UNIVERSITY OF NAIROBI COLLEGE OF HEALTH SCIENCES SCHOOL OF NURSING SCIENCES RESEARCH PROPOSAL DETERMINANTS OF ABORTION COMPLICATIONS AMONG PATIENTSADMITTED AT KENYATTA NATIONAL HOSPITAL ACUTE GYNAECOLOGICAL WARD INVESTIGATOR

Etudes

UNIVERSITY OF NAIROBI
COLLEGE OF HEALTH SCIENCES
SCHOOL OF NURSING SCIENCES
RESEARCH PROPOSAL
DETERMINANTS OF ABORTION COMPLICATIONS AMONG PATIENTSADMITTED AT KENYATTA NATIONAL HOSPITAL ACUTE GYNAECOLOGICAL WARD
INVESTIGATOR: MARGARET WANJIRU NGUGI MBURU
REG NO: H32M3/38853/2016
A RESEARCH PROPOSAL SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF BACHELOR OF SCIENCE DEGREE IN NURSING
October, 2018
DECLARATIONI, Margaret Wanjiru Ngugi Mburu, declare that this proposal entitled “Determinants of Abortion Complications among Patients admitted At Kenyatta National Hospital Acute Gynecological Ward” is completed as an independent work. I certify that all material in this proposal which is not my own work has been identified and cited and that no material has previously been submitted and approved for the award of a degree by this or any other University.

Signature: ………………………..Date: ………………………….

CERTIFICATE OF APPROVAL This research proposal has been done under my supervision and guidance and the report is submitted for award of Bachelor of Science Degree in Nursing of the University of Nairobi with my approval as university supervisor.

DR. Blasio Osogo Omuga,
Lecturer, School of Nursing Sciences,
University of Nairobi,
P.O. BOX 19676 -00202
Nairobi – Kenya
Signature………………………………………………..Date…………………………………………..

DEDICATIONThis proposal is dedicated to my family, friends and colleagues for the immense support they gave me during my research proposal work and studies at University of Nairobi
ACKNOWLEDGEMENTI wish to ac knowledge my supervisor, Dr Blasio Osogo Omuga, for his valuable input in guiding this proposal writing. I also wish to acknowledge Kenyatta national hospital staff, friends, family members and all other persons who contributed directly or indirectly to the successful completion of this proposal development.
TABLE OF CONTENTS
TOC o “1-3” h z u DECLARATION PAGEREF _Toc527976899 h iiCERTIFICATE OF APPROVAL PAGEREF _Toc527976900 h iiiDEDICATION PAGEREF _Toc527976901 h ivACKNOWLEDGEMENT PAGEREF _Toc527976902 h vLIST OF FIGURES PAGEREF _Toc527976903 h ixLIST OF ABBREVIATIONS PAGEREF _Toc527976904 h xOPERATIONAL DEFINITION OF TERMS PAGEREF _Toc527976905 h xiABSTRACT PAGEREF _Toc527976908 h xiiiCHAPTER ONE:1INTRODUCTION AND BACKGROUND INFORMATION PAGEREF _Toc527976909 h 11.0 Introduction PAGEREF _Toc527976910 h 11.1 Background Information PAGEREF _Toc527976911 h 21.2Statement of the Problem PAGEREF _Toc527976912 h 41.3.1 Specific Objectives PAGEREF _Toc527976913 h 51.4 Research Questions PAGEREF _Toc527976914 h 51.5 Significance of the Study PAGEREF _Toc527976915 h 61.6 Justification of the Study PAGEREF _Toc527976916 h 71.7 Delimitation of the Study PAGEREF _Toc527976917 h 7CHAPTER TWO PAGEREF _Toc527976918 h 8LITERATURE REVIEW PAGEREF _Toc527976919 h 82.2.1 Nature of Abortion Complications PAGEREF _Toc527976923 h 102.2.2 Demographic Factors Influencing Abortion Complications PAGEREF _Toc527976924 h 112.2.3 Social Cultural Factors Influencing Abortion Complications PAGEREF _Toc527976925 h 112.2.4 Health Related Factors Influencing Abortion Complications PAGEREF _Toc527976926 h 122. 3 Literature Gaps PAGEREF _Toc527976927 h 132.4 Conceptual Framework PAGEREF _Toc527976928 h 152.5 Operational Framework PAGEREF _Toc527976928 h 15CHAPTER THREE PAGEREF _Toc527976929 h 16RESEARCH METHODOLOGY PAGEREF _Toc527976930 h 163.1 Introduction PAGEREF _Toc527976931 h 163.2 Study Design PAGEREF _Toc527976932 h 163.3 Study Area PAGEREF _Toc527976933 h 163.4 Study Population PAGEREF _Toc527976934 h 163.6 Inclusion and Exclusion Criteria PAGEREF _Toc527976935 h 173.7 Sample Method PAGEREF _Toc527976936 h 183.7.1 Sampling Procedure PAGEREF _Toc527976937 h 183.9 Study Instruments PAGEREF _Toc527976938 h 193.9.1 Questionnaire PAGEREF _Toc527976939 h 193.9.2 Focus Group Discussion guide PAGEREF _Toc527976940 h 203.9.3 Key Informant Interviews PAGEREF _Toc527976941 h 203.10 Pretesting of Study Instrument PAGEREF _Toc527976942 h 213.11 Research Assistants (Selection and Training) PAGEREF _Toc527976943 h 213.12 Data Collection, Cleaning and Storage PAGEREF _Toc527976944 h 213.14 Ethical consideration PAGEREF _Toc527976945 h 223.15 Limitations of the Study PAGEREF _Toc527976946 h 233.16 Study Assumptions PAGEREF _Toc527976947 h 23REFERENCES PAGEREF _Toc527976948 h 24APPENDIX I: INTRODUCTION LETTER PAGEREF _Toc527976950 h 26APPENDIX II: CONSENT FORM PAGEREF _Toc527976952 h 27APPENDIX III: QUESTIONNAIRE PAGEREF _Toc527976955 h 29APPENDIX IV:FOCUS GROUP DISCUSSIONS PAGEREF _Toc527976957 h 31APPENDIX V:KEY INFORMATION GUIDE FOR NURSES PAGEREF _Toc527976959 h 34APPENDIX VI: LETTER REQUESTING FOR APPROVAL TO UON/ ETHICS COMMITTEE PAGEREF _Toc527976961 h 36APPENDIX VII: LETTER TO KNH DEPUTY DIRECTOR OF CLINICAL SERVICES PAGEREF _Toc527976963 h 37APPENDIX VIII: LETTER TO THE NATIONAL COMMISSION FOR SCIENCE, TECHNOLOGY AND INNOVATION PAGEREF _Toc527976966 h 38APPENDIX IX: MAP OF KENYATTA NATIONAL HOSPITAL PAGEREF _Toc527976968 h 39APPENDIX X: PHOTOGRAPH OF KENYATTA NATIONAL HOSPITAL PAGEREF _Toc527976970 h 40CHAPTER 4 PLANNING PAGEREF _Toc527976971 h 414.1 TIME FRAME PAGEREF _Toc527976971 h 414.2 BUDGET PAGEREF _Toc527976971 h 41LIST OF TABLES
Table 3.1: Sample size ……………………………………..…………………………………24
LIST OF FIGURESFig 2.1: Conceptual framework…………………….………………………….……………20
Fig 2.2: Operational framework……………………………………………….……………21
LIST OF ABBREVIATIONSCI Confidence Level
FGD Focus Group Discussions
HB Hemoglobin
KDHSKenya Demographic and Health Survey
KNHKenyatta National Hospital
PAC Post abortion Care
PIDPelvic Inflammatory Disease
SPSSStatistical Package for Social Science
WHOWorld Health Organization
MOHMinistry of Health
OPERATIONAL DEFINITION OF TERMSAbortion; The deliberate termination of a human pregnancy, most often performed during the first 28 weeks.Attitude This reflects on a way of feeling or thinking about something; typically the one that is reflected in a person’s behaviour. This relates to the study subjects way of reacting to or responding to events related to abortion complications weather of positive or negative nature. These include; attitudes on abortion complications and services offered on abortion.

Contraceptive definition; any of various devices or drugs intended to prevent pregnancy: a product, device, or pill that prevents pregnancy.Demographic factors; are personal characteristics that are used to collect and evaluate data on people in a given population. In this study demographic factors will include Age, Marital status, Education level and Employment levels
Determinants: A factor which decisively affects the nature or outcome of something.

Health factors; are any attributes, characteristic or exposure of an individual that increases the likelihood of developing a disease or injury.

Induced abortion; An abortion that is brought about intentionally.

Knowledge; This involves Common understanding on issues related to abortion complication. This includes knowledge on Awareness on abortion, Perception on abortion, Cause of unsafe abortion and Problem solutions on abortion.

Post abortion: The deliberate termination of a pregnancy, usually before the embryo or fetus is capable of independent life. In medical contexts, this procedure is called an induced abortion and is distinguished from a spontaneous abortion (miscarriage) or still birth.

Practice; This relates to the study subjects past experiences in abortion complications that impact on their choices. It include the practices of unsafe abortion and methods of unsafe abortion
Septic abortion; refers to a spontaneous miscarriage or therapeutic/artificial abortion complicated by a pelvic infection.

Socio-economic factors: These are characteristics that indicates how economic and activities affects and is shaped by social processes. These will include Religious norms, Social groups and Peer groups
ABSTRACTWomen in the reproductive age have a challenge of unwanted pregnancies which in turn poses a major health risks to them. The women’s reproductive health has lead to serious and life threatening complications because of unsafe abortions, the unsafe abortions among the women has become a burden, and due to serious health implications, this has imposed a heavy burden on the women and the society.
Methodology: This study will be done in Kenyatta National Hospital Acute Gynaecological Ward. The purpose of this study is to identifying determinants of Abortion Complications among Patients admitted at Kenyatta National Hospital Acute Gynaecological Ward. The study will be guided by the following objectives; To determine nature of complications among patients admitted at Kenyatta National Hospital acute gynaecological ward; to establish demographic factors influencing abortion complications among patients admitted at Kenyatta National Hospital acute gynaecological ward; To determine social cultural factors influencing abortion complications determinant among patients admitted at Kenyatta National Hospital acute gynaecological ward and lastly to find out the health related factors influencing abortion complications determinant among patients admitted at Kenyatta National Hospital acute gynaecological ward. The research design will be a descriptive survey study conducted on patients admitted at Kenyatta National Hospital acute gynaecological ward. The target population of this study will be 200 respondents. Using random sampling; sixty five (65) patients will be the sample size of this study. In executing this study, both qualitative and quantitative methods will be used. The study will use a questionnaire as a tool for collecting data.
Data Analysis and Presentation: The analysis of data will be done using Statistical Package for Social Science (SPSS) version 21.0 software. Reliability will be tested using Chi squire to find out statistical associations and p-value less than 0.05will be declared significant. Data will be collected in the study site after approval from University of Nairobi Ethical and Research Committee then seek informed consent from the respondents before conducting the data collection. The findings will be presented in frequency distribution tables, charts as well as percentages. Averages and proportions will be reported. The data collection exercise will be done by the principal investigator hence consistency. Data will be collected for a period of 2 days, when questionnaires will be filled; it will then be analyzed by the researcher for corrections. Information given will be kept confidential. The institutions policy will be observed and followed. The respondents will be treated fairly in terms of benefits and risks.
Keywords:
Determinants of Abortion Complications; Unsafe abortion; Nature of Abortion; social factors; Health factors; Demographic factors; Kenyatta National Hospital
CHAPTER ONEINTRODUCTION AND BACKGROUND INFORMATION1.0 IntroductionAccording to Khan (2003) he defines unsafe abortion as unskilled termination of pregnancy in an environment that is not in conformity with hygienic standards, he further explains that, worldwide 13% of global maternal deaths is because of unsafe abortions that has remained to be something of serious and continuing public health challenge. Women globally annually about 8.5 million suffer from complications of unsafe abortion, out of the 8.5 million women three million of these women go without treatment or any medical attention. Africa has stringent laws on unsafe abortion, but despite these laws the incidence of unsafe abortion is on the rise this is attributed by the limited access to reproductive health services and the need that has not been meet on family planning services (WHO, 2011)
According to WHO, (2016) the complications that the women suffer due to unsafe abortion are Chronic pain, death, infertility, infection, and heavy bleeding. In the developing countries, the risk of dying because of unsafe abortions is disproportionately high. Reports from the WHO further indicate that approximately 47,000 deaths in 2008 were contributed by unsafe abortion worldwide. Approximately two-thirds of these abortion related deaths were from the developing country particularly Africa. The treatment of unsafe abortion has led to the increasing cost to the health care system. The WHO estimates that the cost for treatment of abortions complications in Africa as at 2014 was $232 million and this could have risen to $562 million if all the women who had the complications due to unsafe abortion sought treatment (WHO, 2016)
Mortality from unsafe abortions can be easily preventable through the following measures and strategies, this are; education on sexuality, awareness on effective use of contraceptive, timely access to care for abortion complications, provision of safe and legally induced abortion. This will help to reduce morbidity and health care cost for abortion complications. These elements, strategies and measures to reduce unsafe abortion that leads to abortion complications are lacking due to laws that are restrictive in governing abortion, unnecessary requirments such as third party authorization; stigma and negative attitude of health care providers; unavailability of services and stigma and negative attitude of health care providers.
Singh, (2010) alludes that it is crucial to create a conducive environment to ensure that there is easy access of safe abortion in order to mitigate the numerous abortion complications associated with unsafe abortion (Singh, 2010)
In the ancient Roman, Grecian and Egyptian history, post-abortion care is of the oldest sexual and reproductive health care services. The Egyptians used different abortion techniques that were documented in the ancient Ebers Papyrus in 1550 BC. One of the leading causes of maternal death in the 21st century is unsafe abortion countries with laws that are restrictive on abortion carry a major share of burden in caring and mitigating this problem. It has been reported that 1 in 4 pregnancies are unintended; in some countries there is unmet need that has not been meet that is high as 51% leading to unintended pregnancy, this has become a major risk for unsafe induced abortion leading to complications. Due to criminalization and stigma in such countries unsafe abortion has been under estimated as only 4% of women of reproductive age has been reported. The current understanding according to Rasch, (2011) is that developing countries have a rate of unsafe induced abortion leading top complications cases as high as 55% compared to developed nations (Rasch, 2011)
Between 1990 and 2008 worldwide the cases of unsafe abortion related to martenal deaths has been decreasing, however, the incidence increased globally from in Africa from 19.7 million to 21.6 million to 6.2 million between 2003 to 2008. In 2008±2009, the unsafe abortion accounted for 13% (1 in 8) of maternal deaths globally. The same year, 68,000 women died from abortion complications. In Africa the year 2003-2008 there were 29,000 maternal deaths which were attributed by abortion related complications with a ratio of 470 deaths per 100, 000 cases of abortion. According to WHO (2011) 5 million women who survived from unsafe abortion ended up with long term complications (WHO, 2011).

1.1 Background InformationMultiple complications occur due to unsafe abortion are very likely to lead to maternal disabilities and deaths. Patients admitted for post care are mostly because of spontenoues and induced abortion that has led to miscarriages. In Africa, Botswana has socio-cultural beliefs is found to be a barrier that has hindered safe post- abortion care. Apart from the social-cultural beliefs also the abortion law in this country has influenced limited access to safe abortion care (WHO, 2015).

Globally, 55.9 million abortions occur each year, from these estimates 59.3 million cases are in developing countries and 6.6 million cases of abortion are from the developed countries. Each year worldwide, 35 abortions occur per 1,000 women aged 15-44 years. In this figures and estimates the rate of abortion in developed countries is significantly lower than that of the developing countries. The annual rates of 35 per 1,000 worldwide, it suggests that a woman would have one abortion in her lifetime (WHO, 2011).

In Africa 60% of unsafe abortions occurs in the adolescent age group, women below age 25 years and 40%. Based on this reports and evidence from WHO, there is need for evaluation of post-abortion care to ensure up-to-date health care of adolescent age group and young women of reproductive age in African settings. The underestimation of incidences of abortion has become a burden in Kenya, this incidences are not well documented or known this is because of the law on abortion in Kenya that is restrictive.
In Kenya, high fertility rates and low contraceptive use have remained a major problem since independence. The current total fertility rate in the country is estimated to be 4.6 while the contraceptive prevalence rate is 46% this is therefore an evident that when there is high unmet need the chance of unintended pregnancies with its consequences to happen is high. According to Kenya Demographic and Health Survey KDHS (2016) unsafe abortions leading to complications likely happen to women with unintended pregnancies (KDHS, 2016)
Unsafe abortion in Kenya is largely contributed by unwanted pregnancies. This has lead therefore unsafe abortions to be the leading cause of mortality and morbidity. According to Kenya Demographic and Health Survey KDHS (2016) 43% of births in Kenya were unwanted. This has been contributed by some of the major hindrances on use of contraceptive among women and girls in Kenya are; inadequate information on sexuality, Stigma and cultural pressure (Singh, 2010)
The account for abortion complications at the Kenyatta National Hospital were more than half of all the gynaecological admissions in 2017, the abortion complications were emergencies that required the patients to be admitted to the hospital for long, required repeated visits by the patients to the facility, others had to be on intensive care unit and also to be attended by health care providers who are highly skilled.

Therefore, in different hospital management settings for this study Kenyatta National Hospital, the nature and degree of abortion complications has to be understood with the aim of generating baseline evidence on post abortion complications. The results from this study on determinants of abortion complications among patients admitted acute gynecological ward will provide policy makers with information needed to enhance post abortion care, with the objective of working towards decreasing the resultant maternal mortality.

1.2Statement of the ProblemIn developing countries, the high cause high maternal morbidity and mortality is due to unsafe abortion. The ministry of Health in Kenya has put in place interventions in the provision of optimal maternal healthcare but still there are increasing numbers of abortions complications in the Hospitals and in particular Kenyatta National Hospital.
The hospital records from January 2017 shows that there is high number of admission of women and girls who had incomplete abortion which lead to various complications which resulted from use of methods which were crude. It is therefore important this study to understand the determinants of abortion complications among women of reproductive age at the admitted at acute gynecological ward at Kenyatta National Hospital. This will help the hospital policy formulation and also the implementation of strategies that are geared towards at promotion of safe motherhood in Kenya. To bring a solution to this problem, there is need to prevent unintended pregnancies which are likely to lead to induced abortion with multiple complication and maternal death by improving and standardizing abortion care and more so by increasing availability of modern contraceptives.
In the Kenyan Constitution 2010, in the opinion of a trained health professional that a patient or client needs emergency treatment or her life or health is in danger, abortion may be granted to a pregnant woman or girl. Nevertheless, According to WHO, (2014) unsafe abortion has led to complications that remains a leading cause of maternal morbidity and mortality in Kenya. Unsafe abortion consumes significant health systems resources in terms of treatment of these complications (WHO, 2014).
The gap in knowledge about abortion is substantial. In order to fill the gaps, there is need by researchers to develop and apply innovative approaches or methods in documenting incidence of abortion and furthermore understanding its causes, conditions and consequences. To fill such gaps, researchers are developing and applying innovative approaches to better document the incidence of abortion and to better understand its causes, conditions and consequences.
This research study will therefore explore on this growing area of concern to examine the determinants of abortion complications, and focus on abortion complications in light of factors known to influence complications by providing an overview of key determinants of abortion complications e.g nature of complications, demographic factors, social cultural factors, health related factors and economic factors influencing abortion complications.
This study therefore seeks to establish the determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward. This study will be helpful in informing and giving future policies to the hospital management and also to other agencies and programs. 1.3 Main ObjectiveTo assess the determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward
1.3.1 Specific ObjectivesTo determine nature of complications among patients admitted at Kenyatta National Hospital acute gynaecological ward
To establish demographic factors influencing abortion complications among patients admitted at Kenyatta National Hospital acute gynaecological ward
To determine social cultural factors influencing abortion complications determinant among patients admitted at Kenyatta National Hospital acute gynaecological ward
To find out the health related factors influencing abortion complications determinant among patients admitted at Kenyatta National Hospital acute gynaecological ward
1.4 Research QuestionsThe study will be guided by the following research questions:
What are some of the nature of abortion complications among patients admitted at Kenyatta National Hospital acute gynaecological ward?
What are the demographic factors influencing abortion complications among patients admitted at Kenyatta National Hospital acute gynaecological ward?
What are the social cultural factors influencing abortion complications determinant among patients admitted at Kenyatta National Hospital acute gynaecological ward?What are the health related factors influencing abortion complications determinant among patients admitted at Kenyatta National Hospital acute gynaecological ward?1.5 Significance of the StudyThe study will be significant to the government as policy makers regarding determinants of abortion complications in health care set up. The study will be significant to the policy makers to gain insight on determinants of abortion complications. It may also help the policy makers and social planners in making or re-evaluating existing guidelines to help the medical practitioners and patients since the study examines a number of background variables to better understand the dynamics of abortion.

Being that there are limited studies linked to determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynecological ward, Nairobi County, the outcome of this study will act as local reference on determinants of abortion complications among patients for future work on research i.e assessing impact of determinants of abortion complications.
The findings of this study would provide information and advice on the possible opportunities that research institutions can use to expand the research, availability, and impact of information on determinants of abortion complications.

The study will inform different organizations and departments at KNH on the determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward. Understanding the determinants that contributes to abortion complications will assist in the adjustment of policies and programs that promote safe abortions.
1.6 Justification of the StudyOne of the major health problem is unsafe abortion which annually claims the lives of thousands of women of reproductive age, and leaves millions of other women with serious complications and disabilities. According to Kenya Demographic Health survey, more than approximately 300,000 abortions occurred in Kenya. This numbers and figures translates to more than 46 abortions for every 1,000 women of reproductive age annually. Hospital studies which examined the issue of abortion further reports high rates of hospital admissions for the treatment of abortion- related complications whereby high related mortality rates have been estimated by the stud by KDHS to result from unsafe induced abortions.
Therefore, there is need for policy development to prevent illegal abortions from occurring, and treat their resulting complications. Effective strategies for addressing illegal abortions results- based evidence of their effects at the individual, social and economic level. The existing research has specifically focused on; estimating incidences of abortion, analyzing perceptions of/ and access to abortions, access to/ and quality of post-abortion care, and lastly investigating medical issues regarding abortions. While these data are important in order to identify extent of the phenomenon for the country, further insight is needed for advocating policy changes that may help tackle illegal unsafe abortions that has lead to complications.
In order to put in place policy changes, there should be economic consequences of illegal abortions which will be used increasingly. In accordance to these, the number of studies on the economic consequences of abortions is growing. However the current knowledge of the determinants of abortion complications in Kenya is extremely weak. The present study may contribute to the fight against illegal (induced) abortion by providing knowledge that may be useful in identifying the determinants of abortion complications among patients in Gynaecological Wards at Kenyatta National Hospital.
1.7 Delimitation of the StudyThe study will be confined to Kenyatta National Hospital Acute Gynaecological Ward. The study attempts to establish the determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward.CHAPTER TWOLITERATURE REVIEW2.0 IntroductionThe chapter will comprise of past studies done on the determinants of abortion complications among patients admitted in acute gynaecological ward in order to conceptualize the study problem with other previous work. The obtained information will be from policy papers, books (published and unpublished books), scientific journals and articles. The researcher will also introduce the conceptual framework that conceptualizes determinants of abortion complications and consequences or impacts of unsafe or illegal abortion.

2.1 Global View on AbortionAbortion is defined by WHO (2016) as removal or expulsion pregnancy of a fetus or embryo before viability from the uterus. An abortion can occur spontaneously which often referred to as miscarriage or this can be purposely induced. Abortion is commonly referred to as induced abortion of a human pregnancy. Induced abortion utilizes medications and surgical procedures in modern medicine. In developed world, when abortion is induced in accordance with the law it is referred to as medicine. Long term psychological or physical problems are not caused by uncomplicated abortions, however approximately 47,000 maternal deaths and 5 million hospital admissions per year occur each year globally as a result of unsafe abortions (WHO, 2016)
WHO, (2016) reveals that slightly under half of those abortions performed unsafely, an estimated 44 million abortions are performed globally each year. Due to increased access to family planning education and contraceptive services, the number of abortions has stabilized in the recent years. According to WHO, (2016) the legal access to induced abortions among women in the world is 40%. The performance of induced abortion has a long history by various methods including the use of sharpened tools, herbal abortifacients, and other traditional methods. Abortion varies substantially around the world according to the legality, prevalence, cultural and religious status (WHO, 2016)
There are specific conditions that determine the legality of abortion this are; rape, defects, high risk of disability, socioecomic factors, the mother’s health being at risk and incest
In some many parts of the world, there are prominent divisive public controversies over the ethical, moral and legal issues of abortion. In these countries there are those are against abortion saying that embryo or fetus is a human with the right to life and therefore doing abortion equate to murder. So other proponents of abortion rights emphasize that it is a woman’s rights to decide about matters that concerns her life or own body. When access to legal abortion is restricted, women seeking to terminate their pregnancies sometimes resort to use of unsafe methods. During abortion, the women attempt to rely on another person to do for them the procedure, these people who do not have proper medical training or access to proper facilities. This process therefore has a tendency to lead to lead to severe complications, such as hemorrhage, damage to internal organs incomplete abortion and sepsis (Selebalo, 2010)
Major cause of injury and death among women worldwide according to WHO (2012) is unsafe abortions. 22 million unsafe abortions are performed annually, 97% take place annually in developing countries, though the data is not precise. Millions of injuries result because of unsafe abortions. In the past decades, the estimates of death have ranged from 37,000 to 70,000, of all the maternal deaths, 13% deaths account from the unsafe abortion.

In Kenya and most countries round the globe public health organizations have generally advocated on emphasizing the training of medical personnel, legalization of abortion, and ensuring access to reproductive-health services with the aim of reducing the number of deaths caused by unsafe abortions that leads to complications of abortion (WHO, 2012). Every year, 46 million abortions take place, the WHO estimates that nearly 22 million are nearly unsafe. More than 500,000 women died because of abortion complications because of unsafe abortion, and countless others suffer life threatening injuries. According to WHO, (2012) 97% of deaths and other abortion complications are related to unsafe abortions
The Kenya’s population doubled in the last decades, the most recent count is 45 million. This population has largely caused birth rate in the country of 36 births/1000 population; the population groth rate is at 2.5% per year in Kenya. This rate indicates that roughly that 1 million people are added to the Kenyan population every year (Gumede, 2004).

Recent studies with continuing figures show that that more than 40% of births in Kenya are unplanned. Among the youths this figures rises to 47%. 39% of Kenyan women use contraceptives in this percentage a third of these women relay on modern methods.
According to Alemu, (2010) about 310,000 abortions occur every year in Kenya. Due to abortion related complications from unsafe abortions usually done in backstreet clinics the number of women admitted every year is more than 21,000 women, 2,600 of these number eventually die. Alemu (2010) indicates that between 25 and 34 years were 40%, teenagers constitute to 16%, 12% of the women were older than 34years. He further indicates that the result of 32% of maternal deaths is because of abortion complications which are related to unsafe abortion, this has made abortion the to be the leading cause of death among women in Kenya. It has been observed from hospital records that 10,000 patients are treated for abortion complications of records from a study by Alemu (2010) unsafe abortions every year at the Kenyatta National Hospital (KNH) in Nairobi, Kenya alone.

2.2Determinants of Abortion Complication among Patients Admitted at Kenyatta National Hospital Acute Gynaecological Ward2.2.1 Nature of Abortion ComplicationsHeavy bleeding; this is one of the common problem after an abortion. Bleeding occurs when pieces of the pregnancy are left in the womb after unsuccessful abortion. This happens because the womb cannot shut itself but instead continuously bleed. It happens because of incomplete abortions. The bleeding often stops when the pieces are removed. One of the major causes of bleeding in caused by torn cervix, sometimes the bleeding is stopped by stitching the torn cervix (KDHS, 2016)
Injury to the Genital tract is another nature of abortion complication characterized by Uterine perforation, in this complication, unless laparoscopic visualization is performed 2% of all abortion patients may suffer perforation of their uterus. Most of these injuries in the uterus will remain undiagnosed and untreated. Another complication is cervical laceration, a significant that cervical laceration requires sutures occurs in at least one percent of first trimester abortions. When lesser lacerations occur and not treated it may result in a long time reproductive damage (KDHS, 2016)
Infection; endometritis is one of the most common type of infection reported it is an infection of the lining of the uterus and genital tract. This nature of complications may involve infection of reproductive organs and the urinary system. Following elective abortion there is up to 5% for first trimester abortions and up to 18% in midtrimester occurrence of genital tract infection. Teenagers are 2.5 times more likely than women who are 20-29 times likely to acquire endometritis following abortion; Endometritis is a post-abortion risk for all women
2.2.2 Demographic Factors Influencing Abortion ComplicationsAge; In terms of age distribution, the cohort with the highest proportion of abortions are age group of 20-24 years this has been identified from several countries from analysis of data. In the Sub Saharan Africa studies by WHO (2014) shows that a large number of teenage women terminate pregnancies. In many countries, there is a substantial proportion of adolescents seeking abortion. Of all the abortions that occur in Africa, 59% are estimated to occur in women aged younger than 25 years. According to KDHS, (2016) among the bulk of abortions, a number of this is the youths
Marital status; According to KDHS, (2016) marital status has been found to be associated with. Reports indicate that those who have been married are likely to seek for abortion. There is a highest proportion of abortion seekers among those who are single, ever marrieds (divorced, separated and widowed) compared with those who are married (KDHS, 2016)
Education level; KDHS (2016) further states that women in the urban areas are more likely to seek for abortion than women in the rural areas. It is revealed from Kenya National Hospital statistics from the gynecological wards that women who are educated from the urban areas are more likely to seek for abortion their counterparts in the rural areas who are less educated.This is influenced by the fact that educated women wish to advance in their careers and profession but don’t want to bear children. So when unwanted pregnancy arise, they tend to seek for abortion (KDHS, 2016)
Employment; in the formal employment, women are more likely to seek for abortion. In contrast, it is also found in the Kenya Demographic Health Survey (2016) that the highest groups among the abortion seekers were students the other group are predominantly traders.
2.2.3 Social Cultural Factors Influencing Abortion ComplicationsBeliefs and cultural practices play significant role in the community in influencing abortion complications and this puts pregnant women at a higher risk, for instances prolonged labour is attributed to infidelity and curse, swelling in pregnancy traditionally signifies a baby boy. Similarly, some communities hold that a woman delivering at the health facility is expected to spend less time for (instance less than three hours) in order to prove that she is a real woman (Ngcobo, 2009)
Cohen (2003) reveals that some communities in East Africa have some cultural practices pertaining in the community as follows: some communities belief in blowing a bottle to expel placenta; some use concoctions to boast HB levels and also use the same concoctions to stimulate contraction ; some communities also keep the mother and baby indoors for a period after delivery, all these factors has fueled women who get unwanted pregnancies to opt for abortion to so as not to go through the humiliation of the community, the stigma and negative attitudes towards pregnancy, hence ending up in nom-clinical abortions which lead to complications (Cohen, 2003)
Ngcobo (2009) identified that the lack of or low contraceptive use because of religious reasons has ended in abortions because of unwanted pregnancies. In most cases, Women who are determined about their families end up using available means to do abortion in order to limit their size of their families by timing their child bearing, even if abortion is illegal women still turn to it if contraception is not a viable option (Cohen, 2003)
2.2.4 Health Related Factors Influencing Abortion ComplicationsPre-term delivery is one of the health factor that is influenced by abortion complication. Women who had one, two, or more previous induced abortions are more likely to have a subsequent pre-term delivery, compared to women who carry to term. (Khitamy, 2013)
Placenta previa – this is a complication due to abortion that leads to abnormal development of the placenta due to uterine damage, this complication increases the risk of it in later years which can be life threatening condition for both the mother and her baby. The condition of placenta previa is a risk of malformation, death and excessive bleeding during labor (Mitchell, 2007)
Pelvic Inflammatory Disease (PID); at the time of abortion a significant number of patients about 20 to 27% of patients seeking abortion have a chlamydia will develop PID, and for patients who are not infected by chlamydia will develop PID within 4 weeks after the first trimester abortion (Mitchell, 2007)
Breast Cancer – After two or more abortion, there is a double risk of being with breast cancer, according to WHO, (2016) the leading cause of abortion-related maternal deaths within a week of abortion are; undiagnosed ectopic pregnancies, hemorrhage, anesthesia complications, infection and embolism. A study by WHO (2016) found that 62% women who had abortions are at higher risk of death from all causes for at least eight years after the abortion. Women are 3.5 times more likely to die after abortion in the year following abortion (WHO, 2016)
2. 3 Literature GapsIt is evident from the reviewed literature so far that there is knowledge deficit about determinants of abortions complications and impacts and consequences of unsafe abortions. In our setting where abortion is illegal abortion related complications and deaths are in most cases high. Health facilities e.g Kenyatta National Hospital need to mechanisms to address factors leading to abortion complications the hospital need to be equipped also to handle fatal complications in good time. In order to ensure implementation of standard protocol and reduce complications, there is need for Kenyatta National Hospital to enhance post-abortion care.
The ignorance of family planning, unstable economic status and unplanned pregnancy among a majority of women of reproductive age play a major role in laying fertile ground for abortion complications. To address abortion-related maternal morbidity and mortality, the study will be critical in developing targeted interventions. Having local data as a nation is important other than relying on studies done in other countries because determinants of abortion complications are different due to differences in nature of complications, demographic factors, health factors, and social cultural factors and economic environments as observed in this study
2.4 Conceptual Framework
Figure 2.1 Diagram showing relationship between the study variables
-655320220980Demographic Factors
00Demographic Factors
Independent Variables Dependent Variables
2098040201930002557780201930Knowledge
00Knowledge
182880020193000
249554920193000
2324100965200043535602489190046475642393950023418809651900

-655320126365Cultural factors
00Cultural factors

6709410203835Abortions Complications
Economic Burdens
Psychological Effects
00Abortions Complications
Economic Burdens
Psychological Effects
Outcome
18529307238900
50482504445Abortions Complications
00Abortions Complications
25577804445Practice
00Practice
464756519875400
21170907238900
4345305381000237045517081400-655320277495Social Factors
00Social Factors

2653030226695Attitude
00Attitude
182880015811500
232410019557900-655320195580Health Related Factors
00Health Related Factors
450469015303400
188214024447500
The diagram above (Figure 2.1) show the conceptual framework on factors influencing Abortion Complications (Independent Variables) has the following determinants, Nature of Abortion and abortion complications as the dependent variable.

2.5 Operational FrameworkFigure 2.2Operational framework showing relationship between the study variables
-655320220980Demographic Factors
Age
Marital status
Education level
Employment levels
00Demographic Factors
Age
Marital status
Education level
Employment levels
Independent Variables Dependent Variables
255778068580Knowledge
Awareness on abortion
Perception on abortion
Cause of unsafe abortion
Problem solutions on abortion
00Knowledge
Awareness on abortion
Perception on abortion
Cause of unsafe abortion
Problem solutions on abortion
209804020193000182880020193000
249554920193000
2324100965200043535602489190046475642393950023418809651900
-655320126365Cultural factors
Beliefs, Values, Attitudes
Cultural practices
00Cultural factors
Beliefs, Values, Attitudes
Cultural practices

6709410203835Abortions Complications
Economic Burdens
Psychological Effects
00Abortions Complications
Economic Burdens
Psychological Effects
Outcome
504825081915Abortions Complications
Economic Burdens
Psychological Effects
Types of complications
Heavy Bleeding
Injury to the Genital Tract
Infections
00Abortions Complications
Economic Burdens
Psychological Effects
Types of complications
Heavy Bleeding
Injury to the Genital Tract
Infections
18529307238900
25577804445Practice
The practices of unsafe abortion
Methods of unsafe abortion
00Practice
The practices of unsafe abortion
Methods of unsafe abortion
464756519875400
42386251752590021170907238900
237045517081400-655320277495Social Factors
Religious norms
Social groups
Peer groups
00Social Factors
Religious norms
Social groups
Peer groups

2653030226695Attitude
Attitudes on abortion complications
Services offered on abortion complications
00Attitude
Attitudes on abortion complications
Services offered on abortion complications
182880015811500
232410019557900-655320195580Health Related Factors
Pre-term delivery
Pelvic Inflammatory Disease
Breast Cancer
00Health Related Factors
Pre-term delivery
Pelvic Inflammatory Disease
Breast Cancer
450469015303400
188214024447500
The diagram above (Figure 2.1) show that factors influencing Abortion Complications (Independent Variables) has the following determinants, Nature of Abortion Complications, Demographic factors, Social cultural factors and Health related factors: Abortion Complications is the dependent variable, this variable is influenced by the determinants or factors that lead to it which includes; Demographic factors, Social cultural factors and Health related factors. Policy changes and laws on abortion act as the intervening or moderating variable, it plays a key role in moderating between factors influencing determinants of abortion complications and abortion complications that patients go through after the unsafe abortion (Author, 2018)
CHAPTER THREERESEARCH METHODOLOGY3.1 IntroductionThis chapter will give the methodology which the researcher will use in the study. The chapter on research methodology included the research design, the study area, the target population, the sample and the sample selection and data collection instruments for collecting data. These sections will be highlighted from the research design to the methods of data analysis and interpretation.

3.2 Study DesignThe study will adopt a descriptive cross-sectional study to address the research objectives of this study. The descriptive cross-sectional study involves determining the frequency with which an event occurs or the relationship between two variables and give description of the state of affairs as it exists at present, furthermore it involves fact-finding enquiries of different kinds. (Shukla, 2008)
3.3 Study AreaThe study will be carried out in Kenyatta National Hospital (KNH), Nairobi County. The hospital is located about 3.5Km west of the city’s central business district west of Upper Hill in Nairobi. The researcher could wishes to identify the determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward.

3.4 Study Population
According to Mugenda ; Mugenda (2003), Target population involves the entire group of households or objects to which the researcher will be interested in generalizing and making conclusions of the study. The study population of 200 will be targeted in the study which will comprise patients admitted in Kenyatta National Hospital acute gynaecological ward.

3.5 Inclusion and Exclusion Criteria
3.5.1Inclusion criteria
Nurses working at Kenyatta National Hospital Acute Gynecological Ward.

Patients admitted At Kenyatta National Hospital Acute Gynecological Ward who have consented
Exclusion criteria
Patients admitted At Kenyatta National Hospital Acute Gynecological Ward who have not been admitted for at least 3 months
Patients admitted At Kenyatta National Hospital Acute Gynecological Ward who have not consented
3.6 Sampling Size DeterminationThe sample size will be determined using Fishers or Cochran’s formula, the formula use 95% confidence interval as shown below;
n = Z2pq
d2
Whereby;
n = is the sample size for the population that is infinite
Z = 1.96 (Confidence level at 95%)
p is the = the estimated proportion with desired characteristics estimated at 95% (0.95)
q is = 1-p (0.05)
d is the = precision of the estimate at 5% (0.05)
The calculation for the sample size will be;
n will therefore calculated as follows (1.96)2 x 0.95 x 0.05
(0.05)2
= 73
The calculation for the sample size for the finite population of 200 respondents will be;
n1 = 1
1/n + 1/N
Where;
n1 = required return sample size because sample > 5%
n = will be the estimated sample size for infinite population
N = will represent the finite population size (study population 200) for this study.

73914015874900n1 = 1
1/73+ 1/200
= 53
Out of the 200 target population, 53 respondents will be selected using random sampling. 12 respondents will be sampled purposively. These will be considered adequate sample size for the study taking into consideration the number of patients admitted in Kenyatta National Hospital acute gynaecological ward. Therefore, the study will have a sample size of 65 respondents. Random and purposive sampling will be used to select the respondents from Kenyatta National Hospital acute gynaecological ward
3.7 Sample Method3.7.1 Sampling ProcedureUsing random sampling and purposive sampling procedure, sixty five (65) patients admitted in Kenyatta National Hospital acute gynaecological ward and nurses will be sampled to participate in this study.
Table 3.1; Table showing the sample size of the studyPatients (women) admitted in Kenyatta National Hospital acute gynaecological ward Frequency (No.) Percentage (%)
Less than 21 years 25 7.1
Greater than 21 years 35 52.1
Don’t know 5 40.1
Total 65 100
3.8 Sampling Interval
The frequency of data collection for this study will be calculated as follows:
Sampling interval (x) = Population size
Sample size
Every xth respondent will be included from the first respondent where x will be the sample Interval until the sample size will be met.

Since the study population 600 and the sample size is 65 x will be calculated as follows:
x = Population size
Sample size
200
65
=3.07
This is approximately equal to 4. Therefore every 4th respondent will be included from the first until the sample size is reached.
3.9 Study InstrumentsThe study used both secondary and primary data to achieve its objectives. Secondary data refers to data that is already in use for other purposes other than that of the researcher. Primary data on the other hand, refers to information gathered at first hand by the researcher from respondents in the field
3.9.1 QuestionnaireQuestionnaires are a quantitative technique for gathering information and will be the major tool for the primary data collection process. The questionnaire will contain questions which comprises of open ended questions and closed-ended question. A list of possible alternatives will accompany this questions, the respondent will be in a position to select the answer that best describes their situation on determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward.

Questionnaires will be self-administered and this will allow for face-to-face interactions with the respondents for further probing. The essence of having semi structured questions is to allow for a process of interaction between the researcher and the respondent where the latter is given an opportunity to give opinions and ideas on the research questions. The researcher will design questionnaires for the respondents, this include; questionnaire for the Hospital staff and the respondents.

3.9.2 Focus Group Discussion guideData collection using questionnaires will be followed by a focus group discussion (FGD) with eight nurse leaders involving three nurse clinicians, three nurse administrators and two nurse educators conveniently selected from KNH. The respondents will be selected because of their knowledge and experience of the study topic. To draw upon participants’ attitudes, beliefs, feelings, experiences and reactions, the study will use focus group discussion.The use of focus group discussion helps to draw upon participants’ attitudes, beliefs, feelings, experiences and reactions in a way which would not be feasible using other methods.

The discussion will start by the researcher welcoming and thanking the participants for agreeing to participate. This will be followed by introductions and the researcher explaining the purpose of the focus group discussion. Participants will then sign consent forms, the will be assigned codes randomly. In order to ensure anonymity the codes will be used to refer each of one of them during the discussion.
The participants will be reminded that the discussion will be open for honest and different viewpoints and that there will be no right or wrong answers. Besides, they will be requested to respect each other and their opinion. The note taker will take took notes as the discussion goes on while the researcher will note the main points which will later be combined
3.9.3 Key Informant InterviewsAfter completing the focus group discussion, key informant interviews will be conducted with the nurses conveniently selected from each of the acute gynecological wards. The researcher will select nurses from the ward because of their involvement in ward/unit leadership, clinical supervision and continuing education activities. To obtain individual’s views, attitudes, beliefs and feelings, the researcher will use single informant interview which is a conversation between the participant and researcher under conditions acceptable to the participant.
The research will utilize interview guide to collect data. The interview guide will be structured to ensure that information about Health Factors, Demographic Factors, Social Factors and Cultural factors will be collected. The interview guide will help the researcher to have a direct interaction with the respondents this will helps the researcher to capture the reactions.
3.10 Pretesting of Study InstrumentThe tool that will be used in this study is questionnaire. To avoid double inclusion of pre-test participants in the main study, the questionnaire will therefore be pre-tested through a pilot test with individuals in the study. To enhance reliability and validity of the study findings, the feedback will help the researcher to make vital adjustments. To ascertain the reliability of the data collection, the instrument will be examined by professionals who include the researcher and supervisor (Thorpe, 2000)
3.11 Research Assistants (Selection and Training)The researcher will recruit and train four research assistants on the purpose of the research, the objectives, how to implement the research tools and data collection techniques. The four assistants will be selected at the level of degree in Nursing.

Also, checking the tool for completeness, the data will be coded and entered to the computer. The research assistants will be introduced to the Deputy Director Clinical Services and to the assistant chief nurse in-charge of the study areas in the hospital. During the data collection process, the researcher will emphasize the importance of ‘honest’ responses and the purpose of the research to the participants. The research assistants will then supervise the questionnaire filling exercise and ensure that participants do not influence each other which could introduce bias. After each filling exercise, they will assist the researcher in collecting the filled questionnaires.

3.12 Data Collection, Cleaning and StorageThe data will be collected using a structured questionnaire. The introductory letter will be issued to the management in Kenyatta National Hospital and the respondents to assure them that the study will be for academic purpose only. The researcher will select respondents admitted at acute gynaecological ward and personally administer the questionnaires. The respondents will be given sample time to respond to the questionnaire after which the researcher picked them for data analysis and presentation. Some respondents might not complete the questionnaire immediately, in such situations, the researcher will leave the questionnaire then to pick on a later date. During piloting, the researcher will visit the study area and administer the instruments.

To remove errors and inconsistencies, the researcher will ensure data that cleaning is done in order to improve quality of the data. Furthermore, data cleaning helps to reduce time and complexity of mining process and increase the quality of data. The researcher will code by organizing and sorting data, this will be done by labeling, compiling and organizing the data collected.
The hard copies will be kept securely in a locked filing cabinet that can be accessed by the researcher only and can only be shared according to the terms of the consent from participants.  If there is a plan to archive data for use by other researchers, prior consent will be needed from the participants. Soft copy data will be stored in Flash Disk and CD ROM, this devices will be not be accessed by any other individual.3.13 Data AnalysisData arising from the questionnaires will be subjected to the descriptive statistics aided by statistical package for social sciences (SPSS) where statistics will be derived and inferred to make interpretations and conclusions. Data resulting from interview guide will be classified into content categories and themes drawn according to the variables of the study.

Data will be analyzed exhaustively on individual questionnaire according to the objectives of the study. The responses from respondents will be presented in terms of tables and percentages. The data will also be evaluated to determine the determinants of abortion complications among patients admitted at Kenyatta National Hospital acute gynaecological ward. To facilitate a discussion of the findings and drawing of conclusions, the data will be interpreted according to the purpose of the study.

3.14 Ethical considerationThe researcher will obtain a permission based on authorization letter from The University of Nairobi/ Kenyatta National Hospital’s Ethics and Research Committee (UoN-KNH ERC),
the researcher will also seek approval from the Nairobi County Government Health Department. Permission will be then sought from Kenyatta National Hospital’s medical superintendent officer/ Nurse in charge for approval. Permission will be obtained from the management of KNH through the office of the Research and Programs department since the findings will be very useful for administrative and educational purposes. The anonymity of the respondents will be maintained all through. The respondents will not be required to provide any identifying details or information such as their names and transcripts. Consent will be obtained from the research respondent.
3.15 Limitations of the StudyThe method used in this study on self-reporting could result in reporting bias. The number of the population under study may be small and this will be generalized. Regarding the nature of the study on abortion, some participants may not be willing to share more information about their experiences on abortion because of fear that someone else may get their information, however the participants will be assured of confidentiality. When participants note that they are being observed, bias may also result therefore distortions of the data to be collected may occur. Lack of previous related studies on this topic at Kenyatta National Hospital limits the literature review to studies done outside the hospital on the related topics. Time required during development of the proposal to the presentation of the results is another limitation of the study.

3.16 Study AssumptionsIt is assumed that the findings are a true reflection of the reality experienced in abortion complications in the in the hospital gynaecological ward. It is recommended that more studies be done to authenticate this. In this study, it is assumed that; the respondents will be honest and truthful when answering the questions. It is also assumed that the respondents will be objective and competent in answering questions. The respondents will cooperate with the researcher in enabling the study to be carried out as planned.REFERENCESAlemu, F.F. (2010). Minors’ awareness about the new abortion law and access to safe abortion services in Ethiopia: The case of Maria Stopes International Ethiopia Centre in Addis Ababa. Amsterdam: University of Amsterdam.

Cohen, S. A. (2003). Contraceptive use is key to reducing abortion worldwide. The Guttmacher Institute. International Journal of Nursing Studies, 40, 73-84.

Harries, J., Orner, P. Gabriel, M. ; Mitchell, E. (2007). Delays in seeking an abortion until the second trimester: A qualitative study in South Africa. BMC Public Health, 4 (7), 1-8.

Harvey, S. M., Beckman, L. J. ; Branch, M. R. (2002). The Relationship of Contextual Factors to Women’s Perceptions of Medical Abortion. Health Care for Women International, 23, 654- 665.

Grobler, H. &Schenck, R. 2009.Person-centered facilitation: Process, Theory, and Practice. (3rd ed). Cape Town: Oxford University Press.

Grey, D. E. (2009).Doing research in the real world. (2nd ed). Los Angeles: Sage
Gumede, T. (2004).Why do women opt for backstreet abortion: A sociological study. Masters of Arts in Sociology, Rand Afrikaans University. South Africa.

Khan, K.S., (2006): WHO analysis of causes of maternal death: a systematic. Lancet, 367: p. 1066-74.

Kenya Demographic and Health Survey (2010-2017) A Report on abortion complications among patients admitted in Major Hospitals in Kenya. Print options; Nairobi.

Khitamy, B. A. B. (2013). Divergent views on Abortion and the period of Ensoulment. Sultan Qaboos University Med J, 13(1), 26-31.

Kurmar, A., Hessini, L & Mitchell, E. M. H. (2009).Conceptualizing abortion stigma, Culture, Health & Sexuality: An International Journal for Research, Intervention and Care.11(6), 626-639.

Milchel, K. K. (2005). Social Work: An empowering profession. (5th ed). Boston: Pearson Publishers.

Mugenda, M.O. &Mugenda, A. (2003) Research Methods, Qualitative and Quantitative approaches: Nairobi: Acts Press.

Ngcobo, B. F. (2009). The Psycho-Social Experiences of Unwed Teenage Mothers in Faith Communities: A Qualitative Study. Masters Degree in Counseling Psychology, University of KwaZulu-Natal, Durban, South Africa.

Selebalo, L. M. M. (2010). The Attitudes of young male learners towards abortion. Masters Degree in Counseling Psychology, University of KwaZulu-Natal, Durban, South Africa.

Shukla, P. (2008). Marketing Research. Paurav Shukla &Ventus Publishing ApS. Journal for research Development, 24(1) 12-18.

Smith, G. C. S. & Pell, J. P. (2001). Teenage pregnancy and risk of adverse perinatal outcomes associated with first and second births: Population based retrospective cohort study. BMJ, 323, 476-479.

Russell, K. &Schutt, B (2009).Investigating the social world: The process and practice of research.(6th ed). Boston: University of Massachusetts.

WHO. (2014). Trends in maternal mortality. Geneva, Switzerland: WHO. Journal of Advanced Nursing, 53(4), 454–458.

WHO. (2012). Safe Abortion: Technical and policy guidance for health systems. (2nd ed). Geneva, Switzerland: WHO.
WHO. (2009). Strengthening cervical cancer prevention and control: Report of the GAVI-UNFPA-WHO meeting. Geneva, Switzerland: WHO.

WHO. (2007). Unsafe abortion: Global and regional estimates of the incidents of unsafe abortion and associated mortality in 2003. (5th ed). Geneva, Switzerland: WHO.
WHO. (2003). Safe abortion: Technical and policy guidance for health systems. Geneva, Switzerland: WHO.

APPENDIX I:INTRODUCTION LETTERMARGARET WANJIRU NGUGI MBURU
P.O BOX 21090 Nairobi
1ST October 2018
TO WHOM IT MAY CONCERN
Dear/ Madam,
REF: RESEARCH STUDY
I am a Bachelor of Science in Nursing student at the University of Nairobi. I am undertaking a research on “Determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward”
I request your cooperation and assistance to enable me complete this exercise. The information will be strictly used for the intended academic purpose and will be treated with utmost confidentiality.
Thank you.

Yours sincerely,
Margaret Wanjiru Ngugi Mburu
(Researcher)
APPENDIX II:CONSENT FORMYou are invited to participate
IntroductionYou are being asked to be in a research study on determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward. You were selected as a possible participant for this study on Determinants of abortion complications among patients admitted at acute gynaecological ward. We ask that you read this form and ask any questions that you may have before agreeing to be in the study.
Purpose of Study: The purpose of this study is to assess the determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological war.

Benefits: This will enable the hospital management and other government agencies to understand determinants of abortion complications among patients. Your contribution will be beneficial to the government as policy makers regarding abortion complications in community’s awareness where basic preventive strategies and specific defensive tools to minimize abortion complications prevalence could be formulated
Risks: While limited, there is a slight risk of distress when taking this survey and some questions asked might make you uncomfortable.

Confidentiality: The records of this study will be kept private. In any sort of report we make public we will not include any information that will make it possible to identify you. Research records are kept in a locked file; only the researchers will have access to the records.
Right to Refuse or Withdraw: The decision to participate in this study is entirely up to you. You may refuse to take part in the study at any time without affecting your relationship with the investigators of this study. Your decision will not result in any loss or benefits to which you are otherwise entitled. You have the right not to answer any single question, as well as to withdraw completely from the interview at any point during the process; additionally, you have the right to request that the interviewer not use any of your interview material.

Consent: Your signature below indicates that you have decided to volunteer as a research participant for this study, and that you have read and understood the information provided above. You are given a signed and dated copy of this form to keep, along with any other printed materials deemed necessary by the study investigators
Participant`s signature……………..……………… Date………………………………
APPENDIX III:QUESTIONNAIREThis research instrument has been formulated to collect data for the purpose of the research meant to create greater understanding on determinants of abortion complications among patients admitted in acute gynaecological ward. Please note that your response to these questions will be confidential and shall be used for the purpose of this research only.
INSTRUCTIONS
Please tick where appropriate and for explanation, please be brief
Section One: Background Information
1.Please indicate your gender
Male ( ) Female ( )
2. What is Marital your status?
Married( )
Single ( )
Divorced ( )
Separated( )
Widower( )
3. What is your Age?
18-24yrs ( )25-30yrs ( )
30-35yrs ( )36-40yrs ( )
41-45yrs ( )46- 50yrs( )
4. What is your highest level of education?
KCSE Diploma Undergraduate Masters PhD
5. Religious Definition?
1 = Protestant
2 = Catholic
3 = Muslim
4 = Other (Specify) ………………………
To what extent do you agree with the following determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward (Select all the appropriate) Give your ratings in the scale of 1-5 (Key Strongly disagreed (1) Disagreed (2) Neutral (3) Agreed (4) Strongly agreed (5)
Determinants of abortion complications among patients admitted in acute gynaecological ward 1 2 3 4 5
Nature of abortion Demographic factors Social factors Health related factors To what extent do you agree with the following information about knowledge on complications of abortion (Select all the appropriate) Give your ratings in the scale of 1-5 (Key Strongly disagreed (1) Disagreed (2) Neutral (3) Agreed (4) Strongly agreed (5)
Knowledge on Complications of Abortion 1 2 3 4 5
Aware that abortion can lead to inability to have children in the future Aware that unsafe abortion can lead to death Aware that bleeding is a possible complication of unsafe abortion.

Know there is a possibility of contracting HIV/AIDS while obtaining abortion
Aware that abortion can lead to infection of the reproductive tract
APPENDIX IV:FOCUS GROUP DISCUSSIONSWELCOME
Thanks for agreeing to be part of this focus group. We appreciate your willingness to participate in this discussion on “Determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward”
INTRODUCTIONS
Moderator; Note Taker
PURPOSE OF FOCUS GROUP
This FGD is part of phase one of the above research topic which involves data collection to Determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynaecological ward. The purpose is to try and understand the determinants of abortion complications.

The end result of the research work will be to get to understand the factors that contribute to abortions complications and to enhance sensitization and education at the largest referral hospital in Kenya. It will also be useful to the nursing department and the hospital at large in handling this problem in nursing practice.

We need your input and want you to share your honest and open thoughts with us.

GROUND RULES
1. WE WANT YOU TO DO THETALKING.
We would like everyone to participate.

We want to hear many different viewpoints from everyone
2. THERE ARE NO RIGHT OR WRONGANSWERS
Every person’s experiences and opinions are important. Speak up whether you agree or disagree.

We want to hear a wide range of opinions.

3. WHAT IS SAID IN THIS ROOM STAYS HERE
We want you to feel free and comfortable when sharing whatever your views/opinions.

We request you to be honest even when your responses are not in agreement with the rest of the group.

In respect for each other, we ask that only one individual speak at a time in the group and that responses made by all participants be kept confidential.

WE WILL BE TAPE RECORDING THEDISCUSSION
We want to capture everything you have to say.

We don’t identify anyone by name in our report. You will remain anonymous.

In which month and year were you born?
Month ( )Year ( )
How old are you? ( ) (in years)
How Many pregnancies have you had in your life?
Sometimes, a pregnancy can end or stop before his term. Have you already gotten pregnant which ended before his term (lost pregnancy)?
Yes ( ) No ( )
How many pregnancies have ended before term? ( )
What was (were) the reason(s)?
Voluntary Interruption ( )Miscarriage ( )
Extra Uterine pregnancy ( )Don’t know ( )
Other (Specify)……………………..

How many children have you given birth to? (Who were breathing)?
Presently, do you have alived children?
Yes ( ) No ( )
In total, how many living children to you have?
Now, I would like to ask about your last pregnancy, that is to say, the one that ended up with a complication which required to be hospitalized.

When you got pregnant for the last time, did you want to get pregnant at this time, did you want to wait until later, or did you want not to have children at all?
Wanted to get pregnant at this time ( )Wanted to wait until later ( )
Wanted not to have any child at all ( )Did not wanted a child at this time ( )
What was the main reason you for which you wanted to wait until later to have a child or for which you did not want children?
Husband/ partner did not want children ( )Already have many kids ( )
Cost of raising a child are high ( )Pregnancy close of the previous ( )
Woman may drop out from school( )Loss of employment ( )
Woman is young ( )Woman is Old ( )
Woman is not married( )Health problem ( )
Fear of being banned ( )
Other Specify ………………………………..

As to your memory, were you using any contraceptive at the time you got pregnant?
Yes ( ) No ( )
Which method of contraception were you using?
Pill ( )IUD ( )Injection ( )
Implants ( )Condom ( )Spermicidal (Foam, Jelly) ( )
Natural method (cycle withdrawal)……………………………..

Abstinence…………………………
Surgical method (litigation, hysterectomy)
Other ( ) Specify ……………………………….

As you know, some women may spontaneously lose their pregnancies while others may use diverse methods to stop theirs. This can happen for various reason; for example, if a woman finds that she is pregnant while she did not want to be so or if it is difficult to keep the pregnancy if her parents, spouse does not agree that the woman retains the pregnancy.

In your entire live, have you ever been in a situation where you or someone you know has done something to stop one of your pregnancies:
Yes ( ) No ( )
Is your last pregnancy(the one for which you have been admitted in the hospital for treatment ended up this way?
Yes ( ) No ( )
APPENDIX V:KEY INFORMATION GUIDE FOR NURSESWhat symptoms did the woman presented at her entry to the hospital?
Bleeding ( )Fever( )Pain ()
Other ( ) Specify………………..Not specify ( )
After how many months/weeks/days did pregnancy ended-up? ( )
Did the woman case show signs of an induced abortion at her entry to hospital?
Yes ( )No ( )Don’t Know ( )
What were the methods used to remove debris from the uterus?
Manual vacuum aspiration ( )Electric aspiration ( )
Evacuation and curettage ( )Dilation and curettage ( )
Dilatation and evacuation ( )Evacuation using ocytocics ( )
No uterine evacuation ( )
Other (Specify)………………………..

Among the following treatments, which ones have been provided to the woman?
Blood transfusion…………..Oral Antibiotics
Intravenous Fluids……………..Analgesic/ Painkiller………..

Other drugs (specify)……………………..

What is the final diagnosis of the woman’s post abortion situation?
Infection/Sepsis ( )
Injury/ or perforation of the uterus ( )
Shock ( )
Injury/ or perforation of the vaginal cervix ( )
No post- abortion complication ( )
Reproductive organ failure ( )
Other (Specify)…………………………..

What is the final diagnosis of the woman’s abortion nature?
Uncomplicated induced abortion ( )
Complicated induced abortion ( )
Uncomplicated spontaneous abortion ( )
Complicated spontaneous abortion ( )
Therapeutic abortion ( )
Thank You for Responding To the Questionnaire. Your Time is Highly Appreciated
APPENDIX VI:LETTER REQUESTING FOR APPROVAL TO UON/ ETHICS COMMITTEEMargaret Wanjiru Ngugi Mburu
C/O School of Nursing Sciences, UON
P.O. BOX 30197 – 00100, Nairobi.

1ST October 2018
The UON/ ETHICS COMMITTEE,
University of Nairobi
P.O. BOX 423 – 00202,
Nairobi.

Dear Sir/Madam,
RE: REQUEST FOR RESEARCH TITLE APPROVAL
I am a Bachelor of Science in Nursing student at the University of Nairobi. As part of my academic requirements at University of Nairobi, I am undertaking a research study on “Determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynecological ward”
I am hereby writing this application letter to request for your approvals for the above mentioned topic to enable me continue with my research study on the above topic and also as part of my study requirement at the University of Nairobi.

Your approval for the above research topic or title to conduct this study will be greatly appreciated.  I would be happy to answer any questions or concerns that you may have at that time. You may contact me at my email address: [email protected],
Margaret Wanjiru Ngugi Mburu
Bachelor of Science in Nursing, University of Nairobi
(Researcher)
Approved by:
___________         ____________________       _________
Print your name and title here     Signature                               Date
APPENDIX VII:LETTER TO KNH DEPUTY DIRECTOR OF CLINICAL SERVICESMargaret Wanjiru Ngugi Mburu
C/O School of Nursing Sciences, UON
P.O. BOX 30197 – 00100, Nairobi.

1ST October 2018
The Deputy Director, Clinical Services,
Kenyatta National Hospital,
Nairobi.

Dear Sir/Madam,
RE: REQUEST TO CONDUCT RESEARCH STUDY AT KNH ACUTE
GYNAECOLOGY WARD:
I am writing to request permission to conduct a research study at Kenyatta National Hospital gynecological ward.  I am currently enrolled in Bachelor of Science in Nursing student at the University of Nairobi and I am in the process of writing my research project.  The study is entitled “Determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynecological ward”.

I hope that the Kenyatta National Hospital will allow me to recruit respondents at gynecological ward from the hospital to anonymously complete a questionnaire.  Due to the nature of the study, I hope to recruit admitted patients at gynecological ward to anonymously complete their own questionnaires. Interested respondents, who volunteer to participate, will be given a consent form to be signed and returned to the primary researcher at the beginning of the research process. If approval is granted, the participants will complete the survey in the gynecological wards or other quiet setting on the Hospital site.
Your approval to conduct this study will be greatly appreciated.  I will follow up with a telephone call next week and would be happy to answer any questions or concerns that you may have at that time. You may contact me at my email address: [email protected]
If you agree, kindly sign below and kindly submit a signed letter of permission on your Hospital’s letterhead acknowledging your consent and permission for me to conduct this survey/study at this Hospital.

Sincerely,
Margaret Wanjiru Ngugi Mburu
Bachelor of Science in Nursing, University of Nairobi
(Researcher)
Approved by:
Name…………………………… Signature ……….…….. Date…………………
APPENDIX VIII:LETTER TO THE NATIONAL COMMISSION FOR SCIENCE, TECHNOLOGYAND INNOVATIONMargaret Wanjiru Ngugi Mburu
C/O School of Nursing Sciences, UON
P.O. BOX 423 – 00202,
Nairobi.

1ST October 2018
The Secretary/ CEO
National Commission for Science, Technology and Innovation,
Nairobi.

Dear Sir/ Madam,
RE: REQUEST FOR RESEARCH AUTHORIZATION
I am a Bachelor of Science in Nursing student at the University of Nairobi. I am undertaking a research on “Determinants of abortion complications among patients admitted in Kenyatta National Hospital acute gynecological ward”
I am hereby writing this application letter to request for your authorizations from the commission for this study to enable me continue with my research study on the above topic and also as part of my study requirement at the University of Nairobi, School of Nursing.

Yours faithfully,
Margaret Wanjiru Ngugi Mburu
Bachelor of Science in Nursing, University of Nairobi
(Researcher)
APPENDIX IX:MAP OF KENYATTA NATIONAL HOSPITAL171450424942000-704850543052000
Source (Google Map)
116332015240000KEY
The arrows points the Study Area
APPENDIX X:PHOTOGRAPH OF KENYATTA NATIONAL HOSPITAL

Source (KNH)
CHAPTER 4 PLANNING4.1 TIME FRAME (Ghant Chart
Weeks 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Problem Identification Proposal writing Seeking consent from ethical committees Recruitment and training of research assistants Pre-testing of study tools Administration of tools Data cleaning and entry Data analysis Report writing and presentation Compilation of final report/dissemination
4.2 BUDGET
ITEM UNIT COST QUANTITY TOTAL COST
HUMAN RESOURCE
Research Assistants (2) 500 4x2x500 4,000.00
Principal Investigator 1,000 1x1x1000 1,000.00
a)Pre-testing of questionnaire Research assistants (2) 500 2x2x500 2,000.00
Principal researcher (1) 1,000 1x5x4x1000 2,000.00
Data collection Research assistants (2) 500 2x5x4x500 20,000.00
Principal researcher (1) 1,000 1x5x4x1000 20,000.00
Sub- total 48,000.00
MATERIALS AND SUPPLIES
Biro pens (1 dozen) 180 180×1 180.00
Pencil (1 dozen) 60 60×1 60.00
Rubbers (3) 10 10×3 30.00
Folders (3) 100 100×3 300.00
File books (3) 65 65×3 195.00
Stapler and staples 600 600 600.00
Sub-total 1,365.00
PROPOSAL AND THESIS
Proposal typing and printing (50 pages) 35 50×35 1,750.00
Photocopying 5 copies (250 pages) 3 250×3 750.00
Photocopying of questionnaire 3 192x3x5 2,880.00
Data analysis 30,000 30,000 30,000.00
Typing and printing of final copy 35 60×35 2,100.00
Photocopying of final copy (5 copies) 3 60x3x5 900.00
Binding of final report (5 copies) 700 700×5 3,500.00
Sub-total 41,880.00
GRAND TOTAL 93,245.00