Determinants of pregnancy termination among married women of reproductive age in Lesotho: evidence from the 2023-24 demographic and health survey using modified Poisson regression analysis

¹Pan African University Life and Earth Sciences Institute (including Health and Agriculture), University of Ibadan, Ibadan, Nigeria, ²Department of Midwifery Science, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini, ³Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan/University College Hospital, Ibadan, Oyo, Nigeria, ⁴Maternity Department, Seboche Mission Hospital, Botha Bothe, Lesotho, ⁵Department of Integrated Epidemiology, Surveillance and Public Health Emergencies, Uganda Ministry of Health, Kampala, Uganda

^&Corresponding author
Mduduzi Colani Shongwe, Department of Midwifery Science, Faculty of Health Sciences, University of Eswatini, Mbabane, Eswatini

Introduction    

Pregnancy termination remains a complex public and reproductive health issue globally, particularly in sub-Saharan Africa [1], where access to safe abortion services is often constrained by restrictive legal frameworks, socio-cultural norms, socio-economic inequalities, limited autonomy in reproductive health decision-making, and limited access to reproductive health services [2,3]. Abortions may occur spontaneously (i.e., miscarriages) or may be induced intentionally (i.e., induced abortions). Globally, an estimated 73 million induced abortions occur annually [4]. Each day, over 120 women globally lose their lives due to complications arising from unsafe induced abortions. These deaths predominantly occur in low and middle-income countries, especially in regions where laws restrict access to safe and legal abortion care [5]. Unsafe pregnancy termination contributes substantially to maternal deaths and long-term reproductive health complications [2].

Lesotho continues to face several reproductive health challenges, including a relatively high maternal mortality rate, currently estimated at 478 deaths per 100,000 live births [6], high teenage pregnancy with an adolescent fertility rate of 90 births per 1,000 [7], and unsafe abortions [8]. Abortion in Lesotho is criminalised under the Penal Code Act of 2010, which permits termination only in cases of rape, incest, or when the pregnant woman's life is at risk, imposing a prison sentence of up to three years on anyone who willingly causes or induces the termination of a pregnancy [9]. These legal restrictions, combined with inadequate sexual health education and limited access to safe abortion services, have created a silent crisis in Lesotho. Many women, often young and vulnerable, are driven to desperate and dangerous measures, risking their health and lives through unsafe abortion procedures [8,10].

A report from the Lesotho Ministry of Health and the United Nations Population Fund (UNFPA) analysing records from hospital admissions revealed that among girls aged 10-14, 35.71% of all hospital admissions were linked to abortions, highlighting both the prevalence of early unintended pregnancies and the risks of unsafe pregnancy termination. The report further indicated that 8.17% of abortion-related admissions involved adolescents aged 15-19, 10.06% were among young women aged 20-24, 15.53% among those aged 25-49, and 8.93% among women aged 50 and above. Within the reproductive age group (15-49 years), 12.35% of hospital admissions were attributable to either induced or spontaneous abortions, reflecting the considerable burden of unsafe or illegal procedures [11].

The Ministry of Health in Lesotho, with support from various stakeholders, has implemented several interventions to reduce maternal mortality, morbidity, and teenage pregnancy, including ensuring access to safe, quality, and effective contraceptives in remote areas [12]. In addition, the country has adopted key strategies, guidelines, and protocols such as the Sexual, Reproductive, Maternal, Newborn, Child, and Adolescent Health (SRMNCAH) strategy, the Intrapartum Care Guidelines, the Labour Care Guide, and the Integrated Management of Neonatal and Childhood Illnesses (IMNCI). Furthermore, accountability is strengthened through monitoring, evaluation, and actionable data systems, including Maternal and Perinatal Death Surveillance and Response (MPDSR), as well as the generation of new evidence to inform policy and practice [6]. Despite the significant progress made, complications due to unsafe abortion continue to be amongst the leading causes of maternal mortality in Lesotho [13].

Research from SSA has found that pregnancy termination is significantly associated with various determinants. For example, being employed, being aged 25-29 years, residing in urban areas [1], being exposed to media, multiparty [14], being educated, being married [15], the richest wealth status, listening to the radio, and watching television [16], were found to be significantly associated with pregnancy termination. Studies on reproductive health issues in Lesotho have often been focused on contraceptive use [17,18], cervical and breast cancer [19-21], sexually transmitted infections, risky sexual behaviours [22,23], and unintended pregnancy [24]. The literature search for this study revealed that studies investigating the determinants of pregnancy termination in Lesotho remain limited. Therefore, this study aimed to fill this gap by identifying the determinants of pregnancy termination among married women in Lesotho, utilising the LDHS data. The findings from this study will provide evidence that is essential for informing interventions aimed at improving reproductive health services, reducing unsafe abortion, and advancing women's reproductive autonomy.

Methods     

Study design: this study employed a cross-sectional design analysing the Lesotho 2023-24 Demographic and Health Survey (LDHS) data.

Study setting: this study was conducted in Lesotho, a small landlocked country in Southern Africa, with an estimated population of 2 million. Lesotho is administratively divided into 10 districts; each district is subdivided into constituencies, and each constituency into community councils [25]. Lesotho faces several public health challenges, including a high prevalence of HIV, with 22.7% of adults above 15 years living with HIV [26].

Data source: data for this analysis were obtained from the 2023-24 LDHS, conducted between November 2023 and February 2024. The LDHS, implemented under the DHS Program, provides nationally representative information on demographic, health, and SRH indicators.

sampling procedures: the 2023-24 LDHS sampling frame was based on the 2016 Population and Housing Census (PHC) prepared by the Lesotho Bureau of Statistics, comprising a complete list of census enumeration areas (EAs). The 2023-24 LDHS employed a two stage stratified sampling design. First, each district was stratified into urban, peri urban, and rural areas, yielding 29 strata (with Butha Buthe having no peri urban areas). Within these strata, 400 EAs were selected with probability proportional to size. In the second stage, 25 households per EA were chosen using systematic equal probability sampling [27,28].

study population: for this study, we used the women's individual recode (IR) dataset, restricting the sample to married women aged 15-49 years. Women with missing data on variables of interest were excluded. After applying the sampling weights, a total of 2,957 married women were included in the final analysis.

Study variables

Outcome variable: the outcome variable for this study was pregnancy termination, derived from a DHS question: "Have you ever had a pregnancy terminated?". In the DHS, pregnancy termination encompasses induced abortion, miscarriage, and stillbirth. Responses were coded as a binary variable: 1 = Yes (respondent has ever terminated a pregnancy) and 0 = No (respondent has never terminated a pregnancy).

Independent variables: maternal age (15 - 19 years, 20 - 24 years, 25 - 29 years, 30 - 34 years, 35 - 39 years, 40 - 44 years, 45 - 49 years), Maternal education (no education, primary, secondary, higher), employment status (not employed, employed), media exposure (No, Yes), internet use (No, Yes), Contraceptive use (Non-user, Traditional, Modern), Decision-making on contraception (Respondent, Husband/partner, Joint decision, Other), Parity (Zero, One birth, Two and three births, Four or more births), Visited a health facility in the last 12 months (No, Yes), Perceived distance to health facility (Not a big problem, Big problem), Husband/partner's education (No Education, Primary, Secondary, Higher), Husband/partner's employment status (Not employed, Employed), Place of residence (Rural, Urban), District (Butha-Buthe, Leribe, Berea, Maseru, Mafeteng, Mohale's Hoek, Quthing, Qacha's Nek, Mokhotlong, Thaba-tsekaage).

Statistical analysis: the data were analysed using Stata version 17.0 statistical software. Sampling weights were applied throughout the analysis to account for the complex survey design of the Demographic and Health Survey, ensuring nationally representative estimates and appropriate standard errors. The analysis included a weighted sample of 2,957 married women of reproductive age from Lesotho. Multicollinearity among independent variables was assessed using the variance inflation factor (VIF), with all variables demonstrating acceptable levels of collinearity. Descriptive statistics, including frequencies and percentages, were computed to describe sample characteristics and estimate the prevalence of pregnancy termination among married women in Lesotho. Cross-tabulations were performed to examine the distribution of pregnancy termination across independent variables.

For inferential analysis, two modified Poisson regression models were fitted using generalised linear models (GLMs) with a log link function and robust standard errors to assess determinants of pregnancy termination among married women in Lesotho. This modelling approach was preferred over logistic regression because the outcome was not rare (i.e., prevalence was greater than 10%), as odds ratios tend to overestimate the strength of associations in such scenarios [29]. In the bivariable model (Model 1), we fitted a crude modified Poisson regression model to examine the independent association between each independent variable and pregnancy termination to generate the crude risk ratios (cRR), with variables significant at p < 0.25 retained for inclusion in the multivariable model using the purposeful selection strategy for regression analysis [30]. In the multivariable model (Model II), we fitted an adjusted modified Poisson regression model that simultaneously included all selected explanatory variables to assess the determinants of pregnancy termination. The results from this model were reported as adjusted risk ratios (aRR) with their 95% confidence intervals (CI). Statistical significance in the multivariable analysis was set at p < 0.05.

Ethical considerations: this study used publicly available data from the DHS program; therefore, ethical approval was not required. Access to the dataset was granted by the DHS program through the Monitoring and Evaluation to Assess and Use Results (MEASURE DHS) online platform.

Results     

Background characteristics of the study participants: this study analysed a weighted sample of 2,957 married women aged 15-49 years in Lesotho. The majority of participants were between 25 and 34 years (35.2%; n = 1,042). More than half of the women (52.6%; n = 1,554) had attained secondary education, and 17.2% (n = 509) had higher education. In terms of employment status, nearly 52% (n = 1,528) were employed. A majority of respondents reported media exposure (78.3%; n = 2,316) and internet use (81.3%; n = 2,405). Regarding contraceptive use, two-thirds (66.0%; n = 1,953) were modern method users, while 32.0% (n = 947) were non-users. Decision-making on contraception was largely joint (47.8%; n = 1,415). In terms of parity, nearly half of the women (49.6%; n = 1,466) had two to three births, while 14.7% (n = 434) had four or more. Most participants (74.8%; n = 2,213) had visited a health facility in the past 12 months, and 74.1% (n = 2,192) reported that distance to a health facility was not a big problem. About 39% (n = 1,140) of the women reported that their husbands/partners had primary education, with the majority of husbands/partners (77.2%; n = 2,284) being employed. Regarding residence, 58.8% (n = 1,738) of women lived in rural areas, while 41.2% (n = 1,219) resided in urban areas. Maseru district accounted for the largest proportion of participants (31.8%; n = 939), followed by Leribe (18.2%; n = 539) and Berea (14.7%; n = 434). The least represented districts were Qacha's Nek (3.0%; n = 89) and Quthing (3.2%; n = 94) (Table 1).

Prevalence of pregnancy termination in Lesotho: the pooled prevalence of pregnancy termination among married women in Lesotho was 16.2% (95% CI: 14.4% - 18.1%). The prevalence varied across districts, with the highest observed in Butha-Buthe (18.7%, 95% CI: 14.3% - 24.1%) and the lowest in Qacha's Nek (9.2%, 95% CI: 5.9% - 14.2%) (Figure 1).

Determinants of pregnancy termination: as presented in Table 2, the adjusted modified Poisson regression model (Model II) identified several determinants significantly associated with pregnancy termination among married women in Lesotho. For instance, older women aged 30-34 years (aRR = 4.09, 95% CI: 1.68-9.97), 35-39 years (aRR = 3.79, 95% CI: 1.55-9.28), 40-44 years (aRR = 4.49, 95% CI: 1.83-11.03), and 45-49 years (aRR = 4.79, 95% CI: 1.93-11.89) were associated with a higher risk of pregnancy termination compared to adolescents aged 15-19 years, respectively, holding the other variables constant in the model. Compared to women who do not use the internet, those who use the internet were associated with a higher risk of pregnancy termination (aRR = 1.36, 95% CI: 1.01-1.84). Visiting a health facility in the last 12 months was also associated with pregnancy termination, with women who had visited a facility being associated with a higher risk of pregnancy termination compared to those who had not (aRR = 1.37, 95% CI: 1.05-1.80), holding the other variables constant in the model. In contrast, modern contraceptive users were associated with a lower risk of pregnancy termination compared to non-users (aRR = 0.72, 95% CI: 0.56-0.91). Similarly, women with two to three births (aRR = 0.62, 95% CI: 0.40-0.94) and those with four or more births (aRR = 0.56, 95% CI: 0.33-0.95) were associated with a lower risk of pregnancy termination compared to nulliparous women, holding the other variables constant in the model. There were also district-level variations with women in Mohale's Hoek (aRR = 0.56, 95% CI: 0.37-0.86), Qacha's Nek (aRR = 0.43, 95% CI: 0.27-0.70), and Thaba-Tseka (aRR = 0.59, 95% CI: 0.40-0.88) being associated with a lower risk of pregnancy termination compared to those in Butha-Buthe, holding the other variables constant in the model.

Discussion     

To achieve Sustainable Development Goal (SDG) 3.1, the World Health Organization has emphasised the need to reduce the global maternal mortality to fewer than 70 deaths per 100,000 live births by 2030. Unsafe pregnancy termination remains a major contributor to maternal mortality, thereby undermining progress toward SDG 3.1 [31]. In this context, the present study utilised nationally representative data from LDHS to determine the prevalence and determinants of pregnancy termination among married women in Lesotho. The prevalence of pregnancy termination among married women in Lesotho was 16.2% (95% CI: 14.4% - 18.1%). The multivariable modified Poisson regression model (Model II) revealed several determinants of pregnancy termination among married women in Lesotho. For instance, being an older woman (30-34, 35-39, 40-44, and 45-49 years), using the internet and visiting a health facility was associated with a higher risk of pregnancy termination. However, modern contraceptive use, having two or more births, and residing in districts such as Mohale's Hoek, Qacha's Nek, and Thaba-Tseka were associated with a lower risk of pregnancy termination.

The prevalence observed in Lesotho was higher than that of studies conducted in Kenya (14.2%) [1] and Mozambique (9%) [32]. However, the prevalence was lower than that observed in Ghana (39.4%) [33]. These differences point to the influence of country-specific factors such as access to contraceptive services, socio-cultural attitudes toward termination, and the legal frameworks regulating abortion. For instance, in Lesotho, limited access to comprehensive reproductive health services, especially in rural areas [12], may increase the likelihood of unintended pregnancies, which in turn may lead to higher rates of pregnancy termination compared to Mozambique and Kenya. Conversely, the lower prevalence compared to Ghana could be attributed to differences in legal frameworks and reproductive health service awareness. Ghana has relatively more liberal abortion laws compared to Lesotho [34], which may facilitate access to safe abortion services.

This study found that maternal age was associated with pregnancy termination, with women aged 30 years and above being associated with a higher risk of pregnancy termination, a finding similar to a study conducted in Ghana and Mozambique [32], suggesting that pregnancy termination is more common among older women. This pattern may reflect the greater exposure of older women to sexual activities and more pregnancies, increasing the probability of experiencing a termination (i.e., whether spontaneous or induced). Furthermore, women in older age groups may have already achieved their desired family size and may therefore be more inclined to avoid additional births. Advanced maternal age is also often associated with increased risk of pregnancy-related complications, which may contribute to decisions to terminate pregnancies [35]. This finding underscores the need for targeted reproductive health interventions ensuring access to family planning services and safe abortion care where legal for older women.

Internet use was associated with a higher risk of pregnancy termination, consistent with evidence from Ghana [36] and Nepal [37], highlighting the influence of media exposure on reproductive health behaviours. Mass media is recognised as a powerful tool for raising awareness on health issues and also to address socio-cultural barriers to health service utilisation. Through digital platforms, internet use among women increases exposure to reproductive health information, including knowledge of abortion methods and services, which may prompt action in the case of unintended pregnancies. This finding underscores the need to harness digital platforms to provide accurate, evidence-based SRH information and to address potential misinformation.

Consistent with a prior study conducted in Ethiopia [38], women who had visited a health facility in the past 12 months were associated with a higher risk of pregnancy termination. Several mechanisms may explain this association. Increased interaction with healthcare systems can enhance access to reproductive health information and post abortion care. On the other hand, facility visits may also occur in response to complications following termination, as women experiencing adverse outcomes are more likely to seek care. Additionally, women who utilise health services may have increased contact with health providers who diagnose and record pregnancy outcomes.

The study further revealed that the use of modern contraceptives was associated with a lower risk of pregnancy termination, similar to findings from other sub-Saharan African countries, such as Angola [39], and Kenya [40]. Effective contraceptive use reduces unintended pregnancies, thereby lowering the likelihood of pregnancy termination. Conversely, limited access to or misconceptions about contraceptives may increase the risk of unintended pregnancies [41]. This finding underscores the need to expand access to modern contraceptive methods, improve education on their use, and address barriers related to cost, availability, and cultural acceptance.

Parity was also significantly associated with pregnancy termination, with women who had two or more children being less likely to terminate a pregnancy. This is consistent with findings from a sub-Saharan African study [42], where women with fewer or no children were more likely to terminate pregnancies, possibly due to socio-economic constraints, stigma associated with early childbearing, or lack of readiness for motherhood. Additionally, women with prior childbearing experience may have better knowledge and utilisation of contraceptive methods [43]. This finding underscores the need for targeted interventions aimed at nulliparous women to prevent unintended pregnancies.

Furthermore, significant district-level variations were observed, with women in Mohale's Hoek, Qacha's Nek, and Thaba-Tseka having a lower risk of pregnancy termination compared to those in Butha-Buthe. Such geographic disparities may be due to differences in service availability and accessibility, local socio-cultural norms regarding fertility and abortion, and programmatic coverage of family planning. For instance, districts such as Mohale's Hoek and Thaba-Tseka implemented reproductive health interventions supported by the United Nations Population Fund in collaboration with the Lesotho Planned Parenthood Association that delivered integrated sexual and reproductive health and HIV outreach services, including family planning, STI management, and HIV testing and counselling, which may have contributed to increased contraceptive uptake and reduced pregnancy termination in these districts [44]. In many contexts, rural or hard-to-reach areas face limited access to SRH services, which can influence both the occurrence and reporting of pregnancy termination. This finding underscores the need to address geographic inequities by strengthening health systems and ensuring equitable distribution of reproductive health services across all districts.

Strengths and limitations: the strengths of this study are the use of a nationally representative dataset, a large sample size, and the application of modified poisson regression models with robust standard errors to assess determinants of pregnancy termination, as this modelling approach does not overestimate the strength of associations compared to logistic regression when the outcome is not rare (i.e., prevalence greater than 10%). However, limitations in this study included the use of a cross-sectional design, which makes it impossible to establish causality and temporality between the outcome variable and independent variables. There is also the possibility of response and social desirability bias due to self-reported data on pregnancy termination.

Conclusion     

This study found that pregnancy termination among married women in Lesotho remains high, with significant variations driven by socio-demographic, reproductive health, and geographic determinants. Older age, internet use, and recent health facility visits were associated with an increased likelihood of pregnancy termination, while modern contraceptive use, higher parity, and residence in districts such as Mohale's Hoek, Qacha's Nek, and Thaba-Tseka were associated with a lower risk. Therefore, there is a need to strengthen and expand equitable access to comprehensive sexual and reproductive health services, particularly modern contraceptives, while targeting high-risk groups such as older and nulliparous women. In addition, policymakers and stakeholders, including SRH programmes and the Lesotho Ministry of Health, should scale up targeted SRH interventions, leveraging digital platforms to disseminate accurate reproductive health information, and address geographic disparities by improving service delivery in underserved districts to reduce unintended pregnancies and associated terminations. Integrating counselling and post-abortion services into routine healthcare will also be critical to improving reproductive health outcomes across the country.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conception and study design: Samkeliso Gift Shongwe and Felleng Elizabeth Mapetla. Data requested from DHS: Samkeliso Gift Shongwe and Kooko Ronald. Data analysis and interpretation: Samkeliso Gift Shongwe and Kooko Ronald. Manuscript drafting: Samkeliso Gift Shongwe, Felleng Elizabeth Mapetla and Kooko Ronald. Manuscript reviewing and supervision: Mduduzi Colani Shongwe and Christopher Odianosen Aimakhu. All authors read and approved the final version of the manuscript.

Acknowledgments     

We thank the DHS Program for permitting us to use the LDHS datasets and the married women who participated in the survey.

Tables and figure     

Table 1: background characteristics of married women aged 15-49 years in Lesotho, based on the 2023-24 DHS data (Weighted N = 2,957)

Table 2: distribution and determinants of pregnancy termination among married women aged 15-49 years in Lesotho, based on the 2023-24 DHS data (N = 2,957)

Figure 1: prevalence of pregnancy termination among married women in Lesotho (Weighted N = 2,957)

References