status, urban/rural status, education, or marital status to examine the evidence for heterogeneous effects of abortion laws.

Sensitivity analysis

Sensitivity analyses will be conducted if there are major differences in quality of the included articles to explore the influence of risk of bias on effect estimates.

Meta-biases

If available, studies will be compared to protocols and registers to identify potential reporting bias within studies. If appropriate and there are a sufficient number of studies included, funnel plots will be generated to determine potential publication bias.

This systematic review will synthesize current evidence on the impact of abortion law reforms on women’s health. It aims to identify which legislative reforms are effective, for which population sub-groups, and under which conditions.

Potential limitations may include the low quality of included studies as a result of suboptimal study design, invalid assumptions, lack of sensitivity analysis, imprecision of estimates, variability in results, missing data, and poor outcome measurements. Our review may also include a limited number of articles because we opted to focus on evidence from quasi-experimental study design due to the causal nature of the research question under review. Nonetheless, we will synthesize the literature, provide a critical evaluation of the quality of the evidence and discuss the potential effects of any limitations to our overall conclusions. Protocol amendments will be recorded and dated using the registration for this review on PROSPERO. We will also describe any amendments in our final manuscript.

Synthesizing available evidence on the impact of abortion law reforms represents an important step towards building our knowledge base regarding how abortion law reforms affect women’s health services and health outcomes; we will provide evidence on emerging strategies to influence policy reforms, implement abortion services, and scale up accessibility. This review will be of interest to service providers, policy makers and researchers seeking to improve women’s access to safe abortion around the world.

Acknowledgements

We thank Genevieve Gore, Liaison Librarian at McGill University, for her assistance with refining the research question, keywords, and Mesh terms for the preliminary search strategy.

Abbreviations

Authors’ contributions.

FI and AN conceived and designed the protocol. FI drafted the manuscript. FI, UVU, and AN revised the manuscript and approved its final version.

The authors acknowledge funding from the Fonds de recherche du Quebec – Santé (FRQS) PhD doctoral awards and Canadian Institutes of Health Research (CIHR) Operating Grant, “Examining the impact of social policies on health equity” (ROH-115209).

Declarations

Not applicable

The authors declare that they have no competing interests.

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Contributor Information

Foluso Ishola, Email: [email protected] .

U. Vivian Ukah, Email: [email protected] .

Arijit Nandi, Email: [email protected] .