Health Care for Women International, 28:654–676, 2007

Copyright © Taylor & Francis Group, LLC

ISSN: 0739-9332 print / 1096-4665 online
DOI: 10.1080/07399330701462223

Unsafe Induced Abortions Among Adolescent

Girls in Lusaka

ELISABETH DAHLBÄCK
Department of Public Health Sciences, Division of International Health (IHCAR),
Karolinska Institutet, Stockholm, Sweden

MARGARET MAIMBOLWA
University of Zambia, Department of Post Basic Nursing, Lusaka, Zambia

LACKSON KASONKA
University Teaching Hospital, Department of Obstetrics and Gynaecology, Lusaka, Zambia

STAFFAN BERGSTRÖM
Department of Public Health Sciences, Division of International Health (IHCAR),
Karolinska Institutet, Stockholm, Sweden

ANNA-BERIT RANSJÖ-ARVIDSON
Department of Woman and Child Health, Division of Reproductive and Perinatal Health,
Karolinska Institutet, Stockholm, Sweden

Our aim in this study was to describe adolescent girls’ cir-

cumstances underlying the decision to resort to unsafe induced
abortions. Thirty-four Zambian girls aged 13 to 19 years admitted
to University Teaching Hospital (UTH) in Lusaka were interviewed
using a semistructured questionnaire with both closed and open-
ended questions. Results revealed that most of the girls were
single, in school, reached higher grades, mainly nulliparous,
and had very low knowledge of contraceptive use. Reasons given
for performing unsafe abortions were fear of facing personal
shame and social stigma following premarital pregnancies, such
as parental disapproval, abandonment by partner, and expulsion
from school. A blend of traditional and modern methods and

Received 25 April 2006; accepted 8 December 2006.

We thank the adolescent girls who generously shared their experiences and for their
participation. Financial support was gratefully received from the Center for Health-Care
Sciences, Karolinska Institutet, Stockholm, Sweden.
Address correspondence to Elisabeth Dahlbäck, Department of Public Health Sciences,
Division of International Health (IHCAR), Karolinska Institutet17177, Stockholm, Sweden.
E-mail: elisabeth.dahlback@ki.se
654
 Unsafe Abortion Among Adolescents in Lusaka 655

medicines were used to abort. Limited access to contraception and

the stigma attached to premarital pregnancies and abortions are
likely to continue to compel girls to rely on clandestine abortions
if comprehensive adolescent reproductive health services are not
provided. The necessity to give adolescent girls more attention and
advocacy is obvious.

A large proportion of unwanted and mistimed pregnancies occur among

unmarried adolescents (10 to 19 years old). Many of these adolescents decide
to terminate their pregnancies because of no other acceptable solution to an
unbearable situation, and as such often resulting in unsafe induced abortions
(Rogo, 1996). Initiation of sexual behavior occurs during adolescence as a
normal part of human development and is linked to beliefs and gender-
related socialization adopted from the surrounding society (Dahlbäck et al.,
2003; Olukoya, Kaya, Ferguson & AbouZahr, 2001; Varga, 2003). Young
women on the African continent, especially those living in the sub-Saharan
region, have a disproportionately heavy burden of reproductive ill health
and death due to complications from pregnancies and unsafe abortions
(Brookman-Amissah & Moyo, 2004). Teenage abortions are described as
controversial and prohibited topics in many African countries due to social,
moral, cultural, religious, and political dimensions (Van Look & Cottingham,
2002), and as a result abortion remains one of the five leading causes of
maternal death (Grimes, 2003; Hord & Wolf, 2004; World Health Organization
[WHO], 2004).
Unsafe abortion is defined as a procedure for terminating an unintended
pregnancy that is carried out either by persons lacking the necessary skills or
in an environment that does not conform to minimal medical standards, or
both (WHO, 2004). That means that unsafe abortion may be performed by
women themselves, by nonmedical persons, or by health workers in unau-
thorized settings. The WHO estimates that nearly 20 million women world-
wide, among whom 2.0–4.4 million are adolescent girls, resort to unsafe abor-
tions each year. More than 25% of the unsafe abortions each year in Africa oc-
cur among girls aged 15 to 19 years, which is higher than in any other region
of developing countries. Annually, about 34000 women in Africa die due to
complications following unsafe abortions (Hord & Wolf, 2004; WHO, 2004).
Because of the difficulties of classifying incomplete abortions, the
distinction between spontaneous and induced abortion is rarely made
in African studies; no questions are asked on admission and very little
preventive action is taken on discharge, as described by Rogo (1996).
Authors of several studies in Sub-Saharan Africa indicate that abortion
remains a prevalent “silent” problem that is grossly under reported. Rasch and
colleagues (2000) have shown that 60% of women admitted with incomplete
abortions to hospitals in Dar es Salaam had their pregnancies illegally
656 E. Dahlbäck et al.

terminated and that 54% of those were 19 years or younger. In Nigeria,

being unmarried was the strongest predictor (43%) for adolescent unsafe
abortion in a first pregnancy (Mitsunaga, Larsen, & Okonofua, 2005). In
Malawi, Uganda, and Zambia adolescents account for 24%–37% of all women
admitted to hospitals for abortion-related complications (Munasinghe, & van
der Broek, 2005). Unsafe abortion is one factor contributing to the high
maternal mortality ratio in Zambia. Medical records at the UTH in Lusaka
show that 15% of all maternal deaths result from illegally induced abortions
(Koster-Oyekan, 1998).
Zambia is one of the few African countries that has liberal abortion
legislation, available since 1972, The Termination of Pregnancy Act, which
allows access to safe abortion on broad medical and social grounds. It is
specified in the Act, however, that the procedure should be performed in
an approved hospital and with the consent of three registered physicians,
including one specialist in the branch of medicine related to the stated
indication (Republic of Zambia, 1972). Despite the liberal legislation on
abortion many Zambian teenage girls still resort to unsafe induced abortion
outside approved facilities, and rely on unskilled providers when faced with
an unwanted pregnancy (Koster-Oyekan, 1998; Likwa & Whittaker, 1996).
Our aim in this study is to describe the situation of adolescent girls
admitted to the hospital after having resorted to unsafe induced abortion,
in order to get a deeper understanding of who these girls are, the reasons
why they perform unsafe induced abortions, who the abortion providers are,
and what abortion methods they use. We also explore the girls’ relationships
with the partners responsible for their pregnancies.

PARTICIPANTS AND METHODS

The study was carried out in Lusaka, the capital city of Zambia, which has a
population of about 1.1 million and a wide representation of different ethnic
groups. This prospective and descriptive study was carried out at the UTH in
Lusaka from January to April 2005. The UTH is one of five referral hospitals
in the country, with a 1900 bed capacity. The gynecological emergency
admission ward is located in the Department of Obstetrics and Gynaecology.
In addition to gynecological screening services, the ward offers postabortion
care (PAC). This includes theater facilities for manual vacuum aspiration
(MVA), counseling services, information, and distribution of contraceptives.
After MVA is performed patients usually stay overnight for observation and
are discharged the following midday.
The participants in this study were selected from a larger interview study
of 87 adolescent girls, aged 13–19 years, who had been admitted to the
gynecological admission ward with the diagnosis of incomplete abortion.
Girls who were severely ill and treated elsewhere in the hospital were
 Unsafe Abortion Among Adolescents in Lusaka 657

excluded. The first one to two girls were consecutively selected on weekdays
from the theater register book in the ward. To be included in this study, the
girls had to have undergone the MVA procedure, been hemodynamically
stable, and given informed consent. Out of the total 87 interviewees, 34 girls
(39%) revealed verbally that they had undergone unsafe induced abortions.
These 34 girls were the respondents of this study.
One Zambian female research assistant (nurse–midwife) was specially
trained in PAC and also to conduct interviews in a nonjudgmental and
empathetic manner to create confidence in the girl and encourage her to
give a description of the true nature of her situation. The research assistant
identified and approached each girl informally on the ward and informed
her about the study and its purpose and invited her to participate. Each
girl was told that participation was voluntary and that information would
be treated as strictly confidential. When a girl consented to participate, the
interview took place in privacy in a separate room. Consent was obtained
by thumbprint only, as many girls feared disclosure of anonymity if they
had to sign their full name. The interviews with the adolescent girls were
held in the ward during the morning hours while they were waiting for the
PAC counseling, which occurred before discharge. Parents or guardians who
accompanied minors (18 years of age and below) had to give their consent
before the interview was carried out. A few girls came with their partners
and others came alone to hospital and reported that their parents did not
know about the pregnancy. In cases where no parents were present to
consent, the girls were regarded as “emancipated minors” (Dickens & Cook,
2005). No parents, guardians, or partners were present during the interviews.
Data were collected by semistructured interviews using a questionnaire with
both closed and open-ended questions. The interviews were held in Bemba,
Nyanja, or English since the research assistant was fluent in these languages.
Each interview lasted for about one-and-a-half hours.

SEMISTRUCTURED INTERVIEWS: QUESTIONNAIRE

The questionnaire for this study was constructed by the research team
(midwives and physicians) based on material from a WHO questionnaire
(WHO, 1999) and similar studies conducted in the Sub-Saharan region
(Calvès, 2002; Rasch, et al., 2000). The girls’ sociocultural context and
vernacular were considered to ensure that the language would be un-
derstandable and not humiliating for adolescent girls. A pilot study was
conducted in December 2004 and the questionnaire was revised accordingly.
The closed questions related to the sociodemographic characteristics of
the participants: age, education, occupation, marital status, and religious
and tribal affiliation. Other questions addressed were about sexual and
658 E. Dahlbäck et al.

reproductive history, length of the relationship with the partner of the index
pregnancy, his reaction to the pregnancy and abortion, and the continuation
of the relationship. The open-ended questions that were asked during the
interview included: What were your reasons for terminating the pregnancy?
Who assisted you to terminate the pregnancy? What method(s) were used?
What kind of relationship do you have to the partner responsible for the
pregnancy?
The research assistant used the questionnaire to focus the discussion and
to encourage dialogue on open-ended questions. When the girl realized that
it was acceptable to talk about the abortion in a nonjudgmental atmosphere,
many started to tell about their experiences either spontaneously or when
probed. That additional information narrated about the abortion episodes
was written down during the interviews.

DATA ANALYSIS
The questionnaire data were entered into the EPI-Info Version 6 statistical
software. Descriptive statistics were used to present quantitative data. In
the analysis of this study, a case study approach was applied, whereby
quantitative and two qualitative approaches, that is, case study (Patton, 2002)
and qualitative content analysis (Graneheim & Lundman, 2004) were used.
The analysis was performed with the following steps:

1. According to the research questions, four content areas (reasons for

abortion, abortion providers, methods used, and partner relationships)
were defined before the analysis commenced.
2. The qualitative data from the open-ended questions of each person were
“condensed” (shortened) while still preserving the core meaning, and
entered into the data software (Downe-Wamboldt, 1992).
3. Each respondent’s qualitative and quantitative data were summarized,
whereby the data were organized and edited into a readable text. This
summary of data represented one case, which contributed to a coherent
individual story of each girl.
4. The analysis started by reading each case study separately. Thereafter,
the summarized text across case studies was read several times in order
to obtain a sense of the whole. Qualitative content analysis was then
applied to portray visible and obvious patterns and themes across case
studies. Meaning units containing aspects relevant to the four content
areas were identified, coded, categorized, and sorted accordingly. Two
themes emerged from the data: Influencing factors for the decision
to induce abortion unsafely and assistance and methods to induce
abortions.
 Unsafe Abortion Among Adolescents in Lusaka 659

Some of the single case studies are presented as short “case reports”
to obtain a better understanding of a girl’s underlying despair behind the
decision to terminate an unwanted pregnancy.

ETHICS
The study was ethically approved by the University of Zambia, Lusaka. All
adolescents were informed that participation was voluntary, and informed
consent was obtained from both the girls and, in case of minors, from a
parent or guardian.

RESULTS
Profile of the Respondents
The respondents’ sociodemographic profile is presented in Table 1. The
mean age of the girls was 17.5 years. Twenty of the girls were still in school,
and the mean years spent in school was 8.8 years (r = 3–12 years). Of the
14 girls who had left school, 9 were 19 years old, 2 were housewives, 1 was
working in a factory, and the remaining 6 were unemployed. Among the
younger girls who had left school, those aged 14 to 18 years old, one girl
was married, one was working as a housemaid, and 3 stayed at home. The
great majority of the girls were single and all but 6 lived with close family
members or relatives. Of the remaining girls, 3 were cohabiting with their
partners and 3 were traditionally married. Protestant was the predominant
religious faith among the girls, followed by Catholic. Fifteen ethnic groups
were represented in the study, of which the Bemba group was the
majority.
The age when they first had sexual intercourse varied among the girls
and ranged from 13 to 18 years (mean age = 16.3). When girls were asked
about their first experience of sexual intercourse, 10 said that it was not
planned or expected and 15 said that they had been forced to have sex. The
other girls said they had planned it.
The majority of the girls claimed that they had, on average, not had more
than one sexual partner during the 6 months prior to the study. Five girls
admitted, however, they had met other sexual partners besides the regular
boyfriend or had had casual relationships. Most of the girls were nulliparous,
except 4 girls who had been pregnant previously and had one living child
each. None of the respondents had ever had an abortion. Regarding the
index pregnancy, 2 girls out of 34 said that the pregnancy was planned
together with the partner; however, both of them opted for termination of
the pregnancy later due to unstable relationships and partner violence.
Contraceptive knowledge and use among the participants was typically
very low. Four girls said they had occasionally used modern contraception,
660 E. Dahlbäck et al.

TABLE 1 Sociodemographic Characteristics of Adolescent Girls Admit-

ted to the Hospital after Unsafe Induced Abortions (N = 34)

Variables N = 34

Age
13–16 years 7
17–19 years 27
Education
In school 20
Out of school 14
Years in school
3–6 years 6
7–9 years 13
10–12 years 15
Occupation
Student 20
Unemployed 9
Housewife 3
Employed 2
Marital status
Single 28
Married (traditional marriage, lobola paid) 3
Cohabiting with partner 3
Living with
Mother and father 7
Mother or father only 7
Sisters and brothers 7
Relatives or guardians 7
Husband or cohabiting w. partner 6
Religion
Protestant 26
Catholic 8
Ethnic groups
Bemba 9
Chewa 4
Mambwe 3
Tonga 3
Mixture of other ethnic groups 15

including condoms. None of them knew about emergency contraception

or were aware of their rights to legal abortion and therefore had never
considered those as alternatives to unsafe induced abortion. Scarce access
to and unwillingness from health staff to provide contraceptives to sexually
active adolescents were pointed out.

Influencing Factors for Deciding to Induce Abortion Unsafely

We suggest that both teenage pregnancies and teenage abortions were
regarded as common, 31 and 22, respectively, in the close neighborhood of
the girls. The girls’ knowledge about locally used abortion methods, whether
traditional or modern, was surprising, as was their awareness about the risks
 Unsafe Abortion Among Adolescents in Lusaka 661

TABLE 2 Factors Influencing Adolescent Girls’ Decisions to Resort to Unsafe Induced

Abortions (N = 34)

Influencing factorsa,b N = 34

Disrupting future plans:

Want to continue education 15
Too young to have children 11
Cannot afford to have a child 7
Shame and stigmatization:
Family shame and social stigmatization 9
Parents/relatives told me to have an abortion 4
Partner-related factors:
Unstable relationship and violence 5
Casual relationship 5
Pregnant as a result of rape 3
Partner told me to have an abortion 6
Partner deny paternity 7
Girlfriends told me to have an abortion 4
a The questions allow for more than one answer.
b Answers have been categorized from open-ended questions.

of performing unsafe abortion. Several of the girls had heard about or knew
classmates who had been severely ill or had died due to complications from
illegal unsafely performed abortions. The girls in this study provided critical
insights into what premarital pregnancy means to them and how different
actors and different situations, seen from their sociocultural and gender point
of view, forced them to abort. These contributing factors were grouped
into three categories, which are quantified, summarized, and shown in
Table 2.

DISRUPTING FUTURE PLANS

Becoming pregnant while still in school was a strong reason for the decision
to terminate pregnancy, as many of the girls did not want to ruin their
opportunity to continue school. Having a child would reduce their future
career prospects with regard to further studies and finding decent work.
Furthermore, results revealed that many of the girls were not ready or felt
too young to commence childbearing and motherhood, whether they were in
school or not. The girls cited financial concerns, such as “I can’t afford to have
a baby now.” They assumed that they would become more economically
disadvantaged as unmarried mothers, especially when their partner denied
fatherhood or refused social and financial support. Some girls said they were
sad but yet happy to have had the abortion because they could continue
school. Returning to school as a teenage unmarried mother brought the risk
of being laughed at or being excluded by the peer group.
662 E. Dahlbäck et al.

CASE REPORT

An 18-year-old girl in grade 11 and her boyfriend, a 24-year-old

university student, got her aunt to assist in terminating the unwanted
pregnancy. Her reason to perform an unsafe abortion was that she wanted
to finish grade 12 with the intention of higher studies. The girl got castor
root oil and aloe vera (Tembwisha) soaked in water and drank the mixture
three times a day until she started to have labor-like pains and vaginal
bleeding. She aborted at home and went to the health clinic where she
was referred to the hospital for further management.

SHAME AND STIGMATISATION

Unmarried adolescent girls who become pregnant face disappointment and
anger from their parents or guardians and fear being chased away from home
in shame. Three of the girls who became pregnant had to stay with their
boyfriends’ families until arrangements between the families had been sorted
out according to traditional mores, those being either agreement of marriage
and payment of lobola (bride price) or paying the “damage” (economic
compensation for impregnating the girl out of wedlock). Four girls were
urged by their parents or relatives to terminate their pregnancies. On the
one hand, parents assisted the girls in resorting to unsafe induced abortion
secretly, and on the other, young girls feared their parents’ reaction when
they became pregnant and wanted to keep them unaware of the shameful
event.
To induce an abortion, however, carried the “double stigma” of social
unacceptability—the unmarried girl became pregnant and then had to have
an abortion in response to the pregnancy. Similarly, a pregnant girl without a
father for her child could risk defamation and be ridiculed in the community,
as well as by her family. Most girls in the study, both in and out of school,
stressed their desire to be married before having children in order to avoid
the social stigma of being an unmarried mother. To marry off a girl who
already had a child tended to bring a lower lobola to the girl’s family. Thus,
to avoid the social shame and stigmatization of being both an unmarried and
pregnant teenager, the girls resorted to unsafe induced abortion.

CASE REPORT

The girl was 16 years old and in school and the boyfriend was 21 and
doing his military training. She reported that the boyfriend put something
in her drink, that she “lost track of what happened” and woke up in the
boyfriend’s house, raped. She got pregnant and became very scared of her
aunt’s reaction and thought she would be chased away if her aunt came
to learn of the pregnancy. The girl was 8 weeks pregnant when she bought
 Unsafe Abortion Among Adolescents in Lusaka 663

Chloroquine over the counter and took 13 capsules at once. “I wanted to

kill both myself and the unborn baby,” she said, as she could not stand
the shame of being raped and furthermore falling pregnant. She aborted
at home, in a suicidal state and was, however, taken by her aunt to the
hospital, where she was taken care of and recovered.

PARTNER-RELATED FACTORS
In this study the age of the girls’ partners varied between 19 and 32 years
(mean = 24). Almost three quarters of the men, however, were 25 years old
or younger. In three couples, the male partner was twice as old as the girl,
and the greatest age variation was between a 14-year-old girl and a 30-year-
old partner. The partner responsible for the pregnancy was known to all of
the 34 girls. The majority (n = 24) of the partners were working as minibus
drivers, clerks, businessmen at the city market, mechanics, bricklayers, or
were self-employed. According to the respondents, men who had a job
were more attractive than unemployed men because they could afford to
offer money or gifts to their girlfriends. The remaining partners were either
students or unemployed.
Three types of relationships were identified among our respondents. The
largest group was referred to as “regular boyfriends” (n = 23). The length
of the relationships varied considerably between the couples. Seven of the
relationships had lasted less than 12 months, and 16 had lasted more than
1 year. The findings showed varying regularity of sexual encounters, from
three to four times a week for some couples to as few as once a month or
less for others. Faithfulness between the partners was in general considered
greater in girls, however, because the partners “movements” (unfaithfulness)
were difficult to control and some girls revealed distrust in their partners.
The second largest group consisted of couples cohabiting or married. Three
girls were married and had celebrated the traditional marriage ceremony,
and their partners had paid the lobola to the girls’ parents, and the other
3 were cohabiting with their partner. Two of these cohabiting girls were
chased away from home to go and stay with their boyfriends when their
pregnancies became known. The third girl eloped with her boyfriend to his
home when they realized she was pregnant. The last group consisted of
5 girls who had been involved in casual sexual encounters with different
partners. In all three groups of relationships, the presence of transactional
sex was explicit; however, the exchange of sex for money or gifts was never
associated with promiscuity or prostitution, but rather recognized as one of
the girls’ benefits of the sexual relationship.
The 14 persons first informed about the girls’ pregnancies were relatives
or friends, and not the partner. In almost half of the pregnancies, the behavior
of the partner played a significant role in the girls’ abortion-decision process
(Table 2). When the girls revealed that they were pregnant, 6 of the regular
boyfriends urged them to induce abortion. All of them accompanied their
664 E. Dahlbäck et al.

girlfriends and paid the fee for the procedure. Seven of the partners denied
any financial and social obligations of paternity or “disappeared out of reach”
after learning of the pregnancy. Girls who became pregnant after casual
relationships or rape did not tell those partners about the pregnancy and the
abortion; it became a “secret” for the individual girl. Other partner-related
reasons to perform unsafe abortions were unstable relationships, some
involving physical and sexual violence. Of the girls who had experienced
forced sex and rape, 3 became pregnant. To escape bad reputations and
the humiliation following violence, rape and pregnancy, interruption of the
pregnancy became the solution for the girls.

CASE REPORT

When a 19-year-old-girl who had left school became pregnant by her

27-year-old partner, she was chased away from her aunt’s place where she
lived to go and stay with the boyfriend. The boyfriend became gradually
more physically violent toward the pregnant girl, who was repeatedly
beaten without any apparent reason. The situation became unbearable
for her and she left the partner, now alone and without any kind of
support. She collected the local roots of the castor oil plant and cut aloe
vera leaves (Tembwisha) to soak in water and drink until she aborted at
home in the pit latrine. Afterward she visited the health center, where she
was referred to the hospital for examination and treatment.

Regarding the continuation of the relationship with the partner after the
abortion, more than half (n = 18) of the girls said they were not going to
continue the relationship; this was either their own choice or because their
partners had abandoned them or denied paternity. The others could not
predict what would happen with their relationships.

CASE REPORT

A 17-year-old girl, in grade 11 and living with her parents, became

pregnant by her 25-year-old boyfriend, who worked as a clerk. Her
boyfriend abandoned her as soon as he learned she was pregnant.
In despair because of broken promises about marriage, her desire to
finish school, and being too young to have a child, she went to “a
certain lady” who prepared one-half a cup of some strong herbal
medicine to drink. After some time she aborted at home and went to
a nearby health clinic, where she was referred to the hospital for medical
management.
 Unsafe Abortion Among Adolescents in Lusaka 665

TABLE 3 Gestational Age of Pregnancy Versus Age, in or out of School, and Years in School
Among Adolescent Girls Admitted to the Hospital After Unsafe Induced Abortions (N = 34)

Gestational Gestational Gestational

weeks <12 weeks 13–18 weeks 19–24 Total
Variable n = 20 n=9 n=5 N = 34

Age
13–16 years 6 1 0 7
17–19 years 14 8 5 27
School
In school 13 6 1 20
Out of school 7 3 4 14
Years in school
3–6 years 2 2 1 5
7–9 years 10 1 3 14
10–12 years 8 6 1 15

Assistance and Methods to Induce Abortion

In this study we found that the unsafe induced abortions were performed
between gestational weeks 7 and 24, according to self-reported information
(Table 3). The majority of the pregnancies were terminated before the end
of the twelfth week of gestation and primarily performed by the girls in the
older age group. Thirteen of the girls who performed the abortion before
the end of twelfth week of gestation were still in school. The mean years in
school of the younger age group compared with the older age group was 8.8
years and 10.3 years, respectively. Gestational age as related to the girls’ age
and years in school is shown in Table 3. The study further shows that more
than two thirds of the girls arranged and paid for the unsafe abortions. Of
the unsafe induced abortions, more than three quarters occurred at home,
at the grandmother’s or the aunt’s place where the fetus was taken care of:
buried in the garden, flushed down the toilet, or put in the pit latrine.

ABORTION PROVIDERS AND APPLIED METHODS

Many of the girls were very well informed about different methods, both
traditional and modern, to induce abortions. All the girls in our study relied
on unsafe induced abortions, according to the Termination of Pregnancy
Act (Table 4). The abortion methods varied widely and so did the abortion
providers, although traditional medicine was the major source. Oral and
vaginal abortifacients were applied and included both traditional and modern
medicine, as well as foreign bodies, which were inserted into the cervix. One
girl got tattoos around her waist that were rubbed with a powder of herbs
to induce abortion. Traditional healers and “old women” performed almost
half of the methods cited. They soaked or boiled local herbs and roots
666 E. Dahlbäck et al.

TABLE 4 Abortion Providers Assisting Unsafe Induced Abortions, Different Methods

Used, Traditional and Modern, to Perform Unsafe Induced Abortions (N = 34)

Abortion providers and methods used to perform unsafe

induced abortionsa,b N = 34

Traditional healers/old women/relativesc 16

Herbs soaked in water to drink 11
Roots soaked in water to drink 7
Inserted stick into cervix 2
Tattoo and powder around waist 1
Private physician or Clinical officers 6
Vaginal tabletsd 3
Injectiond 1
Curettage/operatione 1
Oral contraceptives 2 tablets/day × 21 days 1
Self-medication 12
Panadol, Cafernol, or similar drugsc 12
Chloroquinef 6
Mixture of modern drugs and traditional medicine 5
Oral contraceptive pills 28 at once 1
a The questions allow for more than one answer.
b Answers have been categorized from open-ended questions.
c Traditional medicine implies single dose or combination of traditional methods, some with

repeated doses, as well as a combination of modern and traditional medicine.

d Respondents did not know what kind of tablets or injection were given.
e Metal instrument was used.
f Chloroquine only or a blend of other modern or traditional medicines.

in water and gave them to the pregnant girl to drink in order to provoke
abortion.

CASE REPORT

The girl was 13 years old and her partner was 26. When the pregnancy
was confirmed, the man arranged for an abortion by an elderly woman
without the girl’s knowledge. Abortion was induced by giving the girl a
traditional herbal medicine, which she referred to as “the tea,” to drink.
After the girl had drunk the “tea,” the woman explained that there was no
need to go to the hospital to be “cleaned.” Ten days after the abortion had
occurred at home, the girl was admitted to the hospital in a bad condition
and diagnosed with septic abortion. The man was reported to the police
by the girl’s parents and the case was under investigation.

Unskilled “old women” who insert sticks or roots of cassava into the
cervix carry out another type of traditional method used to provoke unsafe
abortion. When left in place, the cassava dilates the cervix and stimulates
uterine contractions. Two girls who aborted at home were admitted to the
 Unsafe Abortion Among Adolescents in Lusaka 667

hospital with severe infections after having cassava sticks or roots inserted
into their cervixes.

CASE REPORT

One of the girls, 18 years old and in school, had become pregnant after an
occasional sexual relationship with what she called “a womanizer.” He
was around 20 years old and already had impregnated three other girls.
She wanted to interrupt the pregnancy since she knew that the partner
would refuse emotional and/or economic responsibility for it. She got the
advice of a girlfriend to visit “a certain lady” who inserted a “stick” into
her cervix. She paid the woman 25,000 Kwacha (5,000 Kwacha = $U.S.
1) and a blouse for the treatment. She did not abort, however, and went
back a second time and got another “stick” inserted into her cervix. The
girl was admitted to the hospital some days later for complications of the
provoked abortion, but she recovered. Her parents reported the lady to the
police.

Illegal abortion is also provided by health personnel such as private

practitioners and clinical officers who evade the procedures required by
the Termination of Pregnancy Act or by those who lack the necessary
skills or the minimum of medical standards for the procedure (Table 4).
Several of the girls were accompanied either by their partners or by their
mothers, who had arranged with private practitioners or clinical officers to
terminate the pregnancy. The participants were provided with oral or vaginal
tablets, and one was given an injection to terminate the unwanted pregnancy.
One “instrumental abortion” also was performed without anesthesia. None
of the respondents knew what kind of pharmaceutical agents they had
received, except for 2 girls who were instructed to take an overdose of
oral contraception pills. Similarly, when partners or parents had initiated
an unsafe abortion, none of the girls knew how much was paid for the
procedure.

CASE REPORT

The girl, who was 17 years old and out of school, was admitted to the
UTH after having undergone an incomplete abortion outside a legalized
setting. The boyfriend insisted that she should have an abortion done and
arranged with a “doctor” outside town. According to the girl, “long metal
instruments were pushed into the vagina. . . . I could hear the sound.” She
received some painkillers after the procedure was done. Coming home, the
668 E. Dahlbäck et al.

pain became unbearable and big blood clots were discharged. That was
when the mother brought her to hospital for further care.

SELF-INDUCED ABORTIONS
Table 4 shows that a sizeable number of the girls arranged and performed
self-induced abortions by using modern drugs that were considered to be
inexpensive and easily accessible, but, first and foremost, they maintained
secrecy. The girls took overdoses of modern drugs, such as 10–20 tables of
Cafernol, Panadol, or similar drugs bought over the counter or at the market.
However, these drugs were often used in combination with traditional
medicine. Some girls further told how they “cheated” staff at the health
clinics to provide them with a course of Chloroquine when they complained
about malaria symptoms. Six of the girls took overdoses of Chloroquine (10
to 13 tablets at once) as an abortifacient. For 2 of the girls it was obviously
taken as a means for committing suicide.

CASE REPORT

The girl was 17 years old and in grade 11 and her boyfriend was 21
years old and employed. Due to poverty, the mother let the boyfriend pay
for her daughter’s school fee, or as the girl expressed it, “She gave me to
the boyfriend.” When the girl realized that she was pregnant, she became
desperate and wanted to kill herself. She bought Panadol tablets and
mixed them with traditional medicine she got from a traditional healer
to drink for 3 days. She had an incomplete abortion at home; the fetus
was expelled in the pit latrine, but the placenta remained in the uterus
“I snapped the cord using a pad.” The girl was brought to the UTH where
the placenta was removed and she was found to have severe anemia. She
received a blood transfusion and recovered.

When the abortifacient succeeded, it led to vaginal bleeding, backache,

labor-like pains, and partial or complete expulsion of the products of
conception. Abortion methods applied in relation to gestational age did not
indicate any noteworthy difference. After the expulsion of the fetus or when
the bleeding or back pain became unbearable, the girls went to the nearest
clinic. At the clinic they were examined and received a referral letter to UTH
for further treatment, MVA, and PAC.
The risk scenarios these girls have faced because of subjecting
themselves to unskilled providers are obvious. Within this group of 34
adolescent girls, 2 arrived at the hospital in suicidal condition, and 4 girls
were admitted with septic abortion, pelvic inflammatory disease (PID), or
severe anemia secondary to heavy bleeding.
 Unsafe Abortion Among Adolescents in Lusaka 669

DISCUSSION

THE INDUCED ABORTION

This study demonstrates that the girls felt forced by partners, parents, or
the condemning society to resort to unsafe induced abortion to avoid the
consequences of social shame and stigmatization of being both unmarried
and pregnant. In Zambia, premarital sex generally is considered immoral,
and girls in particular are strongly condemned (Pillai & Barton, 1998). It may
be argued that the word ‘illegal’ could be considered inappropriate in this
context. As presented, however, any abortion performed in a nonauthorized
setting by a nonlicensed person is considered illegal according to the
Zambian law. Despite that, girls silently seek “care” from unskilled providers
who apply dangerous methods to induce unsafe abortions outside the formal
health structures. To resort to unsafe abortion is done—not deliberately—but
it may be the only acceptable solution for that particular girl in that particular
situation and at that particular time.
The study further shows how young girls experiment on their own
to terminate unwanted pregnancy by extensive use of self-paid and
self-administered modern drugs (Chloroquine, Cafernol, Panadol), which
potentially compromise young girls’ health due to risk of intoxication.
An increase of self-administered modern drugs was previously recognized
by Koster-Oyekan (1998). Overdosing on these remedies primarily was
assumed to maintain secrecy and, second, not to leave any mechanical
vaginal injuries visible. In comparison with what Likwa and Whittaker (1996)
experienced, less cervix interference was seen among the respondents in this
study.
The opinion that these girls are vulnerable and exposed to risks was
confirmed; they are young, unmarried, mainly nulliparous, rather well
educated, have low economic potential, are mostly in seemingly unreliable
relationships, have low contraceptive use, and rely on unsafe abortion. These
characteristics also have been recognized in studies from Tanzania, Nigeria,
and Ghana (Adanu, Ntumy, & Tweneboah, 2005; Mitsunaga et al., 2005;
Rasch et al., 2000). In this study, however, having more years of education,
belonging to the older age group, and being convinced not to continue
with the pregnancy may be understood as contributing factors for several
of the girls’ decisions to abort. They also had the courage to disclose their
situations despite social stigma and repercussions. However, these girls may
not be representative with regard to the national average of girls attending
upper secondary school, which in Zambia is 27% (Central Statistical Office
[CSO], 2003). Even some of the girls out of school demonstrated a lack of
readiness to commence early premarital childbearing in light of financial
hardship and decided to abort. It also was learned that many of the girls
resorted to unsafe abortions simply because they lacked the knowledge
670 E. Dahlbäck et al.

and access to their rights of contraception and legal abortion. The option
to continue the unwanted pregnancy to its end was believed by most of
the girls to compromise the safety of both the mother and her offspring
secondary to social insecurity, increased poverty, stigmatization, disruption
of school, and ruined aspiration for the future.

GENDER-RELATED FACTORS
The present study shows adolescent girls’ vulnerability also from other
aspects such as poverty, powerlessness, gender inequality, and sexual
coercion. Gender norms are socially constructed, learned, and reconstructed
and vary from culture to culture. These norms are usually different for
girls and boys but also vary within the respective group and over time
(Kimmel, 1995). What girls and boys have in common, however, is that
both are seemingly caught in the gender trap by stereotype gender norms.
Many girls learn during their socialization and initiation rites to be chaste
and submissive to their partners. Several Zambian ethnic groups practice
initiation rites among teenage girls. Pillai and Barton (1998) describe that the
Bembas hold strong norms against premarital sexual relationships and expect
teenage girls to be chaste before marriage. We found in this study, however,
that more than one quarter of the girls were Bembas and had resorted to
induced abortions. It is likely that societal disapproval of girls’ premarital sex
contribute to girls’ under-reporting of their sexual involvement and need for
reproductive health care including safe abortions, for fear of moral and legal
reprisal.
The boys, on the contrary, have during their socialization learned that
men are expected to be knowledgeable about sex and to have sexual
experience before marriage. This is seen almost as a prerequisite to becoming
a man. During their upbringing boys have learned that they are the privileged
sex and are superior to girls. These male expectations likely influence
adolescent boys to exaggerate their sexual experiences to impress and put
pressure on one another and also on girls (Dahlbäck et al., 2003; Plummer
et al., 2004; Silberschmidt & Rasch, 2001; Varga, 2003).
The partner-related factors played a great part in the girls’ final decision
to abort. The impact of receiving money, gifts, or a promise of marriage
in exchange for sexual favors was important for the girls. Transactional sex
should not in this context be compared with prostitution, however, but rather
be seen as a means to gain material benefits or to get financial support to
pay related school costs, or merely as an expression of poverty. Thus, power
imbalance in the relationships, in addition to girls being offered money,
makes the negotiation of safe sex and condom use then more difficult for
girls. That means that girls’ sexual and reproductive health is compromised,
especially since cultural codes restrict girls’ freedom to openly seek health
care when needed (Sundby, 2006).
 Unsafe Abortion Among Adolescents in Lusaka 671

Age asymmetries were explicit in some of the couples, though less

pronounced in this study than in that shown by Koster-Oyekan (1998) and
Silberschmidt and Rasch (2001), where a greater prevalence of older men
referred to as “sugar daddies,” had young girlfriends. In Zambia, however,
men marry later than women. The median age among young women and
men at first marriage differs by about 5 years (CSO 2003), which correlates
to the age difference of most couples in this study. As men remain single
for longer periods and have easier access to income through work, they can
more easily exchange sex for money. Thus, girls’ inferiority with regard to
age, economy, and gender issues may contribute to the girls’ dependency and
violate her autonomy and ability to express her wishes and confidence. The
occurrence of unstable sexual relationships, unfaithfulness, sexual violence,
denial of paternity, and abandonment experienced by the girls in the
study were partner-related determinants, which strongly influenced girls’
decisions to abort. Distrust and negative experiences in relationships were
assumed to undermine girls’ self-esteem and maintain the social and sexual
subordination of girls.

FEAR OF PUNISHMENT
When the girls were asked in a confidential environment and with a
nonjudgmental attitude about what had happened to their pregnancy, some
of the girls first gave another story. Later on many girls told us that they
had been strongly prohibited, either by parents or by the abortionist, to
tell the truth about the abortion procedure for fear of legal reprisals or
negative attitudes from health staff. They were told that they could be refused
medical attention on arrival to the hospital or take the risk of being reported
to the police. The penalty for performing an illegal abortion, according to
the Zambian law, is 7 years imprisonment for the client and 14 years for
the abortionist. The fear of being judged as a “criminal” after a clandestine
abortion maintains the secrecy of the procedure. This fear delays girls in
seeking abortion, and also delays them seeking help when complications
occur, which, in turn, increases the risk of maternal morbidity and mortality
(Olukoya et al., 2001). In this study, several girls’ postponed termination of
their pregnancies until late in the second trimester due to various or changed
circumstances. Nevertheless, a decision to perform an unsafe abortion was
finally made. It was understood that the girls’ contextual environment was
of greatest importance in the determination of the pregnancy outcome.

ADOLESCENTS AND CONTRACEPTION

Contraceptive knowledge and use were low among the girls despite the
fact that all kinds of contraception are available in Lusaka today. The
672 E. Dahlbäck et al.

public opinion in Zambia on prevention of adolescent sexuality, premarital

pregnancies, and abortions, however, is hindered by social and religious
attitudes that disapprove of sexual and reproductive education for unmarried
young people, which obviously is greatly needed. In studies from Zambia
(Maimbolwa, Ahmed, Diwan, & Ransjö-Arvidson, 2003) it was shown that
85% of the adolescent primigravidae had never used contraception and only
2% had received information on sexual and reproductive health matters
from health staff. Other contributing factors likely to compel adolescent
girls to rely on clandestine abortions were reluctance and unwillingness of
health providers to offer education, counseling, and contraceptive services
to unmarried sexually active adolescents (Warenius et al., 2006) or were
due to girls’ lack of confidence in health staff. Furthermore, girls’ meager
ability to negotiate and ensure condom use with their partners, as well
as stigmatization and criminalization associated with abortions, complicate
their situation (Lithur, 2004; Van Look & Cottingham, 2002). In fact, instead
of being protected, young people are at risk.

LEGALIZATION OF ABORTION
Up-to-date, safe, and adequate abortion care for adolescents in Zambia,
as in many other countries, is still met with silence and denial. To leave
these adolescent girls without access to safe abortion care could be regarded
unethically and lack of dignity for girls’ lives and human rights. Difficulties
in the implementation process of safe abortion care are cumbersome for
these young girls. In countries like Zambia with “liberal” abortion laws, the
questions of why illegal induced abortions still appear to be prevalent among
adolescent girls remain. Grimes (2003) states that legalization of abortion is
important, but it is not enough. When abortion is legal but yet restricted,
and abortion services are available but insufficient and inaccessible, or
when information about abortion law is withheld, high abortion-related
morbidity and mortality will remain, particularly among adolescents and
poor women (Adanu et al., 2005; Brookman-Amissah & Moyo, 2004; Shah
& Åhman, 2004). Reproductive health services should further be considered
incomplete unless there is adequate postabortion care offered to all women
in need (Brookman-Amissah & Moyo, 2004; Lithur, 2004). A revision of the
Zambian Termination of Pregnancy Act should be considered to minimize
restrictions and to increase access to safe abortion care for women of all
ages. Furthermore, abortion needs to be destigmatized in order to bring
clandestine abortions to an end (Lithur, 2004). The question remains: When
will the policymakers and the community respond to the Zambian young
girls’ suffering and recognize the urgent need for reproductive health services
as human and legal rights? In comparison with Zambia, where the abortion
act was introduced in 1972, South Africa legalized the abortion act in1996.
 Unsafe Abortion Among Adolescents in Lusaka 673

Statistics in South Africa now show that this has led to a decrease in morbidity
and mortality, especially among teenagers, due to extensive clinical training
programs involving nursing staff (Jewkes, Rees, Dickson, Brown, & Levin,
2005).
It is known that data on induced abortions in developing countries are
inconsistent and notoriously difficult to gather and therefore grossly under
reported (WHO, 2004). Both the national government and nongovernmental
agencies are urged to empower midlevel health-service providers, such
as nurse-midwives with training and equipment to ensure accessibility
and the high quality care of reproductive health including safe abortion.
“Reproductive rights” implies meeting adolescents’ rights to postpone
childbearing and having the means to do so in order to protect their right
to life and survival (Ipas & IHCAR, 2002; Sundby, 2006; Teklehaimanot,
2002).

METHODOLOGICAL CONCERNS
This study contributes to existing literature an insider perspective from
Zambian adolescent girls who had resorted to unsafe induced abortion.
The information was obtained through interviews to make the girls’ own
voices heard, thus disclosing a neglected public health problem. To collect
valid data on unsafe induced abortions in face-to-face interviews with
adolescent girls is a challenging and sensitive task. The strength of face-
to-face interviews is that inconsistent answers and misunderstandings can
be clarified. The method is also preferable to self-reported data, where
under-reporting is more likely to occur (Plummer et al., 2004; Rossier, 2003).
Qualitative methods provide access to the girls’ social world, eliciting their
underlying values, perspectives, and experiences. The dilemma of accuracy
with recall, embarrassment, terminology, and the prohibitive subjects of
sexuality and abortion have to be considered, however, as well as the
hesitance to openly report what actually happened to the pregnancy loss
due to the risk of legal reprisals. To maintain credibility in our study
some questions were approached from several perspectives to get a deeper
understanding of the girls’ realities.
Ethics in research on sensitive topics is a delicate issue (Yamba,
2005). We promised the adolescent girls confidentiality and that none of
the information obtained during the individual interviews regarding their
abortions should be revealed elsewhere. The purpose of the study was to
obtain a deeper understanding of these girls’ situation, which possibly could
be used to motivate and promote intervention programs for adolescent girls’
sexual and reproductive health rights to safe care services, including the right
to safe abortions.
674 E. Dahlbäck et al.

Our study was deliberately conducted in only one hospital in the capital.
It may be argued that the selection of participants is not representative of
all women admitted to UTH for unsafe abortion. The decision to exclude
severely ill girls admitted to the intensive care unit, however, was based
on the problem of interviewing critically ill patients. Several deaths among
adolescent girls were reported, and 4 girls had died in both 2004 and 2005 in
UTH following severe complications of unsafe induced abortions (Dahlbäck,
2006, unpublished data).
Nonetheless, the site enabled us to reach and interview a wide range
of adolescent girls admitted for incomplete abortions. In comparison with
those in rural areas, people in Lusaka have good access to traditional healers
as well as access to modern drugs bought in pharmacies or obtained from
health clinics. Limitations with hospital-based studies are that adolescent
girls may consult private practitioners elsewhere and girls who abort without
any medical complications will not seek hospital care and consequently are
missed. We do not claim to have captured the multifaceted realities of each
girl regarding abortion and its circumstances. Nonetheless, it was possible
to share and learn from the girls’ experiences when the girls were offered
empathy, confidentiality, and privacy.

CONCLUSIONS AND RECOMMENDATIONS

This interview study shows that, despite legal abortion since 1972 in Zambia,
unmarried adolescent girls still resort to clandestine abortion when faced with
unintended pregnancies. Limited information and access to contraception as
well as stigmatization attached to premarital pregnancies and abortions are
likely to continue to compel girls to rely on clandestine abortions unless com-
prehensive adolescent reproductive health services, including safe abortion
care, are provided. Better history taking and monitoring of adolescent girls’
pregnancy loss, done confidentially to determine the amount of induced
abortions, would be very useful in helping policymakers design programs
that promote safe sex and reduce the number of unwanted pregnancies
and abortions among adolescents. In order to prevent injures and deaths
following unintended pregnancies and dangerous unsafe abortions it is
essential to look beyond the medical system and consider the sociocultural
and religious contexts of abortion in Zambia. A human rights perspective
and a “right to life approach” that respects adolescent girls’ and women’s
rights to informed choices and rights to self-determination, privacy, and
confidentiality are needed.
Male adolescents’ responsibility for sexually related behavior and
reproduction should further be addressed to reduce unwanted pregnancies,
sexual coercion, and violence.
 Unsafe Abortion Among Adolescents in Lusaka 675

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