Decision-Making About Abortion in an Abortion-Restricted Setting: A Qualitative Study of Young Women in Namibia.

Background and Aims: Unsafe abortion is one of the leading causes of maternal death in low- and middle-income countries. In Namibia, restrictive abortion legislation limits young women's reproductive autonomy and contributes to unsafe abortion practices. Despite high teenage pregnancy rates and documented barriers to reproductive health services, little is known about factors influencing abortion decision-making among young women in this restrictive context. This study explored abortion decision-making among young women admitted with abortion-related complications at a referral hospital in Kavango East region, Namibia. Methods: We employed a qualitative exploratory descriptive design. In-depth individual interviews were conducted with 15 young women (aged 16-24 years) admitted with abortion-related complications at a referral hospital in Kavango East region, Namibia, during 2022-2023. Participants were purposively sampled for diversity in age, educational status, and pregnancy history. Data were analyzed using thematic analysis following Braun and Clarke's (2006) six-phase approach. The study received ethical approval from the University of Namibia Research Ethics Committee. Results: Participants' ages ranged from 16 to 24 years; 10/15 were currently attending school. and 8/15 had previous pregnancies. Abortion decision-making was highly influenced by personal and interpersonal factors operating within a restrictive legal and social context. Key themes included: (1) fear of rejection by parents and community; (2) lack of social and financial support; (3) desire to pursue education; and (4) expectations to bear children within marriage. Young women demonstrated an understanding of abortion risks yet felt they had limited alternatives. Participants expressed mixed views on abortion legalization, with concerns about reproductive autonomy, social discrimination, and future fertility. Conclusions: Young women's abortion decisions are shaped by complex internal factors (personal aspirations, fears) and external factors (social stigma, lack of support, restrictive policies). Understanding these factors is critical for developing youth-centered reproductive health policies and services. Our findings support the need for policy reform to make safe abortion services available and accessible to young women in Namibia, potentially reducing unsafe abortion-related morbidity and mortality in this vulnerable population.