Over the last decades, several researchers have identified unsafe abortion as an important challenge associated with women's reproductive health in Nigeria. Induced abortion currently accounts for 20,000 of the estimated 50,000 maternal deaths that occur in Nigeria each year.¹ It is thus the single largest contributor to maternal mortality. Numerous studies have documented the social, economic and health problems associated with early and unplanned pregnancies.²

The performance of an abortion is illegal under Nigerian criminal law, unless the woman's life is threatened by the pregnancy. As a result, induced abortions are usually obtained clandestinely, and are frequently unsafe. Unsafe abortion is often the end result of an unwanted pregnancy, which in turn is often the result of lack of contraceptive use. This trend is most profoundly demonstrated among adolescents. Hospital-based studies have shown that in Nigeria up to 80% of patients with abortion-related complications are adolescents.³ Similarly, a community-based study of abortion prevalence found that one-third of women who obtained an abortion were adolescents.⁴

In contrast, the utilization of modern and traditional methods of contraception has always been shown to be poor among Nigerian adolescents. The 1990 Demographic and Health Survey found that only 11% of sexually active women aged 15-19 ever used any modern contraceptive method. Such rates of contraceptive use are much lower than levels seen in similar age-groups in many Sub-Saharan African countries, or than levels in industrialized countries.⁵

The promotion of effective contraceptive use among Nigerian adolescents is a major challenge if their reproductive health is to be improved. Given that Nigerian youths are now marrying later, are increasingly interested in acquiring a formal education and are increasingly having premarital sex,⁶ it is clear that allowing the existing gap between contraceptive need and contraceptive utilization to be left unfilled will result in a dramatic rise in the prevalence of unsafe abortions. This will further compound overall levels of maternal mortality in Nigeria.

Other than identifying at-risk groups that are often unaware of contraception, an effective strategy for increasing the utilization of contraception must also include an understanding of patterns of contraceptive utilization and of societal views on risks associated with abortion. In particular, social and cultural barriers to contraceptive utilization among adolescents need to be analyzed.

This article reports on a qualitative study of the social perceptions of risks associated with abortion and contraception among adolescents in Benin City, Nigeria. Twenty focus-group discussions were undertaken to obtain an understanding of the reasons for the current discrepancy between levels of contraceptive use and abortion prevalence in Nigeria.

The focus-group discussion had two purposes: to explore local attitudes and beliefs concerning abortion, and to explore adolescents' attitudes and beliefs concerning the use of contraceptives. We believe that the findings may have profound implications for the formulation of policies for improving adolescents' utilization of contraception.

Background

Benin City was the capital of the old Benin Empire, a kingdom whose borders extended as far as to the modern-day Dahomey, in the neighboring Republic of Benin. In keeping with the national trend, Benin City has experienced phenomenal growth in population: In the 1960 population census, the city's population was put at about 200,000; today, it is estimated to total more than one million residents.

This rapid population growth is the result of several factors, foremost being the population's high fertility rate, with an average of five or more children per household.⁷ The polygamous culture of the indigenous inhabitants (monogamy being the exception in most households) has also contributed to this trend. Moreover, the city's strategic location as a gateway to all major regions of Nigeria has contributed immensely to its rapidly growing migrant population.

Postindependence, Benin City was one of Nigeria's four regional capitals, bringing about rapid urbanization and the development of several educational institutions. Thus, Benin City has one of the three universities in Edo State, as well as several other secondary and postsecondary institutions funded by the public sector. More recently, as the demand for education far outstrips the public sector's capability of meeting it, the number of privately funded educational institutions in Benin City has risen steeply. Educational enrollment in the city is about the highest in the country, cutting across diverse socioeconomic divides, thus providing unique opportunities for cross-exchanges among those of widely differing backgrounds.

Despite the foregoing, the sexual and reproductive behavior of adolescents in Benin City does not appear to differ remarkably from reports of adolescents' sexual behavior in other areas of Nigeria. In general, this has been characterized by early initiation of sexual activity, nonuse of contraceptives at first sexual intercourse and poor overall utilization of contraceptives. In tandem with this is the high prevalence of reported experience of sexually transmitted diseases (STDs) and poor health-seeking behavior.

Materials and Methods

Focus-group participants were selected geographically from within Benin City on the basis of their current vocation or pursuit. We adopted this approach to accommodate the heterogeneous structure of the adolescent populace, so we could obtain a representative pattern of social interaction. To this end, we organized the focus groups by occupation and by participants' place of residence, thus encompassing a broad range of socioeconomic and educational strata. However, there was considerable overlap in demographic characteristics between groups.

To help generate relevant information, interviewers asked participants confidentially if they had had sexual activity prior to the focus-group session.* The investigators thus knew which focus-group participants reported being sexually active and which had not initiated sexual activity. The former tended to be older than the latter. This information was not disclosed to other focus-group participants, however.

The focus-group discussions were conducted by a team of researchers from the Women's Health and Action Research Centre, led by the first author. Twenty focus-group sessions were conducted with a total of 149 young women aged 15-24. The groups ranged in size from six to 10 participants per session (Table 1). Each discussion generally lasted between 45 and 90 minutes.

To elicit a comprehensive understanding of abortion among adolescents, we adopted an operational definition of abortion during the discussions as being termination of an existing pregnancy or the use of any medium to "bring back a missed period." Similarly, we defined contraception as anything used before or after intercourse with the aim of preventing a pregnancy. These wide-ranging definitions gave participants an opportunity to provide unbiased views of abortion and contraception.

Focus-group participants were generally allowed to express what they knew about abortion and contraception. Thereafter, a detailed discussion of each suggested method of contraception was elicited. This often concerned availability, perceived advantages, side effects and reasons for use or nonuse among adolescents. Questions on fertility control, regarding the use of abortion or contraception, were asked in the third person, to maintain discrete and confidential reporting by the adolescents.

The focus-group discussions were conducted in English or in pidgin English, a local corruption of the English language that is widely spoken and understood. (The language used depended on the group's educational status.) All interviews were audiotaped. In addition, extensive notes were taken during the discussions, and these were subsequently employed when the tapes were reviewed and transcribed.

Results

Knowledge of Abortion

In general, participants were forthcoming in their opinions about adolescents' beliefs on abortion and contraception. Sexually active female youths gave more lengthy responses and more detailed information than those who were not sexually active. More educated discussants tended to give more correct explanations.

There was often a diversity of opinion in the understanding of the term "abortion." While the majority defined abortion as the act or process of terminating an unwanted pregnancy, a minority felt that abortion referred to the termination of pregnancy after 3-4 months with the use of a "sharp metal instrument" or a "drip." Termination of pregnancy at less than 3-4 months was referred to as "D and C" with the use of "sucking" (suggestive of vacuum aspiration for termination of early pregnancy). For instance, a 19-year-old secondary student said that "D and C is when you miss your period for 1 to 2 months." Another focus-group participant (a 22-year-old tertiary student) interrupted a discussion of abortion to express her opinion that abortion meant termination of an advanced pregnancy, in contrast to a D and C: "Wait...you keep talking of D and C, it is abortion, when it is advanced, that is dangerous...." Menstrual regulation and early drug use were some other terms used to differentiate early recourse to pregnancy termination.

When asked how they recognized a pregnancy, youths most often mentioned a missed period or a failure to see the monthly menstrual flow. Few educated participants gave other means, such as early morning vomiting or recognition of body changes.

The major reasons given for why adolescents seek termination of pregnancy were (in order of frequency): the need not to interfere with schooling; not being old enough to get married; fear of family members knowing; not planning to marry the partner; being jilted by a fiancé; following rape or incest; and not knowing the actual father. Less-common reasons were the need to test fertility and, in some cases, as a means of making financial demands on male partners. This last reason was often mentioned by the less-educated participants, although it was also given by more-educated respondents.

Knowledge of Contraception

In general, participants were aware that something could be done to prevent a woman from getting pregnant. The responses on what could be done differed substantially among focus-group participants, however. Young people who reported that they had not initiated sexual activity often had little information on specific means of contraception. In contrast, the other participants were more knowledgeable about specific methods.

Participants mentioned a large variety of modern contraceptive methods—the pill, the IUD, injectables, the male condom and emergency contraception (the product Postinor). However, participants often did not mention the condom as a contraceptive method. When they were asked why, youths' major reason for this observation was that they thought of the condom more as a means of preventing infections than as a way of preventing a pregnancy.

However, when asked to name effective methods of modern contraception, participants often mentioned modern medications, such as APC (a brand of aspirin) and antibiotics, that are not contraceptives. Although the less-educated were more likely to mention ineffective contraceptives, similar patterns were also observed among those who were more educated. For example, a 17-year-old uneducated hairdresser said: "How woman fit prevent belle? Na many ways. She fit use quinine..." [How can a woman prevent getting pregnant? There are many ways. She can take quinine...]. Medications discussed included aspirin, quinine, paracetamol, tetracycline, indocid and ampicillin. They also mentioned menstrogen (a combination of ethinyl estradiol and ethisterone) and "apiol and steel" (parsley oil marketed for correction of female menstrual irregularity).

In general, other than for the condom, there was poor knowledge of the mechanism of action for modern methods, as well as poor knowledge of any noncontraceptive benefits. In contrast, participants often gave a list of adverse effects arising from the use of these methods. For example, reported problems associated with the pill included infertility, frequent periods and "frequent dosing." Participants argued that "the oral contraceptive pills entered into the blood stream and as such directly contaminated the blood, interfering with future fertility" (22-year-old food vendor). (Such views often were expressed even by educated participants.) The IUD was associated with being "missing" and possibly requiring an operation for removal or interfering with fertility. Focus-group participants associated injectables with abscess, paralysis and infertility, while condoms were seen as not being reliable.

Focus-group participants also mentioned a large variety of traditional contraceptive methods,^† and were quick to give details of their uses and sources. Sexually active adolescents were particularly likely to give an in-depth list of traditional methods. This pattern was also common among the educated groups.

Participants often did not mention any adverse effects from natural methods (withdrawal and safe periods) or from traditional methods of contraception. They noted that these methods are used only at times when unprotected exposure occurs at the most fertile period or when periods are missed. However, focus-group members often disagreed on what period constituted the safe period. Often, only a minority of the educated participants provided correct responses.

Fertility Control

Focus-group participants identified several sources of contraception, most often the patent medicine store. According to a 17-year-old out-of-school youth, "If you go any chemist, just tell the person... them go give you something" [If you go to any patent medicine store, the attendant will readily provide contraception on request]. Likewise, a 16-year-old out-of-school youth commented "How person go dey go UBTH because of family planning, if you enter any chemist you will get family planning" [Why would someone go to a tertiary care center in the city because of contraception? If you enter any patent medicine store you will get contraceptives].

The use of patent medicine stores was seen as discrete and confidential. Youths generally agreed, though, that patent medicine dealers provide minimal or no information on the exact nature, known side effects or benefits of these methods.

Focus-group participants generally agreed that adolescents often try to prevent pregnancy. However, they disagreed greatly about what is generally done. The least common choice, especially among older and less-educated youths, was the use of an effective modern contraceptive method. Thus, a 17-year-old secondary student commented that "many of my friends try to prevent getting pregnant, they use safe period or sometimes they use gynaecosid [a hormonal preparation]." A 23-year-old tertiary student remarked that "many girls are doing something to prevent getting pregnant. They use safe period or sometimes drugs like ergometrin or ampicillin...."

The major reasons given were the known side effects of modern methods. For example, a 17-year-old secondary student said that "as for the pill, many girls don't like it; it makes them to put on weight." Side effects were of special concern to the focus-group participants when they were seen as potentially affecting future fertility. As a 20-year-old out-of-school youth recounted, "I know of one woman, she took pills when she was a young girl, when she got married and wanted a child she could not, they told her it is because of the pill."

A recurring theme in the discussions was the view that "women who use contraceptives will find it difficult to conceive when they eventually get married" (20-year-old youth club member). In contrast, side effects from abortion were thought to be few, with the possibility of damage to the womb and infertility being most frequently mentioned. Participants often perceived these risks as remote, however, especially when doctors perform the abortions. For example, according to a 23-year-old tertiary student, "many girls do D and C and don't have problems; these problems (complications of unsafe abortion) is when you go to quacks, they will use all kinds of things...."

When asked whether she knew of a friend who had died from abortion and if mortality from abortion is common in their community, a 20-year-old tertiary student responded: "No... well maybe it happens [a young person dying from an abortion], but who will tell you somebody died from abortion? If someone dies, they [the family] will say it is from a brief illness."

In addition, focus-group participants held the opinion that as abortion may be required only occasionally, it poses no real or immediate threat. This belief was reflected in the views of a 22-year-old undergraduate who drew a relationship between the use and ease of abortion and the continuous, daily use of oral contraceptives: "One D and C is safer than 16 packs of daily pills....many girls say this."

In general, participants believed that abortion-related deaths and other complications arose only when an abortion is performed late in the pregnancy or is done by a quack. Yet focus-group participants could reach no consensus on how a quack can be identified. The majority suggested that adolescents associate a competent provider of abortion services with any private clinic or a "male doctor," or a service that has been used successfully by a peer.

Discussion and Recommendations

We set out to provide a social explanation for the gap between adolescents' use of abortion in Nigeria and their contraceptive use. It is evident that in terms of sexual activity and contraceptive uptake, there are essentially two groups of adolescents.

Adolescents who are not sexually active tend to know less about contraception, although they are aware of abortion. Arguably, such youths are not likely to institute contraceptive use when they initiate sexual activity, so recourse to abortion may be their first attempt at controlling their fertility.

Youths who have initiated sexual activity, on the other hand, know about both contraception and abortion. Our findings suggest that low levels of contraceptive utilization among such young people arise from their perceived risk of side effects. In particular, they understand contraceptives (other than the condom) to mean something that interferes with fertility, while abortion has a similar, but more short-lived, effect. Fertility and infertility would appear to be central issues in youths' decision to use contraceptives or practice abortion. Thus, a plausible potential explanation for the low use of modern contraceptive methods among Nigerian adolescents is the perceived threat of sustained interference with fertility. Such a concern is in keeping with the fact that such modern methods as the pill, injectables and IUDs are used continuously over a lengthy period of time.

Nevertheless, if a threat to future fertility were an overriding concern in adolescent sexual behavior, the expected trend in the community would be a decreased prevalence of premarital sex, illegal abortions and teenage births. The fact that this is not the case suggests that a pregnancy may not be entirely unwanted. A conception proves a woman's fertility and is sometimes seen as a bargaining instrument through which to obtain favor from the male partner, and possibly also to demonstrate the capacity to have a child.

Our findings suggest that a plausible explanation for the prevalence of and resort to abortion among sexually active youths is that illegal abortion is not perceived as an immediate threat to fertility. Rather, the complications of abortion and their potential impact on fertility are seen as remote, occurring only when several steps have failed. This attitude may be strongly reinforced by peers who have had abortions without noticing any outward complications. However, since Nigerian law prohibits abortion, services are generally of poor quality. The absence of any outward complications in the vast majority of induced abortions does not necessarily imply that such procedures are safe. Several previous studies also have shown a high prevalence of a history of abortion and a strong association between such a history and infertility, as well as ectopic pregnancy.⁸

Consistent with earlier explanations, it would appear that traditional contraceptive methods should be more widely accepted in Nigeria, as they only need to be used when contraceptive failure is feared, for example, or when the monthly periods have not returned. Reliance on such methods tends to mirror that of abortion as a means of controlling fertility. This is consistent with results from the 1990 Demographic and Health Survey showing greater acceptance of traditional methods than of modern methods. Unfortunately, adolescents' lack of understanding of these traditional methods, as well as the types of methods mentioned, point to these methods' inefficacy in preventing unwanted pregnancies. In any case, young people tend to use these methods as early abortificients rather than as contraceptives.

In general, adolescents did not feel that having to obtain contraceptives was a major hindrance to use. This is contrary to findings from several published studies.⁹ Youths generally felt that the services offered by patent medicine dealers were sufficient to meet their contraceptive needs. As these dealers are located on street corners, such a finding is not a surprise, as they provide confidential services. This may also explain adolescents' knowledge and use of modern antibiotics and other medications as contraceptives, as these likely were recommended by and procured from patent medicine dealers. Previous studies have shown that patent medicine dealers often are not trained and have diverse educational backgrounds, with a significant number of them not literate.¹⁰

From our results, we can draw several conclusions regarding the design of a comprehensive policy on contraceptive marketing and distribution to adolescents. Crucial among these is the need for a comprehensive policy on adolescent reproductive health. Such a policy must clearly outline a strategy for educating both in-school and out-of-school adolescents about reproductive health before they initiate sexual activity. Information about and knowledge of contraception will be important in adolescents' acceptance of modern methods and their use of such methods at first intercourse. Such a policy must also fully address the social myths and perceptions limiting the use of modern methods, especially with regard to their effect on fertility.

Similarly, there is an urgent need for adequate documentation and understanding of the roles of informal contraceptive delivery points—in particular, patent medicine dealers. Such findings will be crucial towards determining training needs. These providers can act as an important link in providing in-school and out-of-school adolescents with appropriate information, counseling and mechanisms for contraceptive continuation.

Our findings further illustrate the need to review the existing abortion law. It is obvious that adolescents resort to abortion, and a large proportion will continue to do so. What is not obvious, however, is the quality of the services that are provided and who provides these services. Under present conditions, health care providers generally deny their involvement in or practice of illegal abortion. This may have contributed to the ambiguity reported among adolescents in accessing a competent abortion care provider. A revised abortion law would allow for proper documentation of trained abortion care providers and for information about them to be disseminated to the community. It would also allow for statutory regulation and for the monitoring of such services. These could go a long way toward reducing the needless morbidity and mortality arising from induced abortion.

In conclusion, an effective educational strategy on the process of fertility and contraception is needed for Nigerian adolescents. Such a comprehensive policy will be crucial in correcting misconceptions that limit the uptake of modern methods of contraception among adolescents.

Valentine O. Otoide is a senior registrar in the Department of Obstetrics and Gynecology, University of Benin Teaching Hospital, Benin City, Nigeria, and is an associate of the Women's Health and Action Research Centre, Benin City. Frank Oronosaye is a program officer with the Women's Health and Action Research Centre, Benin City. Friday E. Okonofua is a professor in the Department of Obstetrics and Gynecology, University of Benin Teaching Hospital, Benin City, Nigeria, and is executive director of the Women's Health and Action Research Centre, Benin City. The authors would like to thank Abiodun Osawaru and James Falaiye, both of the Women's Health and Action Research Centre, who helped to type and edit the draft of this article.