Introduction

Abortion is common in sub-Saharan Africa (SSA) [1, 2], and because of limited access to safe options, the majority of women and girls in need of pregnancy termination use unqualified and clandestine providers, leading to adverse outcomes [3]. Unsafe abortion and the resulting complications contribute significantly to maternal morbidity and mortality in the region [4]. Region-wide studies have established an increasing incidence of induced and unsafe abortions [5, 6]. Annually, from 2010–2014, about 15% of all pregnancies in Africa ended in abortion [7], of which approximately 8.2 million induced abortions occurred, representing a nearly 100% increase from 1990 and 1994 [1]. Besides demographic changes—specifically, an increase in the number of women of reproductive age [7]—, other reasons for the rise in induced abortions include the growing unmet need for contraception and improvements in technologies and procedures for terminating pregnancies [5]. Evidence from some low and middle-income countries (LMICs) points to the use of abortion as a substitute for contraception [8, 9].

Notably, about 75% of all abortions carried out in Africa are unsafe (i.e., pregnancy termination conducted by providers lacking the necessary skills or in an environment lacking the minimal medical standards or both) [10]. The risk of maternal death from unsafe abortion (one in every 150 procedures) is the highest in the world [11, 12]. The latest estimates show that over 70,000 women die annually from unsafe abortion (the majority being in Africa (38,000) and South Asia (24,000) [13]. Approximately 6.9 million women in developing regions suffer unsafe abortion-related complications and morbidities that require treatment, some with extended hospital stays, and intensive care involving highly skilled, yet scarce, health providers and enormous financial costs [6, 14].

Arguably, more than 98% of women in SSA live in legally restrictive abortion contexts that constrain access to safe abortion, with exceptions only in cases of rape or incest or to save a woman’s life [15–17]. Criminalization has remained the primary tool for regulating abortion in most SSA countries, despite its limited effectiveness in ending or reducing abortions [18, 19]. Rather than limiting abortion rates, criminalization leads to a rise in unsafe abortions, related complications, and increase maternal morbidity and mortality [11, 20]. Global development frameworks long recognized these challenges and proposed bold targets such as the 1994 International Conference on Population and Development (ICPD), where states committed to ensuring access to quality post-abortion care services, despite existing anti-abortion laws. The sustainable development goals (SDGs) targets a global average maternal mortality ratio of less than 70 maternal deaths per 100 000 live births by 2030 [21]. Every country has the mandate to reduce its national maternal mortality ratio from baseline by two-thirds in that timeframe. Within this context, and in light of the potential benefits to women’s health and well-being of reforming abortion laws and policies [11], African countries have forged collective commitments to improve access to safe abortion services, including post-abortion care services. Such commitments encompassed continental frameworks such as the Protocol to the African Charter on Human and Peoples’ Rights on the rights of women in Africa (commonly known as the Maputo Protocol) and the Addis Ababa Declaration on Population and Development in Africa beyond 2014. Profound gaps remain, however, in the domestication and implementation of such progressive instruments at sub-regional or national levels.

Strong arguments exist in support of marshaling policy-relevant evidence to help address the barriers that presently impede the realization of the continental commitments on improved access to safe and legal abortion. An extensive range of studies has addressed critical questions concerning abortion in SSA, among others, on its magnitude, causes, and patterns across particular settings, or levels of access to and utilization, and the quality of abortion and post-abortion care services. However, the kinds of evidence–in substantive, geographic, or methodological terms–that are most relevant to promoting policy progress on abortion across SSA’s sub-regions and countries may not yet exist. Where such evidence is available, there is the need to interrogate and synthesize it for application. A comprehensive scoping review of the literature is needed to identify and provide directions for addressing such gaps. We aim to conduct such a scoping study to map the landscape of extant research on abortion in SSA, clarify key concepts, summarize existing knowledge and pinpoint gaps, both substantive and geographic, requiring further investigation. Even though there is a protocol published by Coast et al., 2019 focusing on the economics of abortion [22], our proposed study is unique in that it has a broader focus on abortion research targeting SSA. This study will synthesize the existing evidence to facilitate debates and advocacy at various levels in SSA and identify gaps for further inquiry.

Materials and methods

We will apply the Joanna Briggs Institute’s approach for conducting a scoping review [23]. The methodology involves a systematic approach to searching, screening, and reporting that encompasses the following stages: (1) identification of the research question (s); (2) identification of relevant databases and studies; (3) selection of studies; (4) data extraction; (5) interpretation, summarization and dissemination of the results.

We will search relevant peer-reviewed, English or French-language articles published between January 1, 2011, and July 31, 2021, without methodological restrictions, in several electronic databases, as well as in general internet sources (Google and Google Scholar).

We focus on articles and reports published between aforementioned dates, because we consider 11 years as a reasonable timeframe to reflect on the extent of research and evidence that is within the realm of ’current’ and valid for informing policy processes and debates. Also, focusing on eleven years will yield a manageable number of articles that could be quickly summarized to inform policy processes and discussions on abortion at the continental level and sub-regions.

Inclusion criteria

We intend to capture all research papers published on abortion in SSA, including those focusing on women, health providers, policymakers, and community members between January 2011 and December 2020. However, to qualify for inclusion, papers have to be:

• Journal articles (peer-reviewed),
• English or French language publications.

We will exclude commentaries, conference abstracts, and posters, working papers, policy briefs, editorials, opinion pieces, and debates. Also, we will exclude technical reports and thesis to avoid double counting. We used Table 1 to present our population, intervention, control, outcomes, timeframe, and settings (PICOTS) [22]. We are interested in studies on women and girls, health providers, and community members as well as policymakers on abortion in SSA. We tailored our search and screening approach to mirror the PICOT in Table 1.

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Table 1. PICOTS table summarising our scoping review approach.

https://doi.org/10.1371/journal.pone.0254818.t001

Data extraction

We will use a standardized frame (Table 2: Extraction framework) to extract information from the included articles.

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Table 2. Extraction framework.

https://doi.org/10.1371/journal.pone.0254818.t002

Supporting information