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Author manuscript
Int Perspect Sex Reprod Health. Author manuscript; available in PMC 2016 August 02.
Published in final edited form as:
Int Perspect Sex Reprod Health. 2015 December ; 41(4): 170–181. doi:10.1363/4117015.
The Incidence of Abortion in Nigeria
Akinrinola Bankole, Isaac F. Adewole, Rubina Hussain, Olutosin Awolude, Susheela Singh, 
and Joshua O. Akinyemi
Akinrinola Bankole is director of international research, Rubina Hussain is research associate and 
Susheela Singh is vice president for research—all at the Guttmacher Institute, New York. Isaac F. 
Adewole is vice chancellor and professor, and Olutosin Awolude is a consultant and lecturer, 
Department of Obstetrics and Gynaecology; and Joshua O. Akinyemi is a lecturer, Department of 
Epidemiology and Medical Statistics—all at the University of Ibadan, Nigeria
Abstract
CONTEXT—Because of Nigeria’s low contraceptive prevalence, a substantial number of women 
have unintended pregnancies, many of which are resolved through clandestine abortion, despite 
the country’s restrictive abortion law. Up-to-date estimates of abortion incidence are needed.
METHODS—A widely used indirect methodology was used to estimate the incidence of abortion 
and unintended pregnancy in Nigeria in 2012. Data on provision of abortion and postabortion care 
were collected from a nationally representative sample of 772 health facilities, and estimates of the 
likelihood that women who have unsafe abortions experience complications and obtain treatment 
were collected from 194 health care professionals with a broad understanding of the abortion 
context in Nigeria.
RESULTS—An estimated 1.25 million induced abortions occurred in Nigeria in 2012, equivalent 
to a rate of 33 abortions per 1,000 women aged 15–49. The estimated unintended pregnancy rate 
was 59 per 1,000 women aged 15–49. Fifty-six percent of unintended pregnancies were resolved 
by abortion. About 212,000 women were treated for complications of unsafe abortion, 
representing a treatment rate of 5.6 per 1,000 women of reproductive age, and an additional 
285,000 experienced serious health consequences but did not receive the treatment they needed.
CONCLUSION—Levels of unintended pregnancy and unsafe abortion continue to be high in 
Nigeria. Improvements in access to contraceptive services and in the provision of safe abortion 
and postabortion care services (as permitted by law) may help reduce maternal morbidity and 
mortality.
Induced abortion is illegal in Nigeria except when performed to save a woman’s life. Both 
the penal code, which is generally applied in the country’s northern states, and the criminal 
code, which generally applies in the southern states, allow this exception, and both regions 
specify similar criminal penalties for noncompliance.1 Yet pregnancy terminations are quite 
common, and because they are often performed clandestinely or by unskilled providers, 
most are unsafe.2 The first national study to examine the incidence of abortion estimated that 
in 1996, about 610,000 abortions, or 25 per 1,000 women aged 15–44, occurred in Nigeria.3 
Author contact: abankole@guttmacher.org. 
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A decade later, another study noted that if the abortion rate had not changed since 1996, then 
760,000 abortions would have occurred in 2006, given the increase in Nigeria’s population 
during this period.4
Since the release of the 1996 estimates, the Nigerian government and other stakeholders 
have initiated a number of policies and programs to improve the reproductive health of 
women in the country. Notable among them are the government’s efforts to achieve the 
United Nations Millennium Development Goals, including Goal 5, to improve maternal 
health. This goal has two targets: to reduce the maternal mortality ratio by 75% between 
1990 and 2015, and to provide universal access to reproductive health by 2015. A 2010 
government report concluded that progress toward achieving these targets has been slow, and 
that the modest progress that has been made in reducing maternal mortality has not been 
accompanied by improvements in other indicators, such as family planning uptake and the 
proportion of births attended by skilled health workers.5
In the hopes of better understanding the scale of clandestine abortion and related 
reproductive health issues facing Nigerian women, we present new estimates of the 
incidence of induced abortion in Nigeria, at the national level and for each of the country’s 
six geopolitical zones.
METHODS
Data Sources
We produced our estimates using the Abortion Incidence Complications Methodology 
(AICM), an indirect approach that has been used to estimate the incidence of abortion in 
more than 15 countries.6–9 The methodology relies on data collected through two surveys: a 
Health Facilities Survey, which gathers information from facilities that treat postabortion 
patients (i.e., women with complications from induced or spontaneous abortions), and a 
Health Professionals Survey, which collects information about abortion provision from 
knowledgeable key informants. These surveys are described in detail below. In addition, we 
used fertility and other data from the 2013 Nigeria Demographic and Health Survey 
(NDHS)10 and population estimates from the United Nation’s 2012 revision of the World 
Population Prospects in our calculations.11 The study was approved by the Guttmacher 
Institute’s institutional review board and by the University of Ibadan Ethical Review 
Committee.
Health Facilities Survey
All public and private health facilities that had the capacity to provide postabortion care 
services were included in the sample frame for the survey. We compiled a list of potentially 
eligible health facilities using the most recent (2007) National Bureau of Statistics’ 
Directory of Health Establishments in Nigeria, supplemented by information from the 2007 
National Health Insurance Scheme and the Ministry of Health’s Department of Hospital 
Services. Slightly more than 5,000 facilities were deemed eligible.
It was important to represent all six of Nigeria’s geopolitical zones, because women’s social 
and demographic characteristics vary greatly across the country, particularly between the 
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northern and southern zones.* Therefore, using information from the Nigerian census and 
the 2008 NDHS,† we grouped the states in each zone into tertiles according to the 
proportion of women who lived in urban areas, and randomly selected one state per tertile 
(and thus three states per zone). This yielded a total of 18 states across the country: Kaduna, 
Kebbi and Jigawa in the North West; Bauchi, Borno and Taraba in the North East; Kwara, 
Nasarawa and Niger in the North Central; Abia, Anambra and Imo in the South East; Cross 
River, Edo and Rivers in the South South; and Lagos, Ogun and Ondo in the South West.
A total of 3,125 facilities that potentially provided post-abortion care were located in the 18 
states. We randomly selected 75% of public secondary hospitals (general, specialist and 
district-level), comprehensive health centers, cottage hospitals and public clinics; 40% of 
private hospitals, clinics and medical centers (a mixture of secondary- and primary-level 
facilities); 40% of public maternity centers (mostly primary-level); and 17% of private 
maternity centers (again, mostly primary-level). In addition, because of their large 
postabortion care caseload, we included all tertiary facilities (teaching hospitals and federal 
medical centers) in the country, regardless of whether they were located in sampled states. 
After exclusion of 45 facilities that no longer existed or were not found, the final sample 
consisted of 1,088 facilities.
Trained interviewers visited each sampled facility between July 2011 and March 2012, and 
used a standardized questionnaire to conduct a face-to-face interview with a senior staff 
member knowledgeable about the facility’s provision of abortion services. Respondents 
were chosen on the basis of their seniority as well as their familiarity with abortion-related 
services at their facility; they either oversaw abortion or postabortion care at the facility, or 
were the only provider or one of the few providers of such services. Interviewers, with the 
support of their supervisors, were responsible for using these criteria to locate appropriate 
respondents. In some instances, the identified respondent was unavailable or was unable to 
complete an interview. In these cases, the interviewer made multiple attempts to interview 
the respondent; if this was not possible, the interviewer sought an interview with the next 
most knowledgeable person, if there was more than one provider.
The response rate for the survey was 98%. An initial analysis found that 314 facilities in our 
sample did not offer postabortion care, and two that did offer such services had not 
responded to a number of key questions; these facilities were removed from our analysis. Of 
the remaining 772 facilities, 48% were in the public sector, and 52% were private or were 
operated by nongovernmental organizations or missions (Table 1, page 171). For each 
geographic zone, we assumed that the proportion of facilities in our sample that did not 
provide postabortion care was representative of the zone as a whole, and proportionally 
reduced the universe of facilities that provide such services in the zone, resulting in an 
estimate that 3,879 facilities provide post-abortion care nationally.
*Residents of the northern zones are largely Muslim, whereas the southern zones’ population is primarily Christian. In addition, the 
proportions of women who live in urban areas and levels of female education are lower in northern zones than in southern ones. 
Compared with the other zones, the North West and North East zones have lower contraceptive prevalence and higher fertility.
†At the time of sampling, the 2013 NDHS was not available.
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Most of the facilities included in this study provided both inpatient and outpatient services 
(Appendix Table 1, page 177). The majority of high-level government facilities (teaching 
hospitals, federal medical centers, and general and specialist hospitals) and private facilities 
had functional manual vacuum aspiration (MVA) equipment; the proportion ranged from 
62% for private maternity centers to 98% for teaching hospitals and federal medical centers. 
Fifty percent of cottage hospitals and other community health centers had functioning MVA 
equipment, but only 10% of government maternity facilities did. With the exception of 
government maternity centers, the majority of facilities in each category had staff trained in 
use of the equipment. All teaching hospitals, federal medical centers, and general and 
specialist hospitals had surgical wards, as did more than 90% of private hospitals, clinics and 
medical centers. Most teaching hospitals and federal medical centers (84%) also reported 
having a separate ward for abortion-related services.
Because of staff shortages and inadequate resources, record-keeping is inadequate at 
facilities in many developing countries. For example, a recent study found medical record-
keeping in six tertiary facilities in Nigeria to be poor in both completeness and quality,12 and 
only 46% of sampled facilities in a 2008 Colombian AICM study were able to provide 
adequate information for the study year, leading the authors to argue that “data maintained 
by facilities are currently too incomplete to be the basis of national estimates of abortion 
incidence.”13(p.116) Because we had similar concerns, we did not rely on official facility 
records to help us determine the number of postabortion care cases or pregnancy 
terminations at the facility. Instead, we obtained caseload estimates for each facility from the 
knowledgeable senior staff member who was interviewed for the survey.
Of the 772 surveyed respondents, 52% were obstetrician/gynecologists, general 
practitioners, other physicians or medical officers; 33% were nurses or midwives; 14% were 
community health extension workers or community health officers; and fewer than 1% were 
other staff (Appendix Table 2, page 178). Fifty-seven percent of respondents had at least 10 
years of work experience, 41% were female and 70% were aged 30–50 (not shown). In 
public teaching hospitals and federal medical centers, and in private hospitals, clinics and 
medical centers, a large majority of respondents were physicians or medical officers (66–
72%; Appendix Table 3, page 178), while in public cottage hospitals, comprehensive health 
centers and public clinics most respondents were nurses, midwives, community health 
extension workers or community health officers (74–93%). General and specialist hospitals 
and private maternity centers had a more balanced mix of respondents.
All respondents provided informed consent; they did not receive remuneration for 
participating. Respondents were asked to estimate the number of patients who received 
postabortion care (for complications of either spontaneous or induced abortion) at their 
facility as outpatients and inpatients. To accommodate the large variation in facility size and 
capacity, we offered respondents three time periods (week, month and year) for which to 
make their estimates, but asked them to answer for only one. They provided estimates for 
both the average week, month or year, and the past week, month or year. We asked for these 
two types of estimates to increase the likelihood of accurate recall and of capturing variation 
within the year. Responses were converted to annual totals and averaged to provide an 
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estimate for the calendar year. Respondents were also asked to estimate the number of 
induced abortions performed at the facility during the same time periods.
In examining the data from the Health Facilities Survey, we became concerned about the 
accuracy of some results, because the proportion of facilities that reported providing 
abortions was very small, regardless of facility type. In the Health Facilities Survey 
conducted for the 1996 estimate of abortions incidence in Nigeria, 33% of respondents 
indicated that their facility provided induced abortion services;3 in the current study, only 
8% of respondents reported that their facility performed abortions (Appendix Table 1). 
Private clinics and medical centers were the most likely to report providing this service 
(21%), followed by teaching hospitals and federal medical centers (14%).
We hypothesized that because of growing social conservatism throughout Nigeria and the 
inhibiting effects of a new antiabortion stance in the national (and a number of state) 
legislative houses, some respondents were misclassifying pregnancy terminations—probably 
intentionally—as cases of postabortion care. The defeat of the 2006 reproductive health bill 
in the Senate (largely because it was considered an abortion bill), and the 2013 repeal of a 
2012 law that, among other things, had expanded the criteria for legal abortion in Imo state, 
exemplify the increasing level of social conservatism in Nigeria.14 Moreover, in a 2009 
study, nearly one-third of 49 Nigerian policymakers surveyed said that abortion should not 
be allowed even to save a woman’s life.15 Because our respondents’ apparent misreporting 
of the number of abortions performed at their facility would have resulted in our 
overestimating the number of postabortion care patients treated in Nigeria, we adjusted their 
estimates in accordance with our experience from a similar study we had conducted (see 
Appendix, page 179).
Health Professionals Survey
The Health Professionals Survey was designed to elicit respondents’ perceptions regarding 
various aspects of abortion provision in Nigeria and the potential health consequences of 
such abortions; topics included the types of providers from whom women obtain abortions, 
the likelihood that these abortions result in complications and the likelihood that women 
obtain treatment at a facility for these complications. Study investigators and the research 
team prepared a list of health professionals knowledgeable about the conditions of abortion 
provision and postabortion care. Interviewers and supervisors from each geopolitical zone 
contributed to the list, ensuring adequate representation of all zones. We drew on 
membership directories of relevant professional associations to further broaden the list; we 
intentionally avoided selecting individuals who had participated in the Health Facilities 
Survey.
The resulting purposive sample of 194 respondents spanned a wide range of professions, 
including doctors, nurses and midwives (54%); program managers and health administrators 
(12%); policymakers, legal practitioners and activists (16%); lecturers and researchers 
(15%); and other experts (4%; Appendix Table 2). We included both medical and 
nonmedical participants because evidence indicates that estimates of the parameters under 
investigation may differ substantially between these two groups.6 The representation of 
medical providers varied from 44% in the South South region to 67% in the South East. 
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About 54% of the sample was from the north, 75% were working in the public sector and 
43% either were currently working in rural areas or had done so in the past five years (not 
shown). All interviews were conducted in person by a small number of trained interviewers 
using a structured questionnaire.
Analysis
The first step of our analysis was to estimate the number of women who receive treatment 
for induced abortion complications in Nigeria’s health facilities. Health Facilities Survey 
respondents were not asked to provide separate estimates for induced and spontaneous 
abortions, because complications of the two often are difficult to distinguish, and because 
restrictive abortion laws may deter accurate reporting. Thus, it was necessary to estimate and 
subtract the number of cases involving complications of spontaneous abortion. To do this, 
we applied an indirect method based on clinical studies that established the biological 
pattern of spontaneous abortion. Using this approach, we estimated that the number of 
miscarriages that occur at 13–22 weeks’ gestation (i.e., those likely to require facility-based 
care) was equal to 3.4% of the number of live births.6
For various reasons, including constraints on access to care, not all women who need care 
for late spontaneous abortions receive treatment at health facilities. We assumed that among 
Nigerian women who require such care, the proportion who receive care is the same as the 
proportion of women giving birth who receive antenatal care in a health facility—41% in the 
North West, 49% in the North East, 67% in the North Central, 91% in the South East, 73% 
in the South South, 90% in the South West and 61% nationally, according to the 2008 
NDHS. Using these proxy proportions, we estimated that 142,430 women received care for 
spontaneous abortion in 2012, and subtracted this number from the total number of 
postabortion care patients to obtain an estimate of the number treated specifically for 
complications of induced abortion.
The next methodological step relied on responses of the knowledgeable health professionals. 
One of three outcomes is likely for women obtaining clandestine abortions: They may 
experience no health complications, or none serious enough to require care; they may 
experience complications, but not receive care; or they may have complications and obtain 
the care they need. Reasons for women’s not receiving care include stigma, cost, distance to 
a health facility and death before having a chance to receive care. Applying a number called 
a multiplier to the number of women treated for complications of induced abortion accounts 
for the women who do not need or receive treatment, and produces an estimate of the total 
number of abortions. For example, a multiplier of 4.0 means that one in four women who 
had an induced abortion received treatment for complications in a health facility. A small 
multiplier reflects either that abortion is generally unsafe or that access to medical care is 
high, whereas a large multiplier indicates that abortion is very safe or that many women do 
not have access to medical care. We calculated separate multipliers for each region (see 
Appendix for further details).
Because of the uncertainty inherent in our estimates, we calculated 95% confidence intervals 
around the total number of abortion complications (induced and spontaneous) treated in 
health facilities. We then applied the methodology described above to the low and high 
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estimates of the number of treated complications to produce upper and lower estimates of 
abortion incidence (number and rate).
RESULTS
Treatment for Abortion-Related Complications
After adjustment of the original Health Facilities Survey data (see Appendix), we estimate 
that 354,400 women were treated for complications of spontaneous or induced abortion in 
Nigeria in 2012 (Table 2, page 174). Slightly more than half of these women (54%) were 
treated in public facilities (not shown); the proportion varied by region, ranging from 34% in 
the South South to 78% in the North East, likely reflecting differences in the availability and 
accessibility of private-sector facilities. Only in the South South and South East zones did 
public facilities treat fewer than half of patients who received postabortion care. Nationally, 
the majority of patients were treated at large hospitals, both in the public sector (59%) and 
private sector (56%). However, the situation varied among regions; for example, in the 
public sector, the proportion of women treated at hospitals ranged from 35% in the North 
Central region to 82% in the North West region.
After subtracting the number of women who had been treated for complications of late 
spontaneous abortions, we estimated that 212,000 women were treated for complications 
associated with induced abortion in Nigeria’s health facilities in 2012 (Table 3). These cases 
accounted for 60% of all women treated for any abortion-related complication in 2012 (not 
shown).
However, not every woman who has complications from unsafe abortion serious enough to 
require treatment in health facilities obtains the care she needs. According to estimates from 
the Health Professionals Survey, 40% of women who had an abortion in 2012 had 
complications warranting treatment in a facility. On the basis of this proportion, we estimate 
that an additional 285,000 women (or seven per 1,000 women aged 15–49) had abortion 
complications but did not receive care that year (not shown).
Number and Rates of Induced Abortion
The multipliers, which account not only for women who did not receive care for 
complications but also those who did not have complications, ranged from 3.9 in the South 
East to 8.4 in the North West (Table 3). Application of these multipliers yields an estimate 
that 1.25 million induced abortions occurred in Nigeria in 2012; our lower and upper 
estimates are 963,000 and 1.54 million. Overall, we estimate that the national induced 
abortion rate was 33 per 1,000 women aged 15–49 (confidence interval, 25–40 per 1,000), 
somewhat higher than the estimated rate of 25 per 1,000 women aged 15–44 (or 23 per 
1,000 women aged 15–49) in 1996. Because of the large differences in the quality of 
reporting of clandestine abortion services, the two studies used different adaptations of the 
AICM, and deriving conclusions from a comparison of the data is difficult. However, the 
1996 abortion rate of 23 per 1,000 women 15–49 falls just outside the confidence interval 
for the 2012 rate, suggesting that abortion incidence may have increased somewhat between 
1996 and 2012.
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Regional abortion rates varied widely. They were lowest in the North Central and South 
West zones (27 per 1,000 in each), slightly higher in the North West and South East zones 
(31 per 1,000 in each) and highest in the North East (41 per 1,000) and South South (44 per 
1,000). To further put the number of induced abortions in context, the abortion ratio (number 
of abortions per 100 live births) was 19 per 100 nationally, and ranged from 14 per 100 in 
the South West to 25 per 100 in the South South.
Pregnancies and Their Outcomes
Obtaining a plausible estimate of the number of abortions allowed us to estimate the number 
of pregnancies that occurred in Nigeria in 2012. This number is the sum of the numbers of 
induced abortions, births and spontaneous abortions among women aged 15–49. To estimate 
the number of births, we applied age-specific fertility rates from the NDHS to the number of 
Nigerian women in five-year age-groups. Estimates of spontaneous abortion were calculated 
according to the formula (derived from clinical studies of pregnancy loss) that the number of 
spontaneous abortions occurring at five or more weeks’ gestation is approximately equal to 
20% of the number of births plus 10% of the number of induced abortions.16,17
These calculations indicate that women aged 15–49 had about 9.22 million pregnancies in 
Nigeria in 2012 (Table 4). The overall pregnancy rate was 241 pregnancies per 1,000 women 
in this age-group. The rate was lowest in the South East (219) and highest in the South South 
(264). The national unintended pregnancy rate was 59 per 1,000 women aged 15–49; 
regionally, the rate ranged from 38 in the North West to 100 in the South South. Nationally, 
24% of pregnancies in 2012 were unintended; the proportion was lowest in the North West 
(16%) and highest in the South South (38%).
The majority of Nigerian women’s pregnancies in 2012 ended in planned births. The 
proportion was 63% for the country as a whole, and ranged from 52% in the South South to 
70% in the North West. About 14% of pregnancies ended in abortion; the proportion varied 
from 11% in the South West to 17% in the South South. At the national level, about 56% of 
unintended pregnancies ended in abortion (not shown); regionally, the proportion was lowest 
in the South West (43%) and highest in the North East (64%) and North West (81%). Fewer 
than half of unintended pregnancies in the three southern regions ended in abortion.
DISCUSSION
Mortality and Morbidity due to Unsafe Abortion
Nigeria has one of the highest maternal mortality ratios in the world.18 Although the 
government has acknowledged the problem and is committed to improving maternal health, 
evidence suggests that progress has been limited, and unsafe abortion remains a major 
contributor to maternal morbidity and mortality.
In a community-based survey conducted in 2002–2003, 25% of women who had had an 
induced abortion reported having had serious complications.19 Another study found that 
women who had been admitted to hospitals for complications of induced abortion had 
suffered a variety of complications, including retained products of conception (50%), 
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bleeding (34%) and fever (34%).20 Two-thirds had had serious complications, such as sepsis, 
pelvic infections and injury from instruments, and some died.
A recent study recorded 137 maternal near-miss cases* in a six-month period at eight large 
hospitals across the country, and found that 13 (10%) were due to unsafe abortion.21 
Another study estimated that in the late 1990s, about 3,000 women died annually from 
unsafe abortion in Nigeria.20 Because this estimate included only women who had died in 
health facilities, and not those who had died from unsafe abortion before reaching a facility, 
the actual number of deaths was likely higher.
We estimate that in 2012, about 212,000 women were treated in health facilities for 
complications of induced abortion, suggesting that unsafe abortion remains an important 
contributor to maternal morbidity and mortality in Nigeria. In addition, an estimated 285,000 
women had complications serious enough to require treatment in health facilities, but did not 
obtain the care they needed. The impact of unsafe abortion extends beyond morbidity and 
mortality; there are also social costs to Nigerian women and their households, including the 
risks associated with breaking the country’s restrictive abortion law and the possibility of 
strong social sanctions.
Furthermore, unsafe abortion imposes a heavy financial burden on both women and 
Nigeria’s fragile health care system. For example, one study estimated that post-abortion 
care cost US$103 per patient in Nigeria in 2005, amounting to US$19 million; the average 
per-case cost for hospital care was US$132, of which 72% (US$95) was borne by women 
and their households.22
Unintended Pregnancy and Abortion
Findings from this study suggest that unintended pregnancy—the root cause of most 
abortions—is still occurring at moderately high levels in Nigeria. The high rates of 
unintended pregnancy and abortion are probably due largely to the combination of low 
prevalence of contraceptive use (especially use of modern methods) and the high proportion 
of women who need methods to avoid unwanted births or (particularly in the case of 
sexually active unmarried young women) to delay their first pregnancy. Women with the 
latter need are not an insignificant group: According to the 2013 NDHS, 40% of never-
married women aged 15–19 had had sex, and about three-quarters of this group had done so 
within the past year.
Evidence from national surveys suggests that the number of abortions in Nigeria is likely to 
remain high in the absence of intervention. According to the 2013 NDHS, Nigerian women 
aged 15–49 had, on average, more children than they wanted (Table 5).10 Although the 
difference between total fertility and wanted fertility was not large, women in all six 
geopolitical zones had more children than they desired. The prevalence of contraceptive use 
remained at virtually the same low level as in the 2008 NDHS—only 16% of women of 
reproductive age were using a method, and only 11% were using a modern method, in 
*A near-miss maternal event is the near-death of a woman from a complication during pregnancy or childbirth or within 42 days of the 
termination of pregnancy (source: Say L, Souza JP and Pattinson RC, Maternal near miss—towards a standard tool for monitoring 
quality of maternal health care, Best Practice and Research, 2009, 23(3): 287–296).
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2013.10 In addition, 14% of women aged 15–49—and 22% of sexually active unmarried 
women in this age group (not shown)—had an unmet need for contraception, meaning that 
they did not want to have a child in the next two years or wanted no more children at all, but 
were not using any contraceptive method (Table 5). Women with unmet need commonly cite 
opposition to contraception (their own, their partner’s or that of another person, such as a 
family member) and fear of side effects as reasons for nonuse.24
The high rates of abortion in the North East and South South are likely related to factors that 
increase women’s need for abortion in these regions. The proportion of women in the North 
East who use contraceptives is the lowest in the country (3%), and the level of unmet need 
(16%) is higher than average. Although the social and demographic characteristics and 
contraceptive behavior of women in the North East are similar to those of their counterparts 
in the neighboring North West zone, the abortion rates differ greatly (41 vs. 31 per 1,000 
women aged 15–19). This difference, together with the slightly higher rates of total fertility 
and wanted fertility in the North West compared with the North East, suggest that women in 
the former zone are more likely than those in the latter to carry their pregnancies to term.
Women in the three southern regions want smaller families (3.9–4.3 children) than do 
women in the northern regions (4.8–6.5), which may indicate that women in the southern 
regions have a relatively strong desire to limit their family size. Although the South South 
ranks second in the proportions of women using any contraceptive method (29%) and any 
modern method (18%), it also has the second highest level of unmet need (18%). This 
suggests that compared with women in other regions, those in the South South may be 
relying on abortion to a greater degree, and on contraception to a lesser degree, to achieve 
the smaller families they desire.
Limitations
Like other indirect estimation techniques, the AICM has limitations. The data on the number 
of postabortion care cases treated in health facilities—a key input variable in our calculation 
of abortion incidence—are derived from respondents’ estimates. We must rely on these 
estimates because facilities’ official records are frequently inaccurate, grossly incomplete or 
nonexistent. We believe that a shift to social and religious conservatism has greatly affected 
the accuracy of facilities’ reporting of abortion provision in Nigeria; while respondents may 
be able to report reasonably accurate estimates of clandestine abortion services and of 
postabortion complication care, a comparison of estimates from this study with those from 
the previous one strongly suggests that many respondents grouped the two services together 
as postabortion complication cases in their reports, thus greatly reducing the reporting of 
abortions. Consequently, to calculate abortion estimates more realistically, we had to make 
several adjustments to ensure realistic abortion estimates. Moreover, to correct for noticeable 
underestimates and overestimates of postabortion care caseloads in some regions and 
facilities, we assumed that service provision in these regions and facilities was similar to that 
in some neighboring regions and facilities. These adjustments likely resulted in a 
conservative estimate of abortion incidence in Nigeria.
Lastly, lacking any direct information on this topic, we calculated the required multipliers 
using data on the perceptions of health professionals. While these respondents were 
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carefully chosen and have extensive expertise on abortion-seeking behavior, the resulting 
multipliers are not exact measures; thus, we present confidence intervals around the 
estimates of abortion incidence.
Implications for Policies and Programs
Given the extent to which unsafe abortions are still occurring in Nigeria, there is strong need 
for the government and local and international stakeholders to make more concerted efforts 
to ensure that women do not continue to suffer or die needlessly from unsafe abortion. Since 
unintended pregnancy is the reason for most abortions, the most important—and least 
expensive—step is to promote access to contraceptive services to prevent such pregnancies. 
Programmatic efforts should strive to increase coverage, provide a wide range of 
contraceptive methods and improve the quality of care; women should have access to 
counseling and be able to switch methods easily when needed.
In 2012, at the Family Planning 2020 Summit in London, the Nigerian government made a 
commitment to increase the contraceptive prevalence rate to 36% by 2018 and to raise total 
spending on reproductive health commodities from US$12 million to US$45.4 million by 
2016.25 While this step is laudable, achieving the goal of 36% will require not only that the 
government fulfill its financial commitment, but, equally importantly, that it be strategic in 
its choices of programs to pursue. The government of Ethiopia has shown, with its very 
successful Health Extension Program, that such a strategy is possible.26 The Nigerian 
government should carry out an assessment to identify the types of programs that will work 
best in the Nigerian context.
Because it typically takes time to see the effects on personal behavior of even the best 
policies and programs, and because contraceptive failures happen even among users of 
modern methods, some women will still seek unsafe abortions, at least in the short run. To 
help such women avoid long-term disability and even death, the government should continue 
to increase and improve access to appropriate, adequate and timely postabortion care 
services. Such efforts should focus on providing access to modern, appropriate and relatively 
noninvasive methods of postabortion care, such as manual vacuum aspiration and 
misoprostol; providing adequate training for relevant cadres of health providers; legally 
permitting and equipping midlevel health practitioners to provide postabortion care; and 
training providers to treat clients in a nonjudgmental manner. In addition, although only a 
small number of women may be eligible for legal abortion under the current law, which 
permits abortion only to save a woman’s life, an efficient process should be established to 
enable eligible women to have access to safe abortion services. To ensure that such abortions 
are performed safely, the government should promote training in the provision of safe 
abortion services at medical schools, during housemanship (postqualification training for 
young doctors, usually during their first two years) and during internships for medical 
students and personnel. Steps should also be taken to ensure that women seeking legal 
abortions have access to the procedure as early as possible, so that they can benefit from the 
use of modern, less invasive methods.
When women and couples begin to want smaller families—and continue to be motivated to 
space their births and avoid premarital childbearing—they will use a combination of means, 
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Bankole et al. Page 12
such as modern or traditional contraceptive methods and abortion, to achieve their goals.27 
Unless adequate measures are taken to prevent unwanted pregnancy and unsafe abortion, the 
health and well-being of women will continue to be at risk in Nigeria.
Acknowledgments
The authors gratefully acknowledge comments and feedback provided on earlier drafts of this paper by Dee Wulf. 
The authors also thank Calvin Chama, Emily Nzeribe, A.O. Oguntayo, Anthony Okonkwo and Rakiya Saidu for 
coordinating and supervising the data collection process. This study was supported by funding from the Dutch 
Ministry of Foreign Affairs, the UK Government and The John D. and Catherine T. MacArthur Foundation. The 
findings and conclusions in this article do not necessarily reflect the positions and policies of the donors.
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APPENDIX: METHODOLOGICAL DETAILS OF CALCULATING ABORTION 
INCIDENCE IN NIGERIA
In this appendix, we present details regarding some of the adjustments and calculations we 
made in estimating the number of induced abortions in Nigeria.
Adjustments to Postabortion Care Caseload
Because the collection and initial analyses of data from the Health Facilities Survey 
identified clear patterns of misreporting, and one case of inadequate sample representation, 
we made several adjustments to the estimates of the number of women treated in health 
facilities for complications of abortion.
Adjustment for misreporting of abortions
The first probable indication of substantial misreporting was the observation during fielding 
of the Health Facilities Survey that respondents were reporting very low numbers of induced 
abortions, even in the types of facilities generally known to be large providers of these 
services. This reluctance to provide information on induced abortion, but not on post-
abortion care, continued throughout fieldwork, despite efforts to reassure respondents that 
the information they provided would be kept confidential. On the basis of findings from the 
1996 Nigerian abortion incidence study1 and from other incidence studies in the region (e.g., 
in terms of typical case loads for given sizes and types of facilities), we concluded that 
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because induced abortion is highly restricted in Nigeria, many abortion procedures were 
being provided clandestinely (mainly in private facilities), and that many induced abortion 
services were being reported as postabortion care services, resulting in underreporting of the 
former and overreporting of the latter.
For example, in the 1996 study, the ratio of reported postabortion care cases to reported 
abortion cases in private facilities was 51:49. In 2012, the ratio was 90:10. Because we had 
no information suggesting that private facilities across Nigeria had stopped providing 
abortions (on the contrary, anecdotal evidence indicates that abortion continues to be a 
commonly provided service at these facilities), we assumed that the ratio had not changed 
since 1996. To correct for this misreporting, we adjusted the 2012 data to reflect the 1996 
case ratio of abortion to postabortion care.
Adjustment for reference period length
We made a second adjustment to take into account an unexpected consequence of using a 
shorter reference period in the Health Facilities Survey than is typically used in the Abortion 
Incidence Complications Methodology (AICM). For the first time in an AICM study, the 
2012 Nigerian Health Facilities Survey asked respondents to estimate the number of 
postabortion care cases treated at their facility in a week; if they were not able to do so 
(probably because the caseload was small or they tended to assess caseloads in terms of a 
longer duration), they were asked to report the number of cases in a month or, if they 
preferred, in a year. The standard AICM approach only asks the respondent to provide 
estimates for a month or year; we added the shorter reference period (one week) because we 
thought respondents from larger facilities would find it easier to estimate for a shorter time 
period. Although respondents were asked to answer for one time period, several reported for 
multiple periods, which allowed us to compare the annual equivalents for these estimates. 
This check revealed that estimates of weekly caseloads yielded much higher annual totals 
than did estimates of monthly caseloads; for example, what would be a minor overestimation 
of one case in a weekly estimate would be inflated to 52 extra cases per year. In light of our 
earlier observation that facilities were overreporting postabortion care caseloads, we 
determined that facilities reporting estimates by the week were more likely than those 
reporting by the month to have contributed to the overestimation of postabortion care cases.
Given this pattern, and because this study was the first to use weekly reporting with the 
AICM methodology, we concluded that to achieve a close approximation to the standard 
approach of using monthly reporting, we must adjust the caseload for facilities that provided 
only weekly estimates. We therefore used the ratio of the annual total based on months to 
that based on weeks (among facilities for which data for both reference periods were 
available) to adjust downward the annual totals for facilities with only weekly data. This 
resulted in a 24% reduction in the number of postabortion care cases from the unadjusted 
national total.
Adjustment for high caseloads in the North East
An additional adjustment was made only to data from the North East zone, where average 
postabortion care caseloads were notably higher than the caseloads at facilities with similar 
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capacities in other zones, including the North West, which is the zone most similar to the 
North East in terms of residents’ socioeconomic and demographic characteristics. To correct 
for this anomaly, we reduced postabortion care caseload estimates for the North East so that 
the ratio of average caseload to average number of beds equaled that of facilities in the same 
category in the North West zone.
Adjustment for underrepresentation of public facilities in the South East
A fourth adjustment was made only for the South East zone, where public facilities were 
poorly represented in the Health Facilities Survey, resulting in exceptionally low average 
postabortion care caseloads in this sector. To correct for this, we adjusted the caseloads so 
that the ratio of the average number of postabortion care cases to the average number of beds 
in each type of public facility in the zone was similar to the ratio in the South West and 
South South zones combined. Again, we took this step because the South West and South 
South zones are most similar to the South East in terms of their sociocultural and 
demographic profiles.
Overall effect of adjustments
In total, the adjustments described above reduced the number of reported postabortion care 
cases by 43%. We acknowledge that the assumptions behind these adjustments are a 
limitation of our analysis. However, the adjustments were made using the best available 
information about abortion service provision, drawing on detailed information from the 1996 
study and on our understanding of the context of abortion and postabortion service provision 
in the country. In addition, the direction of possible bias that may result from these 
adjustments is clear. The adjustment to public facility case-loads in the South East, which 
had the smallest impact on our overall estimates, led to an increase in the number of 
postabortion cases, and an increase in the estimate of abortion incidence for that zone. The 
remaining three adjustments resulted in lower postabortion caseloads, and hence lower 
rather than higher estimates of abortion incidence. Furthermore, without these adjustments, 
the resulting estimated abortion rates would have been too high to be realistic or defensible, 
given other relevant evidence from Nigeria and West Africa, including estimates of abortion 
incidence and fertility and contraceptive behavior.
Calculation of the Multipliers
Health professionals who took part in the Health Professionals Survey were asked to make 
several estimates, including the percentage distribution of women who had abortions 
according to the type of provider they used; the proportion of these women who had 
complications, according to the type of provider they used; and the proportion of women 
with complications who obtained care from a health facility. Recognizing that the 
circumstances under which women obtain abortions in Nigeria vary by women’s area of 
residence and socioeconomic status, we asked survey participants to provide the 
aforementioned estimates separately for four subgroups of women: urban poor, urban 
nonpoor, rural poor and rural nonpoor. Because medical and nonmedical respondents have 
somewhat different areas of expertise concerning abortion service provision and may 
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provide different estimates of these parameters, we calculated estimates separately for the 
two groups and used the unweighted average of the results.
The estimates from the health professionals were weighted by the relative size of the four 
subgroups of women. We then calculated the multiplier (see main article) for each 
geopolitical zone as the inverse of the estimated proportion of abortion recipients in the zone 
who received care in health facilities for complications. In mathematical terms, calculation 
of the multiplier would be expressed in the following terms:
Suppose:
Ajk=% of women who have an abortion complication, by subgroup
Bjk=% of women with complications who obtain care in a health facility, by 
subgroup
Cjk=% obtaining treatment for complications in a health facility, among all 
women having abortions, by subgroup
W=distribution of the population of women according to subgroup
Where:
j=subgroup (rural poor, rural nonpoor, urban poor, urban nonpoor) and
k= type of respondent (medical/nonmedical)
Then:
Cjk=(Ajk*Bjk)
D=Sum(W* Cjk) (i.e., weighted % of women who had an abortion who 
received treatment)
Multiplier (M)=1/D
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TABLE 1
Number of surveyed facilities that provided postabortion care, and estimated total number of facilities that provided such care, by facility type, according to geopolitical zone, Health Facilities Survey, 2012
Facility type Surveyed Estimated totals
Geopolitical zone All % Geopolitical zone All %
distri- distri-
North North North South South South bution North North North South South South bution
West East Central West South East West East Central West South East
Public/government 51 114 62 41 60 41 369 47.8 259 487 204 136 173 88 1,347 34.7
Teaching hospital/FMC 9 7 8 6 5 12 47 6.1 14 7 9 14 10 13 67 1.7
General/specialist hospital 31 44 31 24 26 15 171 22.2 115 81 101 68 78 44 487 12.6
Cottage hospital/CHC/clinic 4 9 17 8 29 11 78 10.1 23 14 68 33 85 23 246 6.3
Maternity center 7 54 6 3 0 3 73 9.5 107 385 26 21 0 8 547 14.1
Private* 68 42 76 92 59 66 403 52.2 402 190 619 426 441 454 2,532 65.3
Hospital 36 18 45 84 33 47 263 34.1 131 84 327 353 210 245 1,350 34.8
Clinic/medical center 9 15 11 6 23 4 68 8.8 75 56 91 41 163 24 450 11.6
Maternity center 23 9 20 2 3 15 72 9.3 196 50 201 32 68 185 732 18.9
All 119 156 138 133 119 107 772 100.0 661 677 823 562 614 542 3,879 100.0
*
Includes 31 facilities operated by nongovernmental organizations or missions.
Notes: Percentages may not total 100.0 because of rounding. FMC=Federal medical center. CHC=Comprehensive health center.
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TABLE 2
Estimated number of women treated for complications of spontaneous or induced abortions, and associated measures, by facility type, according to 
geopolitical zone, Nigeria, 2012
Facility type Geopolitical zone All
North West North East North Central South West South South South East
NUMBER OF WOMEN TREATED
Public/government 42,501 37,955 24,300 35,570 25,009 25,631 190,967
Teaching hospital/FMC 3,765 3,236 5,052 5,205 8,357 12,297 37,912
General/specialist hospital 35,061 21,418 8,543 25,668 10,591 11,650 112,931
Cottage hospital/CHC/clinic 797 2,136 6,575 4,616 6,062 1,645 21,831
Maternity center 2,878 11,165 4,130 81 0 40 18,293
Private* 27,724 10,584 23,717 23,603 47,775 30,026 163,429
Hospital 10,794 5,268 12,327 21,759 23,178 18,686 92,012
Clinic/medical center 2,861 2,090 1,399 1,078 21,516 850 29,794
Maternity center 14,068 3,226 9,990 767 3,082 10,490 41,624
Total 70,225 48,539 48,017 59,173 72,784 55,658 354,397
PERCENTAGES/RATES
% of complications treated in public facilities 61 78 51 60 34 46 54
Treatment rate 7.7 10.0 8.8 9.5 9.4 11.9 9.3
Public/government facilities 4.6 7.8 4.5 5.7 3.2 5.5 5.0
Private facilities 3.0 2.2 4.4 3.8 6.2 6.4 4.3
*
Includes 31 facilities run by nongovernmental organizations or missions.
Notes: All values are adjusted to correct for misclassification. Treatment rate refers to number of women who received treatment in the specified facilities per 1,000 women aged 15–49 in the general 
population. Sums of values may not equal totals because of rounding. FMC=Federal medical center. CHC=Comprehensive health center.
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TABLE 3
Measures used to estimate abortion levels, and key indicators of incidence, by geopolitical zone, Nigeria, 2012
Measure Zone All
North West North East North Central South West South South South East
ABORTION-RELATED
No. of late miscarriages 66,340 33,574 31,212 38,973 29,582 23,122 222,802
No. of women treated for abortion complications 70,225 48,539 48,017 59,173 72,784 55,658 354,397
No. of women treated for complications of spontaneous abortion 27,199 16,552 20,912 35,231 21,595 20,948 142,438
No. of women treated for complications of induced abortion 43,025 31,987 27,105 23,942 51,189 34,710 211,959
% of treated complications due to induced abortion 61 66 56 40 70 62 60
Multiplier 8.4 7.2 5.5 6.9 4.2 3.9 na
No. of abortions 360,552 229,029 147,723 164,003 214,483 134,326 1,250,117
 Lower estimate 300,270 182,584 117,475 98,807 178,896 84,758 962,791
 Upper estimate 420,834 275,474 177,970 229,200 250,071 183,894 1,537,443
DEMOGRAPHIC
No. of women aged 15–49 11,636,504 5,649,521 5,459,670 6,186,806 4,842,436 4,385,825 38,160,762
No. of live births 1,945,456 984,578 915,300 1,142,895 867,514 678,052 6,533,794
RATES/RATIOS
Induced abortion rate* 31.0 40.5 27.1 26.5 44.3 30.6 32.8
 Lower estimate 25.8 32.3 21.5 16.0 36.9 19.3 25.2
 Upper estimate 36.2 48.8 32.6 37.0 51.6 41.9 40.3
Induced abortion ratio† 18.5 23.3 16.1 14.3 24.7 19.8 19.1
Induced abortion treatment rate‡ 3.7 5.7 5.0 3.9 10.6 7.9 5.6
*
Number of abortions per 1,000 women aged 15–49.
†
Number of abortions per 100 live births.
‡
Number of women receiving postabortion care per 1,000 women aged 15–49.
Sources: Abortion-related measures—Health Facilities Survey and Health Professionals Survey. No. of women aged 15–49—reference 11. No. of live births—Calculated from data in reference 10.
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TABLE 4
Selected pregnancy-related measures, and percentage distribution of pregnancies by outcome, all according to geo-political zone, Nigeria, 2012
Measure North West North East North Central South West South South South East All
No. of pregnancies 2,731,155 1,433,426 1,260,854 1,551,877 1,276,948 961,421 9,215,682
Pregnancy rate* 235 254 231 251 264 219 241
Unintended pregnancy rate† 38 64 51 62 100 66 59
% of pregnancies that were unintended 16 25 22 25 38 30 24
Pregnancy outcomes
Birth from planned pregnancy 70 62 65 63 52 58 63
Miscarriage of planned pregnancy 14 12 13 13 10 12 13
Abortion 13 16 12 11 17 14 14
Birth from unplanned pregnancy 2 6 8 11 16 12 8
Miscarriage of unplanned pregnancy 2 3 3 3 5 4 3
Total 100 100 100 100 100 100 100
*
Annual number of pregnancies per 1,000 women aged 15–49.
†
Annual number of unintended pregnancies per 1,000 women aged 15–49.
Note: Sums of percentages may not equal 100 because of rounding.
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Table 5
Selected characteristics women aged 15–49, by geographic zone, Nigeria Demographic and Health Survey, 2013
Characteristic Zone All
North West North East North Central South West South South South East
% living in urban area 29 27 27 77 39 70 42
% with ≥7 yrs. of education 19 22 45 72 72 74 45
% married 85 81 70 66 55 52 72
% Catholic/Protestant 10 16 54 64 97 98 47
% Muslim 90 83 44 35 2 0.3 52
% using any contraceptive method 5 3 14 33 29 27 16
% using a modern method 4 3 11 23 18 14 11
% with unmet need for contraception 11 16 19 12 18 10 14
% of births unplanned* 2 9 10 15 24 18 10
% of births mistimed* 2 8 8 11 20 13 8
% of births unwanted* 0.2 1 3 4 4 5 2
Total fertility rate 6.7 6.3 5.3 4.6 4.3 4.7 5.5
Wanted fertility rate 6.5 6.1 4.8 4.2 3.9 4.3 5.2
*
In past three years.
Source: reference 10.
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APPENDIX TABLE 1
Characteristics of participating facilities, by type, Health Facilities Survey
Facility type N Mean %
no. of 
beds Provides inpatient services Provide outpatient services Has Has Has surgical ward Has Provides induced abortion
functional staff separate 
MVA trained evacuation 
equipment in ward
MVA
Public/government (N=369)
Teaching hospital/FMC 47 272 100 100 98 98 100 84 14
General/specialist hospital 171 84 100 99 85 88 100 45 7
Cottage hospital/CHC/clinic 78 20 85 92 50 61 35 9 1
Maternity center 73 6 87 98 10 22 4 3 4
Private (N=403)*
Hospital 263 28 99 100 72 78 96 31 8
Clinic/medical center 68 15 99 97 83 90 93 14 21
Maternity center 72 13 97 97 62 75 68 15 7
All 772 31 96 98 62 70 71 23 8
*
Includes 31 facilities operated by nongovernmental organizations or missions.
Note: MVA=manual vacuum aspiration. FMC=Federal medical center. CHC=Comprehensive health center.
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APPENDIX TABLE 2
Percentage distribution of survey respondents, by occupation, according to geopolitical zone, Health Facilities Survey and Health Professionals Survey
Respondent N Geopolitical zone All
North West North East North Central South West South South South East
Health Facilities Survey
Physician/medical officer 404 50.4 21.9 48.6 62.2 71.4 69.4 52.3
Nurse/midwife 252 35.9 43.2 33.3 28.1 27.7 24.1 32.6
CHEW/CHO 111 13.7 32.9 17.4 8.9 0.8 6.5 14.4
Other 5 0.0 1.9 0.7 0.7 0.0 0.0 0.6
Total 772 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Health Professionals Survey
Physician 57 13.9 38.5 20.7 16.7 37.0 40.0 29.4
Other medical professional 47 36.1 15.4 27.6 33.3 7.4 26.7 24.2
Program manager/health administrator 23 13.9 7.7 10.3 16.7 22.2 6.7 11.9
Policymaker/politician/lawyer/judge/activist 29 16.7 15.4 13.8 16.7 18.5 15.6 16.0
Lecturer/teacher/researcher 31 16.7 17.9 24.1 16.7 11.1 6.7 14.9
Other 7 2.8 5.1 3.4 0.0 3.7 4.4 3.6
Total 194 100.0 100.0 100.0 100.0 100.0 100.0 100.0
Notes: CHEW=community health extension worker. CHO=community health officer.
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APPENDIX TABLE 3
Percentage distribution of Health Facility Survey respondents, by level of training, according to facility type
Level of training N Government Private*
Teaching hospital/ FMC General/ specialist hospital Cottage hospital/ Maternity center Hospital Clinic/ Medical center Maternity center
CHC/ clinic
Physician/medical officer 404 72 45 26 4 70 66 55
Nurse/midwife 252 26 49 50 35 25 19 20
CHEW/CHO 111 2 5 24 58 5 15 24
Other 5 0 1 0 3 0.4 0 0
Total 772 100 100 100 100 100 100 100
*
Includes facilities operated by nongovernmental organizations and missions.
Notes: FMC=Federal medical center CHC= Comprehensive health center. CHEW=community health extension worker. CHO=community health officer.
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