The Influence of Abortion Legality Knowledge on Abortion Provision and Referral Practices among Reproductive Healthcare Providers in Lomé, Togo Open Access

Anderson, Katherine M. (Spring 2018)

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Despite the significant contribution of unsafe abortion to maternal morbidity and mortality, including accounting for 13 percent of maternal mortality and resulting in 5 million years of productive life lost, it continues to be understudied in contexts of limited legality and high regional stigma. One such context is the capitol city of Lomé, Togo, wherein the majority of induced abortions are performed by untrained providers and by non-recommended methods. Providers have been identified as facilitators and barriers to safe abortion services, and their opinions and provision practices regarding safe abortions can be influenced by knowledge of legality. This influence is complicated under ambiguous circumstances of legality, such as is the care in Togo; while de jure legality includes circumstances of rape, incest, fetal malformation, and risk to the life of the woman, there is little implementation, and articles outlining application have never been issued. As such, understanding Lomé reproductive health care providers’ knowledge of abortion legality and how legality knowledge influences provision and referral practices may have implications for women’s health. Surveys with 60 reproductive health care providers from four healthcare settings in Lomé, Togo, were analyzed to understand this relationship through the lens of the Social Cognitive Theory. Results of this analysis indicate that provider knowledge of legality is low, with the exception of knowledge of the circumstance of fetal malformation; that increased legality knowledge is associated with professions of OBGYN and medical assistant; and that age, profession of medical doctor including OBGYN, and knowledge of the rape circumstances of legality are associated with referral practice. Recommendations include institutionalization of legality education in association with comprehensive abortion care and post-abortion care, comprehensive education at all provider levels, and expansion of abortion legality.

Table of Contents


1. Introduction 1

2. Review of the Literature 2

Togolese Context 3

Theoretical Framework 7

3. Methods 14

Parent Study 14

Procedure 15

Measures 17

Statistical Analysis 18

4. Results 21

Demographics 21

Aim 1 Results 23

Aim 2 Results 26

Aim 3 Results 29

5. Discussion 34

Legality Knowledge 34

Abortion Provision Practices 34

Abortion Referral Practices 35

The Role of Profession 36

Age and Referral 36

Impact of Legality Knowledge on Referral 37

Predictive Ability of the Social Cognitive Theory 38

Limitations 38

Implications 40

References 44

Appendix A: Additional Tables 47

Appendix B: Survey 50


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