KHYBER MEDICAL UNIVERSITY

ADVANCED STUDIES RESEARCH BOARD

BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
No: Date:

RESEARCH PROPOSAL TEMPLATE

Title:

Determinant of self-induced abortion in unintended pregnant patients

attending private maternity clinics in Peshawar, Pakistan

Name of Candidate: Dr. Shaista Nooreen

Name of Supervisor: Dr. Khalid Rehmaan

Co-Supervisors:

1.

2.

3.

Duration of Project: six months

Institute
Institute of Public Health and Social sciences, Khyber Medical University, Peshawar

Budget Required:

Name & Signature of Student/Scholar: Dr. Shaista Nooreen

Name & Signature of the Supervisor: Dr. Khalid Rehman

Name & Signature of Head of Institute: Institute Of Public Health And Social Sciences, Khyber Medical
University, Peshawar
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
1. TITLE:

Determinants of self-induced abortion in unintended pregnant patients attending

private maternity clinics in Peshawar city, Pakistan

2. INTRODUCTION:
(1)
Unintended pregnancy(UP), is an umbrella term for mistimed, Unwanted, and unplanned conception.
(2)
. The reported figures are that Thirty-eight percent of 210 million pregnancies worldwide are estimated to
be unintended, and 22% of them ended up aborted accounting for 13% of maternal deaths (3)(4)(5). Being
illegal in certain countries; is the main reason for underestimating the burden. Other reasons identified by
the literature review are women being ashamed of doing something forbidden, not knowing where to attain
treatment, living too far from a medical center or health facilities not entertaining them, and not being able
to meet the expense of travel to a facility or treatment. (6)
The concept of UP is fundamental to identifying fertility (7) and also addressing the unmet need for
contraception and family planning(8)). Poverty, low knowledge, and lack of access to family planning
services are the main reason contributing to this burden in developing countries(10).
According to WHO, about 74 million UP occur in the developing world; 25 million are induced to
abort in an unsafe way adding annual 47,000 maternal deaths. The remaining continued half-heartedly with
adverse risks and outcomes for the mother and child, extending from malnutrition, illness neglect, and even
death3,11. In South Asia Nepal has one of the highest UP at 41% (12), followed by Pakistan with 38.2%(13) ,
where fertility rate 3.8 birth/woman, induced abortion rate 29/1000women in 2012(previously in 2002
27/1000) with abortion ratio 41/100 live birth(15-49yrs). For Khyber puktoonkwa, 40 percent and 28/100
live birth respectively. The estimated national increase in UP is from 38 to 46 percent (14). In 2012, a total
of approximately 9 million pregnancies in Pakistan, 4.2 million were UP, 623,000 women were admitted
for complications with attempted un safe abortion, being a leading cause (15) accounting 6% of all maternity
deaths nationally.5,6.
Being one of oldest but stigmatized method, induced abortion is seeking in societies where unmet for
contraception and access to birth control method are prevented by social circumstances and relationships.
Despite intensive family planning programs in Pakistan, the contraception rate is not more than 34% with a
constant fertility rate of 3.8 with 20.1% unmet need in the past decade. According to a study conducted by
population council in 2013, half of the unintended pregnancies ended up self-induced abortions; 62% of
these women seek healthcare from private health facilities esp. the small facilities 6 in such unwanted
situations.
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
RATIONALE: Due to limited evidence on the magnitude of self-induced abortion and its contribution
to Maternal morbidity and mortality and the role of private clinics (13%) 3,4,5, there is a felt need to identify
and understand the determinants and associated factors.
our study will provide an evidence base that can be used in health promotion approaches or
interventions to modify family planning services and policies to reduce the impact of self-induction on
mothers’ health in the form improvement in maternity mortalities and morbidities and reducing health care
burden.
3. OBJECTIVE(S):

1) To assess factors associated with self-induced abortions in married females visiting maternity
clinics

4. OPERATIONAL DEFINITIONS:

Un intended pregnancy= An unintended pregnancy is a pregnancy that is either unwanted, such as the
pregnancy occurred when no children or no more children were desired. Or the pregnancy is mistimed,
such as the pregnancy occurred earlier than desired(CDC). self-induced = took some measure like
medicines etc.by herself to get rid of pregnancy
5. MATERIALS AND METHODS:

6a. Study Design: cross sectional study

6b. Study Settings: private maternity clinics
6c. Study Duration: Six months
6d. Sample Size: The sample size will be calculated using the prevalence rate of induced abortion i.e. 50/1000
women%(14), a confidence interval of 95% and with (2.5) S.E. By putting the values in open epi calculator, the
total computed sample size was 290.
6e. Sampling Technique: Two-stage sampling technique
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
6. SAMPLE SELECTION:
7a. Inclusion Criteria: Married Pregnant females with abortion.
7. DATA COLLECTION PROCEDURE:

Data will be collected after the synopsis is approved by the graduate committee, the Ethical board, and the
Advance study review board(ASRB). Data will be collected from maternity clinics in the Peshawar district.
Those women who met inclusion criteria will be included and their privacy and confidentiality will be
maintained throughout the study. Before data collection, Verbal consent will be taken from every
participant followed by a face-to-face interview on a structured questionnaire (13).
The questionnaire for unintended self-induced pregnancy contains three parts;
1. Sociodemographic part including participant age, SES, Education, Residential area, and source of
income.
2. Reproductive history pregnancy-related part consisting of Gestational age in weeks, age at marriage,
parity, Birth spacing in months’, previous history of induced abortion, knowledge about contraceptives,
use of contraceptive, method of contraceptive, use of LIMs.
3. psychosocial part with close-ended question about their reason to abort.
8. DATA ANALYSIS PROCEDURE:

 Data will be analyzed by using Spss 22.

 Continuous variables such as present age, age at marriage, and number of children and birth spacing
duration will be presented as Mean ± SD and C.I.

 Categorical variables such as socioeconomic status, and education level, parity, source of income,
method of contraception, previous history of abortion, the reason for abortion will be presented as
frequency and percentages.

 Chi-square analyses and Multivariable logistic regression analysis will be used to identify factors
associated with unintended self-induced pregnancies.

9. BIBLIOGRAPHY:

1. Ahinkorah BO. Predictors of unmet need for contraception among adolescent girls and young women in selected high
fertility countries in sub-Saharan Africa: a multilevel mixed effects analysis. PloS one. 2020 Aug 6;15(8):e0236352.

2. Goossens J, Van Den Branden Y, Van Der Sluys L, Delbaere I, Van Hecke A, Verhaeghe S, et al. The prevalence of
unplanned pregnancy ending in birth, associated factors, and health outcomes. Hum Reprod. 2016 Dec 1 ;31(12):2821–33.

3. Why do many women’s still die in pregnancy or child birth. World Health organization; 2013.

4. Ahinkorah BO, Seidu AA, Appiah F, Oduro JK, Sambah F, Baatiema L, et al. Effect of sexual violence on planned, mistimed
and unwanted pregnancies among women of reproductive age in sub-Saharan Africa: A multi-country analysis of
Demographic and Health Surveys. SSM - Popul Heal. 2020 Aug 1;11:100601.

5. Eftekhariyazdi M, Mehrbakhsh M, Neamatshahi M, Moghadam MY. Comparison of pregnancy complications in unintended

 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
and intended pregnancy: A prospective follow-up study. BioMedicine. 2021;11(4):51.

6. Sathar Z, Singh S, Rashida G, Shah Z, Niazi R. Induced Abortions and Unintended Pregnancies in Pakistan. Stud Fam Plann
[Internet]. 2014 Dec 1;45(4):471–91.

7. Ahinkorah BO. Individual and contextual factors associated with mistimed and unwanted pregnancies among adolescent girls
and young women in selected high fertility countries in sub-Saharan Africa: a multilevel mixed effects analysis. Plos one.
2020 Oct 22;15(10):e0241050.

8. Bongaarts J. Trends in fertility and fertility preferences in sub-Saharan Africa: the roles of education and family planning
programs. Genus. 2020 Dec 1 ;76(1):1–15.

10. Cleland J, Machiyama K, Casterline JB. Fertility preferences and subsequent childbearing in Africa and Asia: A synthesis of
evidence from longitudinal studies in 28 populations. https://doi.org/101080/0032472820191672880. 2019 Jan 2 ;74(1):1–21.

11. One-in-four pregnancies unplanned, two-thirds of women foregoing contraceptives | | UN News [cited 2022 Mar 12].

12. Puri M, Singh S, Tamang A, Crowell M. Int Perspect Sex Reprod Health. 2016;42(4):197–209.

13. Ranatunga IDJC, Jayaratne K. Proportion of unplanned pregnancies, their determinants and health outcomes of women
delivering at a teaching hospital in Sri Lanka. BMC Pregnancy Childbirth [Internet]. 2020 Dec 1 ;20(1):1–15.

14. Sathar Z, Singh S, Shah ZH, Rashida G, Kamran I, Eshai K. Post-abortion care in Pakistan: A national study.

15. Sarder A, Islam SMS, Maniruzzaman, Talukder A, Ahammed B. Prevalence of unintended pregnancy and its associated
factors: Evidence from six south Asian countries. PLoS One 2021 Feb 1 ;16(2):e0245923.

16. Ali SA, Tikmani SS, Qidwai W. Prevalence and determinants of unintended pregnancy: systematic review. World Family
Medicine Journal: Incorporating the Middle East Journal of Family Medicine. 2016 Jul;99(3671):1-0.

17. Ilboudo PGC, Somda SMA, Sundby J. Key determinants of induced abortion in women seeking postabortion care in hospital
facilities in Ouagadougou, Burkina Faso. Int J Womens Health. 2014 May 29;6(1):565–72.
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258

ANNEXE:
Annexure I: Data Collection Instrument
Date:

This Questionnaire is Anonymous. Please do not write your name.

Title of the study

“Determinants of self-induced abortion in unintended pregnant patients attending private maternity

clinics in Peshawar city, Pakistan

Questionnaire for Unintended induced pregnancy

a) Sociodemographic factors
1. Name
2. Present Age ….
3. Education
a. Illiterate
b. Primary
c. Middle
d. Matric
e. Intermediate
f. Graduation
4. Husband education
a. Illiterate
b. Primary
c. Middle school
d. High school
e. Intermediate/ diploma
f. Graduate
g. Professional
5. Husband occupation ……………..
6. Residential area
a. Urban
b. Non-urban
7. Source of income
Husband income….
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258

8. Living in
a. single family unit
b. joint family unit
9. Age at marriage ………
10. Who accompanied you to this facility
a. Husband
b. In laws
c. Own family
d. Neighbor

Marital history

11. Marital status

a. First wife
b. Second wife
12. Marriage status of patient
c. First marriage
d. Second marriage
b) Pregnancy-related factors
13. Present pregnancy Gestational age
a. Less than 12 weeks
b. More than 12 weeks
14. Previous history of successfully self-induced abortion
a. No
b. Yes
i. How many times…………?
15. Did you use LIMs (labour induce medications)?
a. Yes (Breeky, st mom, pinarcit) how many tablets of ……(please write name of tablets)………
a) Oral b) Per vaginal
b. Other (Brufen, paracetamol, aspirin, buscopan,)
c. Traditional medicine ……..
16. How you get labour induced medications?
a. She herself
b. Husband
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
c. Other please specify…
c) Medical History
17. What are the pre-existing medical illnesses you had?

a) None b) Diabetics mellitus

c) Hypertension d) Epilepsy
e) Heart disease f) Renal disease
g) Asthma h) Psychiatric illness
i) other (specify)

18. Did you take any medications for the above illness?
Yes No
19. If yes, specify...................................
d) Reproductive history
20. How many children do you have?...........
i. Live
ii. dead
21. what is the age of the last child? ………
22. Duration of birth spacing between last pregnancy and present
pregnancy in months…….
23. Do you know about methods of contraception?
a. no
b. yes
24. Have you ever used a family planning method?
Yes …….
No ……...

25. If yes, what was the most recent family planning method you used before this pregnancy?

a) Natural b) Pills
methods
c) Condoms d) DMPA
e) IUCD f) Implants
g) Other
26. why did you use the most recent family planning method?
1. as we completed the family
2. to space the pregnancy
3. as we didn’t want children
4. other
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258

27. Whom did you get advice on how to use that method?

Doctor Health care worker friend Media

28. Were you ever told by a health worker about other methods of family planning that you could use?
Yes No

29. Did you discontinue the most recent method you used?
Yes No

30. If yes, what is the reason? (Number most appropriate reasons, could be more than one answer)

1. Infrequent sex 2. Became pregnant while using

3. Wanted to become 4. Husband /partner disapproved
pregnant
5. Waned more effective 6. Health concerns
method
7. Due to side effects 8. Lack of access /too far
9. Cost is too much 10. Inconvenient
11. Marital dissolution 12. Other

31. If you did not use the family planning method, why didn’t use it? (Number most appropriate
reasons, could be more than one answer)

1. Wanted to become pregnant 2. Lack of knowledge or lack of sources

3. I don’t like to FP 4. Husband disapproves
5. Other people disapprove 6. Infrequent sex
7. Health concerns 8. Problem of access/availability
9. Cost too much 10. Religion reasons
11. inconvenient to use 12. Rumours of side effects
13. Other 14. Don’t know

Yes
No
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
32. Have you ever heard of emergency contraceptive methods (postinor/ Emergency Contraceptive pills)?

33. If yes did you ever use it?

Yes
No

a) Psychosocial factors (Reasons to abort)

1) Did you suffer from any mental health problems before pregnancy? Yes No
2) Have you ever tried to do self-harm? Yes No
3) Have you ever taken a psychoactive substance / or smoked? Yes No
4) Does your husband usually take alcohol? Yes No
5) Does your husband usually take psychoactive substances? Yes No
6) Does your husband usually take smoking tobacco? Yes No
7) If yes, are you having difficulties in your life as a result of his alcohol intake? Yes No
8) Since you were pregnant, have you been abused by your husband? Yes No

9) Since you have been pregnant what are the types of violence you had by your husband?
Emotional Physical

10) How do you rate the relationship you had with your husband?
a. Poor b. Fair c. Averaged. d. Good e. Excellent

11) 12) How do you rate the relationship you had with family members?
a. Poor b. Fair c. Average d. Good e. Excellent

13) Do you have any physically or psychologically handicapped babies? Yes No

14) . Did you have low mood for the last two weeks?
Yes No

15) Did you lack of interest in usually pleasurable activities?

Yes No
16) Were you unable to carry out daily functions?
Yes No
17) Did you experience any stressful life events in the last 6 months? (death, unemployment, separation)
Yes No
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
18) Does anyone directed you to abort?
a. Husband b. In laws c. Herself d. Both husband and she herself

Title of Study:
“Determinants of self-induced abortion in unintended pregnant patients attending private maternity
clinics in Peshawar city, Pakistan”

You are being invited to take part in a research study. Before you decide it is important for you to understand
why the research is being done and what it will involve. Please take time to read the following information
carefully and discuss it with others if you wish. Please ask if there is anything that is not clear or if you would
like more information. Take time to decide whether or not you wish to take part.

Thank you for reading this.

The purpose of the study:

The study is designed to identify “Determinants of self-induce abortion in married patients attending
private maternity clinics”.
This study is a six months’ project and will be completed in 2022 you are being asked to take part in the study.
A total of 300 participants will fill out the questionnaire.

Consenting to take part:

It is up to you to decide whether or not to take part. If you decide to take part, you will be given this
information sheet to keep and be asked to sign a consent form. You will also be given a signed copy of the
consent form to keep. If you decide to take part you are still free to withdraw at any time, or a decision not to
take part will not affect you in any way.

What the study will involve:

The study is based upon on questionnaires will be distributed to each participant. At all times strict
guidelines and procedures will be adhered to so that your identity and anything that you say will be kept
confidential.

The benefits of taking part:

There will be no direct benefits to you, but this information may help Health Authorities and Health
Care Professionals to understand patients’ perspective and needs regarding self-induced abortion in order to
address the problem more efficiently.

Disadvantages of taking part:

 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
There is no disadvantage of taking part in this study; the only disadvantage is that your time will be
consumed in while filling the questionnaire.

Maintaining confidentiality:

If you consent to take part in this study all of the information you will give will be kept strictly
confidential. Any information which will be used will have your name and address removed so that you cannot
be recognized from it.

The Results of the study:

This research is being undertaken to meet the requirement of MS Epidemiology & Biostat in the public
health program registered in the Khyber Medical University, Peshawar.

When all the information is collected and analyzed, the findings will be written up as a thesis.

As part of the process of sharing new knowledge in the scientific and professional communities a series
of shorter articles, based upon the findings will be submitted to scholarly journals for peer review and
publication. Similarly, the information will form the basis for research conference presentations.

Complaints:

If you have any complaints about any aspect of this study, please feel free to contact the primary
supervisor or the ethical review board.

If you require further information, please contact the researcher at the following contact details:

Name of researcher: Dr. Shaista Nooreen

Contact Number: +92-302 835 8050
Email: shaistanooreengmail.com
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258

Annexure-II: Any other Relevant Material (if applicable)

Consent form
Title of study:
“Determinants of self- induced abortion in unintended pregnant patients attending private maternity
clinics in Peshawar city, Pakistan”

INFORMED CONSENT

The purpose of this study is purely academic and to identify Determinants of self- induced abortion

in unintended pregnant patients attending private maternity clinics. In this study a questionnaire

will be used as tool to collect data. I ensure that no risk is related to the study. In case of any discomfort

or feeling embarrassment about any questions feel free to refuse answer. Your participation is

voluntary. Your confidentiality will be maintained and the result will be presented with codes. Feel free

to ask question about the study at any time.

I understand the nature of this study and agree to participate. I have received a copy of consent

Form:

Participant Name_____________________________
Participant Signature__________________________

Date ______________________________________

The contact details of lead Researcher (Principal Investigator) are:

Name: Dr. Shaista Nooreen

 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
Contact # +92 302 835 8050
Email: shaistanooreen@gmail.com

Project Budget
Institution: Institute Of Public Health And Social Sciences, Khyber Medical University, Peshawar

STUDY TITLE:
“Determinants of self- induced abortion in unintended pregnant patients attending private maternity clinics in Peshawar
city, Pakistan”

Budget Amount: Pakistani Rupees

No. Description Unit Rate/Unit No. Frequency/Hours/Day/Months Total Cost In Remark

Rs.
Operational Cost
1. Questionnaire Per page 10 300 8 10x300x8= 24,000.
Print
2. Transport Per 2000 1 5 2000X1x5= 10,000.
fortnight
3. Statistician Per day 15,000. 1 1 15,000x1= 15,000
4. Thesis Book Per book 5000. 1 3 5000X1x3=15,000.
Printing
5. Incentive to Per 2000 1 10 2000x1x10=20,000.
data collectors collectors
6. Miscellaneous 5000.
Grand Total 89,000. Rs.
Round Figure Cost – Rs. 89,000.

GANTT CHART 2022

Activity Month 1 Month 2 Month 3 Month 4 Month 5 Month 6
GC Proposal
submission
ASRB
DATA Collection
Data Entry and
Analysis
Report writing
 KHYBER MEDICAL UNIVERSITY
ADVANCED STUDIES RESEARCH BOARD
BLOCK –IV, PDA BUILDING, PHASE-V, HAYATABAD,
KHYBER PAKHTUNKHWA, PESHAWAR, PAKISTAN
091-9217258, 091-9217703 091-9217704, 091-9217258
Data Submission to
supervisor
Final draft submission