Assessment of Attitudes Towards Induced Abortion Among Adults Residing In Mizan-Aman Town Bench-Maji Zone, Snnprs, South West Ethiopia 2017

Introduction: Induced abortion defined as the intentional termination of the pregnancy for medical or any other reason before it reaches to viability. It is an important cause of bleeding during pregnancy and one of the five leading cause of maternal death in the developing world. It is stigmatized topic, both politically and socially which is surrounded by privacy, shame and misconceptions, which can lead to negative health and social consequences. Community attitudes and stigma, can pose important barriers to accessing reproductive health services. It is believed that the information generated through this study will fill some gaps in the study area in particular, and in the country at large. Objective: To assess the attitude towards induced abortion among adults residing in Mizan Aman town, Bench Majizone, Snnprs, South West Ethiopia, 2017. Methodology: A quantitative community based cross sectional study was used to assess the attitude towards induced abortion among adults residing in Mizan Aman town, Bench Maji zone. A Systematic random sampling technique was used to select study participants. Total samples of the study were 498. Individuals were interviewed by using standardized and structured questionnaire. The data was collected by 4 year Bsc. nursing students and the collected data was analyzed using scientific calculator and the result is presented using tables and charts. Result: Out of 498 study participants 486 responds to the questions which gives response rate of 97.6%. Among the study participants, 200 (41.15%) had positive attitude towards induced abortion and the rest 286 (58.85%) had negative attitude. From the sampled population 270 (55.6%) of the participants support induced abortion if the fetus has serious defect in utero, 394 (81.1%) of the participants support induced abortion if the pregnancy seriously threatens the mother life, 249 (51.2%) of the participants support induced abortion if the family has low income and cannot afford more children and 261 (53.7%) of the participants support induced abortion if the pregnancy is due to rape. Conclusion and Recommendation: Among the participant, more than half had negative attitude towards induced abortion. Since more than half of the respondent opposes induced abortion, the government should design effective policy and implement to the ground to promote safe induced abortion.


Introduction
Induced abortion defined as the intentional termination of the pregnancy for medical or any other reason before it reaches to viability [1]. It is an important cause of bleeding during pregnancy and one of the five leading cause of maternal death in the developing world [2]. Induced abortion Town Bench-Maji Zone, Snnprs, South West Ethiopia 2017 is a sensitive and frequently stigmatized topic, both politically and socially. It is frequently surrounded by privacy, shame and misconceptions, which can lead to negative health and social consequences [3].
Unsafe abortions: occurs when a woman or adolescents may try to end their pregnancies by themselves or with the assist of untrained personal. Unsafe abortion is defined by the World Health Organization (WHO), "as a procedure for terminating unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the medical standards, or both". It also refers to "inappropriate management of complications of spontaneous abortions or miscarriage.
As many as 67,000 women in the world die annually as a result of unsafe abortion and 48% of all abortions Worldwide are deemed unsafe [4]. Every day 192 women die because of complications arising from unsafe abortion and nearly all of them occur in developing countries [5]. Unintended pregnancy poses a major challenge to reproductive health of young adults in developing countries. Some `young women who had unintended pregnancies obtain abortion. Many of which are performed in unsafe condition unintended pregnancies is higher among women who were unmarried, lower economic status, not using contraceptives consistently and attending formal education [6].
Unintended pregnancy is common and abortion rates are rising worldwide. In 2008, 33 million (16%) of about 208 million pregnancies worldwide resulted in unintended births and 41 million (20%) in induced abortions [7]. Be it induced, safe or unsafe, abortion is a universal phenomenon and has existed throughout history.
Many young women in developing countries prefer to undertake unsafe abortion by untrained providers or by using different dangerous self inducement methods which put them in a high risk of death. This is mainly because of various factors such as legal barriers, social stigma and Economic reasons. The aborted women believing that they had committed a sinful and immoral act which is resulted from their family and religious perception about abortion. These feelings led them to keep their abortion as a secret [28]. The same is true in Africa, a study is conducted in Tanzania among 455 women's, admitted to four public Hospital for abortion complications in Dares Salaam, revealed that social stigma for unwed Mother experience is high [29].
A Community based survey was conducted in Zambia among reproductive age group women to assess the knowledge and attitude towards induced abortion with a total sample size of 1484. Among those 16 percent correctly identify abortion legal. Only 40 percent of reproductive age knows that abortion was legally permitted in the extreme situation, 55 percent know that the abortion is legally take place to save the mother's life, the attitude remission conservative [30]. A research which is conducted in 2003 to examine moral attitudes among South Africans: 56% said they believed that induced abortion is wrong even if there is a strong chance of serious defect in the fetus. 70% said they believed that induced abortion is wrong if done primarily because the parents have low income and may be unable to afford another child [31].
An Institution based study was contacted in Uganda to assess the attitude of youth females, who is attending Naguru Teenage Information and Health Center, Kampala with a total sample size of 319 towards induced abortion, 47 (14.7%) had positive attitude towards induced abortion In the Ethiopian context, factors associated with culture, diverse religious opinions, and views on women's rights to control over their own lives and bodies and the right of the fetus to life highly affects the positions on abortion issue [33].
A community based cross sectional study was done to assess the knowledge and attitude of Females towards induced abortion in Bishoftu town, Oromia region. Which is conducted in February 2009 with a total sample of 708, of them 73.4% had positive attitude towards induced abortion and the rest 26.6% had negative attitude [34], Whereas, 272 (85.3%) had Negative attitude [32] 2. Methodology

Study Design
A community based cross-sectional study design was used to asses' attitudes towards induced abortion among adults residing in Mizan Aman town.

Study Period and Setting
Mizan-Teferi with the neighbouring town of Aman forms a separate town called Mizan-Aman surrounded by Debub Bench Woreda. Mizan-Aman town is the largest town and administrative centre for Bench -Maji Zone. This town has latitude and longitude of 7°0ˈN 35° 35ˈ E/ 7.000° N 35.583°E and an elevation of 1451 m above sea level. The town is found at a distance of 561 Km from capital city Addis Ababa and 836 Km from Regional administrative city Hawassa, 50Km and 230Km from Tepi and Jimma towns respectively. It is one of the reform towns in the Region and it is an administrative center of Bench-Maji zone having five kibbles, ten sub-kibbles and 45 localities. The town has a total population of 52,210, of whom 18,625 are male and 33,585 female. Among the total population 31,125 are in adult age group, out of these 17,223 are females and 13,902 are males. The population distribution /density of the town are 1310 person per square kilometer or 13 people per hectare. The majority 45.97% of the inhabitants is Ethiopian Orthodox Christianity follower, 33.8% were Protestants, 17.71% were Muslim follower, and 1.05% practiced traditional beliefs. The town has one Teaching Hospital, and also the location of two institution of Higher education, namely Aman Health science Collage and Mizan-Tepi University. The Teaching Hospital is located in Aman town and established in 1986. It is the only Teaching hospital in the Bench-Maji zone that gives charge free service for pregnant mothers and neonates there for the study was conducted in Mizan-Aman town from April 27 up to May 10, 2017 [35].

Source of Population
Adult men and women found in both Mizan and Aman town.

Study Population
All systematically sampled adult men and women found in both Mizan and Aman town during study Period.

Inclusion Criteria
All male and female adult residents who were living in Mizan-Aman town > than 6 month.

Exclusion Criteria
Adults who have started living in Mizan-Aman town for less than 6 month, Adults who were critically ill and or unable to communicate.

Sample Size Determination
The sample size was determined by using single population proportion formula: After 10% non-response rate was added the total sample size was 332 then multiplied by 1.5 design effect the final total sample size=332*1.5=498 Where: n = sample size Z = standard normal distribution corresponding to significance level at a = 0.05, Za/2= 1.96 P = 0.734, expected proportion, 73.4% of the population have positive attitude towards induced abortion, from study conducted in Bishoftu (33). d = margin of error (5%)

Data Collection Procedures and Tools
Data was collected by three 4 th Year Bsc. nursing students. The attitude of the participants towards induced abortion was assessed by using seven questions. The questionnaires for assessing the level of support of the respondents toward induced abortion across several distinct scenarios developed by GSS. Respondents were provided a dichotomous option for each item, with respondents being asked their thought regarding abortion whether should be marked as ("yes") or should not be marked as ("no") were available with each scenario. Responses for each of these questions were summed to create an overall Abortion Attitudes Index. With each response being receiving a value of 0 or 1 respectively, the Abortion Attitudes index score for each respondent was in the range of from a minimum score of 0 to a maximum score of 7.

Data Quality Assurance
The questioner was first developed in English version then translated to Amharic then it was translated back to English to check for its consistency. The questionnaire was pre-tested on 5% of adults outside of the study area in Sheshekakebelea week before the actual data collection process were started. In the pretest clarity, understandability and arrangement of the questions and other things were checked and the feedback obtained from the pretest was insightful and helped us to make some modification on the way how to conduct the interview and how to approach the participants for effective interview. The data collectors had discussion in detail about the methods before a data collection were started.

Data Analysis and Processing
Data consistency and completeness was checked throughout the data collection, data tallying and data analysis time. Data analysis was made by using scientific calculator. Frequency distribution with the respective percentage is displayed and the Data is presented in tables and charts.

Ethical Considerations
The formal letter was obtained from Department of Nursing and summated to Mizan-Aman woreda Health Bureau Permission letter was obtained from Mizan-Aman woreda Health Bureau. Name and address of the participants was not taken, and the participants were well informed about the aim of the study, the advantages of the study, and their rights even to stop in the middle of the procedure. The Participant was also informed that there is no direct benefit for them. However their participation on this study is very important for achievement of the study and for paving the way for development of intervention strategies in this area. No risk will occur on them because of their participation in this study. All results getting from them; were kept confidential and there were no need of recording their identities. Finally written consent was taken before data collection. We have tried to link severely ill participant to respective units in the hospital.

Socio Demographic Characteristics of the Respondents
This study has assessed adult's attitude towards induced abortion at Mizan-Aman town, Ethiopia. The total sample size of the study was 498 with a respondent rate of 97.6%, beside this there was a non respondent rate of 2.4% because twelve participants were refused and in completed the interviews.
All of the respondents were adult age group, of them 277 (57%) were female in, the rest 209 (43%) were male. According to the findings of the study, 130 (26.75%) of the respondents were within the age group of [18][19][20][21][22][23][24][25]190 15.23% of the respondents had educational level grade 9-12 and the rest 17.7% of the respondents had educational level of college or university under or post graduate. According to occupational status 20.37% were students, 22.43% were private employers, 12.96% Government employers, 20.16% Farmers, 20.78% House wives and the rest 3.3% were UN employers. 10% of the participant had no monthly income and the rest 90% had their own income. The overall sociodemographic data is described in table 1.  From the sampled population 55.6% of the participants support induced abortion if the fetus in utero had serious defect, 34.6% were in a married women that does not want more children, 81.1% support induced abortion if the pregnancy seriously threatens the mother life, 51.2% support induced abortion if the family has low income and cannot afford more children, 53.7% support induced abortion if pregnancy isduetorape, 17.9% support induced abortion if a woman get pregnant from the man that does not to marry, 23.9% support induced abortion if a woman wants to abort for any reason. Generally, attitudes towards induced abortion are described in table 2.
Among the participants, more than half 58.85% of the respondent had negative attitude towards induced abortion upon the woman's demand and the rest 41.15% had positive attitude towards induced abortion upon the woman's demand.

Discussion
In this particular study among the adults studied, less than half of participants had positive attitude towards induced abortion and it is lower as compared to study done in Bishoftu [34]. The variation may be due to socio cultural difference and different sample size.
In contrast to this the result of this study is higher when compared to the study done in Uganda and India [27,32]. The variation may be due to different social and cultural practice of the study area towards induced abortion

Conclusion
More than half of adult's population in Mizan-Aman town had Negative attitude towards induced abortion. Most of the participant support induced abortion if the woman's health is seriously endangered by the pregnancy. In contrast to this most of the participants oppose induced abortion if the woman is not married and does not want to marry the man.

Recommendation
To improve access to safe abortion in Ethiopia, it will need to use a variety of strategies that acknowledge the beliefs of the Ethiopian population and at the same time, seek to reduce the stigma associated with induced abortion. Based on this study we can recommend; To FMOH; The MOH develop a guideline about induced abortion by considering the countries socio-cultural and religious practice.
To Mizan-Aman town Health Department; Do more to bring desired effect on prevention of unsafe abortion.
To Health workers; particularly health extensions can teach the community about the consequence of unsafe abortion and stigma.
To Researcher; In order to expand the validity of this study further research should be conducted on large scale to identify factors that lead to stigma due to induced abortion.

Limitations of the Study
The limitation of this study is that it was conducted only in an urban area and did not include rural areas, and hence findings may not be generalizable to rural settings. The side effect of cross sectional study design is unforgettable.

Acknowledgement
First of all, we would like to express our deep gratitude to our college staffs and colleagues for their continuous advice and professional guidance towards realization of this work.
Secondly, we gratefully thank Mizan Tepi University, College of Health Sciences, department of Nursing for giving this incredible chance and support to prepare this research. Finally, our best thank goes to all those, who in one way or another have contributed to the success of this study.