Drivers, decision making processes and outcomes of unsafe abortion in four districts of Siaya County, Kenya .
Unsafe abortion is a major public health problem causing 13% and 30% of maternal deaths globally and in Kenya respectively. Despite this, the drivers of the practice in Kenyan communities are scarcely documented. Further, little is documented about the decision making process for women who chose unsafe abortion and whether social networks have a role on this. In addition, not much is known about the methods unsafe abortion providers use and the outcomes of the methods. The objectives of this study were, therefore, to determine the drivers of the practice; find out how social networks influence women's decisions to procure abortion; and determine outcomes of methods used in Siaya County. The study employed a mixture of quantitative and qualitative techniques including cross-sectional survey of 320 patients presenting to health facilities after attempted unsafe abortion; case studies of 8 women who had undergone unsafe abortions; one enquiry into unsafe abortion related death using Rashomon technique and in-depth interviews with 12 unsafe abortion providers and 21 key informants. The findings indicated that women procuring unsafe abortions were mostly below the age of 24 years (76%), in their first trimester of pregnancy (85%) and presenting to health facilities with incomplete abortion (87%). The most commonly reported drivers of unsafe abortion included inadequate infrastructure and equipment in health facilities with all facilities studied not having a full complement of recommended conditions. Only 5.5% of eligible health workers were competent and willing to provide termination of pregnancy services. At community level, unsafe abortions were associated with desire for a good life, pressure from social contacts, and the determination of unsafe abortion providers to give the service. Social networks were found to play a role in the woman's decision making process with 95% of the women consulting with their social networks before making a decision. These consultations led to 63% of women owning a decision to abort while the rest were either not sure or even felt compelled to abort. Logistic regression predictions showed that the man causing the pregnancy and the woman's mother were the most influential persons in cases of unsafe abortion. A case fatality rate of 0.3 per 1000 women aged 15 - 44 was recorded. Other severe complications included hemorrhage requiring blood transfusion and pelvic infection. A Chi square test revealed significant difference in the outcomes of unsafe abortion based on the methods used (X2 = 193, df = 30, p 0.05). Logistic regression predictions confirmed that the outcomes depended on methods used, genital tract injury, for example, being 30%, 120% and 370% more likely to occur with use of self -inserted gadgets, self- inserted medicine and gadget inserted by someone else respectively as compared to hemorrhage not requiring transfusion. It is recommended that the Ministries in charge of Health and NGOs running programs to reduce unsafe abortion prioritizes community involvement as a way of reducing unsafe abortion; give unsafe abortion providers capacity to counsel and refer patients to health facilities; and that the identified drivers of unsafe abortion are addressed comprehensively.