Magnitude of Induced Abortion and Associated Factors among Female Students of Hawassa University, Southern Region, Ethiopia, 2019

Objectives This study was aimed at assessing the magnitude of induced abortion and associated factors among students in Hawassa University, southern region, Ethiopia, 2019. Methods An institutional-based cross-sectional study was conducted among a total of 422 students selected on the bases of a probability simple random sampling method. A pretested structured questionnaire was used to collect data. Analysis was made with SPSS 20. Descriptive summary and inferential statistics (binary logistic regression) were used with a 95% CI and P value of less than 5% as a level of significance. Findings were presented in tables, figure, and texts. Confidentiality of information was also secured. Results The prevalence of induced abortion in the study setting was 68.7% (95% CI: 64.15%-73.2%). Participants who used emergency contraceptives had 12 times higher odds of undergoing abortion than those who did not use emergency contraceptives at AOR: 11.95, 95% CI: 5.615-25.326, P < 001. Conclusions A higher prevalence of induced abortion was observed in the study setting. Contraceptive use was the predictor of induced abortion identified. Concerned bodies were recommended to work on the identified determinant of induced abortion in the study setting.


Introduction
Abortion has been an old experience carried out so far by human beings. It has been practiced throughout the world illegally. Globally, it was estimated that around 30 million induced abortions were performed annually [1]. Globally, from 210 million pregnancies that occur annually, about 22% end up in induced abortion [2].
In sub-Saharan Africa (SSA), many women use abortion as a means of family planning methods. With restrictive abortion laws and limited contraceptive access, unsafe abortion accounted for 13% of maternal deaths in SSA [3]. About 9% of maternal deaths in sub-Saharan Africa are attributed to complications of unsafe abortion [4].
An estimated 620,300 induced abortions were performed in Ethiopia annually. The annual abortion rate was 28 per 1,000 women aged 15-49, with the highest in urban areas [5]. Induced abortion is one of the mechanisms to deal with unwanted pregnancy. The university students in Ethiopia dealt with unwanted pregnancy by undertaking induced abortion to terminate pregnancy secretly to avoid stigma following premarital pregnancy [6].
Ethiopia is one of the countries that allowed women to obtain safe and legal abortion under some conditions; these conditions included the following: if the pregnancy was from rape, if there is physical or mental disability, if it would put women on physical health or life risk, or if the woman is younger than 18 and unprepared to give birth [7].
Though most studies in Ethiopia were health facilitybased on patients seeking health service, reproductive health service, particularly abortion-related issues, was not well emphasized. So, the current study assessed the magnitude of induced abortion and associated factors among students at Hawassa University during the year 2019.

Study
Setting and Period. The study was conducted in Hawassa University, located in Southern Nations, Nationalities, and People's Region (SNNPR). It is located 278 kilometers south of Addis Ababa, the capital of Ethiopia. The university is one of the governmental universities located in the southern region of Ethiopia. The university has 7 colleges, with a total of 155,965 populations of which 19,500 were female population. The study was conducted from February to May 2019. An institutional-based cross-sectional study was done. The female students in Hawassa University during the year of 2018/2019 were the source population whereas female students of Hawassa University who were available from February to May 2019 were the study population. Participants were selected on the basis of a simple random sampling technique, where the sampling frame was once determined from registries of the university. Though there were conducted studies, the researcher took 50%, as an estimator of prevalence of induced abortion, to have the maximum sample size. A single population proportion formula was utilized to compute the sample size with its respective standard deviation and margin of error. Accordingly, with the consideration of a 10% nonresponse rate, the final sample was found at 422. A structured pretested self-administered questionnaire was employed among the participants in Amharic (original language) after checking for consistency with English by linguistic professionals. The tool was first developed by the researchers after rigorous reviewing of literatures on the topic, and then, inputs of senior researchers were incorporated into the developed tool. For the coherence, clarity, and conciseness of the questionnaire, native speakers reviewed the tool. The outcome variable was induced abortion measured as follows: abortion is termination of pregnancy before 28 weeks of pregnancy [8]. For the purpose of the current study, induced abortion is "students who terminated their pregnancy intentionally either on their own or by another person" [9].

Statistical Analysis.
Data was entered and further analyzed with SPSS version 20. Descriptive statistics were employed as a summary measure. Associations between covariates and dependent variables were investigated with binary logistic regression with a 95% confidence interval (95% CI) and P value less than 5% as the level of significance. Bivariate logistic regression was done first; then, to take control of effects of confounding variables, multivariate logistic regression was also done.

Sociodemographic Characteristics of the Respondents.
Four hundred twenty-two participants participated in this study with a 100% response rate. Regarding years of education, 17%, 41.2%, 30.6%, 8.8%, and 5.5% of the students were 1 st year, 2 nd year, 3 rd year, 4 th year, and 5 th year students, respectively. Concerning the departments, 32% were engineering, 15.6% were health, and 33.4% were social science, and the remaining 11.1% were agriculture students. More than half (61.6%) of students lived in the campus dormitory; 37.7% of students lived outside the campus. Less than half (42.2%) of students got income from their parents, 29.9% of the students got an income from relatives, and 27.7% of students got income from other sources (Table 1).

Behavioral Characteristics of Participants.
Eighty-two percent of students had history of sexual intercourse. The reasons behind their start of sexual intercourse were the following: 40.3% influence of economic problems, 46.4% peer pressure, 44.1% alcohol consumption, 38.9% personal desire, and 34.8 influence of khat or drugs ( Table 2).

Participant's Knowledge about Abortion.
As to respondent view about whether participants had heard about emergency contraceptives, majority 406 (96%) had information about it, with most 326 (77%) of the respondents having used the drugs. More than half 265 (62%) of respondents reported that they knew where abortion is legally conducted. Most (77%) of the respondents reported that they used emergency contraceptives following sexual intercourse. Regarding the experience of abortion by the study participants, most (69%) of the participants reported that they had undertaken induced abortion, of which more than half (54%) of the participants used medication for termination of the pregnancy. More than half (53%) of the participants reported that holding off sexual intercourse was their choice when their partner was unwilling to use a condom (Table 3).

Magnitude and Associated Factors of Induced Abortion.
The magnitude of induced abortion in the study setting was 68.7% (95% CI: 64.15%-73.2%), whereas only less than onethird (31.3%) did not undergo induced abortion ( Figure 1). The age of participants, year of education, alcohol use, and use of emergency contraceptives have independently shown a statistical association with the occurrence of induced abortion at P value less than 5%. But in the multivariate logistic regression, only emergency contraceptive use was statistically associated with the occurrence of induced abortion. Participants who used emergency contraceptives had 12 times higher odds of taking induced abortion than those who did not use emergency contraceptives (AOR: 11.95, 95% CI: 5.615-25.326, P < 0:001) ( Table 4).

Discussion
The current study found a higher prevalence of induced abortion among university students observed at 68.7%, which was much higher than the findings of the health facility-based study in Guraghe zone of Ethiopia, which revealed the magnitude of induced abortion at 12.3% [9]. This variation might be due to variation in study settings.
The other study in Ethiopian university students revealed that the rate of induced abortion was found at 65 per 1,000 women. Students with history of alcohol use and first year students had higher risk of abortion than their counterparts. About 23.7% of students reported experience of sexual intercourse, and less than half (44%) of respondents reported ever hearing of emergency contraception, of which 36% of those 2 Journal of Pregnancy with sexual experience ever used a condom [10], which was lower than the findings of the current study. The prevalence of induced abortion among precollege students in Ethiopia was observed at 13.6% [11], which was lower than the findings of the current study. The finding from this study was much higher than the findings in China 8.13% [12], Cameroon 21% [13], southern Ethiopia 43.4% [14], Nigeria 51% [15], and Northwestern Ethiopia 4.8% [16]. This variation might be attributed to differences in the time of investigation of sample size, whereas the current finding was almost consistent with the study in Ghana 64% [17].
Evidences suggested that history of abortion and use of contraceptive methods were statistically interrelated with each other. Women who had history of abortion were more likely to be those using any methods of contraceptives. A study in Luanda, Angola, supported that history of induced abortion was associated with the use of contraceptive methods. Those women who had a history of induced abortion were 1.23 times more likely to use a modern contraceptive method as compared to those who never had abortion (RR: 1.23, 95% CI: 1.10-1.36) [18].
Desire to stay in school (28%), fear of parents (24%), and shame of being pregnant (26%) were the major depicted determinants of induced abortion. Most of the participants  were not aware of where abortion is allowed, and some of them had undertaken illegal abortion [13]. The other study in Cameroon depicted that the prevalence of induced abortion was found at 25% [19], of which the finding was lower than the finding of the current study. The prevalence of induced abortion in this study was higher than findings from the following: 33.6% Addis Ababa, Ethiopia [20], 5% in Pakistan [21], and 17% in Iran [22].
A study at Felege Hiwot Hospital, Ethiopia, revealed that being nonmarried and student, age less than 24 years, and having previous history of induced abortion and low monthly income were independent predictors of induced abortion [23], whilst in this study, only emergency contraceptive use was statistically associated with the occurrence of induced abortion.
In the current study, participants who used emergency contraceptives had 12 times higher odds of undergoing abortion than those who did not use emergency contraceptives. Surprisingly, a higher magnitude of induced abortion was observed from the current study than most other previous studies.

Conclusions
A higher prevalence of induced abortion was observed in the study setting. Contraceptive use was the predictor of induced abortion. Participants who used emergency contraceptives had 12 times higher odds of undergoing induced abortion than those who did not use emergency contraceptives. Interventions focused on identified determinants could be recommended.

Data Availability
All the required data has been included within the manuscript.

Ethical Approval
Ethical approval was obtained from the ethical clearance committee of Universal Medical College, prior to commencement of the study. Permit to undertake the study was also sought from the Hawassa University Research Review Committee. Confidentiality of the participants was secured through a coding system. The ethics approval was given in accordance with the Declaration of Helsinki. Briefing about the study was highlighted by the data collector.

Consent
Consent for publication was secured from the study participants.

Conflicts of Interest
The authors declare that they have no competing interest.

Authors' Contributions
Addisu Tadesse Sahile was involved in the design, implementation, data collection, and statistical analysis and drafted the manuscript. Mieraf Shiferaw Beyene was involved in the design, data collection, and review of scientific content of the manuscript. Both authors read and approved the final manuscript.