Vallely et al.

Reproductive Health (2015) 12:22

DOI 10.1186/s12978-015-0015-x

RESEARCH Open Access

Unsafe abortion requiring hospital admission in

the Eastern Highlands of Papua New Guinea - a
descriptive study of women’s and health care
workers’ experiences
Lisa M Vallely1*, Primrose Homiehombo2, Angela Kelly-Hanku2,3 and Andrea Whittaker4

Abstract
Background: In Papua New Guinea induced abortion is restricted under the Criminal Code Law. Unsafe abortions
are known to be widely practiced and sepsis due to unsafe abortion is a leading cause of maternal mortality.
Methods: We undertook a six month, prospective, mixed methods study at the Eastern Highlands Provincial
Hospital. Semi structured and in depth interviews were undertaken with women presenting following induced
abortion. This paper describes the reasons why women resorted to unsafe abortion, the techniques used, decision
to seek post abortion care and women’s reflections post abortion.
Results: 28 women were admitted to hospital following an induced abortion. Reasons for inducing an abortion
included: wanting to continue with studies, relationship problems and socio-cultural factors. Misoprostol was the
most frequently used method to end the pregnancy. Physical and mechanical means, traditional herbs and spiritual
beliefs were also reported. Women sought care post abortion due to excessive vaginal bleeding, and severe
abdominal pain with some afraid they would die if they did not seek help.
Conclusion: In the absence of contraceptive information and services to avoid, postpone or space pregnancies,
women in this setting are resorting to unsafe means to end an unwanted pregnancy, putting their lives at risk.
Women need access to safe, effective means of abortion.
Keywords: Unsafe abortion, Abortion methods, Misoprostol, Traditional herbs, Papua New Guinea

Background and five million women are hospitalized due to complica-

Of the 44 million abortions that took place globally in tions from unsafe abortions [2,3].
2008 nearly half were considered unsafe [1], undertaken ei- Methods of unsafe abortion include: the ingestion of
ther by individuals without the necessary skills to perform harmful substances, physical means such as insertion of a
the procedure, or were self-induced [2]. Forty percent of foreign object or substance through the cervix and into the
women seeking induced abortion live in countries where it uterus, and external force, such as squeezing or massaging
is legally restricted. But even where induced abortion is the abdomen [2,4-6]. It is suggested that the increasing
legal, access to such services is often poor [3]. Most unsafe availability and clandestine use of the E1 prostaglandin
abortions occur in developing countries, in settings where analogue, misoprostol is replacing many of these riskier
standards of care are often poorer and legal restrictions are methods of unsafe abortion in a number of countries
greater [2-4]. Every year an estimated 47,000 women die [4,7,8]. In developing countries, severe complications and
maternal deaths are lower with the use of misoprostol,
even when used incorrectly, when compared to physical
* Correspondence: [email protected]
means of unsafe induced abortion [9,10].
1
Australian Centre of Tropical Medicine and Health, James Cook University, Induced abortion is a sensitive issue, attracting moral con-
Townsville, QLD, Australia demnation, with those implicated in its practice frequently
Full list of author information is available at the end of the article

© 2015 Vallely et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
unless otherwise stated.
Vallely et al. Reproductive Health (2015) 12:22 Page 2 of 11

stigmatised [11]. Stigma may be perceived or experienced “drinking tablets” [30]. The exact nature of the tablets was
for those seeking both abortion and post abortion care; not reported.
stigma is also recognised in relation to service delivery and Aside from earlier work surrounding sexual and repro-
at the policy level [12,13]. In countries where induced abor- ductive health that highlighted women’s experiences of
tion is restricted by criminal law or inaccessible due to induced abortion, [19] no study has described women’s
socio-cultural or geographical barriers, seeking information experiences of induced abortion, specifically relating to
on incidence, practices and outcomes related to induced the socio-cultural context within PNG. The overall aim
abortion is difficult. When it occurs in clandestine situations, of this paper is to describe, from one setting in PNG, the
abortion may not be reported or declared as a spontaneous reasons why women resort to unsafe abortion, the tech-
abortion, due to stigma or barriers such as fear of prosecu- niques used, the consequences leading to hospital ad-
tion [12]. mission and the reasons behind both the abortion and
seeking post abortion care.
The situation in PNG
Papua New Guinea (PNG) is a low-middle income, develop- Methods
ing country [14,15] situated in the Asia-Pacific region. It is a As part of a prospective, mixed-methods study we
country notable for its socio-cultural and linguistic diversity. undertook case note review, semi-structured and in-
Eighty seven percent (87%) of the 7.2 million people reside depth interviews with women admitted to hospital for
in rural and remote areas with poor transportation. While post abortion care. We also undertook in depth, key in-
61% of the population are in paid employment it is notable formant interviews with health care professionals. Data
that the majority of those residing in the rural settings collection took place over a six month period between
remain as subsistence farmers [16,17]. Tribal conflict and May and November 2012 at the Eastern Highlands
accusations of sorcery between different communities or Provincial hospital, Goroka, Eastern Highlands Province,
language groups remains common in PNG and poor secu- Papua New Guinea. All data collection, including clinical
rity affects access to services in many areas. High rates of data and interviews was undertaken by one trained and
domestic violence and rape are also reported [18-22]. experienced research midwife (PH) from the PNG Insti-
Maternal health indicators in PNG are poor. The tute of Medical Research (PNGIMR) and overseen by
country has a low contraceptive prevalence rate for the principle investigator for the study (LV).
modern methods of family planning among married The Eastern Highlands Provincial hospital is the refer-
women (24%) and a high unmet need for family plan- ral hospital for the Eastern Highlands Province, which
ning (27%) [23,24]. The maternal mortality ratio is the has an estimated population of 540,000. Two recent
highest in the Oceania region and one of the highest in studies have been undertaken at the hospital: one identi-
the world, with an estimated 594 maternal deaths per fied that 60% of the 29 maternal deaths that occurred
100,000 live-births [25]. Puerperal sepsis and sepsis due over a 40 month retrospective period were attributable
to unsafe abortion are reported as the second leading to complications of unsafe abortion [26]; the second
cause of maternal mortality, after post-partum haemor- identified that the majority of women presenting for post
rhage [24,26]. abortion care had used misoprostol to end unwanted
In PNG, induced abortion to save a woman’s life or to pregnancies [29].
preserve her physical and mental health may be granted on Over the six month study period we sought to identify
agreement by two medical officers. However, virtually no all women admitted to the hospital with suspected or
safe abortions take place in government facilities through- confirmed abortion, including both spontaneous and in-
out the country. Under PNG’s Criminal Code Act, abortion duced abortion. Women were identified through daily
for socio-cultural reasons or on request remains illegal review of available admission records at the emergency
[27]. Despite the criminal law surrounding abortion, in- department, out-patient department, well woman clinic
duced, unsafe abortions are known to be practised, al- and the obstetrics and gynaecology ward. Inclusion cri-
though documented evidence is limited. Traditional, herbal teria included women admitted with: excessive vaginal
abortifacients and physical and mechanical means to end bleeding; lower abdominal pain with vaginal discharge/
an unwanted pregnancy are described from a number of bleeding; fever with vaginal bleeding/discharge and/or;
societies within PNG [19,28,29]. Self-starvation, self- foreign body in-uteri or pelvic injury. In line with the
poisoning, avoidance of antenatal care, and the use of trad- PNG National Department of Health guidelines, abor-
itional and modern contraceptives, such as the “morning tion was defined as vaginal bleeding before 20 weeks
after pill” to terminate an unwanted pregnancy are re- gestation or fetal weight of less than 500grams. Women
ported [19]. More recently, as part of a wider behavioural presenting after 20 weeks gestation were included in
surveillance survey undertaken in Port Moresby, reports of the study if they specifically indicated interference with
unsafe abortion included the use of herbal medicines and the pregnancy.
Vallely et al. Reproductive Health (2015) 12:22 Page 3 of 11

Semi-structured interviews government organisations providing sexual and reproduct-

Following identification of women meeting the inclusion ive health services. Despite initial interest in the study, four
criteria, women were approached by the research mid- health care workers declined to participate. In depth inter-
wife who described the nature of the study. For those views were undertaken with eight key informants, using an
willing to participate, informed consent procedures were interview guide, in which they were asked open questions
completed prior to completion of a study specific case about their experiences of women accessing abortion and
note record form. Data from this aspect of the study is post abortion care services. Among the eight key infor-
presented elsewhere [31]. During the consent procedure mants, six were from the Eastern Highlands Provincial
for the case record form, women were also asked if they hospital; four from the ward and two from the accident
were prepared to participate in a semi-structured inter- and emergency department. The remaining two informants
view. For those willing to participate in an audio -recorded were from different NGOs based in Goroka. Seven of the
interview with the research midwife, separate consent was informants were women and six were trained as midwives,
gained. including the one male informant. All informants had ex-
Semi-structured interviews were included to ensure all tensive experience working in both the government and
cases of induced abortion were identified, whether they church health services and non-government organisations
had been revealed as such to hospital staff at the time of for between 14 and 36 years.
admission. Interviews with women were undertaken in either Tok
We sought to identify women’s reasons for seeking Pisin (a local lingua franca) or English, as preferred by
hospital level care, their reaction to the pregnancy and the individual woman. All key informant interviews were
their feelings in relation to the pregnancy loss. Questions undertaken in English. Both the semi-structured and
in the semi-structured interviews included: in-depth interview guides were piloted prior to the start
of the study. All interviews were undertaken by the re-
 Can you tell me about why you came to the search midwife who is trained and experienced in under-
hospital? taking such interviews.
 Can you tell me your story about how the
pregnancy ended?
Data analysis
 Do you know why that may have happened?
All semi-structured interviews were transcribed and trans-
 How did you feel when the pregnancy ended?
lated, where necessary, by the research midwife and
reviewed and discussed with the principle investigator to
Forty four women participated in the semi-structured
identify additional cases of induced abortion not identified
interviews of whom 21 had reported that they induced
through the hospital admission records. In-depth interviews
their abortion during the initial hospital admission con-
were transcribed and translated by one member of the re-
sultation. As a result of conducting semi-structured
search team at the PNGIMR. Transcripts were reviewed by
interviews an additional four women not reporting any
two members of the research team (LV, AK-H) and through
interference with their pregnancy during the hospital ad-
a qualitative content analysis approach [32] using continu-
mission process disclosed to the research midwife that
ous comparison an initial coding framework was developed.
they had indeed interfered with their pregnancy.
During the course of analysis, this coding framework was
developed and modified as new themes emerged. All tran-
In-depth interviews
scripts were managed using NVivo9, a qualitative software
All women identified as having had an induced abortion,
management programme.
either through the case note review or semi-structured
interview, were invited by the research midwife to par-
ticipate in a further in-depth interview to gain additional Ethical considerations
insight into the individual experiences of these women, This research was approved by the Institutional Review
including why and how they aborted, and their experi- Board of the PNGIMR (IRB 1201), the Medical Research
ences and perceptions of the health care they received Advisory Committee (MRAC 11.32), PNG and the Univer-
following presentation to hospital. Following informed sity of Queensland Human Ethics Committee in Australia
consent procedures, we used an interview guide to (LV080312). Written consent was obtained from all partici-
undertake eight in-depth interviews. pants for case note review, semi-structured and in-depth
interviews. To ensure anonymity all women participating
Key informant interviews in the semi structured and in-depth interviews were
All key informants were health care workers and were pur- assigned a pseudonym. To ensure anonymity all key infor-
posively selected due to their position within their work mants were assigned a pseudonym and only their place of
place. They worked either at the hospital or at local non- work (hospital or NGO) is noted, not their position.
Vallely et al. Reproductive Health (2015) 12:22 Page 4 of 11

Findings many educational facilities having policies which state a

Over the six-month study period we identified 129 women pregnant student cannot be in attendance. Pregnancy
who met the inclusion criteria. All women were identified therefore threatens a woman’s and her family’s opportunity
through the ward admission book at the obstetric and gy- for social and economic advancement through education.
naecology ward. We positively identified that 92% (119/ This sense of a lack of readiness and desire to continue
129) of these women were admitted following a spontan- their education was combined with fear and worry about
eous or induced abortion. Twenty eight women (28/119; disappointing their family and of bringing shame or embar-
24%) were admitted following unsafe, induced abortion. rassment to their families for being pregnant while still a
Most women (21/28; 75%) reported an induced abortion at student or unmarried. Key informants also stated that
the time of admission. Five women (5/28; 18%) had clinical young girls also feared their parents, as Jay mentions:
signs that an induced abortion had taken place, two of
whom did disclose interference with the pregnancy during “…when they miss their periods they know that they
the semi-structured interview. Two women (2/28; 7%) who are pregnant… they want it out as soon as possible so,
disclosed during their semi structured interview that they how they go about to get this thing out of them, they
had induced their abortion had no clinical signs that the go to the extreme…they are desperate to get it out,
abortion had been induced. the young girls they are scared of their parents….”.
This paper describes themes that emerged during the Jay, HCW, EHP hospital.
analysis process. These have been grouped according to
the following categories: reasons given for ending the Partly, this fear arose out of knowledge of the financial
pregnancy; abortion methods used; seeking post abortion outlay and sacrifices many families had made towards
care and reflections post abortion. their education, as Noreen describes:

Reasons given for ending the pregnancy “As for myself, I thought I must not have this baby,
Women’s reasons for deciding to end their pregnancy I’m still in school….my family [have spent] a lot of
related to the notion of “readiness” for a baby, or related money on school fees and I didn’t think of this and I
to family or relationship issues. did that…… I want[ed] to remove it”.
Noreen, 20 years, grade 8 student.
Not ready: Jeopardising a woman’s education
Among younger and single women, many felt they were In other cases health workers stated that parents actively
not ‘ready’ for a baby, in particular it was understood sought terminations of pregnancy for their daughters so
that the pregnancy and a baby would interfere with their they could continue their studies. In such cases it was not
education as Nema explains: always clear whether the parents were forcing the young
woman to terminate the pregnancy, as Linda described:
“When I told him (boyfriend) … he told [said] me that
we were both mad and we are not ready to make a “Parents come here and ask “Please is there any way
baby and we are not ready to get married… we both [to end a pregnancy], my daughter is pregnant [and]
didn’t want to leave school. We both didn’t want to she needs to continue on with her studies.”…”
have a baby”. Lilian, HCW, EHP hospital.
Nema, single, 15–19 years, grade 8 student.
Although some women were certain that they wished to
Education is highly valued in PNG and represents a con- terminate their pregnancy, others described indecision,
siderable financial investment by a family. The opportunity resorting to abortion due to fear of the perceived and ac-
for secondary education is considered as a means of social tual reactions of their families, as Isabella explains:
mobility. Most families support themselves through sub-
sistence agriculture with few opportunities for wage earn- “….. [I] thought about keeping the baby, however I
ing. There is an expectation that children who receive considered my family, that my father will get cross
secondary or higher education will be able to secure em- with me…. I was afraid and [I] made my decision [to
ployment and help support their families and communities have an abortion]”.
through their wages. For young women an education also Isabella, 22 years, 3rd year university student
means better marriage opportunities and increased bride-
price (money paid to the woman’s family upon marriage by Gender based violence
the groom and his family). In PNG, students studying at There are high rates of gender based violence in PNG
school or university are frequently advised by the educa- [22] but frequently it remains a secretive and shameful
tional institute to leave school during a pregnancy, with topic. One woman in our study presented to hospital
Vallely et al. Reproductive Health (2015) 12:22 Page 5 of 11

reporting an induced abortion, the abortion occurring many communities as a credible explanation for such mis-
following physical violence from her husband. No fortunes as an abortion. An explanation of sorcery and
women in our study reported their pregnancy being the witchcraft may reposition a woman who aborts from being
result of forced sex, although we did not explicitly ask defined as a perpetrator of a criminal act to a victim. Inter-
about this during the interviews. However, as in the case ference with the pregnancy as a result of witchcraft and evil
above, there were indications of coerced abortions. In spirits, directed towards them from another family mem-
one case, a housewife explained how she was excited at ber was identified during our study, as Elisabeth explains:
being pregnant again, however her husband did not want
the baby and he took his wife to a health care worker “…. I was lifted by spirits and thrown away outside
himself to ensure an abortion was undertaken: the house by witches two times…then I was hit on the
back…. my husband found me outside with blood
“My husband brought me to see a relative at the running like water….”
hospital….he did not want the baby so he brought me Elisabeth; 16 weeks gestation, planned pregnancy.
…..[to get an abortion]”.
Mary, 30–34 years, housewife. Assistance in acquiring an abortion
Usually the person to whom the pregnancy was dis-
Relationship problems closed to was involved in helping to find the means to
The dynamics of power within their relationship with end the pregnancy. In some situations that person was
their husbands was another prominent theme in married the boyfriend, as Noreen describes:
women’s discussion of the reasons for their induced
abortions. In some cases women explained that their “……he said to me, "I don’t want you to do that (be
husbands were having extra marital affairs and hence pregnant), I have a lot of friends so I will get this
they did not wish to bring another child into that rela- Cytotec and come and give you and you will end this
tionship. Rose undertook an abortion as a means of pun- pregnancy”…. I was happy that he came and gave it to
ishing her husband: me and I ended this pregnancy…..”
Noreen, 20 years, grade 8 student.
“I was happy that I was pregnant but realised my
husband was having [an] affair with another woman Other women however did not consult with anyone
so I tried ending pregnancy by squeezing my else and acted alone. Kate clearly identifies her agency in
abdomen”. acquiring an induced abortion in her following
Rose, 25–29 years, housewife. statement:

Cultural beliefs “… I alone, I myself made my decision and I went and

In the Eastern Highlands Province, as in other settings asked around and found it….. my husband does not
in PNG, sexual abstinence during breast feeding is know…… I went and got the medicine and I drank”.
understood as a means to prolong breast feeding of the Kate, separated, 15–19 years, subsistence farmer.
infant to ensure good nutrition for the infant [33]. To be
breast feeding while pregnant reveals lack of adherence Nema also describes how her boyfriend’s sister-in-law
to this tradition and therefore brings shame to the helped, wanting to protect the young couple from
couple, in addition to which it is felt that the breast milk unnecessary gossip and information getting back to the
is not as nutritious for the infant, due to the growing young girl’s family:
fetus, as Annemarie describes:
“My thoughts were to abort it and forget…my
“…my child is still an infant and he’s still boyfriend also said that…He said he would find a way
breastfeeding… if I breast feed him, he will be for us and our people [family] would not know…she
malnourished because there’s another baby in the [the boyfriend’s sister-in-law], told me, “We (the
womb so, I thought I must remove [abort] this baby, boyfriend and sister in law) will come to town… if our
so I removed it”. people saw both of you [Nema and her boyfriend] it
Annemarie married, 20–24 years, household wouldn’t be good… I will get [your boyfriend] and
duties. both of us will go and find a way to get help”. I stayed
in the village, that woman [boyfriend’s sister-in-law]
Sorcery, spiritual beliefs and witchcraft are widely be- bought it [tablets from the pharmacy] and gave [it to]
lieved and spoken about in terms of causes of illness in him [boyfriend] and he came and gave [it to] me”.
many cultures within PNG [34] and may be accepted in Nema, single, 15–19 years, grade 8 student.
Vallely et al. Reproductive Health (2015) 12:22 Page 6 of 11

Methods of abortion used and got it directly. He put it [in] and I came… I
A range of methods to end the pregnancy were de- removed it [the fetus]….”.
scribed, including traditional herbs and physical means, Monalisa, separated, 32 years, housewife.
however most women used misoprostol. Key informants
mentioned how traditional methods, including the use “I came to [the hospital] and I did a pregnancy test
of herbs have been used for many years in the commu- and it was positive so they prescribed a medicine for
nity setting. While some informants suggested that trad- me to take, and I went to the chemist and I got the
itional herbs and physical means continue to be used, medicine…She [the nurse] said, “go to the pharmacy
others described an increase in women presenting to because at the hospital we do not supply this
hospital following the use of misoprostol. Some believe medicine….”.
that health care workers are involved in ending an un- Tina, unmarried, 20 years, grade 11 student.
wanted pregnancy, with women gaining access to miso-
prostol through prescriptions. There was also some Women were able to recall quite clearly the instruc-
feeling that health care workers s in some health facil- tions provided when buying the misoprostol, however,
ities were providing abortions, although the abortion for many the instructions and advice was incorrect, as
methods and techniques were not discussed. Kate describes:

Misoprostol “… I bought it … they told me how to use it … I

Women who reported using misoprostol to end their went… I drank 2 [and] I inserted 2 in the vagina…. I
pregnancy took between two and five tablets and both waited and then I felt a bit alright and then, it [the
oral and vaginal routes of administration were described. fetus] came out”.
The misoprostol was obtained through a pharmacy and Kate, separated, 19 years; induced at less than
frequently a family member, friend or boyfriend was in- 12 weeks.
volved in procuring the tablets. The purchase was not al-
ways straight forward, as Nema explains: This incorrect messaging and consequences of incor-
rect dosage of misoprostol was highlighted by the key in-
“They themselves [chemist] have stopped selling to the formants, as Jay describes:
public [meaning not displayed on the shelves]. But there
are relatives…they gave it to her [referring to a friend]”. “She went and she bought some drugs from
Nema, single, 15–19 years, grade 8 student. somebody saying they were a doctor from the hospital
[and] this girl said this guy gave her six tablets, and he
Lucinda explained how she has seen a change in abor- instructed her to put it up her vagina and it will help
tion methods used with misoprostol becoming more her to contract and she will abort the baby. But this
widely recognised as a method of abortion: dose was too much for her, she came and she was in
so much pain, she was screaming and she was yelling
“By my observation…..it’s changed, now they are more and we told [asked] her, “what did you do?” and then
to [using] Misoprostol….. it’s easier than trying to use she said, “oh someone gave me something and I put it
these irons and sticks, and normally people in the [in] and this is what happened….”
village too they come, they ask for this Misoprostol. Jay, HCW, EHP hospital
Like the educated people living in the village, they’ve
done their grade 10, grade 12 and they are in the The only women who reported a dose and route cor-
village, they come and ask….female [relatives] for it. rect for their gestation were those who received their
Like if a mother notices that her child is expecting, misoprostol from health care workers.
she’ll come and ask on behalf of her daughter”. For those women who reported the costs involved in
Lucinda, HCW, EHP hospital. purchasing the misoprostol, none expressed difficulty
finding the money, even though many of the women
Confirming the suspicions of some of the health care were students or housewives with very little income.
workers, there were reports of women obtaining misoprostol Monalisa describes how she had to find K200 (US$ 75)
through health care workers at hospitals outside of Goroka to pay a health care worker for two tablets:
(the capital of EHP), and through a prescription obtained
from another hospital, as Monalisa and Tina explain: “….it’s expensive, they usually charge for them a lot of
money, but as for myself, I promised that I will pay
“I took tablets. Women who used it told me, they half…. I went and gave him K40.00 together with a
bought it from this man [at a health facility] so I went bilum [traditional woven bag of high value] …I
Vallely et al. Reproductive Health (2015) 12:22 Page 7 of 11

promised I will not hide, I will go and pay for [the I’ve witnessed that, the bark of a tree works. I’ve seen
rest of]it ….”. [it] and I’ve witnessed [it], It’s very effective…it
Monalisa, separated, 32 years, housewife. terminates the pregnancy but…. it doesn’t clear the
uterus, it doesn’t expel everything out from the
Frequently the cost was met by family member’s, or the uterus so, there are chances that the mother will have
boyfriend and could be negotiated, as Nema describes: complications from that”.
Frances, HCW, NGO, Goroka.
“…he told me that they charged K200.00 but that
woman [boyfriend’s sister-in-law] made friends with A few women combined the traditional methods of
them and she said “they are school students who came abortion with modern methods. Monalisa describes how
to me with this problem,” …she said “I have K130.00” she initially sought traditional abortifacients, but when
and they helped her”. these did not work she resorted to misoprostol. As in
Nema single, 19 years, grade 8 student. her case, trying various means to abort may result in de-
lays, increasing the risks to women as the gestational age
Traditional herbs increases:
The use of traditional herbs, in particular tree bark or
grasses chewed up and swallowed or squeezed to make a “I said I’ll try in the village, get ginger and those
juice were described by both women and key informants. things and help myself …. they usually plant it
Following their use women reported abdominal cramps differently, the ginger …for aborting babies… I gave
and vomiting before expulsion of the uterine contents, him K10.00….he [the medicine man] brought it, spoke
as Velma describes: [some words over it]…brought it, still talking and
poking it [piercing the stem of ginger with a needle]
“[I] ate some herbs- grass, put salt and ate [the] soft but when he pulled it out it was strong, and he
part, squeezed the green plant and put salt on and the said…“it’s strong”- it means that he is not able to
water drip into [my] mouth and I swallowed it. [I was remove it [fetus], so he said, “that’s alright, leave it”. I
helped by] a woman in the village who knows that…. myself I don’t believe much about this thing in the
for K20.00. [I] felt pain generalized all over the body, village, when I felt I did this… I saw it I said “ah
headache, backache and then [I] gave birth to a baby stupid….”. Those things to abort a child, tree bark or
boy- [fetus], and he made a little noise then [I] cut the that kind of thing…I said I must go to the hospital…
cord”. so I came.
Velma, married, 16 weeks at induced abortion. Monalisa, separated, 32 years, housewife [induced at
5 months using misoprostol].
Key informants also described traditional methods as
an effective means of ending a pregnancy, as Katherine Physical means
explains: Squeezing or tying a rope around the abdomen, under-
taking excessive exercise, running over mountains and
“When I interview them I find that they were using jumping over streams as a means to end the pregnancy
some tree barks, and some grass, which they locally were also described. Annemarie explained how she
use to induce abortion. Traditional methods…. grass… waited until she knew the pregnancy would be far
they just pick the grass and chew it and swallow to enough progressed to enable her to exert enough force
induce the abortion, [same with] the bark of the tree”. on her lower abdomen to interrupt the pregnancy:
Katherine, HCW, NGO Goroka.
“…I went past 3 months and I squeezed my abdomen and
However, there was some concern among the key infor- I killed one [the] baby boy and I removed it … I used my
mants that these traditional methods can be ineffective, hand, myself and squeezed my abdomen 3 times I tried to
leaving women vulnerable to post abortion complications, remove it [abort] and the 4th time I removed it. I allowed
as Frances explains: the baby to grow big then I squeezed it [abdomen] and
removed it. If it was small and I removed [aborted] it will
“It takes 24 hours for this thing to work… in the past, die inside the womb and it will fester [decay]inside so I
those people that were using [preparing and was a little scared and I removed it….”
administering] the barks of a tree were elderly men - Annemarie, married, 16 weeks at abortion.
that [what] I’ve seen, where I come from. Some
[women] they try those things and if it doesn’t work, One young woman, widowed after a tribal fight in her
then they go for some [other] induced abortion…But community described how she turned to her sister for
Vallely et al. Reproductive Health (2015) 12:22 Page 8 of 11

advice on ending her pregnancy, inserting a stick into her complications and the consequent implications on their
vagina to end the pregnancy at eight weeks gestation: health, as Tina explains:

“[My] sister informed me about [using] the plant [stick] “I was a little scared because, I heard that this is
and I went to [the] bush and removed it [the fetus]”. illegal, it's an illegal abortion. I was a little scared but I
Sue, 19 years, widow. knew that if I came to the hospital I will get help ….”.
Tina, unmarried, 20 years, grade 11 student.
Reflecting many of the methods reported from women
in this study, key informants revealed their experiences However, frequently women delayed seeking care post
from both the community and professionally, having abortion, many presenting for hospital level care between
witnessed physical means to end a pregnancy, as Lilian six days and up to four weeks after the abortion had taken
and Okaps describe: place [31]. For many the delay was because the abortion
had taken place without the knowledge of those who the
“….to induce the abortion, some they do it themselves women lived closely with, seeking care meant disclosing
[these] women…get rid of the pregnancy by what had transpired, as Noreen describes:
themselves, they do all sorts of things…they push
sharp instruments into the cervix or into the uterus, “I thought that if I don’t come to the hospital and get
and we’ve witnessed and seen trauma, infected, they help, I remain in the house I will get worse and die….I
come in very septic and some…they take some herbs would get worse if I didn’t tell my family. That’s why
or they drink strong coffee or alcohol they go into all when I told my family they helped me come to the
these [methods] they think they can consume this one hospital”.
to destroy the pregnancy, and some they step on their Noreen, 20 years, grade 8 student.
abdomen, step on their abdomen and do all these
things to force the pregnancy out”. Women described a number of symptoms that triggered
Lilian, HCW, EHP hospital. them to seek care at the hospital. While women expected
to see vaginal bleeding, many became concerned when this
“ I saw them, the mothers would sit down on top of went on for longer than they expected, they saw blood
the abdomen of the young girl and they crush and clots or when they experienced other symptoms such as
abort the baby”. feeling dizzy or abdominal and back pain. Some women
Okaps, male HCW, EHP hospital. felt their symptoms were so severe they feared they may
die if they did not receive health care. A few spoke of the
Seeking care post abortion need to come to the hospital in order to be “cleaned”, to
Key informants spoke of the secrecy surrounding induced ensure no products of conception remained. For many of
abortion, which contravenes social, cultural and Christian the women, once they had disclosed their situation to the
norms in PNG and evokes fear of prosecution among family a vehicle was hired or made available to bring the
women. The issue of not wanting to disclose an induced women into the hospital. Some arrived by a local bus, and
abortion was highlighted by the key informants who recog- others were brought in by ambulance after presenting to
nised that often women presenting to hospital do not dis- their nearest health facility.
close having induced an abortion, which is identified only
upon clinical examination, as Cinta mentioned: Reflections post abortion
A number of the women spoke about their feelings relat-
“When women, from [their] history they present we ing to ending their pregnancy. While most felt relieved
collect information and at times when you are doing that they were no longer pregnant, a few related feelings
speculum examination, you can see that if it is criminal of grief and spoke of regret for what they had done.
abortion like, you’ll see objects like stick or a piece of Annemarie describes feeling relieved, managing the situ-
iron rod or something, you can see, the cervical os and ation as she felt appropriate:
the cervix inside is rough and rugged….and it’s bleeding
from the tear, so you can tell that, it’s criminal abortion “Hmm when he [the fetus] came out straight, I was
which has been induced with instruments….” thinking my [breast feeding] infant will drink good
Cinta, HCW, EHP hospital. breast milk and will have more strength and he will
be fine so I’m happy that I removed it…. We wrapped
Despite the implications involved and the stigma and it [the fetus] with a napkin and I covered him then I
secrecy surrounding abortion, the women in this study buried him inside a hole”.
presented to hospital because they had concerns about Annemarie, aborted at 16 weeks.
Vallely et al. Reproductive Health (2015) 12:22 Page 9 of 11

In contrast Noreen – a young, single woman with no of misoprostol described doses and regimes inaccurate for
previous pregnancy history describes her feelings of guilt their stated gestation, and lack of supervision from an ap-
on aborting her fetus at 12 weeks gestation: propriate health care provider was noted. Given the avail-
ability of misoprostol in this setting, it is also possible that
“I thought back again why [did] I abort this child and other women may have undertaken abortions in the first
I wasn’t happy. When I removed it, I noticed the child trimester with less severe or no complications, thus not re-
had formed already…. and I thought back again why quiring hospital level care and not identified in this study.
did I abort it, I should have kept it”. Highlighted by both the key informants and women par-
Noreen, 20 years old, student ticipating in this study, the use of physical and mechanical
methods to end an unwanted pregnancy are still used by
For some women the grief and loss was made harder some women. However, the increasing availability of miso-
by a lack of empathy from the health care workers at the prostol is perhaps providing an alternative method for
hospital: women, findings identified elsewhere [4,7,8]. As reported
from other settings [4,35], women in our setting also re-
“..I even felt sorry for the little innocent [fetus]…I felt ported the use of herbal remedies to induce abortion. The
shy, guilty…and even sorrow…he [the doctor] was large evergreen tree, Alstonia scholaris is distributed
really cross with me….”. throughout PNG and is recognised for a number of trad-
Beth, aborted at 11 weeks itional uses, including chewing the leaves as an oral contra-
ceptive, and ingestion of the dried bark sap to induce
Discussion abortion [41]. While in some communities in PNG there is
We identified 28 women admitted to hospital following a general knowledge of plant preparations, in some situa-
an induced abortion. Women’s reasons for seeking an tions there may be the need to enlist the more specialized
abortion related to: a lack of “readiness” and poor timing knowledge of a traditional healer or, in some situations a
of the pregnancy, especially with relation to women’s sorcerer. In our study some of the women using trad-
education; not wanting to cause shame or embarrass- itional, herbal methods to end their pregnancy enlisted the
ment to themselves or their family; relationship prob- help of older village women; seeking assistance from a
lems and some cultural beliefs. “medicine man” who used sorcery in anattempt to inter-
Poor timing of pregnancy, including being young and rupt an unwanted pregnancy.
unmarried and wanting to space children is reported from While grounds on which abortion can be legally per-
a number of settings as a reason for ending an unplanned formed has broadened in many developing countries, in
pregnancy [13,35]. In addition to these reasons, out of a countries where it remains illegal, abortions frequently
fear of a missed opportunity for education and all that that continue to take place in unsafe circumstances [6]. In
could mean for the individuals and their families, coupled PNG, as in other settings, the factors that hinder access to
with a fear of responses from the family, it is not perhaps safe abortion also play a role in women accessing health
surprising that the women in our study resorted to induced services for post abortion care, following an unsafe abor-
abortions. In PNG 5% of females finish education early be- tion [2,42]. This study highlights that women fear reper-
cause of pregnancy and marriage, in the Highlands region cussions from both health care workers and the legal
the rate is 9% [17]. As the average age of sexual debut in framework surrounding abortion practices, findings
PNG is 18.7 years for females and the average age at the reflected in other settings [2,7]. Also noted through this
birth of a first child is 20.8 years [23], it is not unexpected study was the use by health care workers of the term
that many school and tertiary students are experiencing “criminal abortion” to describe and induced abortion, per-
unplanned pregnancies. haps highlighting the attitude of health care workers to-
Many of the women reported the use of misoprostol to wards abortion in this setting. The fear of presenting for
end the unwanted pregnancy, a medical method increas- hospital level care led to delays in seeking assistance, both
ingly being used to end unwanted pregnancy in many from family members and the formal health systems with
developing countries [3,7,10,29,36,37], including earlier re- many women only reported seeking health care when they
ports from PNG [29]. While the use of misoprostol is felt their lives were at risk.
associated with less severe outcomes and morbidity, com- As described elsewhere, where induced abortion is re-
pared to the use of substances and physical methods stricted or inaccessible, identifying and reporting abor-
[4,7,8], it is only safer when factors of gestation and correct tion is difficult [2,11]. Even in settings where abortion is
dose are followed [38,39]. Lack of adequate supervision legal, it may be under reported or reported as spontan-
from a skilled health care person [38] and following a sub- eous, especially when it has occurred outside of a legal
optimal misoprostol regime, can lead to several days of framework [2]. While most women reported interference
hospitalisation [40]. Women in our study reporting the use with their pregnancy at their admission consultation,
Vallely et al. Reproductive Health (2015) 12:22 Page 10 of 11

some only identified as an induced abortion during their Authors’ information

semi structured interview. At the time of the study, LV was section head for maternal and child health
at the Papua New Guinea Institute of Medical Research, Goroka, Eastern
This study describes only women presenting for hos- Highlands Province, PNG.
pital level care. One limitation of such a hospital based
study is that it only captures those women able to access Acknowledgements
a health facility or with a morbidity so severe that they The authors thank all the women who willingly shared their personal
experiences of pregnancy loss. We also thank the health care workers for
present for hospital level care. Frequently the young, the making time in their busy schedules to participate in this study. We are
poor and those living in the more remote areas are at grateful to all the staff at the gynaecology ward, especially the ward clerk
greatest risk of not reaching health services for post and staff at the emergency department at Eastern Highlands Provincial
hospital for their support in helping to identify women admitted with
abortion care [7,42,43]. In addition, women experiencing pregnancy loss. This study was supported by funding from AusAID PNG for
a complete abortion, those with less severe morbidity, sexual and reproductive health research at the PNGIMR and by Marie Stopes
and those who undertake an abortion resulting in a ma- PNG.

ternal death remain unaccounted for in the community, Author details

therefore never forming part of any official statistics. 1
Australian Centre of Tropical Medicine and Health, James Cook University,
Only capturing those who reach the hospital only repre- Townsville, QLD, Australia. 2Sexual & Reproductive Health Unit, Papua New
Guinea Institute of Medical Research, PO Box 60, Goroka 441, Eastern
sent a sub-population of all women in this setting under- Highlands Province, Papua New Guinea. 3School of Public Health and
taking an induced abortion. Community Medicine, UNSW Australia, Sydney, Australia. 4School of Political
and Social Inquiry, Faculty of Arts, Monash University, Melbourne, Australia.

Received: 11 March 2014 Accepted: 12 March 2015

Conclusion
This descriptive study provides insight into an area of
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