Delayed decision-making, failed abortion attempts and factors associated with second-trimester abortions in Liberia

Abortion is legally restricted in Liberia with few exceptions. The country also has among the highest maternal mortality ratios in the world, with an estimated 742 deaths per 100,000 live births. The contributions of unsafe abortion to maternal mortality have been investigated in Liberia, but less is known about the magnitude of and circumstances around abortions occurring in the second trimester. We aimed to assess the prevalence and factors associated with second trimester induced abortions among women seeking post-abortion care in Liberia.

We conducted a secondary analysis of data from a Prospective Morbidity Survey conducted at health facilities across Liberia from October to December 2021. We analyzed data from women seeking post-abortion care (PAC) for induced abortions to calculate the proportion occurring in the second trimester and to identify factors associated with second-trimester termination.

Among women seeking PAC after induced abortion, 35 out of 185, or 19.0% (95% CI: 14.0%, 25.3%), had induced abortions during the second trimester. This represented just over 8% (95% CI: 5.9%, 11.0%) of all women seeking PAC. The distribution of women across age, employment status, religious affiliation, and relationship status was largely similar between those who induced abortion in the second trimester and those who terminated their pregnancies in the first trimester. They also had similar reproductive histories, with no differences in history of spontaneous or induced abortion or in the number of living children. About 68% of women who ultimately terminated their pregnancies in the second trimester reported previous attempts at inducing abortion for the same pregnancy. Compared to women with secondary or tertiary level education, women with no formal education or primary school education had 3.1 times the odds of second-trimester abortion (OR = 3.1, 95% CI: 1.4-7.0, P = 0.006). Likewise, women who reported that their pregnancies were intended had 2.2 times the odds of a second-trimester abortion compared to women reporting unintended pregnancies (OR = 2.2, 95% CI: 1.0-4.8, P = 0.045). The direct effects of these factors exhibited some degree of mediation by having made one or more previous attempts at termination and/or by making the decision to terminate later in the pregnancy.

Second-trimester abortion constitutes nearly one-fifth of induced abortions for which PAC is being sought in Liberia. The high prevalence of repeat abortion attempts for the same pregnancy points to limitations in access to safe and effective abortion methods. Similarly, the high rates of unintended pregnancy in the study sample despite reported use of family planning suggests gaps in the quality of family planning services and commodities accessible to women. More comprehensive sexual and reproductive health education is warranted.