Unsafe abortion is one of the leading causes of maternal mortality in the world, with over 20,000 people dying each year due to related complications. In fragile or conflict-affected settings, the complications resulting from unsafe abortion are up to seven times more severe.
Doctors Without Borders/Médecins Sans Frontières (MSF) recently took part in the first-ever study on this issue, focusing on two referral hospitals in Africa: Bangui hospital in the Central African Republic (CAR) and a hospital in Jigawa state in northern Nigeria. Conducted in partnership with Épicentre, the Guttmacher Institute, Ipas, and the Nigerian and Central African Ministries of Health, the Abortion-related Morbidity and Mortality in Fragile and Conflict-affected Settings study (AMoCo) found that in these two hospitals, severe abortion complications were five to seven times more frequent than hospitals in more stable settings in Africa, which were studied by the World Health Organization (WHO) using a similar methodology.
"I was distraught. I had drunk the traditional medicine. Before that, someone had shown me how to insert a piece of iron into my vagina. This person told me it would dilate the cervix, but it didn't work. She also told me to boil the roots of a plant called kava with natron [sodium carbonate] and then drink the mixture. After drinking it, I felt sick to my stomach and dizzy. I couldn't get out of bed. The pain was intense.”
Around 70 percent of maternal deaths occur in sub-Saharan Africa. Among the five main causes are abortion-related complications—an issue in which little progress has been made in recent decades. Yet most abortion-related deaths are the result of unsafe induced abortions, which could be largely avoided by providing comprehensive abortion care, including post-abortion care, contraception, and safe abortion services, so that no one feels they have to resort to dangerous procedures or delay care until it’s too late.
What is an unsafe abortion?
An unsafe induced abortion is one carried out by someone who does not have the necessary skills to perform it, or does not comply with medical standards.
Often, unsafe abortions result in severe abortion-related complications, defined by WHO as potentially life-threatening cases that result in death or near-misses, based on a set of standardized clinical, biological, and treatment criteria used in a multi-country survey on abortion (MCS-A).
In the hospitals MSF studied, more than 50 percent of women admitted for abortion-related complications arrived with severe symptoms, mainly hemorrhage (72 percent in the Nigerian hospital and 58 percent in the Central African hospital).
The severity of complications can be explained by inadequate and inaccessible post-abortion care services. Women in fragile, conflict-affected settings also face a higher risk of exposure to sexual violence, as well as barriers to accessing contraception. These factors increase the risk of unwanted pregnancy and recourse to unsafe abortion, particularly in places where abortion laws are restrictive.
"A woman explained that if I waited any longer, I might die because I was bleeding out. The motorcycle driver said that he had taken a woman in the same condition to the hospital, and that it saved her life. He told us to hurry and that's how they got me here."
1. Unsafe abortion is the leading cause of maternal death in the Central African Republic
With 829 deaths for every 100,000 live births, CAR has one of the highest maternal mortality rates in the world. A study conducted by the Central African Ministry of Health and the United Nations Population Fund estimated that abortion-related complications accounted for almost one in four maternal deaths.
In Bangui hospital, abortion-related complications accounted for 20 percent of all pregnancy-related admissions during the period studied, corroborating these results. More than two-thirds occurred during the first trimester of pregnancy, and more than a quarter of the patients were adolescents aged 18 and under.
“He's preparing his application for military training. It's better to abort this pregnancy if he's not going to be here. He [won't be] comfortable until we've done away with it. At the moment, he has no money to help me with my small business so that I can take care of this pregnancy. How are we going to manage? He was the one who went to see [the hospital health worker]. He said he wanted to have an abortion because he's not ready, so he wants us to do the curettage. [The health worker] agreed.”
2. Access to information is critical for safe abortion care
Around a quarter of the women interviewed in Jigawa and 45 percent in Bangui said they had self-induced their abortion. More than two-thirds of those surveyed in Bangui and almost all—95 percent—of those surveyed in Jigawa had used dangerous methods, including using blunt metal objects or cassava sticks in septic conditions, injections, traditional herbs and remedies, and unprescribed medicines.
At Bangui hospital, women who reported inducing an unsafe abortion were more than three times more likely to experience very severe complications, including death.
“It was just a boyfriend [but] I got pregnant... I tried to abort it myself but it didn't work, so I had to go see a mother in one of the neighborhoods. She asked me for 15,000 CFA francs [about $25] for the abortion, but I only had 13,000 CFA francs, so I gave them to her. She injected me with medicine and dilated my cervix with a cassava stem, and the fetus fell out. Afterwards, I started having abdominal pains."
For most of the women, the only sources of information prior to their unsafe abortion were friends, family members, and colleagues. The methods chosen seemed to be based more on perceived effectiveness and ease of access rather than the women’s safety. Partners are also often involved in the decision to obtain an abortion and the method used. Some patients, abandoned by their partners, may feel they have no choice but to seek an unsafe abortion.
3. Contraception is often inaccessible
One of the root causes of unwanted pregnancy is the difficulty of accessing methods of contraception. Only three percent of the women surveyed in Jigawa and 37 percent of those in Bangui said they were using some form of contraception at the start of their pregnancy. In Nigeria, the main barriers to using modern contraceptives are the husband or family’s refusal, lack of knowledge about pregnancy, and religious beliefs.
In Bangui, the women said they did not use contraception for fear of side effects. They also explained it was difficult to ensure the continuity of contraceptive care, with a lack of alternative methods available, high transport costs, and limited opening hours that make it impossible to buy the drugs.
4. Extreme delays exacerbate complications
Challenges in accessing abortion care also play a role in the severity of complications. For half of the women surveyed, it took two or more days to get to a suitable health facility after the first symptoms appeared; for 27 percent in Nigeria and 16 percent in CAR, it took six days or even longer.
At first, symptoms are often not perceived as serious, let alone a priority. Some women don't even realize they are pregnant yet. In other cases, women simply want to keep their abortion secret.
"I had often heard that after the curettage, you felt better. I thought that one day the fetus would come out and I'd feel better. [But] I couldn't swallow anything. I couldn't get out of bed... I was in pain day and night. I took the medication they gave me, but it wasn't any good. As things got more complicated, I got scared, because my family wouldn't have agreed to me having an abortion. I didn't tell anyone about my situation. I became very withdrawn and shut myself away at home."
When symptoms worsen, many women decide to return to the person who performed the abortion or to untrained care providers, which causes further delays in accessing adequate treatment. Some initially try to manage the symptoms at home with medicines they buy themselves, from pharmaceuticals to traditional treatments.
The lack of information about appropriate health facilities also presents a major obstacle to accessing safe abortion care. Once they locate a facility, they must also find the money to pay for transport and cover the cost of treatment, as well as someone to accompany them. At Bangui hospital, where care is provided free of charge, most of the women who took part in the study didn’t know that they wouldn’t have to pay for a safe abortion.
5. Chronic anemia is an aggravating factor in Nigeria
While admissions for abortion-related complications were less common in the Nigerian hospital (four percent of admissions compared to 20 percent in CAR), more than two-thirds of the women surveyed presented with a severe complication.
In the rural Jigawa region, chronic anemia is common in women, which likely exacerbates the rate of complications. Of patients without significant bleeding, 67 percent had anemia—compared to 38 percent in CAR—suggesting that they probably had underlying chronic anemia. National surveys have confirmed this data, showing that the proportion of women of childbearing age with anemia in Jigawa state is one of the highest in the country.
In addition, 61 percent of abortion-related complications occurred during the second trimester—later than those at Bangui hospital—which may also explain why they were more severe.
How to save lives: Expand access to safe abortion and contraceptive care
Unsafe abortion remains one of the leading causes of maternal mortality in the world, and the only one that is almost entirely preventable.
“In fragile or conflict-affected settings, as elsewhere, in order to save the lives of many women and reduce their suffering, we need to provide access to free contraceptive services in wide range of options, both in primary health centers and in hospitals," explained Dr. Estelle Pasquier, a medical researcher at Epicentre and co-leader of the AMoCo study.
What is a safe abortion?
An abortion is considered safe if the person providing or supporting the abortion is trained and uses an evidence-based method that is appropriate to the pregnancy duration. Medication abortion, or an abortion with pills, is an example of a safe, evidence-based method of abortion.
“We need to invest in improving communities' knowledge of safe contraceptive and abortion methods,” she continued, “and make post-abortion care and safe abortion care easily accessible, including at the primary health care level.”
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