Knowledge, Attitude, and Associated Factors towards Safe Abortion among Private College Female Students in Gondar City, Northwest Ethiopia: A Cross-Sectional Study

Background Women die from complications of unsafe abortion in developing countries because most have little knowledge about how to safely access to abortion care. Studies on knowledge, attitude, and associated factors towards safe abortion are limited in general and particularly among private college students. Therefore, the aim of this study was to assess knowledge, attitude, and associated factors towards safe abortion among private college female students in Gondar City, Northwest Ethiopia. Methods An institution-based cross-sectional study was conducted from April 30, 2019, to May 30, 2019, among private college students in the Gondar town. Data were collected from 633 female students using self-administered questionnaires by a simple random sampling technique. Bivariable and multivariable logistic regression analyses were performed to identify association of dependent and independent variables using SPSS, version 20. Results A total of 633 respondents participated in this study with the response rate of 97.7%. The majority (433 (68.4%)) of students had good knowledge about safe abortion. Older age (AOR = 2.79, 95% CI: 1.16, 7.29), urban residence (AOR = 2.42, 95% CI: 1.26, 4.35), family education (AOR = 3.18, 95% CI: 1.32, 7.06), and ever having heard about safe abortion (AOR = 4.36, 95% CI: 1.89, 10.83) were factors associated with knowledge of students on safe abortion. Regarding attitude, 361 (57%) of students had favorable attitude towards safe abortion. Age (AOR = 6.58, 95% CI: 2.71, 11.21) and urban residence (AOR = 1.51, 95% CI: 1.09, 2.21) were factors significantly associated with attitude towards safe abortion. Conclusion More than half of the participants have good knowledge and attitude towards safe abortion, but still a significant proportion of students have poor knowledge and unfavorable attitude. Information, education, and communication programs on youth reproductive health should be provided to address topics on safe abortion for students. Forums and panel discussions on safe abortion need to be undertaken especially, among youths and students who come from rural area.


Background
Abortion is the termination of pregnancy before fetal viability, which can occur either spontaneously due to complications during pregnancy or can be induced [1]. Abortion is considered as safe when performed by persons with the necessary training and skills and in an environment meeting minimal medical standards, whereas unsafe abortion is done either by persons lacking training and skills or in an environment that lack minimal medical standards, or both [2,3].
Globally, unintended pregnancies and complications of induced abortions are important health problems of youths; each year, approximately 20 million abortions are performed worldwide, around 95% of them are in developing countries [4]. Out of 4.2 million pregnancies, an estimated 420,000 induced abortions occurred in Ethiopia in 2016 [5].
Evidence suggests that a number of reproductive age women died daily because of complications arising from unsafe abortion throughout the world; the majority of this occurred in developing countries; many of them are young age, maybe in their teens, and are likely to have poor knowledge of safe abortion [6].
In Ethiopia, about half of all pregnancy abortions are unsafe because of inadequate information and unfavorable attitude towards safe abortion [7]. A study conducted in Ethiopia revealed that the rate of abortion among students was found to be 65 per 1000 women; and only 16% were reported to be safe abortion [8]. Evidence also indicated that both knowledge and attitude of women towards safe abortion in Ethiopia was limited [9]. In previous studies, marital status, family income, and educational status of the parents were associated with knowledge of safe abortion among students, whereas the previous residence was associated with attitude [9,10].
Safe abortion is an important element of reproductive health care, which involves a range of medical and related health services, including counseling, contraception, and referrals to other reproductive health-care services as appropriate [3,11,12]. However, access to safe abortion continues to depend on several factors such as women's awareness of the law, shortage of safe abortion services provision, and sociocultural pressures [8,13,14].
College students are unprotected to unintentional early sexual encounters that lead to unwanted pregnancies. ey are therefore exposed to seek for induced abortion and candidates to suffer its complications [15]. e students who undergo an induced abortion expose themselves to serious health risks such as hemorrhage, genital injuries, sepsis, and death [16]. ese study participants were chosen because young women in the college environment are away from home for the first time and become free to experiment sex without any parental supervision, especially in the study area students in private colleges are in nondormitories. ere is limited information on knowledge, attitude, and associated factors towards safe abortion in general, and particularly among private college students. erefore, the aim of this study was to assess knowledge, attitude, and associated factors towards safe abortion among private college female students in Gondar City, Northwest Ethiopia. us, this study may help to give attention to the development of guidelines and resources regarding information, education, and communication (IEC) programs on youth reproductive health for college students.

Study Design, Setting, Period, and
Participants. An institution-based cross-sectional study was conducted from April 30, 2019, to May 30, 2019, among private college students in Gondar City. is town is located in the Amhara Regional State of Northwest Ethiopia.
ere were four private colleges in Gondar City during the study period. e number of students from all private colleges was 5,448, of whom 3,756 were female students. Randomly selected female students in private colleges in Gondar City were included in the study. Students who were absent during the time of data collection and incapable to fill the questionnaire were excluded from the study.

Sample Size Determination.
e sample size was determined using the single population proportion formula with the assumption of 95% confidence interval, 5% margin of error, and 74.17% of students who had a positive attitude towards safe abortion was taken from a previous study [17], and a nonresponse rate of 10% was considered. e design effect of 2 was used to account for the stratified sampling involved. e final sample size was determined to be 648.

Sampling Technique.
To obtain the required sample size, stratified random sampling was used to select study participants. First, students were stratified by their department. en, the sample size was proportionally allocated to all the departments in the institutions based on the number of female students in each department. e sample was collected from all departments by computer-generated simple random sampling method from a list of female students obtained from the principal office.

Data Collection Procedure.
e data were collected using a structured and self-administered questionnaire that was designed by reviewing from previous studies [9,10,14,17,18]. e questionnaire was prepared in English, as English language is instructional media for all colleges. e questionnaire consists of all the variables that can meet the objectives of the study, which is related to sociodemographic characteristics, knowledge, and attitude towards safe abortion. Data collectors were selected from health professionals of the University of Gondar comprehensive specialized hospital. e data were collected while students were in classrooms. e completed questionnaires were checked for completeness by the investigators.

Study Variables and Measurements.
e study assessed the knowledge and attitude of participants towards safe abortion. Students' knowledge regarding the safe abortion score was calculated out of the 8 knowledge specific questions that came up with a high internal consistency (Cronbach's alpha � 0.712). Each correct response earned one point and zero for the incorrect one based on the respondent's response. Finally, the respondent who scored greater than or equal to 60% in the knowledge questions were considered as having "good knowledge" and respondents who scored less than 60% were considered as having "poor knowledge." Students' attitude towards the safe abortion score was calculated out of 11 specific questions, which came up with a high internal consistency (Cronbach's alpha � 0.706). A fivepoint Likert scale, coded as 1 � strongly disagree, 2 � disagree, 3 � neutral, 4 � agree, and 5 � strongly agree, which then categorized as "agree" (strongly agree and agree) and "disagree" (strongly disagree, disagree, and neutral). e respondents who scored greater than or equal to the mean score were considered as having "favorable attitude" and those who scored less than the mean score were considered as having "unfavorable attitude" [19]. e independent variables were age, sex, religion, marital status, place of previous resident (either urban or rural), year of study, and income from family.

Data Quality Control.
A pre-test of the data collection tool was carried out in 5% (33 participants) of the study participants who were female students of the Bahir Dar city private college. Training was given to the data collectors before the data collection on objectives of the study, procedure of data collection, ethical consideration, data quality control, and confidentiality. Before the beginning, the respondents were told about the objective of the study and their importance to participate voluntarily in the study. e collected data were checked for completeness and consistency, on a daily basis. Data were kept in a private protected place, and confidentiality was insured by not recording any personal identifiers.

Data Processing and Analysis.
Data were coded and entered using EPI-INFO, version 7.2.2.2, and then transported to SPSS, version 20, for further analysis. Frequencies, percentages, and mean were computed to describe the key variables of the study. Bivariable and multivariable analyses were used to determine the association between different factors and the outcome variables. ose variables having p-value < 0.2 in the bivariable analysis were included in multivariable analysis, and the variables having p-value < 0.05 in the multivariable analysis were considered as statically significant. Odds ratios and the respective 95% confidence intervals were used to assess the strength of association between the variables.

Ethical Considerations
Ethical clearance was obtained from the research review committee of the College of Medicine and Health Sciences, University of Gondar. e objective of the study was explained to the students; then, verbal informed consent was obtained from the study participants. Students were also informed to have the right not to participate on the study, if they were not interested to be involved on it.

Sociodemographic Characteristics of Respondents.
A total of 633 respondents participated in this study, making the response rate of 97.7%. e mean age was 21.8 years (SD ± 2.99). Four hundred ninety-five (78.2%) of students reported that they were living in an urban area before they joined the college. Nearly, two-thirds (389 (61.5%)) of students were single and never been in a relationship. Concerning family education, 338 (53.4%) of them were from both illiterate parents (Table 1).

Knowledge of Respondents on Safe Abortion.
e overall students with knowledge regarding safe abortion were 433 (68. 4%). e majority (609 (96.2%)) of the respondents had ever heard about safe abortion; of those 483 (79.3%) got information from health institutions. Unsafe abortion as a major health problem of Ethiopia was considered by 598 (80.3%) of the participants. Nearly three-fourths (452 (71.4%)) of the respondents replied that Ethiopia has an abortion law. Nearly half (315 (49.9%)) of the respondents mentioned the place where safe abortion performed was the hospital. Among respondents, 376 (59.4%) said less than 3 months of pregnancy is the preferable time to perform the safe abortion (Table 2).

Attitudes of Respondents on Safe Abortion.
Among the study participants, 361 (57%) of respondents had a positive attitude towards safe abortion. e majority (531 (83.9%)) of the respondents disagreed that elective abortion should be legal and accessible under any circumstance. e majority (461 (72.8%)) of respondents have disagreed with the legalization of safe and voluntary abortion. More than two-  (Table 3).

Factors Affecting Students' Knowledge towards Safe
Abortion. In the bivariate analysis, the factors that found to have an association with knowledge towards safe abortion among students were age, marital status, residence, family education, year of study, and ever heard about abortion. In the multivariate analysis, age, family education, residence, and ever heard about abortion had an association with knowledge towards safe abortion. Students who found in the age group of 25 and above were 2.79 times more likely to have good knowledge of safe abortion than those in the age group of 18

Factors Affecting Students' Attitude towards Safe
Abortion. Age, religion, family education, residence, and marital status had an association with the attitude towards safe abortion in the bivariable analysis. All explanatory variables that were considered in the bivariate analyses were included in the multivariable logistic regression. Accordingly, the age of respondents and place of residence were remained to be significantly associated with the attitude of students towards safe abortion.
Students who found in the age group of 25 and above were 6.58 times more likely to have a favorable attitude towards safe abortion than those in the age group of 18-19 (AOR � 6.58, 95% CI: 2.71, 11.21). e students from urban residents were 1.51 more likely to have a favorable attitude towards safe abortion than those from rural residents (AOR � 1.51, 95% CI: 1.09, 2.21) ( Table 5).

Discussion
Assessment of knowledge, attitude, and associated factors towards safe abortion among students is important to minimize the burdens associated with unsafe abortion. is study revealed that the overall knowledge of students regarding safe abortion was 68.4% (95% CI: 64. 8, 72.4). is finding is consistent with other studies done in Kampala, Uganda [14], which documented 72.4% of students had good knowledge of safe abortion. However, this result was higher than that of studies conducted in Mekelle University, Northern Ethiopia [9], Wolaita Sodo University, Southwest Ethiopia [8], and Puducherry, India [20], where the knowledge score of students was reported as 44.1%, 38.8%, and 36%, respectively. e reason for this discrepancy might be due to differences in study participants; only first year students were included in these studies, whereas in our study, the study participants included were the first year and above. It is a fact that as the year of study increases, the level of knowledge of students also increases [21]. Moreover, the variation might be occurred due to differences in access to health information in different settings. As per the study  conducted in Mizan-Tepi University, South West Ethiopia, among female students, 90.52% had adequate knowledge regarding safe abortion [17], which is higher than this finding.
In the present study, students who found in the age group of 25 and above were 2.79 more likely to have adequate knowledge regarding safe abortion than those in the age group of 18-19. is finding is in line with a crosssectional study conducted in Kampala, Uganda [14]. e possible explanation might be the fact that as age increases, students' exposure to information regarding safe abortion could also increase.
is study also showed that students who came from the urban area were more knowledgeable than those living in rural areas. is may be because of urban dwellers who have a chance to access information and educational media. Respondents with both parent literates were more than three times more likely to have good knowledge of safe abortion than their counterparts. is finding was supported by studies done in Mekelle University, Northern Ethiopia [9], and the University of Buenos Aires, Argentina [22]. is may be because parents having higher educational background let their children know additional and important lessons besides the academic program.
is study revealed that students who ever heard about safe abortion were more likely to have good knowledge than those who did not hear about safe abortion. is finding is in agreement with other studies conducted in Mizan-Tepi University, Ethiopia [17], and South Africa [19]. e explanation for this might be that students, who have different information regarding health problems of unsafe abortion, could have increased awareness related to major obstacles for their education and other health-related problems. Furthermore, students are becoming more accessed to different mass media and getting more information about the problem, which may have provided good knowledge regarding safe abortion. In addition, students who have more access to youth-friendly services could have increased awareness related to abortion, which can further increase their knowledge about safe abortion.
In this study, 57% (95% CI: 52.6, 60.8) of students had a positive attitude towards safe abortion. is result is supported by a study done in Mekelle University, Ethiopia, which showed nearly half of the students (52.8%) have a positive attitude towards safe abortion [9]. is finding result is lower than other cross-sectional studies conducted in Mizan-Tepi University [17] and South Africa [19], which reported that 74.17% and 70% of students had a positive attitude towards safe abortion, respectively. is result is higher than a cross-sectional study conducted in the Somali Region, Ethiopia, which revealed 40.7% of students had a favorite attitude towards safe abortion [18]. e reason for this variation may be due to cultural beliefs and socioeconomic status.
According to this study, students who found in the age group of 25 and above were 6.58 times more likely to have a favorable attitude towards safe abortion than those in the age group of in [18][19]. is finding is supported by a previous study conducted among medical school students in South Africa [19]. is study also showed that students from urban residents before joining college were more likely to have a favorable attitude towards safe abortion than those from rural residents. is finding is in agreement with a crosssectional study conducted in the Somali Region [18], Mekelle University, Ethiopia [9], and Kampala, Uganda [14].
is study has some limitations; it assessed both health science and nonhealth science students together without separating them by department, and even the study touches

Conclusion
In conclusion, this study revealed that more than two-thirds of participants had good knowledge and more than half of the participants had a favorable attitude regarding safe abortion, but, still, a significant proportion of students had poor knowledge and unfavorable attitude towards safe abortion. Moreover, the age of students, residence, family education, and ever heard about abortion were factors that associated with knowledge on safe abortion. e age of students and residents had an association with the attitude towards abortion. erefore, information, education, and communication programs on youth reproductive health should be provided to address topics on safe abortion for all college students. Forums and panel discussions on safe abortion need to be undertaken, especially among youths and students who come from rural areas. Youth-friendly service has to be expanded to the rural part of Ethiopia.

Abbreviations
COR: Crude odds ratio AOR: Adjusted odds ratio CI: Confidence interval SPSS: Statistical Package for Social Science WHO: World Health Organization.
Data Availability e data sets are available from the corresponding author upon reasonable request.

Ethical Approval
Ethical clearance was obtained from the research review committee of the College of Medicine and Health sciences, University of Gondar. An official letter was written from University of Gondar, College of Medicine and Health Sciences, to each college where the study was conducted. Consent e objective of the study was explained to the students; then verbal informed consent was obtained from the study participants. ey were informed to have the right not to participate on the study, if they were not interested to be involved on it. Confidentiality of information was maintained by omitting any personal identifier from the questionnaire.

Conflicts of Interest
e authors declare that they have no conflicts of interest.

Authors' Contributions
BDM wrote the proposal, participated in data collection, analysis, and report writing, and drafted the manuscript. CAW made revisions on proposal, participated in data analysis, and drafted the manuscript. All authors reviewed, revised, and approved the manuscript for publication.