Background: Unsafe abortion is a commonly neglected sexual and reproductive health and rights issue despite the serious health problems it causes to women and girls in their reproductive ages. It is classified as a main cause of maternal mortality and morbidity. This paper has considered questions that have the greatest potential to successfully reduce unsafe abortions in the resource poor settings. Methods: We adapted the Child Health and Nutrition Research Initiative (CHNRI) to identify and prioritize many competing sexual and reproductive health and rights research ideas that impact the health of the populations. The implementation was done in three phases which included generation and collection of research ideas from various experts virtually in August 2019 consolidation of the potential questions through thematic analysis conducted in September 2019. Finally, scoring and ranking of the research questions was done in a workshop of experts. Results: Out of a list of 45 priority research questions, two questions were ranked the highest scoring 28 out of the possible 30. The research priorities include: “The effectiveness of interventions (e.g. counseling or incentives or home visits) to increase post abortion uptake and continuance”, “Reducing repeat abortion on improving maternal health outcomes” and “Evaluation of community-based awareness programs to reduce unwanted pregnancies and encourage women to seek help early”. Conclusions: Ten key research priorities in preventing unsafe abortion were identified. The priority list covers areas of focus that could effectively impact preventing unsafe abortions while also acting as a knowledge base for researchers, policy makers and other interested stakeholders who would want to invest in this area.
It is estimated that an average of 73.3 million women and girls induced safe and unsafe abortions between 2015 and 2019 globally. According WHO reports, there were about 39 abortions conducted out of every 1000 women whose ages range between 15 and 45 years. Out of these, one out of every three abortions are carried out in unsafe environments [
Unsafe abortion is one of the mostly neglected reproductive health care problems especially in the developing countries, thereby increasing the impact of maternal mortality and morbidity for millions of women and girls in their reproductive lives. Of these unsafe abortions between 4.7% and 13.2% lead to maternal deaths [
The 2019 International Conference on Population and Development (ICPD) outlined the issues and challenges for work in the area of unsafe abortion and urged governments, health providers and civil society to take major steps to advance women’s and girls’ sexual and reproductive rights, in line with international human rights standards and public health guidance, including liberalizing abortion laws in countries that can revolutionize access and improved safety of abortion around the world [
Sexual reproductive and health rights stakeholders are confronted with new ethical challenges along with global development and population demands which require more investigations. Scarcity and unreliability of data to programmatically respond is also an issue. Moreover, the limited financial and human resources are more pressing in developing countries and have major influence planning and implementing research [
This paper reports part of a larger research prioritization exercise conducted for the WHO African region. The paper focuses on the thematic area of SRHR on preventing unsafe abortion. The research prioritization adopted Child Health and Nutrition Research Initiative (CHNRI approach [
Phase 2 and 3 of the research prioritization process were conducted in a meeting held in Cape Town, South Africa from 29th October to 1st November, 2019. A total of 67 SRHR experts responsible for SRHR programmes from Ministries of health, partners supporting SRHR in the African region and WHO technical officers all from SRHR priority countries. A list of 45 research questions were reviewed with an aim of identifying duplications for merging, out of scope questions and those that had inconsistences in wordings for review. The process generated a list of 23 priority areas. In phase 3, a team of six experts using a modified ranking criteria, scored the final list of research questions against six distinct areas namely magnitude, severity, effectiveness, feasibility, burden and equity. The least score in the scoring criteria was 1 while the highest score was 5. Each question could therefore attain a lowest score of 6 or highest score of 30.
In this paper, we report the results of research prioritization exercise on sexual and reproductive health and rights with a focus on preventing unsafe abortion. A total of 67 experts out of the 80 invited participated in the research prioritization process thus a response rate of 83.7%. The aim of this exercise was to identify key research questions on preventing unsafe abortion that would guide the WHO Africa Region research agenda.
The thematic area on preventing unsafe abortion generated a total of 45 research questions from the online survey. The questions were systematically reviewed by a team of experts who on consensus agreed on 23 key questions to be subjected to scoring and ranking.
| Criteria | Definition | Scoring |
|---|---|---|
| 1) Magnitude | Magnitude of the problem; in terms of the proportion of the population, such as women, under 5 children, elderly, are affected. | 1-2-3-4-5 |
| 2) Severity | Of the condition; i.e. danger to the individual and the community. How serious is the condition. Does it threaten life, cause major suffering, and decrease the ability to lead a normal life. | 1-2-3-4-5 |
| 3) Effectiveness | Based on the best existing evidence and knowledge, would intervention be efficacious in reducing disease burden? It is likely to be effective under programme conditions. | 1-2-3-4-5 |
| 4) Feasibility | Taking into account a) the infrastructure and resources required to deliver effective interventions (e.g. human resources, health facilities, communication and transport infrastructure), and b) the need for change in demand, beliefs and attitudes of users, would you say that the endpoints of the research would be deliverable? affordability and sustainability. | 1-2-3-4-5 |
| 5) Burden | Diseases burden reduction; taking into account the best available information, would you say that reaching of research endpoints would eventually, have a “capacity” to impact directly and indirectly disease burden. E.g. up to 5% to 10% reduction in long run. | 1-2-3-4-5 |
| 6) Equity | Equity enhancing; does the intervention affect mainly the underprivileged in the population? Intervention has potential to improve equity in disease burden distribution in the longer term? | 1-2-3-4-5 |
1 is the lowest score and 5 the highest score. Each question could therefore attain a lowest score of 6 or highest score of 30.
| Title of the research questions | Magnitude | Severity | Effectiveness | Feasibility | Burden | Equity | Total scores |
|---|---|---|---|---|---|---|---|
| 1) Evaluate the effectiveness of interventions (e.g. counselling or incentives, or home visits) to increase post-abortion contraception uptake and continuance, and reduce repeat abortion, on improving maternal health outcomes. | 5 | 5 | 4 | 4 | 5 | 5 | 28 |
| 2) Evaluation of community-based awareness programs to reduce unwanted pregnancies and encourage women to seek help early. | 4 | 5 | 4 | 5 | 5 | 5 | 28 |
| 3) Community and client’s perception towards accessible safe and post abortion services. | 4 | 5 | 4 | 5 | 4 | 5 | 27 |
| 4) Evaluation of the quality of Safe Abortion and post abortion care services. | 4 | 5 | 4 | 5 | 5 | 4 | 27 |
| 5) Evaluation of the effectiveness and feasibility of implementing current guidelines on safe abortion services. | 4 | 4 | 5 | 5 | 5 | 4 | 27 |
| 6) Evaluation of the impact of integrating safe and post abortion services in to routine reproductive health care services. | 5 | 4 | 5 | 4 | 4 | 5 | 27 |
| 7) Perspectives of providers and clients on the law governing provision of abortion services. | 5 | 4 | 4 | 5 | 3 | 4 | 25 |
| 8) Effectiveness, safety and cost of working with other sociocultural organizations in safe abortion services. | 5 | 4 | 4 | 3 | 4 | 4 | 24 |
| 9) Evaluating approaches that work to reduce unsafe abortion among adolescent girls and young women. | 4 | 4 | 4 | 2 | 4 | 4 | 22 |
| 10) Impact of mHealth - use of digital technology to increase knowledge and access to safe abortion services. | 4 | 4 | 3 | 3 | 4 | 3 | 21 |
guidelines on safe abortion services”; and, “evaluation of the impact of integrating safe and post abortion services in to routine reproductive health care services”. The least score question with 21 points was on the “impact of mHealth - use of digital technology to increase knowledge and access to safe abortion services”.
Unsafe abortion is among the causes of maternal mortality and morbidity in countries with restrictive abortion laws [
Community based awareness programs to scale back unwanted pregnancies and encourage women to seek for help early was ranked highly with 28 points out of the possible 30 points. Unsafe abortion is a major consequence of unintended pregnancy mainly due to the high unmet need for contraception. Therefore, preventing unintended pregnancies by promoting contraceptive use would significantly reduce variety of unsafe abortions and maternal deaths [
In recent years, reductions in unplanned pregnancy have led to parallel reductions in unplanned childbearing, with positive benefits for women’s health and children’s well-being. But unplanned pregnancy rates remain high among unmarried women under the age of 30, with majority of the pregnancies unintended [
Ten key research priorities in preventing unsafe abortion identified have the potential of providing direction on areas to focus on in preventing unsafe abortion. Until responsive interventions are taken, complications from unsafe abortion will remain a major cause of maternal mortality and morbidity. The research priority questions if implemented will help inform public dialogue to strengthen advocacy for safe abortion in the WHO Africa region.
NT, OL, BF, MS, DK, DS, AC and EH conceptualized the idea of the research prioritization exercise. KC, AM, TL, consolidated the online survey and provided technical support. All authors read and approved the final manuscript.
We thank all the experts who were involved in the research prioritization exercise for WHO Africa Region. They include: Zan Souleymane, Moufalilou Aboubakar, Bokossa Alexis Richard, Gaston D. Ahounou, Dina Gbenou, Hien Clotaire, Kiemtoré Sibraogo, Traoré Isidore Tiandiogo, Bassounda, Poïdigem, Dadjoari Moussa, Nguetabe Odile, Awad Adam Awad, Foumsou, Kini Brigitte Nsiku, Haimanot Ambelu Workineh, Tenaye Kebede, Girma Gemechu, Mekdes Daba, Deo Roseline, Samuel Oppong, Ivy Osei, Patrick K. Aboagye, Sy Telly, Férida Mara, Alpha Ahmadou Diallo, Tessougue Fatoumata, Idrissa Cissé, Sidy Diallo, Ben Moulaye Haidara, Moussa Kamissoko, Ojo Olumuyiwa, Ufere Joy, Ikpeze Okechukwu Christian, Chris Ega, Kabuteni Theopista John, Utumatwishima Jean Nepo, Ndaruhutse Victor, Ruzindana Kenneth, Mihretu Belete, Sithembile Dlamini-Nqeketo, K.S. Dithole, Rapinyana O., Ntombi Mtshali, Mercy Pindani, Azwihangwisi Helen Mavhandu-Mudzusi, Uta Lehmann, Boniface Ushie, David Norris, Blami Dao, Issiaka Sombie, Seni Kouanda, Richard Adanu,Goma Mboungou Mierette, Mavounia Ndoko Genil, Ngwenya, Mmamoitlamo and Mncwabe Pearl.
The WHO Regional office for Africa.
All authors declare no competing interests.
Ouedraogo, L., Nkurunziza, T., Muriithi, A., Asmani, C., Elamin, H., Zan, S., Belete, M., Dina, G., John, T.K., Françoise, B., Kwami, D., Rahn, K.C., Moazzam, A., Lemi, T., Dao, B., Sombie, I. and Mollent, O. (2021) Research Priorities for Preventing Unsafe Abortions in the WHO Africa Region. Advances in Reproductive Sciences, 9, 24-32. https://doi.org/10.4236/arsci.2021.91003
CHNRI: Child health and nutrition research initiatives; WHO: World Health Organization; UHC: Universal health coverage; SRHR: sexual and reproductive health and rights, EMRO: World Health Organization Office for the Eastern Mediterranean; AFRO: World Health Organization Regional Office for Africa.