Repeated induced abortion among women seeking abortion care services in public health facilities in Harar town, Eastern Ethiopia

Abstract

Repeated induced abortion is a major public health problem that affects an estimated 56 million women worldwide and more than half a million women in Ethiopia each year. There is a scarcity of information on the level of repeated induced abortion and its determinants in the country, particularly in eastern Ethiopia. This study aimed to assess repeated induced abortions and associated factors among women seeking abortion care services in public health facilities in Harar town, eastern Ethiopia. An institution-based cross-sectional study was conducted among 374 women in Harar town from June 01 to July 30, 2022. Data were entered using EpiData version 4.1 and analyzed using SPSS version 27.0. Bivariable and multivariable logistic regression analyses were applied to identify significant factors of repeated induced abortion. The Hosmer and Lemeshow goodness-of-fit test was used to confirm the model’s fitness with a p-value > 0.05. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were used to report the strength of association, and statistical significance was declared at p-values < 0.05. The magnitude of repeated induced abortion among women seeking abortion care in Harar town was 25.7% (95% CI: 21%, 30%). Living far from health facilities (AOR = 4.61, 95% CI: 2.23, 9.53), using substances (AOR = 3.13, 95% CI: 1.65, 5.95), not utilizing post-abortion family planning (AOR = 3.79, 95% CI: 2.04, 7.05), having short interpregnancy intervals (AOR = 4.42, 95% CI: 2.38, 8.22), having multiple sexual partners (AOR = 4.42, 95% CI: 2.38, 8.22), and having poor knowledge about abortion (AOR = 2.47, 95% CI: 1.35, 4.52) were the significant risk factors of repeated induced abortion. One in every four women seeking induced abortion care had repeated induced abortion in Harar town. Distance from nearby health facilities, substance use, post-abortion family planning, interpregnancy interval, multiple sexual partners, and knowledge about abortion were the determinants of repeated induced abortion. Providing behavioral change counseling about sexual and reproductive health for all reproductive-aged women and enhancing reproductive health service utilization is essential to preventing and reducing the burden of repeat-induced abortion.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-026-36475-5.

Introduction

An induced abortion is an intentional termination of pregnancy at any time before the foetal viability to survive outside the uterus, before 28 weeks of gestation. Repeated induced abortion is an induced abortion conducted two times or above before the 28th week of gestation^1,2. Evidence indicated that an average of 73 million induced abortions were conducted each year globally. Around 61% of unintended pregnancies and 29% of overall pregnancies ended with induced abortion³.

Repeated induced abortion is a major public health problem that affects an estimated 56 million women each year worldwide. Among those, 8.5 million occurred in Africa, and 2.7% were in eastern Africa^2,4. In Ethiopia, more than half a million induced abortions are performed yearly^4,5. The burden of repeat-induced abortion varies around the world, ranging from 16% to 70% in many countries^2,6. The prevalence of repeated induced abortion ranged from 20.3% to 34.9% in Ethiopia^7,8.

Termination of pregnancy during the first and second trimesters increased the risk of subsequent birth complications, especially when repeatedly performed with mechanical dilation and curettage. Repeated induced abortion significantly affects the outcome of subsequent pregnancies by increasing the risks of recurrent abortion and preterm birth, with life-threatening complications such as hemorrhage, anemia, sepsis, and maternal death^9–11.

Providing post-abortion care services is an accepted public health strategy to prevent and reduce maternal morbidity and mortality. Post-abortion care (PAC) and comprehensive family planning could help prevent future unintended pregnancies and repeat abortions. The incidence of women seeking repeated induced abortion is an indicator of the frequency of women having unintended pregnancies and a gap in optimal contraceptive use. Post-abortion family planning (PAFP) is a key component of PAC that provides specific targeting to prevent repeat-induced abortions⁴. However, facts on unintended pregnancy and abortion in Ethiopia show that women who want to space births are using induced abortion. In addition, Ethiopia has worked on stabilization of rapid population growth since 1990 through expanding reproductive health services such as family planning, reproductive health education, and safe abortion services, which help to decline the total fertility rate (TFR) in the country^12,13. However, according to World Population Prospects data, the TFR remained high in Ethiopia, which is 4.0 in 2023, and the presence of a higher prevalence of repeated induced abortion indicates gaps in contraceptive use and postabortion counseling¹⁴. There are massive factors affecting repeated induced abortion in developing countries, including Ethiopia. However, little is known about factors associated with repeated induced abortion in Ethiopia. The residence area, women’s age, women’s education status, marital status, and number of sexual partners were the determinants of repeated induced abortion among women in Ethiopia^7,8,15,16.

Despite efforts to improve family planning access and PAC, specifically PAFP, the higher burden of induced abortion was reported each year in Ethiopia. A few previous studies were conducted in one site region of Ethiopia, and among non-governmental facilities^7,8,17,18. In addition, the previous studies failed to assess the most important predictor, the effect of a short inter-pregnancy interval on repeated induced abortion. Overall, there is a scarcity of information on the level of repeated induced abortion and associated factors in the country, particularly in eastern Ethiopia. Therefore, this study aimed to assess repeat induced abortion and associated factors among women seeking abortion services in Harar health facilities, eastern Ethiopia.

Method and materials

Study design, setting and period

An institutional-based cross-sectional study was conducted among women seeking abortion care services in public health facilities in Harar town from June 01 to July 30, 2022. Harar town is the capital city of the Harari regional state, located 526 km to eastern Ethiopia from Addis Ababa, the capital city of Ethiopia. The town has 139,380 total population; 68,048 are females, and 43,339 are women in the reproductive age group. According to Harari Regional Health Bureau’s annual report 2022, there are three public hospitals (two government and one private), eight public health centers, 34 health posts, two non-government clinics, and 38 private clinics in the town. Based on the Harari Regional Health Bureau’s 2022 annual report, a total of 2645 women received comprehensive abortion care (CAC) services in the town. During the study period, six public health facilities (two hospitals and four health centers) provided CAC services in Harar town.

Population

All women in the reproductive age group who were seeking abortion care services at public health facilities in Harar town were the source population. Women in the reproductive age group seeking abortion care services at selected public health facilities in Harar town during the study period comprised the study population. All women in the reproductive age group who had a previous abortion attending selected public health facilities for abortion care services during the data collection period were included in the study. The women seeking abortion care service due to pregnancy complications, those who attended the facilities for PAC service, and those who were critically ill and unable to respond to the interview were excluded from the study.

Sample size and sampling procedure

The sample size (n = 384) was calculated by Epi-Info version 7.1 using a single-population proportion formula with the following assumptions: a confidence level of 95%, 5% a margin of error, and an expected proportion of repeat-induced abortion (34.9%) in Debra Markos, Northwest Ethiopia⁷. Using a 10% non-response rate, the final estimated sample size for the study was 384.

All public health facilities that provide CAC services in the town were selected purposefully. Six public health facilities (two hospitals and four health centers) were providing CAC services in Harar town. The estimated sample size was allocated proportionally to each selected health facility based on the average number of induced abortion case flows in the last six months before the data collection period. Then, a systematic random sampling technique was employed to select the study participants from each selected health facility. The sampling K^th value was calculated using the formula K = N/n, and every second woman was selected for an interview from each facility.

Data collection tool and procedure

The data were collected using a structured questionnaire adapted from the previously published literature^4,8,15,17,18. An exit interview was conducted after completing clinical visits in a separate and quiet area. The questionnaire contains socio-demographic characteristics, behavioural characteristics, and reproductive-related characteristics (S1). Six diploma midwives collected the data under the supervision of three public health officers after training for one day on the objective of the study and the data collection technique.

Induced abortion (IA) is the intentional termination of a pregnancy in health facilities by a trained health professional using aseptic procedures before the age of foetal viability by any means.

Repeat-induced abortion (RIA) was assessed by asking the women about previous induced abortion before the current one. Women seeking abortion care who had at least one prior induced abortion without any medical or surgical indication were considered as repeated induced abortion (coded ˈ1ˈ), and no repeated induced abortion (coded ˈ0ˈ) when the current induced abortion was the first.

Substance use was measured using three dichotomous (yes/no) items asking about habits of substances during the current pregnancy, and then, a composite index score was computed from three items, and substance use was considered ‘Yes’ when the participant used at least one type of substance, and ‘No’ otherwise.

Interpregnancy interval the time from the end of the previous pregnancy to the last normal menstrual period of the current pregnancy. The end date of the previous pregnancy and the conception date of the current pregnancy were confirmed by the woman. If the woman did not know the exact date, the mid-month date was taken for the end date of the previous pregnancy and the conception date of the current pregnancy. The interpregnancy interval is calculated by subtracting the end date of the previous pregnancy from the conception date of the current pregnancy. The pregnancy interval that occurred before 18 months of the previous pregnancy was considered a short inter-pregnancy interval.

Knowledge about abortion was assessed using 18 dichotomous (yes/no) items asking about abortion knowledge. The responses were coded as ‘1’ when correct and ‘0’ when incorrect. Then, a composite index score was computed from 18 items, and the women’s knowledge was considered ‘Good’ when the score was greater than or equal to the mean, and ‘Poor’ otherwise.

Data quality control

The questionnaires, initially prepared in English, were translated into the local languages (Afan Oromo and Amharic) and then back into English by two experts with proficient in both languages. To ensure the questionnaire’s validity, a pretest was conducted on 5% (19 participants) of the study’s sample size in a separate health facility in the town before the actual data collection. Data collectors and supervisors received one day of training on the study’s objectives, and the data collection methods. The internal consistencies of items of the composite index score were checked using a reliability analysis test (Cronbach’s α).

Data processing and analysis

After checking for completeness and consistency, the data were entered into EpiData version 3.1 and analysed using SPSS version 27. Descriptive statistics such as frequency, measure of central tendency, and dispersion were used to characterize the women. The internal consistencies of items were checked for substance use and knowledge using reliability analysis (Cronbach α), and we observed high internal consistency in substance use items (Cronbach’s α = 0.72) and knowledge about abortion items (Cronbach’s α = 0.86). Bivariable and multivariable logistic regression analyses were conducted to identify factors associated with repeated induced abortion. A multivariable logistic regression was fitted to determine the significant risk factors. Hosmer and Lemeshow’s goodness-of-fit test at a p-value > 0.05 was used to confirm the overall adequacy of the model’s fitness. Adjusted Odds Ratio (AOR) with its 95% confidence interval (CI) was used to report the strength of an association and the statistical significance, declared at p-value < 0.05.

Results

Sociodemographic characteristics

A total of 384 eligible pregnant women were invited, and 374 (97.4%) participated in the study. The mean age of the participants was 24.5 (± 5.6) years, and the majority (60.2%) of them were in less than or equal to 24 years age group, followed by 26.4% in the 25–34 years age group, and 13.4% in the 35 and above years age group. The majority (74.1%) of the participants were from urban residences, and around 61.0% of the participants’ education level was secondary school, followed by 23.8% primary school level, and 15.2% no formal education. Among occupational statuses, about 61.2% of the participants were government employees, followed by 16.0% students, 13.4% merchants, and 9.4% housewives. Regarding the marital status, one in every five participants was never married (Table 1).

Table 1.

Sociodemographic characteristics of the women seeking abortion care at public health facilities in Harar town, Eastern Ethiopia, 2022 (n = 374).

Characteristics	Responses	Frequency (%)
Residence area	Rural Urban	97 (25.9) 277 (74.1)
Facility types	Health center Hospital	92 (24.6) 282 (75.4)
Age (in year)	≤ 24 25–34 ≥ 35	225 (60.2) 99 (26.5) 50 (13.4)
Current marital status	Married Divorced Widowed Never married	237 (63.4) 45 (12.0) 14 (3.7) 78 (20.9)
Education level	No formal education Primary school Secondary school	57 (15.2) 89 (23.8) 228 (61.0)
Occupation	Students Housewives Merchants Government employee	60 (16.0) 35 (9.4) 50 (13.4) 229 (61.2)
Religion	Muslims Orthodocs Protestants Others a	216 (57.8) 99 (26.5) 50 (13.4) 9 (2.4)
Ethnicity	Oromo Amhara Harari Others b	238 (63.6) 104 (27.8) 22 (5.9) 10 (2.7)
Have own income	Yes No	161 (43.0) 213 (57.0)
Distance from nearby health facilities	≥ 30 minutes < 30 minutes	120 (32.1) 254 (67.9)
Substance use	Yes No	156 (41.7) 218 (58.3)

^a= Catholics, Adventists; ^b= Somali, Gurage and Tigre.

Reproductive-related characteristics

The mean (± SD) age at first sex is 18.9 (± 2.1), and at most, one in every five women has initiated sexual intercourse before 18 years old. The median gravidity and interquartile range (IQR) of the participants were 2 (IQR = 3, 25th percentile = 1, and 75th percentile = 4); more than half (53.5%) of them were gravida two, followed by 30.5% gravida three to four, and 16.0% greater than or equal to gravida five. The mean (± SD) of alive children was 1.2 (± 1.4), with at most two in every three participants having less than or equal to one alive child, followed by 28.9% having two to four, and 3.7% of participants having greater than or equal to five alive children. The median age and IQR of pregnancy were 7.0 (IQR = 4, 25th percentile = 5, and 75th percentile = 9); the majority (60.7%) of them attended an abortion center at less than or equal to seven weeks, followed by 29.7% 8–14 weeks, and greater than or equal to 15 weeks of gestational age. Among post-abortion family planning use, slightly three in every five women received post-abortion family planning during their previous abortion care, and about 46.0% of women had a short interpregnancy interval. Regarding knowledge about abortion, about 44.9% of women had poor knowledge (Table 2).

Table 2.

Reproductive and related characteristics of the women seeking abortion care at public health facilities in Harar town, Eastern Ethiopia 2022 (n = 374).

Characteristics	Responses	Frequency (%)
Age at first sex (in year)	< 18 ≥ 18	82 (21.9) 292 (78.1)
Have multiple sexual partners (MSP)	Yes No	112 (29.9) 262 (70.1)
Gravidity	2 3–4 ≥ 5	200 (53.5) 114 (30.5) 60 (16.0)
Number of alive children	0–1 2–4 ≥ 5	252 (67.4) 108 (28.9) 14 (3.7)
Have still birth history	Yes No	45 (12.0) 329 (88.0)
Gestational age (in weeks)	≤ 7 8–14 ≥ 15	227 (60.7) 111 (29.7) 36 (9.6)
Short interpregnancy interval	Yes No	172 (46.0) 202 (54.0)
Previous abortion procedure	Medical Surgical Both	307 (82.1) 55 (14.7) 12 (3.2)
Used PAFP during previous abortion	Yes No	220 (58.8) 154 (41.2)
Type of PAFP used	Pills Injectable Implant IUCD	54 (24.6) 107 (48.6) 46 (20.9) 13 (5.9)
Knowledge about abortion	Poor Good	168 (44.9) 206 (55.1)

IUCD = Intrauterine contraceptive device; PAFP = Post abortion family planning.

Magnitude of repeat induced abortion

The magnitude of repeat induced abortion was 25.7% (95% CI: 21%, 30%) among women seeking abortion care services in public health facilities in Harar town. The majority (86.1%) of these abortions were induced during the first trimester, and around 75% of these abortions were conducted in hospitals.

Factors associated with repeat induced abortion

In bivariable analysis, education level, distance from nearby health facilities, substance use, post-abortion family planning (PAFP), interpregnancy interval, multiple sexual partners status, and knowledge about abortion were factors associated with repeat induced abortion. In multivariable analysis, distance from nearby health facilities, substance use, PAFP, interpregnancy interval, multiple sexual partners status, and knowledge about abortion were independent factors associated with repeat induced abortion among women in reproductive age groups (Table 3).

Table 3.

Factors associated with repeat induced abortion among women seeking abortion care at public health facilities in Harar town, Eastern Ethiopia, 2022 (n = 374).

Characteristics	Responses	Repeat induced abortion		COR (CI)	AOR (CI)
		Yes n (%)	No n (%)
Resident area	Rural Urban	38(34.0) 63(22.7)	64(66.0) 214(77.3)	1.75 (1.06, 2.90) 1	1.15 (0.48, 2.80) 1
Facility type	Health center Hospital	71(25.2) 25(27.2)	211(74.8) 67(72.8)	1.11 (0.65, 1.89) 1	1.44 (0.73, 2.83) 1
Marital status	Married Divorced Widowed Never married	61(25.7) 16(35.6) 5(35.7) 14(17.9)	176(74.3) 29(64.4) 9(64.3) 64(82.1)	1 1.59 (0.81, 3.13) 1.60 (0.52, 4.97) 0.63 (0.33, 1.21)	1 2.06 (0.83, 5.08) 2.66 (0.68, 10.30) 0.54 (0.23, 1.25)
Education level	No formal education 1º school 2º school and above	24(42.1) 23(25.8) 49(21.5)	33(57.9) 66(74.2) 179(78.5)	2.66 (1.44, 4.91)** 1.27 (0.72, 2.25) 1	1.57 (0.67, 3.67) 0.74 (0.35, 2.54) 1
Occupation	Students Housewives Merchant Gvn’t employed	14(23.3) 12(34.3) 14(28.0) 56(24.5)	46(76.7) 23(65.7) 36(72.0) 173(75.5)	0.94 (0.48, 1.84) 1.61 (0.75, 3.45) 1.20 (0.60, 2.39) 1	1.32 (0.54, 3.21) 0.38 (0.09, 1.56) 0.55 (0.20, 1.49) 1
Distance from nearby HF	≥ 30 min < 30 min	16(13.3) 80(31.5)	104(86.7) 174(68.5)	1 2.99 (1.66, 5.39)***	1 4.61 (2.23, 9.53)***
Substance use	Yes No	60(38.5) 36(16.5)	96(61.5) 182(83.5)	3.16 (1.95, 5.11)*** 1	3.13 (1.65, 5.95)*** 1
Used PAFP	Yes No	38(17.3) 58(37.7)	182(82.7) 96(62.3)	1 2.89 (1.79, 4.67)***	1 3.79 (2.04, 7.05)***
Short interpregnancy	Yes No	65(37.8) 31(15.3)	107(62.2) 171(84.7)	3.35 (2.05, 5.48)*** 1	4.42 (2.38, 8.22)*** 1
Having MSP	Yes No	49(46.7) 47(17.5)	56(53.3) 222(82.5)	4.13 (2.52, 6.79)*** 1	3.19 (1.67, 6.07)*** 1
Knowledge about abortion	Poor Good	66(39.3) 30(14.6)	102(60.7) 176(85.4)	3.80 (2.31, 6.25)*** 1	2.47 (1.35, 4.52)** 1

Key: *= p-value < 0.05; **= p-value < 0.01; ***= p-value < 0.001; AOR = adjusted odds ratio; HF = Health Facilities; MSP = multiple sexual partners; PAFP = post abortion family planning.

The women who were living away more than 30 minutes on foot from health facilities were 4.6 times (AOR = 4.61, 95% CI: 2.23, 9.53) more likely to have repeated induced abortions than those who were near the health facilities. Women who used substances were about 3.1 times more likely to have repeated induced abortions than those who did not use (AOR = 3.13, 95% CI: 1.65, 5.95). The women who did not utilize PAFP during previous abortions were 3.79 times (AOR = 3.79, 95% CI: 2.04, 7.05) more likely to have repeated induced abortion than those who utilized PAFP. The women who have short interpregnancy intervals were about 4.4 times more likely to have repeated induced abortion AOR = 4.42, 95% CI: 2.38, 8.22) compared to their counterparts. The women who had multiple sexual partners within the last 12 months were 3.1 times more likely to have repeated induced abortions than those women who had not multiple sexual partners (AOR = 4.42, 95% CI: 2.38, 8.22). The women who have poor knowledge about abortion were about 2.5 times more likely (AOR = 2.47, 95% CI: 1.35, 4.52) to have repeated induced abortion than those who have good knowledge (Table 3).

Discussion

This study assessed the magnitude of repeat-induced abortion and associated factors among women seeking abortion care in public health facilities in Harar town, eastern Ethiopia. The finding shows that the magnitude of repeated induced abortion was 25.7% (95% CI: 21%, 30%) in Harar town. This finding was comparable with a study conducted in Nigeria (23.0%)¹⁹. However, this finding was somewhat higher than the studies conducted in Debre Berhan, Central Ethiopia (20.3%)⁸, and in Kenya (16.0%)².

On the other hand, this finding was lower than the studies conducted in Debra Markos, north-western Ethiopia (34.9%)⁷, Addis Ababa, Ethiopia (31.0-33.6%)^18,20, Southern Ethiopia 35.4%¹⁷, Sudan (40.0%), and Tunisia (42.2%)²¹. These differences may be due to methodological differences. For instance, the comparable study conducted in southern Ethiopia included women who had both induced and spontaneous previous abortions, while only women who had previously induced abortions were included in our study. In addition, this difference might be attributed to differences in study populations. For example, the comparable study in Addis Ababa involved women seeking abortion care at non-governmental clinics, but our study focused on women seeking abortion care at public health facilities. Furthermore, this difference might be due to variations in the background of the study participants and variance in the study setting.

This study revealed that distance from nearby health facilities is a significant predictor of repeated induced abortion. The women who were far from public health facilities were 4.6 times more likely to seek repeated induced abortion care compared with their counterparts. This might be due to the women living far from health facilities being more likely to miss an opportunity to utilize reproductive health services including family planning, which increase the risks of unintended pregnancy. In addition, the women who were living far from health facilities were less likely exposed to information about reproductive health services^22,23.

The findings of this study indicated that women who used substances were three times more likely to have repeated induced abortions than those who did not use substances. The finding of this study was supported by the studies conducted in Debre Markos⁷, Ethiopia, and southern Ethiopia¹⁷. This might be due to the use of substances increasing sexual risk-taking behavior that engages women in unprotected sexual intercourse, multiple sexual partners, and lower use of contraceptives, which leads to unintended pregnancy and abortion^24,25.

Women who did not use post-abortion family planning during previous abortions were nearly four times more likely to have a repeated induced abortion than those who used post-abortion family planning. This finding was supported by research conducted in the Democratic Republic of Congo. Missing an opportunity to utilize post-abortion family planning might increase the risks of unwanted pregnancies and result in shorter interpregnancy intervals. This implies that failing to use post-abortion family planning has been increasing the burden of induced abortions. It’s essential to provide and improve the coverage of post-abortion family planning utilization at all levels of health facilities to reduce and prevent repeat induced abortions.

The findings of this study also indicated that women who had short interpregnancy intervals were four times more likely to have repeated induced abortions compared with their counterparts. This could be because women may become pregnant again during the postpartum and post-abortion periods before utilizing effective contraception, resulting in an unintended pregnancy that increases the risk of abortion. Unwanted pregnancies, which are often connected to short interpregnancy intervals, and unexpected pregnancies may actually encourage women to terminate their pregnancies²⁶.

In addition, multiple sexual partners were a substantial risk factor for repeated induced abortion. Women who had several sexual partners within the last 12 months were three times more likely to have a repeated induced abortion than those who did not. This finding of the study is consistent with research undertaken in Debre Markos, Ethiopia⁷, Debre Berhan, Ethiopia⁸, Southern Ethiopia¹⁷, and Cambodia²⁷. This could be because women who have several sexual partners have unstable relationships, resulting in an unmet need for contraception, contraceptive failure, and unintended pregnancy.

Furthermore, the women who had poor knowledge about abortion were two times more likely to have repeated induced abortion compared to those who had good knowledge. This finding was supported by the studies conducted in Debre Berhan and Addis Ababa, Ethiopia^8,18. The women who have poor knowledge about abortion might consider an abortion procedure as a form of family planning. It’s worrisome that women refuse contraceptive use and seek induced abortion in developing countries. Given that, providing effective and behavioural change counselling for the women on recommended and preferable methods to prevent unintended pregnancy would be essential to reducing and preventing repeated induced abortion.

Since the study design is a cross-sectional study, the findings may be affected by drawbacks, and the findings of this study may not represent the women who did not attend health facilities. In addition, social desirability bias may be introduced due to the sensitivity issues with the participants’ history of a previous abortion.

Conclusion

The findings of this study indicated that one in every four women seeking abortion care had repeated induced abortions in Harar town. Distance from nearby health facilities, substance use status, post-abortion family planning utilization, interpregnancy interval, multiple sexual partners, and knowledge about abortion were the main determinants of repeated induced abortion among women in Harar. Providing behavioural change counselling about sexual and reproductive health and reducing short interpregnancy intervals through strengthening reproductive health service utilization is essential to preventing and reducing the burden of repeated induced abortion.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

AOR

Adjusted Odds Ratio

CAC

Comprehensive Abortion Care

LIMIC

Lower Middle-Income Countries

PAC

Post Abortion Care

PAFP

Post Abortion Family Planning

RIA

Repeat Induced Abortion

SSA

Sub-Saharan Africa

WHO

World Health Organization

Author contributions

AM, HM, DA, HAA, and AAU participated in the conception of the idea, development of the proposal, data collection, and analysis, and wrote up the draft results. AM, HM, DA, HAA, and AAU reanalyzed the data and drafted, edited, and revised the drafted manuscript. All authors read and approved the final manuscript.

Data availability

The data of this study are presented in the main manuscript. Any additional files (data) that support the findings are available from the corresponding author upon reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethical approval and informed consent

The ethical clearance was obtained from the Institutional Health Research Ethical Review Committee of the College of Health and Medical Sciences, Haramaya University, Ethiopia (Ref. No: IHREC/101/2022). All study procedures followed the Helsinki Declaration of human research²⁸. Written informed consent was obtained from all participants after explaining the purpose and benefits of the study.