Fertility Regulation Among Women in Abidjan, Côte d’Ivoire: Contraception, Abortion or Both?

Volume 28, Number 3, September 2002 The subject of unsafe abortion figured prominently in the international conferences on reproductive health and rights that took place in Cairo in 1994 and in Beijing in 1995. Throughout Africa, where most countries have highly restrictive abortion laws and pregnancies are often terminated under unsafe conditions, clandestine abortion is a growing public health issue1 and a major cause of maternal mortality and morbidity.2 Unsafe abortion can result in serious and potentially life-threatening consequences, including hemorrhage, genital lesions and infection from a perforated uterus.3 Reliable data on the incidence of induced, clandestine abortion are rare. Researchers studying abortion in North Africa and Sub-Saharan Africa have had to rely on limited, nonrepresentative surveys of women who are willing to talk about their experience and on data from hospitals on patients admitted for treatment of abortion complications.4 Data for Sub-Saharan Africa are particularly scarce,5 although several recent small-scale studies suggest that reliance on clandestine abortion in that region is increasing.6 In the West African nation of Côte d’Ivoire, fertility has started to fall, particularly in the cities. The country’s total fertility rate (TFR) has fallen by two births per woman over the past two decades (i.e., from a TFR of 7.2 in 1980–19817 to 5.2 in 1998–19998). Nonetheless, access to family planning services remains limited and even though contraceptive use is rising, overall prevalence remains low. For example, only 6% of women aged 15–49 were using a modern method in 1994, and that proportion still did not exceed 10% in 1998–1999.9 With so few women practicing contraception overall, the decline in fertility cannot be explained by the increase in contraceptive use alone. Ivorian women are clearly relying on abortion as well as contraception to limit their family size, despite the fact that the procedure is illegal except when the life of the pregnant women is seriously threatened. Even in that case, the Ivorian Penal Code requires the consent of two doctors in addition to that of the attending physician.10 Given the country’s highly restrictive laws, the limited available abortion data are primarily derived from hospital records of women admitted for treatment of abortion complications11 and from maternal mortality estimates.12 Recent studies have found that urban women are more likely than rural women to resort to abortion,13 and that reliance on abortion explains at least part of the recent rapid fertility decline in the major city of Abidjan.14 If the use of abortion is contributing to fertility decline in Côte d’Ivoire, are women resorting to it instead of practicing contraception, or are they practicing abortion and contraception in tandem? How are these two practices related? To better answer these questions, we surveyed 2,400 women in Abidjan retrospectively about their contraceptive and abortion histories. We designed the survey to assess the respective roles of abortion and contraception by asking about four Fertility Regulation Among Women in Abidjan, Côte d’Ivoire: Contraception, Abortion or Both?