The World Health Organization (WHO) defines an abortion as the termination of a pregnancy, whether induced or spontaneous, before 20 weeks of gestation (1). Termination of pregnancy is one of the biggest five causes of maternal mortality in countries with low and middle incomes (2). Globally, an estimated 73 million induced abortions have been carried out annually. Six out of 10 (61%) of all unintended pregnancies, and 3 out of 10 (29%) of all pregnancies, end in induced abortion (1, 3).

Short birth intervals are particularly concerning for maternal health as they increase risks of maternal depletion, insufficient recovery time, and heightened susceptibility to adverse outcomes in subsequent pregnancies (4). Short intervals limit time for physiological recuperation, which can lead to complications such as anemia, malnutrition, and heightened risk of uterine rupture, preterm birth, and maternal mortality (5). Evidence suggests that these intervals strain maternal health resources, impacting both physical and mental health recovery. Additionally, closely spaced pregnancies can exacerbate socioeconomic stressors, particularly in resource-limited settings, compounding health risks (6).

Nearly two thirds of termination of pregnancy occurs in developing countries. In Asia, particularly in south and central Asia, unsafe abortions account for more than half of all abortions undertaken (7). The World Health Organization (WHO) defines unsafe abortions as procedures for terminating unintended pregnancies that are carried out either by individuals lacking the necessary skills or in environments that do not conform to minimal medical standards, or both (8, 9). The WHO's recent definition emphasizes that unsafe abortions are a significant but preventable cause of maternal deaths and morbidities, particularly in developing countries where 97% of unsafe abortions occur. Most terminations of pregnancy (about three out of four) are potentially hazardous in Latin America and Africa. The least safe conditions are used for over half of all abortions in Africa (9). An estimated 55.9 million abortions are performed each year, 49.3 million of which take place in developing countries (10).

The prevalence of pregnancy termination practices varies across country, with 3.1% in western Africa and 3.8% in northern Africa (11, 12). Thirty-seven deaths per 100,000 live births in Sub-Saharan Africa account 13% of all maternal deaths worldwide, and are specifically associated with abortions (13). Termination of pregnancy rates remain high in developing countries, especially in Sub-Saharan Africa (SSA), where abortion is legally limited, despite being lower in developed countries where abortion laws have been liberalized and safe abortion services are freely accessible (14, 15). In Sub-Saharan Africa, 77% of abortions are unsafe because they are handled by unskilled individuals and use non-recommended methods. As of 2019, the region experienced about 6.2 million unsafe abortions annually, which have a detrimental effect on people, families, and healthcare systems.

The studies carried out in different parts of the world revealed that termination of pregnancy was significantly associated with women's age (16, 17), residence (18, 19), poor wealth index (20), use of substance (21), educational level (22, 23). Even though the WHO provides global technical and policy guidance on the use of contraception to prevent unintended pregnancy and abortion, maternal deaths related to abortion remain high in developing countries, especially in Sub-Saharan Africa.

Sub-Saharan African countries are actively working to improve family planning services to prevent unintended pregnancies and reduce the need for pregnancy termination. For instance, Angola is investing $500K USD annually to improve access for young people (24). Benin aims to raise its modern contraceptive prevalence rate to 25% by 2022 (25), while Burundi targets a substantial increase to 60% by 2030 (26). Ethiopia has made remarkable progress, reaching a 41% contraceptive rate (27), and Kenya envisions zero unmet needs by 2030 (28).

Despite the above efforts, maternal mortality and morbidity are still highly related to reproductive health. As far as our search of the literature and knowledge is concerned, there has been no study conducted on termination of pregnancy among women who had a short birth interval in Sub-Saharan Africa, a large sample from DHS data. Therefore, this study used multilevel mixed effect analysis of the most recent Demographic and Health Survey to investigate the prevalence and predictors of pregnancy termination among women who had short birth intervals in Sub-Saharan Africa.

This study aimed to assess the prevalence and determinants of pregnancy termination among reproductive-age women who had short birth intervals in Sub-Saharan Africa using 2015–2022 Demography and Health Survey data from each country. In this study, the prevalence of pregnancy termination among women who had short birth interval in Sub-Saharan African countries was 9.80% (95% CI: 9.69, 9.91). This finding was consistent with a previous study conducted in Ethiopia, 9.8% (33), Sierra Leone, 9% (39), and Ghana, 9% (40). The prevalence of pregnancy termination in this study was higher than the findings conducted in Nigeria, 4.9% (41), East Africa, 5.96% (32), Brazil, 4.5% (42), and Iran, 3.8% (43). These discrepancies could be explained by variations in health policies, healthcare quality, and socioeconomic and cultural differences between countries. The higher percentage of pregnancy termination in our analysis indicates that this issue needs to be given more attention in Sub-Saharan Africa.

On the other hand, the prevalence of pregnancy termination in this study was lower than the findings conducted in Ethiopia, 14.5% (44), Cameroon, 21% (45), Egypt, 21% (46), Nepal, 21.1% (20), and Mozambique, 25% (40). A plausible reason might be attributed to variations in the study period and study population, as well as the progressive enhancement of maternal health care service accessibility and utilization.

In multivariable, multilevel mixed-effect logistic regression analysis, sex of preceding birth, maternal age, presence of pregnancy complications, no ANC visits, previous caesarean section delivery, duration of breastfeeding, type of contraception used, poor household wealth status, and urban residence were found to be significantly associated with pregnancy termination among reproductive-age women who had short birth intervals.

Compared to women whose preceding birth was female, the odds of terminating a pregnancy were 1.21 times greater for women whose previous birth was male. This finding is consistent with the studies conducted in Sub-Saharan Africa (47, 48). The explanation could be cultural Gender preferences, particularly the desire for a male child, can significantly influence pregnancy termination decisions, especially in societies where sons are valued for economic, social, or cultural reasons. Families may feel compelled to continue pregnancies until a male child is born, resulting in higher rates of pregnancy termination, particularly when previous children are female or if there is a perceived need for gender balance. This practice can lead to gender imbalances within populations, affecting social structures and perpetuating discriminatory attitudes toward women. Moreover, the societal pressure to conform to these gender norms can restrict women's reproductive autonomy, reinforcing patriarchal values that undervalue female children and contribute to a cycle of gender-based discrimination that persists across generations. This dynamic not only has implications for individual families but also poses significant challenges to gender equality, with long-term effects on women's health, empowerment, and societal roles (48). The other explanation could be family balancing: Some families may seek a balance in the genders of their children. If a family already has one or more male children, they may choose to terminate a subsequent pregnancy if prenatal testing indicates another male child, in the hope of having a female child in the future (49).

The odds of pregnancy termination were 1.76 times higher among women whose ages were 36–49 years compared to women whose ages were 15–19 years. It is in line with study findings in Ethiopia (50), Ghana (51, 52), Mozambique (40), Sierra Leone (39), and China (53). This may be due to the fact that older women have an increased risk of cardiovascular disease, diabetes mellitus, and chromosomal abnormalities, making them more likely to experience pregnancy complications that could worsen pregnancy terminations (54). On the contrary, studies from Arba Minch and Wolayita Sodo town, Ethiopia (55), East Africa (56), and Chile (57) revealed a strong association between pregnancy termination and younger women age. The explanation might be that adolescent girls and young women are ignorant of safe sex practices, such as how to avoid unwanted pregnancy and complications related to pregnancy termination. Another explanation is that younger women don't know as much about family planning as older women do.

The odds of pregnancy termination were 1.28 times higher among women who had pregnancy complications as compared to women who did not have pregnancy complications. This finding is consistent with previous findings in Iran (58), the United Kingdom (59), Pennsylvania (60), and Canada (61). The possible explanation be due to most pregnancy complications are associated with decreased placental nutrient, which results placental insufficiency and these complications are associated with pregnancy termination, preterm birth and perinatal death (62).

Pregnancy termination was 2.40 times higher among women who had no ANC visits as compared to women who had four or more ANC visits during pregnancy. It is in line with the previous studies conducted in Ethiopia (63, 64), Uganda (65, 66), and Nigeria (67, 68). The possible explanation could be that the lack of ANC visits can hinder the timely detection and management of pregnancy-related issues. During these visits, healthcare providers can identify complications early and offer appropriate interventions, which are crucial in reducing the risk of pregnancy termination. The importance of optimal ANC visits cannot be overstated, as they significantly enhance the likelihood of receiving high-quality care throughout pregnancy, thereby preventing spontaneous pregnancy terminations. Furthermore, rural women often struggle with geographic distances, transportation issues, and socio-cultural factors that hinder their access. In urban areas, challenges such as overcrowded facilities, long waiting times, and economic constraints can also deter timely care (69, 70). Therefore, public health strategies must focus on enhancing ANC services, especially for women in disadvantaged communities.

The odds of pregnancy termination were 1.56 times higher among women who breastfeed for less than 6 months as compared to women who breastfeed for 6 and more months. This finding is in line with the studies conducted in low and middle income countries (49), Canada (71), and The USA (72). The association between short breastfeeding periods and pregnancy termination can be complex and multifaceted. Some of the potential justifications and factors that might explain this association could be breastfeeding as a natural contraceptive: Breastfeeding, especially exclusive breastfeeding, can act as a natural contraceptive method known as lactational amenorrhea, which can delay the return of fertility and menstruation. However, this method is not completely reliable, and its effectiveness can decrease with time, particularly after 6 months or when supplemental feeding is introduced (49). Another justification could be socioeconomic and health factors: Women who breastfeed for shorter periods may do so due to socioeconomic reasons, such as the need to return to work, or health issues that prevent prolonged breastfeeding. These same factors could also contribute to the decision or need for pregnancy termination (73).

Compared to women who utilized modern contraceptive methods, women who used traditional contraceptive methods had 1.67 times higher odds of terminating their pregnancy. This is corroborated by previous studies carried out in (74–76). The association between the use of traditional contraceptive methods and a higher likelihood of pregnancy termination, as compared to the use of modern contraceptive methods, can be attributed to several factors. This justification could be contraceptive effectiveness: Traditional contraceptive methods are generally less effective than modern methods. This lower effectiveness can lead to a higher incidence of unintended pregnancies, which may result in a greater number of pregnancy terminations (47). The other explanation might be personal preferences: Some women may choose traditional methods due to personal or religious beliefs, or due to concerns about the side effects of modern contraceptives. However, this choice may increase the risk of unintended pregnancies and the potential for pregnancy termination (77).

Furthermore, traditional methods often have lower effectiveness, leading to a higher incidence of unintended pregnancies and, consequently, increased pregnancy termination rates. Additionally, personal and religious beliefs significantly influence contraceptive choices; women may prefer traditional methods due to perceptions of safety or cultural acceptability, despite these methods being associated with higher risks of unintended pregnancies (41, 78).

The acceptability of contraception among women is a pivotal factor in the context of pregnancy termination. When contraception is widely accepted and utilized, the rate of unintended pregnancies tends to decrease, subsequently leading to a reduction in the number of pregnancy terminations. Conversely, when women are reluctant to use contraception due to personal beliefs, societal pressures, or lack of access the incidence of unintended pregnancies can increase, potentially resulting in a higher rate of pregnancy terminations (47). This association is further complicated by the influence of partners or spouses, whose acceptance or refusal of contraception can significantly impact a woman's reproductive choices. Therefore, understanding the nuances of contraception acceptability is crucial for public health initiatives aimed at reducing the prevalence of pregnancy termination by addressing the root causes of unintended pregnancies (79–81).

The odds of pregnancy termination were 1.71 times higher among women whose previous mode of delivery was caesarean section as compared to women who had vaginal delivery. It is consistent with studies in France (82) and Scotland (83), however to date, this finding is conflicting the study conducted in Germany (84). Although the exact causes of the link between pregnancy termination and Caesarean delivery are unknown, placental abnormalities may be implicated. But frequently, there is no clear underlying reason for these unfavorable incidences (85). According to this study's analysis of wealth status, women from the poorest homes were 1.50 times more likely than those from the richest households to undergo pregnancy termination. This is consistent with the studies conducted in Nepal (20), India (86), and China (87). The possible explanation could be that women from low-income households have inadequate access to healthcare, poor health care practices, and poor health-seeking behaviour. As a result, the women have a higher probability of pregnancy termination.

The odds of pregnancy termination were 1.31 times higher among women whose place of residence was urban as compared to women from rural areas. This is supported by the previous studies conducted in Ethiopia (19, 55, 88, 89), Cambodia (90), Ghana (91), and India (92). The possible explanation might be that, compared to women in rural areas, women in urban areas have more access to abortion services. In the same manner, premarital sex is more common in urban settings and can result in induced abortions and unwanted pregnancies. The finding of this study is inconsistent with the studies conducted in China (87), and Vietnam (93) where pregnancy termination is strongly associated with women from rural areas. This could be because rural areas lack access to media, which could lead to restricted information regarding abortion complications. It could also be because women are less likely to use maternal health care services, such as family planning, ANC visits, understanding of pregnancy signs, and birth planning.

The study's strength was the utilization of recently conducted large-sample national demography and health surveys from 21 Sub-Saharan African countries. Another strength of this study was the use of mixed multilevel logistic regression to determine two-level factors (individual and community-level factors), which could not be done using ordinary logistic regression. However, the study is limited by its reliance on secondary data, which may lack key variables, including maternal psychological factors that could influence the outcome variables. Additionally, potential biases, such as reporting bias in the DHS data, may further affect our findings.

This study concludes that pregnancy termination rates among women with short birth intervals are high. The study identified that both individual and community-level variables were determinants of pregnancy termination. To effectively reduce pregnancy termination rates in Sub-Saharan Africa, ministries of health should implement targeted interventions that focus on enhancing antenatal care service utilization among women, particularly those from urban areas. This could involve developing comprehensive outreach programs that promote awareness of available services, providing incentives for women to attend antenatal visits, and establishing collaborations with local community organizations to ensure that tailored support reaches those most in need. We also suggested that future research could incorporate qualitative studies to further explore gender preferences and their influence on pregnancy termination.