A Situation Analysis on Abortion in Nigeria

A SITUATION ANALYSIS ON ABORTION IN NIGERIA

COMPILED BY

Professor IAO Ujah, FMCOG, mni

Secretary-General, SOGON &

Focal Point, FIGO Focal Point on Preventing Unsafe Abortion in Nigeria

Department of Obstetrics & Gynaecology

Jos University Teaching Hospital, Jos

Dr S.O. Shittu, FWACS

INTERNATIONAL FEDERATION OF GYNAECOLOGY & OBSTETRICS (FIGO) PREVENTION OF UNSAFE ABORTION

& THE SOCIETY OF GYNAECOLOGY & OBSTETRICS OF NIGERIA (SOGON)

1 INTRODUCTION

1. COUNTRY PROFILE

Nigeria is situated on the west coast of Africa, sharing borders with the Republics of Benin in the west, Cameroon in the east, Niger and Chad in the north. Although it is spatially the fourth largest country on the African continent, with a total land area of 923,768 square kilometers, its population of 144 million (2006 census) is the largest on the continent, hosting a quarter of the continent’s population and constitutes the world’s tenth most populous nation.

The country’s people are diverse, with over 350 ethnic groups, each with distinct historical, social and cultural identities; the larger ones include the Hausa/Fulani in the north, Yoruba and Ibo in the south.

Its vegetation ranges from the swampy rain forest along its southern Atlantic coastline, through the savannah grasslands of the middle-belt, to the almost desert topography of its northernmost areas. Almost the entire country share a common two-phase climatic pattern: a rainy season in the months of April to September and dry, dusty harmattan season particularly in the northern part of the country in October to March.

These diverse vegetations and climate are strong determinants of the occupations and lifestyles of the people in the respective parts of the country. Peasant farming and petty trading remain the dominant occupations of Nigerians inspite of the relegation of agriculture by crude oil as the country’s leading foreign exchange earner since the 1980s. This scenario coupled with rife mismanagement of resources to account for a high prevalence of poverty among its predominantly rural population, as an estimated 70% of its people are reported by the World Bank to still live ‘below the poverty line’1.

The country has a political structure of 36 states and a federal capital territory, which in turn comprise of 774 local government areas. Each of these entities is administered by an elected administration, within the context of a three arms of government viz; the executive, the legislature and the judiciary.

2 2. Nigeria’s Health Care System

Two major health care systems operate in Nigeria; the age-long traditional and the organized orthodox system. The traditional system is operated by individuals with varied capacities and competencies in the likes of Traditional Healers and Traditional Birth Attendants. Although Primary Health Care is the pivot of Nigeria’s National Health Policy, Secondary and Tertiary Health Care facilities backstop their referrals within the three-tier orthodox health system. These levels of health care are operated and funded by the three levels of government; the Local, State and Federal, in conformity to the National Health Policy. As at 2005, the Federal Government estimated that there were a total of 23,640 health facilities in Nigeria2. Of these, 85.8% were primary health care facilities, 14% secondary health and 0.2% tertiary health care facilities. While 38% of these health facilities belong to the private sector, it was estimated that 60% of orthodox health care was provided by the private sector. The latter comprised both service-for-profit and not-for-profit facilities, including the Faith-based organizations.

Both traditional and orthodox health facilities charge user-fees that are diverse in value and form, except in circumstances where waivers are provided by the facility financiers.

The National Health Insurance Scheme (NHIS) became operational in 2005. Although its coverage is less than 1% of the population, it is beginning to reduce the hitherto high out-of-pocket expenses on health for beneficiaries.

Nigeria has one of the largest stocks of human resources for health in Africa comparable only to Egypt and South Africa. There are about 39,210 Medical doctors and 124,629 nurses registered in the country, which translates to about 30 doctors and 100 nurses per 100,000 population 3. This compares to a Sub- Sahara African average of 15 doctors and 72 nurses per 100,000 population4. It is pertinent to acknowledge that the performance of the Nigerian health system is notwithstanding relatively weak, the World Health Report 2000 ranked the Nigerian health system 187th out of the 191 countries assessed, clearly indicating that the organization, management and financing of the system requires review and

3 improvement. A National Health Reform Bill pursuant to improving the national health system is currently receiving the attention of the country’s legislature.

3. Organization of Nigeria Health System

The Nigeria health system operates within the federal design of its political system. Whereas no legal framework exists yet that clearly articulates the roles and responsibilities of the 3 tiers of government, the1988 National Health Policy15 revised in 1996 and 2004 lays out the different functional workings of the system. The FMOH is responsible for defining the overall policy framework for the health system with the participation of the 36 autonomous states and FCT. She is also accountable for strengthening the technical and managerial competence at state level for delivery of secondary health services at state level and defining norms, standards and protocols for drugs, vaccines, research, hospital services, PHC and human resource training for the sector development. The State ministries of health (SMOH) are responsible for state level policies, legislations, protocols in the Health sector. This may be in the form of domesticating national policies and/or initiating new ones. In addition, they oversee secondary health care service delivery, state wide radiological, diagnostic, referral, emergency medical services and support their local governments in delivering effective primary health care (PHC) services. The local government areas are responsible for managing health service delivery at PHC where the bulk of health services exist.

4. The Reproductive Health Profile:

Nigeria has an annual Crude birth rate of 43 per 1000, a Crude death rate of 15 per 1000, with a resultant annual population growth of 2.8%. Therefore, Nigeria has a Population doubling time of 24 years. Although the country’s Total Fertility Rate (TFR) remains high by international standards, there has been a slow but steady decline in recent years: 6.3 in 1982, 6.0 in 1990 and 5.7 in 20035.

4 Although there has been a decline in the family size desired by Nigerians within the past four decades, the 2003 NDHS revealed that large families were still preferred, the ideal numbers expressed by men and women being 6.7 and 8.6 respectively. This scenario partly explains the huge gulf between knowledge of contraceptive methods in the country and actual utilization: whereas 78.5% of women and 90.2 % of men have knowledge, only 8.9% of all women currently use modern contraceptives5.

The Infant Mortality Rate and Maternal Mortality ratio are high, being 100 per 1000 livebirths and 800 per 100,000 livebirths respectively6.

5. SEXUALITY

Early marriage is widely practiced, with 30% of rural women marrying before the age of 19 years. A recent survey portrays a slow but steady decline in median age at first marriage, from 15.5 years in women aged 45-49 years, 16 years in those aged 35-39 years, to 19.1years in those aged 20-24 years5.

One-third of Nigerian women aged 25-49 years reported sexual debut by the age of 15 years, 76% by the age of 20 years and 90% by 25 years. Sexual debut occurs later for men, the respective proportions for those of same age group being: 5.5% at 15 years and 41% at 20 years5.

In the general population, 69% of all sexually active males and 83% of their female counterparts reported having sexual intercourse in the preceding twelve months. The proportion was comparable among the never-married sexually active; 80% for males and 78% for females during the same period7.

Extra-marital sexual intercourse was indulged in by 21.6% of women aged 20-24 years unlike 12.8% of their teenage counterparts. About 4.1% of women admitted ever having sex in exchange for gifts or favors, and this ranged from 0.4% in the north-west zone of the country to 12.1% in the south-south zone7. A non-marital sexual relationship with boyfriends or girlfriends was reported by 10% of females and 19% of males within the preceding year. This also ranged from 1% in the north-west to 28% in the south-south zones.

5 Sexual intercourse with more than one partner within the preceding twelve months was reported by 2.1% sexually active women, and this ranged widely from 1.2% in the north-west to 14.4% in the south- south zone7.

Exposure to sexual intercourse occurs early in Nigeria, earlier for females than males. Whereas this exposure occurs within matrimony in the northern states that in the south is largely extramarital and more likely to involve multiple partners.

6. CONTRACEPTION

Successive surveys and facility studies affirmed high level of knowledge of contraceptives in Nigeria. The NARHS 2005 found 77% of females and 87% of males knew at least one method while the knowledge of a modern method was evident in 71% of the females and 84% of males7. A study in Jos conducted on women with unwanted pregnancy who sought termination of the pregnancy revealed that whereas, 94% of them were aware of the availability of contraceptive services, only 62% of them had ever used a method; those who did used the methods ineffectively8. Furthermore, although as high as 80.8% of these women expressed positive intentions towards post-abortion family planning, only 18.5% of them actually used of a method after the termination of pregnancy. The modern contraceptives most known to respondents included the male condom (70%), Injectable contraceptives (41%), and the Oral Contraceptives (39%). Emergency contraceptives were known to only 24% of all respondents and 25% of the sexually active unmarried ones.

The perception of Nigerians about contraceptives was diverse. For instance, whereas 62% of the males and 55% of females acknowledged their effectiveness and benefits, about half of survey respondents opined that contraceptive use ‘encourage(s) young people to be “loose”’. One third of the respondents also believed that contraceptives could cause infertility in women, almost half regarded religion as being against family planning use, and a similar proportion claimed it encouraged promiscuity among women and men7. Apart from the condom that was regarded as affordable by half of the respondents, all the other modern contraceptives, including Pills, Injectables, intrauterine device and emergency contraceptives were so

6 regarded by less than a third of them. A similar pattern emerged when asked about access to these contraceptives. It can be concluded that although a large proportion of Nigerians have some knowledge of modern contraceptives; their awareness is about the less effective methods7.

Despite the high level of knowledge of contraceptives in the country, the level of contraceptive utilization had not significantly improved over time; the proportion of married women currently using modern contraceptives was 8% in 1999 and 2003 NDHSs and 10% in the NARHS 2005 survey5, 7.

Condom was the most commonly used modern contraceptive by males and females, and 10% of married males and 49% of sexually active unmarried males used this method. For the unmarried males, coitus interruptus was the next most commonly used contraceptive method, 1.2% 7. Only 28.8% of sexually active unmarried women currently used modern contraceptives, 24.7% relied on the condom, 2.6% on rhythm, 2.1% on emergency contraceptives, 1.5% on coitus interruptus, 1.3% on the oral contraceptive pill, and 0.7% on the Injectables.

The foregoing reveals a scenario whereby there is good knowledge of modern contraceptives in the country, albeit those of low effectiveness, but a low level of utilization. When used, preference is given to the user-dependent contraceptive methods, most of which are of low effectiveness.

7. UNWANTED PREGNANCY:

Successive studies on unwanted pregnancy in Nigeria indicate between 20-28% of Nigerian women of reproductive age have ever experienced unwanted pregnancy9, 10, 11. The most extensive survey on the subject was recently published by Bankole et al11, it utilized Demographic Health Survey-style technique to interview 2,978 women of reproductive age in eight states across the country, in 2002-3. The study reported that 27.8% of all the women interviewed had ever experienced unwanted pregnancy and there were no significant geographic variations. The unwanted pregnancy rates for different categories of women were as follows:

 32.8% among unmarried women

7  26.4% among married women

 26.7% among teenagers (women aged below 20 years)

 22.6% among nulliparous women

 30% among women of low socio-economic class

 23% among women of middle class

The unwanted pregnancy rates among the different religious groups were: 49% among those of the Catholic faith, 27% with the Christian Protestants, and 17% among the Muslims. Unwanted pregnancy is therefore a frequent occurrence among Nigerian women of reproductive age, irrespective of their age, marital status, parity, social class and religion.

The same survey also revealed the determinants of unwanted pregnancy to include:

 Being unmarried (25.3%)

 Need to stop or space births (19%)

 Being too young or still in school (17.7%)

 Difficulties with partners (16.4%)

 Economic issues (7%)

 Health problems (2%)

Among women who had ever had an unwanted pregnancy, 50.9% reported that they had ever sought to terminate an unwanted pregnancy and as many as 59% had had previous history of more than two terminations of pregnancy, this includes some women who had terminated their pregnancies up to six (6) times because their pregnancies were unplanned and unwanted. The proportions of women of different profiles who had unwanted pregnancy and sought termination were as follows:

8  Teenagers 54.8%

 Women who had never married 61.7%

 Married women 45.4%

 Nulliparous women 74.3%

 Women with more than three childbirths 40.4%

 Women without education 38.6%

 Women with university education 71.1%

 Women of low socio-economic status 40.7%

 Women of high socio-economic class 69.3%

Women living in urban areas were more likely to have sought an abortion than those living in rural areas (61% vs. 47%), and those in the southern states were more likely to have done so than those living in the northern states (62% vs. 43%). It is obvious from the foregoing that abortion is frequently resorted to by various categories of Nigerian women when confronted with unwanted pregnancies. A study explored reasons why Nigerian women sought abortion rather than use contraception12, 13, the fear of future infertility was advanced as the main reason. Others were perceived adverse effects of modern contraceptives on fertility if it was used continuously or for long period, they saw abortion as an immediate solution to unplanned pregnancy.

8. INTERVENTIONS TO PREVENT UNWANTED PREGNANCY:

Abstinence from sexual intercourse and the use of effective contraceptives are the two effective means of personal prevention of unwanted pregnancy. Although prolonged abstinence is encouraged and

9 supported by most Nigerian cultures, especially within the context of fidelity and celibacy, short-interval abstinence is also widely practiced during pregnancy and breastfeeding, but modern day aculturizing influences are threatening these practices.

The use of effective contraceptives remains low (10%), despite high levels of awareness (71%) of modern contraceptives. Several surveys and studies have documented some of the factors responsible for the low utilization of effective family planning methods5, 7, 14. They consistently referred to respondents’ excuses of: ‘negative side-effects’, ‘high cost’ ‘provider bias’ and ‘religious disapproval’. In some northern states, the name ‘family planning’ invokes revulsion as it is perceived to have internationally-driven agenda of population reduction rather than personal benefits. Although, child birth spacing (CBS) appears to be the preferred nomenclature for family planning it is believed by this group that it is only God that can plan a family.

This perception continues to constitute an obstacle to efforts at improving contraceptive access in the area.

Consequent upon these, interventions to prevent unwanted pregnancy have been restricted to the favourable policy pronouncements of government (National Population Policy 1988) and the efforts of international and non-governmental organizations, which have supported programmes aimed at dismantling these myths and improving access to contraceptives. One of the most outstanding of these efforts was the inter-Agency development of a Family Life Education (FLE) (the country’s version of sexuality education) curriculum for use at various levels of the educational system. Its implementation is however bedeviled by opposition from various religious groups who view it as a promotion of promiscuity among the youths15.

Some organizations including, Ipas, Nigeria, and Campaign Against Unwanted Pregnancy (CAUP) Women’s Health and Action Research Center (WHARC) etc have been at the forefront of the advocacy and sensitization against unsafe abortion, capacity building on Post-Abortion Care (PAC) and research on abortion.

10 Ipas Nigeria’s global reputation in post-abortion care has been brought to bear in Nigeria with increasing intensity from 1987 to date through country wide promotion of the use of Manual Vacuum Aspiration (MVA) and concomitant post-abortion family planning counseling and services, which is a strategy of equipping individual patients treated to avoid future unwanted pregnancies. Ipas Nigeria has to date, trained a large number of doctors, nurses, midwives and community health officers at all levels and sectors of the health system16, 17. The organization entrenched women-centered post-abortion care services and has been articulating a comprehensive abortion care response in anticipation of abortion law reforms in the country.

9. SOCIAL PROTECTION OF PREGNANT WOMEN & MOTHERS:

One of the outstanding uniformities of the diverse Nigerian cultures is found in the premium placed on the family unit; it is desired by the unmarried and cherished and maintained by those already in the union. Belonging to a stable family unit is widely regarded as a criterion for commanding and conferring respect and social honours on individuals. This strong family unit confers social protection on pregnant women and their children. Even further protection for women and children come from the widely practiced ‘extended family system’, where biologically or socially related family units network to share experiences, responsibilities and resources. On the other hand, single parenthood is detested by most Nigerian cultures and is stigmatizing to both the parent and child. On account of this, women with out-of- wedlock pregnancies would go any length to either ‘regularize’ it by identifying a father for the child or terminate the pregnancy forthwith.

10. ABORTION

Globally, 19 million unsafe abortions take place in developing countries annually. Every year, 5.5 million unsafe abortions take place in Africa resulting in over 36,000 maternal deaths. In their life time, “tens of millions of African women will experience an unsafe abortion”

Many researchers estimate there may be as many as one million abortions procured in Nigeria annually 18, 19, but the largest evidence for the determination of the prevalence of abortion in Nigeria was

11 provided by Henshaw et al in 199820. The latter undertook a national random sample survey in all public and private health establishments where abortions might be performed or its complications treated. They showed that about 610,000 abortions were being performed annually and estimated that about 12% of pregnancies in Nigeria end up in induced abortion. With an abortion rate of 25 per 1000 women 15- 44years old, higher rates of 32-46% were observed in the more economically developed south than the northern states rate of 10-13 per 1000 women 15-44 years.

About 87% of the induced abortions in Nigeria were performed in private health facilities and 13% in public facilities. About 40% of induced abortions in Nigeria were performed by physicians: 73% of whom were general practitioners, 10% specialist Gynecologists, 8% other specialists and 8% others. Non- physicians provided 60% of induced abortions in Nigeria, and they included: pharmacists/chemists, paramedics, nurse/midwife, Traditional Birth Attendant and the women herself.

Seventy-six percent of the pregnancies induced, were in the first trimester (below 12 weeks gestation) and 24% in the second trimester (above 13 weeks). The use of Dilatation and Curettage or the MVA were reported as preferred methods used for the abortions, less than 10% of them used the Electric Suction or medical methods. The cost of these services depended on the gestational age of the pregnancy, ranging from $6-13 for below 8 weeks gestation to $25-63 for early second trimester abortions. Non-physicians used methods that ranged from D & C, commercial drugs, injections, sharp objects, to traditional herbs. A facility study conducted in Zaria 12, documented methods frequently used to effect self termination of unwanted pregnancy, albeit unsuccessfully, to include, Menstrogen, Coumorit oral and Codiene. Other less frequently used methods were Dr Bojeans, Primodos, Gyaecosid, native concoction, Potash, Phensic, Conca mixture, Pawpaw leaves and Kanwa. This is a clear demonstration of the extreme desperation on the part of these women who carry unwanted pregnancy.

The proportion of induced abortions that develop complications is unclear but it is widely believed that about 50% of those performed by non-physicians may develop complications 20. The relative frequencies of presentation in hospital with complications incurred from abortions induced by these providers are as follows: pharmacist/chemist (5), paramedic (4), nurse/midwife (3) and Traditional Birth Attendant (1).

12 Many publications have been made on the morbidities and mortalities that attend induced abortion in Nigeria and most of them have, for obvious reasons, been hospital based reports.

Table I: Referral Hospital Data on Induced Abortion Complications (Sourced from different publications)

Authors Archibong 199121 Konje 199222 Anate 199523 Ikpeze 200024 Adefuye 200325

Study site South-South zone South-West North- South-east South-west /location zone Central zone zone zone

Caseload of  49 abortions  25.4%  72 abortions  8 abortions  8.6 abortions abortions annually abortions annually annually annually reported annually  40.2% of gynecology admissions

Patients profile  72% adolescents  42.9%  53.5%  100% - secondary adolescents unmarried  80.9% unmarried school girls  59%  94%  11% had previous  36.9% unmarried nulliparous abortion adolescents  22% students  76%  31.6 already had unemployed child  16% housemaids

Origins of  32.3% Traditional  57.1% private - - - abortion service healers clinics

 23.5% Chemists  17.3% chemists  18.4% Physicians  15.3% homes

 5.1% herbalists

 2% gynecologists

Methods used  Oral  87.5% -  50% were in 2nd - for inducing abortifacients involved trimester abortion instrumentati  Intravenous on  Mostly uterine drugs instrumentatio

13  Sharp metal into n uterus

Complications  72.1% sepsis  58%  27% sepsis  Cervical  71.4% recorded peritonitis lacerations septicemia  41.2%  12.5% hemorrhage hemorrhage  Pelvic abscess  47.6% anemia

 8.8% shock  3.5%  Ruptured  33.3% septicemia uterus peritonitis

 1.4% uterine  Bowel injury perforation

Fatality  20% of maternal  8.4% case  9% case  6% case fatality  20.4% case deaths fatality fatality fatality

Whereas Nigeria has 2% of the world’s population, it accounts for 10% of global maternal mortalities. With a current Maternal Mortality Ratio of 800 per 100,000 livebirths, unsafe abortion is responsible for 11% of these deaths 15. A facility-based study in North Central Nigeria on factors contributing to maternal mortality reported that complications due to unsafe abortion contributed 9.4% to all maternal deaths23. Other studies show that the contribution of abortion to maternal mortality varies widely in Nigeria with as high as 30-40% reported 26, 27.

Table I illustrates direct complications from unsafe abortion resulting in maternal deaths, including, hemorrhage, sepsis, genital and other visceral injuries. The restrictive legal environment in the country has been the leading reason for these untoward outcomes, as the secrecy of procuring these abortions encourages the patronage of quacks that work in unhygienic environment and use obsolete and dangerous tools for their “trade” on the usually desperate women. It is estimated that for every death from unsafe abortion, 30 other survivors live the rest of their lives with reproductive health hazards.

11. MISOPROSTOL AND AVAILABILITY.

Misoprostol, a synthetic Prostaglandin analogue, is a drug registered in Nigeria in 2006 as an oxytocic agent for the prevention and control of postpartum hemorrhage and concerted efforts are ongoing at

14 making the drug become widely available for this purpose across the country. Although studies have been conducted within the country to determine the efficacy of Misoprostol in induction missed abortion 28, 29, its use is very limited to research and for clandestine purposes. The experience in the use of Misoprostol for post abortion care services, pregnancy termination and induction of labour is therefore, very limited, particularly as the drug is registered only for use for the prevention and control of postpartum haemorrhage in Nigeria.

12. LEGAL SITUATION OF ABORTION AND REGULATORY FRAMEWORK

Nigeria’s abortion laws as they are currently are restrictive, permitting it only to save the life of the pregnant woman. The laws are relics of the country’s colonial past, dating back to the English Abortion laws of 1861. The northern states operate a Penal Code, while their southern counterparts run the Criminal versions of the laws. Both Codes prescribe up to 14 years jail term for any provider of abortion service unless performed to save the woman’s life. The woman who procures an abortion is liable to 7 years imprisonment. Other than be in the consciousness of people that they exist, these laws have hardly any restraining effects on women who desire abortions and the service providers, and rather they have fueled the following; clandestine abortion services, delays in detection and treatment of complications, quackery, dearth of training opportunities for orthodox health workers (including specialist Gynecologists), and consequently thousands of preventable complications and maternal deaths annually.

The concerns for these adverse outcomes of unwanted pregnancy that have necessitated three previous unsuccessful attempts at securing reforms on abortion law in the country. These attempts were in 1981, 1992 and 2003 respectively26.

There are efforts by individuals and organizations to present a Bill to reform abortion laws to the National Assembly because “by continuing to adhere to archaic colonial laws, by failing to implement international agreement and by failing to act to the growing evidence, we have allowed abortion to be the killing field in Africa” (Sai, 2006) .

13. ADOPTION-

15 Adoption is the procedure by which a child becomes a full member of a family that is not its biological family and is endowed with legal rights as though a biological child of its adopted family. Although there is legal provision for its practice in Nigeria, the law deriving from the colonial English law of 1926, its practice is restricted to the non-Muslims because of the abhorrence of adoption by the Islamic faith. On the other hand, fostering, the temporary parental caring of non-biological children is deeply entrenched in all cultures and supported by all faiths across Nigeria. Two reports on adoption in Nigeria are noteworthy: one was of 236 adoptions in Lagos, in southwestern Nigeria, between 1973 and 199030; and the other, 61 adoptions between 1991 and 2001in Enugu State in southeastern Nigeria31. Although the preponderance of babies involved in these adoptions were abandoned by their biological parents, the social circumstances for their abandonment were not clear. It will be right to suspect that some of them would have been outcomes of unwanted pregnancies that were not induced at earlier stages, especially with the apparent deterrent effect of the restrictive abortion laws in the country.

14. CONCLUSION:

Nigeria’s high population and high fertility rate, coupled with the very low contraceptive use by its people, sets the country up for high prevalences of unintended and unwanted pregnancy as well as induced abortion. The country’s restrictive abortion laws compel entrapped women to seek clandestine and usually hazardous solutions to such pregnancies, with attendant morbidities and mortalities. For Nigeria to keep pace with the attainment of MDG-5 by 2015, the current 11% contribution of unsafe abortion to its Maternal Mortality Ratio will need to be addressed, and such will obviously require the invigoration of family planning services and its utilization, coupled with the pursuant of abortion law reforms. In parts of the country where adoption is not practiced, especially the predominantly Muslim settlements, fostering should be strengthened to reduce easy resort to abortion by women faced with unwanted pregnancies.

16 15. REFERENCES:

1. World Bank and Federal Ministry of Health (Nigeria). Nigeria Health, Nutrition and population Country Status Report (Main Report). November, 2005.

2. The National Bureau of Statistics (NBS), Central Bank of Nigeria (CBN) and Nigerian Communications Commission (NCC). 2006. Survey on the Socio-Economic Activities in Nigeria for the Year 2005.

3. Federal Ministry of Health (Nigeria). National Human Resources for Health Policy. 2006.

4. WHO World Health Report 2006. URL: http://www.who.int/whr/2006/whr06_en.pdf

5. National Population Commission (Nigeria). Nigeria Demographic and Health Survey 2003. Calverton, Maryland: National Population Commission and ORC/Macro, 2004.

6. Federal Ministry of Health, Abuja, Nigeria 2007. Integrated Maternal, Newborn and Child Health Fact Sheet.

7. Federal Ministry of Health (Nigeria), 2006. National HIV/AIDS and Reproductive Health Survey, 2005, Federal Ministry of Health, Abuja, Nigeria.

8. Ujah, I. A. O. Contraceptive intentions of women seeking induced abortion in the city of Jos, Nigeria. Journal of Obstetrics and Gynaecology (Abingdon). 2000; 20(2):162-166. 9. Okonofua, F. E.; Odimegwu, C.; Ajabor, H.; Daru, P. H.; Johnson, A. Assessing the prevalence and determinants of unwanted pregnancy and induced abortion in Nigeria. Studies in Family Planning. 1999; 30 (1): 67-77. 10. Oye-Adeniran, B.A.; Long, C.M.; Adewole, I. F. Advocacy for Reform of the Abortion Law in Nigeria. Reproductive Health Matters. 2004; 12(24 suppl.) 209-217.

11. Bankole, A.; Sedgh, G.; Oye-Adeniran, B.A.; Adewole, I.F.; Singh, S.; Hussain, R. Unwanted Pregnancy and Associated Factors among Nigerian Women. International Family Planning Perspectives. 2006; 32(4): 175-184

17 12. Ujah, I. A. O. Sexual activity and attitudes toward contraception among women seeking termination of pregnancy in Zaria, Northern Nigeria. International Journal of Gynecology and Obstetrics. 1991, 35, (1): 73-77. 13. Otoide, V. O.; Oronsaye, F.; Okonofua, F. E. Why Nigerian adolescents seek abortion rather than contraception: evidence from focus-group discussions. International Family Planning Perspectives. 2001; 27(2):77-81. 14. Oye-Adeniran, B. A.; Adewole, I. F.; Umoh, A. V.; Iwere, N.; Gbadegesin, A. Induced abortion in Nigeria: findings from focus group discussion. African Journal of Reproductive Health. 2005, 9, (1), 133-141. 15. Federal Ministry of Health, Abuja, Nigeria. 2007. Integrated Maternal, Newborn and Child Health Strategy. 16. Baird, T.; Ogedengbe, B.; Tubi, A.; Shittu, S.O.; Giwa-Osagie, O.; Akinosho, T.; Nigerian Network Develops Strategy to Address Unsafe Abortion. Dialogue. Ipas. 2(3) 1998.

17. Fetters T.; Akiode, A.; Oji, E.; How Far is Too Far? Searching for Postabortion care in Kano State. 2004. Ipas Publications CD 2008.

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